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Methods to evaluate the microbicidal activities of hand-rub and hand-wash

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Article  in  The Journal of hospital infection · October 2009

DOI: 10.1016/j.jhin.2009.06.024 · Source: PubMed

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 ARTICLE IN PRESS
Journal of Hospital Infection (2009) -, 1e9
Available online at www.sciencedirect.com

www.elsevierhealth.com/journals/jhin

REVIEW

Methods to evaluate the microbicidal activities of

hand-rub and hand-wash agents
M. Rotter a, S. Sattar b, S. Dharan c, B. Allegranzi d, E. Mathai d, D. Pittet c,d,*
a
Institute of Hygiene and Medical Microbiology, Medical University of Vienna, Vienna, Austria
b
Centre for Research on Environmental Microbiology, University of Ottawa, Ottawa, Canada
c
Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
d
World Alliance for Patient Safety First Global Patient Safety Challenge, World Health Organization,
Geneva, Switzerland

KEYWORDS Summary In vitro carrier tests, suspension tests, timeekill curves, and
Alcohol-based hand determinations of minimum inhibitory concentrations to evaluate the
rub; microbicidal activities of hand antiseptics provide only a preliminary indi-
Antimicrobial activity;
cation of the antimicrobial spectrum and speed of action of a given formu-
Hand hygiene;
Microbial testing;
lation. Ex vivo testing with human or animal skin at human skin
Soap; temperature and at contact times reflecting field conditions may give a bet-
Standards ter indication of a formulation’s ability to tackle hand-transmitted patho-
gens. Field testing of hands for levels of skin microbiota before and after
antisepsis may be easier to perform, but it is subject to many uncontrolla-
ble factors. Whereas randomised clinical trials may be the ultimate ap-
proach to assess the effectiveness of hand hygiene protocols and
products in preventing microbial cross-transmission and, ultimately, infec-
tions, they can be prohibitively expensive, time-consuming, difficult to de-
sign, and therefore impractical. Hence, the primary emphasis should be on
in vivo testing on human hands, using a well-designed protocol that closely
simulates the recommended field use of the formulation, and possibly fol-
lowed by clinical studies. The use of these method is the most likely to
yield useful data on the potential of a formulation to interrupt the spread
of pathogens transmitted by hands in healthcare settings. This review pro-
vides a critical assessment of the methods currently used to meet regula-
tory requirements for hand antiseptics in Europe and North America.
ª 2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.

* Corresponding author. Address: Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, 4 Rue
Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland. Tel.: þ41 22 372 9828; fax: þ41 22 372 3987.
E-mail address: didier.pittet@hcuge.ch

0195-6701/$ - see front matter ª 2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2009.06.024

