J Egypt Public Health Assoc Vol.

85 N
o
. 5 & 6,2010

Comparative Study on Efficacy of Different
Alcohol Hand Rubs and Routine Hand Wash in a
Health-Care Setting, Alexandria, Egypt
Amani F. Abaza*, Amira E. Amine**, Walaa A. Hazzah**

* Microbiology Department, Alexandria University Students' Hospital,
Alexandria University, Egypt.
** Microbiology Department, High Institute of Public Health, Alexandria
University, Egypt.


ABSTRACT
Background: Antiseptic agents or plain soap and water are mainly used
for hand hygiene in Egypt. The impact of hand hygiene depends not
only on the regularity and thoroughness of the procedures used but also
on the type of hand-washing agent selected. Objectives: To compare the
efficacy of alcohol-based hand rubs versus traditional hand washing
with soap and water in reducing hand contamination during routine
patient care. Material and Methods: The study included 20 volunteered
nurses in 3 intensive care units and the renal dialysis unit, in the
Alexandria University Students' Hospital. A total of 200 samples were
collected by direct finger-print of the dominant hand taken from all
nurses before and after applying hand hygiene procedures. Three hand-
rubs available in the Egyptian market (Brands A, B; alcohol-based
liquid, and C; alcohol-based gel) were used and compared to a locally
prepared hand-rubbing solution (D) and to hand washing with non-
antiseptic soap and water (SW). Results: Hand washing with non-
antiseptic soap and water and all of the four used alcohol-based hand-
rubs showed significant reduction of bacterial counts on the examined
hands. The median percentage reductions were 99%, 94%, 77%, and 87%
with brands A, B, C and D respectively and only 30% reduction with
soap and water (x
2
: 23.023, p <0.001). Conclusions and
Recommendations: Alcohol-based hand rub is far more efficient than
traditional hand washing, and more convenient and time saving.
Locally prepared hand rub is comparable to readymade ones. It is
recommended as a hand hygiene practice in critical areas, particularly
when sink and running water are inaccessible.


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Keywords: Alcohol based, hand hygiene, hand rub, hand wash.
Corresponding Author:
Dr. Amira E. Amine
Microbiology Department, High Institute of Public Health,
Alexandria University, Egypt
E-mail: amiraamine@yahoo.com


INTRODUCTION
Hand hygiene, which refers to routine hand wash, antiseptic hand
wash, antiseptic hand rub or surgical hand antisepsis, is universally
acknowledged as a cornerstone of the prevention of health care-associated
infections (HAIs). It is the simplest and most effective measure for
preventing cross-transmission of microorganisms and reducing patient
morbidity and mortality from HAIs.
(1, 2)

The impact of hand hygiene depends not only on the regularity and
thoroughness of the procedures used but also on the type of hand-washing
agent selected. For most routine activities, hand washing with plain soap is
sufficient since soap will remove most transient microorganisms.
Nevertheless, compliance with hand washing among health care workers
(HCWs) is only about 4050%, which is unacceptably low. This constant
finding is disturbing because studies have shown that this level of
compliance will not reduce the risk of transmission of multi-resistant
bacteria in hospitals. In a study conducted in Egypt (2009) to assess
knowledge, attitude and practice of hand washing among Ain Shams
University Hospital HCWs, it was reported that doctors showed a
significantly higher compliance (37.5%) than other groups of HCWs.
(3)

Attempts to improve compliance have included increasing the number of
accessible sinks and educating HCWs, but none of these interventions led to
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a marked and sustained improvement in compliance. Hand rubbing with
an alcohol based waterless hand antiseptic seems to be the best method of
increasing compliance with hand hygiene.
(4-6)

Alcohol-based hand rubs are recommended for use by HCWs for
routine decontamination. Most of these preparations in the form of liquid
and gel contain between 60% and 70% ethanol.
(7)
Alcohol-based hand gels
are becoming more popular for the post-contamination treatment of hands.
Although their antimicrobial efficacy has been shown to be significantly
lower than liquid hand rubs, gels are acceptable by HCWs.
(8, 9)
The use of
such agents demonstrated significant log reductions in normal flora of the
hands when compared with other antiseptics in single-use trials.
(10)

We aimed to compare the efficacy of alcohol-based hand rubs versus
traditional hand washing with soap and water in reducing hand
contamination during routine patient care, and to evaluate the effectiveness
of the locally prepared hand rubs.

