Compliance of Hand Decontamination of Combined Military Hospital Dhaka (Part-1)

Introduction

Hands are the highways to the transmission and spread of bacteria, pathogens, and viruses that cause diseases, food-borne illness, and infections resulting from hospital treatment (nosocomial). Infectious germs on the hands are the most common ways that people spread infection. This is caused by rubbing their nose or eyes with their hands, which have been contaminated with the cold virus and other bacteria.

The impact of communicable diseases on life expectancy and level of morbidity decreased with the commencement of immunisation programs in 1924 and the discovery of antibiotics in the late 1930s. Yet no sooner had the discovery of antibiotic and chemotherapeutic agents brought benefits to both our general public health and hospital practices than the alarm was raised about emerging resistance of staphylococci to penicillin in the 1940s. By the 1950s, the alarm was raised again, this time about environmental contamination with Staphylococcus aureus and, by the 1980s, hospitals were looking towards imprudent antibiotic treatments as being responsible for the notable rise in prevalence of methicillin-resistant S. aureus (MRSA). The link between poor hand hygiene of health care workers (HCWs) and the spread of infection in hospitals has been known and widely promulgated for the past 150 years, and a causal link between good hand hygiene and reduced risk of nosocomial infection has been demonstrated.³ The concept of decontaminate hands with an antiseptic agent probably emerged in the early 19th century. As early as 1822, a French pharmacist demonstrated that solutions containing chlorides of lime or soda could eradicate the foul odors associated with human corpses and that such solutions could be used as disinfectants and antiseptics . In a paper published in 1825, this pharmacist stated that physicians and other persons attending patients with contagious diseases would benefit from moistening their hands with a liquid chloride solution .

Yet multiple studies have documented the poor compliance of HCWs with hand hygiene practices. With increasing rates of infection and morbidity associated with multiresistant organisms (MROs) in hospitals, hand hygiene has become a key patient safety issue worldwide. In 2005, the World Health Organization launched the first Global Patient Safety Challenge, Clean care is safer care.

Healthcare-associated pathogens are most often transmitted from patient to patient on the  hands of healthcare workers.  Decontamination of hands before and after patient contact is one of the most important measures for preventing the spread of microorganisms in healthcare settings.

“Many personnel don’t realize when they have germs on their hands”. Healthcare workers can get 100s to 1000s  of bacteria on their hands by doing simple tasks  like

1. Pulling  patients up in bed .
2. Taking a blood pressure or pulse,
3. Touching a patient’s hands.
4. Rolling patients over in bed,
5. Touching the patient’s gown or bed sheets,
6. Touching equipment like bedside rails, over bed tables, IV pumps.

Patients often carry resistant bacteria on many areas of their skin, even when they have no wounds or broken skin. Resistant bacteria on the skin or in the gastrointestinal tract of patients often contaminate  items in the immediate vicinity of the patient. Healthcare workers can contaminate  their hands by touching environmental surfaces near affected patients. Evidence  of transmission of pathogens on hands Transmission of health-care—associated pathogens  from one patient to another via the hands of HCWs requires the following sequence of  events:

• Organisms present on the patient’s skin, or that have been shed onto inanimate  objects in close proximity to the patient transferred to the hands of HCWs.
• These organisms be capable of surviving for at least several minutes on the hands  of personnel.
• Next, hand washing or hand antisepsis used by the worker inadequate or omitted entirely, or the agent used for hand hygiene inappropriate.
• Finally, the contaminated hands of the caregiver come in direct contact with another  patient, or with an inanimate object that will come into direct contact with the patient.

Hand decontamination can prevent cross-infection in a hospital, but awareness with recommended instructions often is poor among health professionals in Bangladesh.

Although some tertiary level hospitals in Bangladesh are trying to improve hand decontamination compliance successfully, but none has achieved lasting improvement.

Compliance with hand hygiene guidelines is a remarkably complex issue that relies on a combination of education and training and is influenced by deeply held personal beliefs and the behavior of peers and superiors. A number of studies have described efforts to improve hand hygiene, with most citing “success rates” of compliance of no more than 61%, and fewer sustaining the improvement beyond the life of the initial intervention phase.^. Personnel with heavy workloads have little time to decontaminate their hands. The busier healthcare workers are, the less likely that  they are to decontaminate their hands when recommended. “Skin irritation and dryness of hands is another deterrent to frequent hand washing”. Frequent hand decontamination with soap and water often causes skin irritation and dryness. In winter months, the skin on the hands of some personnel may become so dry and cracked that bleeding occurs when this occurs; personnel avoid decontamination  their hands because it is painful to do so.

So, “Hands should be washed before significant contact with any patient and after activities likely to cause contamination.” But we donot know  about the hospital caregivers  of Bangladesh Armed Forces regarding  hand decontamination practices. Here it is reviewed the current situation of awareness on hand decontamination practices and factors associated with poor compliance.

 Justification of the Study

Improving hand hygiene practices in health care has been a major challenge for more than 160 years. Despite much evidence that hand hygiene practices are effective in preventing infection and reducing the spread of microbial resistance, the hand-cleaning behaviour of health care workers (HCWs) remains largely unchanged. Indeed, in almost all settings where it has been assessed, compliance with hand hygiene practices at appropriate times during the course of patient care has been less than 50%. But should HCWs carry all the blame? How do working conditions affect hand hygiene behaviour? Can behaviour change? If so, how much change in individual behaviour is necessary to reflect change at a group level? Is a major system change sufficient to transform practices? Is hand hygiene behaviour integrated into the theory of ecological perspective once change is targeted? What should the targets for improvement be? How far can HCWs be expected to modify their practices? How long will it take to succeed? How can behavioural change be sustained, if and when it is achieved? What does “success” mean in terms of hand hygiene promotion? What are the best indicators of success? How much local success is needed to predict more global achievements?

Our two hands are the most common vehicles of transmission of infection in hospital. Because “Hands are the number one vector of transmission of communicable diseases.” Normally transient and resident bacteria are found on hands. Transient bacteria are normally picked up by hands in the common activities of daily living, attach loosely to the skin in creases, fats, etc. and are found in greater number under the finger nails ⁶. Transient bacteria can. be removed by washing the hands thoroughly and frequently. Whereas resident bacteria, normally found in creases of hands, cling to the skin by adhesion and absorption and considerable friction with brush is required to remove them. If transient bacteria become resident bacteria the hands are carriers of the particular organisms. About 1-12 % of  resident floras are concentrated in skin creases where lipid and superficial cornifield epithelium make their  removal difficult. Hand decontaminate with the soap and water is simple and cost-effective measure for infection control.

*Hand decontaminate is generally considered to be the most important measure in preventing  the spread of infection. “If you were to ask a public health worker, *What are the ten most deadly weapons? “The answer would not be  “guns” or “drugs” or “knives.” It would be “hands.”¹⁰ More specifically, our ten fingers – those seemingly innocuous digits that, when they are not grasping doorknobs or handling money or flushing the toilet, are busy spreading everydays bugs like E. coli or Shigella or simply the common cold. The hand-hygiene compliance level does not rely on individual factors  said for its promotion. Because of the complexity of the process of change, it is not surprising that solo interventions often fail, and multimodal multidisciplinary strategies are necessary¹². A framework that includes parameters to be considered for hand-hygiene promotion is  proposed, based on epidemiologically driven evidence and review of the current knowledge. Strategies for promotion in hospitals should include reasons for noncompliance with recommendations at individual, group, and institutional levels. Potential tools for change should address each of these elements and consider their interactivity.

So we can say that hand decontamination is the single most important procedure for preventing infection. We  need to know the compliance situation of hand decontamination amongst the HCWs of our hospital for taking necessary measure to improve the overall service delivary of the hospital.

Research Question

What is the compliance of hand decontamination practices among the health care workers at Combined Military Hospital Dhaka?

Study Objectives

General Objective

            To assess the compliance of hand decontamination practices among the health care workers of Combined Military Hospital Dhaka.

Specific Objectives

• To identify the socio demographic characteristics of the healthcare workers of CMH Dhaka.
• To assess the knowledge on hand decontamination practices and about the method and materials of hand decontamination practices among healthcare workers.
• To find out  the compliance on hand decontamination practices among the HCWs of Combined Military Hospital Dhaka.
• To explain the availability of proper hygienic hand wash facilities in CMH Dhaka.

Socio-demographic factors

• Age
• Sex
• Education
• Occupation
• Marital Status
• Income
• Religion

Knowledge related factors

• Knowledge about benefit of hand decontamination
• Knowledge about appropriate timing for hand decontamination
• Knowledge about spending time about hand decontamination
• Knowledge about material used for hand decontamination
• Knowledge about germs that can spread by dirty hands
• Knowledge about facility for hand washing .

Factors Related to compliance

• Promptness  in responding to hand washing when needed

Dependent Variable

• Compliance of hand decontamination practices.
•  Frequency of hand washing

Operational definitions

Health Care Workers (HCW) All personnels working in the hospital except doctors i.e. all nurses, medical assistants, intensive care assisstants, operation theatre assistants, ward boys, cleaners were included as HCWs.

Combined Military Hospital, Dhaka  A 850 bedded referral hospital biggest amongst Armed Forces, with all types of facilities and subspeciality of tertiary level hospital with 1447 manpower.

Antiseptic handwash or HCW handwash. An antiseptic-containing preparation designed for frequent use; it reduces the number of microorganisms on intact skin to an initial baseline level after adequate washing, rinsing, and drying; it is broad-spectrum, fast-acting, and if possible, persistent.

Plain soap. Plain soap refers to detergents that do not contain antimicrobial agents or contain low concentrations of antimicrobial agents that are effective solely as preservatives.

Alcohol-based hand rub. An alcohol-containing preparation designed for application to the hands for reducing the number of viable microorganisms on the hands. Such preparations usually contain 60%–95% ethanol or isopropanol.

Antimicrobial soap. Soap (i.e., detergent) containing an antiseptic agent.

Antiseptic agent. Antimicrobial substances that are applied to the skin to reduce the number of microbial flora. Examples include alcohols, chlorhexidine, chlorine, hexachlorophene, iodine, chloroxylenol (PCMX), quaternary ammonium compounds, and triclosan.

Antiseptic handwash. Washing hands with water and soap or other detergents containing an antiseptic agent.

Antiseptic hand rub Applying an antiseptic hand-rub product to all surfaces of the hands to reduce the number of microorganisms present.

