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State-of-the-art hand hygiene in community medicine
International Journal of Hygiene and Environmental Health
Int. J. Hyg. Environ. Health 206, 465 ± 472 (2003) ¹ Urban & Fischer Verlag http: // www.urbanfischer.de/journals/intjhyg
State-of-the-art hand hygiene in community medicine G¸nter Kampf a,b a b
Bode Chemie GmbH, Scientific Affairs, Hamburg, Germany Institut f¸r Hygiene und Umweltmedizin, Ernst-Moritz-Arndt Universit‰t, Greifswald, Germany
Received April 2, 2003 ¥ Revision received June 27, 2003 ¥ Accepted July 5, 2003
Abstract Hand hygiene becomes more important in community medicine not only since antibiotic resistant bacteria such as MRSA spread within the community. Hands may be colonized with transient microorganism in up to 75%. Among those transient pathogens S. aureus, C. difficile or the hepatitis C virus may be found. During patient care the number of microorganisms on the hands steadily increases. In addition hands may be contaminated with different kinds of germs even if only ™clean∫ activities are carried out. Gloves may be worn but do not provide complete protection from contamination due to leaks. Therefore hands should always be treated after gloves are taken off. State-of-the-art treatment of hands is the hygienic hand disinfection with alcohol-based hand rubs. They are more effective, quicker to carry out, better tolerated by the skin, with a positive effect on compliance, and cost effective in comparison to antiseptic soaps based on chlorhexidine or triclosan and in comparison to normal non-medicated soaps. Healthy skin easily tolerates alcohol-based products from the beginning on. Only health care workers with an underlying irritative contact dermatitis which is often caused by bar or liquid antiseptic soaps may have difficulties to use alcohol-based products initially. In such a case treatment of the underlying skin condition is the way to go and not staying with a preparation which has caused the dermatitis. All this knowledge is now reflected in current guidelines on hand hygiene. Beside liquids alcohol-based gels can be used if they have an antimicrobial activity equal to alcoholbased liquid preparations. Hand hygiene remains the single most important tool to avoid cross transmission of microorganisms between patients. This state-of-the-art hand hygiene should also be emphasized more in community medicine. This review may help to go the first step into this direction. Key words: Hand hygiene ± hand disinfection ± alcohol
Background The health care systems in many countries are under financial pressure. One opportunity to reduce costs is to treat patients in the community instead of in the hospital. Post surgery patients for example may recover after the critical postoperative period at
home if trained nursing and medical staff provides community care. This trend results in an increasing number of community nurses and in an increased number of patients that are treated at home. Another trend is the increasing age and disability of people in the community. Many people require nursing care at home for minor but ongoing diseases.
Corresponding author: Dr. G¸nter Kampf, Scientific Affairs, Bode Chemie GmbH, Melanchthonstr. 27, D-22525 Hamburg, Germany. Phone: 49 40 5400 60, Fax: 49 40 5400 6128, E-mail: [email protected]
1438-4639/03/206-06-465 $ 15.00/0
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This may be the insulin-dependent diabetic who may not be able anymore to inject the insulin her- or himself and who needs professional help. It may be the patient with leg ulcers who requires professional wound care. It may be the stroke patient with permanent disabilities that still allow him to live at home but only with professional help. There are many situations in which community medicine plays a key role for the chance of a patient to be treated at home. At the same time antibiotic resistant bacteria are emerging. The most important one may be methicillin-resistant Staphylococcus aureus (MRSA). In the UK at least 16 endemic strains are known (Working party report, 1995), in Germany at least 6 strains are found in many regions (Witte et al., 1997). For many years it was assumed that MRSA is only transmitted in hospitals. An MRSA patient was easily discharged from hospital because MRSA in the community was basically unknown and it was assumed that MRSA would somehow vanish from the patient. When we now look at MRSA colonization rates in the general community they are still low (Charlebois et al., 2002; Sa-Leao et al., 2001). In 1998 a prevalence of nasal MRSA colonization of 483 residents in the community of Birmingham (UK) was 1.5% (Abudu et al., 2001). In Chicago 2.5% of 122 children colonized with S. aureus and attending an inner city paediatric emergency department were MRSA carriers but lacking traditional risk factors for MRSA infection (Hussain et al., 2001). When we look, however, at the number of patients with community-acquired MRSA disease, a rapid increase can be observed. Skin and soft tissue infections seem to be the predominant clinical presentation (Bukharie et al., 2001), other infections such as gastrointestinal illness may occur (Jones et al., 2002). A few examples are described. In a university hospital in Saudi Arabia, for example, only one community-acquired MRSA case was seen in 1998, but 15 cases were found in 2000 (Bukharie et al., 2001). In a rural community in the USA, MRSA was more often associated with communityacquired infection than methicillin-susceptible S. aureus (MSSA). Even four deaths of previously healthy children were caused by MRSA. MRSA was described to have replaced MSSA as the predominant strain in this community (Groom et al., 2001). In Texas, 7 cases of community-acquired MRSA were identified from 1990 to 1996, and 53 cases were identified from 1997 to 2000 with 35 cases occurring in 2000 (Fergie and Purcell, 2001). All these results indicate that the potential for MRSA distribution in the community was probably greatly underestimated (Chambers, 2001).
