Clinical Problem: Within hospitals, bacterial infections are the cause of many unnecessary illnesses, deaths, and lengthened hospital stays. Due to the infrequency of hand-washing by healthcare professionals, the risk of these infections has increased.
Objective: To determine if using alcohol-based sanitizers will lower the frequency of infections within hospitals. ScienceDirect, PubMed, NCBI, and Research Gate were used to research clinical trials and research studies on the topic. The key search terms used were bacteria, infections, hospital infections, frequency of hospital infections, hand-washing, and hand-sanitizers.
Results: The CDC recommends the use of soap and water to wash hands when they are visibly dirty, but states that alcohol-based sanitizers may be used if they are not (CDC, 2002). This literature stated that the use of alcohol for routine decontamination can reduce the likelihood of infections in health care settings (CDC, 2002).
Conclusion: Through supplementing regular hand-washing with alcohol-based sanitizers, we can reduce the rates of infection in hospitals.
Improving Hand Hygiene and Reducing Bacterial Growth on Hands by Using Alcohol Based Hand Sanitizer Opposed to Hand Soap
In hospitals, bacteria are easily spread to patients, causing infections and lengthening hospital stays unnecessarily. Doctors and nurses are not washing their hands as frequently as necessary due to lack of accessibility to water and time (Luby, et al, 2010). Use of alcohol-based hand sanitizer may increase likelihood of handwashing and may decrease more bacteria per wash than soap (Girou, et al., 2002). Some existing concerns regarding this topic include: Does hand sanitizer reduce the growth of bacteria more than soap? Is there a large difference between the bacteria killed by soap and hand sanitizer? The PICOT question of importance is (P) In the general patient population (I) does the use of alcohol based hand sanitizer (C) compared to hand soap washing (O) reduce bacterial growth and overall hand hygiene (T) within a period of two months? The expected outcome is lowered bacterial infections with increased use of alcohol-based hand sanitizer.
ScienceDirect, Research Gate, PubMed, and NCBI were utilized for searching for clinical trials and research studies on the use of alcohol-based sanitizers in clinical settings. The key search terms used were bacteria, infections, hospital infections, frequency of hospital infections, handwashing, and hand sanitizers.
To determine if alcohol-based sanitizers are a sufficient supplement for handwashing, three randomly controlled trials were analyzed in conjunction with sanitation guidelines put forth by the CDC. In their study on sanitizers versus handwashing, Girou, et al. partook in a randomly controlled trial with a sample size of 23 (n=23) (Girou, et al., 2002). Within this trial, there existed two groups of subjects: 1) hand hygiene using alcohol-based solution, and 2) hand hygiene using soap. The first group had a sample size of 12 (n=12), while the second had a sample size of 11 (n=11). The purpose of this study was to observe whether hand sanitizer would reduce hand contamination as opposed to washing hands with soap (Girou, et al., 2002). Since the subjects were randomly assigned and the data collected was measured blindly, this study was not strongly accurate because of the small sample size (below 30). The description of the methodologies of data collection were well presented, easy to understand, and easy to build off. One weakness is the length of the study is not clear; another was that a small sample size was selected. The result was that hand sanitizer significantly reduces the presence of colony forming units (counts bacteria) by 83% vs 58% with handwashing (Girou, et al., 2002). These statistics gave a p-value of 0.012 (P=0.012), and a median difference in the percentage reduction of 26%, where the median duration of hand-rubbing during both cleaning procedures was 30 seconds (Girou, et al., 2002). For this percentage reduction, there existed a 95% confidence internal of 8% to 44% (Girou, et al., 2002). In addition, it shows that using hand sanitizer reduces CFU increasingly with every use.