Cumulative effect  A progressive decrease in the numbers of microorganisms recovered after repeated applications of a test material.

Decontaminate hands To Reduce bacterial counts on hands by performing antiseptic hand rub or antiseptic handwash.

Detergent. Detergents (i.e., surfactants) are compounds that possess a cleaning action. They are composed of both hydrophilic and lipophilic parts and can be divided into four groups: anionic, cationic, amphoteric, and nonionic detergents. Although products used for hand washing or antiseptic hand wash in health-care settings represent various types of detergents, the term “soap” is used to refer to such detergents in this guideline.

Hand antisepsis. Refers to either antiseptic hand wash or antiseptic hand rub.

Hand hygiene. A general term that applies to either handwashing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis.

Handwashing. Washing hands with plain (i.e., non-antimicrobial) soap and water.

Persistent activity. Persistent activity is defined as the prolonged or extended antimicrobial activity that prevents or inhibits the proliferation or survival of microorganisms after application of the product. This activity may be demonstrated by sampling a site several minutes or hours after application and demonstrating bacterial antimicrobial effectiveness when compared with a baseline level. This property also has been referred to as “residual activity.” Both substantive and nonsubstantive active ingredients can show a persistent effect if they substantially lower the number of bacteria during the wash period.

Substantivity. Substantivity is an attribute of certain active ingredients that adhere to the stratum corneum (i.e., remain on the skin after rinsing or drying) to provide an inhibitory effect on the growth of bacteria remaining on the skin.

Surgical hand antisepsis. Antiseptic handwash or antiseptic hand rub performed preoperatively by surgical personnel to eliminate transient and reduce resident hand flora. Antiseptic detergent preparations often have persistent antimicrobial activity.

Visibly soiled hands. Hands showing visible dirt or visibly contaminated with proteinaceous material, blood, or other body fluids (e.g., fecal material or urine).

Waterless antiseptic agent. An antiseptic agent that does not require use of exogenous water. After applying such an agent, the hands are rubbed together until the agent has dried.

Patient preoperative skin preparation. A fast-acting, broad-spectrum, and persistent antiseptic-containing preparation that substantially reduces the number of microorganisms on intact skin.

Surgical hand scrub. An antiseptic-containing preparation that substantially reduces the number of microorganisms on intact skin; it is broad-spectrum, fast-acting, and persistent.

Limitation of the study

• In this study only verbal answers for complince was recorded. No observational data was taken.
• Self reporting may give overestimated compliance rate.
  • For constraints of time and resources and constraints in the sample size, there may be some bias.
  • The purposively selected sample from one hospital that may not represent all the tertiary level hospitals; hence the findings of the study should not be generalized
  • Identification and finding the key respondents and compilation of the interview was tough. The informant tried to avoid comments and giving negative answers. So, close natural relations with the respondents had to maintain to explore the total study objectives.

 History

For generations, handwashing with soap and water has been considered a measure of personal hygiene ². In 1846, Ignaz Semmelweis observed that women whose babies were delivered by students and physicians in the First Clinic at the General Hospital of Vienna consistently had a higher mortality rate than those whose babies were delivered by midwives in the Second Clinic ¹⁵. He noted that physicians who went directly from the autopsy suite to the obstetrics ward had a disagreeable odor on their hands despite washing their hands with soap and water upon entering the obstetrics clinic. He postulated that the puerperal fever that affected so many parturient women was caused by “cadaverous particles” transmitted from the autopsy suite to the obstetrics ward via the hands of students and physicians. Perhaps because of the known deodorizing effect of chlorine compounds, as of May 1847, he insisted that students and physicians clean their hands with a chlorine solution between each patient in the clinic. The maternal mortality rate in the First Clinic subsequently dropped dramatically and remained low for years. This intervention by Semmelweis represents the first evidence indicating that cleansing heavily contaminated hands with an antiseptic agent between patient contacts may reduce health-care–associated transmission of contagious diseases more effectively than handwashing with plain soap and water.

In 1843, Oliver Wendell Holmes concluded independently that puerperal fever was spread by the hands of health personnel ². Although he described measures that could be taken to limit its spread, his recommendations had little impact on obstetric practices at the time. However, as a result of the seminal studies by Semmelweis and Holmes, handwashing gradually became accepted as one of the most important measures for preventing transmission of pathogens in health-care facilities.

In 1961, the U. S. Public Health Service produced a training film that demonstrated handwashing techniques recommended for use by health-care workers (HCWs) ¹⁶. At the time, recommendations directed that personnel wash their hands with soap and water for 1–2 minutes before and after patient contact. Rinsing hands with an antiseptic agent was believed to be less effective than handwashing and was recommended only in emergencies or in areas where sinks were unavailable.

In 1975 and 1985, formal written guidelines on handwashing practices in hospitals were published by CDC³. These guidelines recommended handwashing with non-antimicrobial soap between the majority of patient contacts and washing with antimicrobial soap before and after performing invasive procedures or caring for patients at high risk. Use of waterless antiseptic agents (e.g., alcohol-based solutions) was recommended only in situations where sinks were not available.

In 1988 and 1995, guidelines for handwashing and hand antisepsis were published by the Association for Professionals in Infection Control (APIC) . Recommended indications for handwashing were similar to those listed in the CDC guidelines. The 1995 APIC guideline included more detailed discussion of alcohol-based hand rubs and supported their use in more clinical settings than had been recommended in earlier guidelines. In 1995 and 1996, the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended that either antimicrobial soap or a waterless antiseptic agent be used for cleaning hands upon leaving the rooms of patients with multidrug-resistant pathogens (e.g., vancomycin-resistant enterococci [VRE] and methicillin-resistant Staphylococcus aureus [MRSA])^. These guidelines also provided recommendations for handwashing and hand antisepsis in other clinical settings, including routine patient care. Although the APIC and HICPAC guidelines have been adopted by the majority of hospitals, adherence of HCWs to recommended handwashing practices has remained low ^18,19.

According to the  Centers for Disease Control, recent studies place hand hygiene adherence in hospitals between  29 percent and 50 percent. Among reasons for poor hand hygiene commonly reported by health care workers are that hand washing causes irritation and dryness, that basins  are inconveniently located, and that they’re too busy to stop and wash their hands. Inadequate hand hygiene is considered the leading cause of health care-associated infections”¹⁰. The  chief requirements of basic hand hygiene for health care workers include decontamination of hands before and after each patient contact, decontaminating hands before putting on gloves and after removing gloves, before handling medications and after handling contaminated objects. “It’s thought that 100 percent adherence to basic hand hygiene would reduce infection more than any other change we could make in hospitals,” said by  Hospital Epidemiologist Thomas R. Talbot III, M.D., the leader of the campaign to improve hand hygiene at VUMC. “Many people think hand hygiene is about self protection, not realizing the key role that it plays in patient safety¹¹,” Talbot said. Easy access to hand washing in a timely fashion .and the availability of soap and other hand washing chemicals both appear to be necessary prerequisites for appropriate hand-hygiene behavior. In particular, in high-demand situations, hand rub with an alcohol-based solution appears to be the only alternative that allows a decent compliance.

A Hospital is an institution for health care providing treatment by specialized staff and equipment, and often but not always providing longer term patient stays¹⁴. Previously hospitals were usually funded by the state, non-profit health organizations or charities, including direct charitable donations but now -a -days hospital setup has become a culture of corporate business organizations and group of companies in this decade in Bangladesh. Despite recent developments in the Bangladesh healthcare sector there is still great concern about the quality of health care services by different types of institutions. It was observed that the overall use rate for public health care services was as low as 30 %, But in this decade there are 3-4 better quality private hospital started  their journey.

Recent developments in the field have stimulated a review of the scientific data regarding hand hygiene and the development of new guidelines designed to improve hand-hygiene practices in health-care facilities.

WHO’s recommendations:

Indications for hand decontamination and hand antisepsis

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 or after using the restroom.

Preferably use an alcohol-based hand rub for routine hand antisepsis in all other clinical situations described in items listed below if hands are not visibly soiled. Alternatively, wash hands with soap and water.

Perform hand decontamination:

• Before and after having direct contact with patients:
• After removing gloves;
• Before handling an invasive device (regardless of whether or not gloves are used) for patient care;
• After contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings;
• If moving from a contaminated body site to a clean body site during patient care;
• After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

Wash hands with either plain or antimicrobial soap and water or rub hands with an alcohol-based formulation before handling medication and preparing food.

When alcohol-based hand rub is already used, do not use antimicrobial soap concomitantly.

Technique

To clean hands properly:

• Rub all parts of the hand with an alcohol-based hand rub or soap and running water.
• Pay special attention to fingertips, between fingers, backs of hands and the base of thumbs.
• Keep nails short and clean.
• Remove rings and bracelets.
• Do not wear artificial nails.
• Remove chipped nail polish.
• Make sure that sleeves are pushed up and do not get wet.
• Clean hands for a minimum of 15 seconds.
• Dry hands thoroughly.
• Apply lotion to hands frequently.

 Use of gloves

• The use of gloves does not replace the need for hand cleansing by either handrubbing or handwashing.
• Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin will occur.
• Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient.

When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to a clean body site within the same patient or to the environment.

Normal bacterial skin flora.  

To understand the objectives of different approaches to hand cleansing, a knowledge of normal bacterial skin flora is essential. Normal human skin is colonized with bacteria; different areas of the body have varied total aerobic bacterial counts (e.g., 1 x 10⁶ colony forming units (CFUs)/cm² on the scalp, 5 x 10⁵ CFUs/cm² in the axilla, 4 x 10⁴ CFUs/cm² on the abdomen, and 1 x 10⁴ CFUs/cm² on the forearm) (13). Total bacterial counts on the hands of medical personnel have ranged from 3.9 x 10⁴ to 4.6 x 10⁶ (14–17). In 1938, bacteria recovered from the hands were divided into two categories: transient and resident . Transient flora, which colonize the superficial layers of the skin, are more amenable to removal by routine handwashing. They are often acquired by HCWs during direct contact with patients or contact with contaminated environmental surfaces within close proximity of the patient. Transient flora are the organisms most frequently associated with health-care–associated infections. Resident flora, which are attached to deeper layers of the skin, are more resistant to removal. In addition, resident flora (e.g., coagulase-negative staphylococci and diphtheroids) are less likely to be associated with such infections. The hands of HCWs may become persistently colonized with pathogenic flora (e.g., S. aureus), gram-negative bacilli, or yeast. Investigators have documented that, although the number of transient and resident flora varies considerably from person to person, it is often relatively constant for any specific person .

