Alcohol with Chlorhexidine Hand Sanitizers: Clinical Effectiveness and Guidelines

TITLE: Alcohol with Chlorhexidine Hand Sanitizers: Clinical Effectiveness and Guidelines

DATE: 10 March 2014

RESEARCH QUESTIONS

1. What is the comparative clinical effectiveness of alcohol-only hand sanitizers and alcohol with chlorhexidine hand sanitizers?

2. What are the evidence-based guidelines regarding the use of alcohol with chlorhexidine hand sanitizers?

KEY MESSAGE

Four non-randomized studies were identified regarding the clinical effectiveness of alcohol-only hand sanitizers and alcohol with chlorhexidine hand sanitizers, while three evidence-based guidelines were identified regarding the use of alcohol with chlorhexidine hand sanitizers.

METHODS

A limited literature search was conducted on key resources including PubMed, The Cochrane Library (2014, Issue 2), University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. No filters were applied to limit the retrieval by study type. Where possible, retrieval was limited to the human population. The search was also limited to documents published between January 1, 2009 and February 28, 2014. Internet links were provided, where available.

The summary of findings was prepared from the abstracts of the relevant information. Please note that data contained in abstracts may not always be an accurate reflection of the data contained within the full article.

Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. Rapid responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report.

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RESULTS

Rapid Response reports are organized so that the higher quality evidence is presented first. Therefore, health technology assessment reports, systematic reviews, and meta-analyses are presented first. These are followed by randomized controlled trials, non-randomized studies, and evidence-based guidelines.

Additional references of potential interest are provided in the appendix.

OVERALL SUMMARY OF FINDINGS

The evidence from four non-randomized studies1-4 indicated that both alcohol-only2,3 and alcohol plus chlorhexidine2,3,4 hand sanitizers were effective for the disinfection of some commonly found hospital pathogens such as human influenza A virus (H1N1; A/New Caledonia/20/99),3 methicillin-resistant Staphylococcus aureus,2,4 and glycopeptide-intermediate S. aureus.4 In addition, solutions with higher concentrations of alcohol appeared to be better at disinfection than those containing lower concentrations.1,2 However, the authors of one non-randomized study observed that solutions containing 70% alcohol, either alone or in combination with chlorhexidine, were less effective against human enterovirus 71 (HEV71) than solutions containing 95% ethanol; and even these high alcohol concentration solutions also did not fully inactivate HEV71.1

Three evidence-based guidelines were identified that mentioned the use of alcohol with chlorhexidine hand sanitizers.5-7 With regard to hand hygiene, the Australian Guidelines for the Prevention and Control of Infection in Healthcare suggest using a hand rub that contains between 60% and 80% percentage volume per volume ethanol or equivalent.6 The Australian guidelines noted that most published clinical studies have been conducted with at least 70% alcohol, 0.5% chlorhexidine, and a skin emollient but state that the efficacy of hand sanitizers are dependent on factors such as the type of alcohol present, the volume of product used, whether the hands were wet at the time of application, and the length of rubbing time.6 One guideline recommends the use of antiseptic alcohol and 0.5% chlorhexidine to cleanse the skin (allowing to fully dry) prior to venous catheter or peripheral catheter insertion and during dressing changes.5 Another guideline by the World Health Organization recommends that a product containing 2% chlorhexidine in 70% isopropyl alcohol be used to cleanse the skin area for at least 30 seconds, and allowing it to fully dry, prior to venepuncture.7 They also indicate that this practice is contraindicated for children under the age of two months.7

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REFERENCES SUMMARIZED

Health Technology Assessments No literature identified.

Systematic Reviews and Meta-analyses No literature identified.

Randomized Controlled Trials No literature identified.

