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http://ocw.usu.ac.id/course/download/1125-INFECTION-AND-TO!ICA"-

!EDIATIC#/$%&itps&slide&in'e%si&noso%o$ial.pd'

http://repositor(.usu.ac.id/)itstrea$/12*+5,/**++/*/Chapter02II.pd'

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http://epu)s.rcsi.ie/ci/7iewcontent.ci9article11*;contete)l.2.,+

!6CID: !6C222

Hand Hygiene for the Prevention of

Nosocomial Infections

nter a$p' !D Dr. $ed.12Garald "Her !ro'. Dr. $ed.*and !etra ast$eier

!ro'. Dr. $ed

Abstract

Background

The WHO regards hand hygiene as an essential tool for the prevention of nosocomial infection,

but compliance in clinical practice is often low.

Methods

The relevant scientific literature and national and international evidence-based recommendations

(Robert och !nstitute "#ermany$, WHO% were evaluated.
http://ocw.usu.ac.id/course/download/1125-INFECTION-AND-TROPICAL-PEDIATRICS/mk_itps_slide_infeksi_nosokomial.pdfhttp://ocw.usu.ac.id/course/download/1125-INFECTION-AND-TROPICAL-PEDIATRICS/mk_itps_slide_infeksi_nosokomial.pdfhttp://repository.usu.ac.id/bitstream/123456789/33474/3/Chapter%20II.pdfhttp://digilib.unimus.ac.id/files/disk1/122/jtptunimus-gdl-ragilarifw-6085-2-babii.pdfhttp://staff.blog.ui.ac.id/wiku-a/files/2012/09/Manajemen-Pencegahan-Surveilans-Untuk-Infeksi-Nosokomial.pdfhttp://staff.blog.ui.ac.id/wiku-a/files/2012/09/Manajemen-Pencegahan-Surveilans-Untuk-Infeksi-Nosokomial.pdfhttp://epubs.rcsi.ie/cgi/viewcontent.cgi?article=1013&context=clinmicarthttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://dx.doi.org/10.3238%2Farztebl.2009.0649http://www.ncbi.nlm.nih.gov/pubmed/?term=Kampf%20G%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=L%26%23x000f6%3Bffler%20H%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Gastmeier%20P%5Bauth%5Dhttp://ocw.usu.ac.id/course/download/1125-INFECTION-AND-TROPICAL-PEDIATRICS/mk_itps_slide_infeksi_nosokomial.pdfhttp://ocw.usu.ac.id/course/download/1125-INFECTION-AND-TROPICAL-PEDIATRICS/mk_itps_slide_infeksi_nosokomial.pdfhttp://repository.usu.ac.id/bitstream/123456789/33474/3/Chapter%20II.pdfhttp://digilib.unimus.ac.id/files/disk1/122/jtptunimus-gdl-ragilarifw-6085-2-babii.pdfhttp://staff.blog.ui.ac.id/wiku-a/files/2012/09/Manajemen-Pencegahan-Surveilans-Untuk-Infeksi-Nosokomial.pdfhttp://staff.blog.ui.ac.id/wiku-a/files/2012/09/Manajemen-Pencegahan-Surveilans-Untuk-Infeksi-Nosokomial.pdfhttp://epubs.rcsi.ie/cgi/viewcontent.cgi?article=1013&context=clinmicarthttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://dx.doi.org/10.3238%2Farztebl.2009.0649http://www.ncbi.nlm.nih.gov/pubmed/?term=Kampf%20G%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=L%26%23x000f6%3Bffler%20H%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Gastmeier%20P%5Bauth%5D


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Results

Hygienic hand disinfection has better antimicrobial efficacy than hand-washing and is theprocedure of choice to be performed before and after manual contact with patients. The hands

should be washed, rather than disinfected, only when they are visibly soiled. &'in irritation is

uite common among healthcare wor'ers and is mainly caused by water, soap, and prolongedwearing of gloves. )ompliance can be improved by training, by placing hand-rub dispensers at

the sites where they are needed, and by physicians setting a good e*ample for others.

Conclusions

!mproved compliance in hand hygiene, with proper use of alcohol-based hand rubs, can reducethe nosocomial infection rate by as much as +.

Keywords: hand h(iene disin'ection co$pliance nosoco$ial in'ection

protecti7e lo7es

Healthcare wor'ers hands represent the principal route of transmission of nosocomial

pathogens. They are coloni/ed permanently by the physiological flora (0resident flora1% andtemporarily, depending on the precise nature of the employees duties, by various pathogens that

do not belong to the physiological flora (0transient flora1% (2%. Staphylococcus aureus, for

e*ample, can survive for over 3 h on the hands and is found in 2 to 45 of staff (table 2%.

Ta)le 1

Frequency and persistence of selected nosocomial pathogens on the hands

of healthcare workers (1

o to:

Clean Hands Campaign

!mprovement of hand hygiene, with the aim of minimi/ing nosocomial infection, is a highpriority of the World Health Organi/ation (WHO%. The promotion of effective measures to

improve hand hygiene (e2% is therefore one of the five foremost goals of the WHOs current

worldwide 6atient &afety !nitiative (7nnounce 7ction on 6atient &afety "High 8s$ !nitiative,Washington, 9), + :ovember 3;%.


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Health (e3%. or studies published from 3; onward we performed a

selective review of the publications in the :ational Bibrary of ?edicine. >urthermore, we

evaluated the recommendations of the following institutionsC

Co$$ission 'or Gospital G(iene and !re7ention o' In'ection o)ert ochInstitute @I @2

Association o' the #cienti3c 6edical #ocieties in er$an( @AJ6F @e+

JGO @3nal reco$$endation @*

Centers 'or Disease Control and !re7ention @CDC @e5.

o to:

Importance of protective gloves

The wearing of protective gloves is a sensible precaution in various clinical situations in order to

prevent gross soiling or contamination (bo* 2%. !t may even brea' the chain of infection more

effectively than hand-washing or hand disinfection. 7 prospective, controlled intervention studyshowed that a training session and the availability of gloves directly at the bedside can

significantly reduce the incidence of Clostridium difficileDassociated diarrhea ()979% (+%. The

hands should be disinfected when protective gloves are ta'en off, because in contrast to surgical

gloves, ordinary protective gloves are often permeable to pathogens even before use. ?oreover,the hands may have come into contact with the potentially contaminated outer surface of the

gloves during removal. !n the case of vancomycin-resistant enterococci (ERF%, a study showed

that despite the use of gloves the same pathogen could be found on the hands of staff involved intreatment in A of cases (8%.

o to:

Box 1

Clinical situations in which the wearing of protecti!e glo!es is especially

indicated

E


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E


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Bene*ts and risks

The limited benefits of hand-washing are accompanied by the ris' of cutaneous irritation andhand ec/ema. >reuent washing of the hands can lead to dryness and impair the barrier function

of the s'in (4%. The s'in thus continually loses fats and water-binding factors, and no*ious

substances can more easily penetrate the epidermis. )linically manifest irritant ec/ema of thehand may gradually develop. #iven the comparatively slight benefit, it swiftly becomes clear

that hand-washing should be seen as an e*ception. ?erely in the case of contamination with

spore-forming bacteria, e.g., C. difficile, is it useful to wash the hands after disinfection, because

bacterial spores are naturally resistant to alcohol.

o to:

Hygienic hand disinfection

"ndications

Hand disinfection is indicated in almost all interactions of medical staff with patients (bo* 3% (3%.

o to:

Box !

+ygienic hand disinfection ,ene*ts the patient in the following clinical

situations (:

Ke'ore in7asi7e procedures e7en i' lo7es will )e worn e..

