Antiseptic handwashes are alcohol-based liquids, gels, and foams that destroy infectious organisms on our hands. Alcohols have been used as effective disinfectants against microbes since as early as the 1820s. Alcohols can easily penetrate the cell membranes of organisms, denature multiple vital proteins required for a microbe’s survival, and disrupt its cell membrane.
Hand Sanitizer
The 2019 Coronavirus pandemic saw a boom in antiseptic handwash use, with multiple companies worldwide churning out antiseptic gels like never before, some not even containing the necessary effective alcohol concentration required to disinfect. Does this leave us at risk for developing a superbug?
A superbug is a microbiological organism that may be a bacterium, virus, parasite, or fungus resistant to multiple antimicrobial drugs that are used to treat infections caused by them. Antimicrobial resistance of microbes due to misuse and overuse of antibiotics has been a topic of concern worldwide for the effective treatment against these organisms developing resistance.
Will similar overuse of antiseptics lead to the formation of a multi-drug-resistant Superbug?
There are varying views regarding this question. Andrew Kemp, head of the Scientific Advisory Board at the British Institute of Cleaning Science, believes the use of alcohol-based hand sanitizers could lead organisms to learn coping skills against it, generating resistance to it and threatening the health of the public worldwide.
He believes there should be more emphasis on washing hands with soap and water than on using hand sanitizers to prevent generating resistance to it, and it should be used as a last resort in the absence of soap and water.
His statements seem justified, as though hand washing with soap and water and rubbing hand sanitizer might seem like serving the same purpose, but their use is situation-specific. No sanitizer beats thorough hand-washing with soap and water. Sanitizers certainly help when you are out and don’t have access to soap and water, thus showing a more temporary approach to maintaining hand hygiene.
Studies have been conducted regarding the generation of antimicrobial resistance, and the results have shown that alcohol-based sanitizer overuse can lead to resistance being developed. This would put an immense burden on health care providers who are already struggling due to antibiotic resistance.
All is not gloomy, though; the studies conducted so far showing the development of resistance to overuse of antiseptics have been done, taking into account the small sample size, and experts in the field advocate continuing the use of hand sanitizers. Hand sanitizers have proven to be effective as a first-line mechanism against infection spread in a hospital setting, particularly against MRSA and against other hospital-acquired infections.
Some believe the use of hand sanitizers is not a concern for the development of antimicrobial resistance, as they function and destroy germs differently compared to antibiotics. Rather, it is the misuse of antibiotics that is the problem; most people stop taking medications at the slightest improvement in symptoms. The improper concentration of antibiotics in the body helps these organisms grow resistant. Thus, the proper use of antibiotics as instructed by your care provider is paramount to halting resistance development.
Some experts believe it’s not the alcohol hand sanitizer causing resistance and superbug formation; instead, it is the below-average alcohol concentration and faulty hand sanitizer composition that may lead to resistance generation. For effective antisepsis with alcohol-based hand sanitizers, the FDA recommends a concentration of 60% to 95% alcohol. Sub-standard hand sanitizers containing less than the approved concentrations of alcohol can be a potential cause of the formation of a superbug resistant to multiple antimicrobials. A 2018 research published by “Science Translational Medicine” showed the ability of microbes to survive in low concentrations of alcohol, but at a concentration of 70% alcohol, the bacteria were killed, which may indicate the necessity of the use of proper hand sanitizers with appropriate alcohol concentration.
The study found that half of these resistant strains were resistant to Vancomycin as well as a last-line antibiotic, raising questions regarding antiseptic-induced antimicrobial resistance. Resistance to low concentrations/wrong hand sanitizers was seen as a possibility in that study, necessitating that proper hand hygiene protocol be followed. Proper handwashing with soap and water is needed whenever possible, and you should not be fully confident just because you have used a hand sanitizer.
In the current setting, amidst a rampant pandemic, maintaining proper hand hygiene is very important in shielding yourself against COVID-19 and many other infectious diseases. Using hand sanitizer with adequate concentration and adequate soap and water handwashing may be the best way to prevent generating antimicrobial resistance and superbug formation.
What can be done to prevent antimicrobial resistance?
- Only use hand sanitizers with an alcohol concentration above 60%
- Adhere to your doctor’s prescription of antibiotics properly.
- There is no substitute for proper soap and water hand washing. Build a habit of washing hands multiple times a day.
Further study in this field is required in a large sample size of hospitals worldwide to see if organisms are developing a tolerance to alcohol and the concentration of alcohol.
However, it cannot be discounted that too much exposure to a similar substance will eventually create resistance due to adaptive mutations, so other forms of disinfectants should also be tried. In case alcohol resistance does develop, other disinfectants can provide a whole new alternative. Disinfectants composed of both Alcohol-Chlorhexidine combined can be used to prevent the spread of microbes tolerant to alcohol only.
Conclusion
It is not fully clear whether excessive use of hand sanitizer can lead to resistance formation against antimicrobials. Maintaining hand hygiene was and is the best preventive measure against the spread of infectious disease during a pandemic. The proper use of hand sanitizers, fulfilling the correct alcohol concentration criteria, is highly recommended for use.
Still, for once, a line should be drawn to separate use from misuse. Indiscriminate use of antibiotics in the past has led to organisms developing resistance to multiple antibiotics, causing a considerable burden to the healthcare system; we do not want the same to happen with hand sanitizers and add more burden on top of it, do we?
References
Pidot, S. J., Gao, W., Buultjens, A. H., Monk, I. R., Guerillot, R., Carter, G. P., Lee, J. Y. H., Lam, M. M. C., Ballard, S. A., Grayson, M. L., Johnson, P. D. R., Howden, B. P., & Stinear, T. P. (2018). Increasing tolerance of hospital Enterococcus faecium to handwash alcohols. Science Translational Medicine, 10(452), eaar6115. https://doi.org/10.1126/scitranslmed.aar6115
Reynolds, S. A., Levy, F., & Walker, E. S. (2006). Hand sanitizer alert. Emerging Infectious Diseases, 12(3), 527–529. https://doi.org/10.3201/eid1203.050955
