http://ocw.usu.ac.id/course/download/1125-INFECTION-AND-TROPICALPEDIATRICS/mk_itps_slide_infeksi_nosokomial.pdf http://repository.usu.ac.id/bitstream/123456789/33474/3/Chapter%20II.pdf http://digilib.unimus.ac.id/files/disk1/122/jtptunimus-gdl-ragilarifw-6085-2-babii.pdf http://staff.blog.ui.ac.id/wiku-a/files/2012/09/Manajemen-Pencegahan-SurveilansUntuk-Infeksi-Nosokomial.pdf http://libmed.ugm.ac.id/files/bookmark.pdf http://epubs.rcsi.ie/cgi/viewcontent.cgi?article=1013&context=clinmicart http://buk.depkes.go.id/index.php? option=com_docman&task=doc_download&gid=712&Itemid=142 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/ Dtsch Arztebl Int. 2009 October; 106(40): 649–655. Published online 2009 October 2. doi: 10.3238/arztebl.2009.0649 PMCID: PMC2770229 Hand Hygiene for the Prevention of Nosocomial Infections Günter Kampf, PD Dr. med.,1,2 Harald Löffler, Prof. Dr. med.,3 and Petra Gastmeier, Prof. Dr. med 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 Koch Institute [Germany], WHO) were evaluated. Results Hygienic hand disinfection has better antimicrobial efficacy than hand-washing and is the procedure 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. Skin irritation is quite common among healthcare workers and is mainly caused by water, soap, and prolonged wearing of gloves. Compliance can be improved by training, by placing hand-rub dispensers at the sites where they are needed, and by physicians setting a good example for others. Conclusions Improved compliance in hand hygiene, with proper use of alcohol-based hand rubs, can reduce the nosocomial infection rate by as much as 40%. Keywords: hand hygiene, disinfection, compliance, nosocomial infection, protective gloves Healthcare workers’ hands represent the principal route of transmission of nosocomial pathogens. They are colonized permanently by the physiological flora (“resident flora”) and temporarily, depending on the precise nature of the employee’s duties, by various pathogens that do not belong to the physiological flora (“transient flora”) (1). Staphylococcus aureus, for example, can survive for over 2 h on the hands and is found in 10% to 78% of staff (table 1). Table 1 Frequency and persistence of selected nosocomial pathogens on the hands of healthcare workers (1) Go to: Clean Hands Campaign Improvement of hand hygiene, with the aim of minimizing nosocomial infection, is a high priority of the World Health Organization (WHO). The promotion of effective measures to improve hand hygiene (e1) is therefore one of the five foremost goals of the WHO’s current worldwide Patient Safety Initiative (Announce Action on Patient Safety [High 5s] Initiative, Washington, DC, 4 November 2006). By September 2008 114 countries had given written undertakings to implement these goals. In Germany, the Clean Hands Campaign (“Aktion saubere Hände”) was launched on 1 January 2008 under the auspices of the Federal Ministry of Health (e2). By 14 June 2009, 550 hospitals had signed up to the campaign, including two thirds of the university hospitals. The goal is to establish hand disinfection as a decisive quality parameter anchored firmly in clinical routine. Go to: Methods We began by examining the scientific literature on the provisional WHO recommendation on hand hygiene from the year 2006 (e3). For studies published from 2006 onward we performed a selective review of the publications in the National Library of Medicine. Furthermore, we evaluated the recommendations of the following institutions: Commission for Hospital Hygiene and Prevention of Infection, Robert Koch Institute (RKI) (2) Association of the Scientific Medical Societies in Germany (AWMF) (e4) WHO (final recommendation) (3) Centers for Disease Control and Prevention (CDC) (e5). Go 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 (box 1). It may even break the chain of infection more effectively than hand-washing or hand disinfection. A prospective, controlled intervention study showed that a training session and the availability of gloves directly at the bedside can significantly reduce the incidence of Clostridium difficile–associated diarrhea (CDAD) (4). The hands should be disinfected when protective gloves are taken off, because in contrast to surgical gloves, ordinary protective gloves are often permeable to pathogens even before use. Moreover, the hands may have come into contact with the potentially contaminated outer surface of the gloves during removal. In the case of vancomycin-resistant enterococci (VRE), a study showed that despite the use of gloves the same pathogen could be found on the hands of staff involved in treatment in 30% of cases (5). Go to: Box 1 Clinical situations in which the wearing of protective gloves is especially indicated Examination of incontinent patients Examination or treatment of MRSA patients Examination or treatment of patients with C. difficile–associated diarrhea Endotracheal aspiration Blood sampling Removal of drains or bandages Handling of secretions or excretions Go to: Hand-washing Indications Hand-washing should be an exception in clinical routine (2, 3). The point of washing the hands is mainly to remove visible soiling and only occasionally to reduce the microbial colonization of the skin—for example in contamination by spores of C. difficile. Hand-washing is therefore indicated considerably less often than generally assumed. It makes sense to wash the hands before starting work, after finishing work, and following visits to the bathroom. In all other clinical situations in which hand hygiene measures are required, hand disinfection should be preferred on grounds of efficacy and skin tolerability. Efficacy Washing with soap and water is much less effective than hygienic hand disinfection (1– 3). Even washing for several minutes reduces the skin’s resident flora hardly at all (table 2). Washing reduces the transient flora (contaminating flora) by only 2 to 3 log10 levels. The same is true for bacterial spores (6). Given the frequently short duration of washing, the efficacy of antimicrobial soaps hardly exceeds that of ordinary soaps (6), so that normal soaps are generally perfectly adequate for everyday clinical use. Table 2 Effect of hand-washing and hand disinfection (1, 24) Go to: Hygienic hand disinfection Indications Hand disinfection is indicated in almost all interactions of medical staff with patients (box 2) (2). C.. difficile. because bacterial spores are naturally resistant to alcohol. Merely in the case of contamination with spore-forming bacteria. is it useful to wash the hands after disinfection. Clinically manifest irritant eczema of the hand may gradually develop. Given the comparatively slight benefit. endoscopy Injections and punctures Before contact with patients who are at particular risk of infection. it swiftly becomes clear that hand-washing should be seen as an exception. Frequent washing of the hands can lead to dryness and impair the barrier function of the skin (7).Benefits and risks The limited benefits of hand-washing are accompanied by the risk of cutaneous irritation and hand eczema. bronchoscopy. even if gloves will be worn. and noxious substances can more easily penetrate the epidermis.g. e.g. Go to: Box 2 Hygienic hand disinfection benefits the patient in the following clinical situations (2): Before invasive procedures. e. Leukemia patients Polytrauma patients Burns patients Irradiated and other severely ill patients Before exposure to potential contamination Preparation of infusions Mixing of combined infusions Drawing up of syringes . Insertion of a venous or bladder catheter Angiography. e. The skin thus continually loses fats and water-binding factors.g. Efficacy The commonly available hand rubs are considerably more effective than hand-washing with soap (2. before manipulation of vascular catheters. auscultation. before and after aspiration Surgical site infection: before and after contact with wounds. Hygienic hand disinfection can make a substantial contribution to preventing these infections if consistently performed at the following junctures (2. before and after contact with the catheter Ventilator-associated pneumonia: before and after intubation. Before and after any contact with Wounds Insertion sites of catheters or drains After contact with Blood. Within 30 s. in the case of potential nosocomial infections (2. the following bacteria are not only greatly reduced but practically completely eliminated (e6): Escherichia coli—most frequent cause of catheter-associated urinary tract infection . before preparation of intravenous medication. palpation) or after contact with potentially infectious materials. e. The most frequent such infections in Germany are catheter-associated urinary tract infection (ca. e. Hand disinfection is most important. surgical site infection (ca. for example. bandages. aspirators. 