Please cite this article in press as: Rotter M et al., Methods to evaluate the microbicidal activities of hand-rub and hand-wash
agents, J Hosp Infect (2009), doi:10.1016/j.jhin.2009.06.024
 ARTICLE IN PRESS
2 M. Rotter et al.
Introduction
Many infectious agents can be carried by contam-
inated hands and appropriate hand hygiene can
reduce the risk of hand-borne infections.1,2 How-
ever, wide variations exist in the products and
practices commonly used for hand hygiene and
these can influence the efficacy of hand antisepsis
in healthcare settings. Evidence-based, published
guidelines are available on hand antisepsis and
many regulatory agencies require hand-wash
(except for non-medicated soaps) and hand-rub
agents to meet certain performance standards
when assessed using standardised test protocols.3,4
Methods for testing the antimicrobial
activity of hand antiseptics
Several methods are available to test the anti-
microbial activity of hand antiseptics, and these
can be broadly classified into in vitro, ex vivo, and
in vivo tests.
None of the following in vitro tests has a direct
bearing on the ‘killing effect’ expected of a product
under in vivo conditions. In addition, tests designed
to determine the minimum inhibitory concentration
(MIC) of chemicals against a wide range of test
organisms cannot separate microbiostatic from
microbicidal activity, only the latter being of some
relevance to hand hygiene. Although minimum
‘microbicidal’ concentrations can be determined,
they are of limited value in determining the contact
time needed to achieve the level of microbial kill
desired. Timeekill curves can be established using
suspension tests such as those described in the
European norm (EN) 13724 or EN 13727. However,
the test conditions in such protocols simply do not
reflect conditions on human skin.5e7
Ex vivo tests with human or animal skin can more
closely simulate the substrates in the field, as long as
the testing is conducted at human skin temperature
and with contact times reflective of field use.8,9
In vivo tests include: the strictly controlled
experimental laboratory test models simulating
practical conditions on the hands of subjects; and
the less-controlled field tests in which the hands of
healthcare workers (HCWs) are assessed in a clinical
setting for either the total microbial release from
their hands, or for enumerating the frequency and
quantity of certain indicator species. These tests
are difficult to control for extraneous influences and
their findings provide only scant data on a given
formulation’s ability to cause a measurable reduc-
tion in hand-transmitted infections.
Please cite this article in press as: Rotter M et al., Methods to evaluate the microbicidal activities of hand-rub and hand-wash
agents, J Hosp Infect (2009), doi:10.1016/j.jhin.2009.06.024
Clinical trials assessing the effectiveness of hand
hygiene measures in preventing the spread of hand-
transmitted pathogens may be the most valuable.
However, these trials are cumbersome, expensive,
and possibly site-specific. To demonstrate a reduc-
tion in hand-transmitted infections from 2% to 1%
by changing to a presumably better hand anti-
septic agent, power analysis estimates would
require almost 2500 subjects in each of two
experimental arms at the statistical pre-setting
of a (unidirectional) ¼ 0.05 and a power of
1  b ¼ 0.9.1 For this reason the number of such
trials remains limited.10e12 Hence, well-controlled
and economically justifiable in vivo laboratory-
based tests remain the most used to provide suffi-
cient data to infer the potential benefits of a given
formulation in the clinical setting.
In vivo laboratory-based tests
In Europe, the most commonly used, laboratory-
based, in vivo methods to test hand antiseptics are
those of the European Committee for Standardiza-
tion (Comité Européen de Normalisation, CEN). Test
methods in current use in Germany and Austria are
those devised by the relevant national scientific
societies and predate the CEN methods.13,14 In the
USA and Canada, such formulations are regulated
by the Food and Drug Administration (FDA) and
Health Canada, respectively, which refer to the
standards of ASTM International.15
These tests belong to two major categories. The
first is designed to evaluate the ability of hand-wash
or hand-rub agents to eliminate transient pathogens
from HCWs’ hands. These procedures, based on the
‘post-contamination treatment’ of hands, involve
the placement of the test organism(s) on the hands
of test subjects followed by exposure to the test
formulation. These methods are useful in testing
the performance of products used in routine hand
hygiene. The second relates specifically to pre-
surgical scrubs and the objective is to evaluate the
test formulation’s ability to reduce the numbers of
resident microbiota on hands. The experimental
designs of these methods are summarised below and
the procedures are detailed in Table I.4
Tests for hygienic hand-wash and hand-rub
agents
These methods use experimental contamination to
test the ability of a formulation to reduce the level
of transient microbiota on hands without regard to
resident micro-organisms (Table I). The CEN and
ASTM requirements for these tests are as follows.
 Microbicidal activity of hand antiseptics
Basic experimental design of current methods to test the efficacy of formulations for hygienic hand antisepsis4
agents, J Hosp Infect (2009), doi:10.1016/j.jhin.2009.06.024
Please cite this article in press as: Rotter M et al., Methods to evaluate the microbicidal activities of hand-rub and hand-wash

Table I
Method Test organism/s Basic procedure
EN 1499 Escherichia coli (K12) Hands are washed with a soft soap, dried, and immersed in broth culture for 5 s; excess fluid is drained
(hygienic handwash) off and hands are air-dried for 3 min. Bacteria are recovered for the initial values by kneading the fingertips
of each hand separately for 60 s in 10 mL of broth without neutralisers. Hands of one half of the volunteers
are treated with the product following the manufacturer’s instructions (but for no longer than 1 min);
the hands of the other half are washed with the reference solution (a 20% solution of soft soap). Recovery
of bacteria for final values (see EN 1500). Within 3 h, the test is repeated with the same subjects acting
with reversed roles (cross-over design).
EN 1500 Escherichia coli (K12) Basic procedure for hand contamination is the same as in EN 1499. For reference hand antisepsis
(hygienic hand rub) (disinfectiona), half of the subjects rub hands for 30 s with 3 mL of isopropanol 60% (volume); the same
operation is repeated with a total antiseptic application (disinfectiona) time not exceeding 60 s. For product
evaluation, the other half of the subjects use the product according to the manufacturer’s instructions
(maximum time allowed: 1 min). Fingertips of both hands are rinsed in water for 5 s and excess water

