Est-ce que la désinfection des mains est un outil efficace pour prévenir les transmissions croisées ? Bertrand Souweine

Est-ce que la désinfection des mains est un outil

efficace pour prévenir les transmissions croisées ?

Bertrand Souweine

1. Flore cutanée et contamination 2. Lavage des mains3. Frictions alcoolique

Efficacité microbiologiqueAspects pratiquesEfficacité clinique

4. Conclusion

Plan



4. Conclusion

Plan

Types of Skin Flora

• Transient flora• Resident flora• Infectious flora

Epiderme superficiel : stratum corneumeffet protecteur contre flore contaminante

squammes

lipides

•H20 assure plasticité, perméabilité // hydratation

•Une couche produite / 24 heures et qui disparaît en 15 jours

•102-103 ufc/cm2, enchâssés en profondeur

•107 particules libérées / j dans air dont 10% contiennent des germes

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 • Very difficult to eliminate (< 50% decrease in

bacteril load after 6 min of handwashing)

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

Infectious Flora

• The etiologic agents of actual infections such as abscess, panaritium, paronychia, and infected eczema on the hands

• S. aureus and β-hemolytic streptococci

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 patient’s blood

pressure or pulse– Assisting patients with

mobility– Touching the patient’s gown

or bed sheets– Touching equipment,

including bedside rails, over bed tables, IV pumps http://www.handhygiene.org/

Acquisition de la flore transitoire ou contaminantetemps de soin dépendante

Pittet Arch Intern Med 1999

Durée de contact : 16 cfu /mn

Port de gants : 3 cfu /mn

Pittet Arch Intern Med 1999

Acquisition de la flore transitoire ou contaminantemême après simple contact patient

Type d’activité : 16-21 cfu /mn

Clin Microbiol Rev. 2004;17(4):863

Transmission of organisms

Transmission of organisms by hands of health care providers between two patients can result in health care associated infections (HAIs).

Adapted from the Swiss Hand Hygiene Campaign


Year Authors(s) Hospital setting Significant results

1977 Casewell and Phillips Adult ICU Reduced rates of HI due toendemic Klebsiella sp

1982 Maki Adult ICU Reduction in HI rates

1984 Massanari et Heirholzer Adult ICU Reduction in HI rates

1992 Doebelling et al. Adult ICU Significant diff. in rates of HIbetween 2 regimens

1994 Webster et al. NICU Elimination of MRSA

1995 Zafar et al. Newborn nursery Elimination of MRSA

2000 Larson et al. MICU/NICU Significant reduction of VRE

2000 Pittet et al. Hospital-wide Significant reduction in HI /MRSA cross transmission

CDC Guideline for HH in healthcare settingsCDC Guideline for HH in healthcare settings

Hygiène des mains et contrôle de l’infection



4. Conclusion

Plan

CID 2000;31:136

Soap

• Plain – Esterified fatty acids

with sodium or potassium hydroxide

– Mechanical removal of dirt and loosely adherent flora (transient>resident)

• Antiseptic

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

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

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

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

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

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

Frequent handwashing with soap and water often causes skin irritation and dryness. Skin irritation are more frequently reported when using antiseptic soap

In the winter months, some personnel may even develop cracks in their skin that cause bleeding, as seen in the adjacent figure.

Another reason why personnel don’t wash their hands often

OBSERVANCE / HYGIENE DES MAINS

Nb d’actions d’hygiène des mains

Nb d’indications à l’hygiène des mains

Observance basale

Soignants 30-40%

Médecins 10-20%

Autres 10-20%

Year author observation observed Opportunity HW %type No

1981 Albert masqued all HCWs a 1,212 494 41297 81 28

1986 Mayer masqued nurses b 142 89 6354 34 63

1987 Donowitz masqued all HCWs a 3226 863 271989 Conly masqued all HCWs c 184 39 211990 Dubbert overt nurses d 811990 Graham masqued all HCWs a 440 140 321990 Simmons masqued all HCWs e 86 10 12

