REVIEW

CURRENT
OPINION What is new with hand hygiene?
Rahel Noemi Stadler and Sarah Tschudin-Sutter

Purpose of review
Healthcare-associated infections (HAIs) challenge healthcare systems worldwide. As healthcare workers’
hands are considered the main vector for transmission of pathogens, effective hand hygiene is the single
most important action to prevent HAIs. We sought to highlight new developments and advances in hand
hygiene.
Recent findings
Hand hygiene compliance averages at 38%. A sustained increase of compliance with a subsequent
decrease of HAIs may be achieved by national, systematic and rigorous education, and auditing
programs. Periodically deployed self-operating hand hygiene surveillance systems coupled with
Downloaded from http://journals.lww.com/co-infectiousdiseases by BhDMf5ePHKbH4TTImqenVBLNPkpHwi7kkvbXPeUMcGQCcLydM4BIO8yp7BMk+lUPgOwBHsUrKD0= on 07/10/2020

personalized reminders could facilitate such efforts. Alcohol-based hand-rub (ABHR) solutions remain the
hand hygiene gold standard, but are modified in texture and composition to better meet healthcare
workers’ preferences. Modifications of the hand hygiene procedure have been proposed targeting both
time and technique of hand rub application. Reducing rub-time from 30 to 15 s and simplifying the
technique to consist of three rather than six steps yielded encouraging results in terms of microbiological
efficacy and higher compliance.
Summary
Implementation and promotion of compliance are the major concerns of today’s research on hand hygiene.
Developments towards better surveillance and systematic education, improved ABHR formulation and
streamlining of hand hygiene actions are paving the way ahead.
Keywords
compliance, hand hygiene, healthcare-associated infections, rub technique

INTRODUCTION implemented their own hand hygiene programs [6].

Healthcare-associated infections (HAIs) burden
patients and healthcare systems, as they are difficult
to treat and increasingly caused by antibiotics-resis-
tant pathogens. They increase morbidity, mortality,
&
length of hospital stay and costs [1,2 ]. HAIs may
predominantly involve multimorbid, immuno-
compromised, geriatric or pediatric patients [2 ].
&
Estimations suggest, that every 10th patient in
developing countries and every 14th patient in
industrialized countries suffers from a HAI [3].
Healthcare workers’ hands represent the main
vector for pathogen transmission and thus, HAIs [4].
Therefore, effective hand hygiene is the single most
important action for prevention of HAIs today [5].
Alcohol-based hand-rubs (ABHRs) are the gold stan-
dard for conduct of hand hygiene, because of their
cost-effective availability, their water- or plumbing-
independence and their proven effectiveness in
reducing microbial load [5].
Since the publication of the World Health Orga-
nization (WHO) guideline on hand hygiene in 2009,
numerous healthcare institutions worldwide have
During this implementation, several problems were
uncovered, mainly achieving and maintaining high
compliance. Addressing these issues, research
steadily evolves and focuses on improving training
and education, analyzing compliance, developing
strategies to overcome low compliance, accessibility
of ABHR and on the efficacy and safety of stream-
lined hand hygiene regimens.
COMPLIANCE
Internationally, compliance with hand hygiene
guidelines ranges from 5 to 89%, averaging at
Division of Infectious Diseases & Hospital Epidemiology, University
Hospital Basel, Basel, Switzerland
Correspondence to Sarah Tschudin-Sutter, MD, MSc, Division of Infec-
tious Diseases & Hospital Epidemiology, University Hospital Basel,
Petersgraben 4 CH-4031 Basel, Switzerland. Tel: +41 61 328 68 10;
fax: +41 61 265 31 98; e-mail: sarah.tschudin@usb.ch
Curr Opin Infect Dis 2020, 33:327–332
DOI:10.1097/QCO.0000000000000654

0951-7375 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved. www.co-infectiousdiseases.com

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Nosocomial and healthcare related infections

EDUCATION AND AUDITING

KEY POINTS
 Compliance depends heavily on personal, institutional,
and product-related factors.
 Education and auditing improve compliance effectively
Over the years, investigations to increase hand
hygiene compliance ranged from new teaching
methods to surveillance strategies. Only multi-
modal measures seem to achieve sustainable results
& &

and may be optimized through electronic devices. [17 ,18 ].

