A review of the science and clinical use of alcohol-based hand rubs
Keywords:SARS-CoV-2, alcohol, hand sanitizer, ethanol, isopropanol, n-propanol
Alcohol has a longstanding history as an antiseptic, and the coronavirus disease 2019 (COVID-19) pandemic has sparked a renewed interest in its use as a hand sanitizer. Alcohol works by denaturing protein and rendering cell membranes permeable. It offers excellent germicidal effects against Gram-positive and Gram-negative bacteria, Mycobacterium tuberculosis, fungi, and lipid-containing viruses. However, it is less reliable against non-lipid containing viruses and is ineffective against bacterial and fungal spores. Alcohol-based hand rub (ABHR) usually contains 60–90% isopropanol or ethanol. Additives such as chlorhexidine to complement the action of alcohol and emollients to ameliorate the drying effect of alcohol are often included to improve the formulation of ABHR. In the clinical setting, ABHR provides biocidal activity against multidrug resistant bacteria such as methicillin-resistant Staphylococcus aureus as well as viruses like human coronavirus, severe acute respiratory syndrome coronavirus, and Middle East respiratory syndrome. Moreover, its use is associated with an improved compliance with hand hygiene, which has been shown to translate into better patient outcomes. However, there are cases of intoxications secondary to ingestion of ABHR or adulterated alcohol when resources are diverted away from the normal beverage production to meet the increased need for hand sanitizer during the COVID-19 pandemic. The risk of unintentional topical absorption and fire hazard among healthcare workers is low but should not be ignored. We proposed recommendations to mitigate the risk of ABHR ingestion and poisoning as well as that of fire hazard.
Mody L, Saint S, Kaufman SR, Kowalski C, Krein SL. Adoption of alcohol-based handrub by United States hospitals: a national survey. Infect Control Hosp Epidemiol 2008; 29: 1177–80. doi: 10.1086/592095
Widmer AF. Replace hand washing with use of a waterless alcohol hand rub? Clin Infect Dis 2000; 31: 136–43. doi: 10.1086/313888
Grayson ML, Melvani S, Druce J, Barr IG, Ballard SA, Johnson PDR, et al. Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers. Clin Infect Dis 2009; 48: 285–91. doi: 10.1086/595845
Laustsen S, Lund E, Bibby BM, Kristensen B, Thulstrup AM, Kjolseth Moller J. Effect of correctly using alcohol-based hand rub in a clinical setting. Infect Control Hosp Epidemiol 2008; 29: 954–6. doi: 10.1086/590393
Pires D, Soule H, Bellissimo-Rodrigues F, Gayet-Ageron A, Pittet D. Hand hygiene with alcohol-based hand rub: how long is long enough? Infect Control Hosp Epidemiol 2017; 38: 547–52. doi: 10.1017/ice.2017.25
Girou E, Loyeau S, Legrand P, Oppein F, Brun-Buisson C. Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ 2002; 325: 362. doi: 10.1136/bmj.325.7360.362
Hugonnet S, Perneger TV, Pittet D. Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Arch Intern Med 2002; 162: 1037–43. doi: 10.1001/archinte.162.9.1037
Presterl E, Suchomel M, Eder M, Reichmann S, Lassnigg A, Graninger W, et al. Effects of alcohols, povidone-iodine and hydrogen peroxide on biofilms of Staphylococcus epidermidis. J Antimicrob Chemother 2007; 60: 417–20. doi: 10.1093/jac/dkm221
Centers for Disease Control and Prevention, United States. Chemical disinfectants – guideline for disinfection and sterilization in healthcare facilities 2016. Available from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-methods/chemical.html [cited 15 June 2020].
Reichel M, Heisig P, Kohlmann T, Kampf G. Alcohols for skin antisepsis at clinically relevant skin sites. Antimicrob Agents Chemother 2009; 53: 4778–82. doi: 10.1128/AAC.00582-09
Centers for Disease Control and Prevention, United States. Hand hygiene recommendations: guidance for healthcare providers about hand hygiene and COVID-19. 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html [cited 15 June 2020].
Centers for Disease Control and Prevention, United States. NIOSH pocket guide to chemical hazards. 2007. Available from: https://www.cdc.gov/niosh/npg/ [cited 15 June 2020].
Food and Drug Administration, United States. Temporary policy for preparation of certain alcohol-based hand sanitizer products during the public health emergency (COVID-19) guidance for industry. 2020. Available from: https://www.fda.gov/media/136289/download. [cited 15 June 2020]
Compounding alcohol-based hand sanitizer during COVID-19 Pandemic. 2020. Available from: https://www.usp.org/sites/default/files/usp/document/about/public-policy/usp-covid19-handrub.pdf [cited 15 June 2020].
Schülke & Mayr GmbH, Germany. Microshield handrub safety data sheet. 2015. Available from: https://www.schuelke.com/media-au-en/docs/SDS/MICROSHIELD-australia-SDS/MS-Hand-Rub.pdf [cited 15 June 2020].
Drugs.com. Purell healthcare advanced hand sanitizer gel. 2019. Available from: https://www.drugs.com/otc/990691/purell-healthcare-advanced-hand-sanitizer-gel.html [cited 15 June 2020].