Transmission of MRSA in the community has been shown to be as high as 60% (Matsumoto et al., 2001). Family members who are living with MRSA carriers are in danger of MRSA transmission (Matsumoto et al., 2001). Visiting nurses, however, are seldom infected with MRSA. Nevertheless, a low rate of hand hygiene before a patient contact may enable cross infection from the hands of visiting nurses to their patients (Matsumoto et al., 2001). MRSA in hospitals is known to be mainly transmitted by the hands of health care workers. This knowledge has been reflected in various national guidelines on infection control measures that should be implemented in cases of MRSA. The guideline of the Robert Koch-Institute (Berlin, Germany), for example, emphasizes the importance of hand disinfection before and after each patient contact (Anonym, 1999). The guideline of the Hospital Infection Society (UK) emphasizes the impact of appropriate hand hygiene to avoid transmission of MRSA (Working party report, 1990). A guideline for MRSA in the community underlines the same issue (Working party report, 1995). The new CDC guideline on hand hygiene underlines the impact of hand antisepsis to reduce transmission of healthcare acquired microorganisms (Boyce and Pittet, 2002). Overall, hand hygiene in community medicine is certainly a topic of increasing importance.
Contamination of hands Hands are permanently colonized with microorganisms. Since 1938 the resident and transient flora are distinguished (Price, 1938). Resident microorganisms are permanent inhabitants of the skin. Staphylococcus epidermidis, Micrococcus luteus, propionibacteria and corynebacteria are common examples of resident bacteria (Evans et al., 1950). Most of them can be found on the superficial layer of the skin and under the most superficial cells of the stratum corneum. On intact skin they usually do not cause any infection but in sterile body tissue or on nonintact skin they may well cause infections. Resident microorganisms can survive longer on the skin in comparison to transient gram-negative rods (Lowbury, 1969). All kinds of microorganisms that colonize the skin for a limited period of time belong to the transient flora. Colonization rates with transient microorganisms on hands of health care workers are summarized in Table 1. Up to 75% of health care workers' (HCW) hands can be colonized or contaminated with pathogens such as S. aureus,
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Table 1. Frequency of colonization of health care workers' hands with various transient microorganisms. Year and reference
Investigated health care workers (n)
Type of microorganism
Colonization on hands (%)
1985 1977 1990 1982 1981 1977 1989 1996 1998 1994 2000
328 163 112 255 103 28 35 73 146 36 240 samples
S. aureus S. aureus S. aureus Gram-negative bacteria Gram-negative bacteria Klebsiella spp. C. difficile C. difficile Yeasts Yeasts HCV
20.5% 15.1% 16.1% 31.3% 21% 17% 59% 14% 46% 75% Range: 3.3% to 23.8%
( Daschner) ( Gr‰f and Mˆnius) ( Opal et al.) ( Adams and Marrie) ( Larson) ( Casewell and Phillips) ( McFarland et al.) ( Samore et al.) ( Huang et al.) ( Strausbaugh et al.) ( Alfurayh et al.)
gram-negative bacteria, yeasts, Clostridium difficile or HCV (hepatitis C virus), depending on the clinical setting, the department and the activity prior to the sampling. The number of microorganisms steadily increases with the duration of patient care, on average 16 microorganisms per minute on the non-gloved hand (Pittet et al., 1999). More microorganisms are found on the hands after specific patient care activities such as direct patient contact, respiratory care, contact with body fluids and after interrupting patient care (Pittet et al., 1999). A simple hand wash alone leads to a significantly higher number of microorganisms on the hands (Pittet et al., 1999). A third group of microorganisms on hands can be described as the infectious flora. This type of flora is not commonly found on healthcare workers' hands. But if a healthcare worker suffers from any infection of the skin or nails, or from predamaged skin, psoriasis or atopic eczema, the infectious flora may well contribute to or even predominate the overall skin flora on hands. A common example in this respect is S. aureus.
