Alcohol hand rubs not enough to curb hospital infections

Making alcohol-based hand gels common and accessible in hospitals increases their use and cuts the amount of microbes on the hands of nursing staff. But it does not cut the rates of device-associated infections, illness caused by drug-resistant bacteria or cases of Clostridium difficile, says a study published in the January Infection Control & Hospital Epidemiology.

Authors and other experts say this situation is not because the products are ineffective. Rather, increases in their use need to be carried out in conjunction with other infection control strategies.

"People get the message [that if you] just clean your hands, all the infections will go away. [But] hand hygiene is not a panacea, and there's not a simple single fix for everything," said Mark E. Rupp, MD, lead author and professor of infectious diseases at the University of Nebraska Medical Center in Omaha.

Researchers did the study in two intensive care units at the medical center over two years. Alcohol-based hand rub and education about its use were provided in one unit the first year and not the other. The second year, the units were flipped. Although the hand hygiene rate nearly doubled where the intervention occurred, no change in the hospital-acquired infection rate was detected. Several theories offer reasons why this intervention did not have the desired effect.

"This is not a strike against the importance of hand hygiene in health care settings," said Gonzalo Bearman, MD, MPH, assistant professor of medicine and associate hospital epidemiologist at Virginia Commonwealth University Medical College in Richmond. "These alcohol hand rubs decreased microbial burden on their hands, and that's really important."

Experts suspect that the study, which took place in a hospital that already had a low infection rate, was not powered enough to detect a difference and that a longer or larger investigation would find one. Also, although hand hygiene increased to as high as 69% at one point, that rate may not be enough to make a dent in the infectious disease burden.

"Maybe we need to be at 90% or 100% before we make a difference," Dr. Rupp said.

Most likely, other strategies are necessary, and they may need to go beyond current recommendations. For example, October 2002 Centers for Disease Control and Prevention guidelines urged fingernail lengths of no longer than a quarter of an inch but left the question of wearing rings unresolved. This study, though, found that nurses were more likely to have large amounts of microbes on their hands if they did not have easy access to alcohol hand rub as well as if they wore rings or had nails longer than the finger tip.

"Our study would show that we need to be even more stringent than the guidelines," Dr. Rupp said.

Experts are calling for increased use of these alcohol-based hand rubs, primarily because they are much more practical for frequent use than soap and water. They also seem to be healthier for those who need to clean their hands frequently, particularly in colder months. A study given at the American Academy of Dermatology annual meeting in San Antonio this month found that health care workers who washed their hands more than 10 times a day were at increased risk of irritant contact dermatitis.

"Health care workers need to decrease hand washing as much as possible in low humidity seasons like winter, consistent with good patient care, and substitute alcohol-based hand cleansers," said Susan Nedorost, MD, lead author on that paper and associate professor of dermatology at Case Western Reserve University in Cleveland.

Improving hygiene and, more important, decreasing nosocomial infections, has long been a focus of various medical societies, public health agencies and quality improvement organizations. American Medical Association policy urges everyone, including health professionals, to consider hand washing a priority.