The Australian National Hand Hygiene Initiative
 Streamlining (i.e. reduction of steps or time) of the (NHHI) provides evidence for the effectiveness of
WHO six-step model is possible and may increase teaching hand hygiene. This standardized, nation-
compliance and effectiveness in daily clinical practice.
wide hand hygiene program was implemented in
 ABHRs are well tolerated and perform well for 2008. The basic principal is to initiate a sustainable
surgical rubbing. culture change. Today, NHHI requires all acute
healthcare facilities in Australia to have a standard-
ized hand hygiene program to become accredited.
& & NHHI promotes ABHR placement at point-of-care,
approximately 38% [5,7 ,8 ]. Limited availability of
visible hand hygiene promotion, national monitor-
hand hygiene supplies, their improper/inconve-
ing of hand hygiene compliance in three audit peri-
nient placement, work overload, pressure, skin reac-
ods annually, and ongoing education through online
tions, diminished risk perception, habit of not
learning tools and onsite courses. Some institutions
washing hands and forgetfulness are associated with
require completion of the online learning modules
low compliance, while importance of social influ-
for all staff at employment and on an annual basis.
ence, attitude towards hand hygiene and role mod-
& These measures enable healthcare organizations to
els are important promoters [9 ]. Hand hygiene is
track their progress, provide feedback and plan cor-
scarcely perceived as a communal responsibility and
rective interventions [19].
healthcare workers disacknowledge hand hygiene as
From 2009 to 2017, overall compliance with
‘duty of care towards their patient’ but acknowledge
hand hygiene increased from 63.6 to 84.3%. This
hand hygiene as ‘duty of care towards themselves’.
increase translates to a reduction of HAIs across
Such perceptions may directly influence the fre-
Australia’s 132 major public hospitals: for every
quency of hand hygiene actions [10]. Very recently,
10% compliance increase, the incidence of hospi-
analysis of an extensive intensive care unit dataset
tal–acquired Staphylococcus aureus bacteremia
revealed, that hand hygiene actions are likelier to be &&
decreased by 15% [20 ]. Although the effect size
performed after contaminating tasks as compared to
might be overestimated as healthcare workers may
before critical tasks, suggesting the strongest prompt
&& perform better with auditors on site (Hawthorne
for hand hygiene being ‘disgust’ [11 ]. Self-protec- & &
Effect) [21 ,22 ], this study is the first to demonstrate
tion appears as a strong driver and false belief of
that hand hygiene compliance reduces HAIs on a
protection (i.e. use of gloves) as impairer to perform &&
national scale [20 ]. The Australian NHHI very
hand hygiene in various other studies conducted in
& & much depends on onsite employees in several dif-
different settings and countries [8 ,12,13,14 ,15]. In
ferent facilities to ensure ongoing education. Such
addition, type and amount of product used, rubbing
considerations pioneer studies investigating elec-
technique and consistency of use are known to
& tronic hand hygiene compliance surveillance and
influence compliance [16 ]. The most common bar-
behavior modification tools, holding promise to
riers towards effective hand hygiene are summarized
improve hand hygiene compliance.
in Table 1.

Table 1. Factors compromising hand hygiene compliance

Personal Institutional Resource-associated

Forgetfulness Patient overcrowding Limited availability of hand hygiene supplies

Habit Work overload Poor quality of hand hygiene-product
Lack of risk perception/knowledge Improper/inconvenient placement Uncomfortable feeling of hand hygiene product
Attitude towards HH of hand hygiene products
Intention for HH (self-protection
vs. patient-protection)
Skin reactions
Use of gloves
& && & &
Information tabulated from references [9 ,10,11 ,12,13,14 ,15,16 ].

328 www.co-infectiousdiseases.com Volume 33  Number 4  August 2020

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.


