Better compliance and better tolerance in relation to a well-conducted introduction to rub-in hand disinfection
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Journal of Hospital Infection (2001) 47: 131–137
doi:10.1053/jhin.2000.0854, available online at http://www.idealibrary.com on
Better compliance and better tolerance in
relation to a well-conducted introduction to
rub-in hand disinfection
R. Girard, K. Amazian and J. Fabry
Hygiene and Epidemiology Unit, Pavillon 1M, Centre Hospitalier Lyon Sud, F-69495 Pierre Benite, France
Summary: The aim of the study was to demonstrate that the introduction of rub-in hand disinfection
(RHD) in hospital units, with the implementation of suitable equipment, drafting of specific protocols, and
training users, improved compliance of hand disinfection and tolerance of user’s hands. In four hospital
units not previously using RHD an external investigator conducted two identical studies in order to measure
the rate of compliance with, and the quality of, disinfection practices, [rate of adapted (i.e., appropriate) pro-
cedures, rate of correct (i.e., properly performed) procedures, rate of adapted and correct procedures carried
out] and to assess the state of hands (clinical scores of dryness and irritation, measuring hydration with a cor-
neometer). Between the two studies, the units were equipped with dispensers for RHD products and staff
were trained. Compliance improved from 62.2 to 66.5%, quality was improved (rate of adapted procedures
from 66.8% to 84.3%, P:1096, rate of correct procedures from 11.1% to 28.9%, P:1096, rate of adapted
and correct procedures from 6.0 to 17.8%, P:1098). The tolerance was improved significantly (P:1092) for
clinical dryness and irritation scores, although not significantly for measurements using a corneometer. This
study shows the benefit of introducing RHD with a technical and educational accompaniment.
© 2001 The Hospital Infection Society
Keywords: Hand-disinfection; tolerance; compliance.
Introduction
Received 23 February 2000; revised manuscript accepted Hand disinfection is considered one of the most
13 September 2000. important measures for preventing hospital-
Most of the data presented in the following paper by Dr Girard acquired infections.1,2 However its implementation
et al. have already appeared in HygièneS, the publication of the
Société Française d’Hygiène Hospitalière. This Journal is not
remain incomplete due to resource difficulties and
indexed in the major databases of medical literature and is workload, with many variations between profes-
published in French. Editorial Advisers of the Journal of sional groups and clinical specialities.3–8
Hospital Infection felt the work was of sufficient interest that it Hand hygiene procedures recommended in
would benefit from a wider readership than it was likely to France9,10 are either washing (simple, hygienic or
receive where first published. We have therefore agreed to
publish the following as a loose translation of the original work
surgical) or hand rubbing with aqueous alcohol
and much of the data presented can also be found in the original solutions (hygienic or surgical rubbing). For each
publication. Girard R, Amazian K, Fabry J. Allez-y: ça marche! level of exposure risk (limited, intermediate or
L’introduction organisée du traitement hygiénique par friction high) two adapted procedures are recommended
permet d’améliorer l’observance et la tolérance. HygieneS 1999; (washing or rubbing). Despite these recommenda-
VII:364–366.
Author for correspondence: Dr R. Girard, Hygiene and
tions, hand disinfection is still often synonymous
Epidemiology Unit, Pavillon 1M, Centre Hospitalier Lyon Sud, merely with washing; rub-in hand disinfection
F-69495, Pierre Benite, Cedex, France. (RHD) has not been adopted on a large scale.
0195-6701/01/020131;07 $35.00 © 2001 The Hospital Infection Society132 R. Girard et al.
RHD was introduced into some hospitals 10 medical offices. These areas were provided with
years ago. In many places, it was introduced pro- incentive stickers.
gressively on the basis of published data,11–14 and to An informative meeting was organized in each of
respond to difficulties with hand washing. Initially, the four units to answer questions from nursing and
RHD was reserved for emergencies, and only later medical staff and to define conditions for using RHD
as a regular procedure with specific protocols, based on local and national recommendations.9,10
which makes it impossible to evaluate its true bene-
fit in these hospitals. In order to determine whether Survey phase 2, after introduction RHD
RHD resulted in greater compliance and improved (3 March to 8 April 1999)
state of hands, we therefore carried out a better This phase began at least two weeks after introduc-
prepared introduction in non-user care units. ing the new procedure in order to give the staff
The introduction of RHD in treatment units in enough time to get used to the product. This phase
this study was associated with a campaign for ade- was carried out by the same investigator in exactly
quate equipment and promoting hand hygiene. the same way as the first phase.
Therefore the benefit measured is that of the com-
plete programme.
Observance study
Materials and methods Hand hygiene procedure definitions
A procedure was classed as ‘adapted’ if it was
Population appropriate for the clinical situation. It was classed
The study was carried out in four hospital units not as ‘correct’ if performed properly, irrespective of its
previously using RHD at the E. Herriot Hospital appropriateness to the clinical situation.
(University Hospital Centre) in Lyon: a rheumatol-
ogy unit, a urology unit, a paediatric unit and a Data collection
paediatric intensive care unit.
All members of staff of all professional cate- All observations were made by the same external
gories were observed: nurses, nursing auxiliaries, investigator using identical methods for both peri-
ancillary staff, paediatric nursing auxiliaries, phys- ods. Each member of nursing staff was observed for
iotherapists and doctors. 1.5 h and for a series of successive activities during
each period. The data gathered for each act included:
the type of activity, the immunocompetence of the
Products
patient concerned, the possible infection by the
The study was carried out using an antiseptic solu- patient concerned, the type of hand hygiene proce-
tion for hands already in use in Lyon: Sterillium® dure carried out (if any), its adapted and correct
(mecetronium etisulfate, propanol-1 and propanol-2; nature, and the type of error for an incorrect proce-
Bode Chemie Gmbh and Co., Hamburg, Germany). dure. All data were recorded anonymously.
Development of the study Main judgement criteria
Survey phase 1, before the introduction of RHD Rate (%) of compliance
(18 November 1998 to 3 February 1999) The rate of compliance for disinfecting hands was
This initial phase was carried out without making defined as the number of hand hygiene procedures
any change to usual hand washing methods in the carried out (washing or antisepsis) compared with
units. It included a compliance study and an assess- the number of situations where this procedure was
ment of the state of hands. considered necessary.
