Antiseptic Stewardship for Alcohol-Based Hand Rubs

Alcohol-based hand rubs are usually based on ethanol, propan-2-ol or propan-1-ol. Some contain additional non-volatile biocidal active substances such as chlorhexidine digluconate, triclosan, benzalkonium chloride, hydrogen peroxide, DDAC, polihexanide, peracetic acid or octenidine dihydrochloride. For the additional biocidal active substances, almost all studies show a lack of efficacy on the skin and a lack of any health benefit (prevention of infection). The focus is therefore on the risks of these substances. Benzalkonium chloride, triclosan, chlorhexidine digluconate and DDAC can cause a strong and stable MIC increase in a wide range of mainly Gram-negative bacterial species. Cross-tolerance between benzalkonium chloride, triclosan and chlorhexidine digluconate is common. Horizontal gene transfer can be successfully induced by ethanol, chlorhexidine digluconate, polihexanide and triclosan in E. coli. The expression of antibiotic resistance gene can be increased by chlorhexidine digluconate in a vanA E. faecium. And efflux pump genes can be upregulated by benzalkonium chloride, chlorhexidine digluconate, triclosan, octenidine dihydrochloride and ethanol in some species. The overall balance is that there is evidence of a number of relevant risks, some of them potentially serious for the development of antibiotic resistance, but no convincing evidence of a health benefit. Alcohol-based hand rubs with additional biocidal active substances should therefore be replaced by formulations based on ethanol, propan-2-ol or propan-1-ol alone as active agents.