Nursing activities with a high risk of contamination of hands During patient care there is always a risk for the health care worker to contaminate the own hands. But the risk depends on the type of nursing activity. Only limited data is available that actually describes the level of contamination of health care workers' hands after specific patient care activities. ™Clean activities∫ have been described as handling sterile material or objects, shaking hands or taking a pulse; ™dirty activities∫ are, for example, contact with secretions, urine, faeces or infected sites (e.g. wounds) (Rotter, 1999). Some specific nursing
activities, however, have been described to lead to a significant contamination of the hands, which is quite surprising because these activities would have to be classified as ™clean∫, such as lifting patients, taking a patient's pulse, blood pressure or oral temperature or touching the patient's hand, shoulder or groin. All these activities may result in an additional hand contamination of up to 1000 colony-forming units per hand as shown with Klebsiella spp. (Casewell et al., 1977). It is easy to imagine that other patient care activities such as washing incontinent patients or a wound dressing change probably results in even higher contamination of the hands.
Prevention of contamination Two basic principles exist to prevent contamination of the hands during nursing activities: performing ™non-touch techniques∫ and wearing gloves. The non-touch technique is, for example, changing dressings with a forceps and thereby not touching the wound. The primary aim is to avoid transmission of organisms from the health care worker's hands to the patient. At the same time, hand contamination from a potentially contaminated wound is prevented. For a long time the non touch technique has been a standard procedure in surgical patient care. Wearing gloves is recommended when contamination of the hands is expected, e.g., during respiratory care of ventilated patients, care of incontinent patients, manipulation of urinary catheters etc. Contamination of hands can be reduced by gloves. But up to 85% of gloves have leaks after use and do not provide complete prevention of contamination (Kralj et al., 1999; Yangco and Yangco, 1989). Hands are contaminated despite wearing gloves in up to 29.4% (Tenorio et al., 2001). It is therefore absolutely necessary to carry out a hygienic hand
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disinfection after gloves are taken off (Anonymous, 2001). Gloves should not be worn too long in order not to enhance dermal irritation although one may be tempted to leave the protective glove on the hands as long as possible. In community medicine, however, it is unlikely that gloves are worn too long.
years. In the USA, for example, alcohols are now considered to be the first choice hand antiseptic for the post contamination treatment of hands (Anonymous, 2001). There are many scientific reasons for this change in hand hygiene as outlined below. Antimicrobial activity and efficacy
Treatment of contamination There are in general 3 different methods to treat contaminated hands: * *
*
Social hand wash (rinse-off products): washing hands with non-medicated soap and water. Hygienic hand wash (rinse-off products): washing hands with medicated soap and water (according to prEN 12054, EN 1499) (DIN EN 1499, 1997; prEN 12054, 1997). Active ingredients such as chlorhexidine or triclosan are often found in medicated soaps. Hygienic hand disinfection (leave-on products): rubbing hands with an alcoholic liquid or gel (according to prEN 12054, EN 1500) (DIN EN 1500, 1997; prEN 12054, 1997). The active ingredients are usually ethanol, n-propanol or iso-propanol. Some rubs contain some additional active ingredients such as chlorhexidine or mecetronium etil sulphate (quaternary ammonium compound).