Introduction of RHD (4 February to 17 February 1999)
Secondary judgement criteria
Each of the four units was equipped to make the
use of RHD instinctive. Dispensers for the hand Rate (%) of adapted procedures
wash agents were installed, close to strategic points This rate enables the suitability of the chosen hand
wherever possible: in treatment rooms, food stores, hygiene procedure to be assessed, i.e., relationshipRub-in hand disinfection 133
Table I Quality criteria for hand disinfecting procedures related to local recommendations
Simple wash Antiseptic wash Hygienic disinfection by friction
Application: hands and wrists Application: hands and wrists Clean and dry hands
Soaping time910 s Soaping time960 s Application: hands and wrists
Rinsing time9washing time Rinsing time9washing time Nails and spaces between
Drying without rubbing Drying without rubbing fingers
Without subsequent Without subsequent Rubbing until dry
contamination contamination
of the microbiological efficiency of the procedure Table II Marking of the dryness score
chosen to the level of risk incurred, in relation with
Observation Points attributed
local recommendations. This is defined as the num-
ber of adapted procedures compared to the number Supple and elastic skin 0
of procedures carried out. Supple skin, dry on surface extensively 1
Dry skin, rough or thickened extensively 2
Desquamation 1
Rate (%) of correct hand hygiene procedures Breaks 1
This rate gives the proportion of procedures per- Peri-ungual dryness
formed correctly. A procedure is considered correct Localized 0.5
if it is carried out according to the protocol set and Extensively 1
complies with the key points specified in Table I. Score obtained for dryness Sum of points
The rate is defined as the number of correct proce-
dures compared to the number of procedures car-
ried out. Incorrect procedures were classed in one Table III Marking of the irritation score
of three categories:
Observation Points attributed
(1) risk of infection – for errors which induced a
No sign of irritation 0
risk of infection (e.g., insufficient contact time);
Redness
(2) risk of causing cutaneous intolerance (e.g., Moderate and localized 1
excessively short rinsing); High and localized or moderate and
(3) double risk in cases of both the above errors. extensive 2
High and extensive 3
Rate (%) of adapted and correct procedures carried out Abrasions 1
Phlyctena 1
This rate is the combination of the criteria used Oedema 1
above for adapted and correct procedures. It is Score obtained for dryness Sum of points
defined as the number of adapted and correct pro-
cedures carried out, compared with the number of
procedures expected. Larson et al.17–19 The dryness score is calculated
For each rate, a gross rate was calculated for the by adding points quantifying the dryness (Table II).
‘before’ and ‘after’ periods, then specific rates for The irritation score is calculated by adding points
units, professional categories and levels of risk. quantifying the irritation (Table III).
The clinical assessment of the cutaneous state of
hands was carried out by the investigator at the same
Tolerance study time as the observation, i.e., once for each period.
This study was carried out using two different
approaches: a clinical method and a para-clinical Judgement criterion for the para-clinical method
method. The judgement criterion used was the average
value of 10 measurements of the hand’s cutaneous
Judgement criteria for the clinical method hydration. Cutaneous hydration was measured using
Two judgement criteria were used, a dryness score a CM825® corneometer (Courage and Khazala
and an irritation score. Electronic, Monte Carlo, France) which measures
These are validated scores previously used by the skin’s electrical capacity, on a scale from 0 to
our team15,16 and initially adapted from articles by 100. Values lower than 35 indicate very dry skin,134 R. Girard et al.
35–50 indicate dry skin and greater than 50 nor- Table IV Gross compliance according to units and periods
mally hydrated skin.
Unit Before After P*
For the first period all measurements were made carried out/expected carried out/expected
in January (the apparatus was not available at the
beginning of the study). For the second period, 1 30/57 45/63 0.03
measurements were taken at the same time as the 52.6% 71.4%
clinical assessments. The measurements were taken 2 86/122 61/89 0.76 (NS)
70.5% 68.5%
using a probe strapped on to the back of the hand
at least 5 min after washing or antisepsis. 3 118/177 81/106 0.08 (NS)
66.7% 76.4%
Tolerance data were marked on a sheet with the
4 148/258 93/163 0.95 (NS)
subject’s name. Separate sheets were used for each
57.4% 57.1%
period to avoid bias.
Total 382/614 280/421 0.15 (NS)
62.2% 66.5%
Analysis methods
* Mantel Haenzel 2 test.
20
Data were entered using Epi Info version 6 and
the SPSS version 821 software. Qualitative judge- Table V Adaptation and quality of procedures by period
ment criteria were compared between the two peri-
ods (before and after) using Mantel Haenzel’s Criteria Before nb (%) After nb (%) P*
Chi-square test with a significance threshold of 5%
Procedures carried out 382 280
(P:0.05).
Adapted procedures 255 236 :1095
The before/after comparison of variables assess- (66.8%) (84.3%)
ing tolerance was carried out using Student’s t-test
Correct procedures 42 81 :1096
for matched series. (11.1%) (28.9%)
Expected procedures 614 421
Results Adapted and correct 37 75 :1098
procedures (6.0%) (17.8%)
Observance * Mantel Haenzel 2 test.
For the first period, 87 subjects were observed for a
total of 105 h 45 min. There were 614 occurrences of ence was also highly significant in all units except
patient contact, (i.e., 5.8/h) warranting hand hygiene. unit 1. Details are given in Table V.
For the second period 77 subjects were observed for
a total of 82 h 10 min. There were 421 occurrences
Observance and level of risk
(i.e., 5.1/h).
The gross rate of compliance was 62.2% during Analysis of compliance rates according to levels of
the first period and 66.5% during the second period risk showed an improvement for both intermediate
(non-significant difference), in only unit 1 was and limited exposure levels of risk. This improve-
there a significant difference (P:0.03). No rela- ment was not significant but was greater for inter-
tionship was shown between the number of occur- mediate (58.2–69.3%) than for limited risk
rences per hour and compliance. The overall results (63.4–65%); no high exposure risk activities were
and the results for each unit are given in Table IV. observed. Analysing the procedure according to the
The rate of adapted procedures increased from level of risk also showed improved compliance.
66.8% during the first period to 84.3% during the This improvement was significant for both inter-
second period (P:1095). The rate of correct pro- mediate (70.7–92.3%, P:1092) and for limited risk
cedures was 11.1% during the first period and (65.7–82.5%, P:1093).
28.9% during the second (P:1096). The quality of
hand hygiene procedures improved significantly dur-
Observance and professional categories
ing the second period in all units except unit 1.
The rate of adapted and correct procedures Nurses showed a significant improvement in com-
increased from 6.0% during the first period to pliance (60.8–68.4%, P:0.05). Improvement was
17.8% during the second (P:1098). This differ- not statistically significant for nursing auxiliaries orRub-in hand disinfection 135
paediatric auxiliaries. For doctors and ancillary Table VI Development of dryness by unit and by period
staff rates of compliance were lower during the sec-
Unit Average score Average score Average P‡
ond period but this is based on a small number of before* after* difference†
observations for these two categories.
The rates of adapted procedures and correct 1 0.90 0.50 90.50 0.05
procedures showed a significant improvement with 2 1.10 1.12 90.04 0.91 (NS)
nurses, paediatric auxiliaries and ancillary staff. For 3 1.07 0.57 90.50 0.01
each rate the values measured for nurses were 4 1.13 0.58 90.39 0.11 (NS)
greater than for other professional groups. Total 1.08 0.66 90.38 0.002
* For all subjects observed.
Procedures † For the 77 subjects observed both before and after.
‡ Student’s t-test for matched series.
During the second period RHD was used in 43.0%
of cases for limited risk and in 36.5% of cases for
intermediate risk. Table VII Development of irritation by unit and by period
Unit Average score Average score Average P‡
Errors before* after* difference†
Simple washing was more correctly carried out dur- 1 0.55 0.20 90.40 0.10 (NS)
ing the second period: 36.2% vs. 15.0%, P:1094. 2 0.53 0.39 90.15 0.43 (NS)
The quality of antiseptic washes remained practi- 3 1.24 0.15 91.04 :1095
cally unchanged. There was a decrease in the num- 4 0.74 0.27 90.33 0.03
ber of errors associated with a tolerance risk Total 0.85 0.24 90.56 :1095
(insufficient rinsing for example) but not a large
reduction in the number of errors which could have * For all subjects observed.
