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|Hand Hygiene FactFinder|
Committed to providing helpful information to International Spine Intervention Society members about key patient safety issues, the Patient Safety Committee has developed a FactFinder series. FactFinders will explore and debunk myths surrounding patient safety issues. The intent of this FactFinder is to present the evidence regarding the importance of hand hygiene and its role in decreasing the risk of infectious complications following spinal procedures.
Myth: Washing hands with soap and water is as effective as using antiseptic solutions or surgical scrubs.
Fact: Non-antimicrobial soaps contain detergents that are effective in removing loose dirt, transient bacteria, and spores from skin surfaces. However, non-antimicrobial soaps have limited bactericidal activity compared to antimicrobial soap, antiseptic hand washes, or surgical scrubs.
In 1822, Labarraque, 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 an 1825 paper, he stated that physicians and other persons attending patients with contagious diseases would benefit from moistening their hands with a liquid chloride solution.1 In 1847, students and physicians working at a maternity clinic were instructed to clean their hands with a chlorine solution between each patient, which resulted in a significant reduction of the maternal mortality rate for years. This intervention was 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 hand washing with plain soap and water.2
In 1975 and 1985, the Centers of Disease Control and Prevention (CDC) published formal written guidelines on hand washing practices in hospitals.3,4 These guidelines recommended hand washing 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, the Association for Professionals in Infection Control (APIC) initially published guidelines for hand washing and hand antisepsis similar to the CDC guidelines but updated APIC guidelines in 1995 included more detailed discussion of alcohol-based hand rubs and supported their use in more clinical settings than had been recommended in earlier guidelines.5,6 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]).7,8 These guidelines also provided recommendations for hand washing 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 health care workers (HCWs) to these recommended hand washing practices has remained low.9,10
Normal Bacterial Skin Flora
To understand the objectives of different approaches to hand cleansing, knowledge of normal bacterial skin flora is essential. Normal human skin is colonized with bacteria. In 1938, bacteria recovered from the hands were categorized as transient or resident.11 Transient flora, which colonize the superficial layers of the skin, are more amenable to removal by routine hand washing. They are often acquired by HCWs during direct patient contact or contact with contaminated surfaces within close proximity of the patient. Transient flora are the organisms most frequently associated with health care-associated infections. In contrast, resident flora are attached to deeper layers of the skin, more resistant to removal, and 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.11,12
Plain (non-antimicrobial) soaps have detergent properties to remove dirt, soil, and various organic substances from the hands. They have minimal, if any, antimicrobial activity but can remove loosely adherent transient flora and spores. Antimicrobial soaps have the same properties as plain soaps with added antimicrobial activity
Antiseptic agents are antimicrobial substances that are applied to the skin to reduce the number of microbial flora; they typically include chemicals such as alcohols, chlorhexidine, chlorine, or iodine. In the United States, antiseptic hand wash products intended for use by HCWs are regulated by the Food and Drug Administration’s (FDA) Division of Over the-Counter Drug Products.13 In 1994, FDA published a "Monograph for Health-Care Antiseptic Drug Products” that separated these antiseptic agents into three categories: preoperative skin preparations, antiseptic hand washes, and surgical hand scrubs. Preoperative skin preparations are fast-acting, broad-spectrum, and persistent antiseptic-containing preparations that substantially reduce the number of microorganisms on intact skin. Antiseptic hand washes are designed for frequent use to reduce the number of microorganisms on intact skin after adequate washing, rinsing, and drying. They are broad-spectrum, fast-acting, and if possible, persistent (i.e., will maintain a long duration of antiseptic activity). Surgical hand scrubs are antiseptic-containing preparations that substantially reduce the number of microorganisms on intact skin. They are broad-spectrum, fast-acting, and persistent.
