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HAND HYGIENE
Dr. Waleed EldarsMedical Microbiology and Immunology
Department
Microbiology Diagnostics and Infection Control Unit
Faculty of Medicine
Mansoura University
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• Definitions
• Hand-borne Microorganisms.
• Types of Hand Hygiene
• Hand Hygiene Techniques
• Recommendations for surgical hand preparation
• Selection and Handling ofHand Hygiene Agents
• Other aspects of hand Hygiene.
• Summary.MDICU
Introduction
• Hand Hygiene: a general term that
applies to either hand washing,
antiseptic hand wash, antiseptic hand
rub, or surgical hand antisepsis.
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• Hand washing: Washing hands with plain or antimicrobial soap and water.
• Hand cleaning: Action of performing hand hygiene for the purpose of physically or mechanically removing dirt, organic material or microorganisms.
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• Hygienic hand antisepsis: Treatment
of hands with either an antiseptic hand
rub or antiseptic hand wash to reduce
the microbial flora.
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Transmission of Pathogens on Hands
• Transmission from patient to patient via HCW hands requires four elements:
– Organisms on HCWs hands (via patient or environment).
– Organisms must survive for several minutes on hands.
– Hand hygiene must be inadequate or agent inappropriate.
– Contaminated hands of HCW must come in contact with another patient (or an inanimate object that will contact patient).
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Hand-borne Microorganisms
• Presence – bacterial counts on hands range from 104 to 106 CFU/cm2.
– Resident microorganisms:attached to deeper layers of the skin and are more resistant to removal;
– less likely to be associated with HAIs.
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– Transient microorganisms: colonize
the superficial layers of skin and
amenable to removable; acquired by
direct contact with patients or
contaminated environment surfaces;
frequently associated with HAIs.
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• Pittet and colleagues studied
contamination of HCWs’ hands before
and after direct patient contact, wound
care, intravascular catheter care,
respiratory tract care or handling
patient secretions.
• Using agar fingertip impression plates,
they found that the number of bacteria
recovered from fingertips ranged from
0 to 300 CFU.
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• Direct patient contact and respiratory
tract care were most likely to
contaminate the fingers of caregivers.
Gram-negative bacilli accounted
for15% of isolates and S. aureus for
11%.• Pittet D et al. Bacterial contamination of the hands of hospital staff
during routine patient care. Archives of Internal Medicine, 1999,
159:821–826.
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• Several other studies have documented that HCWs can contaminate their hands or gloves with Gram-negative bacilli, S. aureus, enterococci or C. difficile by performing “clean procedures” or touching intact areas of skin of hospitalized patients.
• Duckro AN et al. Archives of Internal Medicine, 2005, 165:302–307.
• Lucet JC et al. Journal of Hospital Infection, 2002, 50:276–280.
• McBryde ES et al. Journal of Hospital Infection, 2004, 58:104–108.
• Riggs MM et al. Clinical Infectious Diseases, 2007, 45:992–998.
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• Bhalla and colleagues studied patients
with skin colonization by S. aureus (including MRSA) and found that the
organism was frequently transferred to
the hands of HCWs who touched both
the skin of patients and surrounding
environmental surfaces.• Bhalla A, Aron DC, Donskey CJ. Staphylococcus aureus intestinal
colonization is associated with increased frequency of S. aureus on skin of
hospitalized patients. BMC Infectious Diseases, 2007, 7:105.
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• Hayden and colleagues found that HCWs seldom enter patient rooms without touching the environment, and that 52% of HCWs whose hands were free of VRE upon entering rooms contaminated their hands or gloves with VRE after touching the environment without touching the patient.
• Hayden MK et al. Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant enterococcus or the colonized patientsenvironment. Infection Control and Hospital Epidemiology, 2008, 29:149–154.
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Pittet D et al. Evidence-based model for hand transmission during
patient care and the role of improved practices. Lancet Infectious Diseases, 2006, 6:641–652.
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Pittet D et al. Evidence-based model for hand transmission during
patient care and the role of improved practices. Lancet Infectious Diseases, 2006, 6:641–652.
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Pittet D et al. Evidence-based model for hand transmission during
patient care and the role of improved practices. Lancet Infectious Diseases, 2006, 6:641–652.
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Pittet D et al. Evidence-based model for hand transmission during
patient care and the role of improved practices. Lancet Infectious Diseases, 2006, 6:641–652.
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Pittet D et al. Evidence-based model for hand transmission during
patient care and the role of improved practices. Lancet Infectious Diseases, 2006, 6:641–652.
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HAND HYGIENE
• Recommendations
– IA-strongly recommended for implementation and strongly supported by experimental, clinical or epidemiological studies
– IB- strongly recommended for implementation and supported by some experimental, clinical or epidemiological studies
– IC-required for implementation, as mandated by federal and/or state regulation
– II-suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale.
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Indications for Hand washing and
Hand Antisepsis
A. Wash hands with soap and water when:
• Visibly dirty or contaminated with
proteinaceous material,
• or visibly soiled with blood or other body
fluids,
• or if exposure to potential spore-forming
organisms is strongly suspected or proven
(IB)
• or after using the restroom (II).
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B. Preferably use an alcohol-based hand
rub for routine hand antisepsis in all
other clinical situations described in
items C1 to C6 listed below if hands
are not visibly soiled (IA). Alternatively,
wash hands with soap and water (IB).