ARTICLE IN PRESS
drained off. Fingertips of each hand are kneaded separately in 10 mL of broth with added neutralisers.
These broths are used to obtain the final (post-treatment) values. Within 3 h, the same volunteers repeat
the test, but with reversed roles (cross-over design). Log10 dilutions of recovery medium containing
neutraliser are prepared and plated out. Colony counts are obtained and log reductions calculated.
ASTM E-1174 Serratia marcescens; To test the effectiveness of hand-wash or hand-rub agents for the reduction of transient microbial flora.
(hygienic hand Escherichia coli Before baseline bacterial sampling and prior to each wash with the test material, 5 mL of a suspension of the
wash or hand rub) test organism is applied to and rubbed over hands. Test material is spread over hands and the lower third of
forearms with lathering. Hands and forearms are rinsed with water. Elution is performed after the required
number of washes using 75 mL of eluent for each gloved hand. Eluates are cultured for viable bacteria.
ASTM E-1838 Adenovirus, rotavirus, 10 mL of the test virus suspension in soil load is placed at the centre of each thumb and fingerpad, the inoculum is left
(fingerpad method rhinovirus, to dry and exposed for 10e30 s to 1 mL of the test formulation or control. The fingerpads are then eluted and
for viruses) and hepatitis A virus eluates are assayed for viable virus. Controls included an assessment of input titre, loss on drying of inoculum,
and mechanical removal of virus. The method is applicable for the testing of both hand-wash and hand-rub agents.
ASTM E-2276 E. coli, Serratia Similar to ASTM E-1838
(fingerpad method marcescens,
for bacteria) Staphylococcus
aureus, and
Staphylococcus
epidermidis
ASTM E-2613 (fingerpad Candida albicans, Similar to ASTM E-1838
method for fungi) Aspergillus niger
ASTM E-2011 (whole-hand Rotavirus, rhinovirus This method is designed to confirm the findings of the fingerpad method (E-1838) if necessary. Both
method for viruses) hands are contaminated with the test virus and the test formulation is used to wash or rub them. The
entire surface of both hands is eluted and the eluates are assayed for infectious virus.
a
Term used in the original description of the European Norm (EN) method.
Reproduced with permission from the WHO Guidelines on Hand Hygiene in Health Care, 2009. ª World Health Organization, 2009.

