SUPPLEMENT ARTICLE

Consumer Antibacterial Soaps:

Effective or Just Risky?
Allison E. Aiello,1 Elaine L. Larson,2 and Stuart B. Levy3
1

Department of Epidemiology and Center for Social Epidemiology and Population Health, University of Michigan, Ann Arbor; 2School of Nursing,
Columbia University, New York, New York; and 3Center for Adaptation Genetics and Drug Resistance, Tufts University School of Medicine,
Boston, Massachusetts

Background. Much has been written recently about the potential hazards versus benefits of antibacterial
(biocide)containing soaps. The purpose of this systematic literature review was to assess the studies that have
examined the efficacy of products containing triclosan, compared with that of plain soap, in the community setting,
as well as to evaluate findings that address potential hazards of this usenamely, the emergence of antibioticresistant bacteria.
Methods. The PubMed database was searched for English-language articles, using relevant keyword combinations for articles published between 1980 and 2006. Twenty-seven studies were eventually identified as being
relevant to the review.
Results. Soaps containing triclosan within the range of concentrations commonly used in the community
setting (0.1%0.45% wt/vol) were no more effective than plain soap at preventing infectious illness symptoms and
reducing bacterial levels on the hands. Several laboratory studies demonstrated evidence of triclosan-adapted crossresistance to antibiotics among different species of bacteria.
Conclusions. The lack of an additional health benefit associated with the use of triclosan-containing consumer
soaps over regular soap, coupled with laboratory data demonstrating a potential risk of selecting for drug resistance,
warrants further evaluation by governmental regulators regarding antibacterial product claims and advertising.
Further studies of this issue are encouraged.
In October 2005, the Non-Prescription Drug Advisory
Committee of the US Food and Drug Administration
(FDA) was convened to discuss the potential benefits
and risks associated with antiseptic products marketed
for consumer use, such as soaps labeled as antibacterial. The conclusion of the FDA meeting resulted in
a call for further research regarding the risks and benefits of specific consumer antiseptic products used in
the community setting. Much of the debate regarding
consumer antiseptic products has focused on the use
of antibacterial soaps that contain the active ingredient triclosan. The majority of consumer liquid hand
soaps labeled as antibacterial contain triclosan [1],
and, although the FDA does not formally regulate the
levels of triclosan used in consumer products, most of

Reprints or correspondence: Dr. Allison E. Aiello, Center for Social Epidemiology

and Population Health, 1214 S. University, 2nd Fl., Ann Arbor, MI 48104-2548
(aielloa@umich.edu).
Clinical Infectious Diseases 2007; 45:S13747
 2007 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2007/4505S2-0006$15.00
DOI: 10.1086/519255

the popular liquid hand soap brands contain between

0.1% and 0.45% weight/volume (wt/vol). A chemically
related compound, triclocarban, is used in antibacterial
bar soap formulations.
Triclosan is a phenoxyphenol antimicrobial that is
marketed as an antibacterial ingredient in consumer
hygiene products, but it also has some antiviral and
antifungal activity [2]. It is bacteriostatic at low concentrations and bactericidal at high concentrations [3].
Triclosan has been shown to inhibit the growth of both
gram-positive and gram-negative bacteria in situ, with
varying effectiveness across bacterial species [2]. For
example, triclosan is relatively ineffective at inhibiting
the growth of gram-negative bacteria such as Pseudomonas aeruginosa and Serratia marcescens [2]. Although
the bactericidal activity of triclosan involves some nonspecific killing mechanisms, research findings suggest
that the bacteriostatic action occurs by inhibiting a specific bacterial target, known as the enoyl-acyl carrier
protein reductase [46]. Triclosan shares this bacterial
biosynthetic fatty acid pathway target with the antibiotic isoniazid [5]. These findings have led researchers
Antibacterial Soap Use: Efficacy and Risks CID 2007:45 (Suppl 2) S137