For many decades the social hand wash as well as the hygienic hand wash were regarded in many countries such as the USA and the UK as the method of choice to eliminate the contamination from the HCW's hands. Due to a better understanding of the scientific background and recent studies, new recommendations have been developed over the last
Alcohols such as ethanol, 1-propanol or 2-propanol have a broad spectrum of antimicrobial activity. They are bactericidal, virucidal (coated viruses and some naked viruses), mycobactericidal and fungicidal, but there is practically no sporicidal activity (Hared et al., 1963; Heuzenroeder and Johnson, 1958). A detailed description of the spectrum of virucidal activity of the different alcohols is shown in Table 2. Other active ingredients such as chlorhexidine or triclosan have a smaller spectrum of antimicrobial activity (Pittet and Boyce, 2001). In addition, alcohols are very fast acting and exhibit their full activity within 15 to 30 s. It has been shown that other active ingredients such as chlorhexidine act much slower (Kampf et al., 1999). For decades alcohol-based hand rubs are available as liquids. Since the first commercially available liquid products introduced in the early 1960s (e.g., Sterillium) they where regarded to be the standard for hand disinfection mainly because of their fast and immediate antimicrobial activity. During the last years alcohol-based gels have been found in some countries. Although many HCWs favored this type of hand rub, it was repetitively shown that the antimicrobial activity of most gels is significantly lower in comparison to liquid products (Kramer et al., 2002b; Pietsch, 2001). Those gels are considered not to be suitable for the post contamination treatment of hands in health care settings due to their limited antimicrobial activity (Kramer, et al. 2002b). So far
Table 2. Virucidal activity of different types of alcohols at various concentrations, adapted from (Rudolf and Kampf, 2003). Type of alcohol Coated viruses and concentration HSV, HSV, Vaccinia- BVDV* HIV type 1 type 2 virus Ethanol (60% ± 80%) Ethanol (95%) 1-Propanol (60% ± 80%) 2-Propanol (60% ± 85%)
Naked viruses HBV** Rotavirus Norovirus Papova- PolioAdeno- HAV virus virus*** virus***
±
±
±
±
unknown
±
±
±
±
unknown
comprehensive and immediate activity (15 ± 30 sec); comprehensive and fast activity (up to 2 min); comprehensive and slow activity (> 2 min); ± no activity. * Surrogate virus for HCV; ** antigen test, *** test viruses according to prEN 14476.
Hand hygiene in community medicine
only one gel meets the efficacy standard (EN 1500 within 30 s) which is set by liquid products and which is valid for community medicine, too (Kampf et al., 2002b). Time A HCW has only limited time for patient care activities. That is why time is another topic with influence on hand hygiene practices. To ask busy HCWs to walk away from the patient in order to reach a wash basin gives raise to non-compliance with hand hygiene recommendations (Pittet and Boyce, 2001). For a hand wash, the HCW will have to walk to the next available sink, wash the hands, dry them and walk to the next patient. This may take up to one minute (Voss and Widmer, 1997). Hygienic hand disinfection with an alcohol-based product requires only about 30 seconds because a dispenser may be available next to the patient's bed or a pocket bottle may be available so that no further walking away from the patient is necessary. The hand disinfection may be done during a conversation with the patient which is only possible if the HCW does not have to leave the patient. The use of alcohol-based hand rubs solves two problems often associated with hand washing: lack of facilities (no sinks required) and lack of time (Pittet and Boyce, 2001). Both aspects are particularly important in community medicine especially due to the unique environment during home care activities. Skin care and dermal tolerance Chronic irritative dermatitis of HCWs is an important issue in occupational dermatology. Up to 70% of HCWs were reported to have occupational hand dermatitis, e.g., those reporting a frequency of hand washing exceeding 35 times per shift (Forrester and Roth, 1998). This is mainly explained by the observation that washing hands dries out the skin (Boyce et al., 2000). Rub-in products do not wash off the superficial fat layer of the skin. They may well solve the fat layer but leave it on the skin. In addition, alcohol-based hand rubs usually contain emollients. The effect of the emollients has been well established (Rotter et al., 1991). That is why hand disinfectants are in comparison to hand wash products better tolerated by the HCW (Boyce et al., 2000; Kramer et al., 2002a; 2003; Sauermann et al., 1995; Winnefeld et al., 2000). The ideal hand hygiene product would increase the skin hydration after repetitive use and help the HCW to improve the skin condition. This has been described for an alcohol-based liquid product (Rigaud et al., 2002) and for one alcohol-
