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The Art and Science of Handwashing
Handwashing
80% of common infections spread by hands
Most effective way of preventing the spread
of respiratory tract infections
Handwashing
1822 - Labarraque – French pharmacist
chloride solutions
published paper in 1825
1843 - Oliver Wendell Holmes
decrease in puerperal fever
1846 - Ignaz Semmelweis
chlorine/nail brush
reduced deaths in obstetric wards
20% 1%
Improved Patient Outcomes Associated with Proper Hand
Hygiene
Ignaz Philipp Semmelweis
(1818-65)
Chlorinated lime hand antisepsis
Puerperal fever19th century physicians
miasmas – bad airSemmelweis
incontrovertible proofrefused to publish logic behind his theoryphysician practice did not change
Joseph Lister 20 years laterpublished in Lancet
Handwashing1975, 1985 CDC
Handwashing guidelines1988, 1995APIC
First to recommend alcohol based hand rubs1995,1996HICPAC
Antimicrobial soap/alcohol based agents2002HICPAC/SHEA/APIC/IDSA
Guidelines for Hand Hygiene in Health-Care
Health-Care Associated Infections
USA2 million infections/year 90,000 deaths $ 4.5 billion / year 1/3 preventable
Resident Flora
S. epidermidis / Micrococci / DiphtheroidsSurvive and multiply on skinThroughout skin layersCultured repeatedlyLow virulenceFingernails / crevices / hair follicles / sebaceous
glandsNot easily removed by scrubbing
Transient Flora
E. coli, Klebsiella, Streptococci, Pseudomonas +/- S. aureus
Usually survive less than 24 hours
Do not multiply
Can be easily removed by handwashing
How easy is it to transmit germs?
.
103 – 105 bacteria to hands
Touching patient shoulder
Measuring blood pressureDuckro AN et al. Arch Int Med 2005;165(3):302-7.
Rings:Trick et al,
CID 2003:36
10 fold higher median skin organism count
stepwise increase with number of rings worn
Gloves:
1) reduce transmission from patient to HCW
2) prevent transmission of HCW flora to patient
3) reduce transient contamination of HCW hands
Impact of Hand Hygiene on Hospital Infections
Year Author Setting Impact on Infection Rates
1977 Casewell adult ICU Klebsiella decreased1982 Maki adult ICU decreased 1984 Massanari adult ICU decreased 1990 Simmons adult ICU no effect1992 Doebbeling adult ICU decreased 1994 Webster NICU MRSA eliminated1995 Zafar nursery MRSA eliminated1999 Pittet hospital MRSA decreased
Source: Pittet D: Emerg Infect Dis 2001;7:234-240
General hospital hand hygiene campaign
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
1993 1994 1995 1996 1997 1998Year
new MRSA per 100
admissions
0
2
4
6
8
10
12
14
16
18
20
Nosocomial infections per
100 admissions
MRSA
Nosocomial infections
Pittet, Lancet 2000
Post-surgical acute care unit hand hygiene program
Pre-intervention
Post-intervention
Total infections per 100 patients 12.7 8.9
Total infections per 1000 pt-days 6.2 5.0
BSI per 1000 patient days 9.3 8.9
RTI per 1000 patient days 6.2 3.8
Swoboda Crit Care Med; 2004:32:358
Handwashing ComplianceIntensive Care Units
Profession% Handwashing
University Private
Physicians 28 14
Nurses 43 28
Respiratory therapists 76 48
Radiology technicians 44 25
Albert RK, Condie F. NEJM 1981;304(24):1465-6
Lack of knowledge
Nursing students at some schools in Ontario:• no classroom training in infection
prevention
SARS outbreak:• fewer than 60% of quarantined HCWs
accurately identified why they were being quarantined
How Dirty Are Things?
University of Arizona study:
TucsonChicago
San FranciscoTampa
Location Contamination (%)
Playground 44
Bus Rails 35
Public Restrooms 25
Pens (shared) 16
Vending Machines 14
Public phones* 13
*home phones more contaminated
How easy is it to transmit germs?
10 million E. coli 0157.H7
Patting contaminated ground beefWachtel MR et al. J Food Prot 2003;66(7):1176-83.
103 – 105 bacteria to hands
Touching patient shoulder
Measuring blood pressureHayden MK et al. ICCAC 2001, abstract K-1334
American Society for MicrobiologySurvey and Observational Study
StudyYear
Say they wash*
Actually wash*
Women Men
20008,000 people
5 cities95% 75% 58%
20056,336 people
4 cities91% 90% 75%
NOTE: 2003 Post SARS @ Toronto Airport – 96% actually washed
*After using public washroom
Travellers
Percent who did NOT wash hands
JFK NYC – 29%
San Francisco – 26%
Chicago – 26%
Miami – 26%
Dallas Forth Worth -19%
Toronto – 4%
School
22 million school days lost annually to common cold (CDC 1996)
Am J Infect Control 2000school with handwashing policy
2.42 days missed/student/year
school not using proper hand hygiene
3.02 days missed/student/year
Hand hygiene products
Regular soap
Antibacterial x
Antiseptic
Alcohol based
Hand hygiene products
ProductAntimicrobial
ActivitySustained Activity
Potential for Resistance
Skin Shedding
Soap + none none +++
Antibacterial* Intermittent ++ ++ ++ ++
Continuous +++ +++ +++ +++
Alcohol +++ none none +
Adapted from CID 1999;29:1287-94
* triclosan, hexachlorophene, chlorhexidine gluconate
Antibacterial soaps
Not needed in the community
Not needed routinely in hospital
Promote antibacterial resistance
Antibacterial soaps
Levy S
S. aureus resistance to triclosan
Schweizer et al AAC. 2001,45:428-432
exposure of P. aeruginosa to Triclosan MIC to tetracycline, erythromycin 500X MIC to ciprofloxacin 94X
Triclosan: mechanism of action
Triclosan:
Inhibits fatty acid synthesis (fab I gene)
Target = enoyl reductase
E. coli mutants easily selected with exposure
S. pneumoniae, Enterococcus, lack fab I and are not
susceptible
Yazhankhah SP, et al. Microb Drug Resist 2006;12(2):83-90.