Physiology of normal skin

The primary function of the skin is to reduce water loss, provide protection against abrasive action and microorganisms, and act as a permeability barrier to the environment. The basic structure of skin includes, from outer- to inner-most layer, the superficial region (i.e., the stratum corneum or horny layer, which is 10- to 20-µm thick), the viable epidermis (50- to 100-µm thick), the dermis (1- to 2-mm thick), and the hypodermis (1- to 2-mm thick). The barrier to percutaneous absorption lies within the stratum corneum, the thinnest and smallest compartment of the skin. The stratum corneum contains the corneocytes (or horny cells), which are flat, polyhedral-shaped nonnucleated cells, remnants of the terminally differentiated keratinocytes located in the viable epidermis. Corneocytes are composed primarily of insoluble bundled keratins surrounded by a cell envelope stabilized by cross-linked proteins and covalently bound lipid. Interconnecting the corneocytes of the stratum corneum are polar structures (e.g., corneodesmosomes), which contribute to stratum corneum cohesion.

The intercellular region of the stratum corneum is composed of lipid primarily generated from the exocytosis of lamellar bodies during the terminal differentiation of the keratinocytes. The intercellular lipid is required for a competent skin barrier and forms the only continuous domain. Directly under the stratum corneum is a stratified epidermis, which is composed primarily of 10–20 layers of keratinizing epithelial cells that are responsible for the synthesis of the stratum corneum. This layer also contains melanocytes involved in skin pigmentation; Langerhans cells, which are important for antigen presentation and immune responses; and Merkel cells, whose precise role in sensory reception has yet to be fully delineated. As keratinocytes undergo terminal differentiation, they begin to flatten out and assume the dimensions characteristic of the corneocytes (i.e., their diameter changes from 10–12 µm to 20–30 µm, and their volume increases by 10- to 20-fold). The viable epidermis does not contain a vascular network, and the keratinocytes obtain their nutrients from below by passive diffusion through the interstitial fluid^.

The skin is a dynamic structure. Barrier function does not simply arise from the dying, degeneration, and compaction of the underlying epidermis. Rather, the processes of cornification and desquamation are intimately linked; synthesis of the stratum corneum occurs at the same rate as loss. Substantial evidence now confirms that the formation of the skin barrier is under homeostatic control, which is illustrated by the epidermal response to barrier perturbation by skin stripping or solvent extraction. Circumstantial evidence indicates that the rate of keratinocyte proliferation directly influences the integrity of the skin barrier. A general increase in the rate of proliferation results in a decrease in the time available for 1) uptake of nutrients (e.g., essential fatty acids), 2) protein and lipid synthesis, and 3) processing of the precursor molecules required for skin-barrier function. Whether chronic but quantitatively smaller increases in rate of epidermal proliferation also lead to changes in skin-barrier function remains unclear. Thus, the extent to which the decreased barrier function caused by irritants is caused by an increased epidermal proliferation also is unknown^.

The current understanding of the formation of the stratum corneum has come from studies of the epidermal responses to perturbation of the skin barrier. Experimental manipulations that disrupt the skin barrier include 1) extraction of skin lipids with apolar solvents, 2) physical stripping of the stratum corneum using adhesive tape, and 3) chemically induced irritation. All of these experimental manipulations lead to a decreased skin barrier as determined by transepidermal water loss (TEWL). The most studied experimental system is the treatment of mouse skin with acetone. This experiment results in a marked and immediate increase in TEWL, and therefore a decrease in skin-barrier function. Acetone treatment selectively removes glycerolipids and sterols from the skin, which indicates that these lipids are necessary, though perhaps not sufficient in themselves, for barrier function. Detergents act like acetone on the intercellular lipid domain. The return to normal barrier function is biphasic: 50%–60% of barrier recovery typically occurs within 6 hours, but complete normalization of barrier function requires 5–6 days^.

 Sequence of events of transmission of pathogens on hands

Transmission of health-care–associated pathogens from one patient to another via the hands of HCWs requires the following sequence of events:

• Organisms present on the patient’s skin, or that have been shed onto inanimate objects in close proximity to the patient, must be transferred to the hands of HCWs.
• These organisms must then be capable of surviving for at least several minutes on the hands of personnel.
• Next, handwashing or hand antisepsis by the worker must be inadequate or omitted entirely, or the agent used for hand hygiene must be inappropriate.
• Finally, the contaminated hands of the caregiver must come in direct contact with another patient, or with an inanimate object that will come into direct contact with the patient.

Health-care–associated pathogens can be recovered not only from infected or draining wounds, but also from frequently colonized areas of normal, intact patient skin . The perineal or inguinal areas are usually most heavily colonized, but the axillae, trunk, and upper extremities (including the hands) also are frequently colonized . The number of organisms (e.g., S. aureus, Proteus mirabilis, Klebsiella spp., and Acinetobacter spp.) present on intact areas of the skin of certain patients can vary from 100 to 10⁶/cm². Persons with diabetes, patients undergoing dialysis for chronic renal failure, and those with chronic dermatitis are likely to have areas of intact skin that are colonized with S. aureus ²³. Because approximately 10⁶ skin squames containing viable microorganisms are shed daily from normal skin , patient gowns, bed linen, bedside furniture, and other objects in the patient’s immediate environment can easily become contaminated with patient flora. Such contamination is particularly likely to be caused by staphylococci or enterococci, which are resistant to dessication.

Data are limited regarding the types of patient-care activities that result in transmission of patient flora to the hands of personnel ²⁴. In the past, attempts have been made to stratify patient-care activities into those most likely to cause hand contamination, but such stratification schemes were never validated by quantifying the level of bacterial contamination that occurred. Nurses can contaminate their hands with 100–1,000 CFUs of Klebsiella spp. during “clean” activities (e.g., lifting a patient; taking a patient’s pulse, blood pressure, or oral temperature; or touching a patient’s hand, shoulder, or groin) . Similarly, in another study, hands were cultured of nurses who touched the groins of patients heavily colonized with P. mirabilis; 10–600 CFUs/mL of this organism were recovered from glove juice samples from the nurses’ hands. Recently, other researchers studied contamination of HCWs’ hands during activities that involved direct patient-contact wound care, intravascular catheter care, respiratory-tract care, and the handling of patient secretions . Agar fingertip impression plates were used to culture bacteria; the number of bacteria recovered from fingertips ranged from 0 to 300 CFUs. Data from this study indicated that direct patient contact and respiratory-tract care were most likely to contaminate the fingers of caregivers. Gram-negative bacilli accounted for 15% of isolates and S. aureus for 11%. Duration of patient-care activity was strongly associated with the intensity of bacterial contamination of HCWs’ hands.

HCWs can contaminate their hands with gram-negative bacilli, S. aureus, enterococci, or Clostridium difficile by performing “clean procedures” or touching intact areas of the skin of hospitalized patients . Furthermore, personnel caring for infants with respiratory syncytial virus (RSV) infections have acquired RSV by performing certain activities (e.g., feeding infants, changing diapers, and playing with infants). Personnel who had contact only with surfaces contaminated with the infants’ secretions also acquired RSV by contaminating their hands with RSV and inoculating their oral or conjunctival mucosa. Other studies also have documented that HCWs may contaminate their hands (or gloves) merely by touching inanimate objects in patient rooms ²⁵. None of the studies concerning hand contamination of hospital personnel were designed to determine if the contamination resulted in transmission of pathogens to susceptible patients.

Other studies have documented contamination of HCWs’ hands with potential health-care–associated pathogens, but did not relate their findings to the specific type of preceding patient contact ²⁶. For example, before glove use was common among HCWs, 15% of nurses working in an isolation unit carried a median of 1 x 10⁴ CFUs of S. aureus on their hands ²⁹. Of nurses working in a general hospital, 29% had S. aureus on their hands (median count: 3,800 CFUs), whereas 78% of those working in a hospital for dermatology patients had the organism on their hands (median count: 14.3 x 10⁶ CFUs). Similarly, 17%–30% of nurses carried gram-negative bacilli on their hands (median counts: 3,400–38,000 CFUs). One study found that S. aureus could be recovered from the hands of 21% of intensive-care–unit personnel and that 21% of physician and 5% of nurse carriers had >1,000 CFUs of the organism on their hands (59). Another study found lower levels of colonization on the hands of personnel working in a neurosurgery unit, with an average of 3 CFUs of S. aureus and 11 CFUs of gram-negative bacilli. Serial cultures revealed that 100% of HCWs carried gram-negative bacilli at least once, and 64% carried S. aureus at least once.

Few study result

Several investigators have studied transmission of infectious agents by using different experimental models. In one study, nurses were asked to touch the groins of patients heavily colonized with gram-negative bacilli for 15 seconds — as though they were taking a femoral pulse. Nurses then cleaned their hands by washing with plain soap and water or by using an alcohol hand rinse. After cleaning their hands, they touched a piece of urinary catheter material with their fingers, and the catheter segment was cultured. The study revealed that touching intact areas of moist skin of the patient transferred enough organisms to the nurses’ hands to result in subsequent transmission to catheter material, despite handwashing with plain soap and water.

The transmission of organisms from artificially contaminated “donor” fabrics to clean “recipient” fabrics via hand contact also has been studied. Results indicated that the number of organisms transmitted was greater if the donor fabric or the hands were wet upon contact ³⁰. Overall, only 0.06% of the organisms obtained from the contaminated donor fabric were transferred to recipient fabric via hand contact. Staphylococcus saprophyticus, Pseudomonas aeruginosa, and Serratia spp. were also transferred in greater numbers than was Escherichia coli from contaminated fabric to clean fabric after hand contact (64). Organisms are transferred to various types of surfaces in much larger numbers (i.e., >10⁴) from wet hands than from hands that are thoroughly dried .

Relation of hand decontamination and hospital acquired infection

Hand antisepsis reduces the incidence of health-care–associated infections ³³. An intervention trial using historical controls demonstrated in 1847 that the mortality rate among mothers who delivered in the First Obstetrics Clinic at the General Hospital of Vienna was substantially lower when hospital staff cleaned their hands with an antiseptic agent than when they washed their hands with plain soap and water.

