The Impact of Alcohol Hand Sanitizer Use on Infection Rates in an Extended Care Facility

The impact of alcohol hand sanitizer use on infection rates in an extended care facility

E.J. Fendler, PhDa Y. Ali, PhDa B.S. Hammonda M.K. Lyons, BSN, RNb M.B. Kelley, CRRNb N.A. Vowell, RNb Akron and Columbus, Ohio

Background: Nosocomial infections are a major problem in health care facilities, resulting in extended durations of care and substantial morbidity. Since alcohol gel hand sanitizers combine high immediate antimicrobial efficacy with ease of use, this study was carried out to determine the effect of the use of alcohol gel hand sanitizer by caregivers on infection types and rates in an extended care facility.

Method: Infection rate and type data were collected in a 275-bed extended care facility for 34 months (July 1997 to May 2000), during which an alcohol gel hand sanitizer was used by the caregivers in 2 units of the facility.

Results: The primary infection types found were urinary tract with Foley catheter, respiratory tract, and wound infections. Comparison of the infection types and rates for the units where hand sanitizer was used with those for the control units where the hand sanitizer was not used showed a 30.4% decrease in infection rates for the 34-month period in the units where hand sanitizer was used.

Conclusion: This study indicates that use of an alcohol gel hand sanitizer can decrease infection rates and provide an additional tool for an effective infection control program. (Am J Infect Control 2002;30:226-33.)

Nosocomial infections are a major problem in health settings, attempts to control infections have care facilities, involving at least 2 million patients demanded increasing attention. Since good hand annually and resulting in extended durations of care hygiene is acknowledged as a simple but powerful and substantial morbidity.1 Such infections are esti- technique for preventing nosocomial infections, one mated to cause or contribute to 88,000 deaths annu- focus of these infection control measures is hand ally in the United States and contribute to greater hygiene practices. costs of hospitalization and overall costs of care.1 The incidence of infections in acute-care facilities is Handwashing is still considered the most important approximately 9.8 infections per 1000 patient care- and effective infection control measure to prevent days and is approximately 7.2 infections per 1000 transmission of nosocomial infections.4 However, resident care-days in long-term care facilities.2,3 compliance with handwashing procedures by health Because infections are a major cause of morbidity care workers has been, and continues to be, unac- and mortality in acute, extended, and long-term care ceptably low at 20% to 50%.2,5-8 Recent studies have shown that deterrents to handwashing compliance From GOJO Industries, Inc.,a Akron, and Regency Manor,b Columbus. include the amount of time required for soap-and- Reprint requests: Yusuf Ali, PhD, GOJO Industries, Inc., 1 GOJO Plaza, water handwashing with heavy workloads, skin irri- Akron, OH 44311. tation and dryness caused by frequent handwashing Copyright © 2002 by the Association for Professionals in Infection with soap and water, and poor access to sinks.2,9-13 Control and Epidemiology, Inc. 0196-6553/2002/$35.00 + 0 17/46/120129 Use of waterless, alcohol-based hand sanitizers (gels) doi:10.1067/mic.2002.120129 and rubs (rinses) instead of soap-and-water hand-