† For the 77 subjects observed both before and after.
led to the procedure’s inefficiency and therefore a ‡ Student’s t-test for matched series.
risk of infection (contact time too short).
Tolerance study of individuals lost during the second period did not
differ from the scores of others. Irritation scores
For the clinical method, 86 subjects were seen dur- were reduced significantly after RHD was intro-
ing the first period and 80 during the second duced, particularly in units 3 and 4 (Table VII) and
period. Seventy-seven were seen during both peri- applied to all professional categories.
ods. For the para-clinical method 84 subjects were
seen during the first period, 80 during the second
period, and 76 during both periods. Para-clinical tolerance
Average cutaneous hydration was 36.0 in the first
Development of clinical tolerance: dryness period and 38.9 in the second. The results for indi-
viduals lost in the second period did not differ from
The average dryness score was 1.08 during the first the results of other individuals. As shown in Table
period and 0.66 during the second period. The VIII, there was a non-significant improvement.
scores of individuals lost during the second period Analysis of development of cutaneous hydration
did not differ from the scores of others. There was scores for hands accordingly rank showed lower
an overall decrease in dryness of hands after RHD irritation scores after RHD was introduced for
was introduced. This was significant in units 1 and nurses, paediatric auxiliaries and ancillary staff.
3 (Table VI). Lower dryness scores after RHD was Because of the low number of subjects according to
introduced were found in all professional groups. rank, no statistical test was carried out.
Clinical dryness scores and corneometer measure-
Clinical tolerance: irritation ments were significantly related (in linear regression
R2:0.210, P:1093). No significant relationship
The average irritation score was 0.85 during the was found between the clinical irritation score and
first period and 0.24 during the second. The scores hydration measurements on the corneometer.136 R. Girard et al.
Table VIII Cutaneous hydration scores for hands according to units and meeting. This highlights the importance of prepar-
according to periods ing the introduction of RHD.
Unit Average Average Average P‡ In the other units compliance was improved
before* after* difference† non-significantly (unit 3) or remained unchanged
(units 2 and 4), but the quality of procedures car-
1 37.6 38.9 1.3 0.71 (NS) ried out was significantly greater after the introduc-
2 35.2 28.3 97.0 0.005 tion of RHD, which is perhaps linked to the
3 35.7 38.0 2.0 0.42 (NS) simpler nature of RHD compared to washing. The
4 36.2 44.2 5.0 0.08 (NS) rate of adapted correct procedures carried out is a
Total 36.0 38.9 1.6 0.3 (NS) judgement criterion rarely used in the literature,
but it gives a good overall picture of the practice of
* For all subjects observed.
disinfecting hands. It tripled after the introduction
† For the 76 subjects observed both before and after.
‡ Student’s t-test for matched series. of RHD (from 6.0 to 17.8%), demonstrating the
value of the programme.
The tolerance analysis showed a clear improve-
ment in the state of the hands of nursing staff in
Discussion
the second study period. This improvement was
Compliance with hand disinfection in our study very significant with the method using clinical
was relatively high in comparison with others.3–8 results, both for the type of dryness and the type of
However, it is comparable with the results of our irritation. The difference in dates may explain this,
study carried out in 1998 at the CHLS22 and those but meteorological conditions showed no difference
of other studies23 from outside France. between the two periods. The improvement in the
The compliance varied between units and was no state of hands therefore seems due mainly to RHD,
better where risks were greater, contrary to other as demonstrated by others.14,16 The presence of
studies. The lowest rate of compliance was additives in the solutions helps provide better pro-
recorded in the intensive care unit and was accom- tection for the state of hands.11,12 This improve-
panied by a greater workload in the first period but ment could also be explained by the improved
not in the second. Thus workload does not appear quality of disinfection technique in the second
to be an explanatory factor. period. The errors associated with a tolerance risk
Observance differed between professional cate- almost disappeared in the second period.
gories and was lower for doctors and physiothera- Although time savings were not measured in this
pists, as in other studies.3 These two groups were study, it should be noted that simply washing hands
hardly affected by the campaign: only two doctors requires approximately 1.5 min, excluding time to
attended the informative meetings. The rate of reach a sink, an antiseptic wash needs 2.5 min and
adapted procedures as well as the rate of correct RHD less than 1 min. Since RHD was used in
procedures collected in our study are similar to the almost 40% of cases during the second period, a
rates given in the literature.5 considerable amount of time most have been saved,
The low rate of correct adapted procedures car- which is likely to favour better compliance.
ried out represents an alarming figure, indicating Results obtained with the corneometer correlated
that the daily practice of disinfecting hands falls far well with those of the clinical dryness assessments
short of the recommendations. and the two thus seem to measure the same charac-
The introduction of RHD led to a greater num- teristic. The corneometer appeared less discrimina-
ber of procedures carried out and particularly to tory than the clinical assessment, perhaps because
improved quality, associated with a greater cuta- measurement is carried out on a single point, on the
neous tolerance. This result is similar to studies back of the hand. Dryness on the back of hands
already published which also show a greater effect, often only appears following dryness on nails and
compared with a simple programme for promoting fingers. However, the corneometer was often better
the hygiene of hands.24,25 perceived than the clinical method, which the nurs-
Improved compliance was significantly more pro- ing staff considered subjective. Future studies
nounced in unit 1, which benefited from adapted might explore more discriminatory methods, such
equipment and complete information since all of as measuring the loss of transepidermal water14 or
the nursing staff were present at the informative increasing the number of points measured.Rub-in hand disinfection 137
Although alcohol-based products are suspected mains. HygièneS 1998. Hors série VIII° Congrès de
to be more irritant than soap, our work showed the la SFHH: 49–51.
11. Lauharanta J, Ojajärvi J, Sarna S et al. Prevention of
opposite. However such a test was too short to pro-
dryness and eczema of the hands of hospital staff by
vide a reliable measurement of the different irritant emulsion cleansing instead of washing with soap. J
effects in chronic use. Hosp Infect 1991; 17: 207–215.
In conclusion, our work has demonstrated a vari- 12. Rotter ML, Koller W, Neumann R. The influence of
ety of benefits from the introduction of a well-tol- cosmetic additives on the acceptability of alcohol-
based hand disinfectants. J Hosp Infect 1991; 18:
erated hand disinfection programme using RHD.
(Suppl. B): 57–63.
The study emphasizes the importance of making 13. Kirita T, Hamano K, Ochi T et al. Efficacy and
appropriate equipment available and the need to safety of a quick drying rubbing type povidone-
make particular efforts to include medical staff in iodine alcoholic disinfectant solution. Postgrad Med J
educational efforts. 1993; 69(Suppl. 3): S27–S32.
14. Sauermann G, Proske O, Keyhani R et al. Skin toler-
ance of sterillium and hibiscrub: a comparative clini-
Acknowledgments cal trial. Hyg Med 1995; 20: 184–189.