to explore whether triclosan may influence the emergence of

resistance to antibiotics [79].
Similar to the methods used for testing clinical antibiotic
resistance, a MIC method is used to assess reduced susceptibility
to triclosan. Currently, there are no clinically meaningful MIC
cutoff points for monitoring resistance to biocides, and, therefore, the term reduced susceptibility is commonly used when
discussing bacterial tolerance to triclosan exposure. Similar to
their resistance to antibiotics, bacteria may be intrinsically resistant to triclosan via mechanisms of impermeability, efflux
pumps, biofilms, and enzyme inactivation. The decreased susceptibility of greatest concern regarding triclosan is acquired
tolerance/resistance. The resistance mechanisms are similar to
those producing antibiotic resistance and include mutations at
the drug target site, chromosome-mediated drug efflux, and
overexpression of the target protein. Acquired bacterial resistance mechanisms may lead to an increase in MICs to antibiotics as well as to triclosan [7, 9, 10].
Although several investigators have reviewed studies examining the mechanisms of antiseptic resistance [7, 916], there
are few systematic reviews that have attempted to summarize
the potential risks associated with triclosan in the context of
the purported effectiveness of this antibacterial ingredient used
in hygiene products in the community setting. The efficacy of
soap containing triclosan generally refers to the additional level
of effectiveness beyond the ability of plain soap to simply remove transient organisms via surfactants and the mechanical
action of the wash procedure [17]. The level of effectiveness
may be measured at the microbiological level or at the population level, as added protection against bacterial contamination or the occurrence of common infectious illnesses. Risks,
on the other hand, include the potential for bacteria to become
unsusceptible to triclosan, for the emergence of cross-resistance
to antibiotics, and for the ingredients to become toxic to the
environment and to humans.
Only in the past 5 years has the effectiveness of triclosan for
preventing infectious illnesses in the community setting been
assessed; the first studies of which we are aware were published
in 2002 [18]. In this review, we identify and summarize the
studies examining the efficacy of triclosan by reviewing research
that has examined the effectiveness of these consumer antiseptic
soaps at reducing the incidence of infectious illnesses in the
community setting and bacterial counts on the skin. Second,
we identify and summarize the literature that examines whether
there is a potential risk associated with use of hygiene products
containing triclosan in relation to emergence of microbes that
are less susceptible to triclosan and/or resistant to clinically
used antibiotics. Finally, we weigh the evidence regarding the
risks and benefits and conclude with recommendations for further research and for examining the implications of the current
data on regulation of consumer products containing triclosan.
S138 CID 2007:45 (Suppl 2) Aiello et al.

METHODS
The PubMed database was searched for English-language articles published during the period January 1980July 2006, using keyword combinations for each search strategy. Keywords
included absence, absent*, alcohol, antibacterial cleaning, antibacterial soap, antiseptic, behavior, child care,
child day care, child morbidity, child*, cold, community, day care, day care center, diarrhea*, diarrhoea, education, hand, hand sanitizer, hand wash,
hand wash*, infection control, infectious disease, infectious illness, infectious*, intervention, health intervention, hygiene, hygiene education, infants, infect*,
morbidity, preschool, prevent*, respiratory, sanitation, soap, school, triclocarban, triclosan, wash*,
and water. An asterisk (*) denotes a truncated search method
in which PubMed seeks the first 600 variations of terms with
the same root (for example, infect* would result in a search
for infect, infection, infectious, etc.).
The search results were scanned for research articles and
systematic reviews. In addition, the reference lists in retrieved
review papers were searched for related articles. Articles that
focused on triclosan in dentifrice were excluded, because the
introduction of triclosan in dentifrice was relatively recent
(1997), compared with its introduction in topical antiseptics
(1960s) [3, 19].
Our review of the literature was limited to studies that allowed comparison of the effectiveness of triclosan-containing
soap with that of plain soap. We also included studies that
assessed the effectiveness of triclocarban soap, because this is
a chemically similar compound found in most antibacterial bar
soaps available to consumers. The study outcomes included
reported or diagnosed gastrointestinal infection (such as shigellosis) or upper respiratory tract infection (such as pneumonia), general gastrointestinal and/or respiratory symptom(s)
of infection (such as diarrhea or runny nose), gastrointestinal
and/or respiratory infectious symptomrelated absences (such
as school absence for a cold), and/or skin infections. Microbiological end points were limited to studies that examined the
effect of antibacterial soap containing triclosan on bacterial
reductions on the hand, compared with plain soap. Studies
conducted among volunteer participants that were not associated with the clinical setting were included if they were conducted in natural settings or in a controlled laboratory environment. Because this review focused on the use of hand
products containing triclosan in the community setting, articles
were excluded if the setting was a health care facility, such as
a hospital or residential nursing home, or if the study subjects
were health care workers. Lastly, studies in which triclosan was
combined with other antiseptic ingredients, such as alcohol or
iodine, were excluded, because it would not have been possible

