Hand Hygiene

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Hand Hygiene

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Nosocomial Infections (NIs)

• 2 million NIs annually in U.S. (prevalence rate
  3.5-9)
• UTI, lower respiratory tract infections,
  surgical-site infections and primary septicemia
• Nearly 10 of hospitalized patient and result in
• Prolong hospital stays
• Substantial morbidity and mortality
• Nearly 90000 deaths yearly
• Excessive cost
• Increase 4.5 billion annually

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You may not Realize You Have Germs on Your Hands!

• Nurses, doctors and other healthcare workers can
  contaminate their hands by doing simple tasks,
  including 
• Taking a patients blood  pressure or pulse
• Assisting patients with mobility
• Touching the patients gown  or bed sheets
• Touching equipment,  including bedside rails,
  over  bed tables, IV pumps

http//www.handhygiene.org/
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Hand as a Vectors of Transmission

• Organisms present on the patients skin or on
  inanimate objects
• Organism must be capable of surviving for at
  least several minutes on the hands of personnel
• Handwashing or hand antisepsis is inadequate or
  omitted entirely
• Come in direct contact with another patient, or
  with an inanimate object

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Introduction

• Hand hygiene is the most important tool in NI
  control
• Adherence to hand-washing practices remains
  unacceptable low, rarely exceeding 40

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CID 200031136
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• Ignaz Philipp Semmelweis (1818-65), a Hungarian
  obstetrician educated at the universities of Pest
  and Vienna, introduced antiseptic prophylaxis
  into medicine.

Ignaz Philipp Semmelweis (1818-1865)
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Curr Opin Infect Dis 1998 11 457-460
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Historical Perspective

• 1961 the U.S. Public Health Servicetraining
  film of hand washing
• 1975 and 1985 guideline on handwashing practice
  in hospital published by CDC
• 1988 and 1995 guideline published by APIC 1995
  and 1996 guideline by HICPAC
• 2002 guideline published by HICPAC, SHEA, APIC
  and IDSA

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Types of Skin Flora

• Transient flora
• Resident flora
• Infectious flora

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Resident Flora

• Deeper skin layers
• Mainly CNS, coryneform bacteria and micrococci
  fungi (Malassezia) virus usually not resident on
  the skin
• More resistant to mechanical removal and stable
  over time
• Lower pathogenic potential (not pathogens on
  intact skin)
• Colonization resistance

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Transient Flora

• Superficial layers usually not multiply on the
  skin
• Acquired by contact with patient or environment
• Easily removed by mechanical means
• S. aureus, GNB or candida or virus

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Infectious Flora

• The etiologic agents of actual infections such as
  abscess, panaritium, paronychia, and infected
  eczema on the hands
• S. aureus and ß-hemolytic streptococci

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Clin Microbiol Rev. 200417(4)863
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Clin Microbiol Rev. 200417(4)863
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Aim of Hand Hygiene

• Rapid elimination of transient bacteria
• Persistent antimicrobial activity on the resident
  flora
• Not damage the skin

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Soap

• Plain
• Esterified fatty acids with sodium or potassium
  hydroxide
• Mechanical removal of dirt and loosely adherent
  flora (transientgtresident)
• Antiseptic

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Precaution

• Recontaminated from faucets or by splashes from
  traps or sinks (P. aeruginosa in the tap water)
  or from plain soap (both bar and liquid soaps,
  bar soaps heavier S. marcescens or Serratia
  liquefaciens)
• Outside health care facilities (working hours,
  before eating, after using restroom), use of soap
  and water is recommended

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Chlorhexidine

• A cationic biguanide
• England in 1954 introduced into U.S. in 1970s
• Chlorhexidine base only minimally soluble in
  water, but digluconate is water-soluble
• Exists as acetate (diacetate), gluconate, and
  hydrochloride salts

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Mechanism of Action

• Attach to bacterial cytoplasmic membrane (inner
  membrane)
• Precipitation or coagulation of protein and
  nucleic acids
• Also to the outer membrane in G(-) and the cell
  wall in G()
• Also damage the cytoplasmic membrane of yeasts

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Spectrum of Activity

• Depends on concentration
• lower bacteriostatic against GP bacteria, GNB
  and bacterial spores
• Bacteria
• Good activity against G(), less G(-) and fungi,
  not spores
• Dermatophytes no activity
• Mycobacteria limited
• Virus good for most enveloped virus, low for
  naked viruses