226 Fendler et al June 2002 227 washing has been demonstrated to overcome these rehabilitation. Patient length of stay ranges from 20 barriers to compliance.11-16 Alcohols, in the form of days to permanent placement. both rinses and gels, are one of the most effective agents for reducing the number of viable pathogens Study design on the hands,17-20 including under artificial finger- This study was performed with use of the entire facil- nails.21 Hand disinfection with a well-formulated ity. An alcohol gel hand sanitizer was made available alcohol gel hand sanitizer containing emollients for use by the caregivers on the second and third causes less skin irritation and dryness of the hands floors of the facility. The remainder of the units in the of nurses than does handwashing.12 Introduction of facility served as the control group. easily accessible dispensers with an alcohol-based, waterless handwashing antiseptic also has been The patients in both groups had the same age and demonstrated to lead to significantly higher hand sex distribution and were from the same geographic hygiene rates among health care workers.8 Improving area. However, those in the hand sanitizer group on health care workers’ compliance with recommended the second and third floors of the facility differed hand hygiene measures can reduce transmission of from those in the rest of the facility in their level of nosocomial pathogens16,22 and result in decreased acuity. The patients on the second and third floors infection rates.22 Since alcohol gel hand sanitizers generally have subacute medical conditions and and hand rubs provide high immediate antimicrobial require extensive-assisted to dependent levels of care. efficacy and overcome the obstacles to handwashing Those in the rest of the facility are primarily long- compliance, a study of the effects of alcohol gel hand term care patients with chronic medical conditions sanitizer on infection rates in an extended care facil- and require extensive-assisted to supervisory levels of ity was performed. care. The second and third floors have a lower patient-to-staff ratio and have a higher turnover rate. METHODS Purell Instant Hand Sanitizer (GOJO Industries, Inc, Facilities description Akron, Ohio) was used throughout the study. The in This study was carried out at Regency Manor, vitro antibacterial and antifungal efficacy of the sani- Columbus, Ohio, which is a 275-bed extended care tizer was determined by BioScience Laboratories, Inc. facility specializing in rehabilitation and subacute (Bozeman, Mont) with 15-second timed exposure kill care and has 265 employees. This postacute health tests. ViroMED Laboratories, Inc. (Minneapolis, Minn) care facility provides subacute and transitional care, similarly evaluated the product for antiviral efficacy long-term nursing care, Alzheimer’s and dementia with 30-second exposure kill evaluations for viruses. care, mental illness care, outpatient services, and The 15- and 30-second exposure kill studies were per- dialysis treatment. formed with selected challenge bacteria, fungi, and viruses. The challenge inoculum was introduced to The facility occupies a 3-story main building with 1- the test product at time zero; a portion of the sample story wings. The facility has 6 separate units con- was removed and placed in neutralizing media at the taining 16 double-occupancy rooms, each with a appropriate time (15 or 30 seconds). Standard plate bathroom. The first floor of the main building hous- counting techniques were used to enumerate viable es the offices, cafeteria, activity center, rehabilitation challenge micro-organisms. area, dialysis unit, and units A and B. Units A and B each contain 16 rooms with attached baths. The BioScience Laboratories also performed in vivo testing employee-to-patient ratio ranges from 1 to 4 to 1 to of the product for its effectiveness on the hands with 5. The second floor is an all-female unit with 37 beds the Healthcare Personnel Handwash protocol, a modifi- and 7 bathrooms. The third floor is an all-male unit cation of the American Society for Testing and with 46 beds and 7 bathrooms. The employee-to- Materials’ Standard Method E1174-94.23 Serratia patient ratio is 1 to 8 on the second floor and 1 to 9 marcescens (ATCC 14756) was used as the marker on the third floor. organism with 25 subjects. Evaluations were made of both the immediate and persistent antimicrobial effects Patient types include those with cerebral vascular of the product on the hands during 10 consecutive accidents, mental illness and mental retardation, microbial contamination/product application cycles Alzheimer’s and dementia, fractures, diabetes melli- with a glove-juice sampling procedure.23 The irritation tus, chronic obstructive pulmonary disease, and potential of the product was measured during 15 addi- renal failure (dialysis) and those needing cardiac tional product cycles with standard visual scoring.24 228 Vol. 30 No. 4 Fendler et al