Insertion o' a 7enous or )ladder catheter

Anioraph( )ronchoscop( endoscop(

In4ections and punctures

Ke'ore contact with patients who are at particular ris% o' in'ection e..

"eu%e$ia patients

!ol(trau$a patients

Kurns patients

Irradiated and other se7erel( ill patients

Ke'ore e


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Ke'ore and a'ter an( contact with

Jounds

Insertion sites o' catheters or drains

A'ter contact with Klood secretions eor e*ample, the hands should be disinfected after direct patient contact (measurement of vital

functions, auscultation, palpation% or after contact with potentially infectious materials, e.g.,bandages. Hand disinfection is most important, however, in the case of potential nosocomial

infections (3,A%. The most freuent such infections in #ermany are catheter-associated urinary

tract infection (ca. +3%, ventilator-associated pneumonia (ca. 32%, surgical site infection (ca.

2;%, and catheter-associated bloodstream infection (ca. 5% (5%. Hygienic hand disinfection canma'e a substantial contribution to preventing these infections if consistently performed at the

following unctures (3, A%C

Catheter-associated urinar( tract in'ection: )e'ore place$ent o' the urinar(

catheter )e'ore and a'ter contact with the catheter Lentilator-associated pneu$onia: )e'ore and a'ter intu)ation )e'ore and

a'ter aspiration

#urical site in'ection: )e'ore and a'ter contact with wounds a'ter re$o7al o'a )andae

Catheter-associated )loodstrea$ in'ection: )e'ore place$ent o' 7ascularcatheters )e'ore $anipulation o' 7ascular catheters )e'ore preparation o'intra7enous $edication.

#$cacy

The commonly available hand rubs are considerably more effective than hand-washing with soap

(3, A%. Within A s, for e*ample, the following bacteria are not only greatly reduced but

practically completely eliminated (e;%C

Escherichia coliM$ost 'reuent cause o' catheter-associated urinar( tractin'ection
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Pseudomonas aeruginosaM7er( 'reuent cause o' 7entilator-associatedpneu$onia

Staphylococcus aureusM$ost 'reuent cause o' surical site in'ection

Staphylococcus epidermidisM$ost 'reuent cause o' catheter-associated

)loodstrea$ in'ection.

The same applies to yeasts such as Candidaspp. orRhodotorulaspp. and to coated viruses such

as Hor spore-forming bacteria such as C. difficile, the recommendation isfirst to disinfect the hands in order to 'ill off the vegetative form, then to wash them briefly but

thoroughly to reduce the number of spores as much as possible (e4%.

Bene*ts and risks

Hand disinfection is 'ey to the prevention of nosocomial infections. 7t #eneva Iniversity

Hospital, improvement of the compliance rate from +5 to ;; over a 8-year period loweredthe freuency of nosocomial infections by more than + (2%. Over the same period the rate of

new infections by methicillin-resistant S. aureus(?R&7% was reduced by more than 8 (2%.

!n contrast to popular opinion, the irritant potential of alcohol-based hand rubs is very low.)ommercially available preparations are generally tolerated much better than the detergents inhand-washing agents (4, 22%. Fven freuent, intensive hand disinfection detracts only minimally

from the s'ins barrier function and ma'es the s'in only slightly drier. This is due partly to the

s'in care substances usually found in hand rubs. 7llergic reactions to the ingredients of hand-rubpreparations are e*tremely rare (2,A%.

>or hand disinfection to be effective, both hands must be completely covered. To this end, an

adeuate amount of the hand rub must be applied efficiently. The duration of application should

be 33 to 35 s. &horter application times, e.g., 28 s, almost always fail to cover the handscompletely (23%. &urprisingly, the best results are achieved when users are left to their own

devices, not with a strictly regulated procedure. &pecial attention must be paid to the fingertipsand thumbs, howeverJ these parts of the hand are most li'ely to come into contact with thepatient, and the greatest proportion of the bacteria are found on the fingertips (2A%.

o to:

Hand ec"ema
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There can be no doubt that hygiene precautions are a ris' factor for occupational hand ec/ema.

)onseuently employment in nursing and related professions involves the ris' of contracting

occupational dermatosis (2+%. ?any consider rough, fla'ing s'in on their hands as normal intheir line of wor' and fail to reali/e that this may be the first sign of hand ec/ema (figure 2%. !n a

survey carried out by the #erman )ontact 7llergy #roup (9eutsche onta'tallergiegruppe,

9#%, more than 4 of nursing staff reported irritant s'in symptoms within a year, and +;considered them detrimental in their daily lives (28%.

Fiure 1

Earl( irritant s%in chanes )etween the diits

?ost nurses still believe that alcohol-based hand rubs damage their s'in more than hand-washing(28%. However, alcohol-based preparations are much 'inder to the s'in than hand-washing agentsbecause they are less harmful to the cutaneous barrier (as measured by transepidermal water loss%

and dry the s'in out less (as measured by corneometry% (4, 22%. !nterestingly, the application of

alcohols after hand-washing can even reduce the irritation caused by the washing, probably by

elimination of residual detergent monomers (4%. :evertheless, many users thin' that hand rubsharm their s'in. One reason is the burning felt when the alcohols stimulate the pain receptors in

damaged areas of s'in. The alcohol-based hand rub is then blamed for the symptoms (0it only

burns with the alcohol1% and hand disinfection is abandoned in favor of washing. The burningstops, but the damage acceleratesC a vicious circle begins, resulting in manifest hand ec/ema

(figure 3% and, in the worst case, inability to wor' (2;%.

Fiure 2

6ani'est irritant hand ec>e$a

7 burning sensation on use of a disinfecting hand rub is a warning of impairment of the s'insbarrier function. Those affected should avoid activities harmful to the s'inGwashing, occlusion

(protective gloves%, contact with soaps, direct contact with irritant disinfectantsGand applycopious uantities of s'in protection and s'in care products.

&ome users state that alcohol-based hand rubs have a sensiti/ing effect. :evertheless,sensiti/ation to an alcohol could be e*cluded in all 8 persons who were tested for allergic

reactions to an alcohol-based hand rub because of suspected intolerance. Oversensitivity to an

e*cipient (e.g., cetearyl octanoate% was demonstrated, however (28%.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15


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7n intact cutaneous barrier is of more than ust cosmetic and functional relevance. Fc/ematous

hands are also coloni/ed to a greater degree by pathogens than are healthy hands (24, 25%. The

principles of hand care and protection should therefore be taught to all healthcare wor'ers andshould form part of every training program (2@%. They are also included in the )lean Hands

)ampaign.

o to:

Care and protection of the s#in

7ppropriate precautions when using potentially irritant substances can prevent harm to the s'in.

