Comparative efficacy of hand hygiene agents in the reduction of bacteria and virusesMaterials and methodsStudy populationStudy methods for evaluating efficacy of hand hygiene agentsTest organismsSolution preparationHand hygiene test agentsObservation of health care personnel for determining duration of hand hygiene with an alcohol-based handrubData analysisResultsEfficacy of hand hygiene agents against S marcescensEfficacy of hand hygiene agents against MS2Observation of health care personnel for determining duration of hand hygiene with an alcohol-based handrubDiscussionReferencesComparative efficacy of hand hygieneagents in the reduction of bacteriaand virusesEmily E. Sickbert-Bennett, MS,a,bDavid J. Weber, MD, MPH,aMaria F. Gergen -Teague, MT(A SCP),aMark D. Sobsey, PhD,bGregoryP.Samsa,PhD,cand William A. Rutala, PhD, MPHaChapel Hill an d Durham, North CarolinaBackground: Health care-associated infections most commonly result from person-to-person transmission via the hands of healthcare workers.Methods: We studied the efficacy of hand hygiene agents (n = 14) following 10-second applications to reduce the level ofchallenge organisms (Serratia marcescens and MS2 bacteriophage) from the hands of healthy volunteers using the ASTM-E-1174-94test method.Results: The highest log10reductions of S marcescens were achieved with agents containing chlorhexidine gluconate (CHG),triclosan, benzethonium chloride, and the controls, tap water alone and nonantimicrobial soap and water (episode 1 of handhygiene, 1.60-2.01; episode 10, 1.60-3.63). Handwipes but not alcohol-based handrubs were significantly inferior from theseagents after a single episode of hand hygiene, but both groups were significantly inferior after 10 episodes. After a single episode ofhand hygiene, alcohol/silver iodide, CHG, triclosan, and benzethonium chloride were similar to the controls in reduction of MS2,but, in general, handwipes and alcohol-based handrubs showed significantly lower efficacy. After 10 episodes, only benzethoniumchloride (1.33) performed as well as the controls (1.59-1.89) in the reduction of MS2.Conclusions: Antimicrobial handwashing agents were the most efficacious in bacterial removal, whereas waterless agents showedvariable efficacy. Alcohol-based handrubs compared with other products demonstrated better efficacy after a single episode ofhand hygiene than after 10 episodes. Effective hand hygiene for high levels of viral contamination with a nonenveloped virus wasbest achieved by physical removal with a nonantimicrobial soap or tap water alone. (Am J Infect Control 2005;33:67-77.)For centuries, hand hygiene has been considered animportant measure in promoting both public health andgood personal hygiene. With careful atten tion to handhygiene, lower rates of infectious disease have beendocumented in diverse settings, such as health carefacilities,1-3child care centers,4,5and households.6,7Adequate hand hygiene has the potential to removepathogenic microorganisms from the hands and disruptperson-to-person transmission of infectious diseases.With the increased recognition of the importanceof antiseptic use in health care settings, the armamen-tarium for hand hygiene has now expanded to includeantimicrobial foams, rubs, lotions, wipes, and soaps.Although there are many published experimentalstudies on the efficacy of the currently availableantimicrobial agents,8-23few studies have comparedthe efficacy of multiple agents, and no study hasevaluated both the bactericidal and virucidal efficacy ofthe agents. Comparative efficacy is difficult to extrap-olate from the existing literature because these handhygiene efficacy studies were conducted using a varietyof methodologies. Furthermore, previous hand hygieneFrom the Department of Hospital Epidemiology, University of NorthCarolina Health Care Systema; Department of Environmental Sciencesand Engineering, School of Public Health, University of North Carolinaat Chapel Hill, Chapel Hill, North Carolinab; and Department ofBiostatistics and Bioinformatics, Duke University Medical School,Durham, North Carolina.cSupported by the UNC Health Care System and the NC StatewideProgram in Infection Control and Epidemiology.Reprint requests: David J. Weber, MD, MPH, CB 7030, 130 Mason FarmRoad, University of North Carolina at Chapel Hill, Chapel Hill, NC27599-7030. E-mail: [email protected]. Emily E. Sickbert-Bennett,MS, Hospital Epidemiology, 1001 West Wing, CB 7600, 101 ManningDrive, Chapel Hill, NC 27514; E-mail: [email protected]/$30.00Copyright ª 2005 by the Association for Professionals in InfectionControl and Epidemiology, Inc .doi:10.1016/j.ajic.2004.08.00567efficacy studies have tested the efficacy of handhygiene agents for unrealistically long contact timesof at least 30 seconds, whereas health care profes-sionals have been observed in 8 out of 14 studies towash their hands for less than 10 seconds and neverexceeding 24 seconds.24No observational data wereavailable on the duration of hand hygiene with alcohol-based handrubs. Thus, the largest comparative efficacystudy to date using a standard methodology wasundertaken to test 14 different hand hygiene agentsfor their efficacy in the reduction of both bacteria andviruses from the hands, using the realistic handhygiene use time of 10 seconds. This study wasconducted in conjunction with an analysis of theeffects of test variables on the efficacy of hand hygieneagents.25Based on our previously published work,25this study employed those parameters that mostclearly mimicked clinical use and enhanced thevalidity of a human challenge study. In addition, weobserved hand hygiene among health care providerswith an alcohol-based handrub to determine the du-ration of hand hygiene under actual use conditions.Fig 1. Schematic of experimental design that defines ‘‘baseline,’’ ‘‘episode,’’ and ‘‘evaluation.’’68Vol. 33 No. 2 Sickbert-Bennett et alMATERIALS AND METHODSStudy populationSixty-two healthy, adult, human volunteers wererecruited for 70 hand hygiene efficacy evaluations for14 different hand hygiene test agents (5 evaluations pertest agent). The study was approved by the University ofNorth Carolina School of Medicine Institutional ReviewBoard, and written informed consent was obtained.Subjects were screened by questionnaire and physicalexamination for skin disorders and allergies prior toparticipation and excluded if they had eczema, psori-asis, any other chronic skin condition,
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