Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile

Infect Control Hosp Epidemiol. 2009 Oct;30(10):939-44. doi: 10.1086/605322.


Objective: To evaluate common hand hygiene methods for efficacy in removing Clostridium difficile.

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

Methods: 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.

Results: Under the whole-hand protocol, the greatest adjusted mean reductions were achieved by warm water with plain soap (2.14 log(10) CFU/mL [95% credible interval (CrI), 1.74-2.54 log(10) CFU/mL]), cold water with plain soap (1.88 log(10) CFU/mL [95% CrI, 1.48-2.28 log(10) CFU/mL), and warm water with antibacterial soap (1.51 log(10) CFU/mL [95% CrI, 1.12-1.91 log(10) CFU/mL]), followed by antiseptic hand wipes (0.57 log(10) CFU/mL [95% CrI, 0.17-0.96 log(10) CFU/mL]). Alcohol-based handrub (0.06 log(10) CFU/mL [95% CrI, -0.34 to 0.45 log(10) 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.

Conclusions: 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.

Publication types

  • Evaluation Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Alcohols / pharmacology*
  • Anti-Infective Agents, Local / pharmacology*
  • Clostridioides difficile / drug effects*
  • Clostridioides difficile / isolation & purification
  • Colony Count, Microbial
  • Disinfectants / pharmacology
  • Disinfection / methods
  • Ethanol
  • Hand / microbiology*
  • Hand Disinfection / methods*
  • Humans
  • Hygiene
  • Soaps / pharmacology*
  • Water / pharmacology*


  • Alcohols
  • Anti-Infective Agents, Local
  • Disinfectants
  • Soaps
  • Water
  • Ethanol