3): Catheter-associated urinary tract infection: before placement of the urinary catheter.g. the hands should be disinfected after direct patient contact (measurement of vital functions. after removal of a bandage Catheter-associated bloodstream infection: before placement of vascular catheters. excrement. ventilator-associated pneumonia (ca. 42%). MRSA patients After removal of protective gloves After contact with a patient during a clinical round or in the consultation or treatment room For example. 21%). secretions. or infected regions of the body Urine-collecting systems. 3). 3). tracheal tubes or drains Potentially infectious patients.. however. and catheter-associated bloodstream infection (ca. ventilators. ventilation masks. 8%) (8).g.. 16%). the irritant potential of alcohol-based hand rubs is very low. these parts of the hand are most likely to come into contact with the patient. These include uncoated viruses such as noroviruses and the spores of spore-forming bacteria such as C. because epidemiological studies have shown that as part of a package of measures these preparations make a real contribution to the containment of outbreaks. Hand disinfection thus eliminates the majority of agents known to cause nosocomial infections.g. The duration of application should be 22 to 28 s.. and the greatest proportion of the bacteria are found on the fingertips (13). Over the same period the rate of new infections by methicillin-resistant S. In the case of the noroviruses special virucidal hand rubs are recommended (see the RKI’s list of disinfectant hand rubs [9]). an adequate amount of the hand rub must be applied efficiently. There are only a few pathogens against which the commonly available hand rubs are ineffective. This is due partly to the skin care substances usually found in hand rubs. 15 s. both hands must be completely covered. difficile. difficile. Go to: Hand eczema . HCV. Commercially available preparations are generally tolerated much better than the detergents in hand-washing agents (7. To this end. HIV. intensive hand disinfection detracts only minimally from the skin’s barrier function and makes the skin only slightly drier. Special attention must be paid to the fingertips and thumbs. Shorter application times. aureus (MRSA) was reduced by more than 50% (10). For spore-forming bacteria such as C. Surprisingly. 11). Even frequent. almost always fail to cover the hands completely (12). and to coated viruses such as HBV. then to wash them briefly but thoroughly to reduce the number of spores as much as possible (e7). At Geneva University Hospital. Benefits and risks Hand disinfection is key to the prevention of nosocomial infections. or Rhodotorula spp. e. the recommendation is first to disinfect the hands in order to kill off the vegetative form. Allergic reactions to the ingredients of hand-rub preparations are extremely rare (1. improvement of the compliance rate from 48% to 66% over a 5-year period lowered the frequency of nosocomial infections by more than 40% (10). In contrast to popular opinion. 3). Pseudomonas aeruginosa—very frequent cause of ventilator-associated pneumonia Staphylococcus aureus—most frequent cause of surgical site infection Staphylococcus epidermidis—most frequent cause of catheter-associated bloodstream infection. however. and the influenza viruses. not with a strictly regulated procedure. For hand disinfection to be effective. The same applies to yeasts such as Candida spp. the best results are achieved when users are left to their own devices. In a survey carried out by the German Contact Allergy Group (Deutsche Kontaktallergiegruppe. Some users state that alcohol-based hand rubs have a sensitizing effect. Those affected should avoid activities harmful to the skin—washing. Interestingly. Consequently employment in nursing and related professions involves the risk of contracting occupational dermatosis (14). Many consider rough. however (15). many users think that hand rubs harm their skin. . probably by elimination of residual detergent monomers (7). Figure 2 Manifest irritant hand eczema A burning sensation on use of a disinfecting hand rub is a warning of impairment of the skin’s barrier function. but the damage accelerates: a vicious circle begins. in the worst case. cetearyl octanoate) was demonstrated.There can be no doubt that hygiene precautions are a risk factor for occupational hand eczema. 11). One reason is the burning felt when the alcohols stimulate the pain receptors in damaged areas of skin. more than 70% of nursing staff reported irritant skin symptoms within a year. and 46% considered them detrimental in their daily lives (15). Nevertheless. resulting in manifest hand eczema (figure 2) and. However. the application of alcohols after hand-washing can even reduce the irritation caused by the washing. direct contact with irritant disinfectants—and apply copious quantities of skin protection and skin care products. alcohol-based preparations are much kinder to the skin than hand-washing agents because they are less harmful to the cutaneous barrier (as measured by transepidermal water loss) and dry the skin out less (as measured by corneometry) (7. Nevertheless. inability to work (16). contact with soaps. flaking skin on their hands as normal in their line of work and fail to realize that this may be the first sign of hand eczema (figure 1). sensitization to an alcohol could be excluded in all 50 persons who were tested for allergic reactions to an alcohol-based hand rub because of suspected intolerance. Oversensitivity to an excipient (e. The burning stops.. DKG). occlusion (protective gloves).g. Figure 1 Early irritant skin changes between the digits Most nurses still believe that alcohol-based hand rubs damage their skin more than hand-washing (15). The alcohol-based hand rub is then blamed for the symptoms (“it only burns with the alcohol”) and hand disinfection is abandoned in favor of washing. These precautions should be integrated in the working routine and can. Skin protection products should be applied before starting work and after every break. adequate protection and care of the skin are of paramount importance for the maintenance of a functioning cutaneous barrier (e8). As a secondary aim. Eczematous hands are also colonized to a greater degree by pathogens than are healthy hands (17. evaluation.An intact cutaneous barrier is of more than just cosmetic and functional relevance. only 50% on average. it is also important to reduce hand-washing to a minimum. After work. In other words. skin care creams help to accelerate cutaneous regeneration. who can then institute the appropriate procedures. 18). as well as information on their uses (see the “Occupational Skin Preparations” (“Berufliche Hautmittel”) guideline of the German Working Group for Occupational and Environmental Dermatology [Arbeitsgemeinschaft für Berufs. The principles of hand care and protection should therefore be taught to all healthcare workers and should form part of every training program (19). of course. every second time hand disinfection is required. they should preferably be applied only when work is over (21). measures) (20). including reporting of the case to the accident insurance provider (22). Any member of staff exhibiting clinically manifest cutaneous irritation at work should be referred to a dermatologist or occupational medicine specialist. Moreover. They are also included in the Clean Hands Campaign. it is not carried out. in order to minimize drying out and impairment of the skin’s barrier function by wet work.und Umweltdermatologie. Because components of some of these preparations may promote penetration of irritants. Go to: Care and protection of the skin Appropriate precautions when using potentially irritant substances can prevent harm to the skin. protect the hands without compromising disinfection. if properly implemented. Staff should have access to data showing the efficacy of all preparations employed. ABD]) (21). Skin protection plans should be drawn up with information about the available products and their use (see Technical Rule for Hazardous Substances [TRGS] 401 of June 2008: Risks resulting from skin contact—determination. The primary goal of all initiatives to improve compliance in hand hygiene is optimization of the rate of hand disinfection. These include: . Go to: Compliance Unfortunately the overall rate of compliance in hand hygiene is poor. Barriers There are many different reasons why healthcare workers disinfect their hands much less often than necessary for protection of their patients. primary prevention by means of early education on hand hygiene (e. the doctor may be able to carry a bottle of hand rub in the pocket of his/her lab coat. when established routine behavior has to be changed Disinfecting hand rubs should be available where they are actually needed. dryness.. during