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CDC gives hand to alcohol-based rubs. ('Revolution' in Hygiene).

SAN DIEGO -- "Rub-a-dub-dub" is about to take on a whole new meaning in U.S. health care.

New guidelines on hand hygiene released by the Centers for Disease Control and Prevention promote the use of alcohol-based "rubs," Dr. John M. Boyce said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The guidelines--which apply to all health care settings, not just hospitals--recommend traditional hand washing after using the restroom or for hands that are soiled or have visible blood, bodily fluids, or other proteinaceous materials on them, since alcohol is not very good at cleaning. For hands that are not visibly soiled, use an alcohol-based rub; if that's unavailable, wash with soap, explained Dr. Boyce, who has been a paid consultant for two companies that make hand rubs, Gojo Industries and Bode Chemie.

Health care workers who have never used the alcohol-based rubs often erroneously fear that the products will dry out their hands and cause irritant contact dermatitis--a leading reason for low compliance with hand washing, noted Dr. Boyce, a clinical professor of medicine at Yale University, New Haven. Three randomized comparisons in the last 2 years found that alcohol-based rubs were less irritating than washing with soap and water.

The guidelines advise medical employers to provide hand lotions and creams to workers to minimize irritant contact dermatitis. Institutions should make hand hygiene a priority, monitor compliance and provide feedback to employees, and educate patients and their families to remind workers about hygiene.

In a new and controversial recommendation, the guidelines warn against wearing artificial fingernails or nail extenders during direct contact with patients at high risk for infection because long nails may harbor bacteria.

Federal officials hope that dismal rates of compliance with hand-hygiene guidelines last issued by the CDC in 1985 and by other organizations in 1988 and 1995 will improve with the convenience and user friendliness of the alcohol-based rubs. A 1999 study found, for example, that only 30% of physicians and 52% of nurses complied with hand-washing recommendations.

"We haven't made any progress in improving compliance in the last 20 years. With all the resistant organisms around today, I don't think we can defend" the status quo, said Dr. Boyce, coauthor of the new guidelines and chief of infectious diseases, Hospital of St. Raphael, New Haven.

Traditional prolonged, vigorous hand scrubbing before surgery may be replaced by a short wash with soap and water, followed by application of an alcohol-based rub, he added.

"Surgeons are taking notice of the revolution coming in hand prep," Elaine Larson, Ph.D., an expert on hand hygiene, said at a press briefing.

A traditional surgical scrub costs about $60 in personnel time, compared with $20 for the wash-and-rub method, said Dr. Larson of Columbia University, New York. The surgical suites at Columbia University and at Cornell University, both in New York, are now switching to alcohol-based antisepsis, she said at the meeting sponsored by the American Society for Microbiology.

In 22 studies comparing the antibacterial efficacy of various hand-hygiene products, products containing alcohol or a combination of alcohol and chlorhexidine came out on top in every study Washing with soap and water was the least effective method in nearly every study.

A variety of alcohol-based foams, gels, or lotions are available, and have been the standard for hand hygiene in some European countries for years. Some products come in packets that fit in coat pockets; others are pumped from dispensers. A quarter-size dollop can disinfect hands in 15 seconds or less, compared with a minute or more typically required with traditional hand washing.

New data presented at the meeting supported the use of alcohol-based rubs:

* After staff tried eight alcohol-based rubs to pick the one they liked best, officials at the Veterans Affairs Medical Center, Washington, D.C., installed 500 dispensers in all rooms and educated staff about their use. Over the next 2 years, new cases of methicillin-resistant Staphylococcus aureus fell by 23% and new cases of vancomycin-resistant enterococcus dropped by 40%, said Maureen F. Schultz, R.N., of the center.

* Dr. Andreas F. Widmer of the University of Basel (Switzerland) and associates studied 178 hospital workers before and after a 1-day training on use of an alcohol-based rub. They added fluorescent dye to the rub and examined hands under ultraviolet light to spot areas missed. After training, 90% of workers correctly used two pumps of the rub instead of one rose (up from 54% before), and 74% covered all parts of the hands including fingertips, vs. 31% before training. Levels of colony-forming units under the fingernails dropped significantly after the training.

* Two kinds of alcohol-based rubs--a common waterless form and a newer water-aided form--were compared with a standard iodine brush-based surgical scrub in a randomized trial by volunteers from the surgical services at a community hospital. Participants used each product for all scrubs during 5-day periods. Microbial colony counts were significantly lower on the fifth day of using the waterless rub, compared with the other two products, reported Dr. Chakshu Gupta of St. John Hospital, Detroit.

Participants "overwhelmingly" favored use of the waterless rub, which was less scratchy than using a brush and iodine, he added.

RELATED ARTICLE: Facts on Alcohol-Based Rubs

Dr. Larson answered these questions about alcohol-based hand hygiene:

* Do the new hygiene guidelines apply to places outside health care facilities? The guidelines do not apply to childcare facilities or to the food industry. Individual packets of alcohol-based rubs can come in handy for washing up while traveling if you can't find a sink, and in that sense they may be useful to ambulance drivers and EMTs.

* Should alcohol-based rubs replace soap in our homes? No. You don't want to get rid of the normal flora in the home environment, Alcohol-based rubs may be a useful adjunct for hygiene, however, if someone in the home is immunosuppressed.

* Will these products increase the potential for development of resistant organisms? No. Unlike antimicrobial soaps, which have a theoretical but unproven potential to contribute to the development of microbial resistance, alcohol-based rubs have no mechanism by which they could affect resistance rates.
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Author:Boschert, Sherry
Publication:Internal Medicine News
Date:Nov 15, 2002
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