Classification of Hand Hygiene Hand Hygiene SHEA-ESGNI Course in Hospital Epidemiology Hand hygiene

Hygienic hand wash or rub

Hand wash with unmedicated soap

Hand wash with medicated soap (hand antisepsis)

Andreas F. Widmer, MD,MS Professor of Medicine & Infectious Diseases University of Basel Hospitals & Clinics Basel, Switzerland

Hand rub (waterless alcoholic compound)

Surgical scrub

Surgical scrub with medicated soap

Surgical hand rub (waterless alcoholic compound)

Widmer AF. Clin Infect Dis 2000:31:136-143 Trampuz A & Widmer AF. Mayo Clin.Proc. 2004;79 (1):109-116

Classification of Hand Hygiene • Transient Flora Microbial uptake from the environment or patient contact

Elimination of transient flora - Hygienic hand disinfection (handrub) or - Hygienic handwashing • Resident flora Microorganisms permanently colonizing the skin

1.Hygienic Hand Hygiene 2.Surgical Hand Hygiene

Elimination of transient flora and Reduction of resident flora Effective against regrowth - Surgical handrub or - Surgical handwashing Widmer AF. Clin Infect Dis 2000:31:136-143 Trampuz A & Widmer AF. Mayo Clin.Proc. 2004;79 (1):109-116

Semmelweis: The father of Handwashing ?

•

•

Oct 1847, a patient with uterus carcinoma was admitted. After examination of this patient, physician examined women in labor. During this time, 15% of the women in labor died in Hospital A (physicians and medical studients) compared to less than 3% (Midwifes) in Hospital B (Vienna-Lying). The introduction of handwashing reduced the mortality in Hospital A to rates similar as in Hospital B

Maternal Mortality (%)

Ref. Die Aetiologie , der Begriff und die Prophylaxe des Kindbettfieber Ignaz Semmelweis. Hartleben’s Verlags-Expedition 1861 page 59

18 41 18 42 18 43 18 44 18 45 18 46

•

0 2 4 6 8 10 12 14 16 18

Maternal mortality rates, First and Second Obstetrics Clinics, GENERAL HOSPITAL OF VIENNA, 1841-1846

Semmelweis IP, 1861

First Second

0 2 4 6 8 10 12 14 16 18

Chlor calcii Aqua fontana

May 15, 1847

unc 1 ad duas libras

First Second

50

18

49

48

18

18

46

47

18

45

18

18

43

44

18

18

41

Æ 4 % chlorinated lime wash until hands get slippery

18

18

Semelweiss' original formula for chlorinated lime

Intervention

42

M aternal M ortality

Maternal mortality rates, First and Second Obstetrics Clinics, GENERAL HOSPITAL OF VIENNA, 1841-1850

Rotter M 1994

Semmelweis IP, 1861

Efficacy of 4 % chlorinated lime (Semmelweiss) according to EN 1500

Semmelweis: The Father of Handwashing? •

7 6.82 ± 0.2

6

• 5

• 4

3.7 ± 0.6 Soap

Log Killing 3.1

1.5 ± 0.8 Alcohol

5.3

3 2 1

Method: CL: 4 min. immersion Alcohol: CEN Soap: 1 min. each hand

before

0.6 ± 0.5 Chlorinate Lime Semmelweiss

after

Oct 1847, a patient with uterus carcinoma was admitted. After examination of this patient, physician examined women in labor. .....washed their hands with soap and water. 11/12 women in labor died. Introduction of Hand Disinfection with chlorinated lime eliminated epidemic cases of puerperal fever

Wrong! Semmelweis is father of hand disinfection

6.2

Rotter ML, HIS London 1994, abstract F4/2

Includes activity against spores: C.difficile & B. anthracis

Antibacterial Activity Against Transient Flora

Handwashing (bar soap)

S. aureus P. aeruginosa E. Coli

Mean log10 Reference Reduction 2.54 Lowbury 1964 2.2 Ayliffe 1978 2.5

Rotter 1975

Hand Disinfection (Isopropanol) Mean log10 Reference Reduction 3.7 Ayliffe 1978 3.9 Rotter 1980 4.9