to estimate the independent effects of triclosan compared with

plain soap in these studies [20].
To review the literature associated with risks, articles were
included if they (1) assessed mechanisms of cross-resistance,
using serial culture adaptation methodologies and/or genetic
manipulation of the bacterial molecular target site of triclosan;
(2) assessed levels of susceptibility to triclosan among bacterial
isolates obtained from humans in the community setting; or
(3) examined the statistical association between in-use exposure
to triclosan and reduced susceptibility to triclosan and/or antibiotic resistance among humans living in the community
setting.
Using available data from the retrieved studies, we summarized the findings regarding the efficacy of triclosan for reducing infectious illness symptoms and bacterial growth on
skin. Next, we summarized the studies examining in situ mechanisms of reduced susceptibility to triclosan and cross-resistance with antibiotics. In addition, we summarized the studies
that examined the association between the use of triclosan and
the emergence of antibiotic resistance among individuals living
in the community setting. Lastly, the strengths and limitations
of the studies were assessed by considering methods related to
design and conduct, such as sample size and masking of treatment from study participants.
RESULTS
The PubMed search identified 1793 citations. On the basis of
our inclusion criteria, we identified a total of 27 studies that
examined either the effectiveness of triclosan or the risks of
antibiotic resistance associated with exposure to triclosan.
Efficacy of triclosan. We identified 4 community-based
randomized intervention studies [18, 2123] providing information on the effectiveness of consumer soaps containing triclosan or triclocarban compared with that of plain soap (table
1). Three of these studies were conducted in Pakistan, and 1
was conducted in an urban setting in the United States. The
study sample sizes ranged from 162 to 600 household units,
and all households were required to include a child 4 years
of age. Interventions included household member use of consumer-available bar soap containing 1.2% triclocarban (wt/vol)
or liquid hand soap containing 0.2% triclosan (wt/vol) over a
1-year period. The outcomes recorded infectious illness symptoms such as cough, fever, diarrhea, and skin infections. None
of these studies included the collection of clinical samples for
laboratory identification of the etiologic agent associated with
illness symptoms. All 4 studies showed no significant reduction
in illness symptoms among household members associated with
the use of the biocide-containing soap versus plain soap.
We identified 9 studies that examined the effectiveness of
soap containing triclosan versus plain soap in reducing bacterial
levels on the hands (table 1) [2432]. The majority of the

microbiological effectiveness studies (n p 8 ) were conducted

in a controlled laboratory setting [24, 2632], and 1 was conducted under natural conditions in the household setting [25].
Study sample sizes ranged from 10 to 238 subjects, and study
subjects were characterized as nonclinical volunteers. Slightly
fewer than half (4/9) of the studies mentioned the use of randomization procedures, and only 22% reported masking of
study treatments. Most of the studies examined the normal
skin flora as the outcome, but 2 of the 9 studies used artificial
contamination [24, 32] procedures, by inoculating the skin of
volunteers with S. marcescens. Approximately half (5/9) of the
microbiological studies compared soap with at least 1.0% triclosan (wt/vol) versus plain soap, whereas the others utilized
a concentration of 0.3% triclosan (wt/vol) in the comparison.
Five of the 9 studies reported a significant reduction in bacterial
counts on hands in association with the use of triclosan-containing soap versus plain soap. All but 1 of these 5 studies
utilized soap with a relatively high concentration of triclosan,
1.0% [2931], and 2 of the 5 studies reported a significant
reduction only after multiple hand washes [24, 31], over multiple hand-washing episodes [24, 31], or after washing for 30
s [24, 31]. Only 1 study assessing triclosan at a concentration
of 0.3% wt/vol (a concentration closer to the 0.1%0.45% wt/
vol found in many consumer antibacterial soaps) reported a
significant reduction in bacterial counts, and this reduction was
observed only after 18 hand washes per day, for 30 s each, over
5 consecutive days [31].
Risks associated with triclosan. Our search identified 11
laboratory studies assessing the influence of triclosan exposure
on the emergence of triclosan-tolerant species and cross-resistance to clinical antibiotics (table 2). A range of bacteria was
examined, including gram-negative and gram-positive species;
commonly studied species included Escherichia coli, Staphylococcus aureus, and Salmonella enterica. Seven of the 11 studies
demonstrated cross-resistance to 1 antibiotic for at least 1 of
the bacterial species examined (table 2). Commonly assessed
antibiotics included isoniazid, ciprofloxacin, erythromycin, tetracycline, chloramphenicol, ampicillin, and methicillin. Three
of 11 studies reported an increase in MICs to triclosan among
bacterial species but did not demonstrate cross-resistance to
clinically used antibiotics. One study examining E. coli reported
no evidence of increased tolerance to triclosan or cross-resistance to antibiotics [39]. Given the variety of bacterial species
and antibiotics tested across studies, it was not possible to assess
whether a consistent pattern of cross-resistance for specific organism/antibiotic combinations existed.
We identified only 3 studies that examined the emergence
of antibiotic resistance associated with use of triclosan in the
community setting (table 3). The first study included a convenience sample of 60 households [43] divided into those that
reported using 1 antibacterial hygiene products and those
Antibacterial Soap Use: Efficacy and Risks CID 2007:45 (Suppl 2) S139

S140

10 volunteers

238 primary care

givers

33 nonclinical staff

Larson et al. [25]

Faoagali et al. [26]

162 households

600 households

240 households

600 households

Sample size

Sickbert-Bennett et al. [24]

Microbiological studies

Luby et al. [18]

