HAND HYGIENE

Dr. Waleed EldarsMedical Microbiology and Immunology

Department

Microbiology Diagnostics and Infection Control Unit

Faculty of Medicine

Mansoura University

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• Definitions

• Hand-borne Microorganisms.

• Types of Hand Hygiene

• Hand Hygiene Techniques

• Recommendations for surgical hand preparation

• Selection and Handling ofHand Hygiene Agents

• Other aspects of hand Hygiene.

• Summary.MDICU

Introduction

• Hand Hygiene: a general term that

applies to either hand washing,

antiseptic hand wash, antiseptic hand

rub, or surgical hand antisepsis.

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• Hand washing: Washing hands with plain or antimicrobial soap and water.

• Hand cleaning: Action of performing hand hygiene for the purpose of physically or mechanically removing dirt, organic material or microorganisms.

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• Hygienic hand antisepsis: Treatment

of hands with either an antiseptic hand

rub or antiseptic hand wash to reduce

the microbial flora.

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Transmission of Pathogens on Hands

• Transmission from patient to patient via HCW hands requires four elements:

– Organisms on HCWs hands (via patient or environment).

– Organisms must survive for several minutes on hands.

– Hand hygiene must be inadequate or agent inappropriate.

– Contaminated hands of HCW must come in contact with another patient (or an inanimate object that will contact patient).

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Hand-borne Microorganisms

• Presence – bacterial counts on hands range from 104 to 106 CFU/cm2.

– Resident microorganisms:attached to deeper layers of the skin and are more resistant to removal;

– less likely to be associated with HAIs.

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– Transient microorganisms: colonize

the superficial layers of skin and

amenable to removable; acquired by

direct contact with patients or

contaminated environment surfaces;

frequently associated with HAIs.

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• Pittet and colleagues studied

contamination of HCWs’ hands before

and after direct patient contact, wound

care, intravascular catheter care,

respiratory tract care or handling

patient secretions.

• Using agar fingertip impression plates,

they found that the number of bacteria

recovered from fingertips ranged from

0 to 300 CFU.

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• Direct patient contact and respiratory

tract care were most likely to

contaminate the fingers of caregivers.

Gram-negative bacilli accounted

for15% of isolates and S. aureus for

11%.• Pittet D et al. Bacterial contamination of the hands of hospital staff

during routine patient care. Archives of Internal Medicine, 1999,

159:821–826.

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• Several other studies have documented that HCWs can contaminate their hands or gloves with Gram-negative bacilli, S. aureus, enterococci or C. difficile by performing “clean procedures” or touching intact areas of skin of hospitalized patients.

• Duckro AN et al. Archives of Internal Medicine, 2005, 165:302–307.

• Lucet JC et al. Journal of Hospital Infection, 2002, 50:276–280.

• McBryde ES et al. Journal of Hospital Infection, 2004, 58:104–108.

• Riggs MM et al. Clinical Infectious Diseases, 2007, 45:992–998.

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• Bhalla and colleagues studied patients

with skin colonization by S. aureus (including MRSA) and found that the

organism was frequently transferred to

the hands of HCWs who touched both

the skin of patients and surrounding

environmental surfaces.• Bhalla A, Aron DC, Donskey CJ. Staphylococcus aureus intestinal

colonization is associated with increased frequency of S. aureus on skin of

hospitalized patients. BMC Infectious Diseases, 2007, 7:105.

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• Hayden and colleagues found that HCWs seldom enter patient rooms without touching the environment, and that 52% of HCWs whose hands were free of VRE upon entering rooms contaminated their hands or gloves with VRE after touching the environment without touching the patient.

• Hayden MK et al. Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant enterococcus or the colonized patientsenvironment. Infection Control and Hospital Epidemiology, 2008, 29:149–154.

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Pittet D et al. Evidence-based model for hand transmission during

patient care and the role of improved practices. Lancet Infectious Diseases, 2006, 6:641–652.

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Pittet D et al. Evidence-based model for hand transmission during

patient care and the role of improved practices. Lancet Infectious Diseases, 2006, 6:641–652.

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Pittet D et al. Evidence-based model for hand transmission during

patient care and the role of improved practices. Lancet Infectious Diseases, 2006, 6:641–652.

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Pittet D et al. Evidence-based model for hand transmission during

patient care and the role of improved practices. Lancet Infectious Diseases, 2006, 6:641–652.

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Pittet D et al. Evidence-based model for hand transmission during

patient care and the role of improved practices. Lancet Infectious Diseases, 2006, 6:641–652.

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HAND HYGIENE

• Recommendations

– IA-strongly recommended for implementation and strongly supported by experimental, clinical or epidemiological studies

– IB- strongly recommended for implementation and supported by some experimental, clinical or epidemiological studies

– IC-required for implementation, as mandated by federal and/or state regulation

– II-suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale.

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Indications for Hand washing and

Hand Antisepsis

A. Wash hands with soap and water when:

• Visibly dirty or contaminated with

proteinaceous material,

• or visibly soiled with blood or other body

fluids,

• or if exposure to potential spore-forming

organisms is strongly suspected or proven

(IB)

• or after using the restroom (II).

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B. Preferably use an alcohol-based hand

rub for routine hand antisepsis in all

other clinical situations described in

items C1 to C6 listed below if hands

are not visibly soiled (IA). Alternatively,

wash hands with soap and water (IB).