Rotter 1977

Handwashing (medicated soap) Povidone Iodine 0.75%

3.5

Rotter 1991

Chlorhexidine 4%

3.1

Rotter 1991

60% Isopropanol is significantly more active against bacteria than any medicated soap. Idea by J Boyce

Log Killing of Viruses

Antiviral Activity Against Transient Flora

Polio Virus Type I (Sabin Strain)

Rotavirus mean log10 reduction Chlorhexidine gluconate 4%

0.459

Liquid soap

1.17

PVP-Iodine

1.28

Water

1.34

Ethanol 70%

2.85

Isopropanol 70%

3.14

Water: Soap: PVP Iodine 10% Ethanol 80% Isopropanol Ethanol > 99%

1.0 1.1 1.4 2.2 2.4 3.2

Problem: Standardization Steimann J. Hyg Med 1990;15:7-14 Bellamye et al. J Hosp Infect 1993;24:201-70 handdis99

Antibacterial efficacy of 4% CHX and 1% triclosan handwash products in an acute clinical ward

handdis99

Comparison Handwashing vs Hand Disinfection

n=47

Methods: 30s standardized handwash 30 sec Setting: 30 bed vascular unit (900 bed tertiary care center, Australia)

Recovery of MRSA

ND: Triclosan HD: Chlorhexidine

Recovery of gram-neg.rods

J. L. Faoagali JL Am.J.Infect Control 1999;27 (4):320-326.

Handwashing

Handdisinfection

Prevention of transmission of nosocomial pathogens

++

++++

Microbial effectiveness

+

+++

Minimal time for procedure

+

+++

Side effects

+

+

Risk for Recontamination

yes

no

Towel after procedure

yes

no

Working during procedure

no

yes

Low cost (Sink, water supply, heating) Resources for infrastructure

+

+++

+

+++

Accessability

limited by sinks

unlimited

Flammability

no

+/Widmer AF. Clin Infect Dis 2000

Handwashing (HW) Opportunities in Teaching Hospitals per hour Opportunities for HW - Ward - ICU

20-40 opp/ hr care 43 opp/ hr care 20 opp/ hr care

/HCW Decrease of compliance by 5% per 10 opportunites per hour Correlation between workload and compliance Pittet D . Ann Intern Med 1999. 130:126-130.

Update:Time used for Handwashing vs Hand Disinfection (Geneva data)

Handwashing Versus Alcoholic Rub

Handwashing ICU beds (Nurse - bed ratio 1:1) Nurses per shift Working hrs per shift Opportunities for HW / hr Time committment for hand washing/contact Handwashing episodes /day/ICU Total time spent (min)ª

Hand Disinfection

12 3 8 20

12 3 8 20

2 minutes

0.5 minutes

5760 11520

5760 2880

Nursing hours total (12x24hrs)288 Nursing time lost/day (h)/ICU 192 (66%) ª ICU beds 12 nurses/shift 3 12x3x8x5x2 min (0.5 min)

working hours/shift patient contacts /h

² Nursing time lost/8h shift = 48/8 .

Voss A, Widmer AF. Infect Control Hosp Epidemiol 1997;18:205-208

288 48 (16%) 8 5

Widmer AF. Infection control and prevention strategies in the ICU. Intensive.Care.Med. 1994; 20 Suppl 4:S7-11. Pittet D . Ann Intern Med 1999. 130:126-130.

handwash

EN 1500

Hand hygiene: From Ritual to Evidence-based Medicine # Volunteers Reference

• •

Why hand hygiene ? Hand washing vs Hand disinfection (alcoholic hand-rub)

Test microbes

– Antimicrobial efficacy – Time time time

• • • • •

Determination of residual activity Pass if

European requirements / European Norms Impact of hand-rub technique Impact of training Compliance >25 years after introduction of the alcoholic-hand rub Alcoholic-hand rubs in special situations

Test statistics Significance level (unidirectional) Critical difference between P and R test power

– Norovirus – Anthrax

• •

Side Effects of Alcoholic hand-rubs Fire hazard

EN 1499

EN 12054 EN 12791

Hygienic Handrub

Hygienic Handwash

12-15 propan-2-ol 60 %(v/v) rubbed in for 60 s E. coli NCTC 10538 (artificial contamin.)