91 29 321992 Larson overt all HCWs f 337 102 361992 Doebbeling overt all HCWs na 1,233 492 401993 Zimakoff masqued all HCWs g 1,025 351 34

607 305 501994 Gould overt nurses h 231994 Lund masqued all HCWs a 17 10 41

10 02 201994 Sproat na all HCWs* c 762 234 311994 Wurtz masqued all HCWs j 41 9 221996 Tibballs alterned physicians k 322 37 11

55 31 561997 Larson overt nurses l 151 85 56

310 172 551998 Watanakunakorn masqued all HCWs m 97 38 391999 Khatib masqued RCPs n 537 247 461999 Nishimura hidden camera everybody o 903 658 731999 Pittet overt all HCWs p 450 162 362000 Biscoff alterned all HCWs q 361 59 16

352 29 82000 Maury overt all HCWs r 621 263 422001 Harbarth masqued all HCWs q 2,811 946 39

Observance du lavage des mains : revue de la littérature

%

Trick, CID

07

Reasons Advocated for Poor Handwashing

Compliance• Skin irritation from hand

hygiene products

• Inaccessibility of hand hygiene supplies

• Wearing gloves

• Hands don’t look dirty

• Lack of information on the importance of hand hygiene

• Lack of knowledge of the guidelines

• Too busy/handwashing takes too long

• Male vs female

• Physician vs nurse

• Wearing gloves

• Working in ICU

• Understaffing/overcrowding

Risk factors for Poor Handwashing Compliance

It takes ICU nurses an average of 62 seconds to go to a sink, wash and dry their hands, and return to patient care activities

The time needed for hand hygiene before and after every contact is about 100 min/patient for direct contacts

It takes ICU nurses an average of 62 seconds to go to a sink, wash and dry their hands, and return to patient care activities

Anne Simon

DUREE DU LAVAGE SIMPLE DES MAINS

Hand as a Vectors of Transmission

• Organisms present on the patient’s skin or on inanimate objects

• Organism must be capable of surviving for at least several minutes on the hands of personnel

• Handwashing is inadequate or omitted entirely • Come in direct contact with another patient, or

with an inanimate object

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

• Hand hygiene is the most important tool in NI control

• Adherence to hand-washing practices remains unacceptable low, rarely exceeding 40%



4. Conclusion

Plan

CID 2000;31:136

Poor Kolletchka

Ignaz Philipp Semmelweis (1818-1865)

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

Curr Opin Infect Dis 1998; 11: 457-460

Death of Kolletchka

hand disinfection with a solution of 4% chlorinated

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

Les produits hydro-alcooliques (PHA)

solutions ou gels séchage rapidedésinfection des mainsalcool (60-70%) + émollient +/- autre antiseptique

péril hydriquefriction sans rinçage friction sur mains

sèches +++non visiblement souillées (propres)non poudrées

pas de friction de gants

Mechanism of Action

• Killing not mechanically remove

• Protein denaturation, rapid killing (sec)

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

0 1 2 3

Sterillium®

Hibiscrub®

savon doux

Betadine scrub®

99%90% 99,9%

log 0 1 2 3

Etudes expérimentales de l’activité des savons sur les mains contaminées par C. difficile

(Barbut F. et coll., Hygiènes, 2003, 5, 449-55)

Contamination expérimentale des mains de 14 volontaires

Contamination initiale : 4.2 à 4.8 log10 UFC/ml

Méthode du jus de gants

P=0.36

P<0.01

P<0.01

1 min

30 sec

1 min

30 sec

Diapositive empruntée a F Barbut

Quelle hygiène des mains ?

• Faut il bannir les solutions hydro alcooliques?

