Antiseptic Stewardship for Alcohol-Based Hand Rubs
Alcohol-based hand rubs are usually based on ethanol, propan-2-ol or propan-1-ol. Some of them contain additional non-volatile biocidal agents such as chlorhexidine digluconate, triclosan, benzalkonium chloride, hydrogen peroxide, DDAC, polihexanide, peracetic acid or octenidine dihydrochloride. For the additional biocidal agents, almost all studies indicate a lack of efficacy on the skin and a lack of any health benefit (prevention of infection). Therefore, the risks of these biocidal agents come into the focus. Benzalkonium chloride, triclosan, chlorhexidine digluconate and DDAC can cause a strong and stable MIC increase in numerous mainly Gram-negative bacterial species. Cross-tolerance is frequently found between benzalkonium chloride, triclosan and chlorhexidine digluconate. They can also enhance antibiotic resistance development. Horizontal gene transfer can be successfully induced by chlorhexidine digluconate and triclosan in E. coli. Antibiotic resistance gene expression can be increased by chlorhexidine digluconate in a vanA E. faecium. And efflux pump genes can be up-regulated in some species by benzalkonium chloride and chlorhexidine digluconate. The overall balance provides evidence for a number of relevant risks for additional biocidal agents but no convincing evidence for a health benefit. Alcohol-based hand rubs with additional biocidal agents should therefore be replaced by formulations based on alcohol(s) alone as active agent(s).
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