The impact of intermittent deployment of an
electronic monitoring system (EMS) on the behavior
of healthcare workers was investigated in a Cana-
dian study. A smart badge collected signals on hand
hygiene activity received from electronic units
installed on all soap and ABHR-dispensers and on
the ceilings inside and outside of all patient rooms.
The badges produce real-time prompts (inaudible
vibrations) to perform hand hygiene if opportuni-
ties were missed. As the results of a precursor study
showed that if the same EMS is constantly deployed,
participation rates (badge-use) drop considerably
alongside hand hygiene compliance [23], this study
investigated intermittent deployments over 1 year,
hypothesizing, that the effect of being surveilled
would sustain and participation would remain sta-
ble. To control compliance rate without EMS, simple
counters were fitted to all soap and ABHR-dispensers
unbeknown to the staff. Overall, compliance was
67% during EMS deployment but declined over the
length of each deployment. Compliance assessment
via the dispenser counts exposed a significant
increase during EMS deployments but also a sub-
stantial reduction after the deployment phase. Dis-
pensers located outside patients’ rooms exhibited
the most count variability, being less frequently
activated between deployment periods [24 ].
&
These findings support monitoring as a driver for
better compliance. Potentially, the EMS could be used
&
to replace regular audits [25 ] as they collect data
more reliably and save resources and manpower
&
[26 ]. Furthermore, the intermittent-use strategy
was effective in terms of maintaining staff participa-
tion with the system and long-term hand hygiene
compliance. However, the problem of decreasing
compliance in nonsurveillance periods [24 ,27 ]
& &
and possible adverse feelings against EMS [28 ]
&
remains, maybe reducible by the introduction of
‘respite’ periods (EMS removed), with reintroduction
when dispenser counts drop below a preset level [24 ].
&
Combining the two above-mentioned app-
roaches seems promising, as it would clear compli-
ance control from onsite personnel and possibly
render more reliable data. Additionally, there is a
chance for individual behavior change through the
personalized reminder scheme. However, both
methods require extensive resources and the devel-
opment of stable infrastructures.
STREAMLINING HAND HYGIENE
TECHNIQUE
The proper performance and duration of the six
WHO recommended hand hygiene-steps [5] can be
perceived as too extensive and bothersome in daily
clinical routine and may influence compliance. The
0951-7375 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
What is new with hand hygiene Stadler and Tschudin-Sutter
six-step technique is rarely followed even if a hand
hygiene action is performed when indicated [29].
FROM SIX TO THREE OR FREE – IS A
STEP-DOWN POSSIBLE?
The six-step hand hygiene-technique recommended
by the WHO was developed to assure complete cov-
erage of hands with ABHR [5]. The technique leaves
varying bacterial contamination loads on different
areas of hands and user-friendliness unaddressed.
Additionally, evidence still has to be established, if
&&
the six-step model is the most effective [30 ]. A
simplified hand hygiene-technique proposing
merely three steps was shown to be noninferior in
terms of microbiological efficacy in a standardized
experimental setting as compared with the standard
six-step technique. This simplified procedure consists
of covering the hands based on own judgement,
rubbing the fingertips, that is the most contaminated
areas of hands, in the palm of the alternate hand and
finally rubbing both thumbs. This is to be performed
for 30 s, using 3 ml of ABHR [31]. A cluster-random-
ized trial examined the effects of this three-step
approach on hand hygiene compliance, compliance
with the individual hand hygiene-steps and on the
reduction of bacterial counts in comparison to the
standard method in routine clinical practice. Overall
compliance was 75.9% for the wards assigned to the
three-step technique, and 65.0% for the wards
assigned to the six-step technique. Adherence to all
specified steps was superior for the three-step tech-
nique with 51.7%, versus 12.7% with six steps. Micro-
biological testing confirmed the noninferiority of the
three-step technique regarding bacterial count reduc-
tion. While the first step of the simplified hand
hygiene technique proposes a sequence, which
may depend on individual interpretation, it has
the potential to increase overall compliance and
coverage of the high-touch areas of hands through
&
its simplicity and convenience [32 ].
Some researchers pursue a more radical change to
the hand hygiene technique proposing a ‘no-steps
model’ favoring a self-responsibility guided method
after a thorough education. Following a promising
experimental result [33], a study with undergraduate
medical students indicated that after 4–12 weeks,
students applying ABHR self-responsibly had signifi-
cantly better coverage of their hands than the control
group. The study is limited by the last measurements
being taken in an exam situation and it could not be
guaranteed that students were not taught the six-step
&
model in clinical training [34 ].
Concepts for reduction or amendment of the six
