John A. Molinari, PhD
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Hand washing has been the historical standard for cleanliness since the early 1800s. The classic observations of Semmelweis, Holmes, and others laid the foundation for hand washing being regarded as the most important infection-control measure for preventing cross-infection of pathogens in health-care facilities.
Since that time, a variety of chemical agents have been shown to be effective, ranging from the earliest solutions of lime and soda chlorides to current, less toxic, antimicrobial antiseptics. The U.S. Public Health Service, Association of Practitioners for Infection Control, and other health organizations continue to emphasze the importance of hand washing, hand antisepsis – and most recently – appropriate use of waterless, alcohol-based hand hygiene antiseptics. Using the CDC Guidelines for Infection Control in Dental Health-Care Settings 2003 as a recent source, the following hand hygiene recommendation was provided:
"Perform hand hygiene with either a non-antimicrobial or antimicrobial soap and water when hands are visibly dirty or contaminated with blood or other potentially infectious material. If hands are not visibly soiled, an alcohol-based hand rub can also be used. Follow the manufacturer's instructions."
Numerous products are available to accomplish these cleaning and antisepsis goals. Many contain similar active agents. Individuals often inquire as to what, if any, criteria are available to assist in evaluating a new hand hygiene product for a clinical facility. Consideration of the following areas can provide useful information when considering adoption of a new water-based or waterless formulation.
1) Effectiveness: The primary value of soaps and other anionic detergents lies in their ability to accomplish mechanical cleaning of epithelial tissues. This action results in the removal of debris and other organic substances. Since a basic premise for infection control is to clean first, a plain liquid soap is adequate when washing hands to remove bioburden. Most health-care workers (HCW) use antimicrobial antiseptics with water to routinely wash their hands. The U.S. Food and Drug Administration Division of Over-the-Counter Drug Products is responsible for regulation of these antiseptic hand wash and surgical hand scrub products intended for use by HCW. Optimal features to consider are whether a product has a broad antimicrobial spectrum, exhibits persistent activity (substantivity), and is fast acting on tissues. For soaps and water-based antiseptic products, the ease and extent of lathering also can affect acceptance.
2) Irritation and skin damage: HCW routinely wash their hands or use waterless hand antiseptics 20 to 30 or more times a day at work. At the very least, lubricating skin oils can be removed with these repeated procedures. Frequent hand washing, especially with anionic detergents, greatly increases the potential for dryness and epithelial irritation. In fact, nonspecific irritation dermatitis is the most frequently reported form of skin irritation. This was discussed in more detail in an earlier column (Dental Economics®, December 2009). HCW questions also were raised when waterless, alcohol-based, hand hygiene products were introduced into hospitals and other clinical facilities. The issue centered around potential tissue damage resulting from routine exposure to high concentrations of alcohol. As a result, health professionals were slow to initially use this type of antiseptic. Emollients, such as glycerin or aloe vera, which are added to most products, have fortunately addressed this issue, as they help to moisturize skin and reduce dryness.
3) Personal preferences (e.g., scent): A variety of scented additives are found in many products that are designed for occasional personal use during the day. While these scents may be pleasant for many people, strong fragrances can adversely affect people with sensitive skin and/or allergies to perfumes, laundry detergents, etc. Frequent use of heavily scented agents can cause either a nonspecific or an allergic dermatitis, especially in health-care facilities where multiple hand hygiene procedures are performed daily. Suggestions are to use hand hygiene products that have been developed and tested for health-care facilities and to consider strong scented hand hygiene products as possible causes of dermatitis problems.
In addition to the few considerations discussed above, other factors include compatibility of the agent with lotions used within the clinical setting, dispensing/delivery systems, staff acceptance, and cost per use. Products that are not well accepted by HCW, unfortunately, can act as a deterrent to effective hand hygiene.
Dr. John A. Molinari is director of infection control for THE DENTAL ADVISOR. Previously, he was professor and chairman of the Department of Biomedical Sciences at the University of Detroit Mercy School of Dentistry. Contact him at firstname.lastname@example.org.
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