Numerous studies have documented the in vivo antimicrobial activity of alcohols in effectively reducing the bacterial counts on the hands of HCWs.11,14-16 In addition, alcohol-based products more effectively reduce bacterial counts than soaps or detergents containing hexachlorophene, povidone-iodine, or 4% chlorhexidine.17 In the United States, alcohol-based hand antiseptics contain isopropanol, ethanol, or a combination of the two. Their antimicrobial activity is attributed to their ability to denature proteins. Solutions containing 60%-95% alcohol are most effective and have excellent in vitro germicidal activity against gram-positive and gram-negative vegetative bacteria, including multidrug-resistant pathogens (e.g., MRSA), Mycobacterium TB, and various fungi. Certain enveloped (lipophilic) viruses (e.g., herpes simplex virus, HIV, influenza, etc.) are susceptible to alcohols when tested in vitro. However, alcohols are flammable, requiring providers to rub hands together after application of alcohol-based products until all the alcohol has evaporated.
Preparations containing chlorhexidine act by disrupting the cytoplasmic membranes, resulting in precipitation of cellular contents. Therefore, chlorhexidine products must be repeatedly scrubbed on the skin for a set amount of time, in order to be effective. Compared to alcohol-based preparations, chlorhexidine’s antimicrobial effect occurs more slowly. Chlorhexidine has good activity against gram-positive bacteria, and somewhat less activity against gram-negative bacteria and fungi. It has in vitro activity against enveloped viruses (e.g., HSV, HIV, CMV, influenza, and RSV) but substantially less activity against non-enveloped viruses (e.g., rotavirus, adenovirus, and enteroviruses). Addition of low concentrations (0.5%–1.0%) of chlorhexidine to alcohol-based preparations results in greater residual activity than alcohol alone. Care must be taken to avoid contact with the eyes when using preparations with >1% chlorhexidine, as it can cause conjunctivitis and severe corneal damage.
Iodine and Iodophors
Iodine has been recognized as an effective antiseptic since the 1800s. Iodophors have since replaced iodine as the active ingredient in antiseptics. Iodine molecules rapidly penetrate the cell wall of microorganisms to impair protein synthesis and alter cell membranes. These compounds must typically be allowed to dry on the skin for full antimicrobial activity. 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. Povidone-iodine 5%-10% has been tentatively classified by FDA as a Category I agent (i.e., a safe and effective agent for use as an antiseptic handwash).
Of note, none of the above agents (alcohols, chlorhexidine, iodophors) are reliably sporicidal against Clostridium spp. or Bacillus spp.
Bacteria on the hands of surgeons can cause wound infections if introduced into the operative field during surgery.18 Rapid multiplication of bacteria occurs under surgical gloves if hands are washed with a non-antimicrobial soap. However, bacterial growth is slowed by preoperative scrubbing with an antiseptic agent.19 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.20 Studies have demonstrated that formulations containing 60%-95% alcohol alone or 50%-95% alcohol combined with limited amounts of a quaternary ammonium compound, hexachlorophene, or chlorhexidine gluconate lower bacterial counts on the skin immediately after scrubbing more effectively than other agents. The next most active agents (in order of decreasing activity) are chlorhexidine gluconate, iodophors, triclosan, and plain soap.
Several studies have demonstrated that scrubbing for five minutes reduces bacterial counts as effectively as a 10-minute scrub.21-23 In other studies, scrubbing for two or three minutes reduced bacterial counts to acceptable levels.24-26
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.27,28 Scrubbing with a disposable sponge or combination sponge-brush has reduced bacterial counts on the hands as effectively as scrubbing with a brush.29-31
In addition to hand hygiene, the CDC has recommended that HCWs wear gloves to: 1) reduce the risk of personnel acquiring infections from patients, 2) prevent health-care worker flora from being transmitted to patients, and 3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another. The effectiveness of gloves in preventing contamination of HCWs’ hands has been confirmed in several clinical studies and the Occupational Safety and Health Administration (OSHA) mandates that gloves be worn during all patient-care activities that may involve exposure to blood or body fluids that may be contaminated with blood.
Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the Healthcare Infection Control Practices, Advisory Committee and the HICPAC/SHEA/APIC/IDSA; http://www.cdc.gov/handhygiene/
1. Labarraque AG. Instructions and observations regarding the use of the chlorides of soda and lime. Porter J, ed. [French] New Haven, CT: Baldwin and Treadway, 1829.
2. Semmelweis I. Etiology, concept, and prophylaxis of childbed fever. Carter KC, ed. 1st ed. Madison, WI: The University of Wisconsin Press, 1983.
3. Steere AC, Mallison GF. Handwashing practices for the prevention of nosocomial infections. Ann Intern Med 1975;83:683–90.
4. Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231–43.
5. Larson E. Guideline for use of topical antimicrobial agents. Am J Infect Control 1988;16:253–66.
6. Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251–69.
7. Hospital Infection Control Practices Advisory Committee (HICPAC). Recommendations for preventing the spread of vancomycin resistance. Infect Control Hosp Epidemiol 1995;16:105–13.
8. Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:53–80.
9. Pittet D, Mourouga P, Perneger TV, Members of the Infection Control Program. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126–30.
10. Boyce JM. It is time for action: improving hand hygiene in hospitals. Ann Intern Med 1999;130:153–155.
11. Price PB. Bacteriology of normal skin: a new quantitative test applied to a study of the bacterial flora and the disinfectant action of mechanical cleansing. J Infect Dis 1938;63:301–18.
12. Sprunt K, Redman W, Leidy G. Antibacterial effectiveness of routine hand washing. Pediatrics 1973;52:264–71.
13. Food and Drug Administration. Tentative final monograph for healthcare antiseptic drug products; proposed rule. Federal Register 1994;59:31441–52.
14. Price PB. Ethyl alcohol as a germicide. Arch Surg 1939;38:528–42.
15. Pohle WD, Stuart LS. The germicidal action of cleaning agents- a study of a modification of Price’s procedure. J Infect Dis 1940;67:275–81.
16. Pillsbury DM, Livingood CS, Nichols AC. Bacterial flora of the normal skin: report on the effect of various ointment and solutions, with comments on the clinical significance of this study. Arch Dermatol 1942;45:61–80.
17. Mbithi JN, Springthorpe VS, Sattar SA. Comparative in vivo efficiencies of hand-washing agents against hepatitis A virus (HM-175) and poliovirus type 1 (Sabin). Appl Environ Microbiol 1993;59:3463–9.
18. Boyce JM, Potter-Bynoe G, Opal SM, Dziobek L, Medeiros AA. A common-source outbreak of Staphylococcus epidermidis infections among patients undergoing cardiac surgery. J Infect Dis 1990;161: 493–9.
19. Dewar NE, Gravens DL. Effectiveness of septisol antiseptic foam as a surgical scrub agent. Appl Microbiol 1973;26:544–9
20. Widmer AF. Replace hand washing with use of a waterless alcohol hand rub? Clin Infect Dis 2000;31:136–43.
21. Dineen P. An evaluation of the duration of the surgical scrub. Surg Gynecol Obstet 1969;129:1181–4.
22. O’Farrell DA, Kenny G, O’Sullivan M, Nicholson P, Stephens M, Hone R. Evaluation of the optimal hand-scrub duration prior to total hip arthroplasty. J Hosp Infect 1994;26:93–8.
23. Galle PC, Homesley HD, Rhyne AL. Reassessment of the surgical scrub. Surg Gynecol Obstet 1978;147:215–8.
24. Lowbury EJL, Lilly HA. Disinfection of the hands of surgeons and nurses. Br Med J 1960;1:5184
25. O’Shaughnessy M, O’Malley VP, Corbett G, Given HF. Optimum duration of surgical scrub-time [Short note]. Br J Surg 1991;78:685–6.
26. Wheelock SM, Lookinland S. Effect of surgical hand scrub time on subsequent bacterial growth. AORN J 1997;65:1087–98.
27. Kikuchi-Numagami K, Saishu T, Fukaya M, Kanazawa E, Tagami H. Irritancy of scrubbing up for surgery with or without a brush. Acta Derm Venereol 1999;79:230–2.
28. Meers PD, Yeo GA. Shedding of bacteria and skin squames after handwashing. J Hyg (Lond) 1978;81:99–105.
29. Dineen P. The use of a polyurethane sponge in surgical scrubbing.Surg Gynecol Obstet 1966;123:595–8.
30. Bornside GH, Crowder VH Jr, Cohn I Jr. A bacteriological evaluation of surgical scrubbing with disposable iodophor-soap impregnated polyurethane scrub sponges. Surgery 1968;64:743–51.
31. McBride ME, Duncan WC, Knox JM. An evaluation of surgical scrub brushes. Surg Gynecol Obstet 1973;137:934–6.
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