WHO hand hygiene-steps are emerging and hold
promise.
www.co-infectiousdiseases.com 329
Nosocomial and healthcare related infections
30 SECONDS – NO TIME TO WASTE?
Thirty seconds are recommended to apply ABHR, as
this duration has been shown to eradicate most
pathogens on healthcare workers’ hands and allow
complete drying [5]. However, hand hygiene actions
are rarely performed over a 30-s period in daily clini-
cal practice [29] and may potentially discourage from
performing hand hygiene at all. Thus, reducing appli-
cation time has potential to increase frequency of and
&
compliance with hand hygiene [35 ]. Laboratory
studies showed noninferiority of 15 s for application
&
of ABHR, as compared to the standard of 30 s [36 ,37].
Additionally, wetting of the hands seems to be com-
parable between 15-s and 30-s rubs in volunteers
educated in hand hygiene procedures [38]. In clinical
practice, compliance and ABHR-usage increased in
the 15-s rub group as compared to the 30-s rub group,
whereas the bacterial load on the hands after perfor-
mance of hand rub was comparable between the two
groups, supporting a shorter application time of 15 s
&
in clinical settings [39 ].
Despite these promising results, further research
on reproducibility of these findings in other set-
tings, with the use of different ABHRs, and on the
impact of a shorter application time on viral con-
tamination of hands is needed [40 ].
&
EFFICACY OF ALCOHOL-BASED HAND-
RUBS
Alcohol-based hand rub is considered the gold stan-
dard of hand hygiene [5] because of numerous
advantages, mainly fast, reliable activity, and skin-
friendliness. ABHRs contain 60–85% alcohol and
added humectants, emollients, or moisturizers
&
[40 ]. Combinations of the more viricidal ethanol
and the more bactericidal propanol and/or addition
of chlorhexidine seem to improve overall effective-
&
ness [41 ]. However, ABHR has limitations in effec-
tiveness against protozoan oocysts, certain
nonenveloped viruses (i.e. norovirus) and bacterial
&
spores [40 ,42].
A study proposed that some strains of Enterococ-
cus faecium collected after 2010 had increased toler-
ance to alcohol-containing fluids, indicating the
potential to develop tolerance towards higher alco-
hol concentrations. Nonetheless, it must be men-
tioned, that the alcohol concentrations used in the
study were far below the concentrations used in
commercially available formulations, that is 23%
instead of 60–85%. When testing was performed
with approved formula, the effect was no longer
detectable [43]. Therefore, these results have to be
interpreted with caution. They do, however, empha-
size the importance of proper ABHR formulation
&
[44 ].
330 www.co-infectiousdiseases.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Various forms of ABHR (i.e. gel, foam, watery
solution, wipes) may differ regarding acceptance,
tolerability, and efficacy. Detergent or alcohol wipes
should not be used for hand hygiene, as they tend to
be inferior to the other forms of ABHRs [45]. Some
evidence suggests that foams and gels may be
& &
slightly more appealing than solutions [16 ,46 ].
Benzalkonium chloride may constitute an alco-
hol-free alternative to ABHRs and is mainly formu-
lated as water-based foams. Key assets are
noninflammability, nondamaging to surfaces and
its relative low toxicity even in cases of accidental
ingestion. However, research is needed to confirm
such advantages. Other substances available today
have properties which hinder hand hygiene (i.e. tox-
&
icity) or compliance (i.e. causes skin reactions) [40 ].
ACCESS TO ALCOHOL-BASED HAND-RUB
– A KEY PREREQUISITE
Implementing safer care and hand hygiene in low-
income countries or during epidemics is particularly
challenging. Establishing a sustainable ABHR pro-
duction was critical to contain the 2014–2016 Ebola
outbreak in Liberia, Sierra Leone, and Guinea. Yet,
limited access to the main components of ABHR
(especially bioethanol), disruption of transport, and
conflicts regarding humanitarian donations versus
locally produced ABHRs hampered production
whilst healthcare workers only slowly adapted hand
hygiene measures. Careful planning, coordination,
support of national authorities and nongovernmen-
tal organizations for local ABHR-production, and
access were key. Building local capacities, even in
an emergency and low-income setting, is, however,
ultimately feasible. It demands high adaptability to
regional conditions and sustainability remains an
&&
important issue [47 ].
HAND HYGIENE IN LONG-TERM-CARE
INSTITUTIONS
The rise of multidrug resistance lends urgency to
proper hand hygiene beyond hospital settings. A
German study assessed hand hygiene behavior in
six nursing homes by performing surveys and semi-
structured interviews among nurses and nursing
managers. These explored organizational, social,
and teaching factors potentially hindering effective
hand hygiene. Making residents feel ‘at home’ had
high priority, resulting in ABHRs not being placed at
critical points-of-care and creating an inaccessibility
of ABHRs when needed. In addition, concerns of
accidental ingestion of ABHR outweighed concerns
of transmitting ‘invisible’ pathogens. Nurse manag-
ers added that sufficient surveillance of hand hygiene
Volume 33  Number 4  August 2020