Boyce et al, ICHE 2006

Même constat,

-Diminution de l’incidence des ERV et des SARM (1998-2000) vs (2001-2003)

-Incidence stable pour Clostridium difficile

Gordin et al ICHE 2006

Efficacy

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

applied• Temperature • Organic material

Henri Mondor, 1996 51

Efficacite de l’hygiène des mains sur la flore


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 Aug;16(4):327

PREVALUES

99.9 3.0

90.0 1.0

99.0 2.0

0 60 180 min

LIQUID SOAP

POVIDONE-IODINELIQUID SOAP 0.8%

CHLORHEXIDINE-DETERGENT 4%

POVIDONE-IODINEAQU. SOLUTION 10%

ISO-PROPANOL 60%

HEXACHLOROPHENE-DETERGENT 3%

ISO-PROPANOL 70%

N-PROPANOL 60%

ISO-PROPANOL 70%+CHLORHEXIDINE 0.5%

% Iog 10

0.0 0.0

Handwashing with plain soap

Alcohol-based handrub

Before

After

Handwashing with antiseptic detergent

d’après Pr Bientz, Institut d’hygiène de Strasbourg

The technique used for hand cleansing before patient care affected the amount of bacterial contamination

Handwashing with plain soap

Handwashing with antiseptic detergent

Alcohol-based handrub (ABH)



4. Conclusion

Plan

Temps économisé par l’utilisation de la Friction Hydro-Alcoolique

• Lavage simple des mains :• quitter le lit du patient• aller au lavabo, se mouiller les mains• se laver les mains (= 30 secondes)• se sécher les mains• retourner au lit du patient Total 1 min 30 s

Total 30 s

• Friction avec une SHA :• au lit du malade• durée de friction pour séchage

PLUS RAPIDEPLUS RAPIDEPLUS RAPIDEPLUS RAPIDE

• 40 à 80 secondes pour effectuer le lavage des mains contre seulement 20 secondes pour une désinfection avec la solution hydro-alcoolique

• Pour une équipe de 12 personnes en réanimation au cours d ’une journée de 8h de travail :

Lavage des mains sol. alcoolique

Temps requis 16h 4hForce de travail 17% < 5%

Voss A & Widmer AF ICHE 1997;18:205-8

Widmer CID 2007

Widmer CID 2007

Mayo Clin Proc. 2004;79(1):109

15 Jan 2007 ... Michelle Manhart nude photos are now online. Air Force staff sergeant Michelle Manhart was relieved of her duties for

posing nude in Playboy

2004 2005 2006

N=56

N=61

number of duty days lost

N=210 ; 2.4%

N=78 ; 0.9%

Aviat Space Environ Med. 2007

Effet des SHA sur l’observance

Bischoff et al., Arch Intern Med, 2000

0

20

40

60

Base Après form. SHA 1/4 lits SHA 1/lit

LdM avant soins

LdM après soins

0

20

40

60

Base Après form. SHA 1/4 lits SHA 1/lit

LdM avant soins

LdM après soins

Service de réanimation médicale, 6 mois

Observance à l’hygiène des mains

Maury et al.AJRCCM, 2000 69

Effet des SHA sur l’observance

Évolution selon la catégorie de personnel soignant

bef

ore

pat

ien

t co

nta

ctb

efor

ep

atie

nt

con

tact

afte

rp

atie

nt

con

tact

afte

rp

atie

nt

con

tact

afte

rre

mov

ing

glov

esaf

ter

rem

ovin

ggl

oves

bef

ore

pat

ien

t co

nta

ctb

efor

ep

atie

nt

con

tact

afte

rp

atie

nt

con

tact

afte

rp

atie

nt

con

tact

afte

rre

mov

ing

glov

esaf

ter

rem

ovin

ggl

oves

• Before / after study

• Single centre

• No period randomization

• Overt observations

• Differences in the type of opportunities recorded

• Hawthorne effect

• Handwashing still performed during the ABH period

• Multifaceted programme on hand hygiene practice

Several Limitations in Hand Hygiene Compliance Studies

0

1

2

3

4

5

6

Baseline 2 weeks

Alcohol rub Soap and water

15

17

19

21

23

25

27

Baseline 2 weeks

Alcohol rub Soap and water

Epidermal water contentSelf-reported skin score

Dry

Healthy Dry

Healthy

Effect of Alcohol Handrub on

Skin Condition

Alcohol-based handrub is less damaging to the skin

Boyce, Infection Control and Hospital Epidemiology 2000;21:438-41.