MATERIAL AND METHODS
The Alexandria University Students Hospital is a 220 bedded tertiary
care and referral hospital. The study was performed from June to
September 2009 in three intensive care units (ICUs) with 18 beds and the
renal dialysis unit at the hospital (23 machines). After approval of the ethical
committee, 20 nurses volunteered to participate in a pre/post test designed
study and written informed consents were not required. They performed
the proper hand hygiene procedures under close observation, according to
the policies implemented by the infection control committee in the hospital.
Four hand disinfectants were examined in comparison to hand
washing with non-antiseptic soap and water (SW). These disinfectants
included 3 commercially available in the Egyptian market; 2 hand rub
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liquids as Brand A [ethanol 80%, iso-propanol 45%, n-propanol 30%, and
mecetronium etilsulfate 0.2%] and Brand B [ethanol 96%], and a hand rub
gel Brand C [iso-propanol 60% (v/v) and ethanol 65% (v/v)]. The fourth
disinfectant was a hand rub liquid locally prepared according to the World
Health Organization recommended hand rub formulation (hand rub D)
with ethanol 80% (v/v).
(11)

For each disinfectant, hand samples (imprints of 5 fingertips) were
taken from nurses who have had direct contact with at least one patient
before the use of one specific disinfectant, and after its application.
Microbiological sampling and processing
Two hundred plates were examined for direct finger-prints of the
dominant hand taken before and after hand hygiene procedures. After
hand washing, the hands were dried using disposable tissues and in case of
alcohol hand rubs hands were allowed to air-dry. Each fingertip was
pressed onto a Columbia blood agar plate (one plate / 5 fingers).
Participants were then asked to use one of the tested hand hygiene
methods, then sampling was repeated in the same manner for other
methods, each on a different day. Plates were incubated for 24h at 37C
under aerobic conditions. Total bacterial count was recorded as the number
of colony forming units (CFU)/hand. Bacterial isolates were identified
using standard microbiological procedures.
(12)

Statistical Analysis
Data were analyzed by the Statistical Package for Social Sciences (SSPS
version 11.5). Bacterial counts before and after application of one of the
hand hygiene methods were compared using Wilcoxon signed ranks test.
Percentage reduction for all methods was calculated, tested by Kruskal
Wallis, and comparison between methods was done by Mann Whitney test.
Statistical significance was accepted at p 0.05.
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RESULTS
Bacteria isolated from the fingertips of the nursing staff are shown in
table (1). A total of 124 bacterial agents were isolated. More than half of the
samples (57%) showed mixed pattern of colonization by 2 or more bacterial
isolates, while 43% yielded a single isolate. Coagulase-negative
staphylococci (CoNS) were isolated from 80% of nurses' fingertips, while S.
aureus and Gram-negative bacilli (GNB) were colonizing 8% and 9% of
fingertips samples, respectively (Table 2). Bacterial count before application
of hand hygiene was considered as the baseline and ranged from 10 to 900
CFU/hand, with an average mean of 131.9 (154.8) CFU/hand.
There was a significant percentage reduction in bacterial count for each
method used as hand hygiene, with the gel hand rub (C) being the least
reducing method (p <0.05, using Mann Whitney test); while the locally
prepared hand rub (D) did not show any statistically significant difference
(p >0.05, using Mann Whitney test) when compared to the other hand rubs.

Table (1): Isolated Bacteria from Fingertips of the Nursing Staff
(before performing hand hygiene)
Bacterial Isolates
Frequency of isolation
No. %
CoNS 80 64.5
S. aureus 8 6.5
Diphtheroids 27 21.8
GNB 9 7.3
Total 124 100.0
CoNS: coagulase negative staphylococci
S. aureus: Staphylococcus aureus
GNB: Gram negative bacilli

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Table (2): Frequency of Bacterial Colonization on the Hands of the Nursing
staff
Bacterial Isolates
Bacterial colonization / 100 hands
*

No. %#
CoNS 80 80
S. aureus 8 8
Diphtheroids 27 27
GNB 9 9
* 100 hands: (20 nurses x5times) before performing hand hygiene
CoNS: coagulase negative staphylococci
S. aureus: Staphylococcus aureus, GNB: Gram negative bacilli
#: Percentages do not sum up to 100 due to overlap (mixed colonization)