3
 ARTICLE IN PRESS
4 M. Rotter et al.
CEN standards
The EN 1499 standard is used to test antiseptic
soaps and requires 12e15 subjects.16 The EN 1500 is
used to test antiseptic hand rubs and, in the forth-
coming amendment, requires 18e22 subjects.17 Ex-
perimental contamination is with a non-pathogenic
strain of Escherichia coli K12. Subjects are allotted
randomly to two groups of approximately the same
size, where one group applies the test formulation
according to the manufacturer’s instructions (max-
imum time allowed is 1 min), and the other a refer-
ence antiseptic solution using a standardised
procedure for a total of 60 s (i.e. 2  30 s). In
a consecutive run, the two groups reverse roles
(cross-over design). According to the EN 1499, the
mean reduction caused by the test product in the
numbers of viable bacteria shall be significantly
higher than that obtained with the reference soft
soap.16 To meet the EN 1500 requirement, the
mean reduction in the numbers of viable bacteria
shall not be significantly inferior to that with the
reference alcohol-based hand rub (isopropanol
60% by volume).17
ASTM standards
e ASTM E-1174.18 The efficacy criteria fixed in
the FDA’s Tentative Final Monograph (TFM)
are a 102 reduction of the test strain on each
hand within 5 min after the first use, and
a 103 reduction on each hand within 5 min after
the tenth use.16
e ASTM E-1838 (fingerpad method for viruses).19
This method can be used with equal ease to
test both hand-wash and hand-rub formula-
tions.20e23 When testing hand-wash agents, it
can measure reductions in the levels of viable
virus after exposure to the test formulation
alone, after post-treatment water rinsing,
and post-rinse drying of hands.24 It can also
be applied to more recently discovered viruses
such as caliciviruses.25,26 The risk to subjects is
lower because contamination is limited to
smaller, well-defined areas on the skin as com-
pared with contaminating whole hands.
e ASTM E-2276 (fingerpad method for bacteria).27
This is similar in design and application to the
E-1838 method.18
e ASTM E-2613 (fingerpad method for fungi).28,29
This method is similar in design and application
to E-1838 and E-2276.20,27
e ASTM E-2011 (whole-hand method for vi-
ruses).30,31 In this method, the entire surface
of both hands is contaminated with the test vi-
rus and the hand-wash or hand-rub formulation
being tested is rubbed on them. The surface of
Please cite this article in press as: Rotter M et al., Methods to evaluate the microbicidal activities of hand-rub and hand-wash
agents, J Hosp Infect (2009), doi:10.1016/j.jhin.2009.06.024
both hands is eluted and the eluates are assayed
for viable virus.
Tests for pre-surgical hand preparation
products
Pre-surgical hand preparations are expected to
work against the more difficult-to-remove resident
microbiota. No experimental contamination is
needed to test these.
CEN standard EN 12791 (surgical hand
preparation)32
This standard is comparable to EN 1500, except that
the bactericidal effect of a product is tested: (i) on
clean, but not experimentally contaminated hands;
(ii) with 18e22 subjects; (iii) using the split-hands
model by Michaud et al. to assess the immediate ef-
fect on one hand and a 3 h effect on the other,
meanwhile gloved to detect a potential sustained
activity33; (iv) by a cross-over design where the
two experimental runs necessary for comparison
of the bacterial reduction are spaced by one week
to enable regrowth of the resident flora rather
than following immediately after each other; (v)
where the reference antisepsis procedure is by
n-propanol 60% (by volume) used in as many 3 mL
portions as are necessary to keep hands wet for
3 min; thus, the total volume used varies with the
size and temperature of hands, and other factors;
(vi) where the test product is used according to
the manufacturer’s instructions, although not
exceeding 5 min. The requirements are that the im-
mediate and 3 h effects shall not be inferior to
those of the reference hand antisepsis; if there is
a claim for sustained activity, the product must
demonstrate a significantly lower release of skin
bacteria than the reference at 3 h.
ASTM standard ASTM E-1115 (surgical hand
scrub)34
This test is also designed to measure the reduction
in resident microbiota on hands. It is intended to
determine immediate and persistent effects, after
single or repetitive treatments, or both. It may
also serve to measure cumulative activity after
repetitive treatments. The TFM requires that
products: (i) reduce the number of bacteria by
101 on each hand within 1 min of product use, and
that the bacterial count on each hand shall not
subsequently exceed baseline within 6 h on
day 1; (ii) produce a 102 reduction in bacterial
counts on each hand within 1 min by the end of
day 2; (iii) accomplish a 103 reduction on each
hand within 1 min by the end of day 5 when
compared with the established baseline.15
 ARTICLE IN PRESS
Microbicidal activity of hand antiseptics
In vivo field tests
In contrast to elaborate laboratory-based test
methods, simple in-use tests can be employed in
the clinical setting to document microbial coloni-
sation. A classical method is the fingerprint im-
pression method where imprints of fingertips and
thumb are made on a nutrient agar plate, prefer-
ably containing neutralisers for the non-alcohol-
based antiseptic agents in use for routine hand
hygiene, by applying gentle pressure with the
fingers and thumb on the agar surface.31
Discussion
Since optimal hand hygiene by HCWs is considered
as the most effective means for preventing health-
care-associated infection, the products used to
reduce microbial release from the hands are
important instruments to reduce such infections.
Although the efficacy of these products can be
assessed using several methods, direct comparison
of results from different test populations and
between different laboratories is virtually impos-
sible. One reason is that in vivo laboratory-based
tests have differences in test protocols. A basic
fallacy of the in vivo test methods listed in the TFM
is that the performance criteria for the required
microbial reduction are fixed values, for instance
102. As an antiseptic agent can display a signifi-
cantly different action on different subjects’
hands, the mean outcome of an in vivo test with
a certain antiseptic depends on the composition
of the test population.35 One solution to this prob-
lem is to use a cross-over design and to test both
the test and the reference antiseptic on the
same subjects concurrently as required by EN
1499, EN 1500, and EN 12791. With this approach
every subject acts as his or her own control.
There is controversy over the usefulness of
results from in vitro and in vivo tests with formu-
lations for hand hygiene products containing non-
volatile agents such as quaternary ammonium
compounds, triclosan or chlorhexidine. These
agents attach to surfaces such as the skin or the
microbial cell wall and, under long-term use, could
lead to a sustained (long-lasting), cumulative ef-
fect. Hence, the duration of their activity is not
that scheduled by the test protocol, but much
longer, unless neutralised by appropriate chem-
icals. If such neutralisation is not properly incor-
porated and validated in the test protocol, the
prolonged activity will persist in the sampling
fluids, in their dilutions, and on the counting plates,
thus preventing the growth of microbial cells that
Please cite this article in press as: Rotter M et al., Methods to evaluate the microbicidal activities of hand-rub and hand-wash
agents, J Hosp Infect (2009), doi:10.1016/j.jhin.2009.06.024
5
are still viable. This can overestimate the activity
of the test formulation. For instance, many favour-
