RR5116-Front Cover.p65

Morbidity and Mortality Weekly Report

Recommendations and Reports October 25, 2002 / Vol. 51 / No. RR-16

Centers for Disease Control and PreventionCenters for Disease Control and Prevention

Centers for Disease Control and Prevention

SAFER • HEALSAFER • HEAL

SAFER • HEAL

THIER • PEOPLETHIER • PEOPLE

THIER • PEOPLE

INSIDE: Continuing Education Examination

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

SUGGESTED CITATION

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):[inclusive page numbers].

The MMWR series of publications is published by the

Epidemiology Program Office, Centers for Disease

Control and Prevention (CDC), U.S. Department of

Health and Human Services, Atlanta, GA 30333.

Centers for Disease Control and Prevention

Julie L. Gerberding, M.D., M.P.H.

Director

David W. Fleming, M.D.

Deputy Director for Science and Public Health

Dixie E. Snider, Jr., M.D., M.P.H.

Associate Director for Science

Epidemiology Program Office

Stephen B. Thacker, M.D., M.Sc.

Director

Office of Scientific and Health Communications

John W. Ward, M.D.

Director

Editor, MMWR Series

Suzanne M. Hewitt, M.P.A.

Managing Editor

Rachel J. Wilson

Douglas W. Weatherwax

Project Editors

Malbea A. Heilman

Beverly J. Holland

Visual Information Specialists

Quang M. Doan

Erica R. Shaver

Information Technology Specialists

CONTENTS

Part I. Review of the Scientific Data Regarding

Hand Hygiene ................................................................... 1

Historical Perspective ........................................................ 1

Normal Bacterial Skin Flora .............................................. 2

Physiology of Normal Skin ................................................ 2

Definition of Terms ............................................................ 3

Evidence of Transmission of Pathogens on Hands .............. 4

Models of Hand Transmission ............................................ 5

Relation of Hand Hygiene and Acquisition

of Health-Care–Associated Pathogens ........................... 5

Methods Used To Evaluate the Efficacy

of Hand-Hygiene Products ............................................. 6

Review of Preparations Used for Hand Hygiene ................. 8

Activity of Antiseptic Agents Against

Spore-Forming Bacteria ............................................... 16

Reduced Susceptibility of Bacteria to Antiseptics .............. 17

Surgical Hand Antisepsis ................................................. 17

Relative Efficacy of Plain Soap, Antiseptic

Soap/Detergent, and Alcohols ..................................... 18

Irritant Contact Dermatitis Resulting from

Hand-Hygiene Measures ............................................. 18

Proposed Methods for Reducing Adverse

Effects of Agents .......................................................... 19

Factors To Consider When Selecting

Hand-Hygiene Products ............................................... 20

Hand-Hygiene Practices Among HCWs ........................... 21

Lessons Learned from Behavioral Theories ...................... 25

Methods Used To Promote Improved Hand Hygiene ........ 26

Efficacy of Promotion and Impact of Improved

Hand Hygiene ............................................................. 27

Other Policies Related to Hand Hygiene .......................... 29

Hand-Hygiene Research Agenda..................................... 30

Web-Based Hand-Hygiene Resources ................................ 30

Part II. Recommendations .................................................. 31

Categories ...................................................................... 31

Recommendations .......................................................... 32

Part III. Performance Indicators .......................................... 34

References ......................................................................... 34

Appendix ........................................................................... 45

Continuing Education Activity ......................................... CE-1

Vol. 51 / RR-16 Recommendations and Reports 1

The material in this report originated in the National Center for

Infectious Diseases, James M. Hughes, M.D., Director; and the Division

of Healthcare Quality Promotion, Steve Solomon, M.D., Acting

Director.

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

Prepared by

John M. Boyce, M.D.

Didier Pittet, M.D.

Hospital of Saint Raphael

New Haven, Connecticut

University of Geneva

Geneva, Switzerland

Summary

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regard-

ing handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote

improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care

settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for

handwashing and hospital environmental control, 1985. Infect Control 1986;7:231–43) and the 1995 APIC guideline

(Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings.

Am J Infect Control 1995;23:251–69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels

of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in

vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies

demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs

in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand

antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Part I. Review of the Scientific Data

Regarding Hand Hygiene

Historical Perspective

For generations, handwashing with soap and water has been

considered a measure of personal hygiene (1). The concept of

cleansing hands with an antiseptic agent probably emerged in

the early 19

century. As early as 1822, a French pharmacist

demonstrated that solutions containing chlorides of lime or

soda could eradicate the foul odors associated with human

corpses and that such solutions could be used as disinfectants

and antiseptics (2). In a paper published in 1825, this phar-

macist stated that physicians and other persons attending

patients with contagious diseases would benefit from moist-

ening their hands with a liquid chloride solution (2).

In 1846, Ignaz Semmelweis observed that women whose

babies were delivered by students and physicians in the First

Clinic at the General Hospital of Vienna consistently had a

higher mortality rate than those whose babies were delivered

by midwives in the Second Clinic (3). He noted that physi-

cians who went directly from the autopsy suite to the obstet-

rics ward had a disagreeable odor on their hands despite

washing their hands with soap and water upon entering the

obstetrics clinic. He postulated that the puerperal fever that

affected so many parturient women was caused by “cadaver-

ous particles” transmitted from the autopsy suite to the

obstetrics ward via the hands of students and physicians. Per-

haps because of the known deodorizing effect of chlorine com-

pounds, as of May 1847, he insisted that students and

physicians clean their hands with a chlorine solution between

each patient in the clinic. The maternal mortality rate in the

First Clinic subsequently dropped dramatically and remained

low for years. This intervention by Semmelweis represents the

first evidence indicating that cleansing heavily contaminated

hands with an antiseptic agent between patient contacts may

reduce health-care–associated transmission of contagious dis-

eases more effectively than handwashing with plain soap and

water.

In 1843, Oliver Wendell Holmes concluded independently

that puerperal fever was spread by the hands of health person-

nel (1). Although he described measures that could be taken

to limit its spread, his recommendations had little impact on

2 MMWR October 25, 2002

obstetric practices at the time. However, as a result of the semi-

nal studies by Semmelweis and Holmes, handwashing gradu-

ally became accepted as one of the most important measures

for preventing transmission of pathogens in health-care facilities.

In 1961, the U. S. Public Health Service produced a train-

ing film that demonstrated handwashing techniques recom-

mended for use by health-care workers (HCWs) (4). At the

time, recommendations directed that personnel wash their

hands with soap and water for 1–2 minutes before and after

patient contact. Rinsing hands with an antiseptic agent was

believed to be less effective than handwashing and was recom-

mended only in emergencies or in areas where sinks were un-

available.

In 1975 and 1985, formal written guidelines on

handwashing practices in hospitals were published by CDC

(5,6). These guidelines recommended handwashing with non-

antimicrobial soap between the majority of patient contacts

and washing with antimicrobial soap before and after perform-

ing invasive procedures or caring for patients at high risk. Use

of waterless antiseptic agents (e.g., alcohol-based solutions)

was recommended only in situations where sinks were not

available.

In 1988 and 1995, guidelines for handwashing and hand

antisepsis were published by the Association for Professionals

in Infection Control (APIC) (7,8). Recommended indications

for handwashing were similar to those listed in the CDC guide-

lines. The 1995 APIC guideline included more detailed dis-

cussion of alcohol-based hand rubs and supported their use in

more clinical settings than had been recommended in earlier

guidelines. In 1995 and 1996, the Healthcare Infection Con-

trol Practices Advisory Committee (HICPAC) recommended

that either antimicrobial soap or a waterless antiseptic agent

be used for cleaning hands upon leaving the rooms of patients

with multidrug-resistant pathogens (e.g., vancomycin-resistant

enterococci [VRE] and methicillin-resistant Staphylococcus

aureus [MRSA]) (9,10). These guidelines also provided rec-

ommendations for handwashing and hand antisepsis in other

clinical settings, including routine patient care. Although the

APIC and HICPAC guidelines have been adopted by the

majority of hospitals, adherence of HCWs to recommended

handwashing practices has remained low (11,12).

Recent developments in the field have stimulated a review

of the scientific data regarding hand hygiene and the develop-

ment of new guidelines designed to improve hand-hygiene

practices in health-care facilities. This literature review and

accompanying recommendations have been prepared by a

Hand Hygiene Task Force, comprising representatives from

HICPAC, the Society for Healthcare Epidemiology of America

(SHEA), APIC, and the Infectious Diseases Society of America

(IDSA).

Normal Bacterial Skin Flora

To understand the objectives of different approaches to hand

cleansing, a knowledge of normal bacterial skin flora is essen-

tial. Normal human skin is colonized with bacteria; different

areas of the body have varied total aerobic bacterial counts

(e.g., 1 x 10

colony forming units (CFUs)/cm

on the scalp,

5 x 10

CFUs/cm

in the axilla, 4 x 10

CFUs/cm

on the

abdomen, and 1 x 10

CFUs/cm

on the forearm) (13). Total

bacterial counts on the hands of medical personnel have ranged

from 3.9 x 10

to 4.6 x 10

(14–17). In 1938, bacteria recov-

ered from the hands were divided into two categories: tran-

sient and resident (14). Transient flora, which colonize the

superficial layers of the skin, are more amenable to removal by

routine handwashing. They are often acquired by HCWs dur-

ing direct contact with patients or contact with contaminated

environmental surfaces within close proximity of the patient.

Transient flora are the organisms most frequently associated

with health-care–associated infections. Resident flora, which

are attached to deeper layers of the skin, are more resistant to

removal. In addition, resident flora (e.g., coagulase-negative

staphylococci and diphtheroids) are less likely to be associated

with such infections. The hands of HCWs may become per-

sistently colonized with pathogenic flora (e.g., S. aureus), gram-

negative bacilli, or yeast. Investigators have documented that,

although the number of transient and resident flora varies con-

siderably from person to person, it is often relatively constant

for any specific person (14,18).

Physiology of Normal Skin

The primary function of the skin is to reduce water loss,

provide protection against abrasive action and microorgan-

isms, and act as a permeability barrier to the environment.

The basic structure of skin includes, from outer- to inner-

most layer, the superficial region (i.e., the stratum corneum or

horny layer, which is 10- to 20-µm thick), the viable epider-

mis (50- to 100-µm thick), the dermis (1- to 2-mm thick),

and the hypodermis (1- to 2-mm thick). The barrier to percu-

taneous absorption lies within the stratum corneum, the thin-

nest and smallest compartment of the skin. The stratum

corneum contains the corneocytes (or horny cells), which are

flat, polyhedral-shaped nonnucleated cells, remnants of the

terminally differentiated keratinocytes located in the viable

epidermis. Corneocytes are composed primarily of insoluble

bundled keratins surrounded by a cell envelope stabilized by

cross-linked proteins and covalently bound lipid. Intercon-

necting the corneocytes of the stratum corneum are polar struc-

tures (e.g., corneodesmosomes), which contribute to stratum

corneum cohesion.

Vol. 51 / RR-16 Recommendations and Reports 3

The intercellular region of the stratum corneum is com-

posed of lipid primarily generated from the exocytosis of lamel-

lar bodies during the terminal differentiation of the

keratinocytes. The intercellular lipid is required for a compe-

tent skin barrier and forms the only continuous domain.

Directly under the stratum corneum is a stratified epidermis,

which is composed primarily of 10–20 layers of keratinizing

epithelial cells that are responsible for the synthesis of the stra-

tum corneum. This layer also contains melanocytes involved

in skin pigmentation; Langerhans cells, which are important

for antigen presentation and immune responses; and Merkel

cells, whose precise role in sensory reception has yet to be fully

delineated. As keratinocytes undergo terminal differentiation,

they begin to flatten out and assume the dimensions charac-

teristic of the corneocytes (i.e., their diameter changes from

10–12 µm to 20–30 µm, and their volume increases by 10- to

20-fold). The viable epidermis does not contain a vascular

network, and the keratinocytes obtain their nutrients from

below by passive diffusion through the interstitial fluid.

The skin is a dynamic structure. Barrier function does not

simply arise from the dying, degeneration, and compaction of

the underlying epidermis. Rather, the processes of cornifica-

tion and desquamation are intimately linked; synthesis of the

stratum corneum occurs at the same rate as loss. Substantial

evidence now confirms that the formation of the skin barrier

is under homeostatic control, which is illustrated by the epi-

dermal response to barrier perturbation by skin stripping or

solvent extraction. Circumstantial evidence indicates that the

rate of keratinocyte proliferation directly influences the integ-

rity of the skin barrier. A general increase in the rate of prolif-

eration results in a decrease in the time available for 1) uptake

of nutrients (e.g., essential fatty acids), 2) protein and lipid

synthesis, and 3) processing of the precursor molecules required

for skin-barrier function. Whether chronic but quantitatively

smaller increases in rate of epidermal proliferation also lead to

changes in skin-barrier function remains unclear. Thus, the

extent to which the decreased barrier function caused by irri-

tants is caused by an increased epidermal proliferation also is

unknown.

The current understanding of the formation of the stratum

corneum has come from studies of the epidermal responses to

perturbation of the skin barrier. Experimental manipulations

that disrupt the skin barrier include 1) extraction of skin lip-

ids with apolar solvents, 2) physical stripping of the stratum

corneum using adhesive tape, and 3) chemically induced irri-

tation. All of these experimental manipulations lead to a

decreased skin barrier as determined by transepidermal water

loss (TEWL). The most studied experimental system is the

treatment of mouse skin with acetone. This experiment

results in a marked and immediate increase in TEWL, and

therefore a decrease in skin-barrier function. Acetone treat-

ment selectively removes glycerolipids and sterols from the

skin, which indicates that these lipids are necessary, though

perhaps not sufficient in themselves, for barrier function.

Detergents act like acetone on the intercellular lipid domain.

The return to normal barrier function is biphasic: 50%–60%

of barrier recovery typically occurs within 6 hours, but com-

plete normalization of barrier function requires 5–6 days.

Definition of Terms

Alcohol-based hand rub. An alcohol-containing preparation

designed for application to the hands for reducing the num-

ber of viable microorganisms on the hands. In the United

States, such preparations usually contain 60%–95% ethanol

or isopropanol.

Antimicrobial soap. Soap (i.e., detergent) containing an

antiseptic agent.

Antiseptic agent. Antimicrobial substances that are applied

to the skin to reduce the number of microbial flora. Examples

include alcohols, chlorhexidine, chlorine, hexachlorophene,

iodine, chloroxylenol (PCMX), quaternary ammonium com-

pounds, and triclosan.

Antiseptic handwash. Washing hands with water and soap or

other detergents containing an antiseptic agent.

Antiseptic hand rub. Applying an antiseptic hand-rub prod-

uct to all surfaces of the hands to reduce the number of micro-

organisms present.

Cumulative effect. A progressive decrease in the numbers of

microorganisms recovered after repeated applications of a test

material.

Decontaminate hands. To Reduce bacterial counts on hands

by performing antiseptic hand rub or antiseptic handwash.

Detergent. Detergents (i.e., surfactants) are compounds that

possess a cleaning action. They are composed of both hydro-

philic and lipophilic parts and can be divided into four groups:

anionic, cationic, amphoteric, and nonionic detergents.

Although products used for handwashing or antiseptic

handwash in health-care settings represent various types of

detergents, the term “soap” is used to refer to such detergents

in this guideline.

Hand antisepsis. Refers to either antiseptic handwash or

antiseptic hand rub.

Hand hygiene. A general term that applies to either

handwashing, antiseptic handwash, antiseptic hand rub, or

surgical hand antisepsis.

Handwashing. Washing hands with plain (i.e., non-antimi-

crobial) soap and water.

4 MMWR October 25, 2002

Persistent activity. Persistent activity is defined as the pro-

longed or extended antimicrobial activity that prevents or

inhibits the proliferation or survival of microorganisms after

application of the product. This activity may be demonstrated

by sampling a site several minutes or hours after application

and demonstrating bacterial antimicrobial effectiveness when

compared with a baseline level. This property also has been

referred to as “residual activity.” Both substantive and

nonsubstantive active ingredients can show a persistent effect

if they substantially lower the number of bacteria during the

wash period.

Plain soap. Plain soap refers to detergents that do not con-

tain antimicrobial agents or contain low concentrations of

antimicrobial agents that are effective solely as preservatives.

Substantivity. Substantivity is an attribute of certain active

ingredients that adhere to the stratum corneum (i.e., remain

on the skin after rinsing or drying) to provide an inhibitory

effect on the growth of bacteria remaining on the skin.

Surgical hand antisepsis. Antiseptic handwash or antiseptic

hand rub performed preoperatively by surgical personnel to

eliminate transient and reduce resident hand flora. Antiseptic

detergent preparations often have persistent antimicrobial

activity.

Visibly soiled hands. Hands showing visible dirt or visibly

contaminated with proteinaceous material, blood, or other

body fluids (e.g., fecal material or urine).

Waterless antiseptic agent. An antiseptic agent that does not

require use of exogenous water. After applying such an agent,

the hands are rubbed together until the agent has dried.

Food and Drug Administration (FDA) product categories. The

1994 FDA Tentative Final Monograph for Health-Care Anti-

septic Drug Products divided products into three categories

and defined them as follows (19):

• Patient preoperative skin preparation. A fast-acting, broad-

spectrum, and persistent antiseptic-containing preparation

that substantially reduces the number of microorganisms

on intact skin.

• Antiseptic handwash or HCW handwash. An antiseptic-

containing preparation designed for frequent use; it

reduces the number of microorganisms on intact skin to

an initial baseline level after adequate washing, rinsing,

and drying; it is broad-spectrum, fast-acting, and if pos-

sible, persistent.

• Surgical hand scrub. An antiseptic-containing preparation

that substantially reduces the number of microorganisms

on intact skin; it is broad-spectrum, fast-acting, and

persistent.

Evidence of Transmission

of Pathogens on Hands

Transmission of health-care–associated pathogens from one

patient to another via the hands of HCWs requires the fol-

lowing sequence of events:

• Organisms present on the patient’s skin, or that have been

shed onto inanimate objects in close proximity to the

patient, must be transferred to the hands of HCWs.

• These organisms must then be capable of surviving for at

least several minutes on the hands of personnel.

• Next, handwashing or hand antisepsis by the worker must

be inadequate or omitted entirely, or the agent used for

hand hygiene must be inappropriate.

• Finally, the contaminated hands of the caregiver must come

in direct contact with another patient, or with an inani-

mate object that will come into direct contact with the

patient.

Health-care–associated pathogens can be recovered not only

from infected or draining wounds, but also from frequently

colonized areas of normal, intact patient skin (20– 31). The

perineal or inguinal areas are usually most heavily colonized,

but the axillae, trunk, and upper extremities (including the

hands) also are frequently colonized (23,25,26,28,30–32). The

number of organisms (e.g., S. aureus, Proteus mirabilis, Kleb-

siella spp., and Acinetobacter spp.) present on intact areas of

the skin of certain patients can vary from 100 to 10

/cm

(25,29,31,33). Persons with diabetes, patients undergoing

dialysis for chronic renal failure, and those with chronic der-

matitis are likely to have areas of intact skin that are colonized

with S. aureus (34–41). Because approximately 10

skin

squames containing viable microorganisms are shed daily from

normal skin (42), patient gowns, bed linen, bedside furniture,

and other objects in the patient’s immediate environment can

easily become contaminated with patient flora (30,43–46).

Such contamination is particularly likely to be caused by sta-

phylococci or enterococci, which are resistant to dessication.

Data are limited regarding the types of patient-care activi-

ties that result in transmission of patient flora to the hands of

personnel (26,45–51). In the past, attempts have been made

to stratify patient-care activities into those most likely to cause

hand contamination (52), but such stratification schemes were

never validated by quantifying the level of bacterial contami-

nation that occurred. Nurses can contaminate their hands with

100–1,000 CFUs of Klebsiella spp. during “clean” activities

(e.g., lifting a patient; taking a patient’s pulse, blood pressure,

or oral temperature; or touching a patient’s hand, shoulder, or

groin) (48). Similarly, in another study, hands were cultured

of nurses who touched the groins of patients heavily colo-

nized with P. mirabilis (25); 10–600 CFUs/mL of this

Vol. 51 / RR-16 Recommendations and Reports 5

organism were recovered from glove juice samples from the

nurses’ hands. Recently, other researchers studied contamina-

tion of HCWs’ hands during activities that involved direct

patient-contact wound care, intravascular catheter care, respiratory-

tract care, and the handling of patient secretions (51). Agar

fingertip impression plates were used to culture bacteria; the

number of bacteria recovered from fingertips ranged from 0

to 300 CFUs. Data from this study indicated that direct

patient contact and respiratory-tract care were most likely to

contaminate the fingers of caregivers. Gram-negative bacilli

accounted for 15% of isolates and S. aureus for 11%. Dura-

tion of patient-care activity was strongly associated with the

intensity of bacterial contamination of HCWs’ hands.