Luby et al. [23]

Larson et al. [22]

Luby et al. [21]

Infectious illness studies

Liquid (1.0% Ts)

Liquid (0.2% Ts)

Liquid (1.0% Ts)

Bar (1.2% Tc)

Bar (1.2% Tc)

Liquid (0.2% Ts)

Bar (1.2% Tc)

Antibacterial soap
study group, liquid/
bar (concentration
of Tc or Ts)

Liquid

Liquid

Liquid

Bar

Bar

Liquid

Bar

Nonmedicated plain
soap control group,
liquid/bar

Mean difference in log10 colony-forming

units on hands

Mean log10 bacterial colony-forming

units on hands

Reduction in mean log10 Serratia

marcescens colony-forming units after artificial contamination of hands

Impetigo incidence

Diarrhea symptoms

Multiple symptomsd

Multiple symptoms

Outcome(s)

Studies comparing the efficacy of antibacterial soap containing triclosan (Ts) with that of plain soap.

Study type, reference

Table 1.

Not statistically significant: after 5 days of hand

washing 3 times/day, 4.87 (antibacterial soap)
vs. 4.93 (plain soap) log10 cfu (all P 1 .28)

Not statistically significant: after an immediate

episode of hand hygiene or after a second
hand hygiene episode 3 h later, compared with
baseline, mean difference, 0.0564 log10 cfu
(P 1 .05)

Not statistically significant: after 1 year of use,

4.87 (antibacterial soap) vs. 4.93 (plain soap)
log10 cfu (P 1 .28)

Not statistically significant: after 1 episode of

hand hygiene, 5.77 (antibacterial soap) vs. 5.62
(plain soap) log10 cfu (P 1 .28)

Statistically significant: after 10 episodes of hand

hygiene, 2.49 (antibacterial soap) vs. 1.68 (plain
soap) log10 cfu (P ! .0001) reduction

Not statistically significant: after 1 episode of

hand hygiene, 1.90 (antibacterial soap) vs. 2.00
(plain soap) log10 cfu reduction

Not statistically significant: mean incidence of

diarrhea was 2.02 (antibacterial soap) vs. 1.91
(plain soap)
Not statistically significant: incidence density
ratioe of 0.77 (95% CI, 0.481.24)

Not statistically significant: RR of 0.96 (95% CI,

0.821.12)

Not statistically significant: RR of symptoms

assessed independentlyall 1

Results (antibacterial soap vs. plain soap)

S141

40 nonmedical
volunteers

Larson et al. [31]

Liquid (1.5% Ts)

Liquid (0.3% Ts)

Liquid

Liquid

Bar

Liquid

Liquid

Liquid

Reduction in mean log10 S. marcescens

colony-forming units after artificial
contamination of hands

Mean log10 bacterial colony-forming

units on hands

Mean log10 reduction in bacterial

colony-forming units on hands

Statistically significant: significant reductions were

observed after 1 (2.91 log10 cfu), 4 (3.22 log10
cfu), 7 (3.50 log10 cfu), and 10 (3.78 log10 cfu)
episodes of hand hygiene with antibacterial
soap, compared with 1 episode with plain soap
(2.72 log10 cfu) (all P ! .01)

Statistically significant: after 5 days of use at 18

hand washes/day, 4.56 (antibacterial soap) vs.
5.45 (plain soap) log10 cfu (P ! .05)

Not statistically significant: after 5 days of use at

6 hand washes/day, 5.42 (antibacterial soap) vs.
5.25 (plain soap) log10 cfu (P 1 .05)

Not statistically significant: after 1 day of use at

18 hand washes/day, 6.11 (antibacterial soap)
vs. 5.75 (plain soap) log10 cfu (P 1 .05)

Not statistically significant: after 1 day of use at 6

hand washes/day, 6.17 (antibacterial soap) vs.
5.71 (plain soap) log10 cfu (P 1 .05)

Statistically significant: after 5 sequential washes

spaced 20 min apart, 0.79 (antibacterial soap)
vs. 0.16 (plain soap) log10 cfu reduction (P !
.001)

Statistically significant: after 3-min hand wash,

70.1% (antibacterial soap) vs. 31.9% (plain
soap) reduction (P ! .05)

Percentage reduction in mean log10 bac- Not statistically significant: after 1 episode of
terial colony-forming units on hands
hand hygiene, 48.2% (antibacterial soap) vs.
41.7% (plain soap) reduction
Percentage reduction in mean log10 bac- Not statistically significant: after washing for 3
terial colony-forming units on hands
min, 32.86% (antibacterial soap) vs. 44.93%
(plain soap) reduction
Percentage change in mean log10 bacStatistically significant: after 30-s hand wash,
terial colony-forming units on hands
48.3% (antibacterial soap) vs. 21.9% (plain
soap) reduction (P ! .001)

All infectious illness studies followed participants for 1 year.