able reports on chlorhexidine-containing formula-
tions could be erroneous because neutralisation has
not been appropriately performed.36,37 Therefore,
in testing hand antiseptics, routine screening for
active ingredients with sustained effect and, if
positive, the choice of a suitable neutraliser, as
well as the validation of its proper function, are
of paramount importance to obtain meaningful
results.38
Hygienic hand-wash and hand-rub agents
The strongest evidence for a causal link between
a specific measure of, or a certain product for, hand
hygiene and the frequency of hand-transmitted
infections could probably be obtained by random-
ised clinical trials. As mentioned previously, these
are hardly affordable, difficult to control, and the
results may not be comparable between different
studies considering the large number of additional
factors that could potentially influence the results.1
Furthermore, extraneous factors such as HCWs’
compliance with hand hygiene and the degree of
staff cohorting will play an important role in the
final outcome of such a trial.39
Performance can be much more economically
assessed by using laboratory-based in vivo tests
than by clinical trials. Obviously, laboratory pro-
tocols for in vivo evaluations must be standardised
to allow for comparisons. However, standardised,
different protocols, as well as different perfor-
mance criteria, will still produce different results
and may lead to different and sometimes even
contradictory conclusions. Unfortunately, this is
the case with the existing standardised methods of
EN 1500 and those in the TFM for alcohol-based
hand rubs, where test protocol and requirements
are not the same.16,17,40 For example, in a study by
Kramer et al., various alcohol-based hand-rub gels
accepted by TFM failed the EN 1500.41 Thus, a for-
mulation may pass one criterion, but may not meet
another and vice versa. At the present time, it re-
mains unknown as to which pass criterion is the
right one or what decrease in microbial release is
needed to produce a meaningful reduction in the
hand-borne spread of healthcare-associated
pathogens.40,42
For some protocols, such as the extensive eval-
uations specified in the TFM, costs can be
prohibitive even for large commercial companies.15
These protocols include in vitro MIC measurements
with many clinical and culture collection strains,
timeekill curves, tests to evaluate the potential
to develop antimicrobial resistance, and in vivo
 ARTICLE IN PRESS
6 M. Rotter et al.
tests with at least 2  54 subjects in each arm. The
expenditure is less if the same subjects are used to
test both formulations in a cross-over manner. The
reduction in microbial counts could then be intra-
individually compared, thus allowing a considerable
reduction in sample size while at the same time re-
taining statistical power.
Another shortcoming of existing methods is that
subjects are required to apply a hand hygiene
product for 30 or 60 s, despite the fact that the
average duration of hand hygiene by HCWs has
been observed to be less than 15 s in most
studies.15e17,43e49 Almost no data exist on the
efficacy of antimicrobial soaps or hand rubs under
conditions in which they are actually used,
although some investigators have produced data
with a 15 s social hand-wash or hygienic hand-
wash protocol.50e54 Of note, the reference hand
rub in EN 1500 requires a consecutive two-fold
application of 3 mL alcohol for 30 s, representing
a total of 60 s.16 The reason is that the inferiority
of a product when compared with the reference
is easier to demonstrate with longer exposure
times if the sample size is to be economically
justifiable.
The requirement by the TFM to reduce the
release of transient flora by only 102 within a maxi-
mum time span of 5 min seems to be an unrealisti-
cally low requirement in terms of the needs of
working in a healthcare setting, as even with non-
medicated soap and water a log10 reduction factor
of 3 is achievable within 1 min.15,55e57 Further-
more, the requirement for the residual action of
a hand hygiene product in the non-surgical area
has been challenged.55e57 We believe that a fast
and immediate effect against a broad spectrum of
transient flora is required to render hands safe,
not only in a very short time, but also after the first
application of the formulation. A stronger activity
after the tenth treatment than after the first seems
to be difficult to substantiate as a requirement. The
in vivo field tests, which are easier to perform than
in-use tests, are difficult to control for extraneous
influences, and the fingertip agar imprint technique
provides less accurate bacterial counts than the
rinsing techniques.
Surgical hand preparation
As with hygienic hand antisepsis, a major draw-
back of testing surgical scrubs is the financial cost
associated with the use of the TFM model.15 In ad-
dition to the required in vitro pre-tests, 130 sub-
jects are required for the laboratory in vivo
tests, together with an active control in the sug-
gested parallel arm design. For some products,
Please cite this article in press as: Rotter M et al., Methods to evaluate the microbicidal activities of hand-rub and hand-wash
agents, J Hosp Infect (2009), doi:10.1016/j.jhin.2009.06.024
this number will even have to be multiplied for
concomitant testing of the vehicle and, possibly,
of a placebo to demonstrate efficacy.15
In contrast to the requirement of EN 12791,
where a sustained (or persistent) effect of the
surgical scrub is optional, the TFM model requires
a product to possess this feature. However, this
requirement may be unnecessary as short-chain
aliphatic alcohols, such as ethanol, isopropanol,
and n-propanol, appear fully capable of keeping
the bacterial release on gloved hands signifi-
cantly under the level established at baseline
for more than 6 h.56 Thus, with their strong anti-
bacterial efficacy, the necessity of a sustained
effect is questionable. With respect to the rapid
antibacterial action of suitable alcohols at high
concentrations and with appropriate neutral-
isers, the contribution of supplements to the de-
lay of bacterial regrowth on gloved hands
appears rather minor if a product only exerts an
immediate effect not inferior to that of the ref-
erence antiseptic procedure of EN 12791.58 Fur-
thermore, concerning the recommendation in
the TFM model for a long-term effect (several
days), it is difficult to understand why the effi-
cacy of a scrub is required to increase from the
first to the fifth day of permanent use. Ethical
considerations would suggest that the first pa-
tient on a Monday, when the required immediate
reduction from baseline is only 101, should be
treated according to the same safety precautions
as patients operated on the following Friday
when, according to TFM, the log10 reduction has
to be 3.
A criticism in the CDC/HICPAC guideline for
hand hygiene in healthcare settings is that it is
considered a mistake that both laboratory in vivo
test models, EN 12791 and the TFM model, in-
dicate non-HCWs as surrogates for HCWs as their
hand flora may not be similar.3 However, this argu-
ment is only valid for testing surgical scrubs, be-
cause protocols for evaluating products for
routine hand hygiene include experimental hand
contamination. Furthermore, the antimicrobial
spectrum of a formulation could be determined
from the results of the preceding obligatory
in vitro tests.
Conclusions
It appears necessary that the existing test pro-
tocols be amended to obtain more realistic re-
sults.23 The amendments recommended by the
World Health Organization core group of experts
are summarised in Table II.4 To generate more
 ARTICLE IN PRESS
Microbicidal activity of hand antiseptics 7