The skin compatibility of the product was deter- lance for nosocomial infections throughout the facil- mined with a 21-Day Cumulative Irritancy Assay ity. Nosocomial infections were diagnosed and clas- with Delayed Challenge25 (Dermatological Research sified according to the McGeer et al26 definitions for Laboratory, San Francisco, Calif) and a Human long-term care facilities because the Centers for Repeated Insult Patch Test24 with normal and 10x Disease Control and Prevention criteria27 do not fragrance levels (Clinical Research Laboratories, always apply to institutionalized geriatric patients. Piscataway, New Jersey). For definitions not included by McGeer et al,26 the standard definitions of the Centers for Disease For the experimental units (second and third floors), Control and Prevention27 were used. Nosocomial the alcohol gel hand sanitizer was provided in dis- infections were identified by clinical findings and pensers located on the medication and treatment confirmed by laboratory data. After diagnosis, spec- carts, at the nurses’ stations, and in the dining rooms imens for laboratory analysis were collected by the of the units. Individual bottles also were provided for nursing staff, and the course of treatment was use by the nursing staff. The nursing staff was determined by the staff physician. Specimens were instructed to use the hand sanitizer instead of hand- analyzed by an independent laboratory, and the washing between residents, between procedures, results were returned to the infection control nurse. and before medication administration, unless their All nosocomial infections, including the microbiolog- hands were physically soiled. The staff also were ic data, were fully documented on standard forms. instructed to wash their hands with Micrell All of the infection-rate data for each unit in the facil- Antimicrobial Lotion Soap (GOJO Industries) after ity were collected and compiled on standard forms every 5 uses of hand sanitizer. On the control units, and reported monthly. only handwashing with the same antimicrobial lotion soap was used for hand hygiene. DATA ANALYSIS Infection data were collected for 34 months starting The rate of nosocomial infection was defined as the in January 1997 for each unit in the facility. The study number of infections per 1000 patient-days. The was concluded on April 30, 2000. The hand sanitizer data were analyzed with standard statistical tech- was used on the second and third floors of the facili- niques. The infection rate for the hand sanitizer and ty, and the remainder of the facility units served as control groups were each calculated with the follow- the control group (July 1997 through April 2000). ing equation: Although the level of acuity, medical conditions, and No. of infections occurring during the month x 1000 = patient-to-staff ratios differed, the residents housed in No. of resident days in the month the control units were similar to the residents on the second and third floors with respect to their risk for Infection rate per 1000 patient-days per floor per month acquiring nosocomial infections. Both groups com- prised long-term care patients, ranging from super- The rates of the 6 units in the control group were vised to totally dependent, and included approxi- then averaged to give an average infection rate per mately the same proportion of dialysis, subacute 1000 patient-days per month for the entire control rehabilitation, and mental illness/Alzheimer’s disease population. The rates of the 2 hand sanitizer units patients as well as approximately the same propor- were then averaged to give an average infection rate tion of patients with indwelling Foley catheters. The 2 per 1000 patient-days per month for the entire hand groups intermingled and used the entire facility, sanitizer population. Table 1 shows the average including common areas, cafeteria, lounge areas, infection rates for the 2 groups on a monthly basis. patios, and social rooms. Both groups were exposed The number of patient- (resident-)days per month to the same environmental conditions, to 10% of the was determined by multiplying the average number staff that “floated” throughout the facility, and to the of patient-days by the number of days in that partic- same therapists. ular month. Once the average rate of infection per 1000 patient-days per month was calculated for each DATA COLLECTION group, analysis of variance (1-way ANOVA) was used to calculate the statistical significance between the 6 For the purposes of this study, an infection was control units and the 2 test units. ANOVA allows the defined as nosocomial if it developed more than 72 testing of the differences between the average infec- hours after the patient was admitted to the facility. tion rate of the control units and the average infec- The staff infection control nurse performed surveil- tion rate of the hand sanitizer units. ANOVA does this Fendler et al June 2002 229

Ta b le 1. Infection rates for hand sanitizer and control groups by month

Control units Hand sanitizer units

Infection rate Infection rate (per 1000 (per 1000 Month of study Patient-days patient-days) Patient-days patient-days)

April 2000 4770 3.06 2311 2.50 March 2000 4898 3.29 2480 2.55 February 2000 4524 2.86 2262 1.37 January 2000 5022 2.54 2325 3.00 December 1999 5022 2.64 2356 0.81 November 1999 5032 2.02 2433 3.74 October 1999 4805 2.47 2418 1.34 September 1999 4508 3.33 2400 0.00 August 1999 4836 1.86 2325 2.62 July 1999 4861 4.12 2325 0.46 June 1999 4830 3.81 2280 2.65 May 1999 4928 2.75 2418 0.38 April 1999 4890 3.53 2220 3.92 March 1999 4991 2.76 2356 0.86 February 1999 4388 3.44 2240 3.12 January 1999 5146 2.39 2480 2.44 December 1998 5115 3.22 2387 1.31 November 1998 5100 2.24 2280 2.47 October 1998 5580 2.84 2449 3.22 September 1998 5400 4.81 2430 3.06 August 1998 5363 4.47 2542 4.25 July 1998 5270 4.59 2449 0.90 June 1998 5190 3.15 2250 3.10 May 1998 5146 2.55 2418 3.34 April 1998 4890 3.35 2400 1.23 March 1998 5177 5.62 2356 0.90 February 1998 4984 4.00 2184 1.35 January 1998 5611 3.61 2511 2.69 December 1997 5394 6.14 2511 2.18 November 1997 5520 2.20 2490 3.70 October 1997 5549 1.66 2573 2.80 September 1997 5400 4.53 2310 3.97 August 1997 5301 3.51 2449 2.84 July 1997 5456 2.41 2418 2.78

