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An evidence-based review on the safe and effective use of antiseptic agents in health-care environments

Alcohol and chlorhexidine: practical guidance for health-care workers

By Ali Bayrouti
March 25, 2024
Alcohol and chlorhexidine are easily accessible in most health-care environments. While both support infection control, they differ in their intended uses, mechanisms of action, spectrum of activity, residual effect, and potential adverse effects. The appropriate use and concentration of each depend on the clinical situation and the patient’s condition.

Takeaway messages

  • Routine hand hygiene is paramount in preventing health-care-associated infections. Alcohol-based hand rubs are effective and provide a convenient option for hand hygiene in health-care settings when 3 mL is used for at least 15 seconds (85% weight/weight). Traditional handwashing with soap and water remains indicated when the hands are visibly soiled.
  • Nurses can significantly reduce the spread of infections, improve outcomes and promote safe patient care by using antiseptics appropriately. Following manufacturer and institution recommended concentrations, contact times and application methods will best support evidence-based practice.
  • Alcohol-based antiseptics can be used for hand hygiene and skin preparation before invasive procedures. Remain mindful that repeated use can cause skin dryness, irritation, and possibly dermatitis. Moisturizing creams can help prevent skin damage.
  • Chlorhexidine is effective for surgical site preparation as well as central line insertion and oral care in varying concentrations. It has a prolonged residual effect and is less likely to cause skin irritation. Use with caution in patients with known allergies or skin sensitivities.

Alcohol and chlorhexidine are commonly used antiseptics that target pathogens and reduce the risk of infections. Although both substances effectively target and reduce microorganisms, they differ in mechanisms and properties. Nurses should be aware of these differences to guide clinical practice as both agents are readily available in practice. Nurses are optimally positioned to apply this knowledge appropriately to enhance patient outcomes and reduce the spread of infections in health-care settings.

The objective of this article is to educate practitioners in a summarized, easy-to-understand format  and support evidence-based decision-making in clinical practice for safe patient care delivery. This article examines both antiseptics, reviews existing research on their profiles, effectiveness, and presents key facts about use of both products in clinical environments. The review considers indications for use, optimal concentrations and specific application methods, all of which, when employed correctly, contribute to enhanced safety.


Topic Key points
Broad overview • Alcohol-based antiseptics mainly contain isopropanol, ethanol, n-propanol, or a combination as their active ingredient.
• Commonly used due to its accessibility, rapid onset of action, and affordability.
• Higher concentrations than recommended may be less potent as water is required to denature proteins.
• Products containing 60-95% alcohol are acceptable. The Centers for Disease Control and Prevention (CDC) recommends formulations containing (volume/volume): 80% ethanol; 75% isopropyl alcohol

(Gold, Mirza, & Avva, 2022)
Mechanism of action • Denatures and coagulates proteins, disrupting the cell membrane of microbes affecting their viability.

(CDC, 2002, 2008)
Alcohol-based hand rubs (ABHRs) • Defined as alcohol-containing preparations for hand disinfection. Readily available and reduces the risk of pathogen transmission and health-care-associated infections (HAIs).

(Pires, Soule, Bellissimo-Rodrigues, Gayet-Ageron, & Pittet, 2017)
Effectiveness against microorganisms • Effective against a broad range of gram-positive and gram-negative bacteria, some viruses, and fungi.
• Effective against commonly encountered methicillin-resistant Staphylococcus aureus, Escherichia coli and vancomycin-resistant Enterococci.

(CDC, 2002)
Effectiveness against viruses • Ethanol and propanol are effective agents against some viruses, including coronaviruses.

(Kampf, Todt, Pfaender, & Steinmann, 2020)
Recommended use in health-care settings • ABHRs do not replace handwashing but offer an efficient and effective option for convenient hand hygiene.
• Easy to use, available and proven effective. Used for hand hygiene skin preparation before injections, catheterizations and surgeries.

(CDC, 2016; World Health Organization, 2009)
Recommended concentration for hand sanitizing • The CDC recommends, at minimum, 60% alcohol solution when traditional handwashing is not available.

(CDC, 2023)
Amount of ABHR to apply • 3 mL of ABHR is generally recommended; however, the amount required for effective hand hygiene correlates to individual hand size, with larger hands requiring more hand rub.

(CDC, 2002; Voniatis, Bánsághi, Ferencz, & Haidegger, 2021)
Limitations of alcohol as an antiseptic • Repeated use can cause skin dryness, irritation, and dermatitis.
• Not recommended for medical/surgical instrument sterilization as alcohol lacks sporicidal activity.