In the 1960s, a prospective, controlled trial sponsored by the National Institutes of Health and the Office of the Surgeon General demonstrated that infants cared for by nurses who did not wash their hands after handling an index infant colonized with S. aureus acquired the organism more often and more rapidly than did infants cared for by nurses who used hexachlorophene to clean their hands between infant contacts³³. This trial provided evidence that, when compared with no handwashing, washing hands with an antiseptic agent between patient contacts reduces transmission of health-care–associated pathogens.

Trials have studied the effects of handwashing with plain soap and water versus some form of hand antisepsis on health-care–associated infection rates . Health-care–associated infection rates were lower when antiseptic handwashing was performed by personnel . In another study, antiseptic handwashing was associated with lower health-care–associated infection rates in certain intensive-care units, but not in others .

Health-care–associated infection rates were lower after antiseptic handwashing using a chlorhexidine-containing detergent compared with handwashing with plain soap or use of an alcohol-based hand rinse ³⁶. However, because only a minimal amount of the alcohol rinse was used during periods when the combination regimen also was in use and because adherence to policies was higher when chlorhexidine was available, determining which factor (i.e., the hand-hygiene regimen or differences in adherence) accounted for the lower infection rates was difficult. Investigators have determined also that health-care–associated acquisition of MRSA was reduced when the antimicrobial soap used for hygienic handwashing was changed .

Increased handwashing frequency among hospital staff has been associated with decreased transmission of Klebsiella spp. among patients ; these studies, however, did not quantitate the level of handwashing among personnel. In a recent study, the acquisition of various health-care–associated pathogens was reduced when hand antisepsis was performed more frequently by hospital personnel ³⁸; both this study and another documented that the prevalence of health-care–associated infections decreased as adherence to recommended hand-hygiene measures improved.

Outbreak investigations have indicated an association between infections and understaffing or overcrowding; the association was consistently linked with poor adherence to hand hygiene. During an outbreak investigation of risk factors for central venous catheter-associated bloodstream infections, after adjustment for confounding factors, the patient-to-nurse ratio remained an independent risk factor for bloodstream infection, indicating that nursing staff reduction below a critical threshold may have contributed to this outbreak by jeopardizing adequate catheter care. The understaffing of nurses can facilitate the spread of MRSA in intensive-care settings  through relaxed attention to basic control measures (e.g., hand hygiene). In an outbreak of Enterobacter cloacae in a neonatal intensive-care unit , the daily number of hospitalized children was above the maximum capacity of the unit, resulting in an available space per child below current recommendations. In parallel, the number of staff members on duty was substantially less than the number necessitated by the workload, which also resulted in relaxed attention to basic infection-control measures. Adherence to hand-hygiene practices before device contact was only 25% during the workload peak, but increased to 70% after the end of the understaffing and overcrowding period. Surveillance documented that being hospitalized during this period was associated with a fourfold increased risk of acquiring a health-care–associated infection. This study not only demonstrates the association between workload and infections, but it also highlights the intermediate cause of antimicrobial spread: poor adherence to hand-hygiene policies.

 Plain (non-antimicrobial) soap

Soaps are detergent-based products that contain esterified fatty acids and sodium or potassium hydroxide. They are available in various forms including bar soap, tissue, leaflet, and liquid preparations. Their cleaning activity can be attributed to their detergent properties, which result in removal of dirt, soil, and various organic substances from the hands. Plain soaps have minimal, if any, antimicrobial activity. However, handwashing with plain soap can remove loosely adherent transient flora. For example, handwashing with plain soap and water for 15 seconds reduces bacterial counts on the skin by 0.6–1.1 log₁₀, whereas washing for 30 seconds reduces counts by 1.8–2.8 log₁₀ ². However, in several studies, handwashing with plain soap failed to remove pathogens from the hands of hospital personnel. Handwashing with plain soap can result in paradoxical increases in bacterial counts on the skin. Non-antimicrobial soaps may be associated with considerable skin irritation and dryness ⁴⁵, although adding emollients to soap preparations may reduce their propensity to cause irritation. Occasionally, plain soaps have become contaminated, which may lead to colonization of hands of personnel with gram-negative bacilli ⁴⁷.

Alcohols

The majority of alcohol-based hand antiseptics contain either isopropanol, ethanol, n-propanol, or a combination of two of these products. Although n-propanol has been used in alcohol-based hand rubs in parts of Europe for many years, it is not listed in TFM as an approved active agent for HCW handwashes or surgical hand-scrub preparations in the United States. The majority of studies of alcohols have evaluated individual alcohols in varying concentrations. Other studies have focused on combinations of two alcohols or alcohol solutions containing limited amounts of hexachlorophene, quaternary ammonium compounds, povidone-iodine, triclosan, or chlorhexidine gluconate .

The antimicrobial activity of alcohols can be attributed to their ability to denature proteins ⁵⁰. Alcohol solutions containing 60%–95% alcohol are most effective, and higher concentrations are less potent because proteins are not denatured easily in the absence of water ⁵⁰. The alcohol content of solutions may be expressed as percent by weight (w/w), which is not affected by temperature or other variables, or as percent by volume (vol/vol), which can be affected by temperature, specific gravity, and reaction concentration . For example, 70% alcohol by weight is equivalent to 76.8% by volume if prepared at 15^ºC, or 80.5% if prepared at 25^ºC . Alcohol concentrations in antiseptic hand rubs are often expressed as percent by volume ²¹.

Alcohols have excellent in vitro germicidal activity against gram-positive and gram-negative vegetative bacteria, including multidrug-resistant pathogens (e.g., MRSA and VRE), Mycobacterium tuberculosis, and various fungi ⁵². Certain enveloped (lipophilic) viruses (e.g., herpes simplex virus, human immunodeficiency virus [HIV], influenza virus, respiratory syncytial virus, and vaccinia virus) are susceptible to alcohols when tested in vitro ⁵³. Hepatitis B virus is an enveloped virus that is somewhat less susceptible but is killed by 60%–70% alcohol; hepatitis C virus also is likely killed by this percentage of alcohol ⁵⁴. In a porcine tissue carrier model used to study antiseptic activity, 70% ethanol and 70% isopropanol were found to reduce titers of an enveloped bacteriophage more effectively than an antimicrobial soap containing 4% chlorhexidine gluconate ⁵⁵. Despite its effectiveness against these organisms, alcohols have very poor activity against bacterial spores, protozoan oocysts, and certain nonenveloped (nonlipophilic) viruses.

Numerous studies have documented the in vivo antimicrobial activity of alcohols. Alcohols effectively reduce bacterial counts on the hands ³. Typically, log reductions of the release of test bacteria from artificially contaminated hands average 3.5 log₁₀ after a 30-second application and 4.0–5.0 log₁₀ after a 1-minute application ². In 1994, the FDA TFM classified ethanol 60%–95% as a Category I agent (i.e., generally safe and effective for use in antiseptic handwash or HCW hand-wash products) ²¹. Although TFM placed isopropanol 70%–91.3% in category IIIE (i.e., insufficient data to classify as effective), 60% isopropanol has subsequently been adopted in Europe as the reference standard against which alcohol-based hand-rub products are compared ⁴¹. Alcohols are rapidly germicidal when applied to the skin, but they have no appreciable persistent (i.e., residual) activity. However, regrowth of bacteria on the skin occurs slowly after use of alcohol-based hand antiseptics, presumably because of the sublethal effect alcohols have on some of the skin bacteria . Addition of chlorhexidine, quaternary ammonium compounds, octenidine, or triclosan to alcohol-based solutions can result in persistent activity .

Alcohols, when used in concentrations present in alcohol-based hand rubs, also have in vivo activity against several nonenveloped viruses. For example, 70% isopropanol and 70% ethanol are more effective than medicated soap or nonmedicated soap in reducing rotavirus titers on fingerpads ⁵⁶. A more recent study using the same test methods evaluated a commercially available product containing 60% ethanol and found that the product reduced the infectivity titers of three nonenveloped viruses (i.e., rotavirus, adenovirus, and rhinovirus) by >3 logs ⁴³. Other nonenveloped viruses such as hepatitis A and enteroviruses (e.g., poliovirus) may require 70%–80% alcohol to be reliably inactivated ⁴⁴. However, both 70% ethanol and a 62% ethanol foam product with emollients reduced hepatitis A virus titers on whole hands or fingertips more than nonmedicated soap; both were equally as effective as antimicrobial soap containing 4% chlorhexidine gluconate in reducing reduced viral counts on hands ⁵⁷. In the same study, both 70% ethanol and the 62% ethanol foam product demonstrated greater virucidal activity against poliovirus than either non-antimicrobial soap or a 4% chlorhexidine gluconate-containing soap ⁵⁷. However, depending on the alcohol concentration, the amount of time that hands are exposed to the alcohol, and viral variant, alcohol may not be effective against hepatitis A and other nonlipophilic viruses. The inactivation of nonenveloped viruses is influenced by temperature, disinfectant-virus volume ratio, and protein load. Ethanol has greater activity against viruses than isopropanol. Further in vitro and in vivo studies of both alcohol-based formulations and antimicrobial soaps are warranted to establish the minimal level of virucidal activity that is required to interrupt direct contact transmission of viruses in health-care settings.

Alcohols are not appropriate for use when hands are visibly dirty or contaminated with proteinaceous materials. However, when relatively small amounts of proteinaceous material (e.g., blood) are present, ethanol and isopropanol may reduce viable bacterial counts on hands more than plain soap or antimicrobial soap .

Alcohol can prevent the transfer of health-care–associated pathogens ³⁰. In one study, gram-negative bacilli were transferred from a colonized patient’s skin to a piece of catheter material via the hands of nurses in only 17% of experiments after antiseptic hand rub with an alcohol-based hand rinse ³¹. In contrast, transfer of the organisms occurred in 92% of experiments after handwashing with plain soap and water. This experimental model indicates that when the hands of HCWs are heavily contaminated, an antiseptic hand rub using an alcohol-based rinse can prevent pathogen transmission more effectively than can handwashing with plain soap and water.

Alcohol-based products are more effective for standard handwashing or hand antisepsis by HCWs than soap or antimicrobial soaps . In all but two of the trials that compared alcohol-based solutions with antimicrobial soaps or detergents, alcohol reduced bacterial counts on hands more than washing hands with soaps or detergents containing hexachlorophene, povidone-iodine, 4% chlorhexidine, or triclosan. In studies examining antimicrobial-resistant organisms, alcohol-based products reduced the number of multidrug-resistant pathogens recovered from the hands of HCWs more effectively than did handwashing with soap and water .