training. Reduction of hand-washing to a minimum in order to avoid unnecessary skin irritation Senior members of medical staff must recognize that they have to set an example and act accordingly. Furthermore. If wall dispensers cannot be mounted. Moreover. skin protection and care products must be available to all employees at their workplace. This can by achieved by simple means both in the hospital and the doctor’s office. because behavior learned during basic training is put into practice much more effectively than that taught in later training sessions. or burning combined with inadequate knowledge of the causes Failure of high-ranking medical staff to set an example: junior doctors and nurses will think that hand disinfection cannot be very important if senior doctors dispense with it. e. accompanied by regular motivational campaigns. Measures to achieve improvement Readily implementable measures can be drawn up to counter the above-mentioned factors and improve compliance (box 3). is effective..g.g. . with explanation of the efficacy and cutaneous tolerance of hand hygiene measures). Insufficient knowledge of the clinical situations in which the patient clearly benefits Lack of products or dispensers: unavailability of the disinfecting hand rub right where it is needed Lack of time: hand disinfection is frequently not carried out because of increasing pressure of work. It will then be much more difficult for junior workers not to follow suit. irritation. One can only appeal to all senior staff to set a proper example. or when a ward is over-occupied or under-staffed (23) Cutaneous irritation: skin problems with use. Go to: Box 3 Measures to improve compliance Staff training with regard to the clinical situations in which hand disinfection is indicated Inclusion of the goals in the training program. on average every second necessary disinfection of the hands is not actually carried out. or following disinfection in the case of contamination by spores of bacteria such as C. Go to: Acknowledgments Translated from the original German by David Roseveare. must then be avoided and skin protection and care products applied more intensively. In most clinical situations hygienic disinfection is indicated for hand decontamination on grounds of better efficacy and cutaneous tolerance. difficile.Go to: Conclusion Evidence-based hand hygiene can prevent transmission of the most important nosocomial pathogens and also keep employees’ skin healthy. following disinfection. Go to: Footnotes . e. Compliance could be improved by knowledge of the principal clinical circumstances in which hand disinfection by healthcare workers genuinely benefits the patient. hands contaminated with spore-forming bacteria such as C..g. frequent washing. difficile. In practice. Activities harmful to the skin. Go to: Key Messages Hand disinfection eliminates the transient flora and is one of the most important precautions for specific prevention of transmission of nosocomial infections. A burning sensation on hand disinfection represents an important warning of damage to the cutaneous barrier. The WHO has therefore launched a worldwide initiative to improve compliance. Washing with soap and water is necessary only when the hands are visibly soiled. It should principally be restricted to visibly soiled hands and. The rate of nosocomial infections can be reduced by up to 40% by improved compliance in hand disinfection. Hand-washing damages the skin more than hand disinfection. Gerding DN. [PubMed] 8. Maibach HI. Hamburg. First global patient safety challenge—clean care is safer care. et al. Gastmeier P. Händehygiene. Ausgabe) Bundesgesundheitsblatt. 2009. Tenorio AR. Gergen MF. Efficacy of selected hand hygiene agents used to remove Bacillus atrophaeus (a surrogate of Bacillus anthracis) from contaminated hands. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant Enterococcus species by health care workers after patient care. 3. 2000. 2003.38:37–49. The Journal of the American Medical Association.Conflict of interest statement Dr.289:1274–1277. [PubMed] .43:230–233.157:74–81. How irritant is alcohol? British Journal of Dermatology. Robert Koch-Institut. Stand vom 31. Wischnewski N. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Liste der vom Robert Koch-Institut geprüften und anerkannten Desinfektionsmittel und -verfahren. WHO. Johnson S. The Lancet.32:826–829. Sahgal NB.88:137–140. WHO guidelines on hand hygiene in health care.5. Kampf G. Sickbert-Bennett E. Clinical Microbiology Reviews. Schmermund D.2007 (15. Pittet D. Rutala WA. Professor Löffler has received honoraria for lectures given on behalf of Bode Chemie GmbH. [PubMed] 7. Prospective. 1990. 4.356:1307– 1312. Bundesgesundheitsblatt. 2001. [PubMed] 5. Weber DJ. 1998.50:1335–1356. Journal of Hospital Infection. et al. 2007. Hugonnet S. Kampf is an employee of Bode Chemie GmbH. controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. 2007. 10. Prevalence of nosocomial infections in representative German hospitals. Clinical Infectious Diseases. Robert Koch-Institut. et al. Harbarth S. 2000. 2004. [PubMed] 6. Kampf G. American Journal of Medicine. Geneva: WHO. Badri SM. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. [PMC free article] [PubMed] 2. Kampf G. et al. [PubMed] 9. Kramer A. Olson MM. Go to: References 1. Löffler H. Professor Gastmeier declares that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.17:863–893. 2001. et al. Kaulfers P-M. 2008. et al. Nurses’ perceptions of the benefits and adverse effects of hand disinfection: alcohol-based hand rubs vs. Influence of rub-in technique on required application time and hand coverage in hygienic hand disinfection. Optimierte Versorgung von Patienten mit berufsbedingten Handekzemen: Hautarztverfahren . [PMC free article] [PubMed] 14. Marples RR. Dave J.356:768–769. A hospital-acquired outbreak of methicillinresistant Staphylococcus aureus infection initiated by a surgeon carrier. Richard MA. [PubMed] 16. A stinging cause for preventive skin care. Reichel M. Kampf G. A double outbreak of exfoliative toxin-producing strains of Staphylococcus aureus in a maternity unit. 2009. Schmidt A.Maßnahmen. 2000. Bundesministerium für Arbeit und Soziales (BMAS) 2008 21. Diepgen TL. Chang S-C. Fartasch M. Primary prevention in health care employees: a prospective intervention study with a 3-year training period. Stutz N.160:565–572. Jappe U. Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use. Bruckner T. Larson EL. Eggerstedt S. Diepgen T.47:104–109. Ko W-J. Contact Dermatitis. Berufliche Hautmittel . Winnefeld M.143:546–550.11. Feil Y.145:453–462.Leitlinie der Arbeitsgemeinschaft für Berufs. Dickel H.26:950–953. Perrenoud D. 1988. 1994. Breuer K. British Journal of Dermatology. Bundesministerium für Arbeit und Soziales. [PubMed] 18. Diepgen TL. Composition and density of microflora in the subungual space of the hand. The Lancet. [PubMed] 17. Reith S. Ermittlung . Brandenburg S. Ruffieux C. Blesius CR. Grobb JJ. Occupational skin diseases in Northern Bavaria between 1990 and 1999: a population-based study. Journal of Hospital Infection. British Journal of Dermatology. Drexler H. Becker D. Dulake C. Löffler H. McGinley KJ. TRGS 401: Gefährdung durch Hautkontakt. John SM. Jünger M. [PubMed] 12. [PMC free article] [PubMed] 19. Journal of Clinical Microbiology. 2001. Leitlinien-Register Nr: 013/056.8 [PMC free article] [PubMed] 13. Leyden JJ. 2006.und Umweltdermatologie (ABD) in der Deutschen Dermatologischen Gesellschaft (DDG). hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group. et al. 2008 22. Allmers H. 2000. [PubMed] 20. Kuss O. Wang J-T.54:202–209. BMC Infectious Diseases.Beurteilung . Drancourt M. Lübbe J. British Journal of Dermatology. [PubMed] 15. Skudlik C. Epidemiology and Infection. Effendy I.112:103–114. Nash JQ. 2008.de. [PubMed] 23.net/ http://pmj. [PubMed] 24. www. Clean Care is Safer Care. 2003. Comparison of waterless hand antisepsis agents at short application times: raising the flag of concern. 2003.331:53–59. Kampf G.55:226–231.33:300–313. Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. www. [PubMed] e7.bmj.dermis. e8.77. [PubMed] e1. Validity of the four European test strains of prEN 12054 for the determination of comprehensive bactericidal activity of an alcoholbased hand rub.903. Pittet D. Clostridium difficile .full Postgrad Med J 2001.und Umweltdermatologie. World Health Organization.77:16-19 doi:10. 1999.com/content/77/903/16. Dharan S.1136/pmj. and poor hygiene practices. Händedesinfektion und Händehygiene. e3. [PubMed] e6. Infection Control and Hospital Epidemiology. WHO. e4. Hygiene + Medizin. Boyce JM.int/patientsafety/en/ e2. overcrowding. Sudre P. Kampf G. Hollingsworth A.und Stufenverfahren Haut der gesetzlichen Unfallversicherung.who. Aktion Saubere Hände. Journal of Hospital Infection. Outbreak of Enterobacter cloacae related to understaffing. Pittet D. 2008. Der Hautarzt. MMWR . Infection Control and Hospital Epidemiology.59:692–695.Morbidity & Mortality Weekly Report. Dharan S.was ist für eine effektive Desinfektion zu beachten? Hygiene + Medizin. 