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This review describes Semmelweis' achievement 150 years ago. User acceptability of hand disinfectants has been improved, but Semmelweis' observation that handwashing, in contrast to hygienic hand disinfection, is not always sufficiently effective, is not yet generally acknowledged, and the compliance of medical personnel to the rules of hand hygiene still remains an educational problem to be solved.
Antimicrobial-drug resistance in hospitals is driven by failures of hospital hygiene, selective pressures created by overuse of antibiotics, and mobile genetic elements that can encode bacterial resistance mechanisms. Attention to hand hygiene is constrained by the time it takes to wash hands and by the adverse effects of repeated handwashing on the skin. Alcohol-based hand rubs can overcome the time problem and actually improve skin condition. Universal glove use could close gaps left by incomplete adherence to hand hygiene. Various interventions have been described to improve antibiotic use. The most effective have been programs restricting use of antibiotics and computer-based order forms for health providers.
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A literature review on the use of alcohol-based handrubs highlighted many variations in the terms used to describe the activities related to effective hand hygiene. This suggests that an individual's interpretation of the terms used to describe hand-hygiene activities may lead to a variation in compliance with any protocol or guideline employing them. This article describes an audit that was undertaken to establish whether the definition of the terms handwashing, hygienic handwashing and hygienic handrub varied between grades of staff and disciplines who have direct contact with patients. The aim was to identify different healthcare professionals' understanding of the terms used to describe hand-cleansing activities. The results indicate that a variation in understanding of these terms did exist between these grades and disciplines. This may indicate that there is a need for the definition of the terms used to be clearly stated, consistent in their use and universally adopted.
Changes in undergraduate medical training mean that students have direct patient contact from an early stage of their training. This study aimed to assess the knowledge of third-year medical students at the University of Birmingham Medical School, UK on infection control policy and procedures. A semi-structured questionnaire was distributed to medical students. Out of 322 students, 156 returned completed questionnaires (48%). Results showed that 58% of medical students did not know the correct indications for using alcoholic hand gel, 35% did not know the correct use of gloves, and 50% did not know the exclusion period after an episode of diarrhoea and vomiting. Sixty-four percent of medical students reported formal teaching on hand hygiene, 12% reported informal teaching, 19% reported both types of teaching and 5% reported no hand hygiene teaching at all. Forty-nine percent of medical students thought that there was insufficient emphasis on infection control in their course. These results raised concerns about medical students' knowledge about infection control. The University is currently reviewing the need for a more structured model for the teaching and assessment of infection control.
OBJECTIVE: To evaluate the usefulness of a new alcohol sprayer by comparing it with an individual bottle of alcohol. Patterns of use and perceptions among healthcare personnel were compared for the two products. DESIGN: Observational study recording the volume of alcohol used and the compliance rate (frequency of hand antisepsis per number of opportunities), and a survey of healthcare workers' perceptions of the different hand hygiene strategies. SETTING: A 20-bed medical unit in a public hospital in Marseille, France. PARTICIPANTS: Healthcare workers of an infectious disease unit INTERVENTIONS: Hand hygiene alcohol systems (sprayer vs individual bottle, 70% ethyl alcohol). RESULTS: The sprayer was used more frequently than the individual bottle (12.6 vs 9.7 hand washes per day). With the sprayer system, compliance was 91% for physicians, 28% for nurses, and 8% for housekeeping personnel. Alcohol hand antisepsis was preferred to washing hands with soap and water in low-risk situations such as simple entrance into a room (91% vs 36%; P < 10(-6)) or simple contact with a patient (69% vs 40; P < .005). The sprayer system was considered easier to use (95%), more hygienic (90%), and faster (92%), with a better tolerance than the individual bottle. CONCLUSION: The new alcohol sprayer should improve rapid hand antisepsis.
Despite considerable awareness amongst the healthcare community about the importance of hand hygiene in controlling Healthcare Acquired Infections (HAIs), the problem persists. Mike Allen of Dart Valley Systems explores the issues surrounding good hand hygiene practice in UK hospitals.