Alcohols are effective for preoperative cleaning of the hands of surgical personnel ⁶⁰. In multiple studies, bacterial counts on the hands were determined immediately after using the product and again 1–3 hours later; the delayed testing was performed to determine if regrowth of bacteria on the hands is inhibited during operative procedures. Alcohol-based solutions were more effective than washing hands with plain soap in all studies, and they reduced bacterial counts on the hands more than antimicrobial soaps or detergents in the majority of experiments ⁶¹. In addition, the majority of alcohol-based preparations were more effective than povidone-iodine or chlorhexidine.

The efficacy of alcohol-based hand-hygiene products is affected by several factors, including the type of alcohol used, concentration of alcohol, contact time, volume of alcohol used, and whether the hands are wet when the alcohol is applied. Applying small volumes (i.e., 0.2–0.5 mL) of alcohol to the hands is not more effective than washing hands with plain soap and water ^30,31. One study documented that 1 mL of alcohol was substantially less effective than 3 mL. The ideal volume of product to apply to the hands is not known and may vary for different formulations. However, if hands feel dry after rubbing hands together for 10–15 seconds, an insufficient volume of product likely was applied. Because alcohol-impregnated towelettes contain a limited amount of alcohol, their effectiveness is comparable to that of soap and water ³⁰.

Alcohol-based hand rubs intended for use in hospitals are available as low viscosity rinses, gels, and foams. Limited data are available regarding the relative efficacy of various formulations. One field trial demonstrated that an ethanol gel was slightly more effective than a comparable ethanol solution at reducing bacterial counts on the hands of HCWs . However, a more recent study indicated that rinses reduced bacterial counts on the hands more than the gels tested ⁴². Further studies are warranted to determine the relative efficacy of alcohol-based rinses and gels in reducing transmission of health-care–associated pathogens.

Frequent use of alcohol-based formulations for hand antisepsis can cause drying of the skin unless emollients, humectants, or other skin-conditioning agents are added to the formulations. The drying effect of alcohol can be reduced or eliminated by adding 1%–3% glycerol or other skin-conditioning agents . Moreover, in several recent prospective trials, alcohol-based rinses or gels containing emollients caused substantially less skin irritation and dryness than the soaps or antimicrobial detergents tested ^45,46,63,64. These studies, which were conducted in clinical settings, used various subjective and objective methods for assessing skin irritation and dryness. Further studies are warranted to establish whether products with different formulations yield similar results.

Even well-tolerated alcohol hand rubs containing emollients may cause a transient stinging sensation at the site of any broken skin (e.g., cuts and abrasions). Alcohol-based hand-rub preparations with strong fragrances may be poorly tolerated by HCWs with respiratory allergies. Allergic contact dermatitis or contact urticaria syndrome caused by hypersensitivity to alcohol or to various additives present in certain alcohol hand rubs occurs only rarely .

Alcohols are flammable. Flash points of alcohol-based hand rubs range from 21^ºC to 24^ºC, depending on the type and concentration of alcohol present ⁶⁵. As a result, alcohol-based hand rubs should be stored away from high temperatures or flames in accordance with National Fire Protection Agency recommendations. In Europe, where alcohol-based hand rubs have been used extensively for years, the incidence of fires associated with such products has been low ⁶⁵. One recent U.S. report described a flash fire that occurred as a result of an unusual series of events, which included an HCW applying an alcohol gel to her hands, immediately removing a polyester isolation gown, and then touching a metal door before the alcohol had evaporated ⁶⁶. Removing the polyester gown created a substantial amount of static electricity that generated an audible static spark when the HCW touched the metal door, igniting the unevaporated alcohol on her hands. This incident emphasizes the need to rub hands together after application of alcohol-based products until all the alcohol has evaporated⁶⁶.

Because alcohols are volatile, containers should be designed to minimize evaporation. Contamination of alcohol-based solutions has seldom been reported. One report documented a cluster of pseudoinfections caused by contamination of ethyl alcohol by Bacillus cereus spores ⁶⁶.

Chlorhexidine

Chlorhexidine gluconate, a cationic bisbiguanide, was developed in England in the early 1950s and was introduced into the United States in the 1970s ⁶⁷. Chlorhexidine base is only minimally soluble in water, but the digluconate form is water-soluble. The antimicrobial activity of chlorhexidine is likely attributable to attachment to, and subsequent disruption of, cytoplasmic membranes, resulting in precipitation of cellular contents ². Chlorhexidine’s immediate antimicrobial activity occurs more slowly than that of alcohols. Chlorhexidine has good activity against gram-positive bacteria, somewhat less activity against gram-negative bacteria and fungi, and only minimal activity against tubercle bacilli ⁶⁷. Chlorhexidine is not sporicidal. It has in vitro activity against enveloped viruses (e.g., herpes simplex virus, HIV, cytomegalovirus, influenza, and RSV) but substantially less activity against nonenveloped viruses (e.g., rotavirus, adenovirus, and enteroviruses) ⁵³. The antimicrobial activity of chlorhexidine is only minimally affected by the presence of organic material, including blood. Because chlorhexidine is a cationic molecule, its activity can be reduced by natural soaps, various inorganic anions, nonionic surfactants, and hand creams containing anionic emulsifying agents ⁶⁷. Chlorhexidine gluconate has been incorporated into a number of hand-hygiene preparations. Aqueous or detergent formulations containing 0.5% or 0.75% chlorhexidine are more effective than plain soap, but they are less effective than antiseptic detergent preparations containing 4% chlorhexidine gluconate . Preparations with 2% chlorhexidine gluconate are slightly less effective than those containing 4% chlorhexidine .

Chlorhexidine has substantial residual activity. Addition of low concentrations (0.5%–1.0%) of chlorhexidine to alcohol-based preparations results in greater residual activity than alcohol alone. When used as recommended, chlorhexidine has a good safety record ⁶⁷. Minimal, if any, absorption of the compound occurs through the skin. Care must be taken to avoid contact with the eyes when using preparations with >1% chlorhexidine, because the agent can cause conjunctivitis and severe corneal damage. Ototoxicity precludes its use in surgery involving the inner or middle ear. Direct contact with brain tissue and the meninges should be avoided. The frequency of skin irritation is concentration-dependent, with products containing 4% most likely to cause dermatitis when used frequently for antiseptic handwashing; allergic reactions to chlorhexidine gluconate are uncommon. Occasional outbreaks of nosocomial infections have been traced to contaminated solutions of chlorhexidine .

Chloroxylenol

Chloroxylenol, also known as parachlorometaxylenol (PCMX), is a halogen-substituted phenolic compound that has been used as a preservative in cosmetics and other products and as an active agent in antimicrobial soaps. It was developed in Europe in the late 1920s and has been used in the United States since the 1950s.

The antimicrobial activity of PCMX likely is attributable to inactivation of bacterial enzymes and alteration of cell walls ². It has good in vitro activity against gram-positive organisms and fair activity against gram-negative bacteria, mycobacteria, and certain viruses. PCMX is less active against P. aeruginosa, but addition of ethylene-diaminetetraacetic acid (EDTA) increases its activity against Pseudomonas spp. and other pathogens.

A limited number of articles focusing on the efficacy of PCMX-containing preparations intended for use by HCWs have been published in the last 25 years, and the results of studies have sometimes been contradictory. For example, in studies in which antiseptics were applied to abdominal skin, PCMX had the weakest immediate and residual activity of any of the agents studied . However, when 30-second handwashes were performed using 0.6% PCMX, 2% chlorhexidine gluconate, or 0.3% triclosan, the immediate effect of PCMX was similar to that of the other agents. When used 18 times per day for 5 consecutive days, PCMX had less cumulative activity than did chlorhexidine gluconate. When PCMX was used as a surgical scrub, one report indicated that 3% PCMX had immediate and residual activity comparable to 4% chlorhexidine gluconate ⁶⁹, whereas two other studies demonstrated that the immediate and residual activity of PCMX was inferior to both chlorhexidine gluconate and povidone-iodine ⁶⁸. The disparity between published studies may be associated with the various concentrations of PCMX included in the preparations evaluated and with other aspects of the formulations tested, including the presence or absence of EDTA. PCMX is not as rapidly active as chlorhexidine gluconate or iodophors, and its residual activity is less pronounced than that observed with chlorhexidine gluconate. In 1994, FDA TFM tentatively classified PCMX as a Category IIISE active agent (i.e., insufficient data are available to classify this agent as safe and effective) ²¹. Further evaluation of this agent by the FDA is ongoing.

The antimicrobial activity of PCMX is minimally affected by the presence of organic matter, but it is neutralized by nonionic surfactants. PCMX, which is absorbed through the skin, is usually well-tolerated, and allergic reactions associated with its use are uncommon. PCMX is available in concentrations of 0.3%–3.75%. In-use contamination of a PCMX-containing preparation has been reported ³.

Hexachlorophene

Hexachlorophene is a bisphenol composed of two phenolic groups and three chlorine moieties. In the 1950s and early 1960s, emulsions containing 3% hexachlorophene were widely used for hygienic handwashing, as surgical scrubs, and for routine bathing of infants in hospital nurseries. The antimicrobial activity of hexachlorophene results from its ability to inactivate essential enzyme systems in microorganisms. Hexachlorophene is bacteriostatic, with good activity against S. aureus and relatively weak activity against gram-negative bacteria, fungi, and mycobacteria .

Studies of hexachlorophene as a hygienic handwash and surgical scrub demonstrated only modest efficacy after a single handwash . Hexachlorophene has residual activity for several hours after use and gradually reduces bacterial counts on hands after multiple uses (i.e., it has a cumulative effect) ⁴⁸. With repeated use of 3% hexachlorophene preparations, the drug is absorbed through the skin. Infants bathed with hexachlorophene and personnel regularly using a 3% hexachlorophene preparation for handwashing have blood levels of 0.1–0.6 ppm hexachlorophene. In the early 1970s, certain infants bathed with hexachlorophene developed neurotoxicity (vacuolar degeneration) . As a result, in 1972, the FDA warned that hexachlorophene should no longer be used routinely for bathing infants. However, after routine use of hexachlorophene for bathing infants in nurseries was discontinued, investigators noted that the incidence of health-care–associated S. aureus infections in hospital nurseries increased substantially. In several instances, the frequency of infections decreased when hexachlorophene bathing of infants was reinstituted. However, current guidelines still recommend against the routine bathing of neonates with hexachlorophene because of its potential neurotoxic effects . The agent is classified by FDA TFM as not generally recognized as safe and effective for use as an antiseptic handwash.  Hexachlorophene should not be used to bathe patients with burns or extensive areas of susceptible, sensitive skin. Soaps containing 3% hexachlorophene are available by prescription only .