2008. WHO guidelines on hand hygiene in health care (advanced draft) 2006. Guideline for hand hygiene in health-care settings. 2002. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften.16 .aktion-sauberehaende. Pittet D. www.abd. Arbeitsgemeinschaft für Berufs. e5. Sax H. Cadenas M.20:598–603.51:1–45.241:60–16. Hugonnet S. Harbarth S. The health professional's role in preventing nosocomial infections 1. .wits. H Saloojee. identifying mechanisms to ensure compliance by health professionals remains a perplexing problem. While virulent microorganisms can be cultured from stethoscopes and white coats. and masks have a role in preventing infections. Department of Paediatrics and Child Health. 2. their role in disease transmission remains undefined. South Africa 1. However. Gloves. nurses. health professionals may prevent much unnecessary medical and financial distress to their patients. There is increasing concern worldwide about the rising prevalence of multiresistant. and other health workers. University of the Witwatersrand. A Steenhoff + Author Affiliations 1. but are often used inappropriately.1 2 but their implementation is often hindered by a lack of support from administrators and poor compliance by doctors. gowns. PO Wits. health professionals sometimes act as vectors of disease. increasing service costs unnecessarily. has resorted to using more potent and expensive antibiotics to curb the threat these organisms pose to vulnerable infants. Many are visibly upset when their poor hygiene practices are exposed and are offended when it is suggested that they may be potential vectors of disease and are spreading virulent microorganisms among their patients. Some health professionals suffer from the “Omo syndrome”—a belief that they are always super clean and sterile. in one South African neonatal unit multi-antibiotic resistant klebsiellae are now the commonest organisms cultured.ac. Indeed. Dr
[email protected] Received 12 January 2000 Accepted 9 May 2000 Abstract Despite their best intentions. Frequent hand washing remains the single most important intervention in infection control. disseminating new infections among their unsuspecting clients. like many others. By following a few simple rules identified in this review. Johannesburg 2050.3 While this neonatal unit. Infection control programmes are cost-effective. virulent bacteria. it is clear that the focus of any efforts has to be on the prevention of nosocomial infections. There is greater consensus about sterile insertion techniques for intravascular catheters—a common source of infections—and their care. Attention to simple preventive strategies may significantly reduce disease transmission rates. and fungi.4 Among the numerous risk factors for acquiring a nosocomial infection. and they also overestimate the duration of hand washing.9 At many hospitals and clinics. Poorer hand washing performance was related to increasing nursing workload and the reduced availability of hand decontaminating agents.Aetiology of nosocomial infections Intravascular device related infections and infections acquired through the respiratory tract are among the most common nosocomial infections in critically ill patients. hands were only cleaned after 30% of patient contacts and after 50% of activities likely to result in heavy contamination. hospital staff believe that they wash their hands more often than they actually do. annoying occurrence.5 Hand washing is accepted as the single most important measure in infection control. Voss and Widmer argue that alcoholic hand disinfection. (box 1). Gram negative bacilli and enterococci. soap hand washing would consume 16 hours of nursing time for a 24 hour shift. viruses (which account for up to 20% of cases).10 They estimated that given 100% compliance. particularly in developing countries. Aetiological agents vary and include antibiotic resistant bacteria.8 In a study of nurses' practices. particularlyStaphylococcus aureus. the length of hospital stay is the most important. Alcoholic hand disinfection is generally used in Europe. Hand . while hand washing with medicated soap is more commonly practised in the United States. infants. allows easy and complete compliance without interfering with the quality of patient care.10 The superiority of one method over the other is a moot point. with its rapid activity. superior efficacy. sprays. and minimal time commitment.57 Not surprisingly. and hand towels is a regular. whereas alcoholic hand disinfection from a bedside dispenser requires only three hours. Box 1: Risk factors for nosocomial infection Duration of hospital stay Indwelling catheters Mechanical ventilation Use of total parenteral nutrition Antibiotic usage Use of histamine (H2) receptor blockers (owing to relative bacterial overgrowth) Age—more common in neonates. and the elderly Immune deficiency Hand washing The hands of staff are the commonest vehicles by which microorganisms are transmitted between patients. handwash basins are poorly accessible and the unavailability of soap. resterilised. and of senior staff setting a good example by their own hygienic practices. but they supplement rather than replace hand washing. Gowning Gowns help keep infectious materials off clothing.washing using a spray can be accomplished in 20 seconds. or mortality rates. Sterile gloves are much more expensive than clean gloves and need only be used for certain procedures. It is difficult to provide clear guidelines on how often hands should be washed. Theatre staff are sometimes reluctant to remove their wedding rings when scrubbing up. The Handwashing Liaison Group is emphatic: “an explicit standard [should] be set.12 The value of surgical scrubbing using a brush is questioned. such as when hands are going to make contact with normally sterile body areas or when inserting a central venous or urinary catheter.5 Single use gloves should never be washed. infection. compliance improved by 92%. For gloves to be used appropriately they must be readily available. The thoroughness of application is more important than the time spent on washing or the agent used.19 The universal use of gloves . cannot be overemphasised. compared with 40–80 seconds for soap.14 Alas. There was no change in traffic patterns in the unit or in hand washing behaviour. Gloves Gloves are a useful additional means of reducing nosocomial infection. Clean gloves can be used at all other times.14 15 Larson et alreported that by providing feedback to staff regarding the frequency of hand washing.18 19Wearing gowns did not reduce neonatal colonisation. Higher microbial counts after washing are found in health workers who prefer not to remove rings.11 and may put the patient at risk for a nosocomial infection. Two recent studies confirm that staff gowning in the neonatal intensive care unit is an unnecessary custom.13 Continued monitoring and educational efforts can improve hand washing habits. and gloves must be changed after each patient encounter. although in some centres they are used more as reminders that the patient is isolated. or disinfected. In one study. this is not always the case at many clinics and hospitals in poorer settings. including during wound dressings.17 Not surprisingly. health care workers who wash their hands more often are also more likely to wear gloves. Again. Possible microbial contamination of hands and transmission of infection has been reported despite gloves being worn. that hands should be decontaminated before each patient contact. subjects who washed with an antiseptic soap alone had a twofold greater reduction in bacterial counts than when they scrubbed with a brush.18 and it was not cost-effective. The importance of constantly reminding staff of the need for hand washing. when feedback was stopped compliance quickly returned to baseline levels.”16 We recommend the use of chlorhexidine solution before the performance of invasive procedures. 5%).29 The cuffs and pockets of the coats are the most highly contaminated areas. Nevertheless.23 Tunevall. When originally introduced.20 Masks It has never been shown that wearing surgical facemasks decreases postoperative wound infections. and 75% with antiseptic soap. White coats Like the stethoscope.26 Isopropyl alcohol is an effective cleaning agent. Stethoscopes Some health personnel have difficulty in accepting that the stethoscope. The recommendation that the coat is removed and . Many institutions insist that junior doctors.