The relationship between contamination of patients' hands and transmission of healthcare-associated infection has received only limited attention, but may represent a previously overlooked but potentially significant link in the chain of infection. This paper aims critically to review the literature to determine whether this possible epidemiological relationship is worthy of further consideration. Studies that have investigated the microbiology or hand hygiene behaviours of patients and other groups are examined to establish their limitations and implications for future practice and research. Examples of healthcare-associated infections where improving patient hand hygiene may have a favourable impact on transmission, and how this might be achieved within the context of current UK health service initiatives, are discussed. It is recommended that systematic studies of the role of patients' hands in the chain of hospital infection should be undertaken.
There are no studies about cost-effectiveness of hand hygiene in the literature. Instead of doing studies about cost-effectiveness, investigations on how to convince doctors and nurses that hand hygiene is absolutely necessary, should be performed. Disinfection by physical methods is more cost-effective than disinfection by chemicals.
The transmission dynamics of vancomycin-resistant enterococci (VRE) and factors contributing to their dissemination are complex. Mathematical modeling was used to simulate patterns of dissemination among patients and health care workers (HCWs) and to quantify the contribution of specific factors and infection control interventions on the endemic prevalence (EP) of VRE in a long-term hemodialysis unit. The model predicted that (1) an EP of 12% would be reached over time, regardless of the number of patients initially colonized, (2) endemicity would be sustained by the constant influx of newly colonized patients discharged from the hospital, (3) duration of VRE gastrointestinal colonization would have the most impact on the number of secondary cases, increasing the EP to a maximum of 70%, and (4) decreasing the patient:HCW ratio or improving hand hygiene would decrease the EP to 3%. Decreasing the duration of colonization, limiting hospital acquisition of VRE, and improving compliance with hand hygiene in the hemodialysis unit may decrease the rapidly rising rates of VRE in the patient population.
Three decades ago infection-control programmes were created to control antibiotic-resistant nosocomial infections, but numbers of these infections have continued to increase, leading many to question whether control is feasible. Meticillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci were major problems during the 1990s. Many hospitals have tried antibiotic control but with limited efficacy against these pathogens. Studies of antibiotic restriction, substitution, and cycling have been promising, but more definitive data are needed. Increased compliance with hand hygiene would help but is unlikely to control this problem alone as a result of frequent contamination of other surfaces even when hands are cleansed and high transmission rates when hand hygiene is neglected. For 17 years, the Centers for Disease Control and Prevention have recommended contact precautions for preventing nosocomial spread of important antibiotic-resistant pathogens. Many studies confirm that this approach works when sufficient active-surveillance cultures are undertaken to detect the reservoir for spread. However, most healthcare facilities have not yet tried this approach.
OBJECTIVE: To assess quantitatively the clinical impact of using an alcohol-based handrub (ABHR) in the hospital environment, measuring impact as the incidence of new, nosocomial isolates of drug-resistant organisms. DESIGN: An observational survey from 1998 to 2003 comparing the first 3 years of no ABHR use with the 3 years following, when an ABHR was provided for hand hygiene. SETTING: An inner-city, tertiary-care medical center. INTERVENTION: At baseline, an antimicrobial soap with 0.3% triclosan was provided for staff hand hygiene. The intervention was placement in all inpatient and all outpatient clinic rooms of wall-mounted dispensers of an ABHR with 62.5% ethyl alcohol. Data were collected on change in the incidence of three drug-resistant bacteria. RESULTS: During the 6 years of the survey, all new, nosocomially acquired isolates of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile-associated diarrhea were recorded. On comparison of the first 3 years with the final 3 years, there was a 21% decrease in new, nosocomially acquired MRSA (90 to 71 isolates per year; P = .01) and a 41% decrease in VRE (41 to 24 isolates per year; P < .001). The incidence of new isolates of C. difficile was essentially unchanged. CONCLUSION: In the 3 years following implementation of an ABHR, this hospital experienced the value of reductions in the incidence of nosocomially acquired drug-resistant bacteria. These reductions provide clinical validation of the recent CDC recommendation that ABHRs be the primary choice for hand decontamination.
