Hand hygiene in the new millennium: drawing the distinction between efficacy and effectiveness.

Recently, much attention has been focused on hand hygiene in health care with the publication of a new national guideline.1 In the guideline, washing hands with soap and water is replaced by rubbing hands with an alcohol hand rub as the primary means of hand hygiene to be used by healthcare personnel involved in routine patient care. The rationale behind this shift is the documented increased antimicrobial efficacy of alcohol hand rubs over washing hands with either plain soap and water or an antimicrobial soap. In addition, there is the potential for increased compliance with hand hygiene because hand rubbing requires less time, results in less skin irritation, and does not require proximity to a sink. The only caveat is that the hands must be free from visible soiling prior to the use of an alcohol hand rub.1 Two articles appearing in this issue of Infection Control and Hospital Epidemiology raise important issues pertaining to the position of alcohol hand rubs in the new guideline.2,3 The first of these, by Dharan et al., describes a comparison of the antimicrobial efficacies of several waterless hand hygiene products when used at short application times (15 seconds).2 These investigators compared one gel containing 60% ethanol with four alcohol-based rinses including a reference rinse containing 60% isopropyl alcohol in a crossover study of 12 volunteers in whom they tested the five hand rubs according to a modification of the European standard for establishing the efficacy of alcohol hand rubs (EN 1500). Each test involved determining the log reduction of introduced bacterial contamination on the fingertips of one hand cleaned with the test gel or rinse compared with the other hand cleaned with the reference rinse (60% isopropyl alcohol). The main results of this study were that all hand rinses satisfied the EN 1500 criteria for efficacy as defined by having log bacterial load reductions that were either statistically similar to or superior to the load reduction observed using the reference rinse (60% isopropyl alcohol).2 However, the reduction observed with the gel was consistently approximately 1 log less than that observed with the reference rinse and this difference was statistically significant (P < .025); thus, the gel failed to meet the European standard for efficacy when used for 30 or 15 seconds. In this regard, the findings of Dharan et al. confirm the results of the previous study by Kramer et al. in which none of ten different gel formations met the EN 1500 criteria using a 30-second cleansing period.4 Dharan et al. conclude that in testing performed “under stringent conditions similar to clinical practice,” rinses are more efficacious than alcoholbased gels.2 In the second of these, Mody et al. attempt to measure the impact of an alcohol-based hand rub (62% ethanol gel) on compliance with hand hygiene in a long-term–care facility.3 This was a four-phase interventional trial (ie, baseline, education, introduction of the alcohol rub, and longterm follow-up of the rub) conducted on two 36-bed wards of a long-term–care facility. On ward A, the rub was made available along with usual soap and water hand washing. On ward B, only soap and water hand washing was available. No important difference was found in any outcome measure between the two wards at baseline, and there were no differences between baseline measurements and measurements after the educational intervention in either of the two wards. Following the introduction of the alcohol rub, however, staff on ward A were more likely to agree that the rub was more convenient and faster than soap and water and were more likely to disagree that the alcohol rub was more drying than soap and water. Likewise, staff on ward A self-reported an increased frequency of hand hygiene following introduction of the rub when compared with baseline or with ward B. No differences were