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based hand gel (Kampf et al., 2002a). There is a lot of evidence to suggest that alcohol-based hand rubs are significantly better tolerated by HCWs and their skin than antiseptic soaps based on chlorhexidine or triclosan (Kramer et al., 2002a; Pittet and Boyce, 2001). In contrast to hand rub products, liquid soaps (plain or antimicrobial) often reduce skin hydration and therefore predispose chronic irritative dermatitis of the HCWs hands (Sauermann et al., 1995). Mildness of an antiseptic soap is therefore very important and has been shown only for few products (Kampf et al., 2001). Compliance Non-compliance with hand hygiene remains a major problem in infection control. Compliance rates among health care workers were described to be between 16% and 81% with an estimated average of about 50% (Dubbert et al., 1990; Preston et al., 1981). Nurses seem to comply better with hand hygiene in comparison to doctors (Pittet, 2000; 2001; Pittet and Boyce, 2001) but nevertheless even among nurses the compliance remains too low. Noncompliance was described to be higher during procedures that carry a high risk of bacterial contamination and when the intensity of patient care was high (Pittet et al., 1999). Besides lack of time, skin irritation is one important factor for noncompliance. Soaps and detergents can damage skin when used on a regular basis. Alcohol-based hand rubs, however, have been shown to significantly improve compliance with hand hygiene. Two examples are described in further detail. On a 14-bed medical intensive care unit an alcohol-based hand rub was introduced for hand disinfection in addition to hand washing with soap and water. In a first study period without hand disinfection, the compliance was found (by observation) to be 42.2% among 621 opportunities for hand hygiene. In the second study period with Sterillium the compliance was found to be 60.9% among 905 opportunities for hand hygiene. This was found to be a significant increase of compliance (p < 0.001). This improvement was observed among all subgroups of medical staff such as nurses (45.3% versus 66.9%, p < 0.001), senior physicians (37.2% versus 55.5%, p < 0.001) and residents (46.9% versus 59.1%, p 0.03). Even three months after the second study period, compliance remained better than during the first study period (51.3% versus 42.2%, p 0.007) although it is known that compliance decreases quickly at the end of such a study. In addition rubbing with the product was described
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by all health care workers as an easy procedure (Maury et al., 2000). In another hospital in France, the influence of the introduction of an alcohol-based hand rub on the compliance of hand disinfection was investigated, too. The initial compliance with hand disinfection was very high with 62.6%. Nevertheless, an increase to 66.5% was observed after the introduction of the product. The overall conclusion of the authors was that this introduction (with educational and equipment program) is efficient both for compliance and skin condition (Girard et al., 2001). Improvement of compliance will not only depend on the hand disinfectant itself. A promotion campaign for hand hygiene has been described to substantially improve compliance with hand hygiene (Pittet et al., 2000). If i) health care workers are well educated about all aspects of hand hygiene and the benefit of a high compliance for the patient, and if ii) products with a high antimicrobial activity and a proven skin tolerance are available in the clinical situation where it is needed, and if iii) occupational dermatology can help the health care workers to come up with a skin protection plan which will eventually help to improve compliance, it should be possible to further reduce preventable nosocomial infections. Although all these data were obtained in hospitals they nevertheless provide important and helpful general information for community medicine, too.
observed reduction in infection rates is attributable to improved hand hygiene, the intervention might have prevented more than 900 infections indicating that the whole campaign was largely cost effective (Pittet et al., 2000). The time saved by applying alcohol-based hand rubs will in addition help to reduce costs and to lower the spread of antibioticresistant bacteria.
State-of-the-art hand hygiene State-of-the-art hand hygiene in community medicine is hygienic hand disinfection before and after patient care activities with an alcohol-based hand rub or an alcohol-based hand gel. Gels can only be recommended if they show an antimicrobial activity equal to the liquid preparations. The hand rub is usually applied for 30 s. Hands should be completely dry before the hand rub is applied. The correct technique of rubbing the preparation into the hands will help to prevent untreated skin areas with remaining microorganisms. Washing hands should be limited to situations in which hands are visibly soiled. An increasing awareness among HCWs for the best hand hygiene in community medicine will certainly help to reduce cross infections in the community and may thereby help to limit the spread of multi-drug resistant bacteria outside the hospital.