compliance is often not feasible as most of the care
takes place in closed rooms. Nursing managers under-
estimated the importance of role modelling as most
nurses tailored their own behavior towards that of
their superiors. This study indicates targets to
improve hand hygiene in nursing homes and long-
term-care facilities, highlighting the importance of
& 2. Saleem Z, Godman B, Hassali MA, et al. Point prevalence surveys of health-
role models and organizational policies [48 ].
SURGICAL DISINFECTION – FROM SCRUB
TO RUB
Surgical hand antisepsis traditionally included scrub-
& settings. https://www.cdc.gov/handhygiene/. [Accessed 19 January 2020]
bing with antimicrobial scrub solutions [49 ]. How-
ever, the benefits of ABHR for hand hygiene in
clinical routine suggests that hand rubbing could
substitute scrubbing in preparation for surgery
& uary 2020]
[5,50 ]. Efficacy in terms of bacterial load reduction
suggest noninferiority or even superiority of ABHRs
versus traditional scrubbing. This effect may be
enhanced by adding chlorhexidine to the ABHR-
& 8. Vikke HS, Vittinghus S, Giebner M, et al. Compliance with hand hygiene in
formula [41 ,51]. Furthermore, ABHR rubbing was
not associated with an increase of surgical site infec-
& Large multicenter observational study on hand hygiene compliance in emergency
tions as compared to traditional scrubbing [52 ].
Benefits of ABHR for surgical hand preparation are
independence of water, ease of re-rubbing during
long-hour surgeries, and reduction of irritated skin
reactions. Routine use of ABHR surgical preparation is
&
now supported by more and more evidence [49 ]. A
Brazilian trial was able to show that rubbing with
ABHR enhances the quality of hand hygiene and
reduces the needed preparation time while maintain-
&
ing stable surgical infection rates [53 ]. Based on all
this evidence, surgical hand preparation is likely to
change from scrubbing to rubbing in the near future.
CONCLUSION
Hand hygiene is the most important measure for
prevention of HAIs and containment of epidemics.
Compliance is key and improves through education
and auditing. Electronic devices may facilitate and
personalize these measures. Streamlined hand
hygiene procedures may increase compliance with
and effectiveness of hand hygiene and may replace
the current WHO standards in the near future.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
0951-7375 Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
What is new with hand hygiene Stadler and Tschudin-Sutter
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. World Health Organization. Report on the burden of endemic healthcare-
associated infection worldwide. Geneva, Switzerland: WHO; 2011.
& care-associated infections: a systematic review. Pathog Glob Health 2019;
113:191–205.
Systematic review providing a current summary on prevalence of HAIs, their
characteristics, and the burden caused.
3. World Health Organization. Healthcare-associated infections: fact sheet,
2014. https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.
pdf. [Accessed 20 January 2020]
4. Center for Disease Control and Prevention. Hand hygiene in healthcare
5. World Health Organization. WHO Guidelines on Hand Hygiene in Health-
care. Geneva, Switzerland: WHO; 2009.
6. World Health Organization. Registration Update - Countries or Areas regis-
tered in the global Campaign – SAVE LIVES: clean your Hands: WHO.
https://www.who.int/gpsc/5may/registration_update/en/. [Accessed 15 Jan-
7. Lambe KA, Lydon S, Madden C, et al. Hand hygiene compliance in the ICU: a
& systematic review. Crit Care Med 2019; 47:1251–1257.
Systematic review synthesizing data on compliance with the WHO hand hygiene
guidelines in ICUs, detecting regional, institutional, and profession-associated
differences.
& emergency medical services: an international observational study. Emerg Med
J 2019; 36:171–175.
departments, assessing factors which lead to notably low hand hygiene compli-
ance among emergency personnel.
9. Le CD, Lehman EB, Nguyen TH, Craig TJ. Hand hygiene compliance study at
& a large central hospital in Vietnam. Int J Environ Res Public Health 2019;
16:607.
Study highlighting the persistent common barriers to effective hand hygiene
compliance in a large medical centre. In particular explored are personal influence
factors.