HCWs can contaminate their hands with gram-negative

bacilli, S. aureus, enterococci, or Clostridium difficile by per-

forming “clean procedures” or touching intact areas of the

skin of hospitalized patients (26,45,46,53). Furthermore, per-

sonnel caring for infants with respiratory syncytial virus (RSV)

infections have acquired RSV by performing certain activities

(e.g., feeding infants, changing diapers, and playing with

infants) (49). Personnel who had contact only with surfaces

contaminated with the infants’ secretions also acquired RSV

by contaminating their hands with RSV and inoculating their

oral or conjunctival mucosa. Other studies also have docu-

mented that HCWs may contaminate their hands (or gloves)

merely by touching inanimate objects in patient rooms (46,53–

56). None of the studies concerning hand contamination of

hospital personnel were designed to determine if the contami-

nation resulted in transmission of pathogens to susceptible

patients.

Other studies have documented contamination of HCWs’

hands with potential health-care–associated pathogens, but did

not relate their findings to the specific type of preceding

patient contact (15,17,57–62). For example, before glove use

was common among HCWs, 15% of nurses working in an

isolation unit carried a median of 1 x 10

CFUs of S. aureus

on their hands (61). Of nurses working in a general hospital,

29% had S. aureus on their hands (median count: 3,800 CFUs),

whereas 78% of those working in a hospital for dermatology

patients had the organism on their hands (median count: 14.3

x 10

CFUs). Similarly, 17%–30% of nurses carried gram-

negative bacilli on their hands (median counts: 3,400–38,000

CFUs). One study found that S. aureus could be recovered

from the hands of 21% of intensive-care–unit personnel and

that 21% of physician and 5% of nurse carriers had >1,000

CFUs of the organism on their hands (59). Another study

found lower levels of colonization on the hands of personnel

working in a neurosurgery unit, with an average of 3 CFUs of

S. aureus and 11 CFUs of gram-negative bacilli (16). Serial

cultures revealed that 100% of HCWs carried gram-negative

bacilli at least once, and 64% carried S. aureus at least once.

Models of Hand Transmission

Several investigators have studied transmission of infectious

agents by using different experimental models. In one study,

nurses were asked to touch the groins of patients heavily colo-

nized with gram-negative bacilli for 15 seconds — as though

they were taking a femoral pulse (25). Nurses then cleaned

their hands by washing with plain soap and water or by using

an alcohol hand rinse. After cleaning their hands, they touched

a piece of urinary catheter material with their fingers, and the

catheter segment was cultured. The study revealed that touch-

ing intact areas of moist skin of the patient transferred enough

organisms to the nurses’ hands to result in subsequent trans-

mission to catheter material, despite handwashing with plain

soap and water.

The transmission of organisms from artificially contami-

nated “donor” fabrics to clean “recipient” fabrics via hand

contact also has been studied. Results indicated that the num-

ber of organisms transmitted was greater if the donor fabric or

the hands were wet upon contact (63). Overall, only 0.06% of

the organisms obtained from the contaminated donor fabric

were transferred to recipient fabric via hand contact. Staphylo-

coccus saprophyticus, Pseudomonas aeruginosa, and Serratia spp.

were also transferred in greater numbers than was Escherichia

coli from contaminated fabric to clean fabric after hand con-

tact (64). Organisms are transferred to various types of sur-

faces in much larger numbers (i.e., >10

) from wet hands than

from hands that are thoroughly dried (65).

Relation of Hand Hygiene and

Acquisition of Health-Care–Associated

Pathogens

Hand antisepsis reduces the incidence of health-care–

associated infections (66,67). An intervention trial using his-

torical controls demonstrated in 1847 that the mortality rate

among mothers who delivered in the First Obstetrics Clinic at

the General Hospital of Vienna was substantially lower when

hospital staff cleaned their hands with an antiseptic agent than

when they washed their hands with plain soap and water (3).

In the 1960s, a prospective, controlled trial sponsored by

the National Institutes of Health and the Office of the Sur-

geon General demonstrated that infants cared for by nurses

who did not wash their hands after handling an index infant

colonized with S. aureus acquired the organism more often

and more rapidly than did infants cared for by nurses who

used hexachlorophene to clean their hands between infant

6 MMWR October 25, 2002

contacts (68). This trial provided evidence that, when com-

pared with no handwashing, washing hands with an antisep-

tic agent between patient contacts reduces transmission of

health-care–associated pathogens.

Trials have studied the effects of handwashing with plain

soap and water versus some form of hand antisepsis on health-

care–associated infection rates (69,70). Health-care–associated

infection rates were lower when antiseptic handwashing was

performed by personnel (69). In another study, antiseptic

handwashing was associated with lower health-care–associated

infection rates in certain intensive-care units, but not in

others (70).

Health-care–associated infection rates were lower after anti-

septic handwashing using a chlorhexidine-containing deter-

gent compared with handwashing with plain soap or use of an

alcohol-based hand rinse (71). However, because only a mini-

mal amount of the alcohol rinse was used during periods when

the combination regimen also was in use and because adher-

ence to policies was higher when chlorhexidine was available,

determining which factor (i.e., the hand-hygiene regimen or

differences in adherence) accounted for the lower infection

rates was difficult. Investigators have determined also that

health-care–associated acquisition of MRSA was reduced when

the antimicrobial soap used for hygienic handwashing was

changed (72,73).

Increased handwashing frequency among hospital staff has

been associated with decreased transmission of Klebsiella spp.

among patients (48); these studies, however, did not quanti-

tate the level of handwashing among personnel. In a recent

study, the acquisition of various health-care–associated patho-

gens was reduced when hand antisepsis was performed more

frequently by hospital personnel (74); both this study and

another (75) documented that the prevalence of health-care–

associated infections decreased as adherence to recommended

hand-hygiene measures improved.

Outbreak investigations have indicated an association

between infections and understaffing or overcrowding; the

association was consistently linked with poor adherence to

hand hygiene. During an outbreak investigation of risk fac-

tors for central venous catheter-associated bloodstream infec-

tions (76), after adjustment for confounding factors, the

patient-to-nurse ratio remained an independent risk factor for

bloodstream infection, indicating that nursing staff reduction

below a critical threshold may have contributed to this out-

break by jeopardizing adequate catheter care. The understaffing

of nurses can facilitate the spread of MRSA in intensive-care

settings (77) through relaxed attention to basic control mea-

sures (e.g., hand hygiene). In an outbreak of Enterobacter cloa-

cae in a neonatal intensive-care unit (78), the daily number of

hospitalized children was above the maximum capacity of the

unit, resulting in an available space per child below current

recommendations. In parallel, the number of staff members

on duty was substantially less than the number necessitated

by the workload, which also resulted in relaxed attention to

basic infection-control measures. Adherence to hand-hygiene

practices before device contact was only 25% during the

workload peak, but increased to 70% after the end of the

understaffing and overcrowding period. Surveillance docu-

mented that being hospitalized during this period was associ-

ated with a fourfold increased risk of acquiring a

health-care–associated infection. This study not only demon-

strates the association between workload and infections, but

it also highlights the intermediate cause of antimicrobial spread:

poor adherence to hand-hygiene policies.

Methods Used To Evaluate the Efficacy

of Hand-Hygiene Products

Current Methods

Investigators use different methods to study the in vivo effi-

cacy of handwashing, antiseptic handwash, and surgical hand

antisepsis protocols. Differences among the various studies

include 1) whether hands are purposely contaminated with

bacteria before use of test agents, 2) the method used to con-

taminate fingers or hands, 3) the volume of hand-hygiene prod-

uct applied to the hands, 4) the time the product is in contact

with the skin, 5) the method used to recover bacteria from the

skin after the test solution has been used, and 6) the method

of expressing the efficacy of the product (i.e., either percent

reduction in bacteria recovered from the skin or log reduction

of bacteria released from the skin). Despite these differences,

the majority of studies can be placed into one of two major

categories: studies focusing on products to remove transient

flora and studies involving products that are used to remove

resident flora from the hands. The majority of studies of prod-

ucts for removing transient flora from the hands of HCWs

involve artificial contamination of the volunteer’s skin with a

defined inoculum of a test organism before the volunteer uses

a plain soap, an antimicrobial soap, or a waterless antiseptic

agent. In contrast, products tested for the preoperative cleans-

ing of surgeons’ hands (which must comply with surgical hand-

antisepsis protocols) are tested for their ability to remove

resident flora from without artificially contaminating the vol-

unteers’ hands.

In the United States, antiseptic handwash products intended

for use by HCWs are regulated by FDA’s Division of Over-

the-Counter Drug Products (OTC). Requirements for in vitro

and in vivo testing of HCW handwash products and surgical

Vol. 51 / RR-16 Recommendations and Reports 7

hand scrubs are outlined in the FDA Tentative Final Mono-

graph for Healthcare Antiseptic Drug Products (TFM) (19).

Products intended for use as HCW handwashes are evaluated

by using a standardized method (19). Tests are performed in

accordance with use directions for the test material. Before

baseline bacterial sampling and before each wash with the test

material, 5 mL of a standardized suspension of Serratia

marcescens are applied to the hands and then rubbed over the

surfaces of the hands. A specified volume of the test material

is dispensed into the hands and is spread over the hands and

lower one third of the forearms. A small amount of tap water

is added to the hands, and hands are completely lathered for a

specified time, covering all surfaces of the hands and the lower

third of the forearms. Volunteers then rinse hands and fore-

arms under 40

C tap water for 30 seconds. Ten washes with

the test formulation are required. After the first, third, sev-

enth, and tenth washes, rubber gloves or polyethylene bags

used for sampling are placed on the right and left hands, and

75 mL of sampling solution is added to each glove; gloves are

secured above the wrist. All surfaces of the hand are massaged

for 1 minute, and samples are obtained aseptically for quanti-

tative culture. No neutralizer of the antimicrobial is routinely

added to the sampling solution, but if dilution of the antimi-

crobial in the sampling fluid does not result in demonstrable

neutralization, a neutralizer specific for the test formulation is

added to the sampling solution. For waterless formulations, a

similar procedure is used. TFM criteria for efficacy are as fol-

lows: a 2-log

reduction of the indicator organism on each

hand within 5 minutes after the first use, and a 3-log

reduc-

tion of the indicator organism on each hand within 5 minutes

after the tenth use (19).

Products intended for use as surgical hand scrubs have been

evaluated also by using a standardized method (19). Volun-

teers clean under fingernails with a nail stick and clip their

fingernails. All jewelry is removed from hands and arms. Hands

and two thirds of forearms are rinsed with tap water (38

C–

C) for 30 seconds, and then they are washed with a non-

antimicrobial soap for 30 seconds and are rinsed for 30 seconds

under tap water. Baseline microbial hand counts can then be

determined. Next, a surgical scrub is performed with the test

formulation using directions provided by the manufacturer. If

no instructions are provided with the formulation, two

5-minute scrubs of hands and forearms followed by rinsing

are performed. Reduction from baseline microbial hand counts

is determined in a series of 11 scrubs conducted during 5 days.

Hands are sampled at 1 minute, 3 hours, and 6 hours after the

first scrubs on day 1, day 2, and day 5. After washing, volun-

teers wear rubber gloves; 75 mL of sampling solution are then

added to one glove, and all surfaces of the hands are massaged

for 1 minute. Samples are then taken aseptically and cultured

quantitatively. The other glove remains on the other hand for

6 hours and is sampled in the same manner. TFM requires

that formulations reduce the number of bacteria 1 log

each hand within 1 minute of product application and that

the bacterial cell count on each hand does not subsequently

exceed baseline within 6 hours on day 1; the formulation must

produce a 2-log

reduction in microbial flora on each hand

within 1 minute of product application by the end of the sec-

ond day of enumeration and a 3-log

reduction of microbial

flora on each hand within 1 minute of product use by the end of

the fifth day when compared with the established baseline (19).

The method most widely used in Europe to evaluate the

efficacy of hand-hygiene agents is European Standard 1500–

1997 (EN 1500—Chemical disinfectants and antiseptics.

Hygienic hand-rub test method and requirements) (79). This

method requires 12–15 test volunteers and an 18- to 24-hour

growth of broth culture of E. coli K12. Hands are washed

with a soft soap, dried, and then immersed halfway to the

metacarpals in the broth culture for 5 seconds. Hands are

removed from the broth culture, excess fluid is drained off,

and hands are dried in the air for 3 minutes. Bacterial recovery

for the initial value is obtained by kneading the fingertips of

each hand separately for 60 seconds in 10 mL of tryptic soy

broth (TSB) without neutralizers. The hands are removed from

the broth and disinfected with 3 mL of the hand-rub agent

for 30 seconds in a set design. The same operation is repeated

with total disinfection time not exceeding 60 seconds. Both

hands are rinsed in running water for 5 seconds and water is

drained off. Fingertips of each hand are kneaded separately in

10 mL of TSB with added neutralizers. These broths are used

to obtain the final value. Log

dilutions of recovery medium

are prepared and plated out. Within 3 hours, the same volun-

teers are tested with the reference disinfectant (60% 2-

propanol [isopropanol]) and the test product. Colony counts

are performed after 24 and 48 hours of incubation at 36

The average colony count of both left and right hand is used

for evaluation. The log-reduction factor is calculated and com-

pared with the initial and final values. The reduction factor of

the test product should be superior or the same as the refer-

ence alcohol-based rub for acceptance. If a difference exists,

then the results are analyzed statistically using the Wilcoxon

test. Products that have log reductions substantially less than

that observed with the reference alcohol-based hand rub (i.e.,

approximately 4 log

reduction) are classified as not meeting

the standard.

Because of different standards for efficacy, criteria cited in

FDA TFM and the European EN 1500 document for estab-

lishing alcohol-based hand rubs vary (1,19,79). Alcohol-based

8 MMWR October 25, 2002

hand rubs that meet TFM criteria for efficacy may not neces-

sarily meet the EN 1500 criteria for efficacy (80). In addition,

scientific studies have not established the extent to which

counts of bacteria or other microorganisms on the hands need

to be reduced to minimize transmission of pathogens in health-

care facilities (1,8); whether bacterial counts on the hands must

be reduced by 1 log

(90% reduction), 2 log

(99%), 3 log

(99.9%), or 4 log

(99.99%) is unknown. Several other meth-

ods also have been used to measure the efficacy of antiseptic

agents against various viral pathogens (81–83).

Shortcomings of Traditional Methodologies

Accepted methods of evaluating hand-hygiene products

intended for use by HCWs require that test volunteers wash

their hands with a plain or antimicrobial soap for 30 seconds

or 1 minute, despite the observation in the majority of studies

that the average duration of handwashing by hospital person-

nel is <15 seconds (52,84–89). A limited number of investi-

gators have used 15-second handwashing or hygienic

hand-wash protocols (90–94). Therefore, almost no data exist

regarding the efficacy of plain or antimicrobial soaps under

conditions in which they are actually used by HCWs. Simi-

larly, certain accepted methods for evaluating waterless anti-

septic agents for use as antiseptic hand rubs require that 3 mL

of alcohol be rubbed into the hands for 30 seconds, followed

by a repeat application for the same duration. This type of

protocol also does not reflect actual usage patterns among

HCWs. Furthermore, volunteers used in evaluations of prod-

ucts are usually surrogates for HCWs, and their hand flora

may not reflect flora found on the hands of personnel work-

ing in health-care settings. Further studies should be conducted

among practicing HCWs using standardized protocols to

obtain more realistic views of microbial colonization and risk

of bacterial transfer and cross-transmission (51).

Review of Preparations Used for Hand

Hygiene

Plain (Non-Antimicrobial) Soap

Soaps are detergent-based products that contain esterified

fatty acids and sodium or potassium hydroxide. They are avail-

able in various forms including bar soap, tissue, leaflet, and

liquid preparations. Their cleaning activity can be attributed

to their detergent properties, which result in removal of dirt,

soil, and various organic substances from the hands. Plain soaps

have minimal, if any, antimicrobial activity. However,

handwashing with plain soap can remove loosely adherent tran-

sient flora. For example, handwashing with plain soap and

water for 15 seconds reduces bacterial counts on the skin by

0.6–1.1 log

, whereas washing for 30 seconds reduces counts

by 1.8–2.8 log

(1). However, in several studies, handwashing

with plain soap failed to remove pathogens from the hands of

hospital personnel (25,45). Handwashing with plain soap can

result in paradoxical increases in bacterial counts on the skin

(92,95–97). Non-antimicrobial soaps may be associated with

considerable skin irritation and dryness (92,96,98), although

adding emollients to soap preparations may reduce their pro-

pensity to cause irritation. Occasionally, plain soaps have

become contaminated, which may lead to colonization of

hands of personnel with gram-negative bacilli (99).

Alcohols

The majority of alcohol-based hand antiseptics contain

either isopropanol, ethanol, n-propanol, or a combination of

two of these products. Although n-propanol has been used in

alcohol-based hand rubs in parts of Europe for many years, it

is not listed in TFM as an approved active agent for HCW

handwashes or surgical hand-scrub preparations in the United

States. The majority of studies of alcohols have evaluated

individual alcohols in varying concentrations. Other studies

have focused on combinations of two alcohols or alcohol

solutions containing limited amounts of hexachlorophene,

quaternary ammonium compounds, povidone-iodine,

triclosan, or chlorhexidine gluconate (61,93,100–119).

The antimicrobial activity of alcohols can be attributed to

their ability to denature proteins (120). Alcohol solutions con-

taining 60%–95% alcohol are most effective, and higher con-

centrations are less potent (120–122) because proteins are not

denatured easily in the absence of water (120). The alcohol

content of solutions may be expressed as percent by weight

(w/w), which is not affected by temperature or other variables,

or as percent by volume (vol/vol), which can be affected by

temperature, specific gravity, and reaction concentration (123).

For example, 70% alcohol by weight is equivalent to 76.8%

by volume if prepared at 15

C, or 80.5% if prepared at 25

(123). Alcohol concentrations in antiseptic hand rubs are

often expressed as percent by volume (19).

Alcohols have excellent in vitro germicidal activity against

gram-positive and gram-negative vegetative bacteria, includ-

ing multidrug-resistant pathogens (e.g., MRSA and VRE),

Mycobacterium tuberculosis, and various fungi (120–122,124–

129). Certain enveloped (lipophilic) viruses (e.g., herpes sim-

plex virus, human immunodeficiency virus [HIV], influenza

virus, respiratory syncytial virus, and vaccinia virus) are

susceptible to alcohols when tested in vitro (120,130,131)

(Table 1). Hepatitis B virus is an enveloped virus that is some-

what less susceptible but is killed by 60%–70% alcohol; hepa-

titis C virus also is likely killed by this percentage of alcohol

(132). In a porcine tissue carrier model used to study antisep-

tic activity, 70% ethanol and 70% isopropanol were found to

Vol. 51 / RR-16 Recommendations and Reports 9

reduce titers of an enveloped bacteriophage more effectively

than an antimicrobial soap containing 4% chlorhexidine glu-

conate (133). Despite its effectiveness against these organisms,

alcohols have very poor activity against bacterial spores, pro-

tozoan oocysts, and certain nonenveloped (nonlipophilic)

viruses.

Numerous studies have documented the in vivo antimicro-

bial activity of alcohols. Alcohols effectively reduce bacterial

counts on the hands (14,121,125,134). Typically, log reduc-

tions of the release of test bacteria from artificially contami-

nated hands average 3.5 log

after a 30-second application

and 4.0–5.0 log

after a 1-minute application (1). In 1994,

the FDA TFM classified ethanol 60%–95% as a Category I

agent (i.e., generally safe and effective for use in antiseptic

handwash or HCW hand-wash products) (19). Although TFM

placed isopropanol 70%–91.3% in category IIIE (i.e., insuffi-

cient data to classify as effective), 60% isopropanol has subse-

quently been adopted in Europe as the reference standard

against which alcohol-based hand-rub products are compared

(79). Alcohols are rapidly germicidal when applied to the skin,

but they have no appreciable persistent (i.e., residual) activity.

However, regrowth of bacteria on the skin occurs slowly after

use of alcohol-based hand antiseptics, presumably because of

the sublethal effect alcohols have on some of the skin bacteria

(135,136). Addition of chlorhexidine, quaternary ammonium

compounds, octenidine, or triclosan to alcohol-based solu-

tions can result in persistent activity (1).