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Efficacy

• Reduce transient bacteria by 2.1 to 3 log10
  smaller in resident flora (0.35 to 2.29 log10)
• Activity is greatly reduced in the presence of
  organic matter, natural corks, and hand creams
  containing anionic emulsifying agents
• Substantial residual activity

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Resistance

• If MIC greater than 50 mg/liter
• Uncommon among G() bacteria
• Yes for G(-), such as E.coli, P.mirabilis
  (84.6), P. stuartii, P. aeruginosa, P. cepacia
  and S. marcescens
• C. albicans (10.5)
• Cross-resistance ()
• Mechanism
• Alternation of inner, outer membrane or the cell
  wall

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Adverse Effect

• Temperature greater than 70?, chlorhexidine may
  degrade to para-chloraniline (carcinogenic)
• Conjunctivitis and corneal damage when contacted
  with eye
• Ototoxicity
• Dermatitis is concentration dependent
• Anaphylactic reactions
• Avoid direct contact with brain tissue and the
  meninges

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Ethanol, Isopropanol, and n-Propanol

• Ethanol is introduced in 1888, isopropanol and
  n-propanol in 1904
• Vigorous friction, rinsing with water, and drying
  with a towel are unnecessary

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Mechanism of Action

• Killing not mechanically remove
• Protein denaturation, rapid killing (sec)

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Spectrum of Activity

• Mycobacteria
• Excellent in vitro activity against G() and G(-)
  bacteria
• Virus
• Good activity against enveloped viruese
• Nonenveloped viruses require higher concentration
  (70-80)
• Against most fungi
• Poor or no activity against spores, protozoal
  oocysts

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Efficacy

• The type of alcohol
• Concentration
• Contact time
• Volume used
• Whether the hands are wet when the alcohol
  applied
• Temperature
• Organic material

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When should You Use an Alcohol-based Hand Rub?

• Before having direct contact with patients
• After having direct contact with a patients skin
• After having contact with body fluids, wounds or
  broken skin
• After touching equipment or furniture near the
  patient
• After removing gloves.

http//www.handhygiene.org/
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When should You Use an Alcohol-based Hand Rub?

• DO NOT OPT FOR AN ALCOHOL-BASED
• HAND-RUB WHEN HANDS ARE VISIBLY
• SOILED OR CONTAMINATED WITH
• BLOOD OR BODY FLUIDS!

http//www.handhygiene.org/
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Some Tips on How to Use an Alcohol-based Hand Rub

• Apply 1.5 to 3 ml (about the size of quarter) of
  an alcohol gel or rinse to the palm of one hand,
  and rub hands together
• Cover all surfaces of your hands and fingers,
  including areas around/under fingernails
• Continue rubbing hands together until alcohol
  dries (about 15-25 seconds)
• Make sure your hands are completely dry prior to
  putting on gloves

http//www.handhygiene.org/
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Mayo Clin Proc. 200479(1)109
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Resistance

• No evidence for ethanol, isopropanol, or
  n-propanol
• Mechanism of action
• Rapid killing
• Rapid evaporation

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Adverse Effect

• Skin barrier remains intact, dermal hydration
  does not change significantly and the dermal
  sebum content unchanged
• Allergy is extremely rare alcohol should not be
  applied to wet skin or to hands with soap residue.

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Clin Microbiol Rev. 200417(4)863
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Clin Microbiol Rev. 200417(4)863
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Time-Course of Efficacy of Unmedicated Soap and
Water and Alcohol-Based Handrub in Reducing the
Release of Test Bacteria from Artificially
Contaminated Hands
Curr Opin Infect Dis. 2003 Aug16(4)327
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Mayo Clin Proc. 200479(1)109
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Indication for Handwashing

• Before eating and after using a restroom, wash
  hands with a nonantimicrobial soap and water or
  with an antimicrobial soap and water (IB)
• Antimicrobial-impregnated wipes are not
  substitute for alcohol-based hand rub or
  antimicrobial soap (IB)
• No recommendation for the routine use of
  nonalcohol-based hand rubs for hand hygiene in
  health-care settings

MMWR 2002511-45
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Anesthesiol Clin North America 2004 22 457
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Hand Drying

• Transmission of microorganism is more effective
  in wet environments
• Methods
• Clothtowels not recommended in healthcare
  setting (risk of cross-infection)
• Paper towels safer
• Hot air drying may disperse microorganisms by
  the airborne

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Influence of Handwashing on Skin