10. Salmon S, McLaws M-L. Qualitative findings from focus group discussions on
hand hygiene compliance among healthcare workers in Vietnam. Am J Infect
Control 2015; 43:1086–1091.
11. Chang N-CN, Reisinger HS, Schweizer ML, et al. Hand hygiene compliance at
&& critical points of care. Clin Infect Dis 2020; ciaa130.
Research on a large ICU hand hygiene compliance dataset revealing healthcare
workers’ tendency to perform hand hygiene actions after contaminating tasks
rather than before critical tasks. This indicates a field in which educational
measures need adjustment.
12. Oh HS. Knowledge, perception, performance, and attitude regarding hand
hygiene and related factors among infection control nurses in South Korea: a
cross-sectional study. Am J Infect Control 2019; 47:258–263.
13. Seo HJ, Sohng KY, Chang SO, et al. Interventions to improve hand hygiene
compliance in emergency departments: a systematic review. J Hosp Infect
2019; 102:394–406.
14. Baloh J, Thom KA, Perencevich E, et al. Hand hygiene before donning
& nonsterile gloves: healthcare workers’ beliefs and practices. Am J Infect
Control 2019; 47:492–497.
Study revealing practices and beliefs of healthcare workers ultimately negatively
influencing hand hygiene compliance in case of gloving, because of the notion of
being protected enough.
15. Acquarulo BA, Sullivan L, Gentile AL, et al. Mixed-methods analysis of glove
use as a barrier to hand hygiene. Infect Control Hosp Epidemiol 2019;
40:103–105.
16. Greenaway RE, Ormandy K, Fellows C, Hollowood T. Impact of hand sanitizer
& format (gel/foam/liquid) and dose amount on its sensory properties and
acceptability for improving hand hygiene compliance. J Hosp Infect 2018;
100:195–201.
Thorough study on which properties of ABHR appeal to most healthcare workers,
showcasing a tendency towards foams, fast drying and nonstickyness.
17. Valim MD, Rocha ILdS. Souza TPM, et al. Efficacy of the multimodal strategy
& for hand hygiene compliance: an integrative review. Rev Bras Enferm 2019;
72:552–565.
Review supporting the evidence for effectiveness and sustainability of multimodal
education models to increase hand hygiene compliance.
18. Jamil N, Handiyani H, Pujasari H. A multimodal approach as a strategy to
& improve hand hygiene compliance: a literature review. Enferm Clin 2019; 29
Suppl 2:567–571.
Small literature review assessing effectiveness of multimodal concepts to improve
hand hygiene compliance.
www.co-infectiousdiseases.com 331
Nosocomial and healthcare related infections
19. Australian Committee on Safety and Quality in Healthcare. National Hand
Hygiene Initiative Manual. Sydney: ACSQHC; 2019.
20. Grayson ML, Stewardson AJ, Russo PL, et al. Effects of the Australian
&& National Hand Hygiene Initiative after 8 years on infection control practices,
health-care worker education, and clinical outcomes: a longitudinal study.
Lancet Infect Dis 2018; 18:1269–1277.
Large longitudinal study measuring the effects of a nationally enforced, mandatory
hand hygiene program on patient safety. First study to show that a systematic
education and auditing program for hand hygiene impacts HAIs positively on a
national basis and improves hand hygiene sustainably.
21. Jeanes A, Coen PG, Gould DJ, Drey NS. Validity of hand hygiene compliance
& measurement by observation: a systematic review. Am J Infect Control 2019;
47:313–322.
Systematic review assessing publications on hand hygiene compliance for biases
inherent to direct observation of compliance, revealing considerable lack of validity.
22. Werzen A, Thom KA, Robinson GL, et al. Comparing brief, covert, directly
& observed hand hygiene compliance monitoring to standard methods: a
multicenter cohort study. Am J Infect Control 2019; 47:346–348.
Cohort study comparing hand hygiene compliance rates for overt and covert
monitoring, measuring up to a 29% difference.
23. Pong S, Holliday P, Fernie G. Effect of electronic real-time prompting on hand
hygiene behaviors in healthcare workers. Am J Infect Control 2018; 46:768–774.
24. Pong S, Holliday P, Fernie G. Effect of intermittent deployment of an
& electronic monitoring system on hand hygiene behaviors in healthcare work-
ers. Am J Infect Control 2019; 47:376–380.
Study suggesting an intermittent electronic batch deployment to successfully omit
user-fatigue and increase hand hygiene compliance.
25. Livorsi DJ, Goedken CC, Sauder M, et al. Evaluation of barriers to audit-and-
& feedback programs that used direct observation of hand hygiene compliance:
a qualitative study. JAMA Netw Open 2018; 1:e183344–e183350.
Study assessing the feedback process of hand hygiene compliance auditors and
revealing perceptions of inaccurate data collection and feelings of tension among
monitored staff.
26. McKay KJ, Shaban RZ, Ferguson P. Hand hygiene compliance monitoring: do
& video-based technologies offer opportunities for the future? Infect Dis Health
2020; 25:92–100.
Study outlining current possibilities of video-based monitoring of hand hygiene
compliance: its advantages, disadvantages, and implications.
27. Benudis A, Stone S, Sait AS, et al. Pitfalls and unexpected benefits of an
& electronic hand hygiene monitoring system. Am J Infect Control 2019;
47:1102–1106.
Study encountering unexpected barriers in using an electronic hand hygiene
compliance monitoring system.
28. Tarantini C, Brouqui P, Wilson R, et al. Healthcare workers’ attitudes towards
& hand-hygiene monitoring technology. J Hosp Infect 2019; 102:413–418.
Study exploring the kind and extent of attitudes towards an electronic hand-
hygiene compliance monitoring system in healthcare workers.
29. Stewardson AJ, Iten A, Camus V, et al. Efficacy of a new educational tool to
improve handrubbing technique amongst healthcare workers: a controlled,
before-after study. PLoS One 2014; 9:e105866–e105870.
30. Price L, Melone L, McLarnon N, et al. A systematic review to evaluate the
&& evidence base for the World Health Organization’s adopted hand hygiene
technique for reducing the microbial load on the hands of healthcare workers.
Am J Infect Control 2018; 46:814–823.
Systematic review demonstrating that the WHO six-step hand hygiene technique
reduces bacterial load on hands effectively but could not identify it as the superior
method in comparison to a three-step approach. These suggest that further
research on the topic is needed.
31. Tschudin-Sutter S, Rotter ML, Frei R, et al. Simplifying the WHO ’how to hand
rub’ technique: three steps are as effective as six - results from an experi-
mental randomized crossover trial. Clin Microbiol Infect 2017; 23:409.e1-e4.
32. Tschudin-Sutter S, Sepulcri D, Dangel M, et al. Simplifying the World Health
& Organization Protocol: 3 steps versus 6 steps for performance of hand
hygiene in a cluster-randomized trial. Clin Infect Dis 2019; 69:614–620.
Large trial demonstrating better hand hygiene compliance and comparable micro-
bial load reduction on hands with a three-step method opposed to the WHO six-
step regime in an university hospital.
33. Kampf G, Reichel M, Feil Y, et al. Influence of rub-in technique on required
application time and hand coverage in hygienic hand disinfection. BMC Infect
Dis 2008; 8:149.
34. Sakmen KD, Sterz J, Stefanescu M-C, et al. Impact of the teaching method of
& the rub-in technique for learning hygienic hand disinfection in medical studies:
a comparative effectiveness analysis of two techniques. GMS Hyg Infect
Control 2019; 14:Doc17.
Study implicating efficacy of a self responsible hand hygiene regime over time in a
small study population of medical students.
35. Kenters N, Eikelenboom-Boskamp A, Hines J, et al. Product dose considera-
& tions for real-world hand sanitiser efficacy. Am J Infect Control 2020;
48:503–506.
Study examining the correlation between ABHR-dosage, drying time, and efficacy
with healthcare workers actual habits.
332 www.co-infectiousdiseases.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
36. Pires D, Soule H, Bellissimo-Rodrigues F, et al. Antibacterial efficacy of
& handrubbing for 15 versus 30 seconds: EN 1500-based randomized experi-
mental Study with different loads of Staphylococcus aureus and Escherichia
coli. Clin Microbiol Infect 2019; 25:851–856.
Laboratory study supporting that a 15 s ABHR application time may be noninferior
to the currently recommended 30 s.
37. Pires D, Soule H, Bellissimo-Rodrigues F, et al. Hand hygiene with alcohol-
based hand rub: how long is long enough? Infect Control Hosp Epidemiol
2017; 38:547–552.
38. Paula H, Becker R, Assadian O, et al. Wettability of hands during 15-second
and 30-second handrub time intervals: a prospective, randomized crossover
