CDC is washing its hands of soap and sinks in favor of waterless alcohol rubs

Poor compliance, European data spark paradigm shift

In a radical departure from the traditional emphasis on sinks, soap, and water, the Centers for Disease Control and Prevention (CDC) proposed hand-hygiene recommendations call for the use of waterless alcohol products for virtually all patient care encounters.

The draft guidelines address the historic lack of compliance with hand washing by turning in a striking new direction. "If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands," the recommendations state.1 (See "Watermark: CDC unveils new age of hand hygiene" in this issue.) That particular recommendation was given the highest possible ranking: "1A." That means it is "strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies."2-10

"This represents a pretty revolutionary change in hand hygiene," says Elaine Larson, RN, PhD, professor of pharmaceutical and therapeutic research at Columbia University School of Nursing in New York City. "Now, we still have hand washing when hands are physically soiled. But this would replace hand washing for most health care encounters."

The recommendations represent a collaborative effort between the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) and a hand-hygiene task force, which includes members of the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC), and the Infectious Diseases Society of America (IDSA).

"This guideline represents the biggest change in recommended practice of any [HICPAC] guideline that has ever come out," says Larson, a past chairwoman of the committee who served on the task force as a member of APIC and SHEA. "Most of the [previous] guidelines sort of reflect what is already in practice. This one does not. In Europe, these kinds of products have been used for years, but in this country, this is fairly new. We may see some shock waves across the country."

The practice of using alcohol-based hygienic hand rubs has largely replaced hand washing as the standard of care in Northern Europe, according to Andreas Widmer, MD, MS, a clinician at the University Hospital in Basel, Switzerland. A SHEA representative on the task force, Widmer reports his hospital is using hand disinfection rather than hand washing more than 90% of the time that hand washing is indicated and hands are not visibly soiled. An alcohol dispenser is available between all beds, at each nurse’s desk, and two at each intensive care unit bed, he says.

The historic problem

A cardinal principle of infection control more associated with its breach than its observance, hand washing has been the bane of ICPs for decades. But in reviewing the medical literature regarding hand washing demands and compliance, the CDC guidelines concede "full adherence to previous guidelines may be unrealistic, . . . a facilitated access to hand hygiene could help improve adherence." Reported barriers to hand washing include skin irritation from soaps, inaccessible supplies or sinks, and insufficient time to wash hands between every patient care encounter. As a result, health care workers’ unwashed hands become transiently colonized with all manner of pathogens. Gloves may prevent some transmissions, but can cause problems themselves if not changed routinely between patients. At any rate, health care workers remain the primary vectors for cross-transmission from one patient to the another, sometimes resulting in deadly nosocomial sequelae such as bloodstream infections.

The intention of the new recommendations to use waterless alcohol products, which can be put in mounted dispensers or carried in pocket-size containers, is to increase compliance and reduce infections. When using a waterless antiseptic agent such as an alcohol-based handrub, apply the product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry, the CDC recommends. Follow the manufacturer’s recommendations on the volume of product to use, and hands should be dry and rid of pathogens within 15 to 25 seconds.

Most alcohol-based hand antiseptics contain isopropanol, ethanol, n-propanol, or combinations thereof. The antimicrobial activity of alcohol is due to its ability to denature proteins. Alcohol solutions containing 50% to 80% alcohol are most effective. Alcohols are considered effective against gram-positive and gram-negative vegetative bacteria (including multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci), Mycobacterium tuberculosis, and a variety of fungi and viruses. In studies dealing with antimicrobial-resistant organisms, alcohol-based products reduced the number of pathogens recovered from the hands of health care workers more effectively than hand washing with soap and water.11-13

The guidelines also cite studies that have examined the ability of alcohol to prevent the transfer of health care-acquired pathogens by using experimental models of transmission.14,15 In one study, researchers found that gram-negative bacilli were transferred from a colonized patient’s skin to a piece of catheter material via the hands of nurses in only 17% of experiments following antiseptic hand rub with an alcohol-based hand rinse.16 In contrast, transfer of the organisms occurred in 92% of experiments following hand washing with plain soap and water. In addition, the review of medical studies convinced the CDC and its consultants that alcohol-based solutions were superior to antimicrobial soaps or detergents containing hexachlorophene, povidone-iodine, 4% chlorhexidine, or triclosan.

Larson says she expects some resistance to such a change, but that eventually the new recommendations should result in improved hand-hygiene compliance by health care workers. "The use of the alcohol products is a lot less time-consuming," she says. "You can do it while you are walking down the hall; you don’t have to go to a sink. I think this will improve compliance. Also, a lot of studies show that the alcohol products are milder on your skin than mechanical friction with soap and water. People may be more likely to use it because their hands are not damaged."

The guidelines stress that ICPs use efficacious hand-hygiene products that have low irritancy, particularly when used multiple times per shift. To maximize acceptance of hand-hygiene products by health care workers, solicit input from caregivers regarding the feel, fragrance, and skin tolerance of the products, the CDC recommends. In that regard, one ICP is trying out several alcohol products to ensure worker acceptance.

"If you find one they like, that’s where they buy-in, " says Trish Bednarz, RN, infection control coordinator at Northwestern Memorial Hospital in Chicago. Among the alcohol products being evaluated are those that contain lotions or emollients to minimize skin damage, she adds. After seeing patient colonization with S. aureus decline in care areas where alcohol washes were used, Bednarz is now aiming at going to the waterless products hospitalwide.