12-15 unmedicated liquid soap, 60 s wash E. coli NCTC 10538 (artificial contamin.)

Surgical Hand Disinfection 18-21 propan-1-ol 60 % (v/v) rubbed in for 3 min resident hand flora (mainly CNS)

no Killing of P not < R

no Killing of P>R

yes (3 hrs) Killing of P not < R

Wilcoxon matched-pairs signed-ranks test for evaluation of one P; Steel and Rhyne (k 1) sign-test for Latin square test designs 0.1

0.01

0.1

0.6 log 95%

0.5 log 80-90%

0.8-0.9 log 80-90%

P: Product tested R: Reference (60% v/v Isopropanol) handdis

Hygienic Hand Rub

Hand hygiene: From Ritual to Evidence-based Medicine • •

Why hand hygiene ? Hand washing vs Hand disinfection (alcoholic hand-rub) – Antimicrobial efficacy – Time time time

Leader: D.Pittet

• • • • •

European requirements / European Norms Impact of hand-rub technique Impact of training Compliance >25 years after introduction of the alcoholic-hand rub Alcoholic-hand rubs in special situations

• •

Side Effects of Alcoholic hand-rubs Fire hazard

Widmer AF.

Surgical Hand Hygiene in: WHO Guideline for Hand Hygiene Widmer AF. & Pittet D. J Hosp Infect 2008 Widmer AF. Infect Control Hosp Epidemiol 2004 Widmer AF. Infect Control Hosp Epidemiol 2007

– Norovirus – Anthrax

Areas Missed During Hand Disinfection

Recommended Standard Technique

Areas frequently missed

Appropriate Technique of Hand Hygiene with the Alcoholic Hand – Rub (EN 1500)

FINGERTIPS

Areas missed with disinfection

(%)

Dorsal sides:

Finger pulps Thumbs Palms Interdigital spaces

35% 12% 7% 3%

Palmar sides:

Thumbs First phalanges Dorsa of the hands Interdigital spaces

56% 33% 27% 13%

Buchrieser O.: Hyg Med 1996, Vol. 21, No. 12

handdis99

- Improved fluorescent nonstaining dye in commercial product, - no detectable inhibition with antimicrobial efficacy

Camera: - DV 3 CCD - XGA beamer

Patent™ AF Widmer Non-profit commercialized box made in Switzerland

Correlation between optical scores and antimicrobial killing (log CFU killing)

Hand hygiene: From Ritual to Evidence-based Medicine

Log10 CFU Reduction

I • •

2.5

Why hand hygiene ? Hand washing vs Hand disinfection (alcoholic hand-rub) – Antimicrobial efficacy – Time time time

2

R2=0.89

1.5 1 0.5

• • • • •

European requirements / European Norms Impact of hand-rub technique Impact of training Compliance >25 years after introduction of the alcoholic-hand rub Alcoholic-hand rubs in special situations

• •

Side Effects of Alcoholic hand-rubs Fire hazard

– Norovirus – Anthrax

0 5

4.5

4

3.5

3

2.5

2

1.5

1

0.5

0

Points by Optical Observation

Widmer AF. ICHE 2004;25:207

Does training really make a difference ? a prospective study in a single institution

Impact of Education on the Microbiological effectivenes of the alcoholic hand-rub •

Setting 400 bed geriatric hospital. No infection control in 2001

• • • • •

•

400 bed geriatric university affiliated hospital Contract for IC in 2000 183 HCWs All HCW completed a one hour training in 2001 after baseline testing was completed Complete data from the questionnaire, visualization test and microbiological results of 178 (97%) HCWs were available for analyses No side effect was observed

• •

N LOGREDF

Mean STD logCFU10

•

After education (2002)

before education (2001)