?oreover, adeuate protection and care of the s'in are of paramount importance for themaintenance of a functioning cutaneous barrier (e5%. These precautions should be integrated in

the wor'ing routine and can, if properly implemented, protect the hands without compromising

disinfection. &'in protection plans should be drawn up with information about the available

products and their use (see Technical Rule for Ha/ardous &ubstances "TR#&$ +2 of =une 35C

Ris's resulting from s'in contactGdetermination, evaluation, measures% (3%. &taff should haveaccess to data showing the efficacy of all preparations employed, as well as information on their

uses (see the 0Occupational &'in 6reparations1 (0


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Insucient %nowlede o' the clinical situations in which the patient clearl()ene3ts

"ac% o' products or dispensers: una7aila)ilit( o' the disin'ectin hand ru)riht where it is needed

"ac% o' ti$e: hand disin'ection is 'reuentl( not carried out )ecause o'

increasin pressure o' wor% or when a ward is o7er-occupied or under-staed@2*

Cutaneous irritation: s%in pro)le$s with use e.. dr(ness irritation or)urnin co$)ined with inadeuate %nowlede o' the causes

Failure o' hih-ran%in $edical sta to set an eurthermore,

s'in protection and care products must be available to all employees at their wor'place. One can

only appeal to all senior staff to set a proper e*ample. !t will then be much more difficult forunior wor'ers not to follow suit.

o to:

Box $Measures to impro!e compliance

#ta trainin with reard to the clinical situations in which hand disin'ectionis indicated

Inclusion o' the oals in the trainin prora$ )ecause )eha7ior learneddurin )asic trainin is put into practice $uch $ore eecti7el( than thattauht in later trainin sessions when esta)lished routine )eha7ior has to )echaned

Disin'ectin hand ru)s should )e a7aila)le where the( are actuall( needed.This can )( achie7ed )( si$ple $eans )oth in the hospital and the doctorPs

oce. I' wall dispensers cannot )e $ounted the doctor $a( )e a)le to carr(a )ottle o' hand ru) in the poc%et o' his/her la) coat.

eduction o' hand-washin to a $ini$u$ in order to a7oid unnecessar( s%inirritation

#enior $e$)ers o' $edical sta $ust reconi>e that the( ha7e to set ane


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o to:

Concl%sion

Fvidence-based hand hygiene can prevent transmission of the most important nosocomial

pathogens and also 'eep employees s'in healthy. !n most clinical situations hygienicdisinfection is indicated for hand decontamination on grounds of better efficacy and cutaneoustolerance. Washing with soap and water is necessary only when the hands are visibly soiled, or

following disinfection in the case of contamination by spores of bacteria such as C. difficile.

)ompliance could be improved by 'nowledge of the principal clinical circumstances in which

hand disinfection by healthcare wor'ers genuinely benefits the patient.

o to:

&ey Messages

Gand disin'ection eli$inates the transient Qora and is one o' the $osti$portant precautions 'or speci3c pre7ention o' trans$ission o' nosoco$ialin'ections.

In practice on a7erae e7er( second necessar( disin'ection o' the hands isnot actuall( carried out. The JGO has there'ore launched a worldwideinitiati7e to i$pro7e co$pliance.

The rate o' nosoco$ial in'ections can )e reduced )( up to +0 )( i$pro7edco$pliance in hand disin'ection.

Gand-washin da$aes the s%in $ore than hand disin'ection. It shouldprincipall( )e restricted to 7isi)l( soiled hands and 'ollowin disin'ectionhands conta$inated with spore-'or$in )acteria such as C. difcile.

A )urnin sensation on hand disin'ection represents an i$portant warnin o'da$ae to the cutaneous )arrier. Acti7ities har$'ul to the s%in e.. 'reuentwashin $ust then )e a7oided and s%in protection and care products applied$ore intensi7el(.

o to:

Ac#noledgments

Translated from the original #erman by 9avid Roseveare.

o to:

'ootnotes
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/


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Conflict of interest statement

9r. ampf is an employee of


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11. Jinne'eld 6 ichard 6A Drancourt 6 ro)) UU. #%in tolerance and

eecti7eness o' two hand deconta$ination procedures in e7er(da( hospital use.

Kritish Uournal o' Der$atolo(. 2?1+*:5+,B55. R!u)6edS

12. a$p' eichel 6 Feil V Eerstedt # aul'ers !-6. InQuence o' ru)-in

techniue on reuired application ti$e and hand co7erae in h(ienic handdisin'ection. K6C In'ectious Diseases. 2? R!6C 'ree articleS R!u)6edS

1*. 6cinle( U "arson E" "e(den UU. Co$position and densit( o' $icroQora in the

su)unual space o' the hand. Uournal o' Clinical 6icro)iolo(. 1?2,:5B5*.

R!6C 'ree articleS R!u)6edS

1+. Dic%el G uss O Klesius C #ch$idt A Diepen T". Occupational s%in diseases

in Northern Ka7aria )etween 1 and 1: a population-)ased stud(. Kritish

Uournal o' Der$atolo(. 21?1+5:+5*B+,2. R!u)6edS

15. #tut> N Kec%er D Uappe 8 et al. NursesP perceptions o' the )ene3ts and

ad7erse eects o' hand disin'ection: alcohol-)ased hand ru)s 7s. h(ienichandwashin: a $ulticentre uestionnaire stud( with additional patch testin )( the

er$an Contact Der$atitis esearch roup. Kritish Uournal o' Der$atolo(.

2?1,:5,5B52. R!u)6edS

1,. "))e U ueu< C !errenoud D. A stinin cause 'or pre7enti7e s%in care. The

"ancet. 2?*5,:,B,. R!u)6edS

1. Jan U-T Chan #-C o J-U et al. A hospital-acuired out)rea% o' $ethicillin-

resistant #taph(lococcus aureus in'ection initiated )( a sureon carrier. Uournal o'

Gospital In'ection. 21?+:1+B1. R!u)6edS

1. Da7e U eith # Nash UW 6arples Dula%e C. A dou)le out)rea% o' e


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und #tu'en7er'ahren Gaut der eset>lichen 8n'all7ersicherun. Der Gautar>t.

2?5:,2B,5. R!u)6edS

2*. Gar)arth # #udre ! Dharan # Cadenas 6 !ittet D. Out)rea% o' Entero)acter

cloacae related to understan o7ercrowdin and poor h(iene practices.

In'ection Control and Gospital Epide$iolo(. 1?2:5B,*. R!u)6edS2+. Dharan # Guonnet # #a< G !ittet D. Co$parison o' waterless hand antisepsis

aents at short application ti$es: raisin the Qa o' concern. In'ection Control and

Gospital Epide$iolo(. 2*?2+1:,B1,. R!u)6edS

e1. Jorld Gealth Orani>ation. Clean Care is #a'er Care.

www.who.int/patientsa'et(/en/

e2. A%tion #au)ere Gnde. www.a%tion-sau)erehaende.de.

e*. JGO. JGO uidelines on hand h(iene in health care @ad7anced dra't 2,.

e+. Ar)eitse$einscha't der Jissenscha'tlichen 6edi>inischen Fachesellscha'ten.

Gndedesin'e%tion und Gndeh(iene. G(iene Y 6edi>in. 2?**:*B*1*.

e5. Ko(ce U6 !ittet D. uideline 'or hand h(iene in health-care settins.

eco$$endations o' the healthcare in'ection control practices ad7isor( co$$ittee

and the GIC!AC/#GEA/A!IC/ID#A hand h(iene tas% 'orce. 66J - 6or)idit( ;

6ortalit( Jee%l( eport. 22?51:1B+5. R!u)6edS

e,. a$p' Gollinsworth A. Lalidit( o' the 'our European test strains o' prEN

125+ 'or the deter$ination o' co$prehensi7e )actericidal acti7it( o' an alcohol-

)ased hand ru). Uournal o' Gospital In'ection. 2*?55:22,B2*1. R!u)6edSe. a$p' . Clostridiu$ dicile - was ist 'r eine ee%ti7e Desin'e%tion >u

)eachten9 G(iene Y 6edi>in. 2?**1:5*B5.