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C. Perform hand hygiene:

1) Before and after having direct

contact with patients (IB);

2) After removing gloves (IB);

3) Before handling an invasive device

(regardless of whether or not gloves

are used) for patient care (IB);

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4) After contact with body fluids or

excretions, mucous membranes,

non-intact skin, or wound dressings

(IA);

5) If moving from a contaminated body

site to a clean body site during

patient care (IB);

6) After contact with inanimate objects

(including medical equipment) in the

immediate vicinity of the patient (IB);

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Sax H, et al. 'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene J Hosp Infect 2007; 67(1): 9–21

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D. Wash hands with either plain or

antimicrobial soap and water or rub

hands with an alcohol-based

formulation before handling

medication and preparing food (IB).

E. When alcohol-based hand rub is

already used, do not use antimicrobial

soap concomitantly (II).

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Types of Hand Hygiene

Residual

effect

Speed of

anti-

microbial

action

Agents

Influenc

e on

hand

flora

Main

purposeTechnique

ShortSlowPlain non-

antimicrobial

soap

Partly

removes

transient

flora

Cleansing

after patient

contact &

contaminatio

n

Routine

Hand

wash

Can be

sustained

for agents

such as

Chlorhexidi

n; less so

for alcohol

and

iodophors

Fastest

for

alcohol

Chlorhexidin

Hexa-

chloraphen

Iodine;Iodoph

oo-meta-

xylenol

-Alcohol-

based

waterless

antiseptic

Kills

transient

and

reduces

resident

flora

Hand

antisepsis

prior to

invasive

procedures,

or to

remove

pathogens

(e.g.,

antimicrobi

al resistant

strains).

Antiseptic

Hand

wash or

alcohol-

based

handrub

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Residual

effect

Speed

of anti-

microbi

al

action

Agents

Influence

on hand

flora

Main purposeTechnique

Can be

sustained for

agents such

as

Chlorhexidin

e; less so for

alcohol and

iodophors

Varies

by type

of agent

Fastest

for

alcohol

-Chlorhexidine

Hexachloraphen

e ,

Iodine;Iodophors;

Para-chloro-

meta-xylenol

(PCMX

-Alcohol-

based.waterless

antiseptic.

-after washing

hands by soap

and water.

Kills

transient

flora and

reduces

resident

flora

Preoperative

antisepsis

Surgical

Hand anti-

sepsis

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Hand Hygiene Technique

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• Make sure hands are dry. Use a method

that does not re-contaminate hands.

Make sure towels are not used multiple

times or by multiple people (IB).

• Avoid using hot water, as repeated

exposure to hot water may increase the

risk of dermatitis (IB).

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• Liquid, bar, leaflet or powdered forms

of plain soap are acceptable when

washing hands with a non-

antimicrobial soap and water.

• When bar soap is used, small bars of

soap in racks that facilitate drainage

should be used (II).

Hand Hygiene Technique with Alcohol-

Based Formulation

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Recommendations For Surgical Hand

Preparation

A. If hands are visibly soiled, wash hands with a plain soap before surgical hand preparation (II). Remove debris from underneath fingernails using a nail cleaner, preferably under running water (II).

B. Sinks should be designed to decrease the risk of splashes (II).

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C. Remove rings, watches, and

bracelets before beginning surgical

hand preparation (II). Artificial nails

are prohibited (IB).

D. Surgical hand antisepsis should be

performed using either an

antimicrobial soap or an alcohol-

based hand rub, preferably with

sustained activity, before donning

sterile gloves (IB).

E. If quality of water is not assured in the

operating theatre, surgical hand

antisepsis using an alcohol-based

hand rub is recommended before

donning sterile gloves when

performing surgical procedures (II).

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F. When performing surgical hand

antisepsis using an antimicrobial soap,

scrub hands and forearms for the

length of time recommended by the

manufacturer, 2 to 5 min. Long scrub

times (e.g. 10 min) are not necessary

(IB).

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G. When using an alcohol-based

product, use sufficient product to keep

hands and forearms wet with the hand

rub throughout the procedure (IB).

H. Do not combine surgical hand scrub

and surgical hand rub with alcohol-

based products sequentially (II).

Protocol for surgical scrub with a medicated

soap

Surgical hand preparation technique with an

alcohol-based handrub formulation

Selection and Handling of

Hand Hygiene Agents

• Provide health-care workers with efficacious hand hygiene products that have low irritancy potential (IB).

• To maximize acceptance of hand hygiene products by health-care workers, solicit their input regarding the feel, fragrance, and skin tolerance of any products under consideration. In some settings, cost may be a primary factor (IB).

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• If bar soap is used, small bars (that can

be changed frequently) are preferred.

– Soap should have drainage and should be

kept on racks.

– Liquid soap containers should be cleaned

when empty and refilled with fresh soap;

liquids should not be added to a partially

full dispenser;

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Drying Hands

A variety of methods are used for drying hands:

• Paper towels are the best method to dry hands.

• Cloth towels could be used if appropriately recycled.

• Warm air dryers shorten the time for hands to dry, however, they can only be used by one person at a time and are noisy and have the evidence of infection.

• Hand-drying materials should be placed near the sink in an area that will not become contaminated by splashing.

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Other aspects of hand hygiene

• Do not wear artificial fingernails or

extenders when having direct contact

with patients (IA).

• Keep natural nails short (tips less than

0.5 cm long) (II).

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SUMMARY

• Hand-borne Microorganisms.

• Types of Hand Hygiene and hand

Hygiene Technique

• Recommendations for surgical hand

preparation

• How to select hand hygiene agents.

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Biblography

• CDC: Guideline for Hand Hygiene in Health-Care Settings. MMWR (2002),51:RR-16.

• WHO Guidelines on Hand Hygiene in Health Care (2009)

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