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News story leads to hand hygiene question

Posted By Therese Long, Tuesday, March 01, 2011

One of our OSAP members just sent in this "ASK OSAP QUESTION":

The Fox News Network's program Doctors House Call made a statement that the continued use of alcohol sanitizers has led to intestinal infections caused by a retrovirus. Thus, the doctor was strongly advocating the use of soap and water only for hand hygiene. anything in the literature lately on this?

HERE IS OUR RESPONSE.  WHAT ARE OTHER MEMBERS HEARING OUT THERE?

There have always been some drawbacks with the use of alcohol hand sanitizers in comparison to traditional hand washing, mainly that sanitizers do not work on visible organic matter. This includes common disease-carrying substances such as feces. Therefore, sanitizers should not be relied on in situations where fecal contamination is likely. However, alcohol hand sanitizers have excellent germicidal properties and their use in healthcare settings will not be discontinued at this time.

The CDC is not currently recommending the discontinuation of alcohol hand sanitizers for healthcare facilities. However, no one hand hygiene product may be adequate to meet all of the needs of dental healthcare facilities. Each product (e.g. plain soap, microbial soap, alcohol hand gels) has advantages and disadvantages.

CDC Hand Hygiene Guidelines state that alcohol hand sanitizers are effective in decreasing the transmission of bacterial pathogens, however, alcohol is not effective against Clostridium Difficile.(1)

Alcohols have excellent in vitro germicidal activity against gram-positive and gram-negative vegetative bacteria, including multidrug-resistant pathogens (e.g., MRSA and VRE), Mycobacterium tuberculosis, and various fungi, (Certain enveloped (lipophilic) viruses (e.g., herpes simplex virus, human immunodeficiency virus [HIV], influenza virus, respiratory syncytial virus, and vaccinia virus) are susceptible to alcohols when tested in vitro. Hepatitis B virus is an enveloped virus that is somewhat less susceptible but is killed by 60%--70% alcohol; hepatitis C virus also is likely killed by this percentage of alcohol. In a porcine tissue carrier model used to study antiseptic activity, 70% ethanol and 70% isopropanol were found to reduce titers of an enveloped bacteriophage more effectively than an antimicrobial soap containing 4% chlorhexidine gluconate. Despite its effectiveness against these organisms, alcohols have very poor activity against bacterial spores, protozoan oocysts, and certain nonenveloped (nonlipophilic) viruses. (2)

CDC provides the following information regarding Clostridium difficile:

Clostridium difficile is a spore forming bacterium that may develop due to the prolonged use of antibiotics during healthcare treatment. Clostridium difficile infections cause diarrhea and more serious intestinal conditions such as colitis. CDC provides guidelines and tools to the healthcare community to help end clostridium difficile infections and resources to help the public understand these infections and take measures to safeguard their own health when possible. (3)

Clostridium difficile is a spore forming bacterium that may develop due to the prolonged use of antibiotics during healthcare treatment. Clostridium difficile infections cause diarrhea and more serious intestinal conditions such as colitis. CDC provides guidelines and tools to the healthcare community to help end clostridium difficile infections and resources to help the public understand these infections and take measures to safeguard their own health when possible. (3)

Clostridium difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. (4)

is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. (4)

*Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of C. difficile spores is more challenging than the removal or inactivation of other common pathogens. (4)

*Preventing contamination of the hands via glove use remains the cornerstone for preventing Clostridium difficile transmission via the hands of healthcare workers; any theoretical benefit from instituting soap and water must be balanced against the potential for decreased compliance resulting from a more complex hand hygiene message (4)

CDC Guidelines for Infection Control in Dental Healthcare Settings still recommend the use of alcohol hand sanitizers using the following criteria:

The preferred method for hand hygiene depends on the type of procedure, the degree of contamination, and the desired persistence of antimicrobial action on the skin (Table 2). For routine dental examinations and non-surgical procedures, handwashing and hand antisepsis is achieved by using either a plain or antimicrobial soap and water. If the hands are not visibly soiled, an alcohol-based hand rub is adequate. (5)

The purpose of surgical hand antisepsis is to eliminate transient flora and reduce resident flora for the duration of a procedure to prevent introduction of organisms in the operative wound, if gloves become punctured or torn. Skin bacteria can rapidly multiply under surgical gloves if hands are washed with soap that is not antimicrobial. Thus, an antimicrobial soap or alcohol hand rub with persistent activity should be used before surgical procedures (5).

Alcohol hand rubs are rapidly germicidal when applied to the skin but should include such antiseptics as chlorhexidine, quaternary ammonium compounds, octenidine, or triclosan to achieve persistent activity. Factors that can influence the effectiveness of the surgical hand antisepsis in addition to the choice of antiseptic agent include duration and technique of scrubbing, as well as condition of the hands, and techniques used for drying and gloving. CDC's 2002 guideline on hand hygiene in health-care settings provides more complete information. (5)

Selecting the most appropriate antiseptic agent for hand hygiene requires consideration of multiple factors. Essential performance characteristics of a product (e.g., the spectrum and persistence of activity and whether or not the agent is fast-acting) should be determined before selecting a product. Delivery system, cost per use, reliable vendor support and supply are also considerations. (5)

Resources:

1. CDC Hand Hygiene Guidelines (2002):

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm

2. CDC Hand Hygiene Guidelines (2002): http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

3. CDC Information: http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html

4. CDC FAQ's: http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html

5. CDC Guidelines for Infection Control in Dental Healthcare Settings:

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

For the most current information on infection control issues, please join us in Plano, Texas, June 9-12, 2011, for the OSAP Annual Infection Prevention and Safety Symposium. This information is also available on the OSAP website.

Thank you for your interest in OSAP!

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Comments on this post...

Henry Botuck says...
Posted Saturday, September 10, 2011
Sorry that my comment is 6 months after the question. The response seems inadequate. The questioner wanted to know if repeated use of the alcohol disinfectant indeed caused intestinal infection by retrovirus, and was there any literature about this. The question was not: Do alcohol sanitizers work?
Also, where are alcohol sanitizers that have persistent activity? I haven't been able to find any.
Permalink to this Comment }

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