Iodine and iodophors

Iodine has been recognized as an effective antiseptic since the 1800s. However, because iodine often causes irritation and discoloring of skin, iodophors have largely replaced iodine as the active ingredient in antiseptics.

Iodine molecules rapidly penetrate the cell wall of microorganisms and inactivate cells by forming complexes with amino acids and unsaturated fatty acids, resulting in impaired protein synthesis and alteration of cell membranes. Iodophors are composed of elemental iodine, iodide or triiodide, and a polymer carrier (i.e., the complexing agent) of high molecular weight. The amount of molecular iodine present (so-called “free” iodine) determines the level of antimicrobial activity of iodophors. “Available” iodine refers to the total amount of iodine that can be titrated with sodium thiosulfate. Typical 10% povidone-iodine formulations contain 1% available iodine and yield free iodine concentrations of 1 ppm. Combining iodine with various polymers increases the solubility of iodine, promotes sustained release of iodine, and reduces skin irritation. The most common polymers incorporated into iodophors are polyvinyl pyrrolidone (i.e., povidone) and ethoxylated nonionic detergents (i.e., poloxamers). The antimicrobial activity of iodophors also can be affected by pH, temperature, exposure time, concentration of total available iodine, and the amount and type of organic and inorganic compounds present (e.g., alcohols and detergents)⁷⁰.

Iodine and iodophors have bactericidal activity against gram-positive, gram-negative, and certain spore-forming bacteria (e.g., clostridia and Bacillus spp.) and are active against mycobacteria, viruses, and fungi. However, in concentrations used in antiseptics, iodophors are not usually sporicidal. In vivo studies have demonstrated that iodophors reduce the number of viable organisms that are recovered from the hands of personnel. Povidone-iodine 5%–10% has been tentatively classified by FDA TFM as a Category I agent (i.e., a safe and effective agent for use as an antiseptic handwash and an HCW handwash) . The extent to which iodophors exhibit persistent antimicrobial activity after they have been washed off the skin is unclear. In one study, persistent activity was noted for 6 hours ; however, several other studies demonstrated persistent activity for only 30–60 minutes after washing hands with an iodophor. In studies in which bacterial counts were obtained after gloves were worn for 1–4 hours after washing, iodophors have demonstrated poor persistent activity. The in vivo antimicrobial activity of iodophors is substantially reduced in the presence of organic substances (e.g., blood or sputum) .

The majority of iodophor preparations used for hand hygiene contain 7.5%–10% povidone-iodine. Formulations with lower concentrations also have good antimicrobial activity because dilution can increase free iodine concentrations. However, as the amount of free iodine increases, the degree of skin irritation also may increase. Iodophors cause less skin irritation and fewer allergic reactions than iodine, but more irritant contact dermatitis than other antiseptics commonly used for hand hygiene . Occasionally, iodophor antiseptics have become contaminated with gram-negative bacilli as a result of poor manufacturing processes and have caused outbreaks or pseudo-outbreaks of infection ⁷².

Quaternary ammonium compounds

Quaternary ammonium compounds are composed of a nitrogen atom linked directly to four alkyl groups, which may vary in their structure and complexity. Of this large group of compounds, alkyl benzalkonium chlorides are the most widely used as antiseptics. Other compounds that have been used as antiseptics include benzethonium chloride, cetrimide, and cetylpyridium chloride. The antimicrobial activity of these compounds was first studied in the early 1900s, and a quaternary ammonium compound for preoperative cleaning of surgeons’ hands was used as early as 1935. The antimicrobial activity of this group of compounds likely is attributable to adsorption to the cytoplasmic membrane, with subsequent leakage of low molecular weight cytoplasmic constituents.

Quaternary ammonium compounds are primarily bacteriostatic and fungistatic, although they are microbicidal against certain organisms at high concentrations; they are more active against gram-positive bacteria than against gram-negative bacilli. Quaternary ammonium compounds have relatively weak activity against mycobacteria and fungi and have greater activity against lipophilic viruses. Their antimicrobial activity is adversely affected by the presence of organic material, and they are not compatible with anionic detergents. In 1994, FDA TFM tentatively classified benzalkonium chloride and benzethonium chloride as Category IIISE active agents (i.e., insufficient data exists to classify them as safe and effective for use as an antiseptic handwash. Further evaluation of these agents by FDA is in progress.

Quaternary ammonium compounds are usually well tolerated. However, because of weak activity against gram-negative bacteria, benzalkonium chloride is prone to contamination by these organisms. Several outbreaks of infection or pseudoinfection have been traced to quaternary ammonium compounds contaminated with gram-negative bacilli. For this reason, in the United States, these compounds have been seldom used for hand antisepsis during the last 15–20 years. However, newer handwashing products containing benzalkonium chloride or benzethonium chloride have recently been introduced for use by HCWs. A recent study of surgical intensive-care unit personnel found that cleaning hands with antimicrobial wipes containing a quaternary ammonium compound was about as effective as using plain soap and water for handwashing; both were less effective than decontaminating hands with an alcohol-based hand rub . One laboratory-based study reported that an alcohol-free hand-rub product containing a quaternary ammonium compound was efficacious in reducing microbial counts on the hands of volunteers. Further studies of such products are needed to determine if newer formulations are effective in health-care settings.

Triclosan

Triclosan (chemical name: 2,4,4′ –trichloro-2′-hydroxy-diphenyl ether) is a nonionic, colorless substance that was developed in the 1960s. It has been incorporated into soaps for use by HCWs and the public and into other consumer products. Concentrations of 0.2%–2% have antimicrobial activity. Triclosan enters bacterial cells and affects the cytoplasmic membrane and synthesis of RNA, fatty acids, and proteins. Recent studies indicate this agent’s antibacterial activity is attributable to binding to the active site of enoyl-acyl carrier protein reductase .

Triclosan has a broad range of antimicrobial activity, but it is often bacteriostatic. Minimum inhibitory concentrations (MICs) range from 0.1 to 10 ug/mL, whereas minimum bactericidal concentrations are 25–500 ug/mL. Triclosan’s activity against gram-positive organisms (including MRSA) is greater than against gram-negative bacilli, particularly P. aeruginosa ⁷⁵. The agent possesses reasonable activity against mycobacterial and Candida spp., but it has limited activity against filamentous fungi. Triclosan (0.1%) reduces bacterial counts on hands by 2.8 log₁₀ after a 1-minute hygienic handwash . In several studies, log reductions have been lower after triclosan is used than when chlorhexidine, iodophors, or alcohol-based products are applied . In 1994, FDA TFM tentatively classified triclosan <1.0% as a Category IIISE active agent (i.e., insufficient data exist to classify this agent as safe and effective for use as an antiseptic handwash) ²¹. Further evaluation of this agent by the FDA is underway. Like chlorhexidine, triclosan has persistent activity on the skin. Its activity in hand-care products is affected by pH, the presence of surfactants, emollients, or humectants and by the ionic nature of the particular formulation ⁷⁵. Triclosan’s activity is not substantially affected by organic matter, but it can be inhibited by sequestration of the agent in micelle structures formed by surfactants present in certain formulations. The majority of formulations containing <2% triclosan are well-tolerated and seldom cause allergic reactions. Certain reports indicate that providing hospital personnel with a triclosan-containing preparation for hand antisepsis has led to decreased MRSA infections . Triclosan’s lack of potent activity against gram-negative bacilli has resulted in occasional reports of contamination.

Other agents

Approximately 150 years after puerperal-fever–related maternal mortality rates were demonstrated by Semmelweis to be reduced by use of a hypochlorite hand rinse, the efficacy of rubbing hands for 30 seconds with an aqueous hypochlorite solution was studied once again. The solution was demonstrated to be no more effective than distilled water. The regimen used by Semmelweis, which called for rubbing hands with a 4% [w/w] hypochlorite solution until the hands were slippery (approximately 5 minutes), has been revisited by other researchers. This more current study indicated that the regimen was 30 times more effective than a 1-minute rub using 60% isopropanol. However, because hypochlorite solutions are often irritating to the skin when used repeatedly and have a strong odor, they are seldom used for hand hygiene.

Certain other agents are being evaluated by FDA for use in health-care-related antiseptics. However, the efficacy of these agents has not been evaluated adequately for use in handwashing preparations intended for use by HCWs. Further evaluation of these agents is warranted. Products that use different concentrations of traditional antiseptics (e.g., low concentrations of iodophor) or contain novel compounds with antiseptic properties are likely to be introduced for use by HCWs. For example, preliminary studies have demonstrated that adding silver-containing polymers to an ethanol carrier (i.e., Surfacine^®) results in a preparation that has persistent antimicrobial activity on animal and human skin. New compounds with good in vitro activity must be tested in vivo to determine their abilities to reduce transient and resident skin flora on the hands of HCWs⁷⁸.

Activity of antiseptic agents against spore-forming bacteria

The widespread prevalence of health-care–associated diarrhea caused by Clostridium difficile and the recent occurrence in the United States of human Bacillus anthracis infections associated with contaminated items sent through the postal system has raised concern regarding the activity of antiseptic agents against spore-forming bacteria. None of the agents (including alcohols, chlorhexidine, hexachlorophene, iodophors, PCMX, and triclosan) used in antiseptic handwash or antiseptic hand-rub preparations are reliably sporicidal against Clostridium spp. or Bacillus spp. ^50,67. Washing hands with non-antimicrobial or antimicrobial soap and water may help to physically remove spores from the surface of contaminated hands. HCWs should be encouraged to wear gloves when caring for patients with C. difficile-associated diarrhea . After gloves are removed, hands should be washed with a non-antimicrobial or an antimicrobial soap and water or disinfected with an alcohol-based hand rub. During outbreaks of C. difficile-related infections, washing hands with a non-antimicrobial or antimicrobial soap and water after removing gloves is prudent. HCWs with suspected or documented exposure to B. anthracis-contaminated items also should be encouraged to wash their hands with a non-antimicrobial or antimicrobial soap and water.