SEM

70

1,4749

,93923

,11226

108

2,1927

,86689

,08342

p.-value

p25 years after introduction of the alcoholic-hand rub Alcoholic-hand rubs in special situations – Norovirus – Anthrax

• •

Side Effects of Alcoholic hand-rubs Fire hazard

Compliance with Handwashing Adult hospitals

Unit

Compliance First Author

ICUs

41%

Albert RK

Ward/ICU

Source N Engl J Med 1981;304:1465-1466

32

Conly JM

Am J Infect Control 1989;17:330-339

Ward/ICU

21%

Anonymous

Hosp Infect Control 1989;16:100-101

ICU

30-48%

Doebbeling B

New Engl J Med 1992;327:88-93

SICU

38%

Wurtz R

Am J Infect Control 1994;22:228-300

all ICUs

32%

Meengs MR

Ann Emerg Med 1994;23:1307 1312

ICU

36%

Pittet D.

Ann Intern Medi 1999. 130:126-130.

Ward/ICU

48%

Pittet D.

Ann Intern Medi 1999. 130:126-130.

Implementation tools: Training and education

Compliance with hand hygiene 25 years after introduction of the alcoholic-hand rub Alcoholic-hand rubs in special situations

sterilant (high level disinfectant with prolonged exposure time) high level

Nonlipid or small viruses (e.g. poliovirus, coxsackievirus)

susceptible

Side Effects of Alcoholic hand-rubs Fire hazard

Disinfectant level

Mycobacteria (e.g. M. tuberculosis var. bovis, M.terrae)

– Norovirus – Anthrax

• •

Sterilization EN 554

Bacterial spores (e.g. C. perfr., B. stearothermophilus)

Why hand hygiene ? Hand washing vs Hand disinfection (alcoholic hand-rub) – Antimicrobial efficacy – Time time time

• • • • •

Autoclaving 134º/18m (?)

PRIONS

Fungi (e.g. Candida spp.)

intermediate level

Vegetative bacteria (e.g. S. aureus, P. aeruginosa, Salmonella spp.) Lipid or medium-size viruses (e.g. HSV, CMV, RSV, HIV, CV-urbanii)

low level

Widmer AF. in: Manual of Clinical Microbiology. American Society of Microbiology 2007

Log Killing of Viruses Polio Virus Type I (Sabin Strain)

Water: Soap: PVP Iodine 10% Ethanol 80% Isopropanol Ethanol > 99%

1.0 1.1 1.4 2.2 2.4 3.2

Steimann J. Hyg Med 1990;15:7-14

handdis99

Norovirus Epidemic UHBS 12/2002 n=132

Efficacy of Antiseptic Agents in Reducing Bacillus atrophaeus (Surrogate Anthrax) Spores

18 16

Intervention Hosp Epi C.difficile ? Lancet 2005; Strain 027

12 10 8

- Isolation of patients - Disinfection of floors active against Norovirus (oxygen-releasing agent) - use of an hand alcohol >95% ethanol

6 4 2 0 8.11 9.11 10.11 11.11 12.11 13.11 14.11 15.11 16.11 17.11 18.11 19.11 20.11 21.11 22.11 23.11 24.11 25.11 26.11 27.11 28.11 29.11 30.11 1.12 2.12 3.12 4.12 5.12 6.12 7.12 8.12 9.12 10.12 11.12 12.12 13.12 14.12 15.12 16.12 17.12 18.12 19.12 20.12 21.12 22.12 23.12 24.12 25.12 26.12 27.12 28.12 29.12 30.12 31.12

Anzahl Neuerkrankungen

14

Personal

Patienten

Khanna N & A. F. Widmer. J.Hosp.Infect. 55 (2):131-136, 2003.