e. Ar)eitse$einscha't 'r Keru's- und 8$weltder$atoloie. www.a)d.der$is.net/

http://p$4.)$4.co$/content//*/1,.'ull

Postgrad Med J 2001;771!"1# doi10.11$!%pm&.77.#0$.1!
http://www.ncbi.nlm.nih.gov/pubmed/18704346http://www.ncbi.nlm.nih.gov/pubmed/10501256http://www.ncbi.nlm.nih.gov/pubmed/12683505http://www.who.int/patientsafety/en/http://www.aktion-sauberehaende.de/http://www.ncbi.nlm.nih.gov/pubmed/12418624http://www.ncbi.nlm.nih.gov/pubmed/14572491http://www.abd.dermis.net/http://pmj.bmj.com/content/77/903/16.fullhttp://www.ncbi.nlm.nih.gov/pubmed/18704346http://www.ncbi.nlm.nih.gov/pubmed/10501256http://www.ncbi.nlm.nih.gov/pubmed/12683505http://www.who.int/patientsafety/en/http://www.aktion-sauberehaende.de/http://www.ncbi.nlm.nih.gov/pubmed/12418624http://www.ncbi.nlm.nih.gov/pubmed/14572491http://www.abd.dermis.net/http://pmj.bmj.com/content/77/903/16.full


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)he health professional*s role in preventing

nosocomial infections

1. G #aloo4ee2. A #teenho

M7uthor 7ffiliations

1. Department of Paediatrics and Child Health, ni!ersity of the "it#atersrand, P$ "its,

%ohannesbur& '()(, South Africa1. Dr #aloo4ee2salZchiron.wits.ac.>a

ecei7ed 12 Uanuar( 2

Accepted 6a( 2

Abstract

9espite their best intentions, health professionals sometimes act as vectors of disease,

disseminating new infections among their unsuspecting clients. 7ttention to simple preventivestrategies may significantly reduce disease transmission rates. >reuent hand washing remains

the single most important intervention in infection control. However, identifying mechanisms to

ensure compliance by health professionals remains a perple*ing problem. #loves, gowns, and

mas's have a role in preventing infections, but are often used inappropriately, increasing servicecosts unnecessarily. While virulent microorganisms can be cultured from stethoscopes and white

coats, their role in disease transmission remains undefined. There is greater consensus about

sterile insertion techniues for intravascular cathetersGa common source of infectionsGandtheir care.


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Aetiology of nosocomial infections

!ntravascular device related infections and infections acuired through the respiratory tract are

among the most common nosocomial infections in critically ill patients.+7mong the numerousris' factors for acuiring a nosocomial infection, the length of hospital stay is the most

important. (bo* 2%. 7etiological agents vary and include antibiotic resistant bacteria,particularlyStaphylococcus aureus, #ram negative bacilli and enterococci, viruses (whichaccount for up to 3 of cases%, and fungi.

Box 1+ (is# factors for nosocomial infection

9uration of hospital stay

!ndwelling catheters

?echanical ventilation

Ise of total parenteral nutrition

7ntibiotic usage

Ise of histamine (H3% receptor bloc'ers (owing to relative bacterial overgrowth%

7geGmore common in neonates, infants, and the elderly

!mmune deficiency

Hand ashingThe hands of staff are the commonest vehicles by which microorganisms are transmitted between

patients.8Hand washing is accepted as the single most important measure in infection control.8-

4:ot surprisingly, hospital staff believe that they wash their hands more often than they actuallydo, and they also overestimate the duration of hand washing.5!n a study of nursesN practices,

hands were only cleaned after A of patient contacts and after 8 of activities li'ely to result

in heavy contamination. 6oorer hand washing performance was related to increasing nursingwor'load and the reduced availability of hand decontaminating agents.@7t many hospitals and

clinics, particularly in developing countries, handwash basins are poorly accessible and the

unavailability of soap, sprays, and hand towels is a regular, annoying occurrence.

7lcoholic hand disinfection is generally used in Furope, while hand washing with medicatedsoap is more commonly practised in the Inited &tates.2The superiority of one method over the

other is a moot point. Eoss and Widmer argue that alcoholic hand disinfection, with its rapid

activity, superior efficacy, and minimal time commitment, allows easy and complete compliancewithout interfering with the uality of patient care.2They estimated that given 2

compliance, soap hand washing would consume 2; hours of nursing time for a 3+ hour shift,

whereas alcoholic hand disinfection from a bedside dispenser reuires only three hours. Hand
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washing using a spray can be accomplished in 3 seconds, compared with +D5 seconds for

soap.

Theatre staff are sometimes reluctant to remove their wedding rings when scrubbing up. Highermicrobial counts after washing are found in health wor'ers who prefer not to remove rings,22

and may put the patient at ris' for a nosocomial infection.23The value of surgical scrubbingusing a brush is uestioned. !n one study, subects who washed with an antiseptic soap alone had

a twofold greater reduction in bacterial counts than when they scrubbed with a brush.2A

)ontinued monitoring and educational efforts can improve hand washing habits.2+28Barson et

alreported that by providing feedbac' to staff regarding the freuency of hand washing,

compliance improved by @3.2+7las, when feedbac' was stopped compliance uic'ly returnedto baseline levels. The importance of constantly reminding staff of the need for hand washing,

and of senior staff setting a good e*ample by their own hygienic practices, cannot be

overemphasised.

!t is difficult to provide clear guidelines on how often hands should be washed. TheHandwashing Biaison #roup is emphaticC 0an e*plicit standard "should$ be set, that hands should

be decontaminated before each patient contact.12;We recommend the use of chlorhe*idine

solution before the performance of invasive procedures. The thoroughness of application is more

important than the time spent on washing or the agent used.

,loves

#loves are a useful additional means of reducing nosocomial infection, but they supplement

rather than replace hand washing. 6ossible microbial contamination of hands and transmission ofinfection has been reported despite gloves being worn.24:ot surprisingly, health care wor'ers

who wash their hands more often are also more li'ely to wear gloves.8&ingle use gloves shouldnever be washed, resterilised, or disinfected, and gloves must be changed after each patient

encounter.

&terile gloves are much more e*pensive than clean gloves and need only be used for certain

procedures, such as when hands are going to ma'e contact with normally sterile body areas or

when inserting a central venous or urinary catheter. )lean gloves can be used at all other times,

including during wound dressings. >or gloves to be used appropriately they must be readilyavailable. 7gain, this is not always the case at many clinics and hospitals in poorer settings.

,oning#owns help 'eep infectious materials off clothing, although in some centres they are used more

as reminders that the patient is isolated. Two recent studies confirm that staff gowning in theneonatal intensive care unit is an unnecessary custom.252@Wearing gowns did not reduce

neonatal colonisation, infection, or mortality rates. There was no change in traffic patterns in the

unit or in hand washing behaviour,25and it was not cost-effective.2@The universal use of gloves
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and gowns was found to be no better than the use of gloves alone in preventing rectal

colonisation by vancomicin resistant enterococci in a medical intensive care unit.3

Mas#s

!t has never been shown that wearing surgical facemas's decreases postoperative woundinfections. When originally introduced, the primary function of the surgical mas' was to prevent

the migration of microorganisms residing in the nose and mouth of members of the operating

team to the open wound of the patient. However, it is now recognised that most bacteriadispersed by tal'ing and snee/ing are harmless to wounds.32The prevailing opinion that mas's

are useful in preventing surgical site infection has been challenged.33-3+Orr reported a 8

decrease in wound infections when mas's were not worn, but the study was criticised for lac' ofproper controls.3ATunevall, using better controls, confirmed the earlier findings of lac' of clear

benefit from wearing mas's3+J after 28A4 operations performed with face mas's, 4A wound

infections were recorded (+.4%, while following 2882 operations performed without facemas's, 88 infections occurred (A.8%. The difference was not significant. Thus while mas's may

be used to protect the operating team from drops of infected blood and from airborne infections,they have not been proven to protect the patient.