study. Am J Infect Control 2018; 46:1032–1035.
39. Harnoss JC, Dancer SJ, Kaden CF, et al. Hand antisepsis without decreasing
& efficacy by shortening the rub-in time of alcohol-based handrubs to 15
seconds. J Hosp Infect 2019; 104:419–424.
Cohort study strengthening evidence that a 15 s rub time may be enough for
effective HH in regular clinical practice.
40. Gold NA. U.A. alcohol sanitizer. Treasure Island, FL: StatPearls Publishing;
& 2019.
Comprehensive overview on ABHR compounds, effectiveness and alternatives in
daily clinical routine.
41. Boyce JM. Best products for skin antisepsis. Am J Infect Control 2019;
& 47S:A17–A22.
Comprehensive overview on skin antiseptic compounds, effectiveness, and alter-
natives with focus on surgical preparations.
42. Stuart RL, Marshall C, Harrington G, et al. ASID/ACIPC position statement -
infection control for patients with clostridium difficile infection in healthcare
facilities. Infect Dis Health 2019; 24:32–43.
43. Pidot SJ, Gao W, Buultjens AH, et al. Increasing tolerance of hospital
Enterococcus faecium to handwash alcohols. Sci Transl Med 2018;
10:eaar6115.
44. Pittet D, Peters A, Tartari E. Enterococcus faecium tolerance to isopropanol:
& from good science to misinformation. Lancet Infect Dis 2018;
18:1065–1066.
Correspondence concerning ‘‘Pidot SJ et al. Increasing tolerance of hospital
enterococcus faecium to handwash alcohols. Sci Transl Med.
2018;10(452):eaar6115’’ speaking a word of caution in extrapolation of the
measured effects.
45. Ory J, Zingg W, de Kraker MEA, et al. Wiping is inferior to rubbing: a note of
caution for hand hygiene with alcohol-based solutions. Infect Control Hosp
Epidemiol 2018; 39:332–335.
46. O’Donoghue M, Ho JMC, Pittet D, Suen LKP. Acceptability and tolerability of
& alcohol-based hand hygiene products for elderly residents in long-term care: a
crossover study. Antimicrob Resist Infect Control 2019; 8:165.
Study supporting favorization of gel and foam formats of ABHR and that hand
hygiene is feasible in long-term-care residents.
47. Jacquerioz Bausch FA, Heller O, Bengaly L, et al. Building local capacity in
&& hand-rub solution production during the 2014-2016 Ebola outbreak disaster:
the case of Liberia and Guinea. Prehosp Disaster Med 2018; 33:660–667.
Report of a project to build a sustainable ABHR-production and hand hygiene
program during the 2014–2016 Ebola Outbreak in Liberia and Guinea. The study
highlights the barriers and adaptive ways to overcome them in the context of an
epidemic and a low-income economics.
48. Hammerschmidt J, Manser T. Nurses’ knowledge, behaviour and compliance
& concerning hand hygiene in nursing homes: a cross-sectional mixed-methods
study. BMC Health Serv Res 2019; 19:547–550.
Interview and survey based study exploring influences on hand hygiene compli-
ance amongst nurses in long-term-care institutions.
49. Fry DE. Operating Room Hand Preparation: To scrub or to rub? Surg Infect
& (Larchmt) 2019; 20:129–134.
Review exploring surgical scrubbing and what future ABHR rubbing has as a new
presurgical routine.
50. Ho YH, Wang YC, Loh EW, Tam KW. Antiseptic efficacies of waterless hand
& rub, chlorhexidine scrub, and povidone-iodine scrub in surgical settings: a
meta-analysis of randomized controlled trials. J Hosp Infect 2019;
101:370–379.
Meta-analysis synthesizing evidence that ABHRs and chlorhexidine gluconate
have higher antiseptic efficacies than povidone-iodine in surgical settings.
51. Uppal S, Bazzi A, Reynolds RK, et al. Chlorhexidine-alcohol compared with
povidone-iodine for preoperative topical antisepsis for abdominal hysterect-
omy. Obstet Gynecol 2017; 130:319–327.
52. Kashkoush A, Agarwal N, Ayres A, et al. Scrubbing technique and surgical site
& infections: an analysis of 14,200 neurosurgical cases. J Neurosurg 2019;
1–8. [Epub ahead of print]
Retrospective analysis of a large sample of neurosurgical cases showing no
association between outcome and scrubbing, rubbing, or gloving preference.
53. Gaspar GG, Menegueti MG, Lopes AER, et al. Alcohol-based surgical Hand
& Preparation: translating scientific Evidence into clinical Practice. Antimicrob
Resist Infect Control 2018; 7:80.
Trial supporting the effectiveness and safety of presurgical ABHR-rubbing versus
traditional scrubbing in an orthopedic and cardial surgery ward.
Volume 33  Number 4  August 2020