Clinical Briefs

By Louis Kuritzky, MD

Efficacy of Handrubbing with Alcohol-Based Solution vs. Standard Handwashing with Antiseptic Soap: Randomized Clinical Trial

Handwashing (HWS) is generally recognized as the single most influential factor to reduce transmission of nosocomial infections. Unfortunately, studies indicate that half or less of clinicians comply with appropriate HWS recommendations. Despite interventions to increase adherence with handwashing (eg, more sinks, educational programs), results have been disappointing. Although handrubbing with alcohol (HRA) is suggested as an alternative to HWS, its acceptance has been impeded by lack of clinician confidence that an alcohol based, waterless hand antiseptic is sufficiently effective in reducing bacterial contamination.

Girou and associates performed a prospective, randomized, blinded trial in 3 intensive care units. Subjects (health professionals) were randomly assigned to chlorhexidine 4% (Hibiscrub) or handrubbing with an alcohol- based solution. Hand cultures were performed immediately before, and 1 minute after cleansing.

Both maneuvers were effective in reducing bacterial contamination, but HRA was substantially more effective (83% vs 58% reduction in contaminating bacteria). HWS and HRA occupied essentially the same mean amount of time (about 30 seconds). Previous in-vitro studies have shown that HRA is more effective than soap. Incorporation of HRA may enhance control of nosocomially transmitted infections but may require enhanced clinician education for endorsement.

Girou E, et al. BMJ. 2002;325:362-365.

A Program To Prevent Functional Decline in Physically Frail, Elderly Persons Who Live at Home

Most literature that addresses restoration of function in elders focuses upon rehabilitation of persons who have recently suffered a morbid event, such as a stroke or hip fracture. Whether other frail elders might benefit from prehabilitation’ strategies is little studied. To that end, Gill and colleagues recruited a population (n = 188) of seniors (> age 75) who were defined as "frail" by means of a rapid-gait test and a mobility test (ability to rise from a chair with arms folded).

The intervention program included instructions in safe techniques for moving in bed and outdoors, gait training, removal of environmental hazards (eg, loose rugs, cords, clutter) and installation of adaptive equipment in bathrooms. Interventions were monitored for 16 visits over 6 months, with last follow-up at 12 months.

The recipients of the home intervention had significantly less disability and less admission to a nursing home. Interventions included the service of a physical therapist, but the entire mean cost of intervention, including equipment and supplies, was $1998 per participant. The subjects who suffered severe disability at baseline continued to experience deterioration over time, despite receiving the same interventions. Gill et al comment that though the frequency of physical therapy visits is in excess of that allowed for reimbursement by Medicare, the overall cost-per-patient is comparatively moderate.

Gill TM, et al. N Engl J Med. 2002;347:1068-1074.

Treatment of Chronic Painful Diabetic Neuropathy with Isosorbide Dinitrate Spray

Painful diabetic neuropathy (PDN) is a troublesome and often refractory clinical dilemma. Nitric oxide (NO) production is impaired in PDN and is suspected of playing a pathogenetic role in producing pain and burning. All clinical formulations of nitrates are NO donors. Based upon anecdotal observations that individual PDN patients reported a favorable effect of isosorbide dinitrate (ISDN) spray on pain symptoms, Yuen and colleagues initiated a formal clinical trial.

Patients (n = 22) had all suffered chronic PDN and had failed traditional treatments, such as acetaminophen, amitriptyline, or gabapentin, either due to lack of efficacy, intolerance, or both. The trial was structured such that patients received either 40% propylene glycol (placebo) or 30 mg isosorbide dinitrate (1 spray) QHS in a double-blind crossover fashion for 2 sessions of 4 weeks each, punctuated by a 2-week washout period.

Use of ISDN spray produced a statistically significant reduction in pain and burning. Side effects (transient headache) were mild. ISDN may be of value in treatment of PDN, perhaps through a mechanism of increased delivery of NO.

Yuen KCJ, et al. Diabetes Care. 2002; 25(210):1699-1703.

Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.