These studies did not provide a statistical comparison of the antibacterial treatment arm versus the plain soap treatment arm, so we computed statistical comparisons using the data available from the study. It
was not possible to control for clustering effects in these calculations.
c
Infectious illness symptoms such as diarrhea, cough, congestion, pneumonia, and impetigo.
d
Infectious illness symptoms such as diarrhea, cough, sore throat, fever, and vomiting.
e
Models adjusted for covariates.

NOTE. RR, relative risk; Tc, triclocarban.

12 volunteers

20 volunteer labora- Liquid (2.0% Ts)

tory staff with no
recent contact
with antimicrobial
products

Bendig [30]

Bartzokas et al. [17]

20 students and
employees of a
university

Leyden et al. [29]

Liquid (1.0% Ts)

7 healthy adult men Liquid (0.3% Ts)

without eczema

Namura et al. [28]

Liquid (0.3% Ts)

20 workers in the
food industry

Miller et al. [27]

S142

S. enterica
E. coli
MRSA
Pseudomonas aeruginosa
Methicillin-susceptible S. aureus, MRSA

Mycobacterium smegmatis

Randall et al. [38]

Walsh et al. [39]

Fraise [40]

Chuanchuen et al. [41]

Suller and Russell [42]

McMurry et al. [5]

Ts/isoniazid

Ts/antibiotics

Ts/antibiotics

Ts

Tc

Ts/antibiotics

Ts/antibiotics

Ts/antibiotics

Ts/antibiotics

Ts/antibiotics

Results

A mutation originally selected for on isoniazid also mediated Ts resistance, and vice versa

No consistent pattern between high Ts MICs and antibiotic-resistance profiles after exposure over
1 month; 2 of 3 MRSA strains that were resistant to mupirocin and several other antibiotics
were also less susceptible to Ts; however, coresistance with mupirocin was not plasmid
mediated

A 94-fold increase in MICs to ciprofloxacin was observed among strains that showed high levels
of tolerance to Ts

Threefold increase in MICs to Ts

No evidence of increased tolerance to Ts

Increase in the mean frequency of mutations that confer resistance to ampicillin

An increase in MICs to Ts and cross-resistance with erythromycin and ciprofloxacin was demonstrated
for E. coli O157:H7; adaptation of E. coli O157:H7 to erythromycin also led to an increase
in MICs; S. enterica serotype Virchow demonstrated reduced susceptibility to Ts and crossresistance with erythromycin after serial passage

Four sublethal exposures of E. coli O157:H7 led to an increase in MICs to Ts of 0.25 mg/mL
to 1024 mg/mL; Ts-adapted E. coli O157:H7 demonstrated cross-resistance to a number of antibiotics, including amoxicillin, chloramphenicol, ciprofloxacin, tetracycline, and trimethoprim;
E. coli K-12 and E. coli O55 adapted to Ts showed reduced susceptibility to chloramphenicol
and trimethoprim, respectively; other strains did not demonstrate cross-resistance

S. enterica serotype Virchow became more tolerant to Ts and erythromycin after gradual exposure
to higher concentrations of these agents (up to 1024 mg/mL) over 6 days; adaptive
resistance to Ts and erythromycin was stable for at least 30 days of passage in Ts/antibioticfree medium

Ts-adapted mutants showed reduced susceptibility to tetracycline and chloramphenicol but not to
tobramycin, compared with the wild-type strain; these strains overexpressed the multidrugresistance pump SmeDEF

Ts MIC was increased among E. coli, Klebsiella species, and S. maltophilia only; among bacteria
with high MICs to Ts, there was no increase in MICs to 4 antibiotics after exposure to Ts

This study also looked at drain bacteria; this information is not presented here.
Repeated exposure to sublethal Ts concentrations in nutrient broth and subsequent exposure to several antibiotics.
Repeated exposure to sublethal Tc concentrations in nutrient broth.
Repeated exposure to sublethal Ts concentrations in nutrient broth.
Repeated exposure to sublethal Ts concentrations and subsequent exposure to isoniazid

NOTE. MRSA, methicillin-resistant Staphylococcus aureus; Tc, triclocarban.

E. coli O157:H7, E. coli K-12, S. enterica (serotypes Enteritidis, Typhimurium, and Virchow)

E. coli O111:H24, E. coli O157:H7, E. coli

O55, E. coli K-12

S. enterica (serotypes Enteritidis, Typhimurium,

and Virchow)

S. maltophilia

Braoudaki and Hilton [37]

Braoudaki and Hilton [36]

Braoudaki and Hilton [35]

Sanchez et al. [34]

Ts/antibiotics

Exposure parameters

Types of bacterial species

Ledder et al. [33]

Coagulase-negative Staphylococcus species,

Enterobacter asburiae, Escherichia coli, Klebsiella species, Salmonella enterica (serotypes Enteritidis, Typhimurium, and Infantis),
Stenotrophomonas maltophilia

Reference

Triclosan (Ts) adaptation and antibiotic cross-resistance studies.