*

*

* , P<0.001

RCT: HW vs HR29 nurses

Larson EL CCM 2001

ACCEPTABILITYNo participants

mak

es i

t ea

sier

to

don

glo

ves

Number of participants who preferred

alcohol

chlorhexidine

neither

Number of participants who preferred

alcohol

chlorhexidine

neither



4. Conclusion

Plan

Impact de l’utilisation des SHA sur les taux d’IN

Pittet et al., Lancet 2000

0

20

40

60

80

1994 1995 1996 1997 1998

Ob

serv

ance

(%

)

0

5

10

15

20

25

Pré

vale

nce

des

IN

Observance Prévalence des IN

Impact de l’utilisation des SHA sur l’incidence des SARM

0

20

40

60

80

1993 1994 1995 1996 1997 1998

Po

urc

enta

ge

d'o

bse

rvan

ce

0

0,2

0,4

0,6

0,8

Inci

denc

e de

s S

AR

M/1

00 a

dmis

Observance Incidence des SARM

Pittet et coll., Lancet 2000

ABH introduction

bas

elin

e

bas

elin

e

Education programme

Education programme

AB

H

AB

H

Infection due to MRSA: from 1.67 to 2.77 per 1.000 patient-days

Infections due to VRE from 0.35 to 1.36 per 1.000 patient-days

Cannot detect a change is not absence of change

Absence of training programme

Very low baseline rates of nosocomial infection

Absence of surveillance cultures to detect MRSA/VRE colonization

No data on the rates of MRSA/VRE importation

Baseline

59.5%

26%

21%

22.5%

Overall compliance

Before patient contact

After patient contact

Correctly performed

Intervention

65%

45%

56%

42.6%

P

0.46

<0.01

<0.001

<0.01

P=0,02

Grayson et al.

6 urban sites

Grayson et al.

a total of 65 fewer patients developping MRSA bacteremia during the 24-month intervention period

Acceptability of hand hygiene procedures in the 7 units

P=0.06

Cannot detect a change is not absence of change



4. Conclusion

Plan

ABH is effective in decreasing NI rates

The causal role of microorganisms on hands in the pathogenesis of NI is extremely well established

Traditional soap-and-water hand hygiene is less effective than hand antisepsis

Handwashing as frequent as recommended is often impractical and leads to inflammatory skin reactions

ABH is the simplest and least expensive way of achieving good hand hygiene practice and so of preventing health care associated infections and the spread of antimicrobial resistance

Multifaceted campaign with education programme, meetings, introduction of ABH, training in application of ABH, reminders, monitoring of compliance, monitoring of NI rate, and surveillance feedback are required to promote hand hygiene and reduce cross transmission in ICUs

ABH is effective in decreasing NI rates

• Plus efficace que le lavage avec un savon.

• Action rapide et réalisation rapide.

• Ne nécessite pas de lavabo.

• Actif sur les pathogènes nosocomiaux.

• Toujours à portée de la main.

• Moins irritant pour la peau.

• Moins polluant pour l ’environnement.

• Favorise l ’observance.

Boyce JM.Infect Control Hosp Epidemiol 2000;21:438-441

Daschner Fr. Am J Infect Control 2000;28: 386

Avantages de la friction alcooliqueAvantages de la friction alcoolique

• avant tout contact avec un malade, que des gants aient été portés ou non

• après tout contact avec un malade, que des gants aient été portés ou non

• entre les soins pour un même malade, que des gants aient été portés ou non

• après l’ablation des gants

Quand utiliser les SHA?

AttentionAttentionAttentionAttention

L'alcool ne contient pas d'agent nettoyant

Si mains souillées, lavage des mains impératif

Si C difficile la FHA est précédée d’un lavage avec séchage

MODE D’EMPLOI• Délivrer une dose (3ml) dans le creux de la

main

• Friction des mains jusqu’à évaporation (30 sec.)Paume / paume et paume/dos mainsEspaces interdigitaux, ongles, pouce…

Hand Hygiene

Clean Care is Safer Care

Documents

Est-ce que la désinfection des mains est un outil efficace pour prévenir les transmissions croisées ? Bertrand Souweine