30s 60s

Rutala W. JAMA. 2003;289:1274-1277

Recommendation: Wash hands with soap before entering the OR area

Hand hygiene: From Ritual to Evidence-based Medicine

Lack of Association Between the Increased Incidence of C.difficile–Associated Disease and the Increasing Use of Alcohol-Based Hand Rubs • •

Why hand hygiene ? Hand washing vs Hand disinfection (alcoholic hand-rub)

• • • • •

European requirements / European Norms Impact of hand-rub technique Impact of training Compliance >25 years after introduction of the alcoholic-hand rub Alcoholic-hand rubs in special situations

– Antimicrobial efficacy – Time time time

Use of alcohol hand rub by healthcare workers, in liters per 1,000 patient-days, per quarter, 2000-2003.

Number of patients with 1 or more tests positive for Clostridium difficile toxin per 1,000 patientdays, 2000-2003.

– Norovirus – Anthrax

• •

Bottles vs dispensers / Side Effects of Alcoholic hand-rubs Fire hazard

Boyce JM. Infect Control Hosp Epidemiol 2006;27:479-483

Installed Containers vs portable pocket bottles

• • • • • •

+ No Installation + Always at hand - Small volume - Loss of alcohol content without lid - Spills - Space in pocket

Side Effects of the alcoholic Hand Rub • Colorization of the skin • Dermatitis • Side effects on the floor by spills

34y dermatologist Compliance determined by measuring the level of discolorization of the fingernails reproducible Independently confirmed by on-site visit of a representative of the company

Probable problem: Patentblue

Damage to Alcohol-Non-resistant Floors as Surrogate Marker for Compliance BMT Unit

Hand hygiene: From Ritual to Evidence-based Medicine • •

Why hand hygiene ? Hand washing vs Hand disinfection (alcoholic hand-rub)

• • • • •

European requirements / European Norms Impact of hand-rub technique Impact of training Compliance >25 years after introduction of the alcoholic-hand rub Alcoholic-hand rubs in special situations

– Antimicrobial efficacy – Time time time

– Norovirus – Anthrax

• •

Danger ?: Flammable Alcohols and Fire Safety Flash Points

Ethanol Isopropanol n-Propanol

Side Effects of Alcoholic hand-rubs Fire hazard

Danger ?: Flammable alcohols Flash Points

12°C 13°C 15°C

Ethanol Isopropanol n-Propanol Commercial Products

12°C 13°C 15°C 21°C

Commercial Products 21°C Sterillium Virugard®

0°C

Sterillium ® Desdeman ® Skinman asept ®

21°C 26.5 °C 31°C

Widmer AF. Clin Infect Dis 2000:31:136-143 Rotter ML: Mayhall G. Hosp.Epidemiology and Infection control Mahler R. Personal communication

Log book of Security and Safety: 30 Hospitals 1975- 1999 > 5,000,000 Patients, and > 900,000 HCW years

Not a single accident associated or due to an alocholic hand disinfectant Widmer AF. Clin Infect Dis 2000:31:136-143 Trampuz & Widmer. Mayo Clin Proc 2004 handdis99

handdis99

Surgical hand antisepsis has

1.Hygienic Hand Hygiene 2.Surgical Hand Hygiene

never been proved, in a randomized controlled clinical trial, to be necessary or clinically effective. Rotter ML. Hand washing and hand disinfection in: Mayhall G. Hospital Epidemiology and Infection Control, 1996. Williams and Wilkins.

Reduction of Surgical Hand Antisepsis from 10 to 5 Minutes

History of Surgical Hand Antisepsis 1894 1939 "Rinse with solution"

1972

Medicated soap Alcoholic hand rub

1991 2000 0

3

6

9

12

• 41 orthopedic surgeons and nurses: Average OR > 90 min • Application of 4% chlorhexidine gluconate (Hibiscrub®) 5 or 10 minutes • Results (Log10 CFU Increase during surgery) – Group 5 min : 0.09 – Group10 min: 0.72 p>>>> US – on average , rinses more effective better than gels

•

Main factors to consider – Hygienic hand-rub vs surgical hand-rub (two- vs one product) – Special clinical situations where viruses are of major concern • • •

Norwalk epidemics BMT Pediatrics

– Special practical situation – Pocket bottles vs installed dispensers • Side effects: refatting agent for skin care

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