15. Reat C, Girard R, Fièvre G. Faut-il adopter un anti-
We thank the hygiene team at the Edouard Herriot septique pour les mains? Revue de l’infirmière 1988;
Hospital (Annick Gandin, Geneviève Perrin, 17: 25–27.
Christine Chemorin, Michel Perraud and Françoise 16. Girard R, Réat C, Carboni N et al. L’antisepsie
chirurgical des mains peut-elle remplacer en routine
Tissot Guerraz) for their help as well as RIVADIS
le lavage chirurgical des mains? Essai en bloc
and Bode Chemie Gmbh and Co., who sponsored d’orthopédie réglée. HygièneS 1996; 12: 34–38.
the study. 17. Larson E, Leyden JJ, McGinley KJ et al. Physio-
logic, microbiologic changes in skin related to fre-
quent handwashing. Infect Control 1986; 7: 59–63.
References
18. Larson E, McGinley KJ, Grove GL et al. Physio-
1. Larson E. A causal link between hand washing and logic, microbiologic, and seasonal effects of hand-
risk of infection? Examination of the evidence. Infect washing on the skin of health care personnel. Am J
Control Hosp Epidemiol 1998; 9: 28–36. Infect Control 1986; 14: 51–59.
2. Larson E. APIC guideline for hand washing and 19. Larson E, Friedman C, Cohran J et al. Prevalence
hand antisepsis in health care settings. Am J Infect and correlates of skin damage on the hands of
Control 1995; 23: 251–269. nurses. Heart Lung 1997; 26: 404–412.
3. Albert KA, Condie A. Hand washing patterns in 20. Dean AG, Dean JA, Coulombier D et al. Epi Info
medical intensive-care units. N Engl J Med 1981; version 6: a word processing, database, and statistics
304: 1465–1466. programs for public health on microcomputers.
4. Gould D. Nurses’ hand decontamination practice: Atlanta, GA: Center for Disease Control and
results of local study. J Hosp Infect 1994; 28: 15–30. Prevention.
5. Graham M. Frequency and duration of handwashing 21. SPSS for Microsoft Windows version 8.1 Chicago
in an intensive care unit. Am J Infect Control 1990; IL: SPSS.
18: 77–80. 22. Mosnier G, Girard R. Lavage et antisepsie des mains
6. Dubbert PM, Dolce J, Richter W et al. Increasing en unités de soins: la procédure réalisée est-elle adap-
ICU staff handwashing: effects of education and tée et correcte? IX Congrès de la SFHH, Beaune 4 et
group feedback. Infect Control Hosp Epidemiol 1990; 5 juin 1998.
11: 191–193. 23. Ertzscheid MA, Lecomte F, Bernoud E et al. La
7. Kretzer EK, Larson EL. Behavioral interventions to qualité du lavage des mains dans un établissement
improve infection control practices. Am J Infect d’un Centre Hospitalier Universitaire. HygièneS
Control 1998; 26: 245–253. 1998; VI: 255–258.
8. Kesavan S, Boradawala S, Mulley GP. Now wash 24. Alzieu L, Maury E, Baudel JL et al. Does alcoholic
your hands? A survey of hospital handwashing facili- hand rubbing improve the compliance of health care
ties. J Hosp Infect 1998; 40: 291–293. workers to hand disinfection in MICU? 38th ICAAC
9. Comité technique des Infections nosocomiales 100 San Diego 24–27 September 1998.
Recommandations pour la surveillance et la 25. Bischoff WE, Reynolds TM, Sessler CN et al. Hand
Prévention des Infections Nosocomiales. Paris: washing compliance by health care workers: Impact
Ministère de l’emploi et de la solidarité 1999. of an education and patient awareness program and
10. Lejeune B, Blech MF, Girard R et al. Recommanda- the introduction of a new hand disinfectant. 38th
tions techniques pour le lavage et l’antisepsie des ICAAC San Diego 24–27 September 1998.Journal of Hospital Infection (2003) 55, 1–7
www.elsevierhealth.com/journals/jhin
REVIEW
Dermatological aspects of a successful introduction
and continuation of alcohol-based hand rubs for
hygienic hand disinfection
G. Kampfa,b,*, H. Löfflerc
a
Bode Chemie GmbH and Co., Scientific Affairs, Melanchthonstr. 27, 22525 Hamburg, Germany
b
Institut für Hygiene und Umweltmedizin, Ernst-Moritz-Arndt Universität Greifswald, Hainstr. 27, 17487
Greifswald, Germany
c
Department of Dermatology, Philipps University, Deutschhausstr. 9, 35033 Marburg, Germany
Received 24 March 2003; accepted 28 May 2003
KEYWORDS Summary With the new Centers for Disease Control and Prevention (CDC) guideline on
Alcohol-based hand rubs; hand hygiene, hospitals often introduce alcohol-based hand rubs for hand disinfection.
Occupational dermatitis; Healthcare workers, however, may reject the new products because of skin irritation
Irritant contact or other skin-related problems, which they experience after years of handwashing. In
dermatitis; Detergents; order to facilitate a successful introduction and continued use of alcohol-based hand
Handwash rubs in hospitals, we have reviewed and summarized the major studies on the topic.
Occupational hand dermatitis may occur in up to 30% of healthcare workers. It is
mainly described as an irritant contact dermatitis caused by detergents. The diagnosis
is usually clinical. Allergic reactions are very rare. After using an alcohol-based hand
rub for the first time, healthcare workers may have a burning skin sensation that can be
explained by pre-irritated skin. In this case the skin barrier has usually been impaired
by frequent handwashing or occlusive gloves. This may result in a vicious circle
whereby the healthcare worker increases the frequency of handwashing and reduces
the frequency of hand disinfection. Prevention of irritant contact dermatitis is possible
by selection of a low-irritating hand rub, which contains emollients, the correct use of
the hand rub and a clear guideline when to disinfect and wash hands in the clinical
setting. Common mistakes in the use of alcohol-based hand rubs are application to pre-
irritated skin and washing hands before hand disinfection, which is, in general, not
necessary, or after hand disinfection, which results in washing off the emollients.
Clear preparation and guidance of healthcare workers before the introduction of
alcohol-based hand rubs can help to enhance compliance in hand hygiene. The switch
from handwash to alcohol-based hand rub will improve healthcare workers skin if
mistakes are avoided and hand rinses are used correctly.
Q 2003 The Hospital Infection Society. Published by Elsevier Science Ltd. All rights
reserved.
*Corresponding author. Tel.: þ 49-40-54006-0; Fax: þ49-40-
54006-128.
E-mail address: guenter.kampf@bode-chemie.de
0195-6701/03/$ - see front matter Q 2003 The Hospital Infection Society. Published by Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0195-6701(03)00223-82 G. Kampf, H. Löffler
Table I Comparative maximum permissible levels of important impurities in ethanol and propanol according to the European
Pharmacopoeia
Type of impurity Ethanola n-Propanolb iso-Propanol
Methanol ,200 ppm ,0.1% No limit mentioned
Acetaldehyde and acetal ,10 ppm ,0.1% No limit mentioned
Benzene ,2 ppm ,0.1% ,2 ppm
Non-volatile compounds No limit mentioned ,0.004% ,20 ppm
Total number of impurities ,300 ppm ,0.3% No limit mentioned
a
For both ethanol (96%) and ethanol, anhydrous.
b
Data for n-propanol are obtained from a draft monograph in Pharmeuropa.
Background to alcohol-based hand rinses Ethanol and iso-propanol are for example listed
(ABHRs) in the European Pharmacopoeia,8 n-propanol has
been described in a draft.9 Impurities with a
Hand hygiene is currently undergoing a global possible negative impact on the skin are specifically
renaissance. For decades antiseptic or plain soaps limited (Table I).
have been considered to be the first choice for hand In some European countries ABHRs may be found
decontamination in many countries, e.g. the United as cosmetic products and do not need to comply
States and the United Kingdom.1 In many central with the European drug regulations however they
European countries, however, ABHRs have been must still comply with the Cosmetic Product
used at the same time.2 This is explained mainly by Directive.61
their faster antimicrobial activity,3 broader spec-
trum of antimicrobial activity3 and better skin
tolerance.4 Their use has now been endorsed by Frequency of occupational hand
the new Centers for Disease Control and Prevention dermatitis among healthcare workers
(CDC) guideline on hand hygiene, which clearly (HCWs)
favours ABHRs for hygienic hand disinfection.5 Many
hospitals and their infection control teams now face ABHRs are mainly used by HCWs. This occupation is
the challenge of introducing a new type of hand a classical risk factor for hand dermatitis.10 – 13 The
antiseptic. Experiences with the introduction of most extensive investigations concerning the epi-
ABHRs have been reported. In France, for example, demiology of hand dermatitis in the general
both compliance and skin condition improved after population were performed in Sweden. Meding
introduction of an ABHR.6 In a US hospital, however, et al.14,15 reported a one year prevalence between
compliance increased, but the overall satisfaction 9.7 and 11.8% (with a tendency to decrease in the
with the hand rub was modest.7 This review high- later years) and a point prevalence of 5.4%.15 In
lights the most important dermatological aspects HCWs, a far higher point prevalence of hand
that should be considered when introducing ABHRs dermatitis (17 – 30%10,16) can be found. This is
in a healthcare institution. supported by a retrospective study of Smit and
Coenraads,12 in which an overall incidence of 6.5
cases/1000 person-months in nurses and 1 case/
Quality of ABHRs 1000 person-months in office employees was esti-
mated. The consequences are serious because
Most ABHRs for hygienic hand disinfection or many employees lose their jobs due to hand
surgical hand disinfection in Europe are classed as dermatitis (occupational skin disease). In a popu-
medicinal products. They are therefore subject to lation-based register study of occupational skin
national or European drug laws. This has a major diseases in Northern Bavaria, Dickel et al.13
impact on the quality and documentation required observed an annual incidence rate of 7.3 cases per
for the hand rinse. Active ingredients must have a 10 000 healthcare workers.
quality that is compatible with the European
Pharmacopoeia.8 A minimum level of purity is
thereby guaranteed. The purity of raw materials Causes of occupational hand dermatitis
certainly has an impact on the local tolerance of a
hand rinse. In epidemiological studies it is very difficult toIntroduction and continuation of alcohol-based hand rubs 3
determine the cause of hand dermatitis, as contact the epidermis. Even in the epidermis there are
dermatitis is not a notifiable disorder. The most nerve receptors28 – 30 that are simulated by the
frequent cause of hand dermatitis in the general alcohol, resulting in a burning sensation, but not in
population seems to be irritant contact dermatitis further irritation.20 The cause of the problem of the
(ICD, 35%), followed by atopic dermatitis (22%) and burning senstation is therefore the pre-irritated
allergic contact dermatitis (19%).15 In HCWs the skin, leading to an impaired epidermal barrier and
pathogenesis of a contact dermatitis is also most not the negligible irritation caused by the alcohol
frequently an irritant dermatitis. Allergies are of itself.31 A burning sensation after alcohol appli-
secondary importance.13 Of the many topical cation may indicate that the skin barrier is seriously
preparations HCWs work with, disinfectants (like impaired.
ABHRs) and detergents are the most frequent
contact substances. The results of a questionnaire
showed frequent skin contact with disinfectants Pathogenesis of occupational hand
(76%) and detergents (72%) in the workplace.13 dermatitis
Mostly, relevant allergies in HCW are due to
sensitization against glove ingredients (Latex, In HCWs, the predominant mechanisms of skin
rubber chemicals, starch glove powder) and disin- irritation are repeated exposure to moisture, work
fectant ingredients (glutaraldehyde, formaldehyde with occlusive gloves and contact with aggressive
and glyoxal).17 – 19 With respect to these disinfec- surface disinfections.13,18 Even water on its own can
tant ingredients an increase of the sensitization be an irritant.32 These risk activities often lead to a
rate of HCWs compared with the general population subclinically impaired skin barrier, before the first
is noticeable: glutaraldehyde (9.9% versus 2.6%), clinical irritation (often in the interdigital spaces)
formaldehyde (3.6% versus 2.1%) and glyoxal (4.2% becomes apparent.33,34 Further aggravating factors
versus 1.4%). No allergies have been proven for the are an atopic disposition,35 – 38 genetic predisposi-
alcohol component of the hand disinfectants. tion39 and climatic conditions.40,41 The strongest
However, many nurses complain about burning influence on the manifestation of irritant skin
sensations after contact with ABHRs and assume changes is, by far, individual behaviour. When
an allergy to the product.20 In these cases, allergic mild irritations (like handwashing) affect the skin
patch tests usually show no sensitization. As stated frequently, the regenerating mechanism can no
above, an allergy to ABHRs can therefore be longer maintain a sufficient barrier.42 The skin
discounted. barrier gets more and more disrupted and further
However, the potential for irritation caused by irritation occurs more easily.
ABHR, has to be considered. In a detailed patch test In daily routine, HCWs are exposed to both
study, it was found that a 60% n-propanol solution handwashing and disinfection with ABHR. If the
did not induce any irritation on healthy skin.21 Even epidermal barrier becomes disrupted and alcohol
on pre-irritated skin, the damage to the skin causes a burning sensation during use, this is often
(evaluated by measurement of transepidermal interpreted by the user as ‘aggressiveness’ of the
water loss and skin surface capacitance) caused ABHRs. As a logical consequence, the user reduces
by a 60% n-propanol solution which is the concen- applications of ABHR and tries to compensate with
tration used in daily practice, was very low. For a increased handwashing. This leads, unfortunately,
100% n-propanol solution, the irritation was much to more barrier disruption, which is for a while
greater.21 It can be concluded that the alcohol part unnoticed, but will often lead to clinically relevant
(at least n-propanol) of ABHRs rarely provokes hand dermatitis. A vicious circle is initiated.
relevant irritation on intact skin and that for most
procedures of daily hand hygiene, ABHRs should be
preferred.22,23
Diagnosis and treatment of occupational
hand dermatitis
Clinical symptoms of occupational hand The diagnosis of ICD is predominantly clinical one.
dermatitis Diagnostic tests (like patch tests) are usually
performed to exclude allergic contact dermatitis.