In the last week of May 2005, staff at Mahatma Gandhi Memorial Hospital in KwaZulu-Natal realised that many babies in the high-care nursery ward had bloodstream infections involving Klebsiella pneumoniae bacteria. Attempts to identify a common source of infection failed. The ward was therefore closed and new babies needing high care were admitted to another empty ward. Despite this, babies still became infected. This resulted in a request for assistance from the Department of Medical Microbiology of the Nelson R Mandela School of Medicine. A search for common factors through case history studies of the 26 infected babies showed that blood cultures of the babies remained positive despite the administration of appropriate antibiotics. Different options that could explain this were investigated. The organism was found in intravenous glucose preparations used for multiple dosing. Unopened vials of the same medication were sterile. The nursery was found to lack proper hand-wash facilities and to be overcrowded and understaffed. Reinforcement of hand hygiene and a ban on the multiple dosing of medicines stopped the outbreak. In conclusion, this outbreak resulted from a combination of factors among which lack of hand hygiene and multiple dosing of an intravenous glucose preparation were most significant.
OBJECTIVE: The purpose of this study was to assess the relationship between demographic factors such as age and race and skin condition and bacterial counts on hands of nurses. METHODS: Nurses (n = 111) working in 1 of 2 neonatal ICUs in New York City were surveyed regarding reported hand care practices and demographics, the condition of their hands was assessed by a trained observer and by themselves using validated instruments, and a hand culture was obtained. RESULTS: There were no significant differences in any skin care practices by race, but nurses who wore powder-free gloves were significantly younger than those who did not (P =.004). There were no significant differences in bacterial counts on hands of black or white nurses (mean log colony-forming units 3.49 and 3.61 respectively, P =.63) and no significant correlation between age and microbial counts (r = 0.04, P =.72). In a logistic regression analysis, race, but not age, was a significant predictor of skin health. By both observer (P =.02) and self-assessment (P =.004) black nurses had healthier skin. CONCLUSION: Physiochemical differences in skin associated with demographic factors such as age and race may be exacerbated among those in disciplines such as nursing, for whom the skin of the hands is continually stressed by occupational practices such as frequent hand hygiene. Such demographic factors need be considered when assessing skin condition and when advocating for appropriate strategies to maximize skin health. The recommendations of the new CDC Hand Hygiene Guideline for Healthcare Settings(23) regarding maintaining skin health and providing moisturizers and products that are milder to the skin are timely and should be followed.
BACKGROUND: The Centers for Disease Control and Prevention (CDC) has published guidelines for hand hygiene practices, recommending a handwash regimen that alternates between waterless alcohol products and antimicrobial or nonantimicrobial soap and water. The advent of an alcohol-based product that can be used with or without water (ie, water optional) to decontaminate the hands while providing immediacy of kill and antimicrobial persistence could reduce the confusion associated with handwash guidelines. Such a product has been developed, is alcohol-based (61%), and zinc pyrithione (ZPT) preserved (61% alcohol-ZPT) and has proven to be fully compliant with the Food and Drug Administration (FDA) and CDC guidelines. METHODS: FDA-required testing of the 61% alcohol-ZPT product for the health care personnel handwash indication was performed as outlined in the Tentative Final Monograph (TFM) for Health-Care Antiseptic Drug Products, employing waterless and water-aided product applications. It was next assessed for antimicrobial persistence and residual effects by comparing it, in separate waterless and water-aided applications, with commonly available handwashes containing various antimicrobials in a 5-day study employing 49 subjects, in which samples were collected immediately and at 4 hours and 8 hours postapplication. The skin conditioning properties of this formulation were investigated via appropriate methods. RESULTS: The 61% alcohol-ZPT product easily produced >3.0 log 10 reduction in the indicator strain ( Serratia marcescens ) following the first wash, exceeding the 2.0 log 10 FDA requirement. This level of performance was maintained through the tenth wash, surpassing the 3.0 log 10 FDA requirement for the handwash indication. For the assessment of persistence and residual effect in the waterless mode, the water-optional, 61% alcohol-ZPT product consistently produced log 10 reductions of nearly 3.5 or greater at every point over the entire study period. In the water-aided configuration, similar results were obtained as log 10 reductions of 2.5 were observed. The formulation is nonirritating, actually contributing to hand skin condition. CONCLUSIONS: The 61% alcohol-ZPT product exceeds all FDA criteria for the health care personnel handwash indication and is a significant advancement in the concept of skin antisepsis. It represents a single product suitable for use in all hand hygiene settings, demonstrating improved antimicrobial persistence and residual effects. The 61% alcohol-ZPT formulation contributes positively to overall hand conditioning, and a previously reported study has documented it to be virucidal for several DNA and RNA viruses.