by examining the ratio of variability between 2 RESULTS groups and the variability within each group. Antimicrobial efficacy of alcohol hand Analysis was conducted on a year-by-year basis and for overall performance for 40 months. Statistical sig- sanitizer nificance for the analysis was P ≤ .05. The in vitro antibacterial efficacy data for the alcohol hand sanitizer determined with use of 15-second The infection rates were analyzed further to deter- timed exposure kill tests and the antiviral efficacy mine the percent reduction in the infection rates in determined with use of 30-second exposure kill eval- the hand sanitizer units compared with those of the uations are listed in Table 2. It is apparent that the control units. The following equation was used: alcohol hand sanitizer is highly effective against a broad spectrum of bacteria, including antibiotic- Average rate of infection (control) - resistant species such as methicillin-resistant Average rate of infection (hand sanitizer) Staphylococcus aureus (MRSA) and vancomycin-resis- Average rate of infection (control) tant Enterococcus faecalis (VRE). In addition, it is also x 100 = % Reduction highly effective against fungi and some viruses. 230 Vol. 30 No. 4 Fendler et al

Ta b le 2. In vitro antimicrobial efficacy of Ta b le 3. In vivo efficacy of the alcohol gel hand sanitizer alcohol gel hand sanitizer Wash Wash Wash Wash Reduction No. 1 No. 3 No. 7 No. 10

ATCC No. Percent Log Mean log10 reduction 3.93 3.79 2.96 2.15 10 Mean percent reduction 99.99 99.98 99.89 99.29 Challenge bacteria Bacillus megaterium 14581 >99.998 >4.68 Clostridium difficile 9689 >99.998 >4.75 Corynebacterium diphtheriae 11913 >99.999 >5.00 Enterococcus faecalis* 51575 >99.999 >5.00 of both the immediate and persistent antimicrobial Enterococcus faecium* 51559 >99.999 >5.00 effects of the product on the hands during 10 con- Lactobacillus plantarum 14917 >99.999 >5.00 secutive microbial contamination/product applica- Listeria monocytogenes 15313 >99.999 >5.00 tion cycles show high efficacy (see Table 3). The irri- Staphylococcus aureus† 33591 >99.999 >5.00 Staphylococcus aureus‡CI>99.999 >5.00 tation potential of the product measured during 15 Staphylococcus epidermidis 12228 >99.999 >5.00 additional product cycles with standard visual scor- Streptococcus pneumoniae 33400 >99.994 >4.20 ing showed no skin irritation. Streptococcus pyogenes 19615 >99.999 >5.00 Acinetobacter baumannii 19606 >99.999 >5.00 Skin compatibility of alcohol hand sanitizer Pseudomonas aeruginosa 15442 >99.999 >5.00 Citrobacter freundii 8090 >99.999 >5.00 The results of skin compatibility determinations of Enterobacter aerogenes 13048 >99.999 >5.00 the alcohol hand sanitizer with use of a 21-day Escherichia coli 11229 >99.999 >5.00 Cumulative Irritancy Assay with Delayed Challenge Escherichia coli (O157;H7) 35150 >99.999 >5.00 and a Human Repeated Insult Patch Test gave aver- Klebsiella ozaenae 11296 >99.999 >5.00 age irritancy scores of 0.06 and 0, respectively, on a Klebsiella pneumoniae 13883 >99.999 >5.00 Proteus mirabilis 7002 >99.999 >5.00 scale of 0 to 4. No potential for allergic sensitization Proteus vulgaris 13315 >99.999 >5.00 was found in either test. Salmonella enteritidis 13076 >99.999 >5.00 Salmonella typhimurium 14028 >99.999 >5.00 Infection rates Serratia marcescens 14756 >99.999 >5.00 The rates of infection for the hand sanitizer and con- Shigella dysenteriae 13313 >99.999 >5.00 Shigella sonnei 11060 >99.999 >5.00 trol groups are given in Table 4 for each year of the Challenge fungi study. The use of hand sanitizer significantly reduced Aspergillus flavus 9643 >99.999 >5.00 the infection rate for 1998 and 1999 by 37% and Aspergillus niger 9642 >99.998 >4.72 39%, respectively, and reduced the rates for 1997 and Candida albicans 14053 >99.999 >5.00 January to May 2000 by 18% and 20%, respectively. Candida tropicalis 13803 >99.999 >5.00 Epidermophyton floccosum 52063 >99.988 >3.92 Penicillium citrinum 9849 >99.999 >5.00 The overall effect of hand sanitizer use on infection Trichophyton mentagrophytes 9533 >99.999 >5.00 rates for the 34-month study period is given in Table Challenge virus 5. A significant overall reduction (30%) in infection Adenovirus type 2 VR-846 95.195 1.32 rates for the hand sanitizer units as compared with Coxsackievirus B3 VR-30 99.822 2.75 Hepatitis A virus VR-1073§ 94.377 1.75 the control units was found. The infection rates were Herpes simplex virus type 1 VR-733 ≥99.999 ≥5.00 analyzed from data collected on a monthly report. HIV type 1 HTLV-IIIB ≥99.993 ≥4.14 The monthly infection rates are shown in Table 1. Influenza virus type A2 VR-544 ≥99.999 ≥5.25 Parainfluenza virus type 2 VR-92 ≥99.996 ≥4.39 The infection rates ranged from 3.05 to 4.00 Parainfluenza virus type 3 VR-93 ≥99.993 ≥4.14 Rhinovirus type 14 VR-284 99.438 2.25 throughout the facility during the 6 months before Rhinovirus type 16 VR-1126 ≥99.994 ≥4.25 the start of the study. Rhinovirus type 37 VR-1147 99.822 2.75 Infection types *Vancomycin-resistant strain. †Methicillin-resistant strain. Although patients colonized with nosocomial VRE ‡Vancomycin-tolerant–methicillin-resistant strain. and MRSA were admitted from hospitals, nosocomi- §Variant 18F. al infections at this facility were extremely rare. The most common species identified included In vivo data for the efficacy of the product on the Escherichia coli, Staphylococcus aureus, MRSA, and hands with use of the Healthcare Personnel Proteus mirabilis. The effects of alcohol gel hand san- Handwash protocol are given in Table 3. Evaluations itizer use on the highest frequency infection types, Fendler et al June 2002 231