Barbadoro P, Martini E, Savini S, Marigliano A, Ponzio E, Prospero E, et al. In vivo comparative efficacy of three surgical hand preparation agents in reducing bacterial count. J Hosp Infect 2014; 86: 64–7. doi: 10.1016/j.jhin.2013.09.013
Aly R, Maibach HI. Comparative study on the antimicrobial effect of 0.5% chlorhexidine gluconate and 70% isopropyl alcohol on the normal flora of hands. Appl Environ Microbiol 1979; 37: 610–13. doi: 10.1128/aem.37.3.610-613.1979
Gordin FM, Schultz ME, Huber RA, Gill JA. Reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based handrub. Infect Control Hosp Epidemiol 2005; 26: 650–3. doi: 10.1086/502596
Kaier K, Frank U, Hagist C, Conrad A, Meyer E. The impact of antimicrobial drug consumption and alcohol-based hand rub use on the emergence and spread of extended-spectrum beta-lactamase-producing strains: a time-series analysis. J Antimicrob Chemother 2009; 63: 609–14. doi: 10.1093/jac/dkn534
Halim MMA, Eyada IK, Tongun RM. Prevalence of multidrug drug resistant organisms and hand hygiene compliance in surgical NICU in Cairo University Specialized Pediatric Hospital. Egyptian Pediatric Association Gazette 2018; 66: 103–11. doi: 10.1016/j.epag.2018.09.003
Latour K, Huang TD, Jans B, Berhin C, Bogaerts P, Noel A, et al. Prevalence of multidrug-resistant organisms in nursing homes in Belgium in 2015. PLoS One 2019; 14: e0214327. doi: 10.1371/journal.pone.0214327
Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect 2020; 104: 246–51. doi: 10.1016/j.jhin.2020.01.022
Widmer AF, Conzelmann M, Tomic M, Frei R, Stranden AM. Introducing alcohol-based hand rub for hand hygiene: the critical need for training. Infect Control Hosp Epidemiol 2007; 28: 50–4. doi: 10.1086/510788
Widmer AE, Dangel M. Alcohol-based handrub: evaluation of technique and microbiological efficacy with international infection control professionals. Infect Control Hosp Epidemiol 2004; 25: 207–9. doi: 10.1086/502379
Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 2000; 160: 1017–21. doi: 10.1001/archinte.160.7.1017
Barrera L, Zingg W, Mendez F, Pittet D. Effectiveness of a hand hygiene promotion strategy using alcohol-based handrub in 6 intensive care units in Colombia. Am J Infect Control 2011; 39: 633–9. doi: 10.1016/j.ajic.2010.11.004
Souweine B, Lautrette A, Aumeran C, Bénédit M, Constantin JM, Bonnard M, et al. Comparison of acceptability, skin tolerance, and compliance between handwashing and alcohol-based handrub in ICUs: results of a multicentric study. Intensive Care Med 2009; 35: 1216–24. doi: 10.1007/s00134-009-1485-5
Giannitsioti E, Athanasia S, Antoniadou A, Fytrou H, Athanassiou K, Bourvani P, et al. Does a bed rail system of alcohol-based handrub antiseptic improve compliance of health care workers with hand hygiene? Results from a pilot study. Am J Infect Control 2009; 37: 160–3. doi: 10.1016/j.ajic.2008.04.252
Litovitz T. The alcohols: ethanol, methanol, isopropanol, ethylene glycol. Pediatr Clin North Am 1986; 33: 311–23. doi: 10.1016/S0031-3955(16)35004-0
Soltaninejad K. Methanol mass poisoning outbreak: a consequence of COVID-19 pandemic and misleading messages on social media. Int J Occup Environ Med 2020; 11: e1–3. doi: 10.34172/ijoem.2020.1983
Gormley NJ, Bronstein AC, Rasimas JJ, Pao M, Wratney AT, Sun J, et al. The rising incidence of intentional ingestion of ethanol-containing hand sanitizers. Crit Care Med 2012; 40: 290–4. doi: 10.1097/CCM.0b013e31822f09c0
Rich J, Scheife RT, Katz N, Caplan LR. Isopropyl alcohol intoxication. Arch Neurol 1990; 47: 322–4. doi: 10.1001/archneur.1990.00530030100022
Jarwani BS, Motiani PD, Sachdev S. Study of various clinical and laboratory parameters among 178 patients affected by hooch tragedy in Ahmedabad, Gujarat (India): a single center experience. J Emerg Trauma Shock 2013; 6: 73–7. doi: 10.4103/0974-2700.110745
Pires D, Bellissimo-Rodrigues F, Pittet D. Ethanol-based handrubs: safe for patients and health care workers. Am J Infect Control 2016; 44: 858–9. doi: 10.1016/j.ajic.2016.02.016
Hautemaniere A, Ahmed-Lecheheb D, Cunat L, Hartemann P. Assessment of transpulmonary absorption of ethanol from alcohol-based hand rub. Am J Infect Control 2013; 41: e15–19. doi: 10.1016/j.ajic.2012.09.004
Boyce JM, Pearson ML. Low frequency of fires from alcohol-based hand rub dispensers in healthcare facilities. Infect Control Hosp Epidemiol 2003; 24: 618–19. doi: 10.1086/502262
Kramer A, Kampf G. Hand rub-associated fire incidents during 25,038 hospital-years in Germany. Infect Control Hosp Epidemiol 2007; 28: 745–6. doi: 10.1086/517953
Bryant KA, Pearce J, Stover B. Flash fire associated with the use of alcohol-based antiseptic agent. Am J Infect Control 2002; 30: 256–7. doi: 10.1067/mic.2002.125395
World Health Organization. Alcohol-based handrub risks/hazards. 2020. Available from: https://www.who.int/gpsc/tools/faqs/abhr2/en/ [cited 28 June 2020].
National Fire Protection Association, United States. NFPA 101 life safety code. 2018 ed. 2018. Available from: https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=101 [cited 28 June 2020].
World Health Organization. WHO guidelines on hand hygiene in health care (WHO/IER/PSP/2009/01). 2009. Available from: https://www.who.int/gpsc/information_centre/hand-hygiene-2009/en/ [cited 15 June 2020].
How to Cite
Authors retain copyright of their work, with first publication rights granted to IJIC. Read the full Copyright- and Licensing Statement.