(CDC, 2002, 2008)
Promoting compliance and preventing skin damage • Minimum contact time of 15 seconds
• Allow the solution to dry completely
• Moisturizing creams can prevent skin damage and irritation and promote compliance with hand hygiene.

(Harnoss et al., 2020; Pires et al., 2017)


Topic Key points
Chlorhexidine • Broad-spectrum antiseptic and disinfectant with prolonged residual effect.
• Disrupts the cell membrane of microorganisms.
• Effective against different bacteria, fungi, and viruses.

(Buxser, 2021; Rutter & Macinga, 2013)
Skin tolerability • Can be safely used on intact skin.
• Irritant contact dermatitis may occur.
• Rare occurrence of allergic local reactions and anaphylaxis. Caution in patients with a history of allergies or documented skin sensitivities.

(CDC, 2002; Mimoz et al., 2015)
Central line insertion • Use of chlorhexidine-alcohol provides greater protection and lowers the risk of short-term catheter-related bloodstream infections.
• CDC recommends chlorhexidine-based antiseptic for skin preparation before insertion.

(CDC, 2011; Huang et al., 2013; Mimoz et al., 2015)
Oral care in critically ill patients • Reduces the incidence of ventilator-associated pneumonia.
• The CDC recommends 0.12% chlorhexidine mouthwash for oral care in mechanically ventilated patients. Oral care with chlorhexidine may reduce microbial colonization in this population.

(Kes et al., 2021; Labeau, Van de Vyver, Brusselaers, Vogelaers, & Blot, 2011)


Both chlorhexedine and alcohol are commonly used in health-care settings, individually and in combination to effectively reduce the risk of infection and pathogen transmission. Appropriate selection and use depend on multiple factors. The following table summarizes a comparison of the two antiseptics.

Alcohol Chlorhexidine
Mechanism of action
Denatures proteins in the cell membrane of microorganisms.

(CDC, 2002)
Disrupts microbial cell membranes.

(Buxser, 2021)
Some formulations may be less potent at higher concentrations.
Effective against a broad range of gram-positive and gram-negative bacteria, some viruses, and fungi.

(CDC, 2002; Gold et al., 2022)
Offers broad-spectrum antimicrobial activity.
Effective against different bacteria, fungi, and viruses.

(Buxser, 2021; Rutter & Macinga, 2013)
Residual effect
None-to-weak residual effect.

(CDC, 2002)
Prolonged residual effect.

(Buxser, 2021)

Health-care providers should ensure that they are selecting the correct antiseptic and concentration for their intended use and should follow the recommended contact time for each product based on current guidelines.

When disinfecting with alcohol-based solutions, the CDC (2002) recommends a contact time of 30 seconds or longer for the solution to be effective against a broad range of microorganisms. Pires et al. (2017) conducted an experimental study focusing on the impact of hand-rubbing duration on the reduction of bacterial load on the hands of health-care workers. The investigated durations ranged from 10 to 60 seconds, and the reduction in bacterial load for each duration was assessed. The researchers found that hand rubbing for 15 seconds was not significantly different or inferior to 30 seconds in reducing bacterial counts. Longer durations did not provide additional benefits in terms of bacterial reduction. Similar findings were established by Harnoss et al. (2020). Such evidence suggests that 15 seconds of hand rubbing with ABHRs may be sufficient in ensuring effective hand hygiene.


Alcohol and chlorhexidine are easily accessible in most health-care environments. While both support infection control, they differ in their intended uses, mechanisms of action, spectrum of activity, residual effect, and potential adverse effects. The appropriate use and concentration of each depend on the clinical situation and the patient’s condition.

By reviewing the information in this article, nurses may enhance their knowledge of each product and improve health-care outcomes, including patient safety, by mitigating the risk of infection.


The author affirms that there are no conflicts of interest to disclose and that no funding was received in support of this article.


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Kes, D., Yildirim, T. A., Kuru, C., Pazarlioglu, F., Ciftci, T., & Ozdemir, M. (2021). Effect of 0.12% chlorhexidine use for oral care on ventilator-associated respiratory infections: A randomized controlled trial. Journal of Trauma Nursing, 28(4), 228–234. Retrieved from

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Voniatis, C., Bánsághi, S., Ferencz, A., & Haidegger, T. (2021). A large-scale investigation of alcohol-based handrub (ABHR) volume: Hand coverage correlations utilizing an innovative quantitative evaluation system. Antimicrobial Resistance & Infection Control, 10(49), 49. doi:10.1186/s13756-021-00917-8

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Ali Bayrouti, RN, BN, is a rural and remote practice registered nurse in Alberta, Canada. He currently works as a charge RN covering emergency and acute medical/surgical care.