Cost effectiveness Cost effectiveness is difficult to determine in hand hygiene and has not been studied in community medicine yet. Only limited data from hospitals is available. In one study it has been calculated that the cost of using an alcohol-based hand rub was half as much as the use of an antimicrobial soap for hand washing (Larson et al., 2001). So far only one study has been carried out in which a significant reduction of nosocomial infection due to the promotion of hand hygiene was observed, and in which cost effectiveness calculation was attempted. Over a period of 4 years compliance among HCWs with hand hygiene increased from 48% to 66% (p < 0.001) mostly as a result of enhanced recourse to alcohol-based hand disinfection. The intervention was also associated with a significant reduction in MRSA cross transmission (Pittet et al., 2000). The total cost of the campaign was estimated to be 380.000 SFr. Using a conservative estimate of SFr 3500 saved per hospital-acquired infection, prevention of 108 infections would have offset the whole program costs. And assuming that only 1³4 of the
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including clients of visiting nurse and related infection control. Nippon Koshu Eisei Zasshi 48, 190 ± 199 (2001) Maury, E., Alzieu, M., Baudel, J. L. et al.: Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit. Am. J. Respir. Crit. Care Med. 162, 324 ± 327 (2000) McFarland, L. V., Mulligan, M. E., Kwok, R. Y. Y., Stamm, W. E.: Nosocomial acquisition of Clostridium difficile infection. N. Engl. J. Med. 320, 204 ± 210 (1989) Opal, S. M., Mayer, K. H., Stenberg, M. J. et al.: Frequent acquisition of multiple strains of methicillin-resistant Staphylococcus aureus by healthcare workers in an endemic hospital environment. Infect. Control Hosp. Epidemiol. 11, 479 ± 485 (1990) Pietsch, H.: Hand antiseptics: rubs versus scrubs, alcoholic solutions versus alcoholic gels. J. Hosp. Infect. 48, S33-S36 (2001) Pittet, D.: Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg. Infect. Dis. 7, 234 ± 240 (2001) Pittet, D.: Improving compliance with hand hygiene in hospitals. Infect. Control Hosp. Epidemiol. 21, 381 ± 386 (2000) Pittet, D., Boyce, J. M.: Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect. Dis. 1, 9 ± 20 (2001) Pittet, D., Dharan, S., Touveneau, S., Sauvan, V., Perneger, T. V.: Bacterial contamination of the hands of hospital staff during routine patient care. Arch. Int. Med. 159, 821 ± 826 (1999) Pittet, D., Hugonnet, S., Harbarth, S. et al.: Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 356, 1307 ± 1312 (2000) prEN 12054: Chemische Desinfektionsmittel und Antiseptika. Produkte f¸r die hygienische und chirurgische H‰ndedesinfektion und H‰ndewaschung ± Bakterizide Wirkung ± Pr¸fverfahren und Anforderungen (Phase 2/Stufe 1). (1997) Preston, G. A., Larson, E. L., Stamm, W. E.: The effect of private isolation rooms on patient care practices, colonization and infection in an intensive care unit. Am. J. Med. 70, 641 ± 645 (1981) Price, P. B.: The bacteriology of normal skin: a new quantitative test applied to a study of the bacterial flora and the disinfectant action of mechanical cleansing. J. Infect. Dis. 63, 301 ± 318 (1938) Rigaud, M.-P., Deblangy, C., Fargeot, C. et al.: Evaluation de la tole¬rance cutane¬e d'une solution hydroalcoolique. Hygie¡nes 10, 33 ± 37 (2002) Rotter, M. L.: Hand washing and hand disinfection. In: Mayhall CG (ed): Hospital epidemiology and infection control. 2nd ed. Lippincott Williams & Wilkins, Philadelphia, 1999, p. 1339 ± 1355.
