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Hand Hygiene: Infection Control/Exposure Control Issues for Oral Healthcare Workers

Géza T. Terézhalmy, DDS, MA; Michaell A. Huber, DDS

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Hand antisepsis refers to either (1) antiseptic handwash or (2) antiseptic handrub performed by HCWs.  Antiseptic handwash is defined as washing hands with soap containing an antiseptic agent and water.  Antiseptic handrub is defined as applying an antiseptic handrub product or waterless antiseptic agent (i.e., an antiseptic agent that does not require use of exogenous water) to the hands.  In the United States, all such preparations approved for use in healthcare settings contain ethanol alone or in combination with isopropyl alcohol (i.e., alcohol-based hand rub).  Surgical hand antisepsis is defined as either (1) a surgical antiseptic handwash or (2) a two-stage surgical hand antisepsis performed preoperatively by surgical personnel (see Table 4).

Antiseptic agents are regulated by the FDA’s Division of Over-the-Counter (OTC) Drug Products.  Requirement for in vitro and in vivo testing and criteria for the classification of such products are outlined in the FDA Tentative Final Monograph for Healthcare Antiseptic Drug Products (TFM).27  The FDA TFM of 1994 classifies antiseptic agents as Category I, i.e., generally recognized as safe and effective and not misbranded; as Category II, i.e., not generally recognized as safe and effective or misbranded; or as Category III, available data are insufficient to classify as safe and effective, and further testing is required.  Based on available evidence, the FDA TFM 1994 concluded that only ethanol, 60 to 95%, and povidone iodine, 5 to 10%, formulations have meet the test and product labeling requirements as antiseptic agents for hand antisepsis and surgical hand antisepsis in healthcare settings (Table 2).27

Table 2. The FDA TFM 1994 classification of healthcare antiseptic active ingredients

Hand hygiene products used in healthcare settings should have a broad spectrum, be fast acting, have persistent activity, and reduce the number of microorganisms on intact skin to an initial baseline level (i.e., by 2-log10 or 99% on each hand within 5 minute after the first use of a product and by 3-log10 or 99.9% on each hand within 5 minutes after the tenth use) after adequate washing, rinsing and/or rubbing and drying (Table 3).1,27  Persistent activity is characterized by a prolonged or extended antimicrobial activity that prevents or inhibits the proliferation or survival of microorganisms after application of the product.  This property also has been referred to as “residual activity”.  Substantivity is an attribute of certain active ingredients in antiseptic products that adhere to the stratum corneum (i.e., remain on the skin after rinsing or drying) to provide an inhibitory effect on the growth of microorganisms remaining on the skin.  However, both substantive and nonsubstantive active ingredients can show a persistent effect if they substantially lower the number of bacteria following hand hygiene.

Table 3. The relative effectiveness of various antiseptic agents*
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