Alcohols, when used in concentrations present in alcohol-

based hand rubs, also have in vivo activity against several

nonenveloped viruses (Table 2). For example, 70% isopro-

panol and 70% ethanol are more effective than medicated soap

or nonmedicated soap in reducing rotavirus titers on fingerpads

(137,138). A more recent study using the same test methods

evaluated a commercially available product containing 60%

TABLE 1. Virucidal activity of antiseptic agents against enveloped viruses

Ref. no. Test method Viruses Agent Results

(379)

Suspension HIV 19% EA LR = 2.0 in 5 minutes

(

380

) Suspension HIV 50% EA LR > 3.5

35% IPA LR > 3.7

(

381

) Suspension HIV 70% EA LR = 7.0 in 1 minute

(

382

) Suspension HIV 70% EA LR = 3.2B 5.5 in 30 seconds

(

383

) Suspension HIV 70% IPA/0.5% CHG LR = 6.0 in 15 seconds

4% CHG LR = 6.0 in 15 seconds

(

384

) Suspension HIV Chloroxylenol Inactivated in 1 minute

Benzalkonium chloride Inactivated in 1 minute

(

385

) Suspension HIV Povidone-iodine Inactivated

Chlorhexidine Inactivated

(

386

) Suspension HIV Detergent/0.5% Inactivated in 30 seconds

PCMX

(

387

) Suspension/dried plasma HBV 70% IPA LR = 6.0 in 10 minutes

chimpanzee challenge

(

388

) Suspension/plasma HBV 80% EA LR = 7.0 in 2 minutes

chimpanzee challenge

(

389

) Suspension HSV 95% EA LR > 5.0 in 1 minute

75% EA LR > 5.0

95% IPA LR > 5.0

70% EA + 0.5% CHG LR > 5.0

(

130

) Suspension RSV 35% IPA LR > 4.3 in 1 minute

4% CHG LR > 3.3

(

141

) Suspension Influenza 95% EA Undetectable in 30 seconds

Vaccinia 95% EA Undetectable in 30 seconds

(

141

) Hand test Influenza 95% EA LR > 2.5

Vaccinia 95% EA LR > 2.5

Note: HIV = human immunodeficiency virus, EA = ethanol, LR = Log

reduction, IPA = isopropanol, CHG = chlorhexidine gluconate, HBV = hepatitis B

virus, RSV = respiratory syncitial virus, HSV = herpes simplex virus, HAV = hepatitis A virus, and PCMX = chloroxylenol.

10 MMWR October 25, 2002

ethanol and found that the product reduced the infectivity

titers of three nonenveloped viruses (i.e., rotavirus, adenovi-

rus, and rhinovirus) by >3 logs (81). Other nonenveloped

viruses such as hepatitis A and enteroviruses (e.g., poliovirus)

may require 70%–80% alcohol to be reliably inactivated

(82,139). However, both 70% ethanol and a 62% ethanol

foam product with emollients reduced hepatitis A virus titers

on whole hands or fingertips more than nonmedicated soap;

both were equally as effective as antimicrobial soap contain-

ing 4% chlorhexidine gluconate in reducing reduced viral

counts on hands (140). In the same study, both 70% ethanol

and the 62% ethanol foam product demonstrated greater viru-

cidal activity against poliovirus than either non-antimicrobial

soap or a 4% chlorhexidine gluconate-containing soap (140).

However, depending on the alcohol concentration, the amount

of time that hands are exposed to the alcohol, and viral vari-

ant, alcohol may not be effective against hepatitis A and other

nonlipophilic viruses. The inactivation of nonenveloped

viruses is influenced by temperature, disinfectant-virus vol-

ume ratio, and protein load (141). Ethanol has greater activ-

ity against viruses than isopropanol. Further in vitro and in

vivo studies of both alcohol-based formulations and antimi-

crobial soaps are warranted to establish the minimal level of

virucidal activity that is required to interrupt direct contact

transmission of viruses in health-care settings.

TABLE 2. Virucidal activity of antiseptic agents against nonenveloped viruses

Ref. no. Test method Viruses Antiseptic Result

(

390

) Suspension Rotavirus 4% CHG LR < 3.0 in 1 minute

10% Povidone-Iodine LR > 3.0

70% IPA/0.1% HCP LR > 3.0

(

141

) Hand test Adenovirus 95% EA LR > 1.4

Poliovirus 95% EA LR = 0.2–1.0

Coxsackie 95% EA LR = 1.1–1.3

Finger test Adenovirus 95% EA LR > 2.3

Poliovirus 95% EA LR = 0.7–2.5

Coxsackie 95% EA LR = 2.9

(

389

) Suspension ECHO virus 95% EA LR > 3.0 in 1 minute

75% EA LR < 1.0

95% IPA LR = 0

70% IPA + 0.5% CHG LR = 0

(

140

) Finger pad HAV 70% EA 87.4% reduction

62% EA foam 89.3% reduction

plain soap 78.0% reduction

4% CHG 89.6% reduction

0.3% Triclosan 92.0% reduction

(

105

) Finger tips Bovine n-propanol + IPA LR = 3.8 in 30 seconds

Rotavirus 70% IPA LR = 3.1

70% EA LR = 2.9

2% triclosan LR = 2.1

water (control) LR = 1.3

7.5% povidone-iodine LR = 1.3

plain soap LR = 1.2

4% CHG LR = 0.5

(

137

) Finger pad Human 70% IPA 98.9% decrease in 10 seconds

Rotavirus plain soap 77.1%

(

138

) Finger pad Human 70% IPA 99.6% decrease in 10 seconds

Rotavirus 2% CHG 80.3%

plain soap 72.5%

(

) Finger pad Rotavirus 60% EA gel LR > 3.0 in 10 seconds

Rhinovirus 60% EA gel LR > 3.0

Adenovirus 60% EA gel LR > 3.0

(

139

) Finger pad Poliovirus 70% EA LR = 1.6 in 10 seconds

70% IPA LR = 0.8

(

200

) Finger tips Poliovirus Plain soap LR = 2.1

80% EA LR = 0.4

Note: HIV = human immunodeficiency virus, EA = ethanol, LR = Log

reduction, IPA = isopropanol, CHG = chlorhexidine gluconate, HBV = hepatitis B virus,

RSV = respiratory syncitial virus, HSV = herpes simplex virus, and HAV = hepatitis A virus.

Vol. 51 / RR-16 Recommendations and Reports 11

Alcohols are not appropriate for use when hands are visibly

dirty or contaminated with proteinaceous materials. However,

when relatively small amounts of proteinaceous material (e.g.,

blood) are present, ethanol and isopropanol may reduce

viable bacterial counts on hands more than plain soap or anti-

microbial soap (142).

Alcohol can prevent the transfer of health-care–associated

pathogens (25,63,64). In one study, gram-negative bacilli were

transferred from a colonized patient’s skin to a piece of cath-

eter material via the hands of nurses in only 17% of experi-

ments after antiseptic hand rub with an alcohol-based hand

rinse (25). In contrast, transfer of the organisms occurred in

92% of experiments after handwashing with plain soap and

water. This experimental model indicates that when the hands

of HCWs are heavily contaminated, an antiseptic hand rub

using an alcohol-based rinse can prevent pathogen transmis-

sion more effectively than can handwashing with plain soap

and water.

Alcohol-based products are more effective for standard

handwashing or hand antisepsis by HCWs than soap or anti-

microbial soaps (Table 3) (25,53,61,93,106–112,119,143–

152). In all but two of the trials that compared alcohol-based

solutions with antimicrobial soaps or detergents, alcohol

reduced bacterial counts on hands more than washing hands

with soaps or detergents containing hexachlorophene, povi-

done-iodine, 4% chlorhexidine, or triclosan. In studies exam-

ining antimicrobial-resistant organisms, alcohol-based prod-

ucts reduced the number of multidrug-resistant pathogens re-

covered from the hands of HCWs more effectively than did

handwashing with soap and water (153–155).

Alcohols are effective for preoperative cleaning of the hands

of surgical personnel (1,101,104,113–119,135,143,147,156–

159) (Tables 4 and 5). In multiple studies, bacterial counts on

the hands were determined immediately after using the prod-

uct and again 1–3 hours later; the delayed testing was per-

formed to determine if regrowth of bacteria on the hands is

inhibited during operative procedures. Alcohol-based solutions

were more effective than washing hands with plain soap in all

studies, and they reduced bacterial counts on the hands more

than antimicrobial soaps or detergents in the majority of

experiments (101,104,113–119,135,143,147,157–159). In

addition, the majority of alcohol-based preparations were more

effective than povidone-iodine or chlorhexidine.

The efficacy of alcohol-based hand-hygiene products is

affected by several factors, including the type of alcohol used,

concentration of alcohol, contact time, volume of alcohol used,

and whether the hands are wet when the alcohol is applied.

Applying small volumes (i.e., 0.2–0.5 mL) of alcohol to the

hands is not more effective than washing hands with plain

soap and water (63,64). One study documented that 1 mL of

alcohol was substantially less effective than 3 mL (91). The

ideal volume of product to apply to the hands is not known

TABLE 3. Studies comparing the relative efficacy (based on log

reductions achieved) of plain soap or antimicrobial soaps

versus alcohol-based antiseptics in reducing counts of viable bacteria on hands

Ref. no. Year Skin contamination Assay method Time (sec) Relative efficacy

(

143

) 1965 Existing hand flora Finger-tip agar culture 60 Plain soap < HCP < 50% EA foam

(

119

) 1975 Existing hand flora Hand-rub broth culture — Plain soap < 95% EA

(

106

) 1978 Artificial contamination Finger-tip broth culture 30 Plain soap < 4% CHG < P-I < 70% EA = alc. CHG

(

144

) 1978 Artificial contamination Finger-tip broth culture 30 Plain soap < 4% CHG < 70% EA

(

107

) 1979 Existing hand flora Hand-rub broth culture 120 Plain soap < 0.5% aq. CHG < 70% EA < 4% CHG < alc.CHG

(

145

) 1980 Artificial contamination Finger-tip broth culture 60–120 4% CHG < P-I < 60% IPA

(

) 1980 Artificial contamination Finger-tip broth culture 15 Plain soap < 3% HCP < P-I < 4% CHG < 70% EA

(

108

) 1982 Artificial contamination Glove juice test 15 P-I < alc. CHG

(

109

) 1983 Artificial contamination Finger-tip broth culture 120 0.3–2% triclosan = 60% IPA = alc. CHG < alc. triclosan

(

146

) 1984 Artificial contamination Finger-tip agar culture 60 Phenolic < 4% CHG < P-I < EA < IPA < n-P

(

147

) 1985 Existing hand flora Finger-tip agar culture 60 Plain soap < 70% EA < 95% EA

(

110

) 1986 Artificial contamination Finger-tip broth culture 60 Phenolic = P-I < alc. CHG < n-P

(

) 1986 Existing hand flora Sterile-broth bag technique 15 Plain soap < IPA < 4% CHG = IPA-E = alc. CHG

(

) 1988 Artificial contamination Finger-tip broth culture 30 Plain soap < triclosan < P-I < IPA < alc. CHG < n-P

(

) 1991 Patient contact Glove-juice test 15 Plain soap < IPA-E

(

148

) 1991 Existing hand flora Agar-plate/image analysis 30 Plain soap < 1% triclosan < P-I < 4% CHG < IPA

(

111

) 1992 Artificial contamination Finger-tip agar culture 60 Plain soap < IPA < EA < alc. CHG

(

149

) 1992 Artificial contamination Finger-tip broth culture 60 Plain soap < 60% n-P

(

112

) 1994 Existing hand flora Agar-plate/image analysis 30 Plain soap < alc. CHG

(

150

) 1999 Existing hand flora Agar-plate culture N.S. Plain soap < commercial alcohol mixture

(

151

) 1999 Artificial contamination Glove-juice test 20 Plain soap < 0.6% PCMX < 65% EA

(

152

) 1999 Artificial contamination Finger-tip broth culture 30 4% CHG < plain soap < P-I < 70% EA

Note: Existing hand flora = without artificially contaminatiing hands with bacteria, alc. CHG = alcoholic chlorhexidine gluconate, aq. CHG = aqueous

chlorhexidine gluconate, 4% CHG = chlorhexidine gluconate detergent, EA = ethanol, HCP = hexachlorophene soap/detergent, IPA = isopropanol, IPA-E =

isopropanol + emollients, n-P = n-propanol, PCMX = chloroxylenol detergent, P-I = povidone-iodine detergent, and N.S. = not stated.

12 MMWR October 25, 2002

TABLE 5. Efficacy of surgical hand-rub solutions in reducing the release of resident skin flora from clean hands

Mean log reducation

Study Rub Concentration* (%) Time (min) Immediate Sustained (3 hr)

1 n-Propanol 60 5 2.9

†

1.6

†

2 52.7

†

3 52.5

†

1.8

†

4 52.3

†

1.6

†

5 32.9

4 32.0

†

1.0

†

4 11.1

†

0.5

†

6 Isopropanol 90 3 2.4

1.4

68032.3

1.2

77052.4

†

2.1

†

4 52.1

†

1.0

†

6 32.0

0.7

5 31.7

4 31.5

†

0.8

†

8 21.20.8

4 10.7

†

0.2

9 10.8NA

10 60 5 1.7 1.0

7 Isopropanol + chlorhexidine gluc. (w/v) 70 + 0.5 5 2.5

†

2.7

†

8 21.01.5

11 Ethanol 95 2 2.1 NA

58532.4

12 80 2 1.5 NA

87021.00.6

13 Ethanol + chlorhexidine gluc. (w/v) 95 + 0.5 2 1.7 NA

14 77 + 0.5 5 2.0 1.5

8 70 + 0.5 2 0.7 1.4

8 Chlorhexidine gluc. (aq. Sol., w/v) 0.5 2 0.4 1.2

15 Povidone-iodine (aq. Sol., w/v) 1.0 5 1.9

†

0.8

†

16 Peracetic acid (w/v) 0.5 5 1.9 NA

Note: NA = not available.

Source: Rotter M. Hand washing and hand disinfection [Chapter 87]. In: Mayhall CG, ed. Hospital epidemiology and infection control. 2nd ed. Philadelphia,

PA: Lippincott Williams & Wilkins, 1999. Table 5 is copyrighted by Lippincott Williams & Wilkins; it is reprinted here with their permission and permission from

Manfred Rotler, M.D., Professor of Hygiene and Microbiology, Klinisches Institute für Hygiene der Universitat Wien, Germany.

* Volume/volume unless otherwise stated.

†

Tested according to Deutsche Gesellschaft fur Hygiene, and Mikrobiologic (DGHM)-German Society of Hygiene and Microbiology method.

Tested according to European Standard prEN.

After 4 hours.

TABLE 4. Studies comparing the relative efficacy of plain soap or antimicrobial soap versus alcohol-containing products in

reducing counts of bacteria recovered from hands immediately after use of products for pre-operative cleansing of hands

Ref. no. Year Assay method Relative efficacy

(

143

) 1965 Finger-tip agar culture HCP < 50% EA foam + QAC

(

157

) 1969 Finger-tip agar culture HCP < P-I < 50% EA foam + QAC

(

101

) 1973 Finger-tip agar culture HCP soap < EA foam + 0.23% HCP

(

135

) 1974 Broth culture Plain soap < 0.5% CHG < 4% CHG < alc. CHG

(

119

) 1975 Hand-broth test Plain soap < 0.5% CHG < 4% CHG < alc. CHG

(

118

) 1976 Glove-juice test 0.5% CHG < 4% CHG < alc. CHG

(

114

) 1977 Glove-juice test P-I < CHG < alc. CHG

(

117

) 1978 Finger-tip agar culture P-I = 46% EA + 0.23% HCP

(

113

) 1979 Broth culture of hands Plain soap < P-I < alc. CHG < alc. P-I

(

116

) 1979 Glove-juice test 70% IPA = alc. CHG

(

147

) 1985 Finger-tip agar culture Plain soap < 70% - 90% EA

(

115

) 1990 Glove-juice test, modified Plain soap < triclosan < CHG < P-I < alc. CHG

(

104

) 1991 Glove-juice test Plain soap < 2% triclosan < P-I < 70% IPA

(

158

) 1998 Finger-tip broth culture 70% IPA < 90% IPA = 60% n-P

(

159

) 1998 Glove-juice test P-I < CHG < 70% EA

Note: QAC = quaternary ammonium compound, alc. CHG = alcoholic chlorhexidine gluconate, CHG = chlorhexidine gluconate detergent, EA = ethanol, HCP

= hexachlorophene detergent, IPA = isopropanol, and P-I = povidone-iodine detergent.

Vol. 51 / RR-16 Recommendations and Reports 13

and may vary for different formulations. However, if hands

feel dry after rubbing hands together for 10–15 seconds, an

insufficient volume of product likely was applied. Because

alcohol-impregnated towelettes contain a limited amount of

alcohol, their effectiveness is comparable to that of soap and

water (63,160,161).

Alcohol-based hand rubs intended for use in hospitals are

available as low viscosity rinses, gels, and foams. Limited data

are available regarding the relative efficacy of various formula-

tions. One field trial demonstrated that an ethanol gel was

slightly more effective than a comparable ethanol solution at

reducing bacterial counts on the hands of HCWs (162). How-

ever, a more recent study indicated that rinses reduced bacte-

rial counts on the hands more than the gels tested (80). Further

studies are warranted to determine the relative efficacy of

alcohol-based rinses and gels in reducing transmission of

health-care–associated pathogens.

Frequent use of alcohol-based formulations for hand anti-

sepsis can cause drying of the skin unless emollients, humec-

tants, or other skin-conditioning agents are added to the

formulations. The drying effect of alcohol can be reduced or

eliminated by adding 1%–3% glycerol or other skin-

conditioning agents (90,93,100,101,106,135,143,163,164).

Moreover, in several recent prospective trials, alcohol-based

rinses or gels containing emollients caused substantially less

skin irritation and dryness than the soaps or antimicrobial

detergents tested (96,98,165,166). These studies, which were

conducted in clinical settings, used various subjective and

objective methods for assessing skin irritation and dryness.

Further studies are warranted to establish whether products

with different formulations yield similar results.

Even well-tolerated alcohol hand rubs containing emollients

may cause a transient stinging sensation at the site of any bro-

ken skin (e.g., cuts and abrasions). Alcohol-based hand-rub

preparations with strong fragrances may be poorly tolerated

by HCWs with respiratory allergies. Allergic contact dermati-

tis or contact urticaria syndrome caused by hypersensitivity to

alcohol or to various additives present in certain alcohol hand

rubs occurs only rarely (167,168).

Alcohols are flammable. Flash points of alcohol-based hand

rubs range from 21

C to 24

C, depending on the type and

concentration of alcohol present (169). As a result, alcohol-

based hand rubs should be stored away from high tempera-

tures or flames in accordance with National Fire Protection

Agency recommendations. In Europe, where alcohol-based

hand rubs have been used extensively for years, the incidence

of fires associated with such products has been low (169). One

recent U.S. report described a flash fire that occurred as a

result of an unusual series of events, which included an HCW

applying an alcohol gel to her hands, immediately removing a

polyester isolation gown, and then touching a metal door

before the alcohol had evaporated (170). Removing the poly-

ester gown created a substantial amount of static electricity

that generated an audible static spark when the HCW touched

the metal door, igniting the unevaporated alcohol on her hands

(170). This incident emphasizes the need to rub hands

together after application of alcohol-based products until all

the alcohol has evaporated.

Because alcohols are volatile, containers should be designed

to minimize evaporation. Contamination of alcohol-based

solutions has seldom been reported. One report documented

a cluster of pseudoinfections caused by contamination of ethyl

alcohol by Bacillus cereus spores (171).

Chlorhexidine

Chlorhexidine gluconate, a cationic bisbiguanide, was

developed in England in the early 1950s and was introduced

into the United States in the 1970s (8,172). Chlorhexidine

base is only minimally soluble in water, but the digluconate

form is water-soluble. The antimicrobial activity of

chlorhexidine is likely attributable to attachment to, and sub-

sequent disruption of, cytoplasmic membranes, resulting in

precipitation of cellular contents (1,8). Chlorhexidine’s

immediate antimicrobial activity occurs more slowly than that

of alcohols. Chlorhexidine has good activity against gram-

positive bacteria, somewhat less activity against gram-

negative bacteria and fungi, and only minimal activity against

tubercle bacilli (1,8,172). Chlorhexidine is not sporicidal

(1,172). It has in vitro activity against enveloped viruses (e.g.,

herpes simplex virus, HIV, cytomegalovirus, influenza, and

RSV) but substantially less activity against nonenveloped

viruses (e.g., rotavirus, adenovirus, and enteroviruses)

(130,131,173). The antimicrobial activity of chlorhexidine is

only minimally affected by the presence of organic material,

including blood. Because chlorhexidine is a cationic molecule,

its activity can be reduced by natural soaps, various inorganic

anions, nonionic surfactants, and hand creams containing

anionic emulsifying agents (8,172,174). Chlorhexidine glu-

conate has been incorporated into a number of hand-hygiene

preparations. Aqueous or detergent formulations containing

0.5% or 0.75% chlorhexidine are more effective than plain

soap, but they are less effective than antiseptic detergent prepa-

rations containing 4% chlorhexidine gluconate (135,175).

