Recent studies add fuel to the fire: Should your staff use soap or gel?

Researcher: Waterless antiseptic agents are more effective, convenient

Recent studies are again raising an issue that has dogged same-day surgery managers for years: Should staff use waterless antiseptic agents (gels) when providing routine care for outpatient surgery patients? Or are the tried-and-true health care hand-wash preparations (soaps) more effective?

One of the recent studies weighs in favor of gels. "What I wrote in the paper was that alcohol-based gel appeared to be more efficacious at removing pathogens than antimicrobial soap," says Shelly A. McNeil, MD, fellow in infectious diseases at the University of Michigan Medical Center in Ann Arbor and a physician at Ann Arbor (MI) Veterans Affairs Health Care System. McNeil was the lead researcher on the study, which was presented at the fall Interscience Conference on Antimicrobial Agents and Chemotherapy in San Francisco.

McNeil points out that the study was small and was primarily designed to study pathogens on artificial nails. However, the findings were dramatic. Of 18 health care workers wearing acrylic nails who had pathogens prior to cleansing, only two (11%) were cleared of pathogens after hand washing with soap [Medi-Scrub antimicrobial soap, manufactured by Huntington (IN) Labs]. Five (38%) were cleared of pathogens after using gel (ISAGel, manufactured by Coloplas in North Mankato, MN). (See bar graph, above.)

The study indicates that health care workers wearing artificial nails are more likely than others to have S. aureus, Gram (+) and Gram (-) bacteria, and yeasts on their nails before and after hand washing, and they’re more likely to have a greater quantity of those pathogens.

A representative of the Centers for Disease Control and Prevention (CDC) in Atlanta says that gels appear to be as beneficial as routine soap and water. "I think any data suggest that in routine situations where hand washing is recommended after patient contact, waterless agents can be used," says Michele Pearson, MD, medical epidemiologist in the Hospital Infections Program at the CDC.

One recent study indicates that a combination of an alcohol gel sanitizer with antimicrobial or plain lotion soap is more effective than for the gel or soap alone.1

In European hospitals, gels are commonly used, McNeil says. "That’s what we should be doing: Washing our hands every time you walk into a room and leave," Physicians tend to be worse than nurses about frequent hand cleansing, McNeil says. Gels might be the solution to noncompliance. "These studies have always shown, if you give people easy access to gel, you increase compliance, because gels are easier" to use, McNeil says.

Part of the issue is how health care professionals wash their hands, she says. The CDC recommends that hand washing with soap should last 10 seconds, McNeil says. "Most of us don’t do that."

You can’t "cheat" with gels, however, McNeil points out, because you have to rub the gel on your hands until your hands are dry. "Because there’s more standardized use of it, it’s more effective." The fact that gels take less time than hand washing is a distinct advantage for staff, particularly nurses, McNeil says. She points to a study that indicated hand washing consumes 16 hours of nursing time per eight-hour day shift (12 health care workers), whereas alcoholic hand disinfection (with a gel) required only three hours. The study estimated that all health care workers wash their hands with soap for an average of 16 to 24 minutes per shift.2

"If they’re washing hands the way they’re supposed to, it takes a significant amount of time away from nursing duties," McNeil says.

And the benefits of gels aren’t limited to time savings, says Carla Alvarado, MS, CIC, director of the Occupational Health Program-Safety Department at The University of Wisconsin-Madison. "The advantages of gel are that it is a waterless product, it can be used without a sink or toweling, and it has been used successfully in Europe for well over two decades; it has never been appreciated in the U.S. health care system," she says. "It is excellent."

Her experience indicates that the more health care professionals use gel, the more they appreciate its convenience. She stops short of saying that gel is more effective than soap, however.

When should you use soap?

A gel might be appropriate when nurses are providing routine care in preoperative or postoperative holding areas and aren’t likely to get blood or body fluids on their hands, says Carol Peterson, RN, BSN, MAOM, CNOR, perioperative nursing consultant at the Association of periOperative Registered Nurses in Denver. Sometimes gels are the only alternative when sinks are not located between two patients, she points out. However, "my personal opinion is that gels can’t take the place of good, old-fashioned hand washing."