• Increase skin pH less important as a cause of
  skin irritation
• Reduce lipid content,
• Loss of amino acid and antimicrobial protective
  factors
• Increase transepidermal water loss
• Increase microbial shedding

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Handwashing Remove Lipids from the Skin

• Detergent aspect
• Anionic detergents cause greater skin irritation
• Temperature of water
• Hot water more skin irritation
• Rate of lipid replenishment on the dorsum of
  hands is only 20 after 1 h and 50 after 3 h

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Skin Problems

• Drying and irritation of skin
• Dermatitis
• 10-45 prevalence
• More likely to harbor S. aureus and other germs
• Less effectively in reducing bacteria by plain or
  antiseptic soap
• Shedding more organisms

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Skin Care

• Provide HCWs with hand lotions or creams to
  minimize the occurrence of irritant contact
  dermatitis associated with hand antisepsis or
  handwashing (IA)

MMWR 2002511-45
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Observed Risk Factors

• Physician and nursing assistant status (rather
  than nurse)
• Male gender
• Working in critical care
• Working during the week (versus weekend)
• Wearing gowns/gloves
• Automated sink
• Activities with high risk of cross-transmission
• High number of indications for hand hygiene per
  hour of patient care

Curr Opin Infect Dis. 2003 Aug16(4)327
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Self-Reported Factors

• Skin irritation and dryness associated with the
  use of hand hygiene agents
• Sinks are inconveniently located/shortage of
  sinks
• Lack of soap, paper, towel
• HCW is too busy, has insufficient time for hand
  hygiene
• Understaffing/overcrowding
• Patient needs take priority
• Hand hygiene interferes with HCW-patient relation
• Low risk of acquiring infection from patients

Curr Opin Infect Dis. 2003 Aug16(4)327
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Self-Reported Factors

• Wearing of gloves
• Belief that gloves use obviates the need for hand
  hygiene
• Lack of knowledge of guidelines/protocols
• Not thinking about hand hygiene/forgetfulness
• No role model from colleagues or superiors
• Skepticism about the value of hand hygiene
• Disagreement with recommendations/indications for
  hand hygiene
• Lack of scientific information of definitive
  impact of improved hand hygiene on infection rates

Curr Opin Infect Dis. 2003 Aug16(4)327
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Additional Perceived Barriers

• Lack of active participation in hand hygiene
  promotion at individual or institutional level
• Lack of role model for hand hygiene
• Lack of institutional priority for hand hygiene
• Lack of administrative sanction of
  noncompliers/rewarding of compliers
• Lack of institutional safety climate

Curr Opin Infect Dis. 2003 Aug16(4)327
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EID 20017234
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Gloves

• Contact with blood, body fluids, mucous
  membranes, nonintact skin, or potential
  infectious materials (IC)
• Each pair for each one (IB), same one? (II)
• Not be washed or resuded (IB)
• Hand hygiene

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Rings

• Skin underneath rings is heavily colonized with
  bacteria
• The number of microorganisms increases with the
  number of rings worn
• No recommendation can be made regarding wearing
  rings in health-care settings

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Wrist Watches and Bracelets

• Most guidelines recommend that wrist watches and
  bracelets should be removed before hand hygiene
  practices

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Fingernails, Nail technology and Nail Polish

• Subungual region contains large numbers of
  bacteria (CNS, G(-), yeasts, corynebacteria) and
  largely inaccessible during hand hygiene

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Fingernails, Nail technology and Nail Polish

• Harbor GNB more yeast quite often colonize
  artificial fingernails
• Washing artificial nails is not as effective a s
  natural nails
• Several outbreaks with GNB (especially P.
  aeruginosa) and yeasts

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Fingernails, Nail technology and Nail Polish

• Do not wear artificial fingernails or extenders
  when having direct contact with patients at high
  risk (IA)
• Keep nature nails tips less than ¼-inch long (II)

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Conclusion

• Hands of HCWs are the primary mode of
  transmission of multidrug-resistant pathogens
• Proper hand hygiene is the single most important,
  simplest, and least expensive means of preventing
  health care associated infections and spread of
  antimicrobial resistance

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Conclusion

• Washed with soap and water primarily when visibly
  soiled or contaminated with blood , other body
  fluids, or proteinaceous material
• Alcohol or soap should not be used at the same
  time
• Handwashing doest not abolish, but only reduces
  transmission
• Hand hygiene alone to reduce infection in
  unlikely to be successful when other factors in
  infection control are inadequate

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Thanks for Your Attention