Preparations with 2% chlorhexidine gluconate are slightly less

effective than those containing 4% chlorhexidine (176).

Chlorhexidine has substantial residual activity (106,114–

116,118,135,146,175). Addition of low concentrations

(0.5%–1.0%) of chlorhexidine to alcohol-based preparations

results in greater residual activity than alcohol alone (116,135).

When used as recommended, chlorhexidine has a good safety

14 MMWR October 25, 2002

record (172). Minimal, if any, absorption of the compound

occurs through the skin. Care must be taken to avoid contact

with the eyes when using preparations with

>1% chlorhexidine,

because the agent can cause conjunctivitis and severe corneal

damage. Ototoxicity precludes its use in surgery involving the

inner or middle ear. Direct contact with brain tissue and the

meninges should be avoided. The frequency of skin irritation

is concentration-dependent, with products containing 4%

most likely to cause dermatitis when used frequently for anti-

septic handwashing (177); allergic reactions to chlorhexidine

gluconate are uncommon (118,172). Occasional outbreaks of

nosocomial infections have been traced to contaminated

solutions of chlorhexidine (178–181).

Chloroxylenol

Chloroxylenol, also known as parachlorometaxylenol

(PCMX), is a halogen-substituted phenolic compound that

has been used as a preservative in cosmetics and other prod-

ucts and as an active agent in antimicrobial soaps. It was

developed in Europe in the late 1920s and has been used in

the United States since the 1950s (182).

The antimicrobial activity of PCMX likely is attributable to

inactivation of bacterial enzymes and alteration of cell walls

(1). It has good in vitro activity against gram-positive organ-

isms and fair activity against gram-negative bacteria, myco-

bacteria, and certain viruses (1,7,182). PCMX is less active

against P. aeruginosa, but addition of ethylene-

diaminetetraacetic acid (EDTA) increases its activity against

Pseudomonas spp. and other pathogens.

A limited number of articles focusing on the efficacy of

PCMX-containing preparations intended for use by HCWs

have been published in the last 25 years, and the results of

studies have sometimes been contradictory. For example, in

studies in which antiseptics were applied to abdominal skin,

PCMX had the weakest immediate and residual activity of

any of the agents studied (183). However, when 30-second

handwashes were performed using 0.6% PCMX, 2%

chlorhexidine gluconate, or 0.3% triclosan, the immediate

effect of PCMX was similar to that of the other agents. When

used 18 times per day for 5 consecutive days, PCMX had less

cumulative activity than did chlorhexidine gluconate (184).

When PCMX was used as a surgical scrub, one report indi-

cated that 3% PCMX had immediate and residual activity

comparable to 4% chlorhexidine gluconate (185), whereas two

other studies demonstrated that the immediate and residual

activity of PCMX was inferior to both chlorhexidine glucon-

ate and povidone-iodine (176,186). The disparity between

published studies may be associated with the various concen-

trations of PCMX included in the preparations evaluated and

with other aspects of the formulations tested, including the

presence or absence of EDTA (7,182). PCMX is not as rap-

idly active as chlorhexidine gluconate or iodophors, and its

residual activity is less pronounced than that observed with

chlorhexidine gluconate (7,182). In 1994, FDA TFM tenta-

tively classified PCMX as a Category IIISE active agent (i.e.,

insufficient data are available to classify this agent as safe and

effective) (19). Further evaluation of this agent by the FDA is

ongoing.

The antimicrobial activity of PCMX is minimally affected

by the presence of organic matter, but it is neutralized by non-

ionic surfactants. PCMX, which is absorbed through the skin

(7,182), is usually well-tolerated, and allergic reactions associ-

ated with its use are uncommon. PCMX is available in con-

centrations of 0.3%–3.75%. In-use contamination of a

PCMX-containing preparation has been reported (187).

Hexachlorophene

Hexachlorophene is a bisphenol composed of two phenolic

groups and three chlorine moieties. In the 1950s and early

1960s, emulsions containing 3% hexachlorophene were widely

used for hygienic handwashing, as surgical scrubs, and for rou-

tine bathing of infants in hospital nurseries. The antimicro-

bial activity of hexachlorophene results from its ability to

inactivate essential enzyme systems in microorganisms.

Hexachlorophene is bacteriostatic, with good activity against

S. aureus and relatively weak activity against gram-negative

bacteria, fungi, and mycobacteria (7).

Studies of hexachlorophene as a hygienic handwash and

surgical scrub demonstrated only modest efficacy after a single

handwash (53,143,188). Hexachlorophene has residual activ-

ity for several hours after use and gradually reduces bacterial

counts on hands after multiple uses (i.e., it has a cumulative

effect) (1,101,188,189). With repeated use of 3% hexachlo-

rophene preparations, the drug is absorbed through the skin.

Infants bathed with hexachlorophene and personnel regularly

using a 3% hexachlorophene preparation for handwashing have

blood levels of 0.1–0.6 ppm hexachlorophene (190). In the

early 1970s, certain infants bathed with hexachlorophene de-

veloped neurotoxicity (vacuolar degeneration) (191). As a

result, in 1972, the FDA warned that hexachlorophene should

no longer be used routinely for bathing infants. However,

after routine use of hexachlorophene for bathing infants in

nurseries was discontinued, investigators noted that the inci-

dence of health-care–associated S. aureus infections in hospi-

tal nurseries increased substantially (192,193). In several

instances, the frequency of infections decreased when hexachlo-

rophene bathing of infants was reinstituted. However, current

guidelines still recommend against the routine bathing of neo-

nates with hexachlorophene because of its potential neuro-

toxic effects (194). The agent is classified by FDA TFM as not

Vol. 51 / RR-16 Recommendations and Reports 15

generally recognized as safe and effective for use as an antisep-

tic handwash (19). Hexachlorophene should not be used to

bathe patients with burns or extensive areas of susceptible,

sensitive skin. Soaps containing 3% hexachlorophene are avail-

able by prescription only (7).

Iodine and Iodophors

Iodine has been recognized as an effective antiseptic since

the 1800s. However, because iodine often causes irritation and

discoloring of skin, iodophors have largely replaced iodine as

the active ingredient in antiseptics.

Iodine molecules rapidly penetrate the cell wall of microor-

ganisms and inactivate cells by forming complexes with amino

acids and unsaturated fatty acids, resulting in impaired pro-

tein synthesis and alteration of cell membranes (195).

Iodophors are composed of elemental iodine, iodide or

triiodide, and a polymer carrier (i.e., the complexing agent) of

high molecular weight. The amount of molecular iodine

present (so-called “free” iodine) determines the level of anti-

microbial activity of iodophors. “Available” iodine refers to

the total amount of iodine that can be titrated with sodium

thiosulfate (196). Typical 10% povidone-iodine formulations

contain 1% available iodine and yield free iodine concentra-

tions of 1 ppm (196). Combining iodine with various poly-

mers increases the solubility of iodine, promotes sustained

release of iodine, and reduces skin irritation. The most com-

mon polymers incorporated into iodophors are polyvinyl

pyrrolidone (i.e., povidone) and ethoxylated nonionic deter-

gents (i.e., poloxamers) (195,196). The antimicrobial activity

of iodophors also can be affected by pH, temperature, expo-

sure time, concentration of total available iodine, and the

amount and type of organic and inorganic compounds present

(e.g., alcohols and detergents).

Iodine and iodophors have bactericidal activity against gram-

positive, gram-negative, and certain spore-forming bacteria

(e.g., clostridia and Bacillus spp.) and are active against myco-

bacteria, viruses, and fungi (8,195,197–200). However, in

concentrations used in antiseptics, iodophors are not usually

sporicidal (201). In vivo studies have demonstrated that

iodophors reduce the number of viable organisms that are

recovered from the hands of personnel (113,145,148,152,155).

Povidone-iodine 5%–10% has been tentatively classified by

FDA TFM as a Category I agent (i.e., a safe and effective agent

for use as an antiseptic handwash and an HCW handwash)

(19). The extent to which iodophors exhibit persistent anti-

microbial activity after they have been washed off the skin is

unclear. In one study, persistent activity was noted for 6 hours

(176); however, several other studies demonstrated persistent

activity for only 30–60 minutes after washing hands with an

iodophor (61,117,202). In studies in which bacterial counts

were obtained after gloves were worn for 1–4 hours after wash-

ing, iodophors have demonstrated poor persistent activity

(1,104,115,189,203–208). The in vivo antimicrobial activity

of iodophors is substantially reduced in the presence of

organic substances (e.g., blood or sputum) (8).

The majority of iodophor preparations used for hand

hygiene contain 7.5%–10% povidone-iodine. Formulations

with lower concentrations also have good antimicrobial activ-

ity because dilution can increase free iodine concentrations

(209). However, as the amount of free iodine increases, the

degree of skin irritation also may increase (209). Iodophors

cause less skin irritation and fewer allergic reactions than

iodine, but more irritant contact dermatitis than other anti-

septics commonly used for hand hygiene (92). Occasionally,

iodophor antiseptics have become contaminated with gram-

negative bacilli as a result of poor manufacturing processes

and have caused outbreaks or pseudo-outbreaks of infection

(196).

Quaternary Ammonium Compounds

Quaternary ammonium compounds are composed of a

nitrogen atom linked directly to four alkyl groups, which may

vary in their structure and complexity (210). Of this large

group of compounds, alkyl benzalkonium chlorides are the

most widely used as antiseptics. Other compounds that have

been used as antiseptics include benzethonium chloride,

cetrimide, and cetylpyridium chloride (1). The antimicrobial

activity of these compounds was first studied in the early 1900s,

and a quaternary ammonium compound for preoperative

cleaning of surgeons’ hands was used as early as 1935 (210).

The antimicrobial activity of this group of compounds likely

is attributable to adsorption to the cytoplasmic membrane,

with subsequent leakage of low molecular weight cytoplasmic

constituents (210).

Quaternary ammonium compounds are primarily bacterio-

static and fungistatic, although they are microbicidal against

certain organisms at high concentrations (1); they are more

active against gram-positive bacteria than against gram-

negative bacilli. Quaternary ammonium compounds have rela-

tively weak activity against mycobacteria and fungi and have

greater activity against lipophilic viruses. Their antimicrobial

activity is adversely affected by the presence of organic mate-

rial, and they are not compatible with anionic detergents

(1,210). In 1994, FDA TFM tentatively classified benzalko-

nium chloride and benzethonium chloride as Category IIISE

active agents (i.e., insufficient data exists to classify them as

safe and effective for use as an antiseptic handwash) (19). Fur-

ther evaluation of these agents by FDA is in progress.

Quaternary ammonium compounds are usually well

tolerated. However, because of weak activity against

16 MMWR October 25, 2002

gram-negative bacteria, benzalkonium chloride is prone to con-

tamination by these organisms. Several outbreaks of infection

or pseudoinfection have been traced to quaternary ammonium

compounds contaminated with gram-negative bacilli (211–

213). For this reason, in the United States, these compounds

have been seldom used for hand antisepsis during the last 15–

20 years. However, newer handwashing products containing

benzalkonium chloride or benzethonium chloride have recently

been introduced for use by HCWs. A recent study of surgical

intensive-care unit personnel found that cleaning hands with

antimicrobial wipes containing a quaternary ammonium com-

pound was about as effective as using plain soap and water for

handwashing; both were less effective than decontaminating

hands with an alcohol-based hand rub (214). One laboratory-

based study reported that an alcohol-free hand-rub product

containing a quaternary ammonium compound was effica-

cious in reducing microbial counts on the hands of volunteers

(215). Further studies of such products are needed to deter-

mine if newer formulations are effective in health-care settings.

Triclosan

Triclosan (chemical name: 2,4,4' –trichloro-2'-hydroxy-

diphenyl ether) is a nonionic, colorless substance that was

developed in the 1960s. It has been incorporated into soaps

for use by HCWs and the public and into other consumer

products. Concentrations of 0.2%–2% have antimicrobial

activity. Triclosan enters bacterial cells and affects the cyto-

plasmic membrane and synthesis of RNA, fatty acids, and pro-

teins (216). Recent studies indicate this agent’s antibacterial

activity is attributable to binding to the active site of enoyl-

acyl carrier protein reductase (217,218).

Triclosan has a broad range of antimicrobial activity, but it

is often bacteriostatic (1). Minimum inhibitory concentrations

(MICs) range from 0.1 to 10 ug/mL, whereas minimum bac-

tericidal concentrations are 25–500 ug/mL. Triclosan’s activ-

ity against gram-positive organisms (including MRSA) is

greater than against gram-negative bacilli, particularly

P. aeruginosa (1,216). The agent possesses reasonable activity

against mycobacterial and Candida spp., but it has limited

activity against filamentous fungi. Triclosan (0.1%) reduces

bacterial counts on hands by 2.8 log

after a 1-minute

hygienic handwash (1). In several studies, log reductions have

been lower after triclosan is used than when chlorhexidine,

iodophors, or alcohol-based products are applied

(1,61,149,184,219). In 1994, FDA TFM tentatively classi-

fied triclosan

<1.0% as a Category IIISE active agent (i.e.,

insufficient data exist to classify this agent as safe and effective

for use as an antiseptic handwash) (19). Further evaluation of

this agent by the FDA is underway. Like chlorhexidine,

triclosan has persistent activity on the skin. Its activity in

hand-care products is affected by pH, the presence of surfac-

tants, emollients, or humectants and by the ionic nature of

the particular formulation (1,216). Triclosan’s activity is not

substantially affected by organic matter, but it can be inhib-

ited by sequestration of the agent in micelle structures formed

by surfactants present in certain formulations. The majority

of formulations containing <2% triclosan are well-tolerated

and seldom cause allergic reactions. Certain reports indicate

that providing hospital personnel with a triclosan-containing

preparation for hand antisepsis has led to decreased MRSA

infections (72,73). Triclosan’s lack of potent activity against

gram-negative bacilli has resulted in occasional reports of con-

tamination (220).

Other Agents

Approximately 150 years after puerperal-fever–related

maternal mortality rates were demonstrated by Semmelweis

to be reduced by use of a hypochlorite hand rinse, the efficacy

of rubbing hands for 30 seconds with an aqueous hypochlo-

rite solution was studied once again (221). The solution was

demonstrated to be no more effective than distilled water. The

regimen used by Semmelweis, which called for rubbing hands

with a 4% [w/w] hypochlorite solution until the hands were

slippery (approximately 5 minutes), has been revisited by other

researchers (222). This more current study indicated that the

regimen was 30 times more effective than a 1-minute rub

using 60% isopropanol. However, because hypochlorite solu-

tions are often irritating to the skin when used repeatedly and

have a strong odor, they are seldom used for hand hygiene.

Certain other agents are being evaluated by FDA for use in

health-care-related antiseptics (19). However, the efficacy of

these agents has not been evaluated adequately for use in

handwashing preparations intended for use by HCWs. Fur-

ther evaluation of these agents is warranted. Products that use

different concentrations of traditional antiseptics (e.g., low

concentrations of iodophor) or contain novel compounds with

antiseptic properties are likely to be introduced for use by

HCWs. For example, preliminary studies have demonstrated

that adding silver-containing polymers to an ethanol carrier

(i.e., Surfacine

) results in a preparation that has persistent

antimicrobial activity on animal and human skin (223). New

compounds with good in vitro activity must be tested in vivo

to determine their abilities to reduce transient and resident

skin flora on the hands of HCWs.

Activity of Antiseptic Agents Against

Spore-Forming Bacteria

The widespread prevalence of health-care–associated diar-

rhea caused by Clostridium difficile and the recent occurrence

Vol. 51 / RR-16 Recommendations and Reports 17

in the United States of human Bacillus anthracis infections

associated with contaminated items sent through the postal

system has raised concern regarding the activity of antiseptic

agents against spore-forming bacteria. None of the agents

(including alcohols, chlorhexidine, hexachlorophene,

iodophors, PCMX, and triclosan) used in antiseptic handwash

or antiseptic hand-rub preparations are reliably sporicidal

against Clostridium spp. or Bacillus spp. (120,172,224,225).

Washing hands with non-antimicrobial or antimicrobial soap

and water may help to physically remove spores from the sur-

face of contaminated hands. HCWs should be encouraged

to wear gloves when caring for patients with C. difficile-

associated diarrhea (226). After gloves are removed, hands

should be washed with a non-antimicrobial or an antimicro-

bial soap and water or disinfected with an alcohol-based hand

rub. During outbreaks of C. difficile-related infections, wash-

ing hands with a non-antimicrobial or antimicrobial soap and

water after removing gloves is prudent. HCWs with suspected

or documented exposure to B. anthracis-contaminated items

also should be encouraged to wash their hands with a non-

antimicrobial or antimicrobial soap and water.

Reduced Susceptibility of Bacteria to

Antiseptics

Reduced susceptibility of bacteria to antiseptic agents can

either be an intrinsic characteristic of a species or can be an

acquired trait (227). Several reports have described strains of

bacteria that appear to have acquired reduced susceptibility

(when defined by MICs established in vitro) to certain anti-

septics (e.g., chlorhexidine, quaternary ammonium com-

pounds, and triclosan) (227–230). However, because the

antiseptic concentrations that are actually used by HCWs are

often substantially higher than the MICs of strains with

reduced antiseptic susceptibility, the clinical relevance of the

in vitro findings is questionable. For example, certain strains

of MRSA have chlorhexidine and quaternary ammonium

compound MICs that are several-fold higher than methicillin-

susceptible strains, and certain strains of S. aureus have

elevated MICs to triclosan (227,228). However, such strains

were readily inhibited by the concentrations of these antisep-

tics that are actually used by practicing HCWs (227,228). The

description of a triclosan-resistant bacterial enzyme has raised

the question of whether resistance to this agent may develop

more readily than to other antiseptic agents (218). In addi-

tion, exposing Pseudomonas strains containing the MexAB-

OprM efflux system to triclosan may select for mutants that

are resistant to multiple antibiotics, including fluoroquinolones

(230). Further studies are needed to determine whether

reduced susceptibility to antiseptic agents is of epidemiologic

significance and whether resistance to antiseptics has any

influence on the prevalence of antibiotic-resistant strains (227).

Surgical Hand Antisepsis

Since the late 1800s, when Lister promoted the application

of carbolic acid to the hands of surgeons before procedures,

preoperative cleansing of hands and forearms with an antisep-

tic agent has been an accepted practice (231). Although no

randomized, controlled trials have been conducted to indi-

cate that surgical-site infection rates are substantially lower

when preoperative scrubbing is performed with an antiseptic

agent rather than a non-antimicrobial soap, certain other fac-

tors provide a strong rationale for this practice. Bacteria on

the hands of surgeons can cause wound infections if intro-

duced into the operative field during surgery (232); rapid

multiplication of bacteria occurs under surgical gloves if hands

are washed with a non-antimicrobial soap. However, bacterial

growth is slowed after preoperative scrubbing with an antisep-

tic agent (14,233). Reducing resident skin flora on the hands

of the surgical team for the duration of a procedure reduces

the risk of bacteria being released into the surgical field if gloves

become punctured or torn during surgery (1,156,169). Finally,

at least one outbreak of surgical-site infections occurred when

surgeons who normally used an antiseptic surgical scrub prepa-

ration began using a non-antimicrobial product (234).

Antiseptic preparations intended for use as surgical hand

scrubs are evaluated for their ability to reduce the number of

bacteria released from hands at different times, including 1)

immediately after scrubbing, 2) after wearing surgical gloves

for 6 hours (i.e., persistent activity), and 3) after multiple

applications over 5 days (i.e., cumulative activity). Immediate

and persistent activity are considered the most important in

determining the efficacy of the product. U.S. guidelines rec-

ommend that agents used for surgical hand scrubs should sub-

stantially reduce microorganisms on intact skin, contain a

nonirritating antimicrobial preparation, have broad-spectrum

activity, and be fast-acting and persistent (19,235).