tethoscopes

&ome health personnel have difficulty in accepting that the stethoscope, the symbol of their

professional status, may actually be a vector of disease. !n a study of 28 health care wor'ers (8

paramedics, 8 nurses, and 8 doctors%, staphylococcus species (mostly coagulase negative% werecultured from 5@ of the participantsN stethoscopes, the mean number of colony forming units

increasing the longer stethoscopes were not cleaned.38Overall, +5 of health care providers

cleaned their stethoscopes daily or wee'ly, A4 monthly, 4 yearly, and 4 had never cleanedthem. )leaning the stethoscopeNs diaphragm resulted in an immediate reduction in the bacterialcountGby @+ with alcohol swabs, @ with a non-ionic detergent, and 48 with antiseptic

soap.38

There are no studies on the beneficial effect of regularly cleaning stethoscopes on nosocomial

infection rates. :evertheless, we suggest that regular disinfection should be carried out (at leastonce daily%, as the level of contamination rises from to ;@ after more than one day without

cleaning of the stethoscope.3;!sopropyl alcohol is an effective cleaning agent,34but may dry

out the stethoscopeNs rubber seals and damage the tubing if used routinely.

.hite coatsBi'e the stethoscope, the white coat has long been a symbol of the medical professional. ?any

institutions insist that unior doctors, in particular, wear a white coat as part of a mandatory dress

code. 7bout half of all patients still prefer their doctor to wear one.35However, they may be lessenthusiastic about this if they realised that white coats harbour potential pathogens and are

thereby a source of cross infection, particularly in surgical areas.3@The cuffs and poc'ets of the

coats are the most highly contaminated areas. The recommendation that the coat is removed and
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a plastic apron is donned before wound e*amination is rarely followed in practice. While few

would challenge the sartorial elegance of the white coat, clearly its value needs to be critically

assessed. There is little microbiological evidence for recommending changing white coats moreoften than once a wee', or for e*cluding the wearing of white coats in non-clinical areas. 3@

Intraveno%s catheters

!n critically ill patients, intravenous lines are responsible for at least one uarter of all

nosocomial blood stream infections, with a 38 reported mortality.A?ost causative organismsoriginate from the s'inC staphylococci cause two thirds of the infections, with S aureus

accounting for 8D28 of these. The insertion of an intravenous needle or cannula results in a

brea' in the bodyNs natural defences. Organisms can enter the circulation from contaminated fluidor a giving set, or can grow along the outer surface of the cannula.

6revention of complications reuires careful insertion practice and optimal catheter care.

!nserting a peripheral catheter demands the same precautions as for any surgical procedure. The

hands should be disinfected with alcohol and gloves should be worn. The s'in of the insertionsite must be thoroughly disinfected with alcoholic chlorhe*idine or 4 isopropyl alcohol for at

least A seconds and allowed to dry before inserting the cannula. The insertion site should not be

touched after disinfection. When 3 chlorhe*idine, 2 povidone-iodine, and 4 alcohol werecompared as s'in disinfectants, the rate of catheter associated bacteraemia was almost fourfold

lower in the patients who received chlorhe*idine than in the two other groups. A2

The use of a clear, adhesive, bacteria impermeable dressing to secure the cannula has become

popular. These dressings may be contraindicated as they allow accumulation of blood, sweat, ande*udate, which may promote growth on and in the underlying s'in. !ndeed, a meta-analysis

showed a significantly increased ris' of catheter tip infection when transparent rather than gau/e

dressings were used with either central or peripheral catheters.A3Recently, polyurethanedressings, such as Tegaderm, have been produced which are several times more permeable than

standard dressings.AAThese should minimise the ris' of moisture accumulation and reduce sepsis

rates.AA

Routine replacement of the intravenous line every three to five days is common practice in theI&7 but not in Furope. #uidelines developed by the )enters for 9isease )ontrol and 6revention

recommend that peripheral intravenous catheters be changed every three days. However, routine

replacement of central venous catheters was no longer supported in their latest update.A+7recent &wiss study was unable to show an increased ris' of catheter related complicationsG

phlebitis, infections, and mechanical complicationsGduring prolonged peripheral

catheterisation.A86eripheral catheters can be safely maintained with adeuate monitoring for upto 2++ hours (si* days% in critically ill children.A;

)ontainers of intravenous fluids are usually changed before significant growth occurs, but the

giving set does not need to be replaced more often than every 43 hours.A40>lagging1 each set

with a stic'er displaying the time it had to be replaced resulted in a significant reduction in theincidence of 'lebsiellae in a busy neonatal unit.A5There is no difference in the incidence of
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septicaemia in children who have in-line bacterial filters fitted compared with those who do

not.A@

Box !+ Practical methods for preventing nosocomial infection

WhatNs in

Hand washingC

o as often as possible

o use of alcoholic hand spray

o removing ewellery before washing

&tethoscopeC cleaning with an alcohol swab at least daily

#lovesC supplement rather than replace hand washing

!ntravenous catheterC

o thorough disinfection of s'in before insertion

o changing administration sets every 43 hours

WhatNs out

Hand washingC using a brush

?as'C

o routine use in theatre

o during wound dressing

#owningC routine use in neonatal units

White coatsC enforced use in clinical units

!ntravenous catheterC

o routine removal of peripheral catheters after 43 hours

o use of impermeable, transparent dressings

o in-line bacterial filters
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Concl%sions

?ethods for preventing nosocomial infections are summarised in bo* 3. :osocomial infections

are worth preventing in terms of benefits in morbidity, mortality, duration of hospital stay, andcost. Fducational interventions promoting good hygiene and aseptic techniues have generally

proved to be successful, but these practices are often not sustainable. #reater efforts are beingmade in some countries to ensure the application of the infection control evidence base intopractice.+!n the end, constant vigilance and attention by the individual to what are rather

simple measures is demanded.

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'1##!( :is *actors *or nosocomial in*ection in critically ill children a

prospecti/e cohort study. Crit Care Med 2 hand decontamination practice; results o* a local study. J )osp

3n*ect 251420.

#earch oole #cholar

. [

1. ould D

2. Jilson Karnett U

*. ea$ E

'1##!( 6urses> in*ection"control practice hand decontamination the use o*

glo/es and sharp instruments. 3nt J 6urs Stud $$1


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1.[1. Loss A

2. Jid$er AF

'1##7( 6o time *or hand+ashing?@ )and+ashing /ersus alcoholic ru can +e

aAord 100B compliance@ 3n*ect Control )osp Epidemiol 15204205.

R6edlineSRJe) o' #cienceS

11.[1. #alis)ur( D6

2. Gut3l> !

*. Treen "6+. et al.

'1##7( he eAect o* rings on microial load o* health care +orers> hands.

9m J 3n*ect Control 22

antiseptic soap alone. 9m J 3n*ect Control 21141.


1+.[1. "arson E"
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2. Kr(an U"

*. Adler "6

+. et al.

'1##7( 9 multi*aceted approach to changing hand+ashing eha/iour. 9m J3n*ect Control 2$410.


15.[1. Dorse( #T

2. C(dul%a

*. E$er$an C"

'1##!( 3s hand+ashing teachale@ Failure to impro/e hand+ashing eha/iorin an uran emergency department. 9cad Emerg Med $$!04$!.

R6edlineSRJe) o' #cienceS

1,.[1. Gandwashin "iaison roup

'1###( )and +ashing 'editorial(. 8MJ $15!5!.