Rotter, M. L., Koller, W., Neumann, R.: The influence of cosmetic additives on the acceptability of alcoholbased hand disinfectants. J. Hosp. Infect. 18, 57 ± 63 (1991) Rudolf, M., Kampf, G.: Wirkstoffe. In: Kampf G (ed): H‰ndehygiene im Gesundheitswesen. Springer, Berlin, 2003, p. 71 ± 104. Sa-Leao, R., Sanches, I. S., Couto, I., Alves, C. R., de Lencastre, H.: Low prevalence of methicillin-resistant strains among Staphylococcus aureus colonizing young and healthy members of the community in Portugal. Microb. Drug Resist. 7, 237 ± 245 (2001) Samore, M. H., Venkataraman, L., DeGirolami, P. C., Arbeit, R. D., Karchmer, A. W.: Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am. J. Med. 100, 32 ± 40 (1996) Sauermann, G., Proske, O., Keyhani, R., Leneveu, M.C., Pietsch, H., Rohde, B.: Skin tolerance of Sterillium and Hibiscrub: A comparative clinical trial. Hyg. Med. 20, 184 ± 189 (1995) Strausbaugh, L. J., Sewell, D. L., Ward, T. T., Pfaller, M. A., Heitzman, T., Tjoelker, R.: High frequency of yeast carriage on hands of hospital personnel. J. Clin. Microbiol. 32, 2299 ± 2300 (1994) Tenorio, A. R., Badri, S. M., Sahgal, N. B. et al.: Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant Enterococcus species by health care workers after patient care. Clin. Infect. Dis. 32, 826 ± 829 (2001) Voss, A., Widmer, A. F.: No time for handwashing!? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect. Control Hosp. Epidemiol. 18, 205 ± 208 (1997) Winnefeld, M., Richard, M. A., Drancourt, M., Grobb, J. J.: Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use. Br. J. Dermatol. 143, 546 ± 550 (2000) Witte, W., Kresken, M., Braulke, C., Cuny, C.: Increasing incidence and widespread dissemination of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals in central Europe, with special reference to German hospitals. Clin. Microbiol. Infect. 3, 414 ± 422 (1997) Working party report: Guidelines on the control of methicillin-resistant Staphylococcus aureus in the community. J. Hosp. Infect. 31, 1 ± 12 (1995) Working party report: Revised guidelines for the control of epidemic methicillin-resistant Staphylococcus aureus. J. Hosp. Infect. 16, 351 ± 377 (1990) Yangco, B. G., Yangco, N. F.: What is leaky can be risky: a study of the integrity of hospital gloves. Infect. Control Hosp. Epidemiol. 10, 553 ± 556 (1989)
Int. J. Hyg. Environ. Health 206, 465 ± 472 (2003) ¹ Urban & Fischer Verlag http: // www.urbanfischer.de/journals/intjhyg
State-of-the-art hand hygiene in community medicine G¸nter Kampf a,b a b
Bode Chemie GmbH, Scientific Affairs, Hamburg, Germany Institut f¸r Hygiene und Umweltmedizin, Ernst-Moritz-Arndt Universit‰t, Greifswald, Germany
Received April 2, 2003 ¥ Revision received June 27, 2003 ¥ Accepted July 5, 2003
Abstract Hand hygiene becomes more important in community medicine not only since antibiotic resistant bacteria such as MRSA spread within the community. Hands may be colonized with transient microorganism in up to 75%. Among those transient pathogens S. aureus, C. difficile or the hepatitis C virus may be found. During patient care the number of microorganisms on the hands steadily increases. In addition hands may be contaminated with different kinds of germs even if only ™clean∫ activities are carried out. Gloves may be worn but do not provide complete protection from contamination due to leaks. Therefore hands should always be treated after gloves are taken off. State-of-the-art treatment of hands is the hygienic hand disinfection with alcohol-based hand rubs. They are more effective, quicker to carry out, better tolerated by the skin, with a positive effect on compliance, and cost effective in comparison to antiseptic soaps based on chlorhexidine or triclosan and in comparison to normal non-medicated soaps. Healthy skin easily tolerates alcohol-based products from the beginning on. Only health care workers with an underlying irritative contact dermatitis which is often caused by bar or liquid antiseptic soaps may have difficulties to use alcohol-based products initially. In such a case treatment of the underlying skin condition is the way to go and not staying with a preparation which has caused the dermatitis. All this knowledge is now reflected in current guidelines on hand hygiene. Beside liquids alcohol-based gels can be used if they have an antimicrobial activity equal to alcoholbased liquid preparations. Hand hygiene remains the single most important tool to avoid cross transmission of microorganisms between patients. This state-of-the-art hand hygiene should also be emphasized more in community medicine. This review may help to go the first step into this direction. Key words: Hand hygiene ± hand disinfection ± alcohol
Background The health care systems in many countries are under financial pressure. One opportunity to reduce costs is to treat patients in the community instead of in the hospital. Post surgery patients for example may recover after the critical postoperative period at
home if trained nursing and medical staff provides community care. This trend results in an increasing number of community nurses and in an increased number of patients that are treated at home. Another trend is the increasing age and disability of people in the community. Many people require nursing care at home for minor but ongoing diseases.