Studies have demonstrated that formulations containing

60%–95% alcohol alone or 50%–95% when combined with

limited amounts of a quaternary ammonium compound,

hexachlorophene, or chlorhexidine gluconate, lower bacterial

counts on the skin immediately postscrub more effectively than

do other agents (Table 4). The next most active agents (in

order of decreasing activity) are chlorhexidine gluconate,

iodophors, triclosan, and plain soap (104,119,186,188,

203,204,206,208,236). Because studies of PCMX as a surgi-

cal scrub have yielded contradictory results, further studies

are needed to establish how the efficacy of this compound

compares with the other agents (176,185,186).

18 MMWR October 25, 2002

Although alcohols are not considered to have persistent

antimicrobial activity, bacteria appear to reproduce slowly on

the hands after a surgical scrub with alcohol, and bacterial

counts on hands after wearing gloves for 1–3 hours seldom

exceed baseline (i.e., prescrub) values (1). However, a recent

study demonstrated that a formulation containing 61% etha-

nol alone did not achieve adequate persistent activity at 6 hours

postscrub (237). Alcohol-based preparations containing 0.5%

or 1% chlorhexidine gluconate have persistent activity that,

in certain studies, has equaled or exceeded that of chlorhexidine

gluconate-containing detergents (1,118,135,237).*

Persistent antimicrobial activity of detergent-based surgical

scrub formulations is greatest for those containing 2% or 4%

chlorhexidine gluconate, followed by hexachlorophene,

triclosan, and iodophors (1,102,113–115,159,189,203,

204,206–208,236). Because hexachlorophene is absorbed into

the blood after repeated use, it is seldom used as a surgical

scrub.

Surgical staff have been traditionally required to scrub their

hands for 10 minutes preoperatively, which frequently leads

to skin damage. Several studies have demonstrated that scrub-

bing for 5 minutes reduces bacterial counts as effectively as a

10-minute scrub (117,238,239). In other studies, scrubbing

for 2 or 3 minutes reduced bacterial counts to acceptable

levels (156,205,207,240,241).

Studies have indicated that a two-stage surgical scrub using

an antiseptic detergent, followed by application of an alcohol-

containing preparation, is effective. For example, an initial

1- or 2-minute scrub with 4% chlorhexidine gluconate or

povidone-iodine followed by application of an alcohol-based

product has been as effective as a 5-minute scrub with an

antiseptic detergent (114,242).

Surgical hand-antisepsis protocols have required personnel

to scrub with a brush. But this practice can damage the skin of

personnel and result in increased shedding of bacteria from

the hands (95,243). Scrubbing with a disposable sponge or

combination sponge-brush has reduced bacterial counts on

the hands as effectively as scrubbing with a brush (244–246).

However, several studies indicate that neither a brush nor a

sponge is necessary to reduce bacterial counts on the hands of

surgical personnel to acceptable levels, especially when alcohol-

based products are used (102,117,159,165,233,237,

247,248). Several of these studies performed cultures imme-

diately or at 45–60 minutes postscrub (102,117,

233,247,248), whereas in other studies, cultures were obtained

3 and 6 hours postscrub (159,237). For example, a recent

laboratory-based study using volunteers demonstrated that

brushless application of a preparation containing 1%

chlorhexidine gluconate plus 61% ethanol yielded lower bac-

terial counts on the hands of participants than using a sponge/

brush to apply a 4% chlorhexidine-containing detergent prepa-

ration (237).

Relative Efficacy of Plain Soap,

Antiseptic Soap/Detergent,

and Alcohols

Comparing studies related to the in vivo efficacy of plain

soap, antimicrobial soaps, and alcohol-based hand rubs is prob-

lematic, because certain studies express efficacy as the percent-

age reduction in bacterial counts achieved, whereas others give

log

reductions in counts achieved. However, summarizing

the relative efficacy of agents tested in each study can provide

an overview of the in vivo activity of various formulations

intended for handwashing, hygienic handwash, antiseptic hand

rub, or surgical hand antisepsis (Tables 2–4).

Irritant Contact Dermatitis Resulting

from Hand-Hygiene Measures

Frequency and Pathophysiology of Irritant

Contact Dermatitis

In certain surveys, approximately 25% of nurses report symp-

toms or signs of dermatitis involving their hands, and as many

as 85% give a history of having skin problems (249). Fre-

quent and repeated use of hand-hygiene products, particu-

larly soaps and other detergents, is a primary cause of chronic

irritant contact dermatitis among HCWs (250). The poten-

tial of detergents to cause skin irritation can vary considerably

and can be ameliorated by the addition of emollients and

humectants. Irritation associated with antimicrobial soaps may

be caused by the antimicrobial agent or by other ingredients

of the formulation. Affected persons often complain of a feel-

ing of dryness or burning; skin that feels “rough;” and

erythema, scaling, or fissures. Detergents damage the skin by

causing denaturation of stratum corneum proteins, changes

in intercellular lipids (either depletion or reorganization of

lipid moieties), decreased corneocyte cohesion, and decreased

stratum corneum water-binding capacity (250,251). Damage

* In a recent randomized clinical trial, surgical site infection rates were monitored

among patients who were operated on by surgical personnel who cleaned their

hands preoperatively either by performing a traditional 5-minute surgical hand

scrub using 4% povidone-iodine or 4% antisepsis antimicrobial soap, or by

washing their hands for 1 minute with a non-antimicrobial soap followed by a

5-minute hand-rubbing technique using an alcohol-based hand rinse containing

0.2% mecetronium etilsulfate. The incidence of surgical site infections was

virtually identical in the two groups of patients. (Source: Parienti JJ, Thibon

P, Heller R, et al. for Members of the Antisepsie Chirurgicale des Mains Study

Group. Hand-rubbing with an aqueous alcoholic solution vs traditional surgical

hand-scrubbing and 30-day surgical site infection rates: a randomized

equivalence study. JAMA 2002;288:722–7).

Vol. 51 / RR-16 Recommendations and Reports 19

to the skin also changes skin flora, resulting in more frequent

colonization by staphylococci and gram-negative bacilli

(17,90). Although alcohols are among the safest antiseptics

available, they can cause dryness and irritation of the skin

(1,252). Ethanol is usually less irritating than n-propanol or

isopropanol (252).

Irritant contact dermatitis is more commonly reported with

iodophors (92). Other antiseptic agents that can cause irritant

contact dermatitis (in order of decreasing frequency) include

chlorhexidine, PCMX, triclosan, and alcohol-based products.

Skin that is damaged by repeated exposure to detergents may

be more susceptible to irritation by alcohol-based preparations

(253). The irritancy potential of commercially prepared hand-

hygiene products, which is often determined by measuring

transepidermal water loss, may be available from the manu-

facturer. Other factors that can contribute to dermatitis asso-

ciated with frequent handwashing include using hot water for

handwashing, low relative humidity (most common in winter

months), failure to use supplementary hand lotion or cream,

and the quality of paper towels (254,255). Shear forces associ-

ated with wearing or removing gloves and allergy to latex pro-

teins may also contribute to dermatitis of the hands of HCWs.

Allergic Contact Dermatitis Associated

with Hand-Hygiene Products

Allergic reactions to products applied to the skin (i.e., con-

tact allergies) may present as delayed type reactions (i.e., aller-

gic contact dermatitis) or less commonly as immediate

reactions (i.e., contact urticaria). The most common causes of

contact allergies are fragrances and preservatives; emulsifiers

are less common causes (256–259). Liquid soaps, hand

lotions or creams, and “udder ointments” may contain ingre-

dients that cause contact allergies among HCWs (257,258).

Allergic reactions to antiseptic agents, including quaternary

ammonium compounds, iodine or iodophors, chlorhexidine,

triclosan, PCMX, and alcohols have been reported

(118,167,172,256,260–265). Allergic contact dermatitis

associated with alcohol-based hand rubs is uncommon. Sur-

veillance at a large hospital in Switzerland, where a commer-

cial alcohol hand rub has been used for >10 years, failed to

identify a single case of documented allergy to the product

(169). In late 2001, a Freedom of Information Request for

data in the FDA’s Adverse Event Reporting System regarding

adverse reactions to popular alcohol hand rubs in the United

States yielded only one reported case of an erythematous rash

reaction attributed to such a product (John M. Boyce, M.D.,

Hospital of St. Raphael, New Haven, Connecticut, personal

communication, 2001). However, with increasing use of such

products by HCWs, true allergic reactions to such products

likely will be encountered.

Allergic reactions to alcohol-based products may represent

true allergy to alcohol, allergy to an impurity or aldehyde

metabolite, or allergy to another constituent of the product

(167). Allergic contact dermatitis or immediate contact urti-

carial reactions may be caused by ethanol or isopropanol (167).

Allergic reactions can be caused by compounds that may be

present as inactive ingredients in alcohol-based hand rubs,

including fragrances, benzyl alcohol, stearyl or isostearyl alco-

hol, phenoxyethanol, myristyl alcohol, propylene glycol,

parabens, and benzalkonium chloride (167,256,266–270).

Proposed Methods for Reducing

Adverse Effects of Agents

Potential strategies for minimizing hand-hygiene–related

irritant contact dermatitis among HCWs include reducing the

frequency of exposure to irritating agents (particularly anionic

detergents), replacing products with high irritation potential

with preparations that cause less damage to the skin, educat-

ing personnel regarding the risks of irritant contact dermati-

tis, and providing caregivers with moisturizing skin-care

products or barrier creams (96,98,251,271–273). Reducing

the frequency of exposure of HCWs to hand-hygiene prod-

ucts would prove difficult and is not desirable because of the

low levels of adherence to hand-hygiene policies in the major-

ity of institutions. Although hospitals have provided person-

nel with non-antimicrobial soaps in hopes of minimizing

dermatitis, frequent use of such products may cause greater

skin damage, dryness, and irritation than antiseptic prepara-

tions (92,96,98). One strategy for reducing the exposure of

personnel to irritating soaps and detergents is to promote the

use of alcohol-based hand rubs containing various emollients.

Several recent prospective, randomized trials have demonstrated

that alcohol-based hand rubs containing emollients were

better tolerated by HCWs than washing hands with non-

antimicrobial soaps or antimicrobial soaps (96,98,166). Rou-

tinely washing hands with soap and water immediately after

using an alcohol hand rub may lead to dermatitis. Therefore,

personnel should be reminded that it is neither necessary nor

recommended to routinely wash hands after each application

of an alcohol hand rub.

Hand lotions and creams often contain humectants and

various fats and oils that can increase skin hydration and

replace altered or depleted skin lipids that contribute to the

barrier function of normal skin (251,271). Several controlled

trials have demonstrated that regular use (e.g., twice a day) of

such products can help prevent and treat irritant contact der-

matitis caused by hand-hygiene products (272,273). In one

study, frequent and scheduled use of an oil-containing lotion

improved skin condition, and thus led to a 50% increase in

20 MMWR October 25, 2002

handwashing frequency among HCWs (273). Reports from

these studies emphasize the need to educate personnel regard-

ing the value of regular, frequent use of hand-care products.

Recently, barrier creams have been marketed for the preven-

tion of hand-hygiene–related irritant contact dermatitis. Such

products are absorbed to the superficial layers of the epider-

mis and are designed to form a protective layer that is not

removed by standard handwashing. Two recent randomized,

controlled trials that evaluated the skin condition of caregivers

demonstrated that barrier creams did not yield better results

than did the control lotion or vehicle used (272,273). As a

result, whether barrier creams are effective in preventing irri-

tant contact dermatitis among HCWs remains unknown.

In addition to evaluating the efficacy and acceptability of

hand-care products, product-selection committees should

inquire about the potential deleterious effects that oil-

containing products may have on the integrity of rubber gloves

and on the efficacy of antiseptic agents used in the facility

(8,236).

Factors To Consider When Selecting

Hand-Hygiene Products

When evaluating hand-hygiene products for potential use

in health-care facilities, administrators or product-selection

committees must consider factors that can affect the overall

efficacy of such products, including the relative efficacy of

antiseptic agents against various pathogens (Appendix) and

acceptance of hand-hygiene products by personnel (274,275).

Soap products that are not well-accepted by HCWs can be a

deterrent to frequent handwashing (276). Characteristics of a

product (either soap or alcohol-based hand rub) that can

affect acceptance by personnel include its smell, consistency

(i.e., “feel”), and color (92,277,278). For soaps, ease of lather-

ing also may affect user preference.

Because HCWs may wash their hands from a limited num-

ber of times per shift to as many as 30 times per shift, the

tendency of products to cause skin irritation and dryness is a

substantial factor that influences acceptance, and ultimate

usage (61,98,274,275,277,279). For example, concern regard-

ing the drying effects of alcohol was a primary cause of poor

acceptance of alcohol-based hand-hygiene products in hospi-

tals in the United States (5,143). However, several studies have

demonstrated that alcohol-based hand rubs containing emol-

lients are acceptable to HCWs (90,93,98,100,101,106,

143,163,164,166). With alcohol-based products, the time

required for drying may also affect user acceptance.

Studies indicate that the frequency of handwashing or anti-

septic handwashing by personnel is affected by the accessibil-

ity of hand-hygiene facilities (280–283). In certain health-care

facilities, only one sink is available in rooms housing several

patients, or sinks are located far away from the door of the

room, which may discourage handwashing by personnel leav-

ing the room. In intensive-care units, access to sinks may be

blocked by bedside equipment (e.g., ventilators or intravenous

infusion pumps). In contrast to sinks used for handwashing

or antiseptic handwash, dispensers for alcohol-based hand rubs

do not require plumbing and can be made available adjacent

to each patient’s bed and at many other locations in patient-

care areas. Pocket carriage of alcohol-based hand-rub solutions,

combined with availability of bedside dispensers, has been

associated with substantial improvement in adherence to hand-

hygiene protocols (74,284). To avoid any confusion between

soap and alcohol hand rubs, alcohol hand-rub dispensers

should not be placed adjacent to sinks. HCWs should be

informed that washing hands with soap and water after each

use of an alcohol hand rub is not necessary and is not recom-

mended, because it may lead to dermatitis. However, because

personnel feel a “build-up” of emollients on their hands after

repeated use of alcohol hand gels, washing hands with soap

and water after 5–10 applications of a gel has been recom-

mended by certain manufacturers.

Automated handwashing machines have not been demon-

strated to improve the quality or frequency of handwashing

(88,285). Although technologically advanced automated

handwashing devices and monitoring systems have been

developed recently, only a minimal number of studies have

been published that demonstrate that use of such devices

results in enduring improvements in hand-hygiene adherence

among HCWs. Further evaluation of automated handwashing

facilities and monitoring systems is warranted.

Dispenser systems provided by manufacturers or vendors

also must be considered when evaluating hand-hygiene prod-

ucts. Dispensers may discourage use by HCWs when they

1) become blocked or partially blocked and do not deliver the

product when accessed by personnel, and 2) do not deliver

the product appropriately onto the hands. In one hospital where

a viscous alcohol-based hand rinse was available, only 65% of

functioning dispensers delivered product onto the caregivers’

hands with one press of the dispenser lever, and 9% of dis-

pensers were totally occluded (286). In addition, the volume

delivered was often suboptimal, and the product was some-

times squirted onto the wall instead of the caregiver’s hand.

Only limited information is available regarding the cost of

hand-hygiene products used in health-care facilities (165,287).

These costs were evaluated in patient-care areas at a 450-bed

community teaching hospital (287); the hospital spent $22,000

($0.72 per patient-day) on 2% chlorhexidine-containing prepa-

rations, plain soap, and an alcohol hand rinse. (287) When

Vol. 51 / RR-16 Recommendations and Reports 21

hand-hygiene supplies for clinics and nonpatient care areas

were included, the total annual budget for soaps and hand

antiseptic agents was $30,000 (approximately $1 per patient-

day). Annual hand-hygiene product budgets at other institu-

tions vary considerably because of differences in usage patterns

and varying product prices. One researcher (287) determined

that if non-antimicrobial liquid soap were assigned an arbi-

trary relative cost of 1.0, the cost per liter would be 1.7 times

as much for 2% chlorhexidine gluconate detergent, 1.6–2.0

times higher for alcohol-based hand-rub products, and 4.5

times higher for an alcohol-based foam product. A recent cost

comparison of surgical scrubbing with an antimicrobial soap

versus brushless scrubbing with an alcohol-based hand rub

revealed that costs and time required for preoperative scrub-

bing were less with the alcohol-based product (165). In a trial

conducted in two critical-care units, the cost of using an alco-

hol hand rub was half as much as using an antimicrobial soap

for handwashing ($0.025 versus $0.05 per application, respec-

tively) (166).

To put expenditures for hand-hygiene products into per-

spective, health-care facilities should consider comparing their

budget for hand-hygiene products to estimated excess hospi-

tal costs resulting from health-care–associated infections. The

excess hospital costs associated with only four or five health-

care–associated infections of average severity may equal the

entire annual budget for hand-hygiene products used in

inpatient-care areas. Just one severe surgical site infection, lower

respiratory tract infection, or bloodstream infection may cost

the hospital more than the entire annual budget for antiseptic

agents used for hand hygiene (287). Two studies provided cer-

tain quantitative estimates of the benefit of hand-hygiene–

promotion programs (72,74). One study demonstrated a cost

saving of approximately $17,000 resulting from reduced use

of vancomycin after the observed decrease in MRSA incidence

in a 7-month period (72). In another study that examined

both direct costs associated with the hand-hygiene promotion

program (increased use of hand-rub solution and poster

production) and indirect costs associated with health-care–

personnel time (74), costs of the program were an estimated

$57,000 or less per year (an average of $1.42 per patient

admitted). Supplementary costs associated with the increased

use of alcohol-based hand-rub solution averaged $6.07 per

100 patient-days. Based on conservative estimates of $2,100

saved per infection averted and on the assumption that only

25% of the observed reduction in the infection rate was asso-

ciated with improved hand-hygiene practice, the program was

substantially cost-effective. Thus, hospital administrators must

consider that by purchasing more effective or more acceptable

hand-hygiene products to improve hand-hygiene practices, they

will avoid the occurrence of nosocomial infections; preventing

only a limited number of additional health-care–associated

infections per year will lead to savings that will exceed any

incremental costs of improved hand-hygiene products.

Hand-Hygiene Practices Among HCWs

In observational studies conducted in hospitals, HCWs

washed their hands an average of five times per shift to as

many as 30 times per shift (Table 6) (17,61,90,98,274,288);

certain nurses washed their hands

<100 times per shift (90).

Hospitalwide surveillance of hand hygiene reveals that the

average number of handwashing opportunities varies mark-

edly between hospital wards. For example, nurses in pediatric

wards had an average of eight opportunities for hand hygiene

per hour of patient care compared with an average of 20 for

nurses in intensive-care units (11). The duration of

handwashing or hygienic handwash episodes by HCWs has

averaged 6.6–24.0 seconds in observational studies (Table 7)

(17,52,59,84–87,89,249,279). In addition to washing their

TABLE 7. Average duration of handwashing by health-care

workers

Ref. no. Year Mean/median time

(

392

) 1997 4.7–5.3 seconds

(

303

) 1994 6.6 seconds

(

) 1974 8–9.3 seconds

(

) 1984 8.6 seconds

(

) 1994 <9 seconds

(

) 1994 9.5 seconds

(

) 1991 <10 seconds

(

294

) 1990 10 seconds

(

) 1984 11.6 seconds

(

300

) 1992 12.5 seconds

(

) 1988 15.6–24.4 seconds

(

) 1998 20.6 seconds

(

279

) 1978 21 seconds

(

293

) 1989 24 seconds

TABLE 6. Handwashing frequency among health-care workers

Avg. no./

Ref. no. Year time period Range Avg. no./hr

(

) 1988 5/8 hour N.S.

(

) 1984 5–10/shift N.S.

(

) 2000 10/shift N.S.

(

273

) 2000 12–18/day 2–60

(

) 2000 13–15/8 hours 5–27 1.6–1.8/hr

(

) 1977 20–42/8 hours 10–100

(

391

) 2000 21/12 hours N.S.

(

272

) 2000 22/day 0–70

(

) 1991 1.7–2.1/hr

(

) 1998 2.1/hr

(

279

) 1978 3/hr

(

303

) 1994 3.3/hr

Note: N.S. = Not Stated.

22 MMWR October 25, 2002

hands for limited time periods, personnel often fail to cover

all surfaces of their hands and fingers (288).

Adherence of HCWs to Recommended

Hand-Hygiene Practices

Observational Studies of Hand-Hygiene Adherence. Adher-

ence of HCWs to recommended hand-hygiene procedures has

been poor, with mean baseline rates of 5%–81% (overall aver-

age: 40%) (Table 8) (71,74,86,87,276,280,281,283,285,

289–313). The methods used for defining adherence (or non-

adherence) and those used for conducting observations vary

considerably among studies, and reports do not provide

detailed information concerning the methods and criteria used.