Table 2.

S143
Carriage of 1 antibiotic-resistant
organismb

Not statistically significant

Not statistically significant: several staphylococcal species

showed reduced susceptibility to triclosan

Comparable triclosan MICs among antibacterial vs. nona

antibacterial user homes; no patterns discerned with
antibiotic susceptibilities

Results

This study did not assess statistical significance because the number of final isolates for analysis was limited. Other bacterial isolates obtained in this study were from environmental sources within the
household and are not presented here. The authors reported that the results for the environmental isolates also showed no evidence of cross-resistance.
b
The organisms were the same as those listed for Aiello et al. [44].

Aiello et al. [45] 240 individuals (US) Hands of antibacterial vs. nonantibacterial
user households

Antibiotics, no.

Aiello et al. [44] 240 individuals;

Hands of primary caregivers in houseAcinetobacter species,
628 bacterial isoholds using antibacterial vs. nonantibacEnterobacter spelates (US)
terial products
cies, S. aureus,
coagulase-negative
staphylococcal species, Klebsiella species, Pseudomonas
species

Organism(s)
18

Isolate source
Hands of 12 household members
Staphylococcus aureus
reporting use of antibacterial products vs.
those reporting use of nonantibacterial
products

60 households; 8
bacterial isolates
(US, UK)

Sample size
(location)

Community-level studies of the relationship between exposure to triclosan in home hygiene products and antibiotic resistance.

Cole et al. [43]

Reference

Table 3.

that reported no use of antibacterial hygiene products. Bacteria

were isolated from the hands of household members and their
home environments. There was no information on the concentration or prevalence of triclosan-containing products
among the reported antibacterial-user households. Although
the sample size was not sufficient to make statistical comparisons, the authors of the study still concluded that there was
no association between use of antibacterial products and the
presence of antibiotic-resistant species among household members and their environment.
The next 2 studies were derived from a randomized and
masked intervention trial of 238 households allocated to using
either 0.2% triclosancontaining liquid hand soap or plain
soap [44, 45]. Bacterial samples were obtained from the hands
of household members at baseline and after 1 year of using
the assigned hand hygiene product. Neither of these studies
demonstrated the emergence of antibiotic resistance associated with use, over a 1-year period, of the liquid hand soap
containing 0.2% triclosan compared with plain soap. The authors did note that several species, such as P. aeruginosa and
some coagulase-negative staphylococcal species, demonstrated unexpectedly high MICs to triclosan at both baseline
and the end of the year [44].
DISCUSSION
Triclosan has been used in personal hygiene products in the
United States since the 1960s, and this chemical is now the
most prevalent biocide ingredient in consumer liquid hand
soaps [1]. Our study is, to our knowledge, the first systematic
review of research assessing the risks and potential benefits
associated with the use of soaps containing triclosan in the
community setting. The available data do not support the effectiveness of triclosan for reducing infectious disease symptoms or bacterial counts on the hands when used at the concentrations commonly found in consumer antiseptic hand
soaps. The effectiveness was similar to that of plain soap in the
majority of studies, and a difference in the reduction of bacterial
levels on the hands was generally observed only after longer
hand washes with soap containing relatively high concentrations of triclosan (i.e., 1.0% wt/vol). Regarding the risks associated with triclosan, we identified several studies that supported a relationship between exposure of bacteria to triclosan
in the laboratory and increased MICs to clinically utilized antibiotics. In contrast, research conducted at the population level
showed little evidence of cross-resistance with antibiotics associated with household use of hygiene products containing
triclosan.
Hand hygiene is an important practice for reducing the transmission of infectious illnesses in both the clinical and community setting [46, 47]. Although there are numerous studies
examining the efficacy of antimicrobial hand hygiene agents in
S144 CID 2007:45 (Suppl 2) Aiello et al.

