To the Editor: Johnson et al detailed an intensive hand hygiene program planned to reduce the burden of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infections.1 The results were based on observations before and after the program. Hand hygiene compliance rates reached only 42% despite the program, and there was no effect on patient MRSA colonisation or environmental colonisation or contamination. Outside the intensive care unit, there was no effect on health care worker colonisation. Despite this evidence of ineffectiveness, the program was held responsible for a reduction in hospital-wide rates of clinically important MRSA infections.

The literature on hand hygiene is inadequate. The recent edition of Clinical evidence contains no randomised controlled trials of hand hygiene.2 In fact, the only published randomised trial is the Mortimer study,3 which is now more than 40 years old.

Huynh and Commens made the point that hand hygiene procedures involving application of chemical agents or scrubbing are hazardous for staff and suggested using mechanical barriers (ie, gloves) on clean unscrubbed hands.4

The hand hygiene bandwagon rolls on despite the absence of evidence of benefit for patients and its hazardous nature for staff. Mechanical barriers together with reduced contamination opportunities (hand-shaking, touching telephone handsets and computer key boards) may be better options. We need properly conducted studies to find an effective means of protecting patients from nosocomial infections by MRSA and other agents.

To the Editor: We congratulate Johnson et al on their article, which illustrates a successful hand hygiene program associated with a fall in transmission of multidrug-resistant organisms.1 Their publication is significant for three reasons:

• It is only the second article2 to demonstrate the anticipated relationship between increased hand hygiene and a fall in multidrug-resistant organism transmission;

• It again indicates that 100% compliance in hand hygiene is not necessary to significantly improve outcomes;2,3 and

• It suggests that environmental contamination with MRSA has little relationship to patient colonisation.

However, the specific aspects of their program that led to success are not obvious, and may not relate to a sustained response to either education or the provision of alcohol/chlorhexidine hand hygiene solution. Alternative explanations include:

• The education program and/or overt observation induced a Hawthorne effect on hand hygiene practice;

• The screening and treatment program induced the same effect on hand hygiene behaviour; or

• The treatment of MRSA carriers reduced the size of the MRSA reservoir and thus the probability of transmission and subsequent colonisation.

Although we agree that the approach of Johnson et al is laudable, without teasing out those causal factors that induce the improvement in hand hygiene in health care workers, it remains expensive to implement and maintain. Moreover, there is no evidence that improved hand hygiene would continue if the alcoholic gel alone remained, without all other aspects of the program. This was recognised in the successful Geneva program on which the protocol used by Johnson et al was modelled. In that study, the authors remained so uncertain as to what elements of the program were causal that they stated:

Evidence currently available4 and soon to be amplified5 suggests that hand hygiene practice in health care workers is simply an extrapolation of their community behaviour. Unfortunately, community hand washing behaviour is not microbiologically founded, being developed on the basis of emotion not science. Both the Austin and Geneva protocols supported the introduction of alcoholic hand gel with strong promotion of specific behavioural elements to induce change in hand hygiene practice. Our findings suggest that alcoholic gel is not pivotal to the improvement of hand hygiene, in that behavioural modelling suggests its effect is relatively small and very dependent on concomitant behavioural change.4,5

The World Health Organization World Alliance for Patient Safety has recently advocated the introduction of alcoholic gel into all hospitals.6 While not denying that this is a step toward improvement, we strongly caution against unrealistic expectations of this single intervention. The hand hygiene practices of health care workers are learned behaviours of childhood, continued as professionals, and reinforced in everyone’s daily lives.4,5 Entrenched, longstanding behaviour patterns will not be changed in a sustained fashion by the introduction of a new hand hygiene product.

In reply: Woollard is critical of the lack of randomised controlled data to support the use of alcohol/chlorhexidine hand rub solution (ACHRS). Although a placebo-controlled study would be ideal, it is doubtful whether one could be performed. Apart from the complexity of design and cost, there would be the requirement to ask patients to consent to being treated in a hospital where there was a substantial risk of nosocomial sepsis, but where half the health care workers would not have clean hands when attending them.

Woollard argues that our failure to reduce colonisation or contamination with MRSA shows that our project failed. However, he offers no alternative explanation for the reduction in MRSA bacteraemia, clinical MRSA isolates and resistant gram-negative bacteria that we reported. Our project was a multimodal quality intervention, and we cannot know which component of the project resulted in the benefit, or whether the improvement should be attributed to other confounders, as suggested by Whitby and McLaws. However, we have presented all our data so that readers can draw their own conclusions. It seems unlikely to us that the intervention on which we concentrated our major effort, the progressive introduction and promotion of ACHRS, would be the one component that failed to contribute to the improvement.

Woollard also mentions the potential toxicity of asking health care workers to scrub with a chemical agent, and proposes the use of gloves instead. Our ACHRS is a quick to apply, self-drying solution. It is rubbed on the hands, but scrubbing is not required. We actively monitored rates of cutaneous reactions and found it to be extremely well tolerated.1 Gloves must be changed between patients or when moving from a dirty to a clean site.2 We know that busy health care workers often do not have time to do this, and that hands can become contaminated despite the use of gloves.3

We agree with Whitby and McLaws that simply providing ACHRS, without an active campaign to support its use, is pointless. The provision and promotion of ACHRS is a tool to assist health care workers improve hand hygiene, and is just one component in a web of interventions needed to control nosocomial sepsis. Whether it is cost-effective depends on the largely unknown costs to Australian hospitals of preventable infections. At our institution, we believe that it is worth the money, and continue to require all clinical staff and students to know where to find and when to use ACHRS before they start work.