The majority of studies were conducted with hand-hygiene

adherence as the major outcome measure, whereas a limited

number measured adherence as part of a broader investiga-

tion. Several investigators reported improved adherence after

implementing various interventions, but the majority of stud-

ies had short follow-up periods and did not confirm whether

behavioral improvements were long-lasting. Other studies

established that sustained improvements in handwashing

behavior occurred during a long-term program to improve

adherence to hand-hygiene policies (74,75).

TABLE 8. Hand-hygiene adherence by health-care workers (1981–2000)

Adherence

Before/ Adherence after

Ref. no. Year Setting after baseline intervention Invervention

(

280

) 1981 ICU A 16% 30% More convenient sink locations

(

289

) 1981 ICU A 41% —

ICU A 28% —

(

290

) 1983 All wards A 45% —

(

281

) 1986 SICU A 51% —

MICU A 76% —

(

276

) 1986 ICU A 63% 92% Performance feedback

(

291

) 1987 PICU A 31% 30% Wearing overgown

(

292

) 1989 MICU B/A 14%/28%* 73%/81% Feedback, policy reviews, memo, and posters

MICU B/A 26%/23% 38%/60%

(

293

) 1989 NICU A/B 75%/50% —

(

294

) 1990 ICU A 32% 45% Alcohol rub introduced

(

295

) 1990 ICU A 81% 92% Inservices first, then group feedback

(

296

) 1990 ICU B/A 22% 30%

(

297

) 1991 SICU A 51% —

(

298

) 1991 Pedi OPDs B 49% 49% Signs, feedback, and verbal reminders to physicians

(

299

) 1991 Nursery and NICU B/A

†

28% 63% Feedback, dissemination of literature, and results of

environmental cultures

(

300

) 1992 NICU/others A 29% —

(

) 1992 ICU N.S. 40% —

(

301

) 1993 ICUs A 40% —

(

) 1994 Emergency Room A 32% —

(

) 1994 All wards A 32% —

(

285

) 1994 SICU A 22% 38% Automated handwashing machines available

(

302

) 1994 NICU A 62% 60% No gowning required

(

303

) 1994 ICU Wards AA 30%29% —

(

304

) 1995 ICU Oncol Ward A 56% —

(

305

) 1995 ICU N.S. 5% 63% Lectures, feedback, and demonstrations

(

306

) 1996 PICU B/A 12%/11% 68%/65% Overt observation, followed by feedback

(

307

) 1996 MICU A 41% 58% Routine wearing of gowns and gloves

(

308

) 1996 Emergency Dept A 54% 64% Signs/distributed review paper

(

309

) 1998 All wards A 30% —

(

310

) 1998 Pediatric wards B/A 52%/49% 74%/69% Feedback, movies, posters, and brochures

(

311

) 1999 MICU B/A 12%/55% —

(

) 2000 All wards B/A 48% 67% Posters, feedback, administrative support, and alcohol rub

(

312

) 2000 MICU A 42% 61% Alcohol hand rub made available

(

283

) 2000 MICU B/A 10%/22% 23%/48% Education, feedback, and alcohol gel made available

CTICU B/A 4%/13% 7%/14%

(

313

) 2000 Medical wards A 60% 52% Education, reminders, and alcohol gel made available

Note: ICU = intensive care unit, SICU = surgical ICU, MICU = medical ICU, PICU = pediatric ICU, NICU = neonatal ICU, Emerg = emergency, Oncol =

oncology, CTICU = cardiothoracic ICU, and N.S. = not stated.

* Percentage compliance before/after patient contact.

†

After contact with inanimate objects.

Vol. 51 / RR-16 Recommendations and Reports 23

BOX 1. Factors influencing adherence to hand-hygiene practices*

Observed risk factors for poor adherence to recommended hand-hygiene practices

• Physician status (rather than a nurse)

• Nursing assistant status (rather than a nurse)

• Male sex

• Working in an intensive-care unit

• Working during the week (versus the weekend)

• Wearing gowns/gloves

• Automated sink

• Activities with high risk of cross-transmission

• High number of opportunities for hand hygiene per hour of patient care

Self-reported factors for poor adherence with hand hygiene

• Handwashing agents cause irritation and dryness

• Sinks are inconveniently located/shortage of sinks

• Lack of soap and paper towels

• Often too busy/insufficient time

• Understaffing/overcrowding

• Patient needs take priority

• Hand hygiene interferes with health-care worker relationships with patients

• Low risk of acquiring infection from patients

• Wearing of gloves/beliefs that glove use obviates the need for hand hygiene

• Lack of knowledge of guidelines/protocols

• Not thinking about it/forgetfulness

• No role model from colleagues or superiors

• Skepticism regarding the value of hand hygiene

• Disagreement with the recommendations

• Lack of scientific information of definitive impact of improved hand hygiene on health-care–associated infection rates

Additional perceived barriers to appropriate hand hygiene

• Lack of active participation in hand-hygiene promotion at individual or institutional level

• Lack of role model for hand hygiene

• Lack of institutional priority for hand hygiene

• Lack of administrative sanction of noncompliers/rewarding compliers

• Lack of institutional safety climate

* Source: Adapted from Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000;21:381–6.

Factors Affecting Adherence. Factors that may influence

hand hygiene include those identified in epidemiologic stud-

ies and factors reported by HCWs as being reasons for lack of

adherence to hand-hygiene recommendations. Risk factors for

poor adherence to hand hygiene have been determined objec-

tively in several observational studies or interventions to

improve adherence (11,12,274,292,295,314–317). Among

these, being a physician or a nursing assistant, rather than a

nurse, was consistently associated with reduced adherence (Box 1).

In the largest hospitalwide survey of hand-hygiene practices

among HCWs (11), predictors of poor adherence to recom-

mended hand-hygiene measures were identified. Predictor

variables included professional category, hospital ward, time

of day/week, and type and intensity of patient care, defined as

the number of opportunities for hand hygiene per hour of

patient care. In 2,834 observed opportunities for hand

hygiene, average adherence was 48%. In multivariate analysis,

nonadherence was lowest among nurses and during weekends

24 MMWR October 25, 2002

(Odds Ratio [OR]: 0.6; 95% confidence interval [CI] = 0.4–

0.8). Nonadherence was higher in intensive-care units com-

pared with internal medicine wards (OR: 2.0; 95% CI =

1.3–3.1), during procedures that carried a high risk of bacte-

rial contamination (OR: 1.8; 95% CI = 1.4–2.4), and when

intensity of patient care was high (21–40 handwashing

opportunities — OR: 1.3; 95% CI = 1.0-1.7; 41–60 oppor-

tunities — OR: 2.1; 95% CI = 1.5-2.9; >60 opportunities —

OR: 2.1; 95% CI = 1.3–3.5). The higher the demand for hand

hygiene, the lower the adherence; on average, adherence

decreased by 5% (

+ 2%) for each increase of 10 opportunities

per hour when the intensity of patient care exceeded 10

opportunities per hour. Similarly, the lowest adherence rate

(36%) was found in intensive-care units, where indications

for hand hygiene were typically more frequent (on average, 20

opportunities per patient-hour). The highest adherence rate

(59%) was observed in pediatrics wards, where the average

intensity of patient care was lower than in other hospital areas

(an average of eight opportunities per patient-hour). The

results of this study indicate that full adherence to previous

guidelines may be unrealistic, and that facilitated access to

hand hygiene could help improve adherence (11,12,318).

Perceived barriers to adherence with hand-hygiene practice

recommendations include skin irritation caused by hand-

hygiene agents, inaccessible hand-hygiene supplies, interfer-

ence with HCW-patient relationships, priority of care (i.e.,

the patients’ needs are given priority over hand hygiene), wear-

ing of gloves, forgetfulness, lack of knowledge of the guide-

lines, insufficient time for hand hygiene, high workload and

understaffing, and the lack of scientific information indicat-

ing a definitive impact of improved hand hygiene on health-

care–associated infection rates (11,274,292,295,315–317).

Certain perceived barriers to adherence with hand-hygiene

guidelines have been assessed or quantified in observational

studies (12,274,292,295,314–317) (Box 1).

Skin irritation by hand-hygiene agents constitutes a sub-

stantial barrier to appropriate adherence (319). Because soaps

and detergents can damage skin when applied on a regular

basis, HCWs must be better informed regarding the possible

adverse effects associated with hand-hygiene agents. Lack of

knowledge and education regarding this subject is a barrier to

motivation. In several studies, alcohol-based hand rubs con-

taining emollients (either isopropanol, ethanol, or n-propanol

in 60%–90% vol/vol) were less irritating to the skin than the

soaps or detergents tested. In addition, the alcohol-based prod-

ucts containing emollients that were tested were at least as

tolerable and efficacious as the detergents tested. Also, studies

demonstrate that several hand lotions have reduced skin scal-

ing and cracking, which may reduce microbial shedding from

the hands (67,272,273).

Easy access to hand-hygiene supplies, whether sink, soap,

medicated detergent, or alcohol-based hand-rub solution, is

essential for optimal adherence to hand-hygiene recommen-

dations. The time required for nurses to leave a patient’s bed-

side, go to a sink, and wash and dry their hands before attending

the next patient is a deterrent to frequent handwashing or hand

antisepsis (11,318). Engineering controls could facilitate

adherence, but careful monitoring of hand-hygiene behavior

should be conducted to exclude the possible negative effect of

newly introduced handwashing devices (88).

The impact of wearing gloves on adherence to hand-

hygiene policies has not been definitively established, because

published studies have yielded contradictory results

(87,290,301,320). Hand hygiene is required regardless of

whether gloves are used or changed. Failure to remove gloves

after patient contact or between “dirty” and “clean” body-site

care on the same patient must be regarded as nonadherence to

hand-hygiene recommendations (11). In a study in which

experimental conditions approximated those occurring in clini-

cal practice (321), washing and reusing gloves between

patient contacts resulted in observed bacterial counts of 0–4.7

log on the hands after glove removal. Therefore, this practice

should be discouraged; handwashing or disinfection should

be performed after glove removal.

Lack of 1) knowledge of guidelines for hand hygiene, 2)

recognition of hand-hygiene opportunities during patient care,

and 3) awareness of the risk of cross-transmission of patho-

gens are barriers to good hand-hygiene practices. Furthermore,

certain HCWs believe they have washed their hands when

necessary, even when observations indicate they have not

(89,92,295,296,322).

Perceived barriers to hand-hygiene behavior are linked not

only to the institution, but also to HCWs’ colleagues. There-

fore, both institutional and small-group dynamics need to be

considered when implementing a system change to secure an

improvement in HCWs’ hand-hygiene practice.

Possible Targets for Hand-Hygiene Promotion

Targets for the promotion of hand hygiene are derived from

studies assessing risk factors for nonadherence, reported rea-

sons for the lack of adherence to recommendations, and addi-

tional factors perceived as being important to facilitate

appropriate HCW behavior. Although certain factors cannot

be modified (Box 1), others can be changed.

One factor that must be addressed is the time required for

HCWs to clean their hands. The time required for traditional

handwashing may render full adherence to previous guide-

lines unrealistic (11,12,318) and more rapid access to hand-

hygiene materials could help improve adherence. One study

conducted in an intensive-care unit demonstrated that it took

Vol. 51 / RR-16 Recommendations and Reports 25

nurses an average of 62 seconds to leave a patient’s bedside,

walk to a sink, wash their hands, and return to patient care

(318). In contrast, an estimated one fourth as much time is

required when using alcohol-based hand rub placed at each

patient’s bedside. Providing easy access to hand-hygiene

materials is mandatory for appropriate hand-hygiene behavior

and is achievable in the majority of health-care facilities (323).

In particular, in high-demand situations (e.g., the

majority of critical-care units), under hectic working condi-

tions, and at times of overcrowding or understaffing, HCWs

may be more likely to use an alcohol-based hand rub than to

wash their hands (323). Further, using alcohol-based hand rubs

may be a better option than traditional handwashing with plain

soap and water or antiseptic handwash, because they not only

require less time (166,318) but act faster (1) and irritate hands

less often (1,67,96,98,166). They also were used in the only

program that reported a sustained improvement in hand-

hygiene adherence associated with decreased infection rates

(74). However, making an alcohol-based hand rub available

to personnel without providing ongoing educational and

motivational activities may not result in long-lasting improve-

ment in hand-hygiene practices (313). Because increased use

of hand-hygiene agents might be associated with skin dryness,

the availability of free skin-care lotion is recommended.

Education is a cornerstone for improvement with hand-

hygiene practices. Topics that must be addressed by educa-

tional programs include the lack of 1) scientific information

for the definitive impact of improved hand hygiene on health-

care–associated infection and resistant organism transmission

rates; 2) awareness of guidelines for hand hygiene and insuffi-

cient knowledge concerning indications for hand hygiene

during daily patient care; 3) knowledge concerning the low

average adherence rate to hand hygiene by the majority of

HCWs; and 4) knowledge concerning the appropriateness,

efficacy, and understanding of the use of hand-hygiene and

skin-care–protection agents.

HCWs necessarily evolve within a group that functions

within an institution. Possible targets for improvement in hand-

hygiene behavior not only include factors linked to individual

HCWs, but also those related to the group(s) and the institu-

tion as a whole (317,323). Examples of possible targets for

hand-hygiene promotion at the group level include education

and performance feedback on hand-hygiene adherence; efforts

to prevent high workload, downsizing, and understaffing; and

encouragement and provision of role models from key mem-

bers in the work unit. At the institutional level, targets for

improvement include 1) written guidelines, hand-hygiene

agents, skin-care promotions and agents, or hand-hygiene

facilities; 2) culture or tradition of adherence; and 3)

administrative leadership, sanction, support, and rewards. Sev-

eral studies, conducted in various types of institutions, reported

modest and even low levels of adherence to recommended

hand-hygiene practices, indicating that such adherence varied

by hospital ward and by type of HCW. These results indicate

educational sessions may need to be designed specifically for

certain types of personnel (11,289,290,294,317,323).

Lessons Learned from Behavioral

Theories

In 1998, the prevailing behavioral theories and their appli-

cations with regard to the health professions were reviewed by

researchers in an attempt to better understand how to target

more successful interventions (317). The researchers proposed

a hypothetical framework to enhance hand-hygiene practices

and stressed the importance of considering the complexity of

individual and institutional factors when designing behavioral

interventions.

Although behavioral theories and secondary interventions

have primarily targeted individual workers, this practice might

be insufficient to produce sustained change (317,324,325).

Interventions aimed at improving hand-hygiene practices must

account for different levels of behavior interaction

(12,317,326). Thus, the interdependence of individual fac-

tors, environmental constraints, and the institutional climate

must be taken into account in the strategic planning and

development of hand-hygiene campaigns. Interventions to pro-

mote hand hygiene in hospitals should consider variables at

all these levels. Various factors involved in hand-hygiene

behavior include intention, attitude towards the behavior, per-

ceived social norm, perceived behavioral control, perceived

risk for infection, hand-hygiene practices, perceived role model,

perceived knowledge, and motivation (317). The factors nec-

essary for change include 1) dissatisfaction with the current

situation, 2) perception of alternatives, and 3) recognition,

both at the individual and institutional level, of the ability

and potential to change. Although the latter implies educa-

tion and motivation, the former two necessitate a system

change.

Among the reported reasons for poor adherence with hand-

hygiene recommendations (Box 1), certain ones are clearly

associated with the institution or system (e.g., lack of institu-

tional priority for hand hygiene, administrative sanctions, and

a safety climate). Although all of these reasons would require a

system change in the majority of institutions, the third

requires management commitment, visible safety programs,

an acceptable level of work stress, a tolerant and supportive

attitude toward reported problems, and belief in the efficacy

26 MMWR October 25, 2002

of preventive strategies (12,317,325,327). Most importantly,

an improvement in infection-control practices requires 1) ques-

tioning basic beliefs, 2) continuous assessment of the group

(or individual) stage of behavioral change, 3) intervention(s)

with an appropriate process of change, and 4) supporting

individual and group creativity (317). Because of the com-

plexity of the process of change, single interventions often fail.

Thus, a multimodal, multidisciplinary strategy is likely neces-

sary (74,75,317,323,326).

Methods Used To Promote Improved

Hand Hygiene

Hand-hygiene promotion has been challenging for >150

years. In-service education, information leaflets, workshops

and lectures, automated dispensers, and performance feedback

on hand-hygiene adherence rates have been associated with

transient improvement (291,294–296,306,314).

Several strategies for promotion of hand hygiene in hospi-

tals have been published (Table 9). These strategies require

education, motivation, or system change. Certain strategies

are based on epidemiologic evidence, others on the authors’

and other investigators’ experience and review of current

knowledge. Some strategies may be unnecessary in certain cir-

cumstances, but may be helpful in others. In particular, chang-

ing the hand-hygiene agent could be beneficial in institutions

or hospital wards with a high workload and a high demand

for hand hygiene when alcohol-based hand rubs are not avail-

able (11,73,78,328). However, a change in the recommended

hand-hygiene agent could be deleterious if introduced during

winter, at a time of higher hand-skin irritability, and if not

accompanied by the provision of skin-care products (e.g., pro-

tective creams and lotions). Additional specific elements should

be considered for inclusion in educational and motivational

programs (Box 2).

Several strategies that could potentially be associated with

successful promotion of hand hygiene require a system change

(Box 1). Hand-hygiene adherence and promotion involve fac-

tors at both the individual and system level. Enhancing indi-

vidual and institutional attitudes regarding the feasibility of

making changes (self-efficacy), obtaining active participation

of personnel at both levels, and promoting an institutional

safety climate represent challenges that exceed the current per-

ception of the role of infection-control professionals.

Whether increased education, individual reinforcement tech-

nique, appropriate rewarding, administrative sanction,

enhanced self-participation, active involvement of a larger

number of organizational leaders, enhanced perception of

health threat, self-efficacy, and perceived social pressure

(12,317,329,330), or combinations of these factors can

improve HCWs’ adherence with hand hygiene needs further

investigation. Ultimately, adherence to recommended hand-

hygiene practices should become part of a culture of patient

safety where a set of interdependent quality elements interact

to achieve a shared objective (331).

On the basis of both these hypothetical considerations and

successful, actual experiences in certain institutions, strategies

to improve adherence to hand-hygiene practices should be both

multimodal and multidisciplinary. However, strategies must

be further researched before they are implemented.

TABLE 9. Stategies for successful promotion of hand hygiene in hospitals

Strategy Tool for change* Selected references

†

Education E (M, S) (

74,295,306,326,393

)

Routine observation and feedback S (E, M) (

74,294,306,326,393

)

Engineering control

Make hand hygiene possible, easy, and convenient S (

74,281,326,393

)

Make alcohol-based hand rub available S (

)

(at least in high-demand situations) S (

74,283,312

)

Patient education S (M) (

283,394

)

Reminders in the workplace S (

74,395

)

Administrative sanction/rewarding S (

12,317

)

Change in hand-hygiene agent S (E) (

11,67,71,283,312

)

Promote/facilitate skin care for health-care–workers’ hands S (E) (

67,74,274,275

)

Obtain active participation at individual and institutional level E, M, S (

74,75,317

)

Improve institutional safety climate S (M) (

74,75,317

)

Enhance individual and institutitional self-efficacy S (E, M) (

74,75,317

)

Avoid overcrowding, understaffing, and excessive workload S (

11,74,78,297,396

)

Combine several of above strategies E, M, S (

74,75,295,306,317,326

)

* The dynamic of behavioral change is complex and involves a combination of education (E), motivation (M), and system change (S).

†

Only selected references have been listed; readers should refer to more extensive reviews for exhaustive reference lists (

1,8,317,323,397

Vol. 51 / RR-16 Recommendations and Reports 27

BOX 2. Elements of health-care worker educational and motivational programs

Rationale for hand hygiene

• Potential risks of transmission of microorganisms to patients

• Potential risks of health-care worker colonization or infection caused by organisms acquired from the patient

• Morbidity, mortality, and costs associated with health-care–associated infections

Indications for hand hygiene

• Contact with a patient’s intact skin (e.g., taking a pulse or blood pressure, performing physical examinations, lifting the

patient in bed) (25,26,45,48,51,53)

• Contact with environmental surfaces in the immediate vicinity of patients (46,51,53,54)

• After glove removal (50,58,71)

Techniques for hand hygiene

• Amount of hand-hygiene solution

• Duration of hand-hygiene procedure

• Selection of hand-hygiene agents

— Alcohol-based hand rubs are the most efficacious agents for reducing the number of bacteria on the hands of

personnel. Antiseptic soaps and detergents are the next most effective, and non-antimicrobial soaps are the least

effective (1,398).

— Soap and water are recommended for visibly soil hands.