the clinical setting (reviewed in [46]), few have examined the

efficacy of biocide-containing hand hygiene products frequently
utilized in the community setting. The 4 available studies that
examined the efficacy of biocide-containing soap compared
with that of plain soap at reducing infectious illnesses showed
no significant differences in any of the infectious illness symptoms that were assessed [18, 2123]. All of these studies were
large, randomized, 1-year intervention studies that included
rigorous follow-up of study participants and illness outcomes.
The study populations ranged in age, but all 4 studies required
households to have at least 1 child residing in the home. The
null findings were consistent across various study settings, ranging from urban upper Manhattan to squatter settlements in
Pakistan. Even in areas with high rates of infectious illnesses,
such as the urban squatter settlements in Karachi, there was
little benefit associated with use of the soap containing triclocarban compared with plain soap.
None of these studies gathered clinical isolates for the identification of the biological agent associated with the illness
symptoms, so it is was not possible to assess whether the reported symptoms were associated with organisms other than
bacteria, such as viruses. Triclosan is less effective against viral
agents [2]; therefore, it is possible that this ingredient showed
no impact on infectious illnesses in the household setting because a majority of the infectious etiologies may be associated
with viral pathogens. Still, when examining impetigo, for which
a viral etiology is unlikely, the results can be regarded more
decisively and suggest that triclosan provides little benefit for
reducing skin infections caused by bacteria in the community
setting [18]. Symptoms such as coughing, sneezing, fever, and
diarrhea are commonly observed for many of the significant
infectious illnesses observed in the community setting and may
be related to infection by viruses or bacteria [48]. Therefore,
the available community-based intervention studies suggest
that consumer products containing triclosan or triclocarban
are not effective against the most common infectious illnesses
affecting individuals in the community setting. For these reasons, the public health utility of this antibacterial ingredient
for preventing common infectious illnesses, as a measure of
added protection beyond that afforded by plain soap use, has
not been shown. We were unable to identify any studies that
examined the efficacy of soaps containing triclosan among
other populations living in the community setting, such as
elderly or immunocompromised individuals. Therefore, it is
unknown whether soaps containing triclosan could provide
protection to groups potentially at higher risk for infection.
Many of the available bacterial reduction studies we reviewed
tested the efficacy of hand hygiene agents used for 30 s.
Similar to our review, others have shown that an increased
application time of various hand hygiene agents tends to result
in greater efficacy [49]. It is unlikely that a 30-s duration

reflects the normal hand-washing practices in the community

setting. Even health care professionals generally wash their
hands for a much shorter duration [46], and studies of hand
washing in the community setting indicate suboptimal handwashing practices [50].
Another factor that has been identified as an important parameter for enhancing the efficacy of antiseptic hand hygiene
agents is the concentration of the ingredient [49]. In our review,
the majority of studies that identified a significant reduction
in bacterial levels on the hands utilized soap with a concentration of 1.0% triclosan. Other factors, such as experimental
contamination versus normal flora, may also lead to findings
of enhanced efficacy [49]. Likewise, we identified 2 studies that
used artificial contamination [24, 32], and both reported significant reductions with the use of the soap containing triclosan,
compared with plain soap. Study design issues, such as a lack
of randomization to treatment arms and a lack of masking
among study subjects, may also have affected the findings in
some of these reports.
Collectively, the microbiological efficacy studies strongly suggest that concentrations of triclosan used in consumer liquid
hand soaps do not provide a benefit over plain soap for reducing bacterial levels found on the hands. Although some of
these studies were limited by study design flaws and variability
in testing procedures, the results regarding the lack of efficacy
were consistent among studies utilizing a concentration of triclosan found in most consumer liquid hand soaps.
Research regarding the risks associated with triclosan use has
primarily been conducted under controlled laboratory conditions. This research has elucidated several molecular mechanisms by which sublethal exposure to triclosan may lead to the
emergence of antibiotic-resistant bacteria among select species
[10]. Some of the triclosan-adapted bacterial species, such as
E. coli and P. aeruginosa, were able to grow in cultures with
concentrations of triclosan of up to 1024 mg/mL, which is close
to the concentrations added to many consumer soaps (i.e., 1000
mg/mL p 0.1% triclosan [wt/vol]). These findings were relatively species specific, and much lower concentrations were
required to inhibit other organisms, such as staphylococci. Most
of the studies followed similar testing procedures for assessing
triclosan MICs and antibiotic resistance. However, the bacterial
species tested and the antibiotics assessed varied across studies.
This limited our ability to classify species- and antibiotic-specific cross-resistance patterns.
There have been only a few studies that have attempted to
assess the relationship between biocide-containing soap use and
the emergence of antibiotic resistance in the community setting.
Interestingly, the laboratory findings have not been corroborated among the intervention studies that were conducted in
the community under in-use conditions. There are several factors that might explain the discrepancy. First, laboratory testing

