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Hand Hygiene with Soap and Water Is Superior to Alcohol Rub and Antiseptic Wipes for Removal of Clostridium difficile

  • Matthew T. Oughton (a1), Vivian G. Loo (a2) (a3), Nandini Dendukuri (a4) (a5), Susan Fenn (a5) and Michael D. Libman (a2) (a3)...

To evaluate common hand hygiene methods for efficacy in removing Clostridium difficik.


Randomized crossover comparison among 10 volunteers with hands experimentally contaminated by nontoxigenic C. difficile.


Interventions included warm water with plain soap, cold water with plain soap, warm water with antibacterial soap, antiseptic hand wipes, alcohol-based handrub, and a control involving no Intervention. All interventions were evaluated for mean reduction in colony-forming units (CFUs) under 2 contamination protocols: “whole hand” and “palmar surface.” Results were analyzed according to a Bayesian approach, by using hierarchical models adjusted for multiple observations.


Under the whole-hand protocol, the greatest adjusted mean reductions were achieved by warm water with plain soap (2.14 log10 CFU/mL [95% credible interval (Cri), 1.74-2.54 log10 CFU/mL]), cold water with plain soap (1.88 log10 CFU/mL [95% Cri, 1.48-2.28 log10 CFU/mL), and warm water with antibacterial soap (1.51 log10 CFU/mL [95% Cri, 1.12-1.91 logu, CFU/mL]), followed by antiseptic hand wipes (0.57 log10 CFU/mL [95% Cri, 0.17-0.96 log10 CFU/mL]). Alcohol-based handrub (0.06 log10 CFU/mL [95% CrI, -0.34 to 0.45 log10 CFU/mL]) was equivalent to no Intervention. Under the palmar surface protocol, warm water with plain soap, cold water with plain soap, and warm water with antibacterial soap again yielded the greatest mean reductions, followed by antiseptic hand wipes (26.6, 26.6, 26.6, and 21.9 CFUs per plate, respectively), when compared with alcohol-based handrub. Hypothenar (odds ratio, 10.98 [95% Cri, 1.96-37.65]) and thenar (odds ratio, 6.99 [95% Cri, 1.25-23.41]) surfaces were more likely than fingertips to remain heavily contaminated after handwashing.


Handwashing with soap and water showed the greatest efficacy in removing C. difficile and should be performed preferentially over the use of alcohol-based handrubs when contact with C. difficile is suspected or likely.

Corresponding author
Department of Medicine, McGill University, Division of Infectious Diseases and Department of Microbiology, Sir Mortimer B. Davis-Jewish General Hospital, Room G-143, 3755 chemin Côte-Ste-Catherine, Montreal, QC, CanadaH3T 1E2 (
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1. J Pépin , L Valiquette , B Cossette . Mortality attributable to nosocomial Clostridium difficile-associated disease during an epidemic caused by a hypervirulent strain in Quebec. CMAJ 2005;173:10371042.

2. VG Loo , L Poirier , MA Miller , et al.A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality (published correction appears in N Engl J Med 2006;354:2200). N Engl J Med 2005;353:24422449.

3. R Ricciardi , DA Rothenberger , RD Madoff , NN Baxter . Increasing prevalence and severity of Clostridium difficile colitis in hospitalized patients in the United States. Arch Surg 2007;142:624631.

4. LC McDonald , GE Killgore , A Thompson , et al.An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005;353:24332441.

5. S Dial , JAC Delaney , AN Barkun , S Suissa . Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 2005;294:29892995.

6. ER Dubberke , KA Reske , J Noble-Wang , et al.Prevalence of Clostridium difficile environmental contamination and strain variability in multiple health care facilities. Am J Infect Control 2007;35:315318.

7. KM Bettin , CR Clabots , PA Mathie , K Willard , DN Gerding . Effectiveness of liquid soap vs. Chlorhexidine gluconate for the removal of Clostridium difficile from bare hands and gloved hands. Infect Control Hosp Epidemiol 1994;15:697702.

8. DN Gerding , S Johnson , LR Peterson , ME Mulligan , J Silva Jr. Clostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol 1995;16:459477.

9. AB Zafar , LA Gaydos , WB Furlong , MH Nguyen , PA Mennonna . Effectiveness of infection control program in controlling nosocomial Clostridium difficile. Am J Infect Control 1998;26:588593.

10. M Day . Chief medical officer names hand hygiene and organ donation as public health priorities. BMJ 2007;335:113.

12. JM Boyce , D Pittet . Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002;23(12 Suppl):S3S40.

15. RLP Jump , MJ Pultz , CJ Donskey . Vegetative Clostridium difficile survives in room air on moist surfaces and in gastric contents with reduced acidity: a potential mechanism to explain the association between proton pump inhibitors and C. difficile-associated diarrhea? Antimicrob Agents Chemother 2007;51:28832887.

16. MM Riggs , AK Sethi , TF Zabarsky , EC Eckstein , RLP Jump , CJ Donskey . Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007;45:992998.

17. S King . Provision of alcohol hand rub at the hospital bedside: a case study. J Hosp Infect 2004;56(Suppl 2):1012.

18. G Gopal Rao , A Jeanes , M Osman , C Aylott , J Green . Marketing hand hygiene in hospitals: a case study. J Hosp Infect 2002;50:4247.

19. JM Boyce , C Ligi , C Kohan , D Dumigan , NL Havill . Lack of association between the increased incidence of Clostridium difficile-associated disease and the increasing use of alcohol-based hand rubs. Infect Control Hosp Epidemiol 2006;27:479483.

20. FM Gordin , ME Schultz , RA Huber , JA Gill . Reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based handrub. Infect Control Hosp Epidemiol 2005;26:650653.

21. AD Russell . Bacterial spores and chemical sporicidal agents. Clin Microbiol Rev 1990;3:99119.

22. ZA Quraishi , M McGuckin , F Blals . Duration of handwashing in intensive care units: a descriptive study. Am J Infect Control 1984;12:8387.

23. BCC Lam , J Lee , YL Lau . Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics 2004;114:e565e571. Available at: http://pediatrics.aap Accessed August 19, 2009.

24. S Lund , J Jackson , J Leggett , L Hales , R Dworkin , D Gilbert . Reality of glove use and handwashing in a community hospital. Am J Infect Control 1994;22:352357.

25. EL Larson , KJ McGinley , A Foglia , et al.Handwashing practices and resistance and density of bacterial hand flora on two pediatric units in Lima, Peru. Am J Infect Control 1992;20:6572.

26. B Michaels , V Gangar , A Schultz , et al.Water temperature as a factor in handwashing efficacy. Food Serv Technol 2002;2:139149.

27. D Pittet , P Mourouga , TV Perneger , Members of the Infection Control Program. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126130.

29. E Girou , S Loyeau , P Legrand , F Oppein , C Brun-Buisson . Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ 2002;325:362365.

30. EL Larson , J Cimiotti , J Haas , et al.Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units. Arch Pediatr Adolesc Med 2005;159:377383.

31. S Hugonnet , TV Perneger , D Pittet . Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Arch Intern Med 2002;162:10371043.

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