Ta b le 4. Effects of alcohol gel hand sanitizer use on infection rates by year

% Reduction in Average rate infection rates of infection compared with Location Total patient-days Total infections per 1000 control

Statistical analysis for 2000 (January through April) Hand sanitizer units 9378 22 2.35 19.9 % Control units 19,214 54 2.94 — Statistical analysis for 1999* Hand sanitizer units 28,251 51 1.80 38.5 % Control units 58,237 165 2.93 — Statistical analysis for 1998* Hand sanitizer units 28,656 67 2.32 37.4 % Control units 62,826 223 3.70 — Statistical analysis for 1997 Hand sanitizer units 14,751 44 2.98 11.6 % Control units 32,620 110 3.37 —

*The difference is statistically significant (P < .05).

Ta b le 5. Overall statistical analysis of effect of alcohol gel hand sanitizer use on overall infection rates

% Reduction in Average rate infection rates of infection compared with Location Total patient-days Total infections per 1000 control

Hand sanitizer units 81,036 184 2.27 30.4 % Control units 172,897 552 3.19

The difference is statistically significant (P < .05).

Ta b le 6. Effect of alcohol gel hand sanitizer on individual infection types

% Reduction in Average rate infection rates of infection compared with Location Total patient-days Total infections per 1000 control

Overall statistical analysis for urinary tract infections (Foley catheter infections) Hand sanitizer units 81,036 51 0.63 18.2 % Control units 172,897 133 0.77 Overall statistical analysis for respiratory tract infections Hand sanitizer units 81,036 87 1.07 21.9 % Control units 172,897 237 1.37