— Alcohol-based hand rubs are recommended for routine decontamination of hands for all clinical indications (except

when hands are visibly soiled) and as one of the options for surgical hand hygiene.

Methods to maintain hand skin health

• Lotions and creams can prevent or minimize skin dryness and irritation caused by irritant contact dermatitis

• Acceptable lotions or creams to use

• Recommended schedule for applying lotions or creams

Expectations of patient care managers/administrators

• Written statements regarding the value of, and support for, adherence to recommended hand-hygiene practices

• Role models demonstrating adherence to recommended hand hygiene practices (399)

Indications for, and limitations of, glove use

• Hand contamination may occur as a result of small, undetected holes in examination gloves (321,361)

• Contamination may occur during glove removal (50)

• Wearing gloves does not replace the need for hand hygiene (58)

• Failure to remove gloves after caring for a patient may lead to transmission of microorganizations from one patient to

another (373).

Efficacy of Promotion and Impact

of Improved Hand Hygiene

The lack of scientific information of the definitive impact

of improved hand hygiene on health-care–associated infec-

tion rates is a possible barrier to appropriate adherence with

hand-hygiene recommendations (Box 1). However, evidence

supports the belief that improved hand hygiene can reduce

health-care–associated infection rates. Failure to perform

appropriate hand hygiene is considered the leading cause of

health-care–associated infections and spread of multiresistant

organisms and has been recognized as a substantial contribu-

tor to outbreaks.

Of nine hospital-based studies of the impact of hand

hygiene on the risk of health-care–associated infections

(Table 10) (48,69–75,296), the majority demonstrated a tem-

poral relationship between improved hand-hygiene practices

and reduced infection rates.

In one of these studies, endemic MRSA in a neonatal intensive-

care unit was eliminated 7 months after introduction of a new

28 MMWR October 25, 2002

hand antiseptic (1% triclosan); all other infection-control

measures remained in place, including the practice of con-

ducting weekly active surveillance by obtaining cultures (72).

Another study reported an MRSA outbreak involving 22 in-

fants in a neonatal unit (73). Despite intensive efforts, the

outbreak could not be controlled until a new antiseptic was

added (i.e., 0.3% triclosan); all previously used control mea-

sures remained in place, including gloves and gowns, cohorting,

and obtaining cultures for active surveillance.

The effectiveness of a longstanding, hospitalwide program

to promote hand hygiene at the University of Geneva hospi-

tals was recently reported (74). Overall adherence to hand-

hygiene guidelines during routine patient care was monitored

during hospitalwide observational surveys. These surveys were

conducted biannually during December 1994–December

1997, before and during implementation of a hand-hygiene

campaign that specifically emphasized the practice of bedside,

alcohol-based hand disinfection. Individual-sized bottles of

hand-rub solution were distributed to all wards, and custom-

made holders were mounted on all beds to facilitate access to

hand disinfection. HCWs were also encouraged to carry bottles

in their pockets, and in 1996, a newly designed flat (instead of

round) bottle was made available to further facilitate pocket

carriage. The promotional strategy was multimodal and

involved a multidisciplinary team of HCWs, the use of wall

posters, the promotion of antiseptic hand rubs located at bed-

sides throughout the institution, and regular performance feed-

back to all HCWs (see http://www.hopisafe.ch for further

details on methodology). Health-care–associated infection

rates, attack rates of MRSA cross-transmission, and consump-

tion of hand-rub disinfectant were measured. Adherence to

recommended hand-hygiene practices improved progressively

from 48% in 1994 to 66% in 1997 (p < 0.001). Whereas

recourse to handwashing with soap and water remained stable,

frequency of hand disinfection markedly increased during the

study period (p < 0.001), and the consumption of alcohol-

based hand-rub solution increased from 3.5 to 15.4 liters per

1,000 patient-days during 1993–1998 (p < 0.001). The

increased frequency of hand disinfection was unchanged after

adjustment for known risk factors of poor adherence. During

the same period, both overall health-care–associated infection

and MRSA transmission rates decreased (both p < 0.05). The

observed reduction in MRSA transmission may have been

affected by both improved hand-hygiene adherence and the

simultaneous implementation of active surveillance cultures

for detecting and isolating patients colonized with MRSA

(332). The experience from the University of Geneva hospi-

tals constitutes the first report of a hand-hygiene campaign

with a sustained improvement over several years. An additional

multimodal program also yielded sustained improvements in

hand-hygiene practices over an extended period (75); the

majority of studies have been limited to a 6- to 9-month

observation period.

Although these studies were not designed to assess the inde-

pendent contribution of hand hygiene on the prevention of

health-care–associated infections, the results indicate that

1977

1982

1984

1990

1992

1994

1995

2000

(

)

(

)

(

)

(

296

)

(

)

(

)

(

)

(

)

(

)

Adult ICU

NICU

Newborn nursery

MICU/NICU

Hospitalwide

Reduction in health-care–associated infections caused by endemic

Klebsiella

spp.

Reduction in health-care-associated infection rates

Reduction in health-care–associated infection rates

No effect (average hand hygiene adherence improvement did not reach statistical

significance)

Substantial difference between rates of health-care–associated infection between two

different hand-hygiene agents

Elimination of MRSA, when combined with multiple other infection-control measures.

Reduction of vancomycin use

Elimination of MRSA, when combined with multiple other infection-control measures

85% relative reduction of VRE rate in the intervention hospital; 44% relative reduction

in control hospital; no change in MRSA

Substantial reduction in the annual overall prevalence of health-care–associated

infections and MRSA cross-transmission rates. Active surveillance cultures and

contact precautions were implemented during same period

2 years

N.S.

11 months

8 months

9 months

3.5 years

8 months

5 years

TABLE 10. Association between improved adherence with hand-hygiene practice and health-care–associated infection rates

Duration

Year Ref. no. Hospital setting Results of follow-up

Note: ICU = intensive care unit, NICU = neonatal ICU, MRSA = methicillin-resistant

Staphylococcus aureus

, MICU = medical ICU, and N.S. = not stated.

Vol. 51 / RR-16 Recommendations and Reports 29

improved hand-hygiene practices reduce the risk of transmis-

sion of pathogenic microorganisms. The beneficial effects of

hand-hygiene promotion on the risk of cross-transmission also

have been reported in surveys conducted in schools and day care

centers (333–338), as well as in a community setting (339–341).

Other Policies Related to Hand

Hygiene

Fingernails and Artificial Nails

Studies have documented that subungual areas of the hand

harbor high concentrations of bacteria, most frequently

coagulase-negative staphylococci, gram-negative rods (includ-

ing Pseudomonas spp.), Corynebacteria, and yeasts

(14,342,343). Freshly applied nail polish does not increase

the number of bacteria recovered from periungual skin, but

chipped nail polish may support the growth of larger numbers

of organisms on fingernails (344,345). Even after careful

handwashing or the use of surgical scrubs, personnel often

harbor substantial numbers of potential pathogens in the sub-

ungual spaces (346–348).

Whether artificial nails contribute to transmission of health-

care–associated infections is unknown. However, HCWs who

wear artificial nails are more likely to harbor gram-negative

pathogens on their fingertips than are those who have natural

nails, both before and after handwashing (347–349). Whether

the length of natural or artificial nails is a substantial risk fac-

tor is unknown, because the majority of bacterial growth

occurs along the proximal 1 mm of the nail adjacent to sub-

ungual skin (345,347,348). Recently, an outbreak of

P. aeruginosa in a neonatal intensive care unit was attributed

to two nurses (one with long natural nails and one with long

artificial nails) who carried the implicated strains of Pseudomo-

nas spp. on their hands (350). Patients were substantially more

likely than controls to have been cared for by the two nurses

during the exposure period, indicating that colonization of

long or artificial nails with Pseudomonas spp. may have con-

tributed to causing the outbreak. Personnel wearing artificial

nails also have been epidemiologically implicated in several

other outbreaks of infection caused by gram-negative bacilli

and yeast (351–353). Although these studies provide evidence

that wearing artificial nails poses an infection hazard, addi-

tional studies are warranted.

Gloving Policies

CDC has recommended that HCWs wear gloves to 1)

reduce the risk of personnel acquiring infections from patients,

2) prevent health-care worker flora from being transmitted to

patients, and 3) reduce transient contamination of the hands

of personnel by flora that can be transmitted from one patient

to another (354). Before the emergence of the acquired

immunodeficiency syndrome (AIDS) epidemic, gloves were

worn primarily by personnel caring for patients colonized or

infected with certain pathogens or by personnel exposed to

patients with a high risk of hepatitis B. Since 1987, a dramatic

increase in glove use has occurred in an effort to prevent trans-

mission of HIV and other bloodborne pathogens from

patients to HCWs (355). The Occupational Safety and Health

Administration (OSHA) mandates that gloves be worn dur-

ing all patient-care activities that may involve exposure to blood

or body fluids that may be contaminated with blood (356).

The effectiveness of gloves in preventing contamination of

HCWs’ hands has been confirmed in several clinical studies

(45,51,58). One study found that HCWs who wore gloves

during patient contact contaminated their hands with an

average of only 3 CFUs per minute of patient care, compared

with 16 CFUs per minute for those not wearing gloves (51).

Two other studies, involving personnel caring for patients with

C. difficile or VRE, revealed that wearing gloves prevented hand

contamination among the majority of personnel having

direct contact with patients (45,58). Wearing gloves also pre-

vented personnel from acquiring VRE on their hands when

touching contaminated environmental surfaces (58). Prevent-

ing heavy contamination of the hands is considered impor-

tant, because handwashing or hand antisepsis may not remove

all potential pathogens when hands are heavily contaminated

(25,111).

Several studies provide evidence that wearing gloves can help

reduce transmission of pathogens in health-care settings. In a

prospective controlled trial that required personnel to routinely

wear vinyl gloves when handling any body substances, the

incidence of C. difficile diarrhea among patients decreased from

7.7 cases/1,000 patient discharges before the intervention to

1.5 cases/1,000 discharges during the intervention (226). The

prevalence of asymptomatic C. difficile carriage also decreased

substantially on “glove” wards, but not on control wards. In

intensive-care units where VRE or MRSA have been epidemic,

requiring all HCWs to wear gloves to care for all patients in

the unit (i.e., universal glove use) likely has helped control

outbreaks (357,358).

The influence of glove use on the hand-hygiene habits of

personnel is not clear. Several studies found that personnel

who wore gloves were less likely to wash their hands upon

leaving a patient’s room (290,320). In contrast, two other stud-

ies found that personnel who wore gloves were substantially

more likely to wash their hands after patient care (87,301).

The following caveats regarding use of gloves by HCWs

must be considered. Personnel should be informed that gloves

30 MMWR October 25, 2002

do not provide complete protection against hand contamina-

tion. Bacterial flora colonizing patients may be recovered from

the hands of

<30% of HCWs who wear gloves during patient

contact (50,58). Further, wearing gloves does not provide com-

plete protection against acquisition of infections caused by

hepatitis B virus and herpes simplex virus (359,360). In such

instances, pathogens presumably gain access to the caregiver’s

hands via small defects in gloves or by contamination of the

hands during glove removal (50,321,359,361).

Gloves used by HCWs are usually made of natural rubber

latex and synthetic nonlatex materials (e.g., vinyl, nitrile, and

neoprene [polymers and copolymers of chloroprene]). Because

of the increasing prevalence of latex sensitivity among HCWs

and patients, FDA has approved several powdered and powder-

free latex gloves with reduced protein contents, as well as syn-

thetic gloves that can be made available by health-care

institutions for use by latex-sensitive employees. In published

studies, the barrier integrity of gloves varies on the basis of

type and quality of glove material, intensity of use, length of

time used, manufacturer, whether gloves were tested before or

after use, and method used to detect glove leaks (359,361–

366). In published studies, vinyl gloves have had defects more

frequently than latex gloves, the difference in defect frequency

being greatest after use (359,361,364,367). However, intact

vinyl gloves provide protection comparable to that of latex

gloves (359). Limited studies indicate that nitrile gloves have

leakage rates that approximate those of latex gloves (368–371).

Having more than one type of glove available is desirable,

because it allows personnel to select the type that best suits

their patient-care activities. Although recent studies indicate

that improvements have been made in the quality of gloves

(366), hands should be decontaminated or washed after

removing gloves (8,50,58,321,361). Gloves should not be

washed or reused (321,361). Use of petroleum-based hand

lotions or creams may adversely affect the integrity of latex

gloves (372). After use of powdered gloves, certain alcohol

hand rubs may interact with residual powder on the hands of

personnel, resulting in a gritty feeling on the hands. In facili-

ties where powdered gloves are commonly used, various alcohol-

based hand rubs should be tested after removal of powdered

gloves to avoid selecting a product that causes this undesirable

reaction. Personnel should be reminded that failure to remove

gloves between patients may contribute to transmission of

organisms (358,373).

Jewelry

Several studies have demonstrated that skin underneath rings

is more heavily colonized than comparable areas of skin on

fingers without rings (374–376). One study found that 40%

of nurses harbored gram-negative bacilli (e.g., E. cloacae, Kleb-

siella, and Acinetobacter) on skin under rings and that certain

nurses carried the same organism under their rings for several

months (375). In a more recent study involving >60 intensive

care unit nurses, multivariable analysis revealed that rings were

the only substantial risk factor for carriage of gram-negative

bacilli and S. aureus and that the concentration of organisms

recovered correlated with the number of rings worn (377).

Whether the wearing of rings results in greater transmission

of pathogens is unknown. Two studies determined that mean

bacterial colony counts on hands after handwashing were simi-

lar among persons wearing rings and those not wearing rings

(376,378). Further studies are needed to establish if wearing

rings results in greater transmission of pathogens in health-

care settings.

Hand-Hygiene Research Agenda

Although the number of published studies concerning hand

hygiene has increased considerably in recent years, many ques-

tions regarding hand-hygiene products and strategies for

improving adherence of personnel to recommended policies

remain unanswered. Several concerns must still be addressed

by researchers in industry and by clinical investigators (Box 3).

Web-Based Hand-Hygiene

Resources

Additional information regarding improving hand hygiene

is available at http://www.hopisafe.ch

University of Geneva Hospitals, Geneva, Switzerland

http://www.cdc.gov/ncidod/hip

CDC, Atlanta, Georgia

http://www.jr2.ox.ac.uk/bandolier/band88/b88-8.html

Bandolier journal, United Kingdom

http://www.med.upenn.edu

University of Pennsylvania, Philadelphia, Pennsylvania

Vol. 51 / RR-16 Recommendations and Reports 31

As in previous CDC/HICPAC guidelines, each recommen-

dation is categorized on the basis of existing scientific data,

theoretical rationale, applicability, and economic impact. The

CDC/HICPAC system for categorizing recommendations is

as follows:

Category IA. Strongly recommended for implementation and

strongly supported by well-designed experimental, clinical, or

epidemiologic studies.

Category IB. Strongly recommended for implementation and

supported by certain experimental, clinical, or epidemiologic

studies and a strong theoretical rationale.

BOX 3. Hand-hygiene research agenda

Education and promotion

• Provide health-care workers (HCWs) with better education regarding the types of patient care activities that can result

in hand contamination and cross-transmission of microorganisms.

• Develop and implement promotion hand-hygiene programs in pregraduate courses.

• Study the impact of population-based education on hand-hygiene behavior.

• Design and conduct studies to determine if frequent glove use should be encouraged or discouraged.

• Determine evidence-based indications for hand cleansing (considering that it might be unrealistic to expect HCWs to

clean their hands after every contact with the patient).

• Assess the key determinants of hand-hygiene behavior and promotion among the different populations of HCWs.

• Develop methods to obtain management support.

• Implement and evaluate the impact of the different components of multimodal programs to promote hand hygiene.

Hand-hygiene agents and hand care

• Determine the most suitable formulations for hand-hygiene products.

• Determine if preparations with persistent antimicrobial activity reduce infection rates more effectively than do prepa-

rations whose activity is limited to an immediate effect.

• Study the systematic replacement of conventional handwashing by the use of hand disinfection.

• Develop devices to facilitate the use and optimal application of hand-hygiene agents.

• Develop hand-hygiene agents with low irritancy potential.

• Study the possible advantages and eventual interaction of hand-care lotions, creams, and other barriers to help mini-

mize the potential irritation associated with hand-hygiene agents.

Laboratory-based and epidemiologic research and development

• Develop experimental models for the study of cross-contamination from patient to patient and from environment to

patient.

• Develop new protocols for evaluating the in vivo efficacy of agents, considering in particular short application times

and volumes that reflect actual use in health-care facilities.

• Monitor hand-hygiene adherence by using new devices or adequate surrogate markers, allowing frequent individual

feedback on performance.

• Determine the percentage increase in hand-hygiene adherence required to achieve a predictable risk reduction in infec-

tion rates.

• Generate more definitive evidence for the impact on infection rates of improved adherence to recommended hand-

hygiene practices.

• Provide cost-effectiveness evaluation of successful and unsuccessful promotion campaigns.

Part II. Recommendations

Categories

These recommendations are designed to improve hand-

hygiene practices of HCWs and to reduce transmission of

pathogenic microorganisms to patients and personnel in health-

care settings. This guideline and its recommendations are not

intended for use in food processing or food-service establish-

ments, and are not meant to replace guidance provided by

FDA’s Model Food Code.

32 MMWR October 25, 2002

Category IC. Required for implementation, as mandated by

federal or state regulation or standard.

Category II. Suggested for implementation and supported

by suggestive clinical or epidemiologic studies or a theoretical

rationale.

No recommendation. Unresolved issue. Practices for which

insufficient evidence or no consensus regarding efficacy exist.

Recommendations

1. Indications for handwashing and hand antisepsis

A. When hands are visibly dirty or contaminated with

proteinaceous material or are visibly soiled with blood

or other body fluids, wash hands with either a non-

antimicrobial soap and water or an antimicrobial soap

and water (IA) (66).

B. If hands are not visibly soiled, use an alcohol-based

hand rub for routinely decontaminating hands in

all other clinical situations described in items 1C–J

(IA) (74,93,166,169,283,294,312,398). Alterna-

tively, wash hands with an antimicrobial soap and

water in all clinical situations described in items

1C–J (IB) (69-71,74).

C. Decontaminate hands before having direct contact

with patients (IB) (68,400).

D. Decontaminate hands before donning sterile gloves

when inserting a central intravascular catheter (IB)

(401,402).

E. Decontaminate hands before inserting indwelling

urinary catheters, peripheral vascular catheters, or

other invasive devices that do not require a surgical

procedure (IB) (25,403).

F. Decontaminate hands after contact with a patient’s

intact skin (e.g., when taking a pulse or blood

pressure, and lifting a patient) (IB) (25,45,48,68).

G. Decontaminate hands after contact with body fluids

or excretions, mucous membranes, nonintact skin,

and wound dressings if hands are not visibly soiled

(IA) (400).

H. Decontaminate hands if moving from a

contaminated-body site to a clean-body site during

patient care (II) (25,53).

I. Decontaminate hands after contact with inanimate

objects (including medical equipment) in the

immediate vicinity of the patient (II) (46,53,54).

J. Decontaminate hands after removing gloves (IB)

(50,58,321).

K. Before eating and after using a restroom, wash hands

with a non-antimicrobial soap and water or with an

antimicrobial soap and water (IB) (404-409).

L. Antimicrobial-impregnated wipes (i.e., towelettes)

may be considered as an alternative to washing hands

with non-antimicrobial soap and water. Because they

are not as effective as alcohol-based hand rubs or

washing hands with an antimicrobial soap and water

for reducing bacterial counts on the hands of HCWs,

they are not a substitute for using an alcohol-based

hand rub or antimicrobial soap (IB) (160,161).

M. Wash hands with non-antimicrobial soap and water

or with antimicrobial soap and water if exposure to

Bacillus anthracis is suspected or proven. The physical

action of washing and rinsing hands under such

circumstances is recommended because alcohols,

chlorhexidine, iodophors, and other antiseptic agents

have poor activity against spores (II) (120,172,

224,225).

N. No recommendation can be made regarding the

routine use of nonalcohol-based hand rubs for hand

hygiene in health-care settings. Unresolved issue.

2. Hand-hygiene technique

A. When decontaminating hands with an alcohol-based

hand rub, apply product to palm of one hand and

rub hands together, covering all surfaces of hands

and fingers, until hands are dry (IB) (288,410).

Follow the manufacturer’s recommendations

regarding the volume of product to use.

B. When washing hands with soap and water, wet hands

first with water, apply an amount of product

recommended by the manufacturer to hands, and

rub hands together vigorously for at least 15 seconds,

covering all surfaces of the hands and fingers. Rinse

hands with water and dry thoroughly with a

disposable towel. Use towel to turn off the faucet

(IB) (90-92,94,411). Avoid using hot water, because

repeated exposure to hot water may increase the risk

of dermatitis (IB) (254,255).

