Commentary: Reexamining Methods and Messaging for Hand Hygiene in the Era of Increasing Clostridium difficile Colonization and Infection

Abstract

There is little question that use of alcohol-based hand rub (ABHR) as the primary mode of hand hygiene in healthcare settings, which is strongly encouraged by the Centers for Dis­ ease Control and Prevention and the World Health Organi­ zation, has increased adherence to recommended hand hy­ giene practices worldwide. Compared with use of soap and water, use of ABHR requires less time, irritates hands less, and is possible at the patient bedside more often. Although ABHR has excellent germicidal activity against a broad spec­ trum of bacteria and viruses, including multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus species, ABHR is not efficacious against spore-forming organisms, such as Clostridium difficile. The 2009 World Health Organization guidelines accommodate this discrepancy in ABHR efficacy by recommending hand washing with soap and water for visibly soiled hands or “if exposure to potential spore-forming organisms is strongly suspected or proven, including out­ breaks of C. difficile [infection]”; for all other situations, the guidelines recommend use of ABHR as the preferred means of routine hand hygiene in healthcare facilities. As C. difficile infection rates increase in the United States, many healthcare facilities have begun encouraging the routine use of soap and water for the care of all patients with active C. difficile–associated diarrhea. However, experts and clinicians have expressed concern about the patientand situation-spe­ cific nature of the recommendations; they fear that incon­ sistency in hand hygiene messaging could potentially dis­ courage ABHR use, which could plausibly decrease the frequency with which healthcare personnel perform hand hy­ giene when indicated. In this issue of the journal, Jabbar et al confirm that hand washing with soap and water demonstrates efficacy superior to that of ABHR use in reducing C. difficile spore counts on hands. Furthermore, the authors report that C. difficile spores were readily transferred through hand-to-hand contact sub­ sequent to hand hygiene with ABHR. The study enlisted 10 volunteers who cleansed their hands with nonmedicated soap and water before inoculation of the palm with a 100-mL C. difficile spore suspension of 500,000 colony-forming units (CFU). Volunteers then performed a 15-second bipalmar hand rub and a 3-minute air dry. A postinoculation stamp for culture was performed before volunteers cleansed their hands with 1 of 5 agents: 5 mL of chlorhexidine gluconate soap (Hibiclens) and water, 2 mL each of 1 of the 3 ABHR products, or water only (control). Immediately after hand hygiene, a post–hand hygiene stamp for culture was per­ formed to assess the log reduction in spore concentration for the 4 hand hygiene products tested relative to the water con­ trol. For chlorhexidine soap and only 1 of the 3 ABHR prod­ ucts, log reductions in residual spore concentrations on hands were significantly greater than log reductions with the water control; chlorhexidine soap and water showed significantly greater log reductions, compared with all 3 ABHR products. The article by Jabbar et al follows a recent article by Ough­ ton et al in which similar conclusions were drawn: use of ABHR did not produce statistically significant log reductions in spore concentration, compared with no hand hygiene at all, and washing with either antimicrobial or plain soap dem­ onstrated significantly greater reductions in spore concentra­ tion than did use of ABHR. The articles by both Oughton et al and Jabbar et al represent in vivo studies that confirm in vitro findings about the superior efficacy of washing with soap and water, compared with the efficacy of using ABHR, for the purpose of eliminating C. difficile spores. These studies relay a clear message: the efficacy of washing with soap and water is superior to that of using ABHR for eliminating C. difficile spores from hands. Hospital admin­ istrators and infection control personnel, however, must set hand hygiene policies that consider C. difficile infections as well as other healthcare-associated infections. Recommending that healthcare personnel use soap and water for patients with