Most infection control experts agree that there are times when soap is more appropriate, such as when you have hands soiled with blood or feces.

"Gel kills the bacteria, but it doesn’t get rid of blood or stool," McNeil says. In those cases, use soap and water, she advises. Additionally, most gel manufacturers recommend you use soap and water every six to 10 uses because the gel builds up on hands, McNeil says. "But there’s no reason not to use gel on a routine basis."

At the University of Wisconsin Hospitals and Clinics in Madison, lotion soap and alcohol-based gels are used in routine patient care. "You can’t have one without the other, Alvarado says.

When soap is used, it’s critical that the hand washing is adequate, McNeil emphasizes. In her study, nurses were asked to wash hands as they normally would. "In most situations, washing hands as they normally would, I can tell you it was fairly brief and may not have been adequate to get rid of pathogens," she says.

Her research indicates that it’s particularly important for staff with artificial nails to do a thorough job of hand washing, McNeil says. For example, her research indicated that most of the pathogens accumulate under the artificial nails, which is an ignored area of hand washing, she says. "Even if they’re washing for 10 seconds, it won’t clear those pathogens."

While using gels seems to offer multiple advantages, your staff might be resistant to using them, experts warn. Many nurses think the alcohol in the gel is extremely drying, but it’s not, Alvarado emphasizes. Health care professionals have a built-in aversion that the gels are like the pourable isopropyl alcohol, she says. However, "emollients are blended into these products and, in some studies, maintain the integrity of the skin."3,4,5

Additionally, some nurses think gels aren’t as effective as soap and water, Alvarado says. Well-founded data on gels goes a long way toward swaying nurses’ opinions however, she adds.

"Clearly, there’s lots of evidence they’re just as good as soap, and some that they’re better than soap," McNeil says. Gels are an important adjunct to hand washing, but they’re not supposed to replace hand washing, she emphasizes. "They have a big role to playing in reducing the nosocomial infection rate."


1. Paulson DS, Fendler EJ, Dolan MJ, et al. A close look at alcohol gel as an antimicrobial sanitizing agent. Am J Infect Control 1999: 27:332-338.

2. Voss A, Widmer AF. No time for handwashing? Handwashing v. alcoholic rub: Can we afford 100% compliance? Infect Control Hosp Epidemiol 1997; 18:205-208.

3. Boyce JM, Kelliher S, Vallende N, et al. Hand disinfection with an alcohol gel causes less skin irritation and dryness of nurses’ hands than soap and water handwashing (abstract). Presented at the Ninth Annual Scientific Meeting of Society for Healthcare Epidemiology of America. San Francisco; April 1999.

4. Voss A, Widmer AF. No time for handwashing? Handwashing versus alcoholic rub: Can we afford 100% compliance? Infect Control Hosp Epidemiol 1997; 18:205-208.

5. Rotter ML. Alcohols for antisepsis of hands and skin. In: Ascenzi JM, ed. Handbook of Disinfectants and Antiseptsis. New York: Marcel Decker; 1996, pp. 177-233. n

For more information on soap and gel, contact:

Hospital Infection Program, Centers for Disease Control and Prevention, 1600 Clifton Road N.E., Mail Stop E 69, Atlanta, GA 30333. Telephone: (404) 639-6413. Fax: (404) 639-6459.

Shelly A. McNeil, MD, Division of Infectious Diseases [111–I], Ann Arbor Veterans Affairs Health Care System, 2215 Fuller Road, Ann Arbor, MI 48105. Telephone: (734) 761-7984. Fax: (734) 769-7039. E-mail: smcneil@umich. edu.

Carol Peterson, RN, BSN, MAOM, CNOR, Perioperative Nursing Consultant, Association of periOperative Registered Nurses, 2170 S. Parker Road, Suite 300, Denver, CO 80231-5711. Telephone: (800) 755-2676, Ext. 392. Fax: 303-338-5165. E-mail: