WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
incident underscores the fact that, following the application of
alcohol-based handrubs, hands should be rubbed together until
all the alcohol has evaporated.
In the USA, shortly after publication of the 2002 CDC/HICPAC
hand hygiene guideline, fire marshals in a number of states
prohibited the placement of alcohol-based handrub dispensers
in egress corridors because of a concern that they may
represent a fire hazard. On 25 March 2005, the Center for
Medicare and Medicaid Services adopted a revised version of
the USA National Fire Protection Agency’s Life Safety Code that
allows such dispensers to be placed in egress corridors. The
International Fire Code recently agreed to accept alcohol-based
handrubs in corridors. In addition, the CMS 3145-IFC (Fire
Safety Requirement for Certain Health Care Facilities, Alcohol-
Based Hand Sanitizer and Smoke Detector Amendment) was
published in March 2005, addressing this issue. 990
23.6.2 Other safety-related issues
Accidental and intentional ingestion and dermal absorption of
alcohol-based preparations used for hand hygiene have been
reported. 599,778-780 Acute, severe alcohol intoxication resulting
from accidental ingestion of an unknown quantity of alcoholbased
handrub was recently reported in the United Kingdom,
resulting in the unconsciousness of an adult male patient
(Glasgow Coma Scale 3). 778,781 This unusual complication of
hand hygiene may become more common in the future, and
security measures are needed. These may involve: placing
the preparation in secure wall dispensers; labelling dispensers
to make the alcohol content less clear at a casual glance and
adding a warning against consumption; and the inclusion of an
additive in the product formula to reduce its palatability. In the
meantime, medical and nursing staff should be aware of this
potential risk.
Alcohol toxicity usually occurs after ingestion. It is primarily
metabolized by an alcohol dehydrogenase in the liver to
acetone. Symptoms and signs of alcohol intoxication include
headache, dizziness, lack of coordination, hypoglycaemia,
abdominal pain, nausea, vomiting, and haematemesis. Signs of
severe toxicity include respiratory depression, hypotension, and
coma. Among alcohols, isopropyl alcohol appears to be more
toxic than ethanol, but less so than methanol. Blood isopropyl
alcohol levels of 50 mg/dl are associated with mild intoxication
and 150 mg/dl with deep coma. Apparently, isopropyl alcohol
has no adverse effects on reproduction and is not genotoxic,
teratogenic, or carcinogenic. 991
In addition to accidental ingestion, alcohols can be absorbed
by inhalation and through intact skin, although the latter
route (dermal uptake) is very low. Any absorption exceeding
certain levels may result in toxicity and chronic disease in
animals 992 and humans. 780 Recently, the Health Council of the
Netherlands 993 suggested to classify ethanol as carcinogenic
and to include it in skin notation because of the fear of an
increased risk of breast and colorectal cancer in persons with
an occupational exposure to ethanol. While the Dutch Social
and Economic Council advised the Ministry of Social Affairs and
Employment to consider an exception for the use of alcoholbased
handrubs in health-care settings, the Ministry of Social
Affairs and Employment rejected such an exception and set
the maximum amount of occupational absorbed ethanol at
such a low level that the decision could possibly lead to a ban
of ethanol-containing handrubs in the Netherlands if upheld.
Obviously, such a decision would be disastrous for health-care
settings and could induce other countries to consider similar
measures. Indeed, while there are no data to show that the
use of alcohol-based handrub may be harmful – and studies
evaluating the absorption into blood show that it is not –
reduced compliance with hand hygiene will lead to preventable
HCAIs.
Data used by the Dutch Heath Council estimated the
absorption level after spraying of the total body under occlusive
circumstances and after exposure times of up to 24 hours,
although this is obviously not relevant for the application of
handrubs. Furthermore, they estimated a worst case dermal
uptake of 30 mg ethanol after a single application to hands
and forearms, and a daily uptake of 600 mg/day after 20
applications per day, an estimate that has been proven wrong
by several new studies. 782,784,994,995
In practice, absorption of ethanol from a handrub would be by
a combination of dermal absorption and inhalation. In a study
using a solution of 44% ethanol sprayed on the skin and left for
15 minutes, there was no positive identification of ethanol in any
of the blood samples taken (limit of detection was 9 mg/litre). 994
Turner and colleagues evaluated the dermal absorption through
HCW’s intact skin 599 :3 ml of an isopropyl alcohol-containing
handrub (52.6% (w/w) isopropyl alcohol) were applied to HCWs’
hands every 10 minutes over a 4-hour period. A blood sample
was taken 5 minutes after the final application of handrub and
blood isopropyl alcohol levels were measured. In 9 out of 10
participants, a rise in the blood isopropyl alcohol level was
noted at very low levels (the highest observed level was 0.18
mg/dl), much less than the levels achieved with mild intoxication
(50 mg/dl).
More recently, Miller and colleagues conducted two studies
in which large amounts of an ethanol-based handrub were
used very frequently over periods of several hours; they found
that blood alcohol levels at the end of the trial periods were
below the level of detection. 782,995 Brown and colleagues
exposed HCWs to intensive use (30 times/hour) of ethanoland
isopropanol-based handrub solutions and found only
extremely low concentrations of ethanol in the blood (far too
low to cause symptoms) and that blood isopropanol levels were
undetectable. 783 Similarly, insignificant levels of ethanol were
detected in the breath of a few study participants and no trace
of isopropanol. Kramer and colleagues studied the intensive use
of handrub solutions containing 55–95% ethanol and found that
blood ethanol concentrations were far below levels that would
result in any noticeable symptoms. For example, the highest
median blood ethanol concentration after intensive use of a 95%
ethanol hand rub was 20.95 mg/litre, whereas levels of 200–
500 mg/litre are needed to impair fine motor coordination, and
levels of 500–1000 mg/litre are needed to impair judgement. 784
The presence of ethanol in the blood of human beings can
also have other origins. Ethanol can be found in ripe fruit with
concentrations of 0.6% or higher as a product of fermentation
by natural yeasts. 996 A very small amount of ethanol is present
as an endogenous substance in the blood, probably resulting
from microbial production in the gastrointestinal tract. Studies
have shown concentrations ranging from 0 mg/litre to1.6
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