Reduced susceptibility of bacteria to antiseptics

Reduced susceptibility of bacteria to antiseptic agents can either be an intrinsic characteristic of a species or can be an acquired trait . Several reports have described strains of bacteria that appear to have acquired reduced susceptibility (when defined by MICs established in vitro) to certain antiseptics (e.g., chlorhexidine, quaternary ammonium compounds, and triclosan) ⁸¹. However, because the antiseptic concentrations that are actually used by HCWs are often substantially higher than the MICs of strains with reduced antiseptic susceptibility, the clinical relevance of the in vitro findings is questionable. For example, certain strains of MRSA have chlorhexidine and quaternary ammonium compound MICs that are several-fold higher than methicillin-susceptible strains, and certain strains of S. aureus have elevated MICs to triclosan . However, such strains were readily inhibited by the concentrations of these antiseptics that are actually used by practicing HCWs . The description of a triclosan-resistant bacterial enzyme has raised the question of whether resistance to this agent may develop more readily than to other antiseptic agents . In addition, exposing Pseudomonas strains containing the MexAB-OprM efflux system to triclosan may select for mutants that are resistant to multiple antibiotics, including fluoroquinolones . Further studies are needed to determine whether reduced susceptibility to antiseptic agents is of epidemiologic significance and whether resistance to antiseptics has any influence on the prevalence of antibiotic-resistant strains .

Surgical hand antisepsis

Since the late 1800s, when Lister promoted the application of carbolic acid to the hands of surgeons before procedures, preoperative cleansing of hands and forearms with an antiseptic agent has been an accepted practice Although no randomized, controlled trials have been conducted to indicate that surgical-site infection rates are substantially lower when preoperative scrubbing is performed with an antiseptic agent rather than a non-antimicrobial soap, certain other factors provide a strong rationale for this practice. Bacteria on the hands of surgeons can cause wound infections if introduced into the operative field during surgery; rapid multiplication of bacteria occurs under surgical gloves if hands are washed with a non-antimicrobial soap. However, bacterial growth is slowed after preoperative scrubbing with an antiseptic agent . Reducing resident skin flora on the hands of the surgical team for the duration of a procedure reduces the risk of bacteria being released into the surgical field if gloves become punctured or torn during surgery. Finally, at least one outbreak of surgical-site infections occurred when surgeons who normally used an antiseptic surgical scrub preparation began using a non-antimicrobial product.

Antiseptic preparations intended for use as surgical hand scrubs are evaluated for their ability to reduce the number of bacteria released from hands at different times, including 1) immediately after scrubbing, 2) after wearing surgical gloves for 6 hours (i.e., persistent activity), and 3) after multiple applications over 5 days (i.e., cumulative activity). Immediate and persistent activity are considered the most important in determining the efficacy of the product. U.S. guidelines recommend that agents used for surgical hand scrubs should substantially reduce microorganisms on intact skin, contain a nonirritating antimicrobial preparation, have broad-spectrum activity, and be fast-acting and persistent .

Studies have demonstrated that formulations containing 60%–95% alcohol alone or 50%–95% when combined with limited amounts of a quaternary ammonium compound, hexachlorophene, or chlorhexidine gluconate, lower bacterial counts on the skin immediately postscrub more effectively than do other agents. The next most active agents (in order of decreasing activity) are chlorhexidine gluconate, iodophors, triclosan, and plain soap ^71,72. Because studies of PCMX as a surgical scrub have yielded contradictory results, further studies are needed to establish how the efficacy of this compound compares with the other agents .

Although alcohols are not considered to have persistent antimicrobial activity, bacteria appear to reproduce slowly on the hands after a surgical scrub with alcohol, and bacterial counts on hands after wearing gloves for 1–3 hours seldom exceed baseline (i.e., prescrub) values. However, a recent study demonstrated that a formulation containing 61% ethanol alone did not achieve adequate persistent activity at 6 hours postscrub. Alcohol-based preparations containing 0.5% or 1% chlorhexidine gluconate have persistent activity that, in certain studies, has equaled or exceeded that of chlorhexidine gluconate-containing detergents .

Persistent antimicrobial activity of detergent-based surgical scrub formulations is greatest for those containing 2% or 4% chlorhexidine gluconate, followed by hexachlorophene, triclosan, and iodophors. Because hexachlorophene is absorbed into the blood after repeated use, it is seldom used as a surgical scrub.

Surgical staff have been traditionally required to scrub their hands for 10 minutes preoperatively, which frequently leads to skin damage. Several studies have demonstrated that scrubbing for 5 minutes reduces bacterial counts as effectively as a 10-minute scrub. In other studies, scrubbing for 2 or 3 minutes reduced bacterial counts to acceptable levels .

Studies have indicated that a two-stage surgical scrub using an antiseptic detergent, followed by application of an alcohol-containing preparation, is effective. For example, an initial 1- or 2-minute scrub with 4% chlorhexidine gluconate or povidone-iodine followed by application of an alcohol-based product has been as effective as a 5-minute scrub with an antiseptic detergent ⁸⁶.

Surgical hand-antisepsis protocols have required personnel to scrub with a brush. But this practice can damage the skin of personnel and result in increased shedding of bacteria from the hands. Scrubbing with a disposable sponge or combination sponge-brush has reduced bacterial counts on the hands as effectively as scrubbing with a brush. However, several studies indicate that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands of surgical personnel to acceptable levels, especially when alcohol-based products are used ^61,63,. Several of these studies performed cultures immediately or at 45–60 minutes postscrub, whereas in other studies, cultures were obtained 3 and 6 hours postscrub⁸⁴. For example, a recent laboratory-based study using volunteers demonstrated that brushless application of a preparation containing 1% chlorhexidine gluconate plus 61% ethanol yielded lower bacterial counts on the hands of participants than using a sponge/brush to apply a 4% chlorhexidine-containing detergent preparation ⁸⁴.

Frequency and pathophysiology of irritant contact dermatitis

In certain surveys, approximately 25% of nurses report symptoms or signs of dermatitis involving their hands, and as many as 85% give a history of having skin problems. Frequent and repeated use of hand-hygiene products, particularly soaps and other detergents, is a primary cause of chronic irritant contact dermatitis among HCWs. The potential of detergents to cause skin irritation can vary considerably and can be ameliorated by the addition of emollients and humectants. Irritation associated with antimicrobial soaps may be caused by the antimicrobial agent or by other ingredients of the formulation. Affected persons often complain of a feeling of dryness or burning; skin that feels “rough;” and erythema, scaling, or fissures. Detergents damage the skin by causing denaturation of stratum corneum proteins, changes in intercellular lipids (either depletion or reorganization of lipid moieties), decreased corneocyte cohesion, and decreased stratum corneum water-binding capacity. Damage to the skin also changes skin flora, resulting in more frequent colonization by staphylococci and gram-negative bacilli. Although alcohols are among the safest antiseptics available, they can cause dryness and irritation of the skin. Ethanol is usually less irritating than n-propanol or isopropanol ⁸⁷.

Irritant contact dermatitis is more commonly reported with iodophors. Other antiseptic agents that can cause irritant contact dermatitis (in order of decreasing frequency) include chlorhexidine, PCMX, triclosan, and alcohol-based products. Skin that is damaged by repeated exposure to detergents may be more susceptible to irritation by alcohol-based preparations. The irritancy potential of commercially prepared hand-hygiene products, which is often determined by measuring transepidermal water loss, may be available from the manufacturer. Other factors that can contribute to dermatitis associated with frequent handwashing include using hot water for handwashing, low relative humidity (most common in winter months), failure to use supplementary hand lotion or cream, and the quality of paper towels. Shear forces associated with wearing or removing gloves and allergy to latex proteins may also contribute to dermatitis of the hands of HCWs⁸⁷.

Allergic contact dermatitis associated with hand-hygiene products

Allergic reactions to products applied to the skin (i.e., contact allergies) may present as delayed type reactions (i.e., allergic contact dermatitis) or less commonly as immediate reactions (i.e., contact urticaria). The most common causes of contact allergies are fragrances and preservatives; emulsifiers are less common causes . Liquid soaps, hand lotions or creams, and “udder ointments” may contain ingredients that cause contact allergies among HCWs .

Allergic reactions to antiseptic agents, including quaternary ammonium compounds, iodine or iodophors, chlorhexidine, triclosan, PCMX, and alcohols have been reported . Allergic contact dermatitis associated with alcohol-based hand rubs is uncommon. Surveillance at a large hospital in Switzerland, where a commercial alcohol hand rub has been used for >10 years, failed to identify a single case of documented allergy to the product . In late 2001, a Freedom of Information Request for data in the FDA’s Adverse Event Reporting System regarding adverse reactions to popular alcohol hand rubs in the United States yielded only one reported case of an erythematous rash reaction attributed to such a product (John M. Boyce, M.D., Hospital of St. Raphael, New Haven, Connecticut, personal communication, 2001). However, with increasing use of such products by HCWs, true allergic reactions to such products likely will be encountered.

Allergic reactions to alcohol-based products may represent true allergy to alcohol, allergy to an impurity or aldehyde metabolite, or allergy to another constituent of the product. Allergic contact dermatitis or immediate contact urticarial reactions may be caused by ethanol or isopropanol. Allergic reactions can be caused by compounds that may be present as inactive ingredients in alcohol-based hand rubs, including fragrances, benzyl alcohol, stearyl or isostearyl alcohol, phenoxyethanol, myristyl alcohol, propylene glycol, parabens, and benzalkonium chloride ⁹⁰.

Factors to consider when selecting hand-hygiene products

When evaluating hand-hygiene products for potential use in health-care facilities, administrators or product-selection committees must consider factors that can affect the overall efficacy of such products, including the relative efficacy of antiseptic agents against various pathogens (Appendix) and acceptance of hand-hygiene products by personnel . Soap products that are not well-accepted by HCWs can be a deterrent to frequent handwashing. Characteristics of a product (either soap or alcohol-based hand rub) that can affect acceptance by personnel include its smell, consistency (i.e., “feel”), and color . For soaps, ease of lathering also may affect user preference.

Because HCWs may wash their hands from a limited number of times per shift to as many as 30 times per shift, the tendency of products to cause skin irritation and dryness is a substantial factor that influences acceptance, and ultimate usage . For example, concern regarding the drying effects of alcohol was a primary cause of poor acceptance of alcohol-based hand-hygiene products in hospitals in the United States. However, several studies have demonstrated that alcohol-based hand rubs containing emollients are acceptable to HCWs ^46,48,64. With alcohol-based products, the time required for drying may also affect user acceptance.

