Alcohol Rub, Soap and Water Equal in Presurgical Hand Disinfection

March 22, 2010 (Atlanta, Georgia) — Rates of surgical site infection after the use of plain soap and water or an alcohol-based rub for surgical hand preparation were comparable (about 8%) in a rural hospital setting in Kenya, new study findings suggest.

Stephan Harbarth, MD, from the Division of Infectious Diseases at Geneva University Hospitals in Switzerland, and colleagues reported the findings here at the Fifth Decennial International Conference on Healthcare-Associated Infections 2010.

"Our hypothesis had been that the use of alcohol-based hand rubs may decrease infection rates, but this was not the case," Dr. Harbarth told Medscape Infectious Diseases. "Alcohol-based hand rubs for surgical hand preparation have been evaluated only in high-income countries, and there has been no previous comparison of these rubs with plain soap and water," he noted during his presentation.

The study examined 3317 adult patients who were to undergo clean or clean-contaminated surgery. The surgeons of these patients were randomized to the plain soap and water protocol or to the alcohol-based hand rub protocol. After the exclusion of patients with insufficient data, data from 3133 patients (94%) were analyzed.

Of the 3133 patients, 255 (8.1%) developed surgical site infections. Rates for the 2 study groups were similar: 8.3% for alcohol-based hand rub and 8.0% for plain soap and water (odds ratio, 1.03; 95% confidence interval [CI], 0.80 - 1.33). This outcome remained similar after adjustment for confounding factors, which included type of anesthesia, surgical specialty, and perioperative prophylaxis (adjusted OR, 1.07; 95% CI, 0.81 - 1.41).

The cost difference between the 2 methods of surgical hand preparation was minimal: €4.60 per week for the alcohol-based hand rub and €3.30 for the soap and water.

"Our findings have huge policy implications because they show that locally produced alcohol hand rubs are feasible and they are at least as good as soap and water," Dr. Harbarth said.

He added that lapses in the availability of running water highlight the importance of this finding. "For instance, just after we ended this study, the water supply at the hospital cut off for a week, so you cannot easily quantify the benefit of both approaches being equivalent," he said. "We certainly think there are some policy implications in these findings."

Dr. Harbarth pointed out that their findings might also be explained by the fact that other factors contribute to the incidence of surgical site infection in settings with limited resources. According to a multivariate logistic regression analysis, independent predictors of surgical site infection in this setting included duration of surgery and wound contamination class.

The most important aspect of these findings is that they indicate the feasibility of making "relatively inexpensive alcohol-based hand rub solutions available in resource-poor areas, and that these can be used in situations when a clean water supply needed for presurgical handwashing is not available," said John M. Boyce, MD, chief, Infectious Diseases Section and hospital epidemiologist at the Hospital of Saint Raphael in New Haven, Connecticut.

"Another remarkable feature of the study is that it demonstrates that careful prospective controlled trials of potential infection control measures can be successfully completed in geographic areas with very limited resources," he told Medscape Infectious Diseases.

The study was funded by an unrestricted grant from the Velux Foundation, through the Swiss Academy of Sciences. Dr. Harbarth has disclosed no relevant financial relationships. Dr. Boyce reports consultantships with GOJO Industries, Clorox Corporation, 3M Corporation, Advanced Sterilization Products, Cardinal Health, the Soap & Detergent Association; and honoraria from Advanced Sterilization Products.

Fifth Decennial International Conference on Healthcare-Associated Infections (ICHAI) 2010: Abstract 384. Presented March 20, 2010.