t
INFECTION PREVENTION & CONTROL
based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Antiseptic soaps and detergents are the next most effective and non-antimicrobial soaps are the least effective”.1,2 This is a clear contradictory position to that of the WHO statement: “Alcohols are not good cleansing agents and their use is not recommended when hands are dirty or visibly contaminated with proteinaceous materials”.14
This apparent contradiction in
advice makes the important choice of which guidance to follow an even more complex decision for clinical teams when deciding the best method of hand hygiene for their areas of practice. It is also not now backed by the evidence, which heavily weighs in favour of hand washing over time.4
In fact, it is only
recently that any research has been published on the effects on skin bacterial counts of alcohol gels past 10 mins from application.4
There can be no doubt that there is the potential to transfer bacteria from patient to patient on the hands of clinical staff,17
and as
such cross contamination from the hands of clinical staff remains a potential danger to all patients in healthcare facilities. Yet another important factor in the WHO guidance is compliance, including the correct frequency of use (as per manufacturers’ instructions). These are thought to be probably as important as the choice of hand disinfectant.1
A highly efficacious product
used less frequently than recommended, or applied incorrectly is perhaps of less use than, a less efficacious product used more frequently and applied correctly.14 The question then remains: “What advice should healthcare institutions choose to follow, as their strategy for disinfecting hands?”
Efficacy testing vs outcome studies?
What evidence should we be looking for in order to adapt our practices, efficacy testing or patient outcome studies? There is a significant difference between the evidence provided by efficacy tests, which look at Colony Forming Units (CFUs), and outcome studies which are extremely difficult, costly and take up large amounts of the researcher’s time to do in large enough numbers of patients to be statistically relevant. In its guidance the WHO admits that not enough evidence has yet been gathered linking hospital HAI or SSI rates to either hand sanitation or surface bio burden,14 reasoning that in order to be statistically relevant, the number of people required in a sample large enough to prove a reduction in infection rates of just 1% from 2% to 1% is 2500 and from 7% to 5% is 3100.14 The immediate difficulty of controlling extraneous variables particular to HAIs in samples of this size is well known. If such studies of this size and nature were to be done, they should also include, surface and hand bacterial CFU counts as a way of reducing at least some of the variables.
JUNE 2018
3500 3250 3000 2750 2500 2250 2000 1750 1500 1250 1000 750 500 250 0
3500 3250 3000 2750 2500 2250 2000 1750 1500 1250 1000 750 500 250 0
Comparison over time Hand Wash V Alcohol Liquid V Alcohol Gel 3491
Average Bacterial CFU Counts per cm2
Wash only
70% Alcohol Gel Group 72% Alcohol Liquid Group
1582 1452 125412611241
606 362 222 246 243 Pre Wash Post wash 163
5 mins Post Treatment
1 hour Post Treatment
Graph 1 (above) demonstrates the adverse effects of alcohol gel over time, when used in isolation as per the US CDC guidance.
Comparison over time
Average Bacterial CFU Counts per cm2
Wash only
70% Alcohol Gel Group 72% Alcohol Liquid Group 5th Generation Si Quat
1582 1452 125412611241 1282 3491
606 362 222 246 243 Pre Wash Post wash 46 163 46
5 mins Post Treatment
15
1 hour Post Treatment
Graph 2 shows a comparison with between alcohol gel, alcohol liquid and a 5th generation SiQAC in isolation, after hand washing with soap and running water.
This type of study, may then provide the missing evidence of a link between HAIs, SSIs and the frequency of use and choice of hand sanitiser/ surface disinfectant. Published evidence, does not link total bacterial CFU counts, individual species, on hands, surfaces or in the air to either HAI or SSI rates.40,41,42,43,44,45,46,47 In the WHO guidance, there is a distinction between types of alcohol used (ethyl, Isopropyl etc). However, no distinction is made between types of alcohol liquid or gel hand rubs, in any publications from either the CDC1,2
or WHO.14 This is even
though the bacterial count results when using the two types of product have been shown to be significantly different.4 In fact, the WHO guide recommends the use of alcohol gels over alcohol liquid rubs, as they appear to have a less damaging effect to the skin over time and multiple applications.14
The efficacy testing over
extended time periods would not support this and difficult choices will have to be made.
Efficacy or usability?
It is a surprise that a literature search will find numerous studies into the efficacy of alcohol gels over periods of up to 10 mins,39,40,41,42,43,44
published study looking at the efficacy of alcohol gels for longer than 10 mins after application to the skin.4
yet there is still is only one Again, none of these
studies look into a direct linking with either HAI or SSI rates and surface or air contamination levels. Individually, the persistent bacterial kill of the 5th Generation SiQAC would appear to be the most effective, however in practical use, how can we be assured of low bacterial counts when moving from patient to patient? During the Swine Flu pandemic, SiQAC hand sanitisers with long term persistent kill of microorganisms were used in the NHS
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