C. Liquid, bar, leaflet or powdered forms of plain soap

are acceptable when washing hands with a non-

antimicrobial soap and water. When bar soap is used,

soap racks that facilitate drainage and small bars of

soap should be used (II) (412-415).

D. Multiple-use cloth towels of the hanging or roll type

are not recommended for use in health-care settings

(II) (137,300).

3. Surgical hand antisepsis

A. Remove rings, watches, and bracelets before

beginning the surgical hand scrub (II) (375,378,416).

B. Remove debris from underneath fingernails using a

nail cleaner under running water (II) (14,417).

Vol. 51 / RR-16 Recommendations and Reports 33

C. Surgical hand antisepsis using either an antimicrobial

soap or an alcohol-based hand rub with persistent

activity is recommended before donning sterile gloves

when performing surgical procedures (IB)

(115,159,232,234,237,418).

D. When performing surgical hand antisepsis using an

antimicrobial soap, scrub hands and forearms for the

length of time recommended by the manufacturer,

usually 2–6 minutes. Long scrub times (e.g., 10

minutes) are not necessary (IB) (117,156,205,

207,238-241).

E. When using an alcohol-based surgical hand-scrub

product with persistent activity, follow the

manufacturer’s instructions. Before applying the

alcohol solution, prewash hands and forearms with

a non-antimicrobial soap and dry hands and forearms

completely. After application of the alcohol-based

product as recommended, allow hands and forearms

to dry thoroughly before donning sterile gloves (IB)

(159,237).

4. Selection of hand-hygiene agents

A. Provide personnel with efficacious hand-hygiene

products that have low irritancy potential,

particularly when these products are used multiple

times per shift (IB) (90,92,98,166,249). This

recommendation applies to products used for hand

antisepsis before and after patient care in clinical areas

and to products used for surgical hand antisepsis by

surgical personnel.

B. To maximize acceptance of hand-hygiene products

by HCWs, solicit input from these employees

regarding the feel, fragrance, and skin tolerance of

any products under consideration. The cost of hand-

hygiene products should not be the primary factor

influencing product selection (IB) (92,93,166,

274,276-278).

C. When selecting non-antimicrobial soaps,

antimicrobial soaps, or alcohol-based hand rubs,

solicit information from manufacturers regarding any

known interactions between products used to clean

hands, skin care products, and the types of gloves

used in the institution (II) (174,372).

D. Before making purchasing decisions, evaluate the

dispenser systems of various product manufacturers

or distributors to ensure that dispensers function

adequately and deliver an appropriate volume of

product (II) (286).

E. Do not add soap to a partially empty soap dispenser.

This practice of “topping off” dispensers can lead to

bacterial contamination of soap (IA) (187,419).

5. Skin care

A. Provide HCWs with hand lotions or creams to

minimize the occurrence of irritant contact dermatitis

associated with hand antisepsis or handwashing (IA)

(272,273).

B. Solicit information from manufacturers regarding

any effects that hand lotions, creams, or alcohol-

based hand antiseptics may have on the persistent

effects of antimicrobial soaps being used in the

institution (IB) (174,420,421).

6. Other Aspects of Hand Hygiene

A. Do not wear artificial fingernails or extenders when

having direct contact with patients at high risk (e.g.,

those in intensive-care units or operating rooms) (IA)

(350–353).

B. Keep natural nails tips less than 1/4-inch long (II)

(350).

C. Wear gloves when contact with blood or other

potentially infectious materials, mucous membranes,

and nonintact skin could occur (IC) (356).

D. Remove gloves after caring for a patient. Do not wear

the same pair of gloves for the care of more than one

patient, and do not wash gloves between uses with

different patients (IB) (50,58,321,373).

E. Change gloves during patient care if moving from a

contaminated body site to a clean body site (II)

(50,51,58).

F. No recommendation can be made regarding wearing

rings in health-care settings. Unresolved issue.

7. Health-care worker educational and motivational pro-

grams

A. As part of an overall program to improve hand-

hygiene practices of HCWs, educate personnel

regarding the types of patient-care activities that can

result in hand contamination and the advantages and

disadvantages of various methods used to clean their

hands (II) (74,292,295,299).

B. Monitor HCWs’ adherence with recommended

hand-hygiene practices and provide personnel with

information regarding their performance (IA)

(74,276,292,295,299,306,310).

C. Encourage patients and their families to remind

HCWs to decontaminate their hands (II) (394,422).

8. Administrative measures

A. Make improved hand-hygiene adherence an

institutional priority and provide appropriate

34 MMWR October 25, 2002

administrative support and financial resources (IB)

(74,75).

B. Implement a multidisciplinary program designed to

improve adherence of health personnel to

recommended hand-hygiene practices (IB) (74,75).

C. As part of a multidisciplinary program to improve

hand-hygiene adherence, provide HCWs with a

readily accessible alcohol-based hand-rub product

(IA) (74,166,283,294,312).

D. To improve hand-hygiene adherence among

personnel who work in areas in which high workloads

and high intensity of patient care are anticipated,

make an alcohol-based hand rub available at the

entrance to the patient’s room or at the bedside,

in other convenient locations, and in individual

pocket-sized containers to be carried by HCWs (IA)

(11,74,166,283,284,312,318,423).

E. Store supplies of alcohol-based hand rubs in cabinets

or areas approved for flammable materials (IC).

Part III. Performance Indicators

1. The following performance indicators are recommended

for measuring improvements in HCWs’ hand-hygiene

adherence:

A. Periodically monitor and record adherence as the

number of hand-hygiene episodes performed by

personnel/number of hand-hygiene opportunities, by

ward or by service. Provide feedback to personnel

regarding their performance.

B. Monitor the volume of alcohol-based hand rub (or

detergent used for handwashing or hand antisepsis)

used per 1,000 patient-days.

C. Monitor adherence to policies dealing with wearing

of artificial nails.

D. When outbreaks of infection occur, assess the

adequacy of health-care worker hand hygiene.

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395. Khatib M, Jamaleddine G, Abdallah A, Ibrahim Y. Hand washing and

use of gloves while managing patients receiving mechanical ventilation

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396. Haley RW, Bregman DA. The role of understaffing and overcrowding

in recurrent outbreaks of staphylococcal infection in a neonatal spe-

cial-care unit. J Infect Dis 1982;145:875–85.

397. Pittet D, Boyce JM. Hand hygiene and patient care: pursuing the

Semmelweis legacy. Lancet Infectious Diseases 2001;April:9–20.

398. Boyce JM. Scientific basis for handwashing with alcohol and other

waterless antiseptic agents. In: Rutala WA, ed. Disinfection, steriliza-

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and Epidemiology, Inc, 2001.

399. O’Boyle CA, Henly SJ, Duckett LJ. Nurses’ motivation to wash their

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401. Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chevrolet

JC, Pittet D. Impact of a prevention strategy targeted at vascular-

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cet 2000;355:1864–8.

402. Bull DA, Neumayer LA, Hunter GC, et al. Improved sterile technique

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403. Hirschmann H, Fux L, Podusel J, et al. The influence of hand hygiene

prior to insertion of peripheral venous catheters on the frequency of

complications. J Hosp Infect 2001;49:199–203.

404. Drusin LM, Sohmer M, Groshen SL, Spiritos MD, Senterfit LB,

Christenson WN. Nosocomial hepatitis A infection in a paediatric

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405. Doebbeling BN, Li N, Wenzel RP. An outbreak of hepatitis A among

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406. Standaert SM, Hutcheson RH, Schaffner W. Nosocomial transmis-

sion of Salmonella gastroenteritis to laundry workers in a nursing home.

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break of viral gastroenteritis in a nursing home: importance of exclud-

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408. Schaffner W, Lefkowitz LB Jr, Goodman JS, Koenig MG. Hospital

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411. Mermel LA, Josephson SL, Dempsey J, Parenteau S, Perry C, Magill

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S55–S57.

Vol. 51 / RR-16 Recommendations and Reports 45

Appendix

Antimicrobial Spectrum and Characteristics of Hand-Hygiene Antiseptic Agents*

Group

Alcohols

Chlorhexidine (2%

and 4% aqueous)

Iodine compounds

Iodophors

Phenol derivatives

Tricolsan

Quaternary

ammonium

compounds

Gram-positive

bacteria

+++

Gram-negative

bacteria

+++

Mycobacteria

+++

—

Fungi

+++

—

Viruses

+++

Speed of action

Fast

Intermediate

Slow

Comments

Optimum concentration 60%–

95%; no persistent activity

Persistent activity; rare allergic

reactions

Causes skin burns; usually too

irritating for hand hygiene

Less irritating than iodine;

acceptance varies

Activity neutralized by nonionic

surfactants

Acceptability on hands varies

Used only in combination with

alcohols; ecologic concerns

Note: +++ = excellent; ++ = good, but does not include the entire bacterial spectrum; + = fair; — = no activity or not sufficient.

* Hexachlorophene is not included because it is no longer an accepted ingredient of hand disinfectants.

46 MMWR October 25, 2002

Vol. 51 / RR-16 Recommendations and Reports 47

48 MMWR October 25, 2002

Recommendations and Reports October 25, 2002 / Vol. 51 / No. RR-16

Morbidity and Mortality Weekly Report

Centers for Disease Control and PreventionCenters for Disease Control and Prevention

Centers for Disease Control and Prevention

SAFER • HEALSAFER • HEAL

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Continuing Education Activity Sponsored by CDC

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

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CE-2 MMWR October 25, 2002

1. Hand hygiene refers to . . .

A. handwashing using plain soap and water.

B. using an antiseptic hand rub (e.g alcohol, chlorhexidine, iodine).

C. handwashing using antimicrobial soap and water.

D. all of the above.

2. Hand hygiene adherence in health-care facilities might be improved by . . .

A. providing personnel with individual containers of alcohol-based hand

rubs.

B. providing personnel with hand lotions or creams.

C. providing personnel with feedback regarding hand-hygiene adherence/

performance.

D. all of the above.

3. Alcohol-based hand rubs have good or excellent antimicrobial activity

against all of the following except . . .

A. viruses.

B. fungi.

C. mycobacteria.

D. bacterial spores.

E. gram-positive and gram-negative bacteria.

4. Alcohol-based hand rubs are indicated for all of the following clinical

situations except . . .

A. when the hands are visibly soiled.

B. preoperative cleaning of hands by surgical personnel.

C. before inserting urinary catheters, intravascular catheters, or other

invasive devices.

D. after removing gloves.

5. Each of the following statements regarding alcohol-based hand rubs

is true except . . .

A. alcohol-based hand rubs reduce bacterial counts on the hands of

health-care personnel more effectively than plain soaps.

B. alcohol-based hand rubs can be made more accessible than sinks or

other handwashing facilities.

C. alcohol-based hand rubs require less time to use than traditional

handwashing.

D. alcohol-based hand rubs have been demonstrated to cause less skin

irritation and dryness than handwashing using soap and water.

E. alcohol-based hand rubs are only effective if they are applied for

>60

seconds.

6. Which of the following statements regarding preoperative surgical

hand antisepsis is true?

A. Antimicrobial counts on hands are reduced as effectively with a

5-minute scrub as with a 10-minute scrub.

B. A brush or sponge must be used when applying the antiseptic agent to

adequately reduce bacterial counts on hands.

C. Alcohol-based hand rubs for preoperative surgical scrub have been

associated with increased surgical site infection rates.

D. A and B are true.

E. A and C are true.

Goal and Objectives

This MMWR provides evidence-based recommendations for hand hygiene in health-care settings. These recommendations were developed by the Healthcare

Infection Control Practices Advisory Committee (HICPAC), the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection

Control and Epidemiology, and the Infectious Diseases Society of America Hand Hygiene Task Force. The goal of this report is to provide guidance for clinicians

and other health-care practitioners regarding strategies to improve hand-hygiene practices and reduce transmission of microorganisms in health-care settings. Upon

completion of this educational activity, the reader should be able to 1) describe the indications for hand hygiene in health-care settings; 2) list the advantages of

alcohol-based hand rubs; and 3) describe the barriers to hand hygiene in health-care settings.

To receive continuing education credit, please answer all of the following questions.

7. Antimicrobial-impregnated wipes (i.e., towelettes) . . .

A. might be considered as an alternative to handwashing with plain soap

and water.

B. are as effective as alcohol-based hands rubs.

C. are as effective as washing hands with antimicrobial soap and water.

D. A and C.

8. The following statements regarding hand hygiene in health-care

settings are true except . . .

A. Overall adherence among health-care personnel is approximately 40%.

B. Poor adherence to hand-hygiene practice is a primary contributor to

health-care–associated infection and transmission of antimicrobial-

resistant pathogens.

C. Personnel wearing artificial nails or extenders have been linked to

nosocomial outbreaks.

D. Hand hygiene is not necessary if gloves are worn.

9. Indicate your work setting.

A. State/local health department.

B. Other public health setting.

C. Hospital clinic/private practice.

D. Managed care organization.

E. Academic institution.

F. Other.

10. Which best describes your professional activities?

A. Patient care — emergency/urgent care department.

B. Patient care — inpatient.

C. Patient care — primary-care clinic or office.

D. Laboratory/pharmacy.

E. Public health.

F. Other.

11. I plan to use these recommendations as the basis for . . . (Indicate all

that apply.)

A. health education materials.

B. insurance reimbursement policies.

C. local practice guidelines.

D. public policy.

E. other.

12. Each month, approximately how many patients do you examine?

A. None.

B. 1–5.

C. 6–20.

D. 21–50.

E. 51–100.

F. >100.

13. How much time did you spend reading this report and completing the

exam?

A. 1–1.5 hours.

B. More than 1.5 hours but fewer than 2 hours.

C. 2–2.5 hours.

D. More than 2.5 hours.

Vol. 51 / No. RR-16 Recommendations and Reports CE-3

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October 25, 2002/Vol. 51/No. RR-16

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

To receive continuing education credit, you must

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1. [ ] A [ ] B [ ] C [ ] D 14. [ ] A [ ] B [ ] C [ ] D [ ] E

2. [ ] A [ ] B [ ] C [ ] D 15. [ ] A [ ] B [ ] C [ ] D [ ] E

3. [ ] A [ ] B [ ] C [ ] D [ ] E 16. [ ] A [ ] B [ ] C [ ] D [ ] E

4. [ ] A [ ] B [ ] C [ ] D 17. [ ] A [ ] B [ ] C [ ] D [ ] E

5. [ ] A [ ] B [ ] C [ ] D [ ] E 18. [ ] A [ ] B [ ] C [ ] D [ ] E

6. [ ] A [ ] B [ ] C [ ] D [ ] E 19. [ ] A [ ] B [ ] C [ ] D [ ] E

7. [ ] A [ ] B [ ] C [ ] D 20. [ ] A [ ] B [ ] C [ ] D [ ] E

8. [ ] A [ ] B [ ] C [ ] D 21. [ ] A [ ] B [ ] C [ ] D [ ] E

9. [ ] A [ ] B [ ] C [ ] D [ ] E [ ] F 22. [ ] A [ ] B [ ] C [ ] D [ ] E

10. [ ] A [ ] B [ ] C [ ] D [ ] E [ ] F 23. [ ] A [ ] B [ ] C [ ] D [ ] E [ ] F

11. [ ] A [ ] B [ ] C [ ] D [ ] E

12. [ ] A [ ] B [ ] C [ ] D [ ] E [ ] F

13. [ ] A [ ] B [ ] C [ ] D

14. After reading this report, I am confident I can describe the guidance

for clinicians and other health-care practitioners regarding strategies

to improve hand-hygiene practices and reduce transmission

of microorganisms in health-care settings.

A. Strongly agree.

B. Agree.

C. Neither agree nor disagree.

D. Disagree.

E. Strongly disagree.

15. After reading this report, I am confident I can describe the indications

for hand hygiene in health-care settings.

A. Strongly agree.

B. Agree.

C. Neither agree nor disagree.

D. Disagree.

E. Strongly disagree.

16. After reading this report, I am confident I can list the advantages

of alcohol-based hand rubs.

A. Strongly agree.

B. Agree.

C. Neither agree nor disagree.

D. Disagree.

E. Strongly disagree.

17. After reading this report, I am confident I can describe the barriers

to hand hygiene in health-care settings.

A. Strongly agree.

B. Agree.

C. Neither agree nor disagree.

D. Disagree.

E. Strongly disagree.

18. The objectives are relevant to the goal of this report.

A. Strongly agree.

B. Agree.

C. Neither agree nor disagree.

D. Disagree.

E. Strongly disagree.

19. The tables and text boxes are useful.

A. Strongly agree.

B. Agree.

C. Neither agree nor disagree.

D. Disagree.

E. Strongly disagree.

20. Overall, the presentation of the report enhanced my ability to

understand the material.

A. Strongly agree.

B. Agree.

C. Neither agree nor disagree.

D. Disagree.

E. Strongly disagree.

Check One

CME Credit

CHES Credit

CEU Credit

CNE Credit

CE-4 MMWR October 25, 2002

Correct answers for questions 1–8

1. D; 2. D; 3. D; 4. A; 5. E; 6. A; 7. A; 8. D.

21. These recommendations will affect my practice.

A. Strongly agree.

B. Agree.

C. Neither agree nor disagree.

D. Disagree.

E. Strongly disagree.

22. The availability of continuing education credit influenced my decision

to read this report.

A. Strongly agree.

B. Agree.

C. Neither agree nor disagree.

D. Disagree.

E. Strongly disagree.

23. How did you learn about this continuing education activity?

A. Internet.

B. Advertisement (e.g., fact sheet, MMWR cover, newsletter, or journal).

C. Coworker/supervisor.

D. Conference presentation.

E. MMWR subscription.

F. Other.

All MMWR references are available on the Internet at http://www.cdc.gov/mmwr. Use the search function to find specific articles.

——————

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health

and Human Services.

——————

References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of

these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the

content of these sites. URL addresses listed in MMWR were current as of the date of publication.

Hospital Infection Control Practices Advisory Committee Members

Chair: Robert A. Weinstein, M.D., Cook County Hospital, Chicago, Illinois.

Co-Chair: Jane D. Siegel, M.D., University of Texas Southwestern Medical Center, Dallas, Texas.

Executive Secretary: Michele L. Pearson, M.D. CDC, Atlanta, Georgia.

Members: Raymond Y.W. Chinn, M.D., Sharp Memorial Hospital, San Diego, California; Alfred DeMaria, Jr, M.D., Massachusetts Department of Public

Health, Jamaica Plain, Massachusetts; Elaine L. Larson, Ph.D., Columbia University School of Nursing, New York, New York; James T. Lee, M.D., Ph.D.,

University of Minnesota, Minneapolis, Minnesota; Ramon E. Moncada, M.D., Coronado Physician’s Medical Center, Coronado, California; William A.

Rutala, Ph.D., University of North Carolina, Chapel Hill, North Carolina; William E. Scheckler, M.D., University of Wisconsin, Madison, Wisconsin; and

Marjorie A. Underwood, Mt. Diablo Medical Center, Concord, California.

Hand Hygiene Task Force Members

Chair: John M. Boyce, M.D., Hospital of Saint Raphael, New Haven, Connecticut.

Members: Barry M. Farr, M.D., University of Virginia, Charlottesville, Virginia; William R. Jarvis, M.D., CDC, Atlanta, Georgia; Elaine L. Larson, Ph.D.,

Columbia School of Nursing, New York, New York; Maryanne McGuckin, DrScEd, University of Pennsylvania, Philadelphia, Pennsylvania; Carol O’Boyle,

Ph.D., Minnesota Department of Health, Minneapolis, Minnesota; Didier Pittet, M.D., University of Geneva, Geneva, Switzerland; Jane D. Siegel, M.D.,

University of Texas Southwestern Medical Center, Dallas, Texas; Marjorie A. Underwood, Mt. Diablo Medical Center, Concord, California; Andreas F.

Widmer, M.D., University Hospitals, Basel, Switzerland; Jolynn Zeller, Avera St. Lukes Hospital, Aberdeen, South Dakota; and Beth H. Stover, Kosair

Children’s Hospital, Louisville, Kentucky.

Disclosure of Financial Interests and Relationships

John Boyce: Research and educational grants from Gojo Industries; honorarium from Procter and Gamble; and consultant to Bode Chemical.

Barry Farr: Research support from Gojo Industries.

Elaine Larson: Received products for testing in research studies from Procter and Gamble, 3M Corporation, and Steris.

Carol O'Boyle: Honorarium from 3M Corporation.

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