urinary tract infections with Foley catheters and res- handwashing procedures by health care workers has piratory tract infections, are given in Table 6. been, and continues to be, unacceptably low.2,5-8,12 Because of the importance of hand hygiene, several DISCUSSION studies have addressed the issue of noncompliance with hand hygiene guidelines.2,8-10,12,13,16,28-30 The Hand hygiene is considered to be the most important use of waterless alcohol-based hand sanitizers and and effective infection control measure to prevent rubs instead of soap-and-water handwashing has transmission of nosocomial pathogens in health care been demonstrated to overcome these barriers to settings. The results of hospital-based studies, pub- compliance,11-16 to lead to significantly higher hand lished between 1977 and 1995, on the impact of hand hygiene rates among health care workers,8 and to hygiene on the risk of nosocomial infection have been decrease absenteeism due to illness among elemen- reviewed by Larson.22 However, compliance with tary schoolchildren.31 The use of alcohol-based hand 232 Vol. 30 No. 4 Fendler et al

sanitizers and rubs has recently been reviewed by on Nosocomial and Healthcare-associated Infections; March 5-9, 2000; Pittet and Boyce32 and was found to be the most prac- Atlanta (GA). 2. Pittet D, Mourounga P, Perneger TV. Compliance with handwashing in a tical means of improving hand hygiene compliance. teaching hospital. Ann Intern Med 1999;130:126-30. 3. Jackson NM, Fierer J, Connor-Barrett E, Fraser D, Klauber MR, Hatch R, et al. Several studies have indicated a temporal relation Intensive surveillance for infections in the three year study of nursing home between improved soap-and-water handwashing patients. Am J Epidemiol 1992;135:685-96. practices and infection rates,22 and a recent study 4. Jarvis WR. Handwashing—the Semmelweis lesson forgotten? Lancet demonstrated that sustained improvement in hand 1994;344:1311-2. 5. Meengs MR, Giles BK, Chisholm CD. Handwashing frequency in an emer- hygiene compliance with an alcohol hand rub was gency department. J Emerg Nurs 1994;20:183-8. 16 associated with decreased infection rates. However, 6. Doebbeling BN, Stanley GL, Sheetz CI. Comparative efficacy of alternative no clinical studies have been carried out on the effect hand-washing agents in reducing nosocomial infections in intensive care of the use of an alcohol gel hand sanitizer for hand units. N Engl J Med 1992;327:88-93. hygiene on infection rates in a health care facility. 7. Goldmann D, Larson E. Hand-washing and nosocomial infections. N Engl J Med 1992;327:120-2. This 34-month investigation demonstrates the effect 8. Bischoff WE, Reynolds TM,Sessler CN, Edmond MB,Wenzel RP.Handwashing of alcohol gel hand sanitizer use on the infection rates compliance by health care workers.The impact of introducing an accessible, and types in an extended care facility. Comparison of alcohol-based hand antiseptic. Arch Intern Med 2000;160:1017-21. the infection types and rates for the units where the 9. Larson E, Killien M. Factors influencing handwashing behavior in patient care hand sanitizer was used with those for the control personnel. Am J Infect Control 1982;10:93-9. units where the hand sanitizer was not used showed 10. Zimakoff J, Kjelsbert AB, Larsen SO.A multicenter questionnaire investigation of attitudes toward hand hygiene, assessed by the staff in fifteen hospitals in an overall decrease of 30.4% in infection rates for the Denmark and Norway. Am J Infect Control 1992;20:58-64. 34-month period in the units where the hand sanitiz- 11. Voss A,Widmer AF. No time for handwashing? Handwashing versus alcoholic er was used. Comparison of the data for each year rub: can we afford 100% compliance? Infect Control Hosp Epidemiol shows that the percent reduction ranges from 11.6% 1997;18:205-8. for 1997 to 38.5% for 1999. Since the differences 12. Boyce JM, Kellilher S,Vallande N. Skin irritation and dryness associated with two hand hygiene regimens: soap and water hardwashing versus hand anti- between years reflect changes in the average rate of sepsis with an alcoholic hand gel. Infect Control Hosp Epidemiol infection per 1000 patient-days for both the hand 2000;21:442-8. sanitizer units and the control units depending on the 13. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control years compared, these differences probably reflect a Hosp Epidemiol 2000;21:381-6. variation in infection rate due to factors other than 14. Ojajärvi J. Handwashing in Finland. J Hosp Infect 1991;18(supplement B):35-40. hand sanitizer use. Decreases were also found in both 15. Zaragoza M, Saliés M, Gomez J, Bayas JM,Trilla A. Handwashing with soap or alcoholic solutions? A randomized clinical trial of its effectiveness. Am J Infect urinary tract (UTI) and respiratory tract infections. Control 1999;27:258-61. 16. Pittet D, Hugonnet S, Harbarth P, Mourouga P, Sauvan V,Touveneau S, et al. The continued emergence and control difficulties with Effectiveness of a hospital-wide programme to improve compliance with multidrug resistant pathogens, such as MSRA, VRE, hand hygiene. Lancet 2000;356:1307-12. and extended spectrum -lactamase-producing gram- 17. Rotter ML. Hand washing and hand disinfection. In: Mayhall CG, editor. Hospital epidemiology and infection control. Baltimore: Williams & Wilkins; negative bacilli, are major problems in acute and long- 1996. p. 1052-68. term care facilities alike. Alcohol rubs and alcohol gel 18. Rotter ML. Alcohols for antisepsis of hands and skin. In: Ascenzi JM, editor. hand sanitizers have the highest antimicrobial efficacy Handbook of disinfectants and antiseptics. New York: Marcel Dekker; 1996. and speed of kill against these resistant pathogens. p. 177-233. Consequently, use of these products as part of an 19. Ali Y,Dolan MJ, Fendler EJ, Larson EL.Alcohols. In: Block SS, editor. Sanitization, disinfection and sterilization. Philadelphia: Lippincott Williams and Wilkins; infection control program can have a significant effect 2001. p. 229-53. on both health outcomes and health care costs. 20. Guilhermetti M, Hernandes SED, Fukushigue Y, Garcia LB, Cardoso CL. Effectiveness of hand-cleansing agents for removing methicillin-resistant CONCLUSION Staphylococcus aureus from contaminated hands. Infect Control Hosp Epidemiol 2001;22:105-8. The use of an alcohol gel hand sanitizer by caregivers in 21. McNeil SA, Foster CL, Hedderwick SA, Kaufman CA. Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of arti- an extended care facility significantly reduced the infec- ficial fingernails worn by health care workers. Clin Infect Dis 2001;32:367-72. tion rates during a 34-month period. This study indi- 22. Larson E. Skin hygiene and infection prevention: more of the same or differ- cates that use of an alcohol gel hand sanitizer is an ent approaches? Clin Infect Dis 1999;29:1287-94. effective additional tool in an infection control program. 23. Paulson DS, Fendler EJ, Dolan MJ,Williams RA. A close look at alcohol gel as an antimicrobial sanitizing agent. Am J Infect Control 1999;27:332-8. References 2000;28:323. 1. Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial 24. Patil SM, Patrick E, Maibach HI. Animal, human, and in vitro test methods infections: morbidity, mortality, cost, and prevention. Infect Control Hosp for predicting skin irritation. In: Marzulli FN, Maibach HI, editors. Epidemiol 1996;17:552-7; 2000 CDC 4th Dicennial International Conference Dermatotoxicology.Washington (DC):Taylor & Francis; 1996; p. 411-36. Fendler et al June 2002 233

25. Phillips L II , Steinberg M, Maibach HI, Akers WA. A comparison of rabbit and 29. Muto CA, Sistrom MG, Farr BM. Hand hygiene rates unaffected by installa- human skin response to certain irritants. Toxicol Appl Pharmacol tion of dispensers of a rapidly acting hand antiseptic. Am J Infect Control 1972;21:369-82. 2000;28:273-6. 26. McGeer A, Campbell B, Emori TG, Hieholtzer WJ, Jackson MM, Nicolle LE, et 30. Harris AD, Samore MH, Nafziger R, DiRosario K, Roghmann MC, Carmeli Y. al. Definitions of infection for surveillance in long-term care facilities. Am J A survey on handwashing practices and opinions of healthcare workers. J Infect Control 1991;19:1-7. Hosp Infect 2000;45:318-21. 27. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for 31. Hammond B, Ali Y, Fendler E, Dolan M, Donovan S. Effect of hand sanitizer nosocomial infections, 1998. Am J Infect Control 1988;16:128-40. use on elementary school absenteeism. Am J Infect Control 2000;28:340-6. 28. Farr BM. Reasons for noncompliance with infection control guidelines. Infect 32. Pittet D, Boyce JM. Hand hygiene and patient care: pursuing the Semmelweis Control Hosp Epidemiol 2000;21:411-6. legacy. Lancet Infectious Diseases 2001;April:9-20.

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