DISCUSSION
Hands are normally colonized by resident and transient bacterial flora,
according to the layer of skin they colonize. Resident flora, the less
pathogenic bacteria is more resistant to remove (e.g., CoNS and
Diphtheroids). Transient flora is more likely to cause disease and is less
resistant to remove. (e.g: S. aureus, GNB). Hands are contaminated by this
flora during contact with patients or environmental flora contaminated by
patients environment.
(12,13)
Their number increases with the duration of
clinical activities, on average by 16 CFU /min.
(14)

CoNS are the main type of resident skin flora, they are found on
almost every hand.
(15)
In our study, CoNS colonized 80% of nurses hands.
Nearly similar results were reported by Cimiotti et al. (NY-USA, 2004),
where CoNS were found to colonize 133 (86.3%) and 74 (92.5%) of hands of
the experienced nurses and newly graduate nurses respectively; though
methicillin-resistant CoNS were isolated significantly more often from the
experienced nurses than from the new graduate nurses (95% and 33%
respectively).
(16)
In another study (Michigan-USA, 2000), out of all isolated
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bacteria colonizing hand flora of 119 nurses working in neonatal ICUs,
85.7% were staphylococci. CoNS were also found on and under the nails of
all HCWs participating.
(17)

Regarding transient flora, S. aureus was found to colonize 8% of
examined hands in the present study, while GNB were isolated from 9% of
samples, including Escherichia coli, Klebsiella pneumoniae, Proteus
mirabilis, and Pseudomonas aeruginosa. Likewise, equivalent results were
reported for S. aureus and GNB colonization in 4% and 14% of HCWs in a
recent study (Egypt, 2010).
(18)
Similarly, Cook et al. (NY- USA, 2007) found
that GNB represented 6.6% of total bacterial isolates of hands of HCWs in
ICUs.
(19)

Epidemics have been reported due to contaminated hands of HCWs
with transient flora. Therefore, hand hygiene was considered as the most
important, cheapest and most effective infection control measure in
preventing horizontal transmission of HAIs. In the meantime, HCWs
showed poor compliance to hand washing, mostly due to increased patient
workload, decreased staffing, long distances to sinks and availability of
water, and the washing and drying could be difficult owing to time
constraint, especially in ICUs. Thus, hand rubbing with alcohol based
solution was introduced to provide effective antisepsis, which does not
require the use of sinks and is easier than using soap.
(20, 21)

Moreover, the antimicrobial effect of alcohol rubs far exceeds that of
hand washing with un-medicated soap, as illustrated in the present study
where SW showed the least (30%) percentage reduction (Table 3). Also, the
antimicrobial efficacy of alcohol rubs is not only directly related to the
concentration but, when comparing mean reduction factors of
corresponding concentrations, there is also a clear ranking of order in the
efficacy of the alcohols formulations: ethanol is less effective than iso-
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propanol.
(22)
This goes with our results as Brand A showed the highest
(99%) percentage reduction, while the brands B and D (locally prepared)
were 94% and 87%, respectively, yet with no statistically significant
differences. It was also demonstrated that hand rubs were also affected by
their types where the gel hand rub (Brand C) had the least efficacy among
hand rubs in reducing bacterial hand contamination (77%).

Table (3): Percentage Reduction of Bacterial Counts after Performing Hand
Hygiene
Bacterial counts (CFU/hand)
Hand hygiene
method
Mean ( SD )
Median %
reduction
Z (p)
SW 43.86 ( 38.36) 30 2.802
*
(0.005)
A 82.30 ( 36.14) 99 3.230
*
(0.001)
B 79.45 ( 32.49) 94 3.733
*
(<0.001)
C 65.55 ( 30.93) 77 3.636
*
(<0.001)
D 71.12 ( 34.01) 87 2.978
*
(0.003)

(P 23.023
*
(<0.001)
A, B: liquids, and C: gel (commercial handrubs)
D: liquid (locally prepared handrub)

: Chi square for Kruskal Wallis test, Z: Z for Wilcoxon signed ranks test
* : Statistically significant at p 0.05

CONCLUSION AND RECOMMMENDATIONS
Alcohol-based hand rub is far more efficient than traditional hand
washing, and more convenient and time saving. It is recommended as a
hand hygiene practice in critical settings such as dialysis units and ICUs,
particularly when sink and running water are inaccessible. Alcohol-based
hand gels should not replace liquid hand disinfectants, as they have lower
efficacy in reducing bacterial contamination.
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Taking into consideration the limited resources in developing
countries that lead to difficulties in maintaining hand hygiene practices; it
could be encouraging to utilize the locally prepared hand rubs that are
comparable to the commercial brands, with same efficacy and at a lower
cost.

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