The reason for the burning sensation on contact Because most subjects suspect that an allergy to
with ABHRs is a pre-irritated skin. If the skin ABHR is responsible for their hand dermatitis, an
barrier is disrupted, e.g. by frequent wet allergic patch test is often performed. As the true
work,24 – 27 alcohol may penetrate more easily into explanation is usually not the ABHR but rather the4 G. Kampf, H. Löffler
individual’s behaviour (e.g. frequent handwashing), as well as at regular intervals during working
these tests are usually negative. Irritant tests, like practice. Knowledge about irritation and irritants,
the epicutaneous patch test with sodium lauryl such as actual irritants in a given working environ-
sulphate, are helpful in evaluating an individual skin ment, and the advantages of ABHRs over handwash-
susceptibility, but the value of these tests should ing must be stressed. All possible individual means
not be overestimated, because the pathogenesis of of prevention such as protection by gloves, clothes,
ICD is based on the combination of individual barrier creams and correct skin cleaning should be
predisposition with external irritation.43 considered.51 Practical illustrations such as the
When skin changes are apparent and the diag- testing of cream applications with a fluorescence
nosis is clear, early treatment is essential. In HCWs, technique are very helpful.52,53
ICD appears mostly in the interdigital spaces and on The use of a moisturizer in supporting the
the dorsum of the hands. Rough and scaly skin is regeneration of the skin barrier is widely accepted
predominant with only minor inflammation. The even by affected individuals. It forms part of
main symptom (if any) is a burning sensation. This secondary prevention, because it is mostly intro-
stage of the disorder is best treated by avoidance of duced after the first skin changes are visible. This
the irritation and the application of lipid-rich approach is supported by most dermatologists, but
tropical agents. When the inflammation gets its efficacy is unconfirmed. Only a few studies with
worse, a short application of a corticosteroid- repeated irritation and subsequent application of a
containing external agent is often required.44,45 If moisturizer have been undertaken.54 Usually, a
the ICD is not treated adequately, allergens may slight improvement was noted at the treated areas,
penetrate the disrupted barrier into inflamed tissue but the effect was not dramatic. Further studies,
with numerous stimulated immunocompetent cells, especially under daily working conditions, are
causing a second problem: allergic contact derma- needed.
titis.46 At this stage, the skin often shows pro-
nounced erythema and vesicles, and the
predominant problem is itching. The best therapy Common mistakes in the use of ABHR
at this stage is immunosuppressive topical external
agents such as corticosteroids or tacrolimus. In the
chronic stages, ICD and allergic contact dermatitis Unhealthy/irritated skin
of the hands may have a similar clinical picture.
Damaged skin is not always visible and may well be
tolerated by the HCW if no alcohol is applied.
Especially in situations where ABHR are introduced
Prevention of occupational hand for the first time, it is crucial to make sure that the
dermatitis skin is healthy before the alcohol is applied.
Otherwise there might be a burning sensation,
There are several measures possible to prevent the erythema or fissures. The HCW might reject the
above course of events. The most effective is ABHR due to symptoms that are the result of pre-
primary prevention,47 which can be separated into existing skin disorders.
collective and individual measures. The develop-
ment of low-irritating disinfectants (like ABHR) is a
Handwash before hand disinfection
preventive measure and part of the creation of a
safe occupational environment. The correct use of
hand disinfections is important among the individ- In general there is no need to wash before hygienic
ual measures of prevention.48 In general, it is not hand disinfection. Washing the hands will result in
necessary that irritants (e.g. handwashing) are moist skin, which predisposes to toxic skin reac-
avoided completely. In most cases a reduction of tions. In addition washing removes the superficial
the duration of frequency of exposure is suffi- sebum layer of the skin and thereby enhances skin
cient.49 Wherever possible replacement of incor- irritation and dryness. For this reason ABHR should
rect, irritant behaviour (here handwashing) by less only be applied to dry hands.
irritant measures (like use of ABHR) is rec-
ommended. This change in behaviour must be Handwash after hand disinfection
taught, as must the correct use of gloves and
protective clothing. Regular teaching is one of the Hands should not be washed immediately after
most important measures in the prevention of hygienic hand disinfection. This will remove not
ICD.18,24,50 This should take place during induction, only the superficial sebum layer of the skin, but inIntroduction and continuation of alcohol-based hand rubs 5
Table II Aspects of correct hand hygiene with ABHR
Type of procedure Aspect of use Correct application
Hand disinfection Type of alcohol-based hand rub Hand rub with emollients,55 minimal risk of skin irritation and
minimal risk of skin sensitization
Procedure for hand rub Apply product to dry and clean skin. Rub the product into the
skin until the skin is dry (approx. 30 s). No handwashing
immediately after hand disinfection. Minimize number of
handwashes between disinfections
Handwashing Type of soap Mild, non-alkaline
Procedure for handwash Cold water. Minimize duration of handwashing. Do not use
brushes. Rinse off residual soap. No handwash immediately
before hand disinfection unless hands are visibly soiled
Skin care General aspects Use lotions or creams between hand hygiene procedures.
Older skin may require more intensive skin care
Gloves General aspects Hands should be dry before gloves are put on (after
handwashing or hand disinfection). Wear gloves only as long
as necessary
Hands should only be washed when they are visibly soiled.
addition the emollients that are included in many possible. Residual soap should be rinsed off com-
ABHR in order to improve the skin care after use. pletely. Brushes should not be used.
Skin care lotions and creams should be used
between hand hygiene procedures, especially at
Choice of ABHR
the end of a shift. Older skin may require more
intensive skin care. Hands should be dry before
The ABHR should be a formulation with emolli- gloves are put on. Gloves should be worn only as
ents.55 Lack of emollients may lead to dryness of long as necessary.
the skin and may impair compliance. Subjective
assessment of the emollient effect may reveal
considerable differences.56 The hand rub should
References
have only a minimal risk of skin irritation and
sensitization.57 – 59 Finally user acceptability may be 1. Pittet D, Boyce JM. Hand hygiene and patient care: pursuing
a key factor irrespective of other objective factors. the Semmelweis legacy. Lancet Infect Dis 2001;1:9—20.
User acceptability may be influenced by factors like 2. Rotter M, Skopec M. Entwicklung der Händehygiene und die
smell, skin feeling after application and speed of Bedeutung der Erkenntnisse von Ignaz Ph. Semmelweis. In:
Kampf G, editor. Hände-Hygiene im Gesundheitswesen,
drying.60 Gels should, in addition, be assessed for
Berlin: Springer; 2003. p. 1—27.
tackiness and build up.7,60 3. Rudolf M, Kampf G. Wirkstoffe. In: Kampf G, editor.
Händehygiene im Gesundheitswesen. Berlin: Springer;
2003. p. 71—104.
How to use ABHR correctly 4. Rotter ML. Arguments for the alcoholic hand disinfection.
J Hosp Infect 2001;48(Suppl. A):S4—S8.
The right way to use ABHRs is summarized in 5. Boyce JM, Pittet D. Guideline for hand hygiene in health-care
settings. Recommendations of the healthcare infection
Table II. As stated above, hand rubs should only
control practice advisory committee and the HICPAC/
be applied to dry and clean skin. A product should SHEA/APIC/IDSA hand hygiene task force. MMWR 2002;51:
be rubbed into the skin until the skin is dry. This will 1—45.
take approximately 30 s. Hands should not be 6. Girard R, Amazian K, Fabry J. Better compliance and better
washed immediately after the hand disinfection, tolerance in relation to well-conducted introduction to rub-
in hand disinfection. J Hosp Infect 2001;47:131—137.
because it will remove the superficial skin sebum 7. Harbarth S, Pittet D, Grady L, et al. Interventional study to
and the emollients of the hand rub. Between evaluate the impact of an alcohol-based hand gel in
applications of hand rubs, hands should be washed improving hand hygiene compliance. Pediatr Infect Dis J
only when they are visibly soiled. A mild, non- 2002;21:489—495.
alkaline soap should be used. Water for a handwash 8. Anonymous. Europäisches Arzneibuch. 4th ed. Bonn:
Bundesinstitut für Arzneimittel und Medizinprodukte; 2002.
should be cold. The duration of the handwash 9. Anonymous. n-Propanol. Pharmeuropa 2001;13:427—428.
should be as long as necessary to remove visible 10. Kavli G, Angell E, Moseng D. Hospital employees and skin
contamination but at the same time as short as problems. Contact Dermatitis 1987;17:156—158.6 G. Kampf, H. Löffler
11. Shmunes E. Occupational skin diseases and the occupational investigation of irritant patch test reactions: a study of
health nurse. Occupat Health Nursing 1983;31:16—17. patients with hand eczema, atopic dermatitis and controls.
12. Smit HA, Coenraads PJ. A retrospective cohort study on the Acta Derm Venereol 1992;173(Suppl.):1—26.
incidence of hand dermatitis in nurses. Int Arch Occup 36. Bäurle G, Hornstein OP, Diepgen TL. Professionelle Handek-
Environ Health 1993;64:541—544. zeme und Atopie. Dermatosen/Occup Environ 1985;33:
13. Dickel H, Kuss O, Schmidt A, Kretz J, Diepgen TL. Importance 161—165.
of irritant contact dermatitis in occupational skin disease. 37. Tupker RA, Coenraads PJ, Fidler V, De Jong MC, van der Meer
Am J Clin Dermatol 2002;3:283—289. JB, De Monchy JG. Irritant susceptibility and weal and flare
14. Meding B, Jarvholm B. Hand eczema in Swedish adults— reactions to bioactive agents in atopic dermatitis: II.
changes in prevalence between 1983 and 1996. J Invest Influence of season. Br J Dermatol 1995;133:365—370.
Dermatol 2002;118:719—723. 38. Tupker RA, Coenraads PJ, Fidler V, De Jong MC, van der Meer
15. Meding B, Swanbeck G. Epidemiology of different types of JB, De Monchy JG. Irritant susceptibility and weal and flare
hand eczema in an industrial city. Acta Derm Venereol 1990; reactions to bioactive agents in atopic dermatitis:
153(Suppl.):1—43. I. Influence of disease severity. Br J Dermatol 1995;133:
16. Smit HA, Burdorf A, Coenraads PJ. Prevalence of hand 358—364.
dermatitis in different occupations. Int J Epidemiol 1993;22: 39. Holst R, Möller H. One hundred twin pairs patch tested with
288—293. primary irritants. Br J Dermatol 1975;93:145—149.
17. Schunch A, Uter W, Geier J, Frosch PJ, Rustemeyer T. 40. Uter W, Gefeller O, Schwanitz HJ. An epidemiological study
Contact allergies in healthcare workers. Results from the of the influence of season (cold and dry air) on the
IVDK. Acta Derm Venereol 1998;78:358—363. occurrence of irritant skin changes of the hands. Br J
18. Stingeni L, Lapomarda V, Lisi P. Occupational hand derma- Dermatol 1998;138:266—272.
titis in hospital environments. Contact Dermatitis 1995;33: 41. Uter W, Geier J, Land M, Pfahlberg A, Gefeller O, Schnuch A.
172—176. Another look at seasonal variation in patch test results. A
19. Crippa M, Pasolini G. Allergic reactions due to glove- multifactorial analysis of surveillance data of the IVDK.
lubricant-powder in healthcare workers. Int Arch Occup Information Network of Departments of Dermatology.
Environ Health 1997;70:399—402. Contact Dermatitis 2001;44:146—152.
20. Lubbe J, Ruffieux C, Perrenoud D. A stinging cause for 42. Malten KE. Thoughts on irritant contact dermatitis. Br J
preventive skin care. Lancet 2000;356:768—769. Dermatol 1981;7:238—247.
21. Lubbe J, Ruffieux C, van Melle G, Perrenoud D. Irritancy of 43. Löffler H, Pirker C, Aramaki J, Frosch PJ, Happle R, Effendy I.
the skin disinfectant n-propanol. Contact Dermatitis 2001; Evaluation of skin susceptibility to irritancy by routine patch
45:226—231. testing with sodium lauryl sulfate. Eur J Dermatol 2001;11:
22. Widmer AF. Replace hand washing with use of a waterless 416—419.
alcohol hand rub? Clin Infect Dis 2000;31:136—143. 44. Lachapelle JM. Efficacy of protective creams and/or gels.
23. Pietsch H. Hand antiseptics: rubs versus scrubs, alcoholic Curr Probl Dermatol 1996;25:182—192.
solutions versus alcoholic gels. J Hosp Infect 2001;48(Suppl. 45. Loden M, Andersson AC. Effect of topically applied lipids on
A):S33—S36. surfactant-irritated skin. Br J Dermatol 1996;134:215—220.
24. Elsner P. Irritant dermatitis in the workplace. Dermatol Clin 46. Löffler H, Effendy I, Happle R. Irritant contact dermatitis.
1994;12:461—467. Hautarzt 2000;51:203—215.
25. Nilsson E, Bäck O. The importance of anamnestic infor- 47. Löffler H, Effendy I. Prevention of irritant contact dermati-
mation of atopy, metal dermatitis and earlier hand eczema tis. Eur J Dermatol 2002;12:4—9.
for the development of hand dermatitis in women in wet 48. Pittet D. Improving compliance with hand hygiene in
hospital work. Acta Derm Venereol 1986;66:45—50. hospitals. Infect Control Hosp Epidemiol 2000;21:381—386.
26. Meding B. Differences between the sexes with regard to 49. Lachapelle JM. Principles of prevention and protection in
work-related skin disease. Contact Dermatitis 2000;43: contact dermatitis (with special reference to occupational
65—71. dermatology). In: Rycroft RJG, Menné T, Frosch PJ,
27. Schwanitz HJ, Uter W. Interdigital dermatitis: sentinel skin Lepoittevin JP, editors. Textbook of contact dermatitis,
damage in hairdressers. Br J Dermatol 2000;142: 3rd ed. Berlin: Springer; 2001. p. 979—993.
1011—1012. 50. Wigger-Alberti W, Elsner P. Preventive measures in contact
28. Lauria G. Innervation of the human epidermis. A historical dermatitis. Clin Dermatol 1997;15:661—665.
review. Ital J Neurol Sci 1999;20:63—70. 51. Pittet D. Improving adherence to hand hygiene practice: a
29. Johansson O. The innervation of the human epidermis. multidisciplinary approach. Emerg Infect Dis 2001;7:
J Neurol Sci 1995;130:228. 234—240.