R FEE Full te


25/45

*. Easa D

+. et al.

'1##


26/45

22.[1. 6itchell NU

2. Gunt #

'1##1( Surgical *ace mass in modern operating roomsIa costly and

unnecessary ritual@ J )osp 3n*ect 152$#42


27/45

'1##!( =e/el o* stethoscope contamination in the hospital en/ironment.

Sch+ei Med ochenschr 12!22$7422$an !

'1##5( 3s our appearance important to patients@ Fam Pract 1$#14$#7.

R A)stract /FEE Full te


28/45

*1.[1. 6a%i D

2. iner 6

*. Al7arado CU

'1##1( Prospecti/e randomised trial o* po/idone iodine alcohol and

chlorhe-idine *or the pre/ention o* in*ection associated +ith central /enous

and arterial catheters. =ancet $$5$$#4$


29/45

*5.[1. Kreen>er T

2. Conen D

*. #a%$ann !

+. et al.

'1##5( 3s routine replacement o* peripheral intra/enous catheters necessary@

9rch 3ntern Med 151141!.


*,.[1. arland U#

2. Dunne J6

*. Ga7ens !

+. et al.

'1##2( Peripheral intra/enous catheter complications in critically ill children

a prospecti/e study. Pediatrics 5#11


30/45

*.[1. Newall F

2. anson

*. o)ertson U

'1##5( se o* in"line lters in pediatric intra/enous therapy. Journal o*

3ntra/enous 6ursing 21!!470.

#earch oole #cholar

+.[1. Uenner EA

2. 6ac%intosh C

*. #cott 6

'1###( 3n*ection controlI e/idence into practice. J )osp 3n*ect


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Results

Hygienic hand disinfection has better antimicrobial efficacy than hand-washing and is theprocedure of choice to be performed before and after manual contact with patients. The hands

should be washed, rather than disinfected, only when they are visibly soiled. &'in irritation is

uite common among healthcare wor'ers and is mainly caused by water, soap, and prolongedwearing of gloves. )ompliance can be improved by training, by placing hand-rub dispensers at

the sites where they are needed, and by physicians setting a good e*ample for others.

Conclusions

!mproved compliance in hand hygiene, with proper use of alcohol-based hand rubs, can reducethe nosocomial infection rate by as much as +.

Keywords: hand h(iene disin'ection co$pliance nosoco$ial in'ection

protecti7e lo7es

Healthcare wor'ers hands represent the principal route of transmission of nosocomial

pathogens. They are coloni/ed permanently by the physiological flora (0resident flora1% andtemporarily, depending on the precise nature of the employees duties, by various pathogens that

do not belong to the physiological flora (0transient flora1% (2%. Staphylococcus aureus, for

e*ample, can survive for over 3 h on the hands and is found in 2 to 45 of staff (table 2%.

Ta)le 1

Frequency and persistence of selected nosocomial pathogens on the hands

of healthcare workers (1

o to:

Clean Hands Campaign

!mprovement of hand hygiene, with the aim of minimi/ing nosocomial infection, is a highpriority of the World Health Organi/ation (WHO%. The promotion of effective measures to

improve hand hygiene (e2% is therefore one of the five foremost goals of the WHOs current

worldwide 6atient &afety !nitiative (7nnounce 7ction on 6atient &afety "High 8s$ !nitiative,Washington, 9), + :ovember 3;%.


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Health (e3%. or studies published from 3; onward we performed a

selective review of the publications in the :ational Bibrary of ?edicine. >urthermore, we

evaluated the recommendations of the following institutionsC

Co$$ission 'or Gospital G(iene and !re7ention o' In'ection o)ert ochInstitute @I @2

Association o' the #cienti3c 6edical #ocieties in er$an( @AJ6F @e+

JGO @3nal reco$$endation @*

Centers 'or Disease Control and !re7ention @CDC @e5.

o to:

Importance of protective gloves

The wearing of protective gloves is a sensible precaution in various clinical situations in order to

prevent gross soiling or contamination (bo* 2%. !t may even brea' the chain of infection more

effectively than hand-washing or hand disinfection. 7 prospective, controlled intervention studyshowed that a training session and the availability of gloves directly at the bedside can

significantly reduce the incidence of Clostridium difficileDassociated diarrhea ()979% (+%. The

hands should be disinfected when protective gloves are ta'en off, because in contrast to surgical

gloves, ordinary protective gloves are often permeable to pathogens even before use. ?oreover,the hands may have come into contact with the potentially contaminated outer surface of the

gloves during removal. !n the case of vancomycin-resistant enterococci (ERF%, a study showed

that despite the use of gloves the same pathogen could be found on the hands of staff involved intreatment in A of cases (8%.

o to:

Box 1

Clinical situations in which the wearing of protecti!e glo!es is especially

indicated

E


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E


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Bene*ts and risks

The limited benefits of hand-washing are accompanied by the ris' of cutaneous irritation andhand ec/ema. >reuent washing of the hands can lead to dryness and impair the barrier function

of the s'in (4%. The s'in thus continually loses fats and water-binding factors, and no*ious

substances can more easily penetrate the epidermis. )linically manifest irritant ec/ema of thehand may gradually develop. #iven the comparatively slight benefit, it swiftly becomes clear

that hand-washing should be seen as an e*ception. ?erely in the case of contamination with

spore-forming bacteria, e.g., C. difficile, is it useful to wash the hands after disinfection, because

bacterial spores are naturally resistant to alcohol.

o to:

Hygienic hand disinfection

"ndications

Hand disinfection is indicated in almost all interactions of medical staff with patients (bo* 3% (3%.

o to:

Box !

+ygienic hand disinfection ,ene*ts the patient in the following clinical

situations (:

Ke'ore in7asi7e procedures e7en i' lo7es will )e worn e..

Insertion o' a 7enous or )ladder catheter

Anioraph( )ronchoscop( endoscop(

In4ections and punctures

Ke'ore contact with patients who are at particular ris% o' in'ection e..

"eu%e$ia patients

!ol(trau$a patients

Kurns patients

Irradiated and other se7erel( ill patients

Ke'ore e


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Ke'ore and a'ter an( contact with

Jounds

Insertion sites o' catheters or drains

A'ter contact with Klood secretions eor e*ample, the hands should be disinfected after direct patient contact (measurement of vital

functions, auscultation, palpation% or after contact with potentially infectious materials, e.g.,bandages. Hand disinfection is most important, however, in the case of potential nosocomial

infections (3,A%. The most freuent such infections in #ermany are catheter-associated urinary

tract infection (ca. +3%, ventilator-associated pneumonia (ca. 32%, surgical site infection (ca.

2;%, and catheter-associated bloodstream infection (ca. 5% (5%. Hygienic hand disinfection canma'e a substantial contribution to preventing these infections if consistently performed at the

following unctures (3, A%C

Catheter-associated urinar( tract in'ection: )e'ore place$ent o' the urinar(

catheter )e'ore and a'ter contact with the catheter Lentilator-associated pneu$onia: )e'ore and a'ter intu)ation )e'ore and

a'ter aspiration

#urical site in'ection: )e'ore and a'ter contact with wounds a'ter re$o7al o'a )andae

Catheter-associated )loodstrea$ in'ection: )e'ore place$ent o' 7ascularcatheters )e'ore $anipulation o' 7ascular catheters )e'ore preparation o'intra7enous $edication.