Corresponding author: Dr. G¸nter Kampf, Scientific Affairs, Bode Chemie GmbH, Melanchthonstr. 27, D-22525 Hamburg, Germany. Phone: 49 40 5400 60, Fax: 49 40 5400 6128, E-mail: [email protected]
1438-4639/03/206-06-465 $ 15.00/0
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This may be the insulin-dependent diabetic who may not be able anymore to inject the insulin her- or himself and who needs professional help. It may be the patient with leg ulcers who requires professional wound care. It may be the stroke patient with permanent disabilities that still allow him to live at home but only with professional help. There are many situations in which community medicine plays a key role for the chance of a patient to be treated at home. At the same time antibiotic resistant bacteria are emerging. The most important one may be methicillin-resistant Staphylococcus aureus (MRSA). In the UK at least 16 endemic strains are known (Working party report, 1995), in Germany at least 6 strains are found in many regions (Witte et al., 1997). For many years it was assumed that MRSA is only transmitted in hospitals. An MRSA patient was easily discharged from hospital because MRSA in the community was basically unknown and it was assumed that MRSA would somehow vanish from the patient. When we now look at MRSA colonization rates in the general community they are still low (Charlebois et al., 2002; Sa-Leao et al., 2001). In 1998 a prevalence of nasal MRSA colonization of 483 residents in the community of Birmingham (UK) was 1.5% (Abudu et al., 2001). In Chicago 2.5% of 122 children colonized with S. aureus and attending an inner city paediatric emergency department were MRSA carriers but lacking traditional risk factors for MRSA infection (Hussain et al., 2001). When we look, however, at the number of patients with community-acquired MRSA disease, a rapid increase can be observed. Skin and soft tissue infections seem to be the predominant clinical presentation (Bukharie et al., 2001), other infections such as gastrointestinal illness may occur (Jones et al., 2002). A few examples are described. In a university hospital in Saudi Arabia, for example, only one community-acquired MRSA case was seen in 1998, but 15 cases were found in 2000 (Bukharie et al., 2001). In a rural community in the USA, MRSA was more often associated with communityacquired infection than methicillin-susceptible S. aureus (MSSA). Even four deaths of previously healthy children were caused by MRSA. MRSA was described to have replaced MSSA as the predominant strain in this community (Groom et al., 2001). In Texas, 7 cases of community-acquired MRSA were identified from 1990 to 1996, and 53 cases were identified from 1997 to 2000 with 35 cases occurring in 2000 (Fergie and Purcell, 2001). All these results indicate that the potential for MRSA distribution in the community was probably greatly underestimated (Chambers, 2001).
Transmission of MRSA in the community has been shown to be as high as 60% (Matsumoto et al., 2001). Family members who are living with MRSA carriers are in danger of MRSA transmission (Matsumoto et al., 2001). Visiting nurses, however, are seldom infected with MRSA. Nevertheless, a low rate of hand hygiene before a patient contact may enable cross infection from the hands of visiting nurses to their patients (Matsumoto et al., 2001). MRSA in hospitals is known to be mainly transmitted by the hands of health care workers. This knowledge has been reflected in various national guidelines on infection control measures that should be implemented in cases of MRSA. The guideline of the Robert Koch-Institute (Berlin, Germany), for example, emphasizes the importance of hand disinfection before and after each patient contact (Anonym, 1999). The guideline of the Hospital Infection Society (UK) emphasizes the impact of appropriate hand hygiene to avoid transmission of MRSA (Working party report, 1990). A guideline for MRSA in the community underlines the same issue (Working party report, 1995). The new CDC guideline on hand hygiene underlines the impact of hand antisepsis to reduce transmission of healthcare acquired microorganisms (Boyce and Pittet, 2002). Overall, hand hygiene in community medicine is certainly a topic of increasing importance.
Contamination of hands Hands are permanently colonized with microorganisms. Since 1938 the resident and transient flora are distinguished (Price, 1938). Resident microorganisms are permanent inhabitants of the skin. Staphylococcus epidermidis, Micrococcus luteus, propionibacteria and corynebacteria are common examples of resident bacteria (Evans et al., 1950). