infection control & hospital epidemiology

february 2016, vol. 37, no. 2

concise communication

Should Alcohol-Based Handrub Use Be

Customized to Healthcare Workers
Hand Size?
Fernando Bellissimo-Rodrigues, MD, PhD;1,2
Herv Soule, Pharm;1 Angle Gayet-Ageron, MD, PhD;1
Yves Martin, Eng;1 Didier Pittet, MD, MS1

We evaluated whether the volume of alcohol-based handrub used by

healthcare workers affects the residual bacterial concentration on
their hands according to hand size. Bacterial reduction was
signicantly lower for large hands compared with small hands, which
suggests a need for customizing the volume of alcohol-based handrub
for hand hygiene.
Infect. Control Hosp. Epidemiol. 2 01 6; 3 7( 2) :2 1 9 2 21

Because cross-transmission by healthcare worker (HCW) hands

is involved in a large proportion of healthcare-associated
infections, hand hygiene is considered critical by both the
Centers for Disease Control and Prevention and the World
Health Organization.13 Over the past 20 years, alcohol-based
handrubs (ABHR) have become the preferential tool for hand
hygiene in healthcare settings because of their high
antimicrobial efcacy, tolerability, and accessibility.13 There is
common sense and microbiologic evidence that the volume of
ABHR used should be large enough to cover the whole surface
area of both hands, but there is no consensus on how much is
the minimum necessary, and whether HCW hand size
inuences it.47 The objective of this study was to evaluate
whether the amount of ABHR used by HCWs for handrubbing
impacts the residual concentration of bacteria on their hands
according to their hand size.

Prior to each contamination procedure, participants were asked

to wash their hands with 5 mL of plain soap for 1 minute. Hands
were contaminated articially by inserting them into the bacterial
suspension up to the mid-carpals for 5 seconds, and then, held
up to dry for 3 minutes. After the rst contamination procedure,
baseline bacterial recovery was obtained using the ngertip
method. As a next step, participants washed their hands, recontaminated them in the same way as before, and undertook a hand
friction action with no ABHR using the World Health Organization recommended sequence for hand hygiene.2 Following the
process above, a second baseline recovery of bacteria was
performed.
After these 2 measurements were taken, participants applied
the reference EN 1500 ABHR (2-propanol 60%) varying every
0.5 mL from 0.5 to 3 mL. HCWs with large hands were
investigated further with the application of 4, 5, and 6 mL of
ABHR. At each application stage, the ABHR test volume was
dispensed into the dominant hand of the HCW, and then the
recommended World Health Organization sequence was
followed for 30 seconds. After each action, the surviving
bacteria were recovered from the participants dominant hand.
At the end of the experiment, HCWs were asked to wash their
hands with a 2% chlorhexidine handwash for 2 minutes.
Each sample was studied in a minimum of 4 different
dilutions to accurately estimate bacterial counts. After dilution, 1-mL samples were distributed in tryptic soy agar plates
within 30 minutes of recovery and incubated for 24 to 48 h at
36C 1C. Bacterial colony-forming units were counted by
visual inspection of each plate, adjusted for the corresponding
dilution factor, and converted to log10. For each HCW and
volume of ABHR applied, a log10 reduction was calculated.
We used a generalized linear mixed model with a random
effect on the intercept and on the slope for the volume, to assess
the log10 reduction depending on hand size (continuous and
categorical formats) and volume of ABHR. Statistical analyses
were performed using Stata/IC, version 13 (StataCorp).
Statistical signicance was dened as P < .05 (2-sided).

m e th o d s
We conducted a laboratory-based experimental study at the
University of Geneva Hospitals, using 15 healthy HCWs from the
infection control program with extensive training and expertise
in hand hygiene. In the experiment, hand hygiene action was
completed under the close supervision of 2 senior infection
control experts. HCWs had their hand surface area calculated by
standard methods and classied as small (375 cm2), medium
(376424 cm2), or large (425 cm2).8
We used the reference strain Escherichia coli ATCC 10536
grown according to the European Norm 1500 standard
(EN 1500)9 to obtain a homogeneous bacterial suspension
containing from 2.0 108 to 2.0 109 colony-forming units/mL.

resul ts
Four participants had small hands (mean [SD] hand surface
area, 332.9 [22.2] cm2), 6 had medium hands (404.2 [9.7]
cm2), and 5 had large hands (473.2 [40.4] cm2). Overall, the
mean (SD) level of contamination of hands at baseline was 6.2
(0.58) log10 and there was no difference between the hand size
categories (P = .372).
Figure 1A shows the interquartile E. coli log10 reduction
observed according to the volume of ABHR applied. The mean
reduction of bacterial count was 0.28 log10 for each additional
increase of 0.5 mL of ABHR (95% CI, 0.200.36, P < .001).
Bacterial reduction was inversely and signicantly associated