#$cacy

The commonly available hand rubs are considerably more effective than hand-washing with soap

(3, A%. Within A s, for e*ample, the following bacteria are not only greatly reduced but

practically completely eliminated (e;%C

Escherichia coliM$ost 'reuent cause o' catheter-associated urinar( tractin'ection
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#E6http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R8http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#E6


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Pseudomonas aeruginosaM7er( 'reuent cause o' 7entilator-associatedpneu$onia

Staphylococcus aureusM$ost 'reuent cause o' surical site in'ection

Staphylococcus epidermidisM$ost 'reuent cause o' catheter-associated

)loodstrea$ in'ection.

The same applies to yeasts such as Candidaspp. orRhodotorulaspp. and to coated viruses such

as Hor spore-forming bacteria such as C. difficile, the recommendation isfirst to disinfect the hands in order to 'ill off the vegetative form, then to wash them briefly but

thoroughly to reduce the number of spores as much as possible (e4%.

Bene*ts and risks

Hand disinfection is 'ey to the prevention of nosocomial infections. 7t #eneva Iniversity

Hospital, improvement of the compliance rate from +5 to ;; over a 8-year period loweredthe freuency of nosocomial infections by more than + (2%. Over the same period the rate of

new infections by methicillin-resistant S. aureus(?R&7% was reduced by more than 8 (2%.

!n contrast to popular opinion, the irritant potential of alcohol-based hand rubs is very low.)ommercially available preparations are generally tolerated much better than the detergents inhand-washing agents (4, 22%. Fven freuent, intensive hand disinfection detracts only minimally

from the s'ins barrier function and ma'es the s'in only slightly drier. This is due partly to the

s'in care substances usually found in hand rubs. 7llergic reactions to the ingredients of hand-rubpreparations are e*tremely rare (2,A%.

>or hand disinfection to be effective, both hands must be completely covered. To this end, an

adeuate amount of the hand rub must be applied efficiently. The duration of application should

be 33 to 35 s. &horter application times, e.g., 28 s, almost always fail to cover the handscompletely (23%. &urprisingly, the best results are achieved when users are left to their own

devices, not with a strictly regulated procedure. &pecial attention must be paid to the fingertipsand thumbs, howeverJ these parts of the hand are most li'ely to come into contact with thepatient, and the greatest proportion of the bacteria are found on the fingertips (2A%.

o to:

Hand ec"ema
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#E7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R1http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R12http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#E7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R10http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R1http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R12http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R13http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/


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There can be no doubt that hygiene precautions are a ris' factor for occupational hand ec/ema.

)onseuently employment in nursing and related professions involves the ris' of contracting

occupational dermatosis (2+%. ?any consider rough, fla'ing s'in on their hands as normal intheir line of wor' and fail to reali/e that this may be the first sign of hand ec/ema (figure 2%. !n a

survey carried out by the #erman )ontact 7llergy #roup (9eutsche onta'tallergiegruppe,

9#%, more than 4 of nursing staff reported irritant s'in symptoms within a year, and +;considered them detrimental in their daily lives (28%.

Fiure 1

Earl( irritant s%in chanes )etween the diits

?ost nurses still believe that alcohol-based hand rubs damage their s'in more than hand-washing(28%. However, alcohol-based preparations are much 'inder to the s'in than hand-washing agentsbecause they are less harmful to the cutaneous barrier (as measured by transepidermal water loss%

and dry the s'in out less (as measured by corneometry% (4, 22%. !nterestingly, the application of

alcohols after hand-washing can even reduce the irritation caused by the washing, probably by

elimination of residual detergent monomers (4%. :evertheless, many users thin' that hand rubsharm their s'in. One reason is the burning felt when the alcohols stimulate the pain receptors in

damaged areas of s'in. The alcohol-based hand rub is then blamed for the symptoms (0it only

burns with the alcohol1% and hand disinfection is abandoned in favor of washing. The burningstops, but the damage acceleratesC a vicious circle begins, resulting in manifest hand ec/ema

(figure 3% and, in the worst case, inability to wor' (2;%.

Fiure 2

6ani'est irritant hand ec>e$a

7 burning sensation on use of a disinfecting hand rub is a warning of impairment of the s'ins

barrier function. Those affected should avoid activities harmful to the s'inGwashing, occlusion

(protective gloves%, contact with soaps, direct contact with irritant disinfectantsGand applycopious uantities of s'in protection and s'in care products.

&ome users state that alcohol-based hand rubs have a sensiti/ing effect. :evertheless,

sensiti/ation to an alcohol could be e*cluded in all 8 persons who were tested for allergicreactions to an alcohol-based hand rub because of suspected intolerance. Oversensitivity to an

e*cipient (e.g., cetearyl octanoate% was demonstrated, however (28%.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R14http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F1/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R11http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R7http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R16http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/figure/F2/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/#R15


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7n intact cutaneous barrier is of more than ust cosmetic and functional relevance. Fc/ematous

hands are also coloni/ed to a greater degree by pathogens than are healthy hands (24, 25%. The

principles of hand care and protection should therefore be taught to all healthcare wor'ers andshould form part of every training program (2@%. They are also included in the )lean Hands

)ampaign.

o to:

Care and protection of the s#in

7ppropriate precautions when using potentially irritant substances can prevent harm to the s'in.

?oreover, adeuate protection and care of the s'in are of paramount importance for themaintenance of a functioning cutaneous barrier (e5%. These precautions should be integrated in

the wor'ing routine and can, if properly implemented, protect the hands without compromising

disinfection. &'in protection plans should be drawn up with information about the available

products and their use (see Technical Rule for Ha/ardous &ubstances "TR#&$ +2 of =une 35C

Ris's resulting from s'in contactGdetermination, evaluation, measures% (3%. &taff should haveaccess to data showing the efficacy of all preparations employed, as well as information on their

uses (see the 0Occupational &'in 6reparations1 (0


39/45

Insucient %nowlede o' the clinical situations in which the patient clearl()ene3ts

"ac% o' products or dispensers: una7aila)ilit( o' the disin'ectin hand ru)riht where it is needed

"ac% o' ti$e: hand disin'ection is 'reuentl( not carried out )ecause o'

increasin pressure o' wor% or when a ward is o7er-occupied or under-staed@2*

Cutaneous irritation: s%in pro)le$s with use e.. dr(ness irritation or)urnin co$)ined with inadeuate %nowlede o' the causes

Failure o' hih-ran%in $edical sta to set an eurthermore,

s'in protection and care products must be available to all employees at their wor'place. One can

only appeal to all senior staff to set a proper e*ample. !t will then be much more difficult forunior wor'ers not to follow suit.

o to:

Box $Measures to impro!e compliance

#ta trainin with reard to the clinical situations in which hand disin'ectionis indicated

Inclusion o' the oals in the trainin prora$ )ecause )eha7ior learneddurin )asic trainin is put into practice $uch $ore eecti7el( than thattauht in later trainin sessions when esta)lished routine )eha7ior has to )echaned

Disin'ectin hand ru)s should )e a7aila)le where the( are actuall( needed.This can )( achie7ed )( si$ple $eans )oth in the hospital and the doctorPs

oce. I' wall dispensers cannot )e $ounted the doctor $a( )e a)le to carr(a )ottle o' hand ru) in the poc%et o' his/her la) coat.

eduction o' hand-washin to a $ini$u$ in order to a7oid unnecessar( s%inirritation

#enior $e$)ers o' $edical sta $ust reconi>e that the( ha7e to set ane


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o to:

Concl%sion

Fvidence-based hand hygiene can prevent transmission of the most important nosocomial

pathogens and also 'eep employees s'in healthy. !n most clinical situations hygienicdisinfection is indicated for hand decontamination on grounds of better efficacy and cutaneoustolerance. Washing with soap and water is necessary only when the hands are visibly soiled, or

following disinfection in the case of contamination by spores of bacteria such as C. difficile.

