Volume 184 - Issue 5
Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection
Authors: Paul D R Johnson and M Lindsay Grayson
Med J Aust 2006; 184 (5): 253-254. || doi: 10.5694/j.1326-5377.2006.tb00223.x
Published online: 6 March 2006
Published online: 6 March 2006
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.
References
- Graham M, Nixon R, Burrell LJ, et al. Low rates of cutaneous adverse reactions to alcohol-based hand hygiene solution during prolonged use in a large teaching hospital. Antimicrob Agents Chemother 2005; 49: 4404-4405.<eMJA full text>
- McBryde ES, Bradley LC, Whitby M, McElwain DL. An investigation of contact transmission of methicillin-resistant Staphylococcus aureus. J Hosp Infect 2004; 58: 104-108. 0_i1091543
- Pessoa-Silva CL, Dharan S, Hugonnet S, et al. Dynamics of bacterial hand contamination during routine neonatal care. Infect Control Hosp Epidemiol 2004; 25: 187-188. 0_CBBJDFJC