Studies indicate that the frequency of handwashing or antiseptic handwashing by personnel is affected by the accessibility of hand-hygiene facilities . In certain health-care facilities, only one sink is available in rooms housing several patients, or sinks are located far away from the door of the room, which may discourage handwashing by personnel leaving the room. In intensive-care units, access to sinks may be blocked by bedside equipment (e.g., ventilators or intravenous infusion pumps). In contrast to sinks used for handwashing or antiseptic handwash, dispensers for alcohol-based hand rubs do not require plumbing and can be made available adjacent to each patient’s bed and at many other locations in patient-care areas. Pocket carriage of alcohol-based hand-rub solutions, combined with availability of bedside dispensers, has been associated with substantial improvement in adherence to hand-hygiene protocols ⁹⁸. To avoid any confusion between soap and alcohol hand rubs, alcohol hand-rub dispensers should not be placed adjacent to sinks. HCWs should be informed that washing hands with soap and water after each use of an alcohol hand rub is not necessary and is not recommended, because it may lead to dermatitis. However, because personnel feel a “build-up” of emollients on their hands after repeated use of alcohol hand gels, washing hands with soap and water after 5–10 applications of a gel has been recommended by certain manufacturers.

Automated handwashing machines have not been demonstrated to improve the quality or frequency of handwashing (88,285). Although technologically advanced automated handwashing devices and monitoring systems have been developed recently, only a minimal number of studies have been published that demonstrate that use of such devices results in enduring improvements in hand- decontamination adherence among HCWs. Further evaluation of automated handwashing facilities and monitoring systems is warranted.

Dispenser systems provided by manufacturers or vendors also must be considered when evaluating hand-hygiene products. Dispensers may discourage use by HCWs when they 1) become blocked or partially blocked and do not deliver the product when accessed by personnel, and 2) do not deliver the product appropriately onto the hands.

To put expenditures for hand- decontamination products into perspective, health-care facilities should consider comparing their budget for hand- decontamination products to estimated excess hospital costs resulting from health-care–associated infections. The excess hospital costs associated with only four or five health-care–associated infections of average severity may equal the entire annual budget for hand- decontamination products used in inpatient-care areas. Just one severe surgical site infection, lower respiratory tract infection, or bloodstream infection may cost the hospital more than the entire annual budget for antiseptic agents used for hand decontamination. Thus, hospital administrators must consider that by purchasing more effective or more acceptable hand-hygiene products to improve hand- decontamination practices, they will avoid the occurrence of nosocomial infections; preventing only a limited number of additional health-care–associated infections per year will lead to savings that will exceed any incremental costs of improved hand- decontamination products⁹⁹.

Hand- decontamination practices among HCWs

In observational studies conducted in hospitals, HCWs washed their hands an average of five times per shift to as many as 30 times per shift  ^2946,93; certain nurses washed their hands <100 times per shift (90). Hospital wide surveillance of hand hygiene reveals that the average number of handwashing opportunities varies markedly between hospital wards. For example, nurses in pediatric wards had an average of eight opportunities for hand hygiene per hour of patient care compared with an average of 20 for nurses in intensive-care units ¹⁸. The duration of handwashing or hygienic handwash episodes by HCWs has averaged 6.6–24.0 seconds in observational studies. In addition to washing their hands for limited time periods, personnel often fail to cover all surfaces of their hands and fingers ⁹⁹.

Adherence of HCWs to recommended hand- decontamination practices

Observational studies of hand- decontamination adherence. Adherence of HCWs to recommended hand- decontamination procedures has been poor, with mean baseline rates of 5%–81% (overall average: 40%) ^95,97. The methods used for defining adherence (or nonadherence) and those used for conducting observations vary considerably among studies, and reports do not provide detailed information concerning the methods and criteria used. The majority of studies were conducted with hand- decontamination adherence as the major outcome measure, whereas a limited number measured adherence as part of a broader investigation. Several investigators reported improved adherence after implementing various interventions, but the majority of studies had short follow-up periods and did not confirm whether behavioral improvements were long-lasting. Other studies established that sustained improvements in handwashing behavior occurred during a long-term program to improve adherence to hand- decontamination policies ^38,39.

Factors affecting adherence

Factors that may influence hand hygiene include those identified in epidemiologic studies and factors reported by HCWs as being reasons for lack of adherence to hand- decontamination recommendations. Risk factors for poor adherence to hand decontamination have been determined objectively in several observational studies or interventions to improve adherence Among these, being a physician or a nursing assistant, rather than a nurse, was consistently associated with reduced adherence^{18,19,93,100,101,102,105}. as shown in following paragraph:.

Observed risk factors for poor adherence to recommended hand decontamination practices🙁 Adapted from Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000;21:381-6)

• Physicians status
• Nusrsing Assistants status
• Male Sex
• Working in ICU
• Working during the week versus weekend
• Wearing gowns/ gloves
• Automated sinks
• Activities with high risk of cross transmission
• High number of opportunities for hand decontamination per hour of patient care

2.14..2.1. Self reported factors for poor adherence with hand decontamination

• Hand decontamination agents cause irritation and dryness
• Sinks are inconveniently located/ shortage of sinks
• Lack of soap and paper towels
• Often too busy/insufficient time
• Understaffing/overcrowding
• Patient needs take priority
• Hand hygiene interfares with health care workers relationships with patients
• Low risk of acquiring infection from patients
• Wearing of gloves/ beliefs that glove use obviates the need for hand decontamination
• Lack of knowledge of guidelines/protocols
• Not thinking about it/forgetfulness
• No role model from collegues or superiors
• Skepticism regarding the value of hand decontamination disagreement with the recommendation
• Lack of scientific information of definitive impact of improved hand decontamination on health care associated infection rates.

2.14..2.1. Additional perceived barriers to appropriate hand hygiene

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

In the largest hospital wide survey of hand-hygiene practices among HCWs , predictors of poor adherence to recommended hand-hygiene measures were identified. Predictor variables included professional category, hospital ward, time of day/week, and type and intensity of patient care, defined as the number of opportunities for hand hygiene per hour of patient care. In 2,834 observed opportunities for hand hygiene, average adherence was 48%. In multivariate analysis, nonadherence was lowest among nurses and during weekends (Odds Ratio [OR]: 0.6; 95% confidence interval [CI] = 0.4–0.8). Nonadherence was higher in intensive-care units compared with internal medicine wards (OR: 2.0; 95% CI = 1.3–3.1), during procedures that carried a high risk of bacterial contamination (OR: 1.8; 95% CI = 1.4–2.4), and when intensity of patient care was high (21–40 hand decontamination opportunities — OR: 1.3; 95% CI = 1.0-1.7; 41–60 opportunities — OR: 2.1; 95% CI = 1.5-2.9; >60 opportunities — OR: 2.1; 95% CI = 1.3–3.5). The higher the demand for hand hygiene, the lower the adherence; on average, adherence decreased by 5% (+ 2%) for each increase of 10 opportunities per hour when the intensity of patient care exceeded 10 opportunities per hour. Similarly, the lowest adherence rate (36%) was found in intensive-care units, where indications for hand decontamination were typically more frequent (on average, 20 opportunities per patient-hour). The highest adherence rate (59%) was observed in pediatrics wards, where the average intensity of patient care was lower than in other hospital areas (an average of eight opportunities per patient-hour). The results of this study indicate that full adherence to previous guidelines may be unrealistic, and that facilitated access to hand decontamination could help improve adherence.

Perceived barriers to adherence with hand- decontamination practice recommendations include skin irritation caused by hand-hygiene agents, inaccessible hand-hygiene supplies, interference with HCW-patient relationships, priority of care (i.e., the patients’ needs are given priority over hand hygiene), wearing of gloves, forgetfulness, lack of knowledge of the guidelines, insufficient time for hand decontamination, high workload and understaffing, and the lack of scientific information indicating a definitive impact of improved hand hygiene on health-care–associated infection rates . Certain perceived barriers to adherence with hand-hygiene guidelines have been assessed or quantified in observational studies .

Skin irritation by hand-hygiene agents constitutes a substantial barrier to appropriate adherence. Because soaps and detergents can damage skin when applied on a regular basis, HCWs must be better informed regarding the possible adverse effects associated with hand- decontamination agents. Lack of knowledge and education regarding this subject is a barrier to motivation. In several studies, alcohol-based hand rubs containing emollients (either isopropanol, ethanol, or n-propanol in 60%–90% vol/vol) were less irritating to the skin than the soaps or detergents tested. In addition, the alcohol-based products containing emollients that were tested were at least as tolerable and efficacious as the detergents tested. Also, studies demonstrate that several hand lotions have reduced skin scaling and cracking, which may reduce microbial shedding from the hands ^92,93.

Easy access to hand- decontamination supplies, whether sink, soap, medicated detergent, or alcohol-based hand-rub solution, is essential for optimal adherence to hand- decontamination recommendations. The time required for nurses to leave a patient’s bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent handwashing or hand antisepsis . Engineering controls could facilitate adherence, but careful monitoring of hand-hygiene behavior should be conducted to exclude the possible negative effect of newly introduced hand decontamination devices.

The impact of wearing gloves on adherence to hand- decontamination policies has not been definitively established, because published studies have yielded contradictory results ¹⁰⁷. Hand hygiene is required regardless of whether gloves are used or changed. Failure to remove gloves after patient contact or between “dirty” and “clean” body-site care on the same patient must be regarded as nonadherence to hand-hygiene recommendations ¹⁸. In a study in which experimental conditions approximated those occurring in clinical practice , washing and reusing gloves between patient contacts resulted in observed bacterial counts of 0–4.7 log on the hands after glove removal. Therefore, this practice should be discouraged; handwashing or disinfection should be performed after glove removal¹⁰⁸.

Lack of 1) knowledge of guidelines for hand hygiene, 2) recognition of hand-hygiene opportunities during patient care, and 3) awareness of the risk of cross-transmission of pathogens are barriers to good hand-hygiene practices. Perceived barriers to hand-hygiene behavior are linked not only to the institution, but also to HCWs’ colleagues. Therefore, both institutional and small-group

dynamics need to be considered when implementing a system change to secure an improvement in HCWs’ hand-hygiene practice.

Another Part of the Post:

 Thesis Paper on Compliance of Hand Decontamination of Combined Military Hospital Dhaka (Part-1)

 Thesis Paper on Compliance of Hand Decontamination of Combined Military Hospital Dhaka (Part-2)