HYGIENEAND
HEALTHCAREASSOCIATED
INFECTIONS
III
HAND HYGIENE
MUDr. Bohdana Rezková, Ph.D.
Microflora of
the hand skin
Resident flora (resident microbiota) - under the superficial cells of
the stratum corneum and also found on the surface of the skin
(Staphylococcus epidermidis, Streptococci, S. hominis and other coagulasenegative
staphylococci, followed by coryneform bacteria - propionibacteria,
corynebacteria, dermobacteria, and micrococci ….).
 !!! Persistent colonization by pathogenic flora - S. aureus,
Gram-negative bacilli, or yeast.
Transient flora (transient microbiota) - colonize the superficial
layers of the skin and are more amenable to removal by routine
handwashing (Staphylococcus aureus, Proteus mirabilis, Klebsiella spp.,….).
 !!! Often acquired during direct contact with patients or
contaminated environmental surfaces adjacent to the patient.
Definitions
Hygienic handrub
 Treatment of hands with an alcohol-based handrub to reduce the
transient flora without necessarily affecting the resident skin flora.
Hygienic handwash
 Treatment of hands with a detergent and water to reduce the
transient flora without necessarily affecting the resident skin flora.
Surgical hand preparation
History
Studies by Ignaz Semmelweis inVienna in the mid-1800s:
 maternal mortality rates, mostly attributable to puerperal fever,
were substantially higher in one clinic compared with the other
(16% versus 7%),
 doctors and medical students often went directly to the delivery
suite after performing autopsies and had a disagreeable odour on
their hands despite handwashing with soap and water before
entering the clinic.
 His hypothesis: “cadaverous particles” were transmitted via the
hands of doctors and students from the autopsy room to the
delivery theatre and caused the puerperal fever.
 Semmelweis recommended that hands be scrubbed in a
chlorinated lime solution before every patient contact and
particularly after leaving the autopsy room.
 Following the implementation of this measure, the mortality rate
fell dramatically to 3%!!!
Transmission
of pathogenes
by hands
 diabetics, patients undergoing dialysis for chronic renal failure,
and those with chronic dermatitis – high S. aureus skin areas
colonization,
 patient gowns, bed linen, bedside furniture and other objects in
the immediate environment of the patient become contaminated
with patient flora.
 certain microorganisms can also play an important role in
environmental contamination due to their long-time survival
capacities (G+ - Acinetobacte baumanii,….)
NO jewellery!!!
 Several studies have shown that skin underneath rings is more
heavily colonized than comparable areas of skin on fingers without
rings.
 WHO: „The consensus recommendation is to strongly discourage the
wearing of rings or other jewellery during health care. If religious or
cultural influences strongly condition the HCW’s attitude, the
wearing of a simple wedding ring (band) during routine care may be
acceptable, but in high-risk settings, such as the operating theatre,
all rings or other jewellery should be removed.“
Fingernails??? Artificial fingernails
 WHO:„Consensus recommendations are that HCWs do not wear
artificial fingernails or extenders when having direct contact with
patients and natural nails should be kept short (0.5 cm long or
approximately ¼ inch long)“
Nail polish
 WHO: „Freshly applied nail polish does not increase the number of
bacteria recovered from periungual skin, but chipped nail polish may
support the growth of larger numbers of organisms on fingernails“.
Solutions
for
handrubbing
Aqueous solution
 the need of immersion of
hands
 dilution, stability
 the need od drying
 irritating
 colouring
 frequent use causes damage
of hand skin
Alcohol-based
disinfectant
 comfortable use
 application on dry hands
 quick drying
 content of protecting
substances
 parfumed
 availability at the point of
care (within arm’s reach)
 Risk: flammable
Alcohol
antiseptics
and their
efficacy
I
 contain either ethanol, isopropanol or n-propanol, or a
combination of two of these products,
 solutions containing 60–80% alcohol are most effective, with
higher concentrations being less potent,
 no activity against bacterial spores, and very poor activity
against some non-enveloped (non-lipophilic) viruses.
Alcohol
antiseptics
and their
efficacy
II
 non-enveloped viruses (hepatitisA and enteroviruses -poliovirus)
may require 70–80% alcohol to be reliably inactivated.
Centres for
deasease
control and
prevention
CDC
 https://www.youtube.com/watch?v=BaHTZdJWYVw
5th May
International
Hand Hygiene
Day
Handwashing
WHEN?
 Hands visibly dirty, contaminated with proteinaceous
material, or visibly soiled with blood or body fluids (also
before eating or after using the toilet!)
 The only method of decontamination of hands in
exposure of spore-forming pathogenes (e.g.,
Clostridium difficile).
 Use an alcohol-based handrub as the preferred
means for routine hand antisepsis in all other clinical
situations
How to
handwash
byWHO
 Wet hands with water and apply the amount of product necessary
to cover all surfaces.
 Rinse hands with water and dry thoroughly with a single-use
towel.
 Use clean, running water whenever possible.
 Avoid using hot water, as repeated exposure to hot water may
increase the risk of dermatitis.
The
technique
for
handwashing
Handrubbing
WHEN?
How to
handrub
byWHO
 Apply a palmful of alcohol-based handrub and cover all surfaces of
the hands. Rub hands until dry.
The
technique
for
handrubbing
Frequently
missed areas
(byCDC)
BBE
BBE = Bare Below the Elbows
(Initiative of SHEA, Special Report, Medscape Infectious Diseases, 2014)
 Preventive strategy to improve the effectiveness of hand hygiene.
 Hands and forearms are free of jewellery and sleeves are above
the elbow.
 Long sleeves have been found to be contaminated with pathogens
MRSA) , and can impede appropriate hand hygiene.
Rules for use of
gloves!!!
1. Handwashing or handrubbing must be performed before
donning gloves to prevent glove contamination and possible
cross-transmission in case of glove damage or improper
use/efficacy.
2. Gloves must be removed to perform handwashing or
handrubbing to protect a body site from the flora from another
body site or skin area previously touched within the same
patient.
3. Hand hygiene must be performed immediately after glove
removal to prevent HCW contamination and further
transmission and dissemination of microorganisms.