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. we suggest that regular disinfection should be carried out (at least once daily). they have not been proven to protect the patient.27 but may dry out the stethoscope's rubber seals and damage the tubing if used routinely. wear a white coat as part of a mandatory dress code.21 The prevailing opinion that masks are useful in preventing surgical site infection has been challenged. particularly in surgical areas. 7% yearly.7%). 37% monthly.22-24 Orr reported a 50% decrease in wound infections when masks were not worn. the white coat has long been a symbol of the medical professional. 73 wound infections were recorded (4. while following 1551 operations performed without face masks. 48% of health care providers cleaned their stethoscopes daily or weekly.25 There are no studies on the beneficial effect of regularly cleaning stethoscopes on nosocomial infection rates. About half of all patients still prefer their doctor to wear one. after 1537 operations performed with face masks. the symbol of their professional status. Cleaning the stethoscope's diaphragm resulted in an immediate reduction in the bacterial count—by 94% with alcohol swabs. 90% with a non-ionic detergent. the primary function of the surgical mask 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. they may be less enthusiastic about this if they realised that white coats harbour potential pathogens and are thereby a source of cross infection. However. and 7% had never cleaned them. as the level of contamination rises from 0% to 69% after more than one day without cleaning of the stethoscope.25 Overall. and 50 doctors). using better controls.28 However. confirmed the earlier findings of lack of clear benefit from wearing masks24. may actually be a vector of disease. it is now recognised that most bacteria dispersed by talking and sneezing are harmless to wounds. in particular. staphylococcus species (mostly coagulase negative) were cultured from 89% of the participants' stethoscopes. Thus while masks may be used to protect the operating team from drops of infected blood and from airborne infections. In a study of 150 health care workers (50 paramedics. 50 nurses. 55 infections occurred (3. the mean number of colony forming units increasing the longer stethoscopes were not cleaned. but the study was criticised for lack of proper controls. The difference was not significant. such as Tegaderm®. have been produced which are several times more permeable than standard dressings.37 “Flagging” each set with a sticker displaying the time it had to be replaced resulted in a significant reduction in the incidence of klebsiellae in a busy neonatal unit. The insertion of an intravenous needle or cannula results in a break in the body's natural defences.31 The use of a clear. adhesive. and exudate. infections.30 Most causative organisms originate from the skin: staphylococci cause two thirds of the infections. a meta-analysis showed a significantly increased risk of catheter tip infection when transparent rather than gauze dressings were used with either central or peripheral catheters.34 A recent Swiss study was unable to show an increased risk of catheter related complications— phlebitis. with S aureus accounting for 5–15% of these. or for excluding the wearing of white coats in non-clinical areas. bacteria impermeable dressing to secure the cannula has become popular. but the giving set does not need to be replaced more often than every 72 hours. the rate of catheter associated bacteraemia was almost fourfold lower in the patients who received chlorhexidine than in the two other groups.35 Peripheral catheters can be safely maintained with adequate monitoring for up to 144 hours (six days) in critically ill children. The hands should be disinfected with alcohol and gloves should be worn. Inserting a peripheral catheter demands the same precautions as for any surgical procedure. and mechanical complications—during prolonged peripheral catheterisation.a plastic apron is donned before wound examination is rarely followed in practice. Indeed. which may promote growth on and in the underlying skin. Prevention of complications requires careful insertion practice and optimal catheter care. intravenous lines are responsible for at least one quarter of all nosocomial blood stream infections. Guidelines developed by the Centers for Disease Control and Prevention recommend that peripheral intravenous catheters be changed every three days. 10% povidone-iodine. clearly its value needs to be critically assessed.29 Intravenous catheters In critically ill patients.36 Containers of intravenous fluids are usually changed before significant growth occurs.38 There is no difference in the incidence of . with a 25% reported mortality. polyurethane dressings. Organisms can enter the circulation from contaminated fluid or a giving set. While few would challenge the sartorial elegance of the white coat. The insertion site should not be touched after disinfection. When 2% chlorhexidine.33 Routine replacement of the intravenous line every three to five days is common practice in the USA but not in Europe. routine replacement of central venous catheters was no longer supported in their latest update. However. or can grow along the outer surface of the cannula. and 70% alcohol were compared as skin disinfectants.32 Recently. sweat. The skin of the insertion site must be thoroughly disinfected with alcoholic chlorhexidine or 70% isopropyl alcohol for at least 30 seconds and allowed to dry before inserting the cannula. There is little microbiological evidence for recommending changing white coats more often than once a week. These dressings may be contraindicated as they allow accumulation of blood.33These should minimise the risk of moisture accumulation and reduce sepsis rates. transparent dressings o in-line bacterial filters .septicaemia in children who have in-line bacterial filters fitted compared with those who do not.39 Box 2: Practical methods for preventing nosocomial infection What's in Hand washing: o as often as possible o use of alcoholic hand spray o removing jewellery before washing Stethoscope: cleaning with an alcohol swab at least daily Gloves: supplement rather than replace hand washing Intravenous catheter: o thorough disinfection of skin before insertion o changing administration sets every 72 hours What's out Hand washing: using a brush Mask: o routine use in theatre o during wound dressing Gowning: routine use in neonatal units White coats: enforced use in clinical units Intravenous catheter: o routine removal of peripheral catheters after 72 hours o use of impermeable. (Oxford University Press. Saloojee H. Oxford). 2. Search Google Scholar 2. Mehtar S (1992) Hospital infection control: setting up with minimal resources. and cost. University of Pretoria. van Wersmeskerken A (1999) Neonatal bacteraemia and pseudobacteraemia at Chris Hani Baragwanath Hospital. Wenzel RP (1995) The economics of nosocomial infections. References 1. but these practices are often not sustainable. . [CrossRef][Medline][Web of Science] 3. 4.40 In the end. Nosocomial infections are worth preventing in terms of benefits in morbidity. Singh-Naz N. duration of hospital stay. ↵ 1. Sprague BM. ↵ 1. Search Google Scholar 4. mortality. Pretoria. Educational interventions promoting good hygiene and aseptic techniques have generally proved to be successful. constant vigilance and attention by the individual to what are rather simple measures is demanded.Conclusions Methods for preventing nosocomial infections are summarised in box 2. Patel KM. ↵ 1. J Hosp Infect 31:79–87. 3. ↵ 1. et al. 2. Proceedings of the Eighteenth Conference on Priorities in Perinatal Care in Southern Africa. Greater efforts are being made in some countries to ensure the application of the infection control evidence base into practice. (1996) Risk factors for nosocomial infection in critically ill children: a prospective cohort study. Wilson Barnett J. ↵ 1. 2. . the use of gloves and sharp instruments. [CrossRef][Medline][Web of Science] 8. ↵ 1. ↵ 1. Larson EL (1995) APIC guideline for handwashing and hand antisepsis in health care settings. J Hosp Infect 28:15–20. Jarvis WR (1994) Hand washingthe Semmelweis lesson forgotten. Search Google Scholar 9. Gould D (1995) Nurses' hand decontamination practice. ↵ 1. Crit Care Med 24:875–878. [CrossRef][Medline][Web of Science] 7. Int J Nurs Stud 33:143–160. Gould D. [CrossRef][Medline][Web of Science] 5. 3. Reybrouck G (1983) Role of the hands in the spread of nosocomial infection. Ream E (1996) Nurses' infection-control practice: hand decontamination. results of a local study. ↵ 1. Lancet 344:1311– 1312. [CrossRef][Medline][Web of Science] 6. J Hosp Infect 4:103–110. Am J Infect Control 23:251–269. (1997) A randomized trial of surgical scrubbing with a brush compared to antiseptic soap alone. Hutfilz P. Smaill F. [Medline] 13. Wilcox L. Nurs Stand 11:44–46. Treen LM. Voss A.[CrossRef][Medline][Web of Science] 10. Am J Infect Control 25:24–27. Larson EL. 2. 2. Bernthal E (1997) Wedding rings and hospital-acquired infection.↵ 1. Loeb MB. 4. 3.↵ 1. Am J Infect Control 25:11–15. 2. . 3.↵ 1. et al. [Medline][Web of Science] 11.↵ 1. et al.↵ 1. [CrossRef][Medline][Web of Science] 12. Salisbury DM. [CrossRef][Medline][Web of Science] 14. Widmer AF (1997) No time for handwashing!? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol 18:205–208. 4. (1997) The effect of rings on microbial load of health care workers' hands. Emerman CL (1996) Is handwashing teachable? Failure to improve handwashing behavior in an urban emergency department. (1997) A multifaceted approach to changing handwashing behaviour. Adler LM. Dorsey ST. Olsen RJ. 4. . 3. 2. [FREE Full text] 17. Coyle MB. 2. Pelke S. JAMA 270:350–353. Am J Infect Control 25:3–10. Acad Emerg Med 3:360–365. Cydulka RK.2. 4. et al.↵ 1. [CrossRef][Medline][Web of Science] 18.↵ 1. Ching D.↵ 1. (1993) Examination gloves as barriers to hand contamination in clinical practice. 3. 2. BMJ 318:686. 3. Lynch P. [CrossRef][Medline][Web of Science] 15. Bryan JL. [Medline][Web of Science] 16. et al. Handwashing Liaison Group (1999) Hand washing (editorial).↵ 1. Ann Intern Med 125:448–456. 3. et al. (1994) Gowning does not affect colonization or infection rates in a neonatal intensive care unit. [CrossRef][Medline][Web of Science] 19. 2. Hayden MK. 2. Arch Pediatr Adolesc Med 148:1016–1020.. Lim SH. [CrossRef][Medline] 20. Slaughter S. 4. London). Int J Nurs Pract 1:52–58. 3rd ed. Malathi I (1995) Does routine gowning reduce nosocomial infection and mortality rates in a neonatal nursery? A Singapore experience. (1996) A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. et al.3.↵ 1. Easa D. Search Google Scholar . et al. 4. Tan SG. 2. A practical handbook (Chapman and Hall. 4. 3. [Medline][Web of Science] 21. 3. Nathan C.↵ 1.↵ 1. (1992) Control of hospital infection. Ayliffe GAJ. Lowbury EJL. Geddes AM. 22. [CrossRef][Medline][Web of Science] 25. Genné D.↵ 1. et al. [CrossRef][Medline][Web of Science] 23. Search Google Scholar 24. . Jones JS. 2. Riekse R (1995) Stethoscopes: a potential vector of infection? Ann Emerg Med 26:296– 299. 2. 4.↵ 1. Orr NWM (1981) Is a mask necessary in the operating theatre? Ann R Coll Surg Engl 63:391–392.↵ 1. Mitchell NJ. de Torrenté A. [CrossRef][Medline][Web of Science] 26. 2. Hoerle D. Humair L. 3.↵ 1. Hunt S (1991) Surgical face masks in modern operating rooms—a costly and unnecessary ritual? J Hosp Infect 18:239–242. Tunevall TG (1991) Postoperative wound infections and surgical face masks: a controlled study. World J Surg 15:383–387.↵ 1. 3. [CrossRef][Medline][Web of Science] 28. [Abstract/FREE Full text] 29. Hollis P (1991) Microbial flora on doctors' white coats. 3. Menahem S. 2. Search Google Scholar 30. Wong D. Shvartzman P (1998) Is our appearance important to patients? Fam Pract 15:391–397. Search Google Scholar . J Chemother 7 (suppl 3) 55–66. Pierson C. 3. [Medline][Web of Science] 27.↵ 1. BMJ 303:1602–1604. Schweiz Med Wochenschr 126:2237–2240. [In French.↵ 1. Nye K. Pittet D. 3. 2. Marinella MA. A potential source of nosocomial infection? Arch Intern Med 157:786–790. 2. .↵ 1.↵ 1. 2.]. Chenoweth C (1997) The stethoscope.(1996) Level of stethoscope contamination in the hospital environment. Auckenthaler R (1995) Intravascular device-related infections in critically ill patients. Hulliger S. Elliot TSJ (1997) Do dressings with increased permeability reduce the incidence of central venous catheter related sepsis? Intensive Crit Care Nurs 13:26–29. 4. [CrossRef][Medline][Web of Science] . [CrossRef][Medline] 34. 2. Tebbs SE. Lancet 338:339–343. Am J Infect Control 24:262– 293. [CrossRef][Medline][Web of Science] 33. 3. Alvarado CJ (1991) Prospective randomised trial of povidone iodine. 2.↵ 1. 3.↵ 1.↵ 1. (1992) Transparent polyurethane film as an intravenous catheter dressing. Part I. Intravascular device-related infections: an overview. [CrossRef][Medline][Web of Science] 32. 3. Reynolds MG. Maki DG. Hoffmann KK. The Hospital Infection Control Practices Advisory Committee. Weber DJ. et al.31. A meta-analysis of the infection risks. 2. JAMA 267:2072–2076.↵ 1. Samsa GP. Ringer M. alcohol and chlorhexidine for the prevention of infection associated with central venous and arterial catheters. Pearson ML (1996) Guidelines for prevention of intravascular device-related infections. Dunne WM. 3.35.↵ 1. 4. 2. et al. Infect Control 8:113–116. (1998) Is routine replacement of peripheral intravenous catheters necessary? Arch Intern Med 158:151–156. 4. S Afr Med J 83:298. Bregenzer T. Havens P.↵ 1. Garland JS. (1987) Safety of changing intravenous administration sets containing burettes at longer than 48 hour intervals. 2. Wainer S (1993) Drip “flagging” [letter]. Gray G. Sakmann P. 2. [Abstract/FREE Full text] 37. 3. [Medline][Web of Science] . (1992) Peripheral intravenous catheter complications in critically ill children: a prospective study. Reidy MD. Pediatrics 89:1145–1150. Snydman DR. et al. 3. et al. Perrt LK. [Medline][Web of Science] 38. [CrossRef][Medline][Web of Science] 36. Conen D.↵ 1. 4. 2.↵ 1. 2. Dr. med.nlm. but compliance in clinical practice is often low.nih.. med Abstract Background The WHO regards hand hygiene as an essential tool for the prevention of nosocomial infection. Journal of Intravenous Nursing 21:66–70.ncbi. PD Dr. J Hosp Infect 42:91–104. 3.↵ 1. 2. Jenner EA. Hand Hygiene for the Prevention of Nosocomial Infections Günter Kampf. 2009 October.. Dr. http://www. Search Google Scholar 40. Mackintosh C.gov/pmc/articles/PMC2770229/ Dtsch Arztebl Int. .2 Harald Löffler. WHO) were evaluated. Prof. 106(40): 649–655.↵ 1. Newall F. Robertson J (1998) Use of in-line filters in pediatric intravenous therapy. Published online 2009 October 2.3 and Petra Gastmeier.1.39. med. 3. Prof. Ranson K. Methods The relevant scientific literature and national and international evidence-based recommendations (Robert Koch Institute [Germany]. Scott GM (1999) Infection control— evidence into practice. The hands should be washed. is a high priority of the World Health Organization (WHO). protective gloves Healthcare workers’ hands represent the principal route of transmission of nosocomial pathogens. can survive for over 2 h on the hands and is found in 10% to 78% of staff (table 1). by placing hand-rub dispensers at the sites where they are needed. for example. Washington. disinfection. 4 November 2006). The promotion of effective measures to improve hand hygiene (e1) is therefore one of the five foremost goals of the WHO’s current worldwide Patient Safety Initiative (Announce Action on Patient Safety [High 5s] Initiative. By September 2008 114 countries had given written undertakings to implement these goals. and by physicians setting a good example for others. rather than disinfected. They are colonized permanently by the physiological flora (“resident flora”) and temporarily. with the aim of minimizing nosocomial infection. compliance. Conclusions Improved compliance in hand hygiene. depending on the precise nature of the employee’s duties. with proper use of alcohol-based hand rubs. Staphylococcus aureus. In Germany. by various pathogens that do not belong to the physiological flora (“transient flora”) (1). and prolonged wearing of gloves. Table 1 Frequency and persistence of selected nosocomial pathogens on the hands of healthcare workers (1) Go to: Clean Hands Campaign Improvement of hand hygiene. Skin irritation is quite common among healthcare workers and is mainly caused by water. soap. nosocomial infection. Keywords: hand hygiene.Results Hygienic hand disinfection has better antimicrobial efficacy than hand-washing and is the procedure of choice to be performed before and after manual contact with patients. Compliance can be improved by training. can reduce the nosocomial infection rate by as much as 40%. the Clean Hands Campaign (“Aktion saubere Hände”) was launched on 1 January 2008 under the auspices of the Federal Ministry of . DC. only when they are visibly soiled. a study showed that despite the use of gloves the same pathogen could be found on the hands of staff involved in treatment in 30% of cases (5). the hands may have come into contact with the potentially contaminated outer surface of the gloves during removal. Furthermore. including two thirds of the university hospitals. we evaluated the recommendations of the following institutions: Commission for Hospital Hygiene and Prevention of Infection. A prospective. In the case of vancomycin-resistant enterococci (VRE). Go 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 (box 1). By 14 June 2009. because in contrast to surgical gloves. Robert Koch Institute (RKI) (2) Association of the Scientific Medical Societies in Germany (AWMF) (e4) WHO (final recommendation) (3) Centers for Disease Control and Prevention (CDC) (e5).Health (e2). controlled intervention study showed that a training session and the availability of gloves directly at the bedside can significantly reduce the incidence of Clostridium difficile–associated diarrhea (CDAD) (4). Go to: Methods We began by examining the scientific literature on the provisional WHO recommendation on hand hygiene from the year 2006 (e3). It may even break the chain of infection more effectively than hand-washing or hand disinfection. Go to: Box 1 Clinical situations in which the wearing of protective gloves is especially indicated Examination of incontinent patients Examination or treatment of MRSA patients . 