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220

infection control & hospital epidemiology

february 2016, vol. 37, no. 2

gure 2. Bacterial reduction on hands among healthcare

workers with large hands according to the volume of alcohol-based
handrub applied for 30 seconds using the World Health
Organization technique (n = 4). E. coli, Escherichia coli.

gure 1. A, Median bacterial reduction (interquartile log10) on

healthcare worker hands according to the volume of alcohol-based
handrub applied for 30 seconds using the World Health Organization
technique (n = 15). B, Mean bacterial reduction on healthcare worker
hands according to hand size categories and the volume of alcoholbased handrub applied for 30 seconds using the World Health
Organization technique (n = 15). E. coli, Escherichia coli.

with hand surface area (0.003 [95% CI, 0.006 to 0.0005],

P = .019).
Figure 1B shows the mean log10 reduction of E. coli per hand
size group according to the volume of ABHR applied. The
log10 reduction was signicantly different by hand size category (interaction term P = .01): the mean log10 reduction per
each additional 0.5 mL of ABHR was 0.40 (95% CI, 0.270.52,
P < .001) in the small hand size category, 0.32 (0.210.42,
P < .001) in the medium hand size category, and 0.15
(0.030.26, P = .011) in the large hand size category. Figure 2
shows E. coli log10 reduction per participant with large hands
according to the volume of ABHR applied, including larger
volumesthat is, 4, 5, and 6 mL.

d i s c u s s io n
Signicant efforts have been made globally to improve hand
hygiene compliance in healthcare.2,5 At this time, however,

there is a need to move the issue further forward by improving

the quality of hand hygiene technique and antimicrobial
efcacy, considering the evidence that a poorly performed
hand hygiene action is less effective and may compromise
patient safety.4,5
This experimental study demonstrates a strong relationship
between the reduction of bacterial count on hands and
the amount of ABHR used for hand hygiene, taking into
account the hand surface area. It is a matter of concern that
HCWs with large hands could not achieve a minimum of
2 log10 reduction of bacteria on their hands by the application
of 3 mL of ABHR, the volume recommended by most
manufacturers. That concern gets greater when we realize that
the mean application volume of ABHR in clinical practice may
be lower than 1 mL.10
Our results are signicant: under the strict experimental
conditions of our study design, even one of the most powerful
ABHR available, applied under controlled conditions by
trained, supervised experts, did not reach the expected
bacterial reduction when the volume applied was not adapted
to the hand size, a parameter yet unrecognized in daily clinical
practice.
Our study has some limitations. First, we tested only one
strain and one ABHR; further testing is necessary to verify
whether these ndings could be generalized to other pathogens
and other ABHR formulations. Second, we did not test the
effect of poor or suboptimal hand hygiene technique. This
could be assessed in the future. Finally, the minimum
reduction of bacteria necessary to avoid transmission between
patients through HCW hands, or from a dirty to clean body
site within the same patient, remains a matter of debate.1
Future studies should address this question and ultimately
clarify the clinical relevance of our study ndings; further
evidence between microbiologic efcacy and clinical
effectiveness should be provided.

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customizing hand hygiene to the hand size

In conclusion, this study demonstrates that the volume of

ABHR applied on the hands of HCWs was associated with the
microbiologic efcacy of the hand hygiene procedure, and that
the HCW hand size signicantly affects that association. These
results suggest the need for customizing the volume of ABHR
used for hand hygiene actions according to the size of HCW
hands to ensure appropriate hand antisepsis and, possibly,
patient safety.

a ck n ow le d g m e n t s
We acknowledge all the HCWs who participated as volunteers in the present
study, and Ross Leach for his substantial editing contribution to the manuscript.
Financial support. Infection Control Programme, University of Geneva
Hospitals and Faculty of Medicine, Geneva, Switzerland.
Potential conicts of interest. All authors report no conicts of interest
relevant to this article.
Afliations: 1. Infection Control Programme and World Health Organization Collaborating Centre on Patient Safety (Infection Control & Improving
Practices), University of Geneva Hospitals and Faculty of Medicine, Geneva,
Switzerland; 2. Social Medicine Department, Ribeiro Preto Medical School,
University of So Paulo, Ribeiro Preto, So Paulo, Brazil.
Address correspondence to Didier Pittet, MD, MS, Infection Control
Programme and WHO Collaborating Centre on Patient Safety, University of
Geneva Hospitals, 4 Rue, Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland
(didier.pittet@hcuge.ch).
Presented in part: Third International Conference on Prevention and
Infection Control; Geneva, Switzerland; June 18, 2015 (Abstracts 302 and 303).
Received July 29, 2015; accepted September 14, 2015; electronically
published November 24, 2015
2015 by The Society for Healthcare Epidemiology of America. All rights
reserved. 0899-823X/2016/3702-0016. DOI: 10.1017/ice.2015.271

221

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