In their study on waterless hand sanitizers in international medicine, Luby, et al. created another randomly controlled trial with the purpose of initiating hand hygiene into low-income residents of Bangladesh, and to increase the use of hygiene methods so that a subsequent study can measure the effects of hand hygiene on health (Luby, et al., 2010). The study was conducted by introducing soap and hand sanitizer, in a randomized controlled trial design, to thirty different housing compounds within Bangladesh. The subjects, or the thirty different housing compounds, where randomized and designated into three different groups, each containing ten different housing compounds: 1) handwashing with soap, 2) handwashing with sanitizer, or 3) no intervention. Field workers recorded use of hand hygiene methods by these groups before and after intervention (Luby, et al., 2010). One strength of this study is it measured varying age groups separately. This study also measured separate points of exposure with opportunity for cleansing before and after intervention. One weakness of this study was the observation of hand hygiene by the field workers could have distorted the actual tendency of the people to use hand hygiene when unobserved. Before the study, the baseline results of hand hygiene within the housing compounds was that after defecation, individuals washed their hands 26% of the time, and after cleaning a child’s anus, they washed their hands 30% of the time (Luby, et al., 2010). Outside of these two occurrences, those within the housing compounds tended to wash their hands <1% of the time (Luby, et al., 2010). Following the study, it was shown that individuals in the first group (soap and water) now washed their hands 85-91% of the time after coming into contact with fecal matter, 26% of the time before preparing food, and 26% of the time before eating (Luby, et al., 2010). In contrast to this, it was shown that those individuals in the second group (hand sanitizer), washed their hands more than the control group (10.4% versus 2.3%), but 25% less than the first group (soap and water) (Luby, et al., 2010). The p-value of the study from the sample of thirty housing compounds was 1.2 (Luby, et al., 2010). It was established that waterless sanitizer increased the frequency of hand hygiene when compared with the control group, but not at prime contamination times, where individuals preferred to use soap and water. With this in mind, it is suggested that combining the two group factors would create the greatest frequency of handwashing, where sanitizer was used for lightly dirty hands, and soap was used otherwise.
In the study in Indian Pediatrics on hand hygiene within the neonatal ICU, Sharma, et al. investigated alcohol-based sanitizers with the purpose of comparing the efficacy of hand hygiene from the use of plain non-antimicrobial bar soap, alcohol hand rub, and povidone-iodine hand scrub on nurses in the Neonatal Intensive Care Unit (Sharma, et al., 2013). The study’s design was randomized cross-over and controlled trial which used a three-armed implementation. This study also measured the outcome blindly. A sample of 35 nurses was used and split into three groups: 1) handwashing with soap, 2) alcohol hand rub, and 3) povidone-iodine hand scrub. To measure the results, cultures were taken before and after each hand hygiene use, to measure the colony-forming unit count (CFU-C). The strengths of this study include extensive measures to avoid unnatural data such as: 14-day neutral periods, exclusion from specific tasks that would lead to over contamination, and special care instructions for neutral periods. Also, the subjects were vetted to include only people who were seasoned nurses and people who had at least 1 year working in the NICU to control natural hand flora was even and stable within the group. One of the weaknesses of this study is the failure to disclose the time frame in which this study was conducted. The study was also lacking detailed information about the process of the data collection. The results found differences between the three groups through the differing CFU-C numbers. For post-hygiene, it was found that the CFU-C was 60 for the first group, 8 for the second, and 10.5 for the third, giving a p-value of less than 0.001, and indicating that the alcohol rub gave the best results immediately following hand hygiene (Sharma, et al., 2013). For absolute reduction in the CFU-C values, it was shown that the median values were 15, 100, and 40, respectively, again with a p-value of less than 0.001 (Sharma, et al., 2013). In this case, it again showed the alcohol rub to be superior to the other two. With these results in mind, the study found that hand rubbing alcohol increased hand hygiene more than that of non-microbial bar soap and povidone-iodine when looking at the colony forming unit counts of bacteria over time (Sharma, et al., 2013).
The guidelines for the prevention of infections within health care facilities by the CDC, recommends that soap and be used to wash hands when they are visibly dirty, but states that alcohol-based sanitizers may be used if they are not (CDC, 2002). These recommendations received Category IA strength grades, which means that they are supported by extensive experimental, clinical, and epidemiological studies (CDC, 2002).
