Show Me the Science

• Germs are everywhere. They are within and on our bodies and on every surface you touch. But not all germs are bad. We need some of these germs to keep us healthy and our immune system strong.
• Your hands have good germs on them that your body needs to stay healthy. These germs live under the deeper layers of the skin.
• Your hands can also have bad germs on them that make you sick. These germs live on the surface and are easily killed/wiped away by the alcohol-based hand sanitizer.
• Using an alcohol-based hand sanitizer is the preferred way to keep your hands clean.
• Alcohol-based hand sanitizers kill the good and bad germs, but the good germs quickly come back on your hands.

• Wash your hands for at least 15 seconds, not specifically 15 seconds.
• The time it takes is less important than making sure you clean all areas of your hands.
• Alcohol-based hand sanitizers are the preferred way to clean your hands in healthcare facilities.

References

1. Guidelines for Hand Hygiene in Healthcare Settings Published 2002 [PDF – 496 KB] ; pp. 8 and 32.

An alcohol-based hand sanitizer is the preferred method for cleaning your hands when they are not visibly dirty because it:

• Is more effective at killing potentially deadly germs on hands than soap
• Is easier to use during the course of care, especially
  • when moving from soiled to clean activities with the same patient or resident
  • when moving between patients or residents in shared rooms or common areas
• Improves skin condition with less irritation and dryness than soap and water

References

1. Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings
2. Guidelines for Hand Hygiene in Healthcare Settings Published 2002 [PDF – 496 KB]; 25.

These areas are most often missed by healthcare providers when using alcohol-based hand sanitizer:

• Thumbs
• Fingertips
• Between fingers

References

1. Widmer, A. F., Dangel, M., & RN. (2004). Alcohol-based hand rub: evaluation of technique and microbiological efficacy with international infection control professionals. Infection Control and Hospital Epidemiology, 25(3), 207-209.

• References
  1. Guidelines for Hand Hygiene in Healthcare Settings Published 2002 [PDF – 496 KB]; 29-30.

• Use the right amount of alcohol-based hand sanitizer product to clean your hands
• The efficacy of alcohol-based hand sanitizer depends on the volume applied to the hands

References

1. Widmer, A. F., Dangel, M., & RN. (2007). Introducing alcohol-based hand rub for hand hygiene: the critical need for training. Infection Control and Hospital Epidemiology, 28(1), 50-54.

• C. difficile is a spore-forming bacterium that can lead to a common healthcare-associated infection causing severe diarrhea. Spores are an inactive form of the germ and have a protective coating allowing them to live on surfaces for months.
• The bacteria can be transferred to patients via the hands of healthcare providers who have touched a contaminated surface or item.
• Unless hands are visibly soiled, alcohol-based hand sanitizer (ABHS) is preferred over soap and water for cleaning hands in most clinical situations.^1,2 This recommendation does not vary when caring for patients with C. difficile infection (CDI).
  • Although there is a theoretical advantage to cleaning hands with soap and water when caring for patients with CDI, CDC still indicates a preference for ABHS as studies have not shown a clear prevention benefit for soap and water and removing ABHS risks reducing hand hygiene compliance overall.
• When entering the room of a patient with C. difficile, the priority should be to ensure glove use (in addition to a gown) and proper technique when removing gloves to minimize the risk of self-contamination.³ Current evidence demonstrates that C. difficile spores may not be fully removed from hands, regardless of the method used to clean hands. This further emphasizes the need for appropriate use of gloves for the care of patients with CDI.
  • One study found that most hand wash products produced less than a 1-log reduction in difficile spores and found the number of spores removed did not vary statistically from the number of spores removed from washing hands with tap water alone.^3,4
  • Several controlled studies have found alcohol-based hand rub to be ineffective at removing or inactivating C. difficile spores from the hands of volunteers contaminated with a known number of spores compared to hand washing.^3,5,6
  • Notably, one study did find a reduction of spores from the palmar surface of the hand with the alcohol-based hand rub.^3,5
• Although alcohol-based hand rub is ineffective at removing or disinfecting C. difficile spores in controlled laboratory experiments, clinical studies have not demonstrated an increase in CDI with the use of ABHS products or a decrease in CDI with the use of soap and water.³ For example:
  • Knight et al. found no evidence of an increase in CDI after implementation of an ABHS policy in a 795-bed community teaching hospital, including during the care of patients with CDI (incidence rate of 3.98 per 10,000 patient-days after implementation, compared with 4.96 before; P=.0036).⁷
  • Boyce et al. demonstrated no increase in the incidence of CDI over a three-year period despite a significant and progressive increase in the use of ABHS in their 500-bed hospital. In addition, they found an increase in the overall hand hygiene compliance rate from 38% at baseline to 63% after ABHS implementation.⁸
  • An observational study compared three years without ABHS use to three years with ABHS as the primary method for cleaning hands and demonstrated a 21% decrease in healthcare-acquired methicillin-resistant Staphylococcus aureus (MRSA), a 41% decrease in vancomycin-resistant Enterococcus (VRE), and no change in the incidence of CDI.⁹
• As an additional precaution during outbreaks of C. difficile, CDC encourages hand washing with soap and water after the care of patients with known or suspected infections.¹
  • This is recommended due to the theoretical increased efficacy of soap and water for removing spores from hands, although evidence for this recommendation is limited. Proper use of gloves (in addition to a gown) to reduce bioburden on the hands should be emphasized. Access to ABHS should not be restricted.

References

1. Glowicz J, Landon E, Sickbert-Bennett E, et al. SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 Update. Infect Control Hosp Epidemiol 2023;44(3), 355-376. doi:10.1017/ice.2022.304
2. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51 (No. RR-16).
3. Kociolek LK, Gerding DN, Carrico R, et al. Strategies to prevent Clostridioides difficile infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023;44(4), 527–549.
4. Edmonds SL, Zapka C, Kasper D, et al. Effectiveness of hand hygiene for removal of Clostridium difficile spores from hands. Infect Control Hosp Epidemiol 2013;34:302–305.
5. Jabbar U, Leischner J, Kasper D, et al. Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands. Infect Control Hosp Epidemiol 2010;31:565–570.
6. Oughton MT, Loo VG, Dendukuri N, et al. Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile. Infect Control Hosp Epidemiol 2009;30:939–944.
7. Knight N, Strait T, Anthony N, et al. Clostridium difficile colitis: a retrospective study of incidence and severity before and after institution of an alcohol-based hand rub policy. Am J Infect Control 2010;38:523–528.
8. Boyce JM, Ligi C, Kohan C, et al. Lack of association between the increased incidence of Clostridium difficile–associated disease and the increasing use of alcohol-based hand rubs. Infect Control Hosp Epidemiol 2006;27:479–483.
9. Gordin FM, Schultz ME, Huber RA, et al. Reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based handrub. Infect Control Hosp Epidemiol. 2005 Jul;26(7):650-3. doi: 10.1086/502596. PMID: 16092747.

• Alcohol-based hand rub (or sanitizers) do not contribute to antibiotic resistance.
• Alcohol-based hand sanitizers kill germs, including antibiotic-resistant germs, by destroying the proteins and protective outer membrane that germs need to survive.
• Antibiotic resistance happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them.

Find more information on ways to protect yourself and your family.

Studies show that some healthcare providers practice hand hygiene less than half of the times they should. Healthcare providers might need to clean their hands as many as 100 times per 12-hour shift, depending on the number of patients and intensity of care. Know what it could take to keep your patients safe.