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We read with great interest the study by Traore and coauthors, comparing an alcohol hand gel with a liquid hand hygiene formulation in an intensive care unit . The authors reported better user acceptability for the gel. Compliance for both formulations was significantly better (P = 0.035) when healthcare workers had easy access to hand rubs, but the difference in compliance between the gel and the liquid was not statistically significant.
We are concerned that readers may conclude that gels are generally better than and preferable to liquids. The abstract points out that the gel performed significantly better on skin tolerance parameters. Easy access, however, was the only significant predictor for compliance. The article also mentions 'superior acceptance' of the gel, but acceptability scores of 39.1 and 40 (P = 0.44) were presented. Surprisingly, compliance was considerably lower compared with an earlier report from the same institution .
The two-phase study design may have biased the results, with the gel coming second and with improvements noted in the second phase. In any ongoing hand hygiene campaign, it is probable that compliance and acceptability will increase with time. Also, the second phase occurred during summer – a season less likely to cause dry, irritant skin.
Previous studies found that most liquid hand rubs present significantly better antimicrobial performance than gels , and the authors wisely chose a gel that meets the stringent EN 1500 standards. Many gels, however, do not meet these EN 1500 standards.
The authors are to be congratulated on publishing this study. We think that the data presented, however, do not allow such strong, general statements to be made in favour of gels. There may also be local preferences. For example, settings with long-standing usage of alcohol for hand hygiene (for example, many parts of Europe) almost exclusively use liquids, with no associated compliance and acceptability problems.
Liquids act more rapidly (~15 s) and leave less residual substance on hands. Gels require about 30 seconds to act, and time loss can reduce compliance . The technique of rubbing is also important; some hand surfaces are often missed. Only liquids have been evaluated for staff training requirements and for surface coverage . In conclusion, each institution should evaluate formulations based on local needs, taking antimicrobial activity into account. It may be useful to provide both gel and liquid, as the authors suggested.