Handrubbing with sprayed alcohol-based hand rub: an alternative method for effective hand hygiene

Summary

Background

Hand hygiene is crucial in infection prevention and control. It is unclear whether sprayed alcohol-based hand rub (ABHR) is non-inferior to the World Health Organization (WHO)-recommended method of handrubbing with poured ABHR.

Aim

To test whether sprayed ABHR can be an alternative (non-inferior) method for effective hand hygiene with/without handrubbing.

Methods

A laboratory experiment was conducted with ABHR (isopropanol 60% v/v) according to European Norm 1500. Hand hygiene was performed by: (1) handrubbing with ABHR poured on to the palm of the hand; (2) handrubbing with sprayed ABHR; and (3) applying sprayed ABHR to hands without handrubbing. Hands were contaminated with Escherichia coli ATCC 10536, followed by hand hygiene and microbiological sampling. A generalized linear mixed model with a random intercept per subject was used to analyse the reduction in bacterial count following hand hygiene.

Findings

In total, 19 healthcare workers participated in the study. Handrubbing with sprayed ABHR was non-inferior [margin log₁₀ 0.6 colony-forming units (cfu)/mL] to the WHO-recommended method of handrubbing with poured ABHR; bacterial count reductions were log₁₀ 3.66 cfu/mL [95% confidence interval (CI) 1.68–5.64] and log₁₀ 3.46 cfu/mL (95% CI 1.27–5.65), respectively. Conversely, non-inferiority was not found for sprayed ABHR without handrubbing [bacterial count reduction log₁₀ 2.76 cfu/mL (95% CI 1.65–3.87)].

Conclusion

Handrubbing with sprayed ABHR was non-inferior to handrubbing with ABHR poured on to the palm of the hand to reduce bacterial counts on hands under experimental conditions. Handrubbing with sprayed ABHR may be an acceptable alternative hand hygiene method pending assessment in other settings and for other pathogens.

Introduction

Healthcare-associated infections (HAIs) are a major patient safety problem. Disease-causing pathogens can be transmitted to patients through the hands of healthcare workers (HCWs); therefore, hand hygiene is one of the most important measures in preventing HAIs [1,2]. However, HCW compliance with hand hygiene is known to be insufficient. This has led the World Health Organization (WHO) to develop a multi-modal hand hygiene improvement strategy aimed at increasing compliance with hand hygiene [[2], [3], [4], [5]]. The WHO guidelines recommend that hand hygiene should be performed using a liquid alcohol-based hand rub (ABHR); the ABHR should be poured on to the palm of the hand and a six-step handrubbing technique should be performed for 20–30 s [2].

ABHR is also available in other formats, including gels, foams, and wipes, and their antimicrobial efficacy has been studied extensively [[6], [7], [8], [9], [10], [11], [12]]. However, the antimicrobial efficacy of sprayed ABHR has not been assessed, despite the fact that spray dispensers have a number of advantages including direct dispensation of ABHR on to hand surfaces; avoidance of spillages; and delivery of precise, customized volumes [13]. If sprayed ABHR can be distributed evenly on to the hands, it is also unclear if handrubbing would be required for effective hand hygiene. The antimicrobial action of ABHR can be attributed to the protein denaturation effect of alcohol [2], and it remains unknown whether handrubbing is required solely to help spread the liquid ABHR on to all surfaces of the hands or if the efficacy of hand hygiene is affected if the handrubbing action is omitted. As the utilization of sprays to deliver liquid ABHR has become more common in healthcare facilities, it is important to clarify the role that these sprays can play in effective hand hygiene.

This study aimed to determine whether the antimicrobial efficacy of sprayed ABHR, with or without handrubbing, is non-inferior to handrubbing with poured ABHR, as currently recommended by the WHO guidelines.