550 hospitals had signed up to the campaign. Moreover. The goal is to establish hand disinfection as a decisive quality parameter anchored firmly in clinical routine. The hands should be disinfected when protective gloves are taken off. For studies published from 2006 onward we performed a selective review of the publications in the National Library of Medicine. ordinary protective gloves are often permeable to pathogens even before use. Given the frequently short duration of washing. the efficacy of antimicrobial soaps hardly exceeds that of ordinary soaps (6). difficile. difficile–associated diarrhea Endotracheal aspiration Blood sampling Removal of drains or bandages Handling of secretions or excretions Go to: Hand-washing Indications Hand-washing should be an exception in clinical routine (2. The point of washing the hands is mainly to remove visible soiling and only occasionally to reduce the microbial colonization of the skin—for example in contamination by spores of C. hand disinfection should be preferred on grounds of efficacy and skin tolerability. 3). In all other clinical situations in which hand hygiene measures are required. after finishing work. Even washing for several minutes reduces the skin’s resident flora hardly at all (table 2). Table 2 Effect of hand-washing and hand disinfection (1. Efficacy Washing with soap and water is much less effective than hygienic hand disinfection (1– 3). 24) . The same is true for bacterial spores (6). Washing reduces the transient flora (contaminating flora) by only 2 to 3 log10 levels. It makes sense to wash the hands before starting work. so that normal soaps are generally perfectly adequate for everyday clinical use. Hand-washing is therefore indicated considerably less often than generally assumed. Examination or treatment of patients with C. and following visits to the bathroom. even if gloves will be worn. e. it swiftly becomes clear that hand-washing should be seen as an exception.g. e. Leukemia patients Polytrauma patients Burns patients Irradiated and other severely ill patients Before exposure to potential contamination Preparation of infusions Mixing of combined infusions Drawing up of syringes . Clinically manifest irritant eczema of the hand may gradually develop. Given the comparatively slight benefit. bronchoscopy. Go to: Hygienic hand disinfection Indications Hand disinfection is indicated in almost all interactions of medical staff with patients (box 2) (2). endoscopy Injections and punctures Before contact with patients who are at particular risk of infection.. and noxious substances can more easily penetrate the epidermis.g. because bacterial spores are naturally resistant to alcohol. Frequent washing of the hands can lead to dryness and impair the barrier function of the skin (7). Insertion of a venous or bladder catheter Angiography. C. difficile. is it useful to wash the hands after disinfection.Benefits and risks The limited benefits of hand-washing are accompanied by the risk of cutaneous irritation and hand eczema. Merely in the case of contamination with spore-forming bacteria.g. The skin thus continually loses fats and water-binding factors. e. Go to: Box 2 Hygienic hand disinfection benefits the patient in the following clinical situations (2): Before invasive procedures. before and after contact with the catheter Ventilator-associated pneumonia: before and after intubation. tracheal tubes or drains Potentially infectious patients. ventilator-associated pneumonia (ca. palpation) or after contact with potentially infectious materials. auscultation. surgical site infection (ca. Within 30 s. e. in the case of potential nosocomial infections (2. however. 8%) (8). ventilators. Hand disinfection is most important. 3). before manipulation of vascular catheters. 21%).. e. and catheter-associated bloodstream infection (ca. 3): Catheter-associated urinary tract infection: before placement of the urinary catheter. excrement. ventilation masks. Before and after any contact with Wounds Insertion sites of catheters or drains After contact with Blood. Hygienic hand disinfection can make a substantial contribution to preventing these infections if consistently performed at the following junctures (2. secretions. aspirators. 16%).g. the hands should be disinfected after direct patient contact (measurement of vital functions. bandages. before preparation of intravenous medication. Efficacy The commonly available hand rubs are considerably more effective than hand-washing with soap (2. before and after aspiration Surgical site infection: before and after contact with wounds.g. after removal of a bandage Catheter-associated bloodstream infection: before placement of vascular catheters. MRSA patients After removal of protective gloves After contact with a patient during a clinical round or in the consultation or treatment room For example. for example. the following bacteria are not only greatly reduced but practically completely eliminated (e6): Escherichia coli—most frequent cause of catheter-associated urinary tract infection . 3). or infected regions of the body Urine-collecting systems. 42%).. The most frequent such infections in Germany are catheter-associated urinary tract infection (ca. For spore-forming bacteria such as C. improvement of the compliance rate from 48% to 66% over a 5-year period lowered the frequency of nosocomial infections by more than 40% (10). the best results are achieved when users are left to their own devices. the irritant potential of alcohol-based hand rubs is very low. Commercially available preparations are generally tolerated much better than the detergents in hand-washing agents (7. These include uncoated viruses such as noroviruses and the spores of spore-forming bacteria such as C. Surprisingly. HCV. both hands must be completely covered. not with a strictly regulated procedure. Special attention must be paid to the fingertips and thumbs. The same applies to yeasts such as Candida spp. intensive hand disinfection detracts only minimally from the skin’s barrier function and makes the skin only slightly drier. however. difficile. and the influenza viruses. At Geneva University Hospital. The duration of application should be 22 to 28 s. In the case of the noroviruses special virucidal hand rubs are recommended (see the RKI’s list of disinfectant hand rubs [9]). because epidemiological studies have shown that as part of a package of measures these preparations make a real contribution to the containment of outbreaks. 15 s. Allergic reactions to the ingredients of hand-rub preparations are extremely rare (1. Pseudomonas aeruginosa—very frequent cause of ventilator-associated pneumonia Staphylococcus aureus—most frequent cause of surgical site infection Staphylococcus epidermidis—most frequent cause of catheter-associated bloodstream infection. In contrast to popular opinion. difficile. Benefits and risks Hand disinfection is key to the prevention of nosocomial infections. Go to: Hand eczema . and the greatest proportion of the bacteria are found on the fingertips (13). almost always fail to cover the hands completely (12). Even frequent.. HIV.g. Shorter application times. e. and to coated viruses such as HBV. To this end. an adequate amount of the hand rub must be applied efficiently. 3). This is due partly to the skin care substances usually found in hand rubs. these parts of the hand are most likely to come into contact with the patient. the recommendation is first to disinfect the hands in order to kill off the vegetative form. For hand disinfection to be effective. There are only a few pathogens against which the commonly available hand rubs are ineffective. 