A Guide to Hand-Hygiene Agents
By Deb Paul-Cheadle, RN, CIC
Waterless alcohol rubs have replaced soap and water as the leading recommended tool for hand disinfection, as stated by the Centers for Disease Control and Prevention (CDC)'s revised Guideline for Hand Hygiene. This mindset change occurred after multiple studies showed that handwashing protocols bear no resemblance to what actually occurs in healthcare settings.
Education and re-education were thought to be the solution, but in all fairness to healthcare professionals, the reason we are not washing correctly is not due to a deficiency in knowledge. The time demand, inconvenience of repeated handwashing, a desire to prevent or not aggravate hand dermatitis, poor access to sinks or sinks that are blocked by patient equipment are usually the contributors to low rates of handwashing compliance.
Studies show that the time it takes to effectively degerm your hands with soap and water is between 10 and 60 seconds. It takes the active antimicrobial ingredients in soaps up to 60 seconds to destroy most organisms. The ideal duration for handwashing is not known. Handwashing for 15 seconds removes most transient organisms. If hands are visibly soiled, more time is required for handwashing. The observed average handwashing time is 7 to 10 seconds. This tells us that when you think your hands are clean, they are not. The beauty of the alcohol degermers is the time factor -- five seconds and 99 percent of the organisms on your hands are killed. This includes viruses. Alcohol rubs also provide improved access, as there is no need for sinks or water. Another perk is that the newer degermers have emollients that actually improve the skin, and after initial stinging, if used on hands with dermatitis and open cracks, significant improvement with actual clearing of problems can be achieved.
My experience with the waterless degermers began in 1999. We were looking for something other than soap that we could try on the hands of healthcare workers (HCW) complaining of dermatitis. We had 27 HCWs with significant dermatitis who were under the care of dermatologists. We had been unsuccessful with different soaps. The HCWs were each given an alcohol-based waterless degermer with emollients to use instead of soaps. Every HCW experienced dramatic improvement, with complete resolution of dermatitis and skin excoriation in 25 HCWs. The other two HCWs saw great improvement, but with underlying eczema, they continue to see their dermatologists for creams they only use when not working.
With this success in the healing of damaged hands, it was decided to trial the degermer in the Neonatal Intensive Care Unit. Not only were the HCWs pleased, we also saw a reduction in babies with Staphylococcus aureus and methicillin-resistant Staph aureus (MRSA). It was decided to place the product at every isolette. Within the month, the MRSA population dropped to zero, with no recurrence. A study was also conducted to look at the cost of usage. Results showed an actual savings, as the cost of the product was far outweighed by the reduction in use of paper towels, lotions and waste management. Needless to say, the hospital implemented the product institution-wide. The only drawback was the minimal persistence the degermer provided, in comparison with antimicrobial products.
The following review provides an overview of how certain agents work, and what organisms they are active against. Once I understood the mechanisms of action, it became easy to embrace the revolution in hand hygiene that is taking place in the healthcare world today.
These are very effective antimicrobial agents. When used in concentrations greater than 61 percent, alcohols act by rapidly denaturating DNA, RNA and lipid biomolecules that are essential for microbial growth and development. Alcohol does not harm skin cells, as the body rapidly re-supplies intra-cellular water that is lost in denaturing. Alcohols are very effective against gram-negative and gram-positive bacteria, fungi, viruses, including hepatitis B and C, HIV, RSV, CMV, influenza and the herpes family. Alcohol application provides the fastest and greatest reduction in microbial counts on the skin, and bacterial resistance to alcohol is non-existent. Alcohol is considered to be the safest topical antiseptic to use.
Chlorehexidine Gluconate (CHG)
This agent works by disrupting cell membranes, which is why it is very important to rinse hands thoroughly after use. GHG is considered broad spectrum but it is not as effective against gram-negative bacteria. CHG has minimal action against Tubercule bacilli and mycobacterium species and it has a fair fungicidal action. CHG is effective against HIV, herpes, CMV and influenza. CHG is better at "sticking" to the skin, therefore providing persistence, but it is not as rapid or extensive as the alcohols. The activity of CHG is very pH dependent, (5.5-7.0). Bacterial resistance to CHG has been reported. Acute skin irritations, contact dermatitis, anaphylaxis from allergic reactions, Ototoxixity and corneal damage have been reported with CHG use, therefore, the FDA categorizes CHG containing formulations as drug products requiring formal approval.
Preparations containing iodine work by releasing free iodine into the interior of a microorganism, which causes toxic oxidation and substitution reactions within the cells. Iodine has a wide range of activity, including spores, gram-negative and gram-positive bacteria, fungi, viruses and tuberculosis. It works rapidly, but has poor persistence. It is rapidly neutralized by blood and organic material. Iodine is generally considered a safe product, although skin irritation has been reported. The skin and mucous membranes can absorb iodine and iodophores. Induction of hypothyroidism in newborns has been documented. These products also need FDA approval.
Trizenol Technology Products
These are alcohol and zinc combinations. This combination provides persistence for hours after use. They can be used with or without water, and this capability makes the removal of surface dirt and organic material possible when needed. Trizenol products provide broad spectrum and rapid antimicrobial action (the same as alcohol, as this is the active ingredient), with excellent antimicrobial persistence (up to six hours). Emollients have been added to maintain skin integrity. These abilities make this an exciting breakthrough in hand hygiene. This product is classified as a cosmetic, and does not need FDA approval.
The CDC would like to see waterless degermers outside of every patient room. Fire marshals do not want to see it in the hallways. Safety department personnel have concerns regarding the product being in patient rooms. This has been an interesting dilemma, and we are working on solutions that are not cost prohibitive. Alcohol products that come in pocket-size containers are a convenient but expensive approach to this roadblock. The manufacturer is exploring the use of a fireproof wall mount.
The use of alcohol hand rubs is a fundamental change in the way hospitals comply with hand-hygiene imperatives. It is a change that will ultimately allow healthcare professionals to do the right thing more frequently. By making good hand hygiene easier, compliance rates will go up and infection rates will go down. The CDC has gone so far as to actually say, "Stop trying to get healthcare workers to wash their hands! Start giving them alcohol hand rubs."
Deb Paul Cheadle, RN, CIC, works in infection control for Spectrum Health in Grand Rapids, Mich.