30. Guidry G, Landis SC, Davis BM, Albers KM. Overexpression of 52. Wigger-Alberti W, Maraffio B, Wernli M, Elsner P. Training
nerve growth factor in epidermis disrupts the distribution workers at risk for occupational contact dermatitis in the
and properties of sympathetic innervation in footpads. application of protective creams: efficacy of a fluorescence
J Comp Neurol 1998;393:231—243. technique. Dermatology 1997;195:129—133.
31. Boyce JM. Using alcohol for hand antisepsis: dispelling old 53. Wigger-Alberti W, Maraffio B, Wernli M, Elsner P. Self-
myths. Infect Control Hosp Epidemiol 2000;21:438—441. application of a protective cream. Pitfalls of occupational
32. Tsai TF, Maibach HI. How irritant is water? An overview. skin protection. Arch Dermatol 1997;133:861—864.
Contact Dermatitis 1999;41:311—314. 54. Halkier-Sörensen L, Thestrup Pedersen K. The efficacy of a
33. Uter W, Gefeller O, Schwantiz HJ. Frühe irritative Hautschä- moisturizer (Locobase) among cleaners and kitchen assist-
den bei Friseurlehrlingen. Hautarzt 1995;46:771—778. ants during everyday exposure to water and detergents.
34. Schwanitz HJ, Uter W. Interdigitalraumekzem. In: Schwanitz Contact Dermatitis 1993;29:226—271.
HJ, Uter W, Wulfhorst B, editors. Neue Wege zur Präven- 55. Rotter ML, Koller W, Neumann R. The influence of cosmetic
tion—Paradigma Friseurekzem. Osnabrück: Universitätsver- additives on the acceptability of alcohol-based hand disin-
lag Rasch; 1996. p. 151—158. fectants. J Hosp Infect 1991;18:57—63.
35. Agner T. Noninvasive measuring methods for the 56. Kramer A, Bernig T, Kampf G. Clinical double-blind trial onIntroduction and continuation of alcohol-based hand rubs 7
the dermal tolerance and user acceptability of six alcohol- 59. Kampf G, Muscatiello M, Häntschel D, Rudolf M. Dermal
based hand disinfectants for hygienic hand disinfection. tolerance and skin hydration properties of a new ethanol-
J Hosp Infect 2002;51:114—120. based hand gel. J Hosp Infect 2002;52:297—301.
57. Labadie J-C, Kampf G, Lejeune B, et al. Recommendation for 60. Kampf G, Rudolf M, Labadie J-C, Barrett S. Spectrum of
surgical hand disinfection—requirements, implementation antimicrobial activity and user acceptability of the hand
and need for research. A proposal by representatives of the disinfectant agent Sterillium Gel. J Hosp Infect 2002;52:
SFHH, DGHM and DGKH for a European discussion. J Hosp 141—147.
Infect 2002;51:312—315. 61. Council Directive 76/768 of 27 July 1976 on the approxi-
58. Kampf G, Bielfeldt S, Pfannenbecker U, Rudolf M. Dermal mation of the laws of the Member States relating to cosmetic
and mucosal tolerance of a new antiseptic liquid soap. Occup products; amended by six further directives.
Environ Dermatol 2001;49:198—201.Journal of Hospital Infection 81 (2012) 31e35
Available online at www.sciencedirect.com
Journal of Hospital Infection
journal homepage: www.elsevierhealth.com/journals/jhin
Dermal and pulmonary absorption of ethanol from
alcohol-based hand rub
D. Ahmed-Lecheheb a, b, *, L. Cunat a, c, P. Hartemann a, d, A. Hautemanière a, c, d
a
Department of Environment and Public Health, Faculty of Medicine, Nancy University, Nancy, France
b
INSERM U-954, Nutrition, Genetics and Environmental Risk Exposure, Faculty of Medicine, Nancy University, Nancy, France
c
RHEM 4369 Relation Environment Micro-Organisms, Faculty of Medicine, Nancy University, Nancy, France
d
Infection Prevention and Control, University Hospital of Nancy, Nancy, France
A R T I C L E I N F O S U M M A R Y
Article history: Background: Ethanol intoxication of healthcare workers (HCWs) using alcohol-based hand
Received 13 September 2011 rubs (ABHRs) in the workplace is a potentially serious issue. This study quantified the level
Accepted 7 February 2012 of ethanol absorption among HCWs after hygienic hand disinfection.
Available online 22 March 2012 Methods: Eighty-six HCWs from Nancy University Hospital were tested before and after
a 4-h shift. Participants used ABHR containing 70% ethanol. Levels of ethanol, acetalde-
Keywords: hyde and acetate in blood and urine were determined using gas chromatography. A
Ethanol breathalyzer was used to measure the level of ethanol in expired air.
Workstation Results: Ethanol [mean concentration 0.076 (standard deviation 0.05) mg/L] was detected
Toxicology in the expired air of 28 HCWs 1e2 min post exposure. Ethanol, acetaldehyde and acetate
Dermal absorption were undetectable in blood after a 4-h shift, and urine tests were negative in all
Pulmonary absorption participants.
Conclusion: Ethanol exposure from ABHR, particularly inhalation of vapours, resulted in
positive breathalyzer readings 1e2 min after exposure. Dermal absorption of ethanol was
not detected. Pulmonary absorption was detected but was below toxic levels.
Ó 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction hands are not visibly soiled.5 Most commercially available
ABHRs contain 60e95% alcohol in the form of ethanol, propan-
Alcohol-based hand rubs (ABHRs) are currently the first 1-ol, propan-2-ol or a combination of these.6,7
choice for hand hygiene in healthcare settings because they A small amount of alcohol is absorbed from ABHRs and can
have better antimicrobial activity than antiseptic soaps,1,2 are be detected in the blood.8,9 As ethanol intoxication of
effective, easy to use and improve compliance.3,4 Their use is healthcare workers (HCWs) at work is potentially serious,
recommended before and after patient contact, and for particularly for pregnant women and motorists, it is important
procedures such as intravenous cannulation, provided the to elucidate the effects of frequent use of ABHRs on blood
levels. Most countries have legal blood alcohol levels for
drivers of 0.0e0.8 mg/mL (a potentially fatal concentra-
tion).10 Estonia, Hungary, Latvia, the Czech Republic,
* Corresponding author. Address: Department of the Environment
and Public Health, Faculty of Medicine, Nancy University, 9 Avenue de
Romania and Slovakia have zero tolerance regarding blood
la Forêt de Haye, B.P. 184, 54505 Vandoeuvre-les-Nancy, France. alcohol levels in drivers. Also, alcohol consumption varies with
Tel.: þ33 3 83 68 34 80; fax: þ33 3 83 68 34 89. religion and culture.11 Muslim HCWs may be concerned about
E-mail address: djihane.lecheheb-ahmed@medecine.uhp-nancy.fr exposure to alcohol,12 producing a potential barrier to the use
(D. Ahmed-Lecheheb). of ABHRs.
0195-6701/$ e see front matter Ó 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2012.02.006You can also read