"We are doing the trial at the beginning of January throughout the rest of the hospital," Bednarz says. "Regular soap will remain, and if your hands are visibly soiled or contaminated, [then wash them]. But for the most part, I want people to start using the waterless [product] and possibly carry it in a pocket. . . . If you just put on a little of the gel or foam and rub it into your hands, seconds later you’ve removed all the transient organisms from your hands. When you go from bed to bed or room to room, you know that your hands are really clean."

Can the battle be won?

Though many ICPs will be discussing the issue with their infection control committees if the recommendations hold in the final version of the draft — the comment period closed Dec. 24, 2001 — other ICPs such as Bednarz have already been convinced that the alcohol rubs are the way to go.

"I’ve added alcohol hand-wash dispensers throughout my hallways for my nursing staff," says Susan Kraska, RN, CIC, an ICP at Memorial Hospital of South Bend, ID. "It gives them more opportunities, and they can do it on the run," she explains. Studies presented at infection control meetings showed compliance could be improved, she says. "That resolved it for me," Kraska says. "Then once the issue with anthrax came out, I said, OK folks we have bigger and more important things to be responding to. We are going to need to pay more attention to hand washing.’ It will be part of our performance appraisal [as a quality improvement indicator]."

But is not so easy as simply supplying the waterless products and standing back and watching compliance improve, warns Barry Farr, MD, hospital epidemiologist at the University of Virginia in Charlottesville. Farr has installed the alcohol rubs throughout his hospital facilities, but still finds compliance falling off if there isn’t a process of monitoring and giving feedback to workers. The guidelines recommend that such a process be implemented as part of the transition to waterless products. The CDC encourages, as part of an overall program to improve hand-hygiene practices, ICPs must 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. They also should monitor workers’ adherence with recommended hand-hygiene practices and provide personnel with information regarding their performance, the CDC advises.

"There are probably 40 studies that show that if you monitor and give feedback, hand-washing compliance goes up," says Farr, who represented the IDSA on the task force. "After they stop giving the feedback, in virtually all [studies], the compliance fades."

Efforts to monitor compliance and provide feedback can be complemented by strategies such as following the overall use of the alcohol products through purchasing records. The battle to achieve compliance — and improve patient safety — remains to be won. But the alcohol rubs may give ICPs, finally, the upper hand. "It’s easier to use, quicker, and kinder and gentler to your hands," Farr says. "It’s far faster than soap and water. Therefore it’s more cost-effective with health care worker’s time since we have a national nursing shortage and general shortage in [fiscal] resources. It saves money in essence because they spend less time doing it."


1. Centers for Disease Control and Prevention, the CDC Healthcare Infection Control Practices Advisory Committee, Boyce JM, Pittet D, and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Draft Guidelines for Hand Hygiene in Healthcare Settings. Web site:

2. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000; 356:1,307-1,312.

3. Larson EL, Eke PI, Laughon BE. Efficacy of alcohol-based hand rinses under frequent-use conditions. Antimicrob Agents Chemother 1986; 30:542-544.

4. Larson EL, Aiello AE, Bastyr J, et al. Assessment of two hand hygiene regimens for intensive care unit personnel. Crit Care Med 2001; 29:944-951.

5. Boyce JM. Scientific basis for handwashing with alcohol and other waterless antiseptic agents. In: Rutala, WA, eds. Disinfection, Sterilization and Antisepsis: Principles and Practices in Healthcare Facilities. Washington, DC: Association for Professionals in Infection Control and Epidemiology Inc.; 2001, pp. 140-151.

6. Widmer AF. Replace hand washing with use of a waterless alcohol hand rub? Clin Infect Dis 2000; 31:136-143.

7. Mayer JA, Dubbert PM, Miller M, et al. Increasing handwashing in an intensive care unit. Infect Control 1986; 7:259-262.

8. Bischoff WE, Reynolds TM, Sessler CN, et al. Handwashing compliance by health care workers. The impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 2000; 160:1,017-1,021.

9. Graham M. Frequency and duration of handwashing in an intensive care unit. Am J Infect Control 1990; 18:77-80.

10. Maury E, Alzieu M, Baudel JL., et al. Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit. Am J Respir Crit Care Med 2000; 162:324-327.

11. Casewell MW, Law MM, Desai N. A laboratory model for testing agents for hygienic hand disinfection: Handwash-ing and chlorhexidine for the removal of klebsiella. J Hosp Infect 1988; 12:163-175.

12. Wade JJ, Desai N, Casewell MW. Hygienic hand disinfection for the removal of epidemic vancomycin-resistant Enterococcus faecium and gentamicin-resistant Enterobacter cloacae. J Hosp Infect 1991; 18:211-218.

13. Huang Y, Oie S, Kamiya A. Comparative effectiveness of hand-cleansing agents for removing methicillin-resistant Staphylococcus aureus from experimentally contaminated fingertips. Am J Infect Control 1994; 22:224-227.

14. Marples RR, Towers AG. A laboratory model for the investigation of contact transfer of micro-organisms. J Hyg (Camb) 1979; 82:237-248.

15. Mackintosh CA, Hoffman PN. An extended model for transfer of micro-organisms via the hands: differences between organisms and the effect of alcohol disinfection. J Hyg 1984; 92:345-355.

16. Ehrenkranz N J, Alfonso BC. Failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters. Infect Control Hosp Epidemiol 1991; 12:654-662.