Non-Randomized Studies

1. Chang SC, Li WC, Huang KY, Huang YC, Chiu CH, Chen CJ, et al. Efficacy of alcohols and alcohol-based hand disinfectants against human enterovirus 71. J Hosp Infect. 2013 Apr;83(4):288-93. PubMed: PM23399482

2. Perona PJ, Johnson AJ, Perona JP, Issa K, Kapadia BH, Bonutti PM, et al. Effectiveness of various hospital-based solutions against community- acquired methicillin-resistant Staphylococcus aureus. J Long Term Eff Med Implants. 2013;23(1):23-9. PubMed: PM24266441

3. Grayson ML, Melvani S, Druce J, Barr IG, Ballard SA, Johnson PD, et al. Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers. Clin Infect Dis. 2009 Feb 1;48(3):285-91. PubMed: PM19115974

4. Wootton M, Walsh TR, Davies EM, Howe RA. Evaluation of the effectiveness of common hospital hand disinfectants against methicillin-resistant Staphylococcus aureus, glycopeptide-intermediate S. aureus, and heterogeneous glycopeptide-intermediate S. aureus. Infect Control Hosp Epidemiol. 2009 Mar;30(3):226-32. PubMed: PM19199533

Guidelines and Recommendations

5. O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011 May;52(9):e162-e193. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3106269 PubMed: PM21460264 See: Section on Skin Preparation Recommendations

6. NHMRC. Australian guidelines for the prevention and control of infection in healthcare [Internet]. Commonwealth of Australia; 2010. [cited 2014 Mar 10]. Available from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cd33_infection_control_h ealthcare.pdf See: B1.1.3 What product should be used? pg. 37

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7. Who guidelines on drawing blood: best practices in phlebotomy [Internet]. Geneva: World Health Organization; 2010. [cited 2014 Mar 10]. Available from: http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf See: Sections on a) Practical Guidance on Venepuncture for Blood Donation, Step 3 - Disinfect the Skin b) Section on Contraindications, second bullet

PREPARED BY: Canadian Agency for Drugs and Technologies in Health Tel: 1-866-898-8439 www.cadth.ca

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APPENDIX – FURTHER INFORMATION:

Systematic Reviews and Meta-analyses – Separation Between Surgical Hand Scrub and Hand Sanitizer Unclear

8. Maiwald M, Chan ES. The forgotten role of alcohol: a systematic review and meta- analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis. PLoS One. 2012;7(9):e44277. doi: 10.1371/journal.pone.0044277. Epub 2012 Sep 5. Review. PMID: 22984485 [PubMed - indexed for MEDLINE] Free PMC Article http://www.ncbi.nlm.nih.gov/pubmed/22984485

Randomized Controlled Trial – Alternate Comparator

9. Chow A, Arah OA, Chan SP, Poh BF, Krishnan P, Ng WK, et al. Alcohol handrubbing and chlorhexidine handwashing protocols for routine hospital practice: a randomized clinical trial of protocol efficacy and time effectiveness. Am J Infect Control. 2012 Nov;40(9):800- 5. PubMed: PM22325731

Non-Randomized Studies – Alternate Comparators

10. Macias JH, Arreguin V, Munoz JM, Alvarez JA, Mosqueda JL, Macias AE. Chlorhexidine is a better antiseptic than povidone iodine and sodium hypochlorite because of its substantive effect. Am J Infect Control. 2013 Jul;41(7):634-7. PubMed: PM23380379

11. Burch TM, Stanger B, Mizuguchi KA, Zurakowski D, Reid SD. Is alcohol-based hand disinfection equivalent to surgical scrub before placing a central venous catheter? Anesth Analg. 2012 Mar;114(3):622-5. PubMed: PM22190557

12. Park GW, Barclay L, Macinga D, Charbonneau D, Pettigrew CA, Vinje J. Comparative efficacy of seven hand sanitizers against murine norovirus, feline calicivirus, and GII.4 norovirus. J Food Prot. 2010 Dec;73(12):2232-8. PubMed: PM21219741

Clinical Practice Guidelines – Methodology Uncertain

Hand Hygiene Product Placement

13. Centre for Healthcare Related Infection Surveillance and Prevention (CHRISP). Hand hygiene. Product selection [Internet]. Queensland Government; 2013. [cited 2014 Mar 10]. Available from: http://www.health.qld.gov.au/chrisp/hand_hygiene/product_select.pdf See: Sections on; a) Location of Alcohol Based Hand Rub Solution Dispensers b) Clinical Area Placement Considerations

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