The PICOT question of our study asks if the use of alcohol-based hand sanitizers will reduce bacterial growth and overall hand hygiene in the general population when compared to hand washing within a two-month period. Girou, et al. (2002) demonstrated that alcohol-based sanitizers reduced the counts of bacteria by 26% as compared to handwashing. While this study produces promising results for answering the PICOT question of importance—that hand sanitizers are better as compared to hand washing, its blind data collection combined with its small sample size makes us question its accuracy. In addition to this, Luby, et al. (2010) showed that waterless sanitizers increased the frequency of hand hygiene (p-value=1.2), where water access is an issue. This study took place in Bangladesh, a low-income area where water access has been shown to be a problem. This relates to our initial study of hand hygiene within healthcare facilities because of the concern that the health care professionals themselves do not practice frequent enough hand hygiene. While the individuals within these two places are vastly different, they are similar in terms of the fact that the reason they are not practicing frequent enough hand hygiene is because of their lack of access to cleaning mechanisms. With this in mind, the study by Luby, et al. (2010) shows that for individuals who do not practice frequent hand hygiene, hand sanitizers are an effective method of increasing the frequency and decreasing bacterial growth. Further, Sharma, et al. (2013) established that alcohol-based sanitizers increased hand hygiene more than soap, water, and iodine-based measures. This study took place in an Indian Pediatrics facility, and focused on comparing the efficacy of hand hygiene between the different methods for accomplishing it. In contrast to the first two studies analyzed, which related to the PICOT question itself, but did not directly relate to the field of healthcare, the study by Sharma, et al. (2013) directly relates to both our PICOT question, as well as to our reasoning for completing it–to increase hand hygiene in healthcare facilities. Finally, the Centers for Disease Control and Prevention’s (2002) guideline recommends that health care professionals should supplement handwashing with alcohol rubs when hands are not visibly dirty, to reduce rates of infection. This complements the previous studies, which discussed how hand sanitizers increased the frequency of hand hygiene, because it functions to combine the two methods to create the most efficient method of cleaning hands. If simply switching to hand sanitizers would increase hand hygiene frequency, then utilizing both hand sanitizers as well as soap and water should even further increase its frequency.
Across the studies, it was shown that alcohol-based sanitizers worked to increase the rates at which hands were washed and sanitized. The study by Girou, et al. (2002) was determined to have a lower rate of accuracy, due to the blind data collection and small sample size, however, the studies by Luby, et al. (2010) and Sharma, et al. (2013) were both randomly controlled with larger sample sizes, indicating relatively higher rates of accuracy. In addition to this, since the three studies, as well as the CDC guideline (2002), reinforce each other, we should assume that the general facts and suggestions they put forward are true, and can all be used to answer the proposed PICOT question. In terms of the PICOT question, we can say that in the general patient population, the use of alcohol based hand sanitizer has the potential to reduce bacterial growth and overall hand hygiene over two months. However, we do not have clearly defined evidence as to whether it would be able to completely replace hand washing as a hygiene measure. While more research is required to determine if alcohol-based sanitizers are superior to handwashing, it is clear that its prevalence can reduce infection overall through increasing frequency.
The CDC (2002) guidelines state that within hospitals, hands should be decontaminated as frequently as possible to reduce the rates of infection. To make this easier on health care professionals, they state that visibly dirty hands should be washed, otherwise sanitizers can be used. Research confirms that alcohol-based sanitizers can increase hand hygiene, however supplemental evidence-based research is required to determine if alcohol-based sanitizers could exclusively be used by health care personnel.
CDC. (2002, October 25). Guideline for Hand Hygiene in Health-Care Settings. Retrieved from CDC: https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
Girou, E., Loyeau, S., Legrand, P., Oppein, F., & Brun-Buisson, C. (2002). Efficacy of hand rubbing with alcohol based solution versus standard handwashing with antiseptic soap: Randomized clinical trial. Retrieved from BMJ, 325-362: https://doi.org/10.1136/bmj.325.7360.362
Luby, S., Kadir, M., Yushuf Sharker, M., Yeasmin, F., Unicomb, L., & Sirajul Islam, M. (2010). A community-randomised controlled trial promoting waterless hand sanitizer and handwashing with soap, Dhaka, Bangladesh. Tropical Medicine & International Health, 15, 1508-1516.
Sharma, V., Dutta, S., Taneja, N., & Narang, A. (2013). Comparing hand hygiene measures in a neonatal ICU: a randomized crossover trial. Indian Pediatrics, 50, 917-921.