may not be generalizable to the emergence of antibiotic resistance in the environment. Laboratory exposure conditions may
not mirror exposures that occur in the environment under
natural antiseptic use conditions. For example, it is possible
that bacterial species are exposed to higher concentrations of
triclosan under in-use conditions in household settings, compared with relatively low concentrations often used in laboratory studies. This may reduce the selective pressures for
antibiotic-resistant bacteria under in-use conditions in the
household. Second, selective pressures in the environment may
weed out cross-resistant organisms. Organisms that are selected
for resistance to both triclosan and antibiotics may be less fit
for survival in the environment when they are carrying plasmids
or must maintain costly genetic target mutations. Despite these
caveats, there are many examples with antibiotics in which
difficulty in obtaining resistant mutants in the laboratory did
not predict the relative ease of their emergence in the clinical
settingsfor example, the fluoroquinolones.
Studies that have assessed whether there is an association
between exposure to products containing triclosan and antibiotic resistance in the community setting may not be large or
long enough to identify the emergence of antibiotic resistance.
For example, the 2 studies by Aiello et al. [44, 45] suggest a
trend toward resistance, but the studies were powered to detect
only moderate to high changes in antibiotic resistance over a
1-year period. The study by Cole et al. [43] examined only S.
aureus from the hands and had a relatively small number of
isolates available for comparison. Moreover, this study did not
randomize households to antiseptic product use or utilize
masking of treatments, which could reduce the ability to detect
a difference between user groups. The longest period of followup among these studies was 1 year [44, 45], which may not
adequately reflect the time course for the development of resistance associated with use of products containing triclosan.
Lastly, baseline levels of susceptibility to triclosan among bacterial species in the community setting are virtually unknown.
Thus, it is difficult to show a change if the organisms have
already achieved some level of resistance [44]. Most of the data
on MICs to triclosan are from studies of clinical laboratory
strains and culture type collections [2]. Consumer hygiene
products containing triclosan have been used since the 1960s,
and no formal surveillance mechanisms exist for assessing susceptibilities of bacteria to this agent in the community setting.
Further research is clearly needed to assess whether the emergence of antibiotic resistance in the community setting is associated with the growing use of soaps containing triclosan.
Because our key aim in this review was to assess the efficacy
of and risks associated with the use of soaps containing triclosan
in the community setting, our literature search excluded studies
conducted in the clinical setting and those with health care
workers as study subjects. We did include 3 studies that did
Antibacterial Soap Use: Efficacy and Risks CID 2007:45 (Suppl 2) S145

not specifically state the source of volunteers included in their

studies [20, 24, 28], because there was no indication that these
subjects were derived from the clinical setting. Because of our
focus on the community, we also excluded studies that assessed
exposure to triclosan in the clinical setting and the emergence
of antibiotic resistance. Two of the studies by Luby et al. [21,
23] did not present a statistical comparison of the antiseptic
treatment arm and the plain soap treatment arm, so we computed statistical comparisons by use of the data available from
the study. Therefore, it is possible that these 2 studies did not
have adequate sample sizes to detect differences between treatment arms using biocide-containing versus plain soap. The
differences, however, were very small and showed an even
slightly higher level of infectious illness symptoms, for some
of the outcomes, among the biocide-containing soap users
compared with the plain soap users.
Because hand soaps are one of the most commonly available
hygiene products containing triclosan, we limited our review
to studies that provided the results of exposure to these products among isolates of bacteria from humans. Two of the studies
included in our review isolated bacterial species from humans
and the environment [33, 43]. For these studies, we reported
only the results regarding the isolates from humans. Importantly, the results were similar regardless of isolate source [33,
43]. In addition, our search did not include studies that were
published in languages other than English. PubMed was the
only search database utilized; therefore, print sources such as
conference abstracts were excluded.
CONCLUSIONS
The results of our review call into question the marketing of
soaps containing triclosan as a product providing efficacy beyond the use of plain soap in the community setting. Soaps
containing triclosan at concentrations used in the community
setting (0.2% or 0.3% wt/vol) were generally no more efficacious than plain soap at preventing infectious illness symptoms
and reducing bacterial levels on the hands. Several studies demonstrated laboratory evidence of triclosan-adapted cross-resistance with antibiotics among multiple species of bacteria. There
are still too few studies that have been conducted in the community setting to adequately assess whether the emergence of
antibiotic resistance in that setting is associated with the use
of consumer soaps containing triclosan. Longitudinal studies
are needed to assess changes in levels of antibiotic resistance
associated with use of soap containing triclosan over time, and
large databases of isolates are required to examine within-species changes in antibiotic-resistance profiles. Still, current findings warrant actions by the FDA for evaluating consumer product advertising claims. Future research should be directed at
addressing both the efficacy of and risks associated with the
use of triclosan. For instance, data are needed to assess whether
S146 CID 2007:45 (Suppl 2) Aiello et al.

products containing triclosan provide an added level of protection among high-risk groups, such as immunocompromised
individuals living in the household setting.
Acknowledgments
We are grateful to Rebecca M. Coulborn for editing the manuscript.
Supplement sponsorship. This article was published as part of a supplement entitled Annual Conference on Antimicrobial Resistance, sponsored by the National Foundation for Infectious Diseases.
Potential conflicts of interest. All authors: no conflicts.

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