11). Hand disinfection thus eliminates the majority of agents known to cause nosocomial infections. or Rhodotorula spp. then to wash them briefly but thoroughly to reduce the number of spores as much as possible (e7). Over the same period the rate of new infections by methicillin-resistant S. aureus (MRSA) was reduced by more than 50% (10). in the worst case. Interestingly.g. Nevertheless. more than 70% of nursing staff reported irritant skin symptoms within a year. Those affected should avoid activities harmful to the skin—washing. sensitization to an alcohol could be excluded in all 50 persons who were tested for allergic reactions to an alcohol-based hand rub because of suspected intolerance. DKG). Figure 2 Manifest irritant hand eczema A burning sensation on use of a disinfecting hand rub is a warning of impairment of the skin’s barrier function. flaking skin on their hands as normal in their line of work and fail to realize that this may be the first sign of hand eczema (figure 1). inability to work (16). The burning stops. contact with soaps. In a survey carried out by the German Contact Allergy Group (Deutsche Kontaktallergiegruppe. direct contact with irritant disinfectants—and apply copious quantities of skin protection and skin care products. Consequently employment in nursing and related professions involves the risk of contracting occupational dermatosis (14). However. probably by elimination of residual detergent monomers (7). resulting in manifest hand eczema (figure 2) and. however (15). 11).. many users think that hand rubs harm their skin. Some users state that alcohol-based hand rubs have a sensitizing effect. but the damage accelerates: a vicious circle begins. Figure 1 Early irritant skin changes between the digits Most nurses still believe that alcohol-based hand rubs damage their skin more than hand-washing (15). cetearyl octanoate) was demonstrated. Many consider rough. . Nevertheless. the application of alcohols after hand-washing can even reduce the irritation caused by the washing.There can be no doubt that hygiene precautions are a risk factor for occupational hand eczema. occlusion (protective gloves). and 46% considered them detrimental in their daily lives (15). Oversensitivity to an excipient (e. The alcohol-based hand rub is then blamed for the symptoms (“it only burns with the alcohol”) and hand disinfection is abandoned in favor of washing. alcohol-based preparations are much kinder to the skin than hand-washing agents because they are less harmful to the cutaneous barrier (as measured by transepidermal water loss) and dry the skin out less (as measured by corneometry) (7. One reason is the burning felt when the alcohols stimulate the pain receptors in damaged areas of skin. An intact cutaneous barrier is of more than just cosmetic and functional relevance. Staff should have access to data showing the efficacy of all preparations employed. 18). as well as information on their uses (see the “Occupational Skin Preparations” (“Berufliche Hautmittel”) guideline of the German Working Group for Occupational and Environmental Dermatology [Arbeitsgemeinschaft für Berufs. if properly implemented. Because components of some of these preparations may promote penetration of irritants. it is not carried out. evaluation. every second time hand disinfection is required. they should preferably be applied only when work is over (21).und Umweltdermatologie. Go to: Compliance Unfortunately the overall rate of compliance in hand hygiene is poor. who can then institute the appropriate procedures. The primary goal of all initiatives to improve compliance in hand hygiene is optimization of the rate of hand disinfection. As a secondary aim. of course. in order to minimize drying out and impairment of the skin’s barrier function by wet work. They are also included in the Clean Hands Campaign. These precautions should be integrated in the working routine and can. Any member of staff exhibiting clinically manifest cutaneous irritation at work should be referred to a dermatologist or occupational medicine specialist. Skin protection products should be applied before starting work and after every break. The principles of hand care and protection should therefore be taught to all healthcare workers and should form part of every training program (19). only 50% on average. Moreover. Go to: Care and protection of the skin Appropriate precautions when using potentially irritant substances can prevent harm to the skin. it is also important to reduce hand-washing to a minimum. Skin protection plans should be drawn up with information about the available products and their use (see Technical Rule for Hazardous Substances [TRGS] 401 of June 2008: Risks resulting from skin contact—determination. including reporting of the case to the accident insurance provider (22). ABD]) (21). These include: . Barriers There are many different reasons why healthcare workers disinfect their hands much less often than necessary for protection of their patients. protect the hands without compromising disinfection. measures) (20). After work. Eczematous hands are also colonized to a greater degree by pathogens than are healthy hands (17. skin care creams help to accelerate cutaneous regeneration. adequate protection and care of the skin are of paramount importance for the maintenance of a functioning cutaneous barrier (e8). In other words. It will then be much more difficult for junior workers not to follow suit. the doctor may be able to carry a bottle of hand rub in the pocket of his/her lab coat. This can by achieved by simple means both in the hospital and the doctor’s office. Moreover. when established routine behavior has to be changed Disinfecting hand rubs should be available where they are actually needed. skin protection and care products must be available to all employees at their workplace..g. Insufficient knowledge of the clinical situations in which the patient clearly benefits Lack of products or dispensers: unavailability of the disinfecting hand rub right where it is needed Lack of time: hand disinfection is frequently not carried out because of increasing pressure of work. dryness. One can only appeal to all senior staff to set a proper example. or burning combined with inadequate knowledge of the causes Failure of high-ranking medical staff to set an example: junior doctors and nurses will think that hand disinfection cannot be very important if senior doctors dispense with it. Furthermore. Measures to achieve improvement Readily implementable measures can be drawn up to counter the above-mentioned factors and improve compliance (box 3). If wall dispensers cannot be mounted. primary prevention by means of early education on hand hygiene (e. accompanied by regular motivational campaigns.. Go to: Box 3 Measures to improve compliance Staff training with regard to the clinical situations in which hand disinfection is indicated Inclusion of the goals in the training program. Reduction of hand-washing to a minimum in order to avoid unnecessary skin irritation Senior members of medical staff must recognize that they have to set an example and act accordingly. .g. during training. because behavior learned during basic training is put into practice much more effectively than that taught in later training sessions. with explanation of the efficacy and cutaneous tolerance of hand hygiene measures). or when a ward is over-occupied or under-staffed (23) Cutaneous irritation: skin problems with use. irritation. is effective. e. g. Go to: Key Messages Hand disinfection eliminates the transient flora and is one of the most important precautions for specific prevention of transmission of nosocomial infections. must then be avoided and skin protection and care products applied more intensively. Washing with soap and water is necessary only when the hands are visibly soiled.. Activities harmful to the skin. Go to: Acknowledgments Translated from the original German by David Roseveare. difficile. Hand-washing damages the skin more than hand disinfection. or following disinfection in the case of contamination by spores of bacteria such as C. It should principally be restricted to visibly soiled hands and. difficile. hands contaminated with spore-forming bacteria such as C. In practice. e. Compliance could be improved by knowledge of the principal clinical circumstances in which hand disinfection by healthcare workers genuinely benefits the patient. The rate of nosocomial infections can be reduced by up to 40% by improved compliance in hand disinfection. Go to: Footnotes . frequent washing.Go to: Conclusion Evidence-based hand hygiene can prevent transmission of the most important nosocomial pathogens and also keep employees’ skin healthy. on average every second necessary disinfection of the hands is not actually carried out. The WHO has therefore launched a worldwide initiative to improve compliance. In most clinical situations hygienic disinfection is indicated for hand decontamination on grounds of better efficacy and cutaneous tolerance. following disinfection. A burning sensation on hand disinfection represents an important warning of damage to the cutaneous barrier. et al.5. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant Enterococcus species by health care workers after patient care. Journal of Hospital Infection. [PubMed] 7. Stand vom 31. Pittet D. 1998. Kampf G. Robert Koch-Institut. 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