Each year an estimated 4900 cases of primary Toxoplasma infection occur in pregnant women in France, a country with a high prevalence. Since 1992 all pregnant women at risk of Toxoplasma infection have been required to undergo monthly serological testing. This case-control study, the first of its kind in France, was undertaken to identify risk factors for Toxoplasma infection during pregnancy, with a view to improving primary prevention among non-immune pregnant women. A total of 80 pregnant women who seroconverted to Toxoplasma were matched with 80 pregnant women who had repeatedly negative tests. The women were interviewed by telephone, using a standardized questionnaire, to determine socio-demographic characteristics, exposure to possible risk factors and the type of information on prevention received during pregnancy. The risk factors for Toxoplasma infection included in a multivariate analysis were poor hand hygiene (OR = 9.9; 95%CI: 0.8-125), consumption of undercooked beef (OR = 5.5; 95%CI: 1.1-27), having a pet cat (OR =4.5; 95%CI: 1.0-19.9), frequent consumption of raw vegetables outside the home (OR = 3.1; 95%,CI: 1.2-7.7) and consumption of undercooked lamb (OR = 3.1; 95%CI: 0.85-14). Receipt of documentary advice on prevention was associated with a lower risk of infection. Prevention campaigns among pregnant women in France could be improved and should focus on eating habits, hand hygiene and cats.
Hospital-acquired infections (HAI) are notorious for the manner in which they complicate the course of the original illness, increase costs of hospital stay and delay recovery. This review will briefly outline the problems presented by HAI in developed countries and present evidence that Staphylococcus aureus and gram negative bacilli, the main causative agents, reach susceptible patients via the contact rather than airborne route, predominantly on the hands of hospital staff. Good hand hygiene could help reduce the economic burden and patient distress caused by HAI, but there is evidence that it is infrequently and poorly performed by nurses, the health care staff most frequently in continuous contact with patients. Possible reasons are explored in an attempt to identify strategies to improve hand hygiene.
A population sample from a community in a developing urban area (Botshabelo), which obtains its treated water supply from a communal standpipe system, was subjected to a short Health and Hygiene Awareness and Education (HHA&E) programme to improve its practices on storing water in, and handling water from, storage containers at home. The problem was that the community's practices lead to the deterioration of the microbiological quality of the water in domestic storage containers. Measuring changes in the practices, as well as the microbiological quality of water in the containers, were the instruments used to determine whether the programme had a positive educational effect. This paper reports on selected elements of the practices measurement. Structured interviews, observations and statistical analyses assessed three variables--container hygiene, container storage and hand hygiene. Results indicated insignificant improvements in practices. This was supported by insignificant improvements in the microbiological water quality, that was still above health-safety limits. This implied that short-term "quick fix" HHA&E programmes would tend to be ineffective. Results also suggested that some negative water-hygiene habits may readily change (container hygiene and storage), while behaviour of a more personal nature, such as hand-washing, was not easily changed.