ABHR Limitations

ABHR is not always the recommended HH product, there are some situations when washing hands with soap and water is preferred (1):

Bacterial spores
Alcohol has virtually no activity against bacterial spores.   Washing hands with soap and water is preferred in this situation because it is the best method of physically removing spores from the hands(1).  However, the vegetative form of Clostridium difficile is highly sensitive to ABHR. 

The 2010 ASID / AICA position statement on Infection Control Guidelines for Patients with Clostridium difficile Infection (CDI) in Healthcare Settings recommends the primary use of ABHR in accordance with the WHO 5 Moments for Hand Hygiene when caring for patients with CDI. Gloves should be used during the care of patients with CDI, to minimise spore contamination, and if hands become soiled, or gloves have not been used, then hands must be washed with soap and water. 

Non-enveloped (non-lipophilic) viruses

Alcohol has a poor activity against some non-enveloped viruses. (e.g. rotavirus, norovirus, polio, Hepatitis A). However, there is conflicting evidence suggesting that ABHR is more effective than soaps in reducing virus titres on finger pads (1,25,26). Thus, in norovirus outbreaks it is usually best to reinforce the use of ABHR, unless hands are visibly soiled – when soap and water HH is preferred.
 
Other organisms
Alcohol has a poor activity against tropical parasites, and protozoan oocysts. Hand washing is preferred.