)ompliance could be improved by 'nowledge of the principal clinical circumstances in which

hand disinfection by healthcare wor'ers genuinely benefits the patient.

o to:

&ey Messages

Gand disin'ection eli$inates the transient Qora and is one o' the $osti$portant precautions 'or speci3c pre7ention o' trans$ission o' nosoco$ialin'ections.

In practice on a7erae e7er( second necessar( disin'ection o' the hands isnot actuall( carried out. The JGO has there'ore launched a worldwideinitiati7e to i$pro7e co$pliance.

The rate o' nosoco$ial in'ections can )e reduced )( up to +0 )( i$pro7edco$pliance in hand disin'ection.

Gand-washin da$aes the s%in $ore than hand disin'ection. It shouldprincipall( )e restricted to 7isi)l( soiled hands and 'ollowin disin'ectionhands conta$inated with spore-'or$in )acteria such as C. difcile.

A )urnin sensation on hand disin'ection represents an i$portant warnin o'da$ae to the cutaneous )arrier. Acti7ities har$'ul to the s%in e.. 'reuentwashin $ust then )e a7oided and s%in protection and care products applied$ore intensi7el(.

o to:

Ac#noledgments

Translated from the original #erman by 9avid Roseveare.

o to:

'ootnotes
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/


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Conflict of interest statement

9r. ampf is an employee of


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)ased hand ru). Uournal o' Gospital In'ection. 2*?55:22,B2*1. R!u)6edSe. a$p' . Clostridiu$ dicile - was ist 'r eine ee%ti7e Desin'e%tion >u

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!6CID: !6C2,*12+
http://www.ncbi.nlm.nih.gov/pubmed/18704346http://www.ncbi.nlm.nih.gov/pubmed/10501256http://www.ncbi.nlm.nih.gov/pubmed/12683505http://www.who.int/patientsafety/en/http://www.aktion-sauberehaende.de/http://www.ncbi.nlm.nih.gov/pubmed/12418624http://www.ncbi.nlm.nih.gov/pubmed/14572491http://www.abd.dermis.net/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2631724/http://www.ncbi.nlm.nih.gov/pubmed/18704346http://www.ncbi.nlm.nih.gov/pubmed/10501256http://www.ncbi.nlm.nih.gov/pubmed/12683505http://www.who.int/patientsafety/en/http://www.aktion-sauberehaende.de/http://www.ncbi.nlm.nih.gov/pubmed/12418624http://www.ncbi.nlm.nih.gov/pubmed/14572491http://www.abd.dermis.net/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2631724/


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'eeding bac# s%rveillance data to prevent

hospital-ac/%ired infections0

. a(nes C. ichardsU. EdwardsT. . E$oriT. GoranU. Alonso-Echano7e #.Frid%in . "awton . !ea7( andU. Tolson

Abstract

We describe the )enters for 9isease )ontrol and 6reventionNs :ational :osocomial !nfections&urveillance system. Flements of the system critical for successful reduction of nosocomial

infection rates include voluntary participation and confidentialityJ standard definitions and

protocolsJ identification of populations at high ris'J site-specific, ris'- adusted infection ratescomparable across institutionsJ adeuate numbers of trained infection control professionalsJ

dissemination of data to health-care providersJ and a lin' between monitored rates and

prevention efforts.

'%ll )ext

The Full Te


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$ulti7ariate inde< o' patient suscepti)ilit( and wound conta$ination. A$ UEpide$iol. 15 Fe)?121@2:2,B215. R!u)6edS

Olson 66 "ee UT. Ur Continuous 1-(ear wound in'ection sur7eillance.esults ad7antaes and unanswered uestions. Arch #ur. 1

Uun?125@,:+B*. R!u)6edS

E$ori T Cul7er DG Goran TC Uar7is J Jhite UJ Olson D Kaner4ee #Edwards U 6artone JU a(nes ! et al. National nosoco$ial in'ectionssur7eillance s(ste$ @NNI#: description o' sur7eillance $ethods. A$ U In'ectControl. 11 Fe)?1@1:1B*5. R!u)6edS

Cul7er DG Goran TC a(nes ! 6artone JU Uar7is J E$ori T Kaner4ee#N Edwards U Tolson U# Genderson T# et al. #urical wound in'ection rates)( wound class operati7e procedure and patient ris% inde TG Jen>el !. !ostdischare sur7eillance 'or nosoco$ial woundin'ection: a )rie' re7iew and co$$entar(. A$ U In'ect Control. 12Au?2@+:2,B21*. R!u)6edS

#ands Line(ard !latt . #urical site in'ections occurrin a'ter hospitaldischare. U In'ect Dis. 1, Apr?1*@+:,*B. R!u)6edS

E$ori T Edwards U Cul7er DG #artor C #troud "A aunt EE Goran TC

a(nes !. Accurac( o' reportin nosoco$ial in'ections in intensi7e-care-unitpatients to the National Nosoco$ial In'ections #ur7eillance #(ste$: a pilotstud(. In'ect Control Gosp Epide$iol. 1 6a(?1@5:*B*1,. R!u)6edS

6onitorin hospital-acuired in'ections to pro$ote patient sa'et(--8nited#tates 1-1. 66J 6or) 6ortal J%l( ep. 2 6ar *?+@:1+B15*.R!u)6edS

#chec%ler JE Kri$hall D Kuc% A# Farr K6 Fried$an C ari)aldi A ross!A Garris UA Gierhol>er JU Ur 6artone JU et al. euire$ents 'orin'rastructure and essential acti7ities o' in'ection control and epide$iolo( inhospitals: A consensus panel report. #ociet( 'or Gealthcare Epide$iolo( o'

A$erica. A$ U In'ect Control. 1 Fe)?2,@1:+B,. R!u)6edS 6assanari 6 Jil%erson #wart>endru)er #. Desinin sur7eillance 'or

nonin'ectious outco$es o' $edical care. In'ect Control Gosp Epide$iol. 15Uul?1,@:+1B+2,. R!u)6edS
http://www.ncbi.nlm.nih.gov/pubmed/4014116http://www.ncbi.nlm.nih.gov/pubmed/2346380http://www.ncbi.nlm.nih.gov/pubmed/1850582http://www.ncbi.nlm.nih.gov/pubmed/1656747http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1647025/http://www.ncbi.nlm.nih.gov/pubmed/3105338http://www.ncbi.nlm.nih.gov/pubmed/1524269http://www.ncbi.nlm.nih.gov/pubmed/8603978http://www.ncbi.nlm.nih.gov/pubmed/9613690http://www.ncbi.nlm.nih.gov/pubmed/10737441http://www.ncbi.nlm.nih.gov/pubmed/9503113http://www.ncbi.nlm.nih.gov/pubmed/7673650http://www.ncbi.nlm.nih.gov/pubmed/4014116http://www.ncbi.nlm.nih.gov/pubmed/2346380http://www.ncbi.nlm.nih.gov/pubmed/1850582http://www.ncbi.nlm.nih.gov/pubmed/1656747http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1647025/http://www.ncbi.nlm.nih.gov/pubmed/3105338http://www.ncbi.nlm.nih.gov/pubmed/1524269http://www.ncbi.nlm.nih.gov/pubmed/8603978http://www.ncbi.nlm.nih.gov/pubmed/9613690http://www.ncbi.nlm.nih.gov/pubmed/10737441http://www.ncbi.nlm.nih.gov/pubmed/9503113http://www.ncbi.nlm.nih.gov/pubmed/7673650

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