Triclosan and antibiotic resistance
Resistance to triclosan:Mutation in fab I gene
• fab I potential site for development of new antibiotics
Activation / upregulation of efflux pumps • Multi-drug efflux = cross resistance
Other resistance mechanisms not well understoodCo-resistance to other antibiotics
Thorrold CA, et al.Int J Food Microbiol 2007;113(3):315-20. Seaman PF, et al. J Antimicrob Chemother 2007;59(1):43-50.
Akimitsu et al.
Antimicrob Agents Chemother 1999;43:3042-3
Methicillin Resistant S. aureus (MRSA):
Link:
antimicrobial soap and community acquired MRSA
Antibacterial Household Products: Cause for Concern
Stuart B. LevyEmerging Infectious Diseases, 2001;7(3):512-515
Antimicrobial Resistance
Allergy Link
Cause for Concern
Allergy Link• Too much hygiene and increased allergy
children on farms < allergies than children in citiesBraun-Fahrlander. Clin Exp Allergy 1999;29:28-34
• Excessive hygiene may interfere with immune system maturation of T helper cells
• eliminate stimulation from commensal microflora• immune system not confronted with enough antigens
Folkerts et al. Immunol Today 2000;21:118-20
Antibacterial products
> 700 different products
toothbrushes
plastic containers/chopsticks
sheets, towels, beds
window cleaner
No demonstrated health benefit in the household
BacteriaGood or Bad Germs?
60% of earth biomass
2-3 billion microbial species
< 0.5% have been identified
Preceded plants / animals
> 3 billion years
Essential to life
Both internal / external environments
Antibacterial soaps
Not needed in the community
Not needed routinely in hospital
No enhanced activity against viruses, fungi
Promote antibacterial resistance
Antiseptic soaps
Not needed in the community for general hand hygiene
Have a role in hospital setting
May promote antibacterial resistance
Alcohol Based Waterless Agents
Advantages - no water required- fast to use Voss, Widmer. Infect Control Hosp Epidemiol 1997
- less drying time- less skin shedding Meers, Yeo. J Hyg 1978 - broad spectrum efficacy
kill bacteria (fungi, viruses
- do not promote resistance
Alcohol Based Waterless Agents
Disadvantages:
not effective in presence of organic material will kill resident flora
SHOULD NOT REPLACE SOAP AND WATERSHOULD NOT REPLACE SOAP AND WATER
When to Wash Hands
Before eating or preparing food
After using the toilet or helping a child use the toilet
Before and after diapering
After handling shared objects such as toys
After wiping your nose or helping a child wipe
his / her nose
Handwashing
Not long enough
average 9.5 seconds need 15-20 seconds
Use soap and water
(water alone does not get rid of germs)
Rub hands together for 20 seconds
Sing Twinkle, Twinkle Little Star Song
Rinse for 10 seconds
Dry with a towel
How to Wash Hands
Hand Drying
Removes 42% more germs than washing alone
Use towels and avoid sharing towels
Hot air dryers promote bacterial growth because hands are left warm and moist
Does Handwashing Work?
Ryan M. Health Naval Research Center, San Diego
Recruits ordered to wash hands at least 5 times /day
45% reduction in respiratory illness
Ryan MA et al. Am J Prev Med 2001;21(2):79-83
Lee M. Canadian Journal of Infection, Toronto
Nurses - at least 7 handwashing episodes/day
Decreased number of enteric / respiratory infections
Lee MB. Can J Infect Control 2000;19:89-91
Effect of Antibacterial Home Cleaning and Handwashing Products on Infectious Diseases
Larson et al Annals of Internal Medicine 2004
Randomized double blind clinical trial 238 inner city homes with at least 1 preschool aged child - NY
Conclusion
Antibacterial products did not reduce the risk for symptoms of viral infectious diseases in households of healthy people
fever/sore throat/runny nose/vomiting/diarrhea
The Effect of Hand Hygiene on Illness Rate Among Students in University Residence
HallsAJIC 2003;31:364-70
College dorms randomized :
Alcohol hand rubs in various locations vs. not.
Alcohol hand rub groups: 14.8% -39.9% reduction in respiratory illness
symptoms 43% fewer sick days
Effect of Handwashing on Child Health: A Randomised Controlled Trial
Squatter settlements in Karachi
50% reduction in pneumonia
53% reduction in diarrhea
34% reduction in impetigo
No difference between plain soap and antibacterial soap
Lancet 2005;366:225-233
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