Comparative Efficacy of Alternative Hand-Washing Agents in Reducing Nosocomial Infections in Intensive Care Units

Effective hand-washing can prevent nosocomial infections, particularly in high-risk areas of the hospital. There are few clinical studies of the efficacy of specific hand-cleansing agents in preventing the transmission of pathogens from health care workers to patients. For eight months, we conducted a prospective multiple-crossover trial involving 1894 adult patients in three intensive care units (ICUs). In a given month, the ICU used a hand-washing system involving either chlorhexidine, a broad-spectrum antimicrobial agent, or 60 percent isopropyl alcohol with the optional use of a nonmedicated soap; in alternate months the other system was used. Rates of nosocomial infection and hand-washing compliance were monitored prospectively. When chlorhexidine was used, there were 152 nosocomial infections, as compared with 202 when the combination of alcohol and soap was used (adjusted incidence-density ratio [IDR], 0.73; 95 percent confidence interval, 0.59 to 0.90). The largest reduction with chlorhexidine was in gastrointestinal infections (IDR, 0.19; 95 percent confidence interval, 0.05 to 0.64). When chlorhexidine was available, the rates of nosocomial infection declined in each of the ICUs, and health care workers washed their hands more often than when alcohol and soap were used (relative risk, 1.28; 95 percent confidence interval, 1.02 to 1.60). The total volume of alcohol and soap used was 46 percent that of chlorhexidine (P<0.001). A hand-disinfection system using an antimicrobial agent (chlorhexidine) reduces the rate of nosocomial infections more effectively than one using alcohol and soap. The improvement may be explained at least in part by better compliance with hand-washing instructions when chlorhexidine was used. (N Engl J Med 1992;327: 88–93.), NOSOCOMIAL infections represent major sources of morbidity and mortality for patients in the intensive care unit (ICU).^{1 2 3 4 5} Important risk factors for such infections include life-threatening medical or surgical conditions, the immunocompromised state, alterations in flora due to exposure to multiple antibiotics, and the disruption of skin and mucous membrane by the use of invasive devices.^{6 7 8 9} The organisms causing these infections include antibiotic-resistant gram-negative bacilli, staphylococci, enterococci, and candida species.¹⁰ Most endemic infections are transmitted by the hands of health care workers.¹¹ Similarly, outbreaks of infection due to the transmission of a specific pathogen from patient to patient or from a…