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C. Perform hand hygiene:
1) Before and after having direct
contact with patients (IB);
2) After removing gloves (IB);
3) Before handling an invasive device
(regardless of whether or not gloves
are used) for patient care (IB);
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4) After contact with body fluids or
excretions, mucous membranes,
non-intact skin, or wound dressings
(IA);
5) If moving from a contaminated body
site to a clean body site during
patient care (IB);
6) After contact with inanimate objects
(including medical equipment) in the
immediate vicinity of the patient (IB);
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Sax H, et al. 'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene J Hosp Infect 2007; 67(1): 9–21
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D. Wash hands with either plain or
antimicrobial soap and water or rub
hands with an alcohol-based
formulation before handling
medication and preparing food (IB).
E. When alcohol-based hand rub is
already used, do not use antimicrobial
soap concomitantly (II).
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Types of Hand Hygiene
Residual
effect
Speed of
anti-
microbial
action
Agents
Influenc
e on
hand
flora
Main
purposeTechnique
ShortSlowPlain non-
antimicrobial
soap
Partly
removes
transient
flora
Cleansing
after patient
contact &
contaminatio
n
Routine
Hand
wash
Can be
sustained
for agents
such as
Chlorhexidi
n; less so
for alcohol
and
iodophors
Fastest
for
alcohol
Chlorhexidin
Hexa-
chloraphen
Iodine;Iodoph
oo-meta-
xylenol
-Alcohol-
based
waterless
antiseptic
Kills
transient
and
reduces
resident
flora
Hand
antisepsis
prior to
invasive
procedures,
or to
remove
pathogens
(e.g.,
antimicrobi
al resistant
strains).
Antiseptic
Hand
wash or
alcohol-
based
handrub
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Residual
effect
Speed
of anti-
microbi
al
action
Agents
Influence
on hand
flora
Main purposeTechnique
Can be
sustained for
agents such
as
Chlorhexidin
e; less so for
alcohol and
iodophors
Varies
by type
of agent
Fastest
for
alcohol
-Chlorhexidine
Hexachloraphen
e ,
Iodine;Iodophors;
Para-chloro-
meta-xylenol
(PCMX
-Alcohol-
based.waterless
antiseptic.
-after washing
hands by soap
and water.
Kills
transient
flora and
reduces
resident
flora
Preoperative
antisepsis
Surgical
Hand anti-
sepsis
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Hand Hygiene Technique
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• Make sure hands are dry. Use a method
that does not re-contaminate hands.
Make sure towels are not used multiple
times or by multiple people (IB).
• Avoid using hot water, as repeated
exposure to hot water may increase the
risk of dermatitis (IB).
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• Liquid, bar, leaflet or powdered forms
of plain soap are acceptable when
washing hands with a non-
antimicrobial soap and water.
• When bar soap is used, small bars of
soap in racks that facilitate drainage
should be used (II).
Hand Hygiene Technique with Alcohol-
Based Formulation
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Recommendations For Surgical Hand
Preparation
A. If hands are visibly soiled, wash hands with a plain soap before surgical hand preparation (II). Remove debris from underneath fingernails using a nail cleaner, preferably under running water (II).
B. Sinks should be designed to decrease the risk of splashes (II).
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C. Remove rings, watches, and
bracelets before beginning surgical
hand preparation (II). Artificial nails
are prohibited (IB).
D. Surgical hand antisepsis should be
performed using either an
antimicrobial soap or an alcohol-
based hand rub, preferably with
sustained activity, before donning
sterile gloves (IB).
E. If quality of water is not assured in the
operating theatre, surgical hand
antisepsis using an alcohol-based
hand rub is recommended before
donning sterile gloves when
performing surgical procedures (II).
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F. When performing surgical hand
antisepsis using an antimicrobial soap,
scrub hands and forearms for the
length of time recommended by the
manufacturer, 2 to 5 min. Long scrub
times (e.g. 10 min) are not necessary
(IB).
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G. When using an alcohol-based
product, use sufficient product to keep
hands and forearms wet with the hand
rub throughout the procedure (IB).
H. Do not combine surgical hand scrub
and surgical hand rub with alcohol-
based products sequentially (II).
Protocol for surgical scrub with a medicated
soap
Surgical hand preparation technique with an
alcohol-based handrub formulation
Selection and Handling of
Hand Hygiene Agents
• Provide health-care workers with efficacious hand hygiene products that have low irritancy potential (IB).
• To maximize acceptance of hand hygiene products by health-care workers, solicit their input regarding the feel, fragrance, and skin tolerance of any products under consideration. In some settings, cost may be a primary factor (IB).
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• If bar soap is used, small bars (that can
be changed frequently) are preferred.
– Soap should have drainage and should be
kept on racks.
– Liquid soap containers should be cleaned
when empty and refilled with fresh soap;
liquids should not be added to a partially
full dispenser;
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Drying Hands
A variety of methods are used for drying hands:
• Paper towels are the best method to dry hands.
• Cloth towels could be used if appropriately recycled.
• Warm air dryers shorten the time for hands to dry, however, they can only be used by one person at a time and are noisy and have the evidence of infection.
• Hand-drying materials should be placed near the sink in an area that will not become contaminated by splashing.
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Other aspects of hand hygiene
• Do not wear artificial fingernails or
extenders when having direct contact
with patients (IA).
• Keep natural nails short (tips less than
0.5 cm long) (II).
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SUMMARY
• Hand-borne Microorganisms.
• Types of Hand Hygiene and hand
Hygiene Technique
• Recommendations for surgical hand
preparation
• How to select hand hygiene agents.
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Biblography
• CDC: Guideline for Hand Hygiene in Health-Care Settings. MMWR (2002),51:RR-16.
• WHO Guidelines on Hand Hygiene in Health Care (2009)
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