Table II Amendments recommended by the World Health Organization Guidelines on hand hygiene in health care
on protocols and requirements for the testing of hand hygiene formulations
e Protocols should be adapted to obtain comparable results on efficacy.

e Protocols should be updated so that they are economically justifiable.

e In vivo test conditions should be modified in areas such as duration of application, the choice of test organism,
or the use of subjects to reflect realities.

e Requirements for efficacy should be formulated to meet objectively identified needs.

e In vivo studies in the laboratory on pre-surgical hand preparation should be designed as clinical studies, i.e.
to determine non-inferiority to an agreed reference antiseptic procedure rather than using comparative
designs.

e Any surrogate organisms used in in vivo tests must represent pathogens known for their potential to survive on
and be spread by contaminated hands.

e Protocols for controlled field trials should help to ensure that hand hygiene products are evaluated under
more realistic conditions.

direct proof of clinical effectiveness in reducing
the spread of healthcare-associated infections,
well-controlled clinical studies are urgently
needed.
Acknowledgements
We thank all members of the Infection Control
Programme, University of Geneva Hospitals, and
Rosemary Sudan for expert editorial assistance, and
members of the WHO First Global Patient Safety
Challenge ‘Clean Care is Safer Care’ core group
(lead, D. Pittet): B. Cookson, N. Damani, D. Gold-
mann, L. Grayson, E. Larson, G. Mehta, Z. Memish,
H. Richet, H. Sax, W.H. Seto, A. Voss, and A.
Widmer. WHO takes no responsibility for the in-
formation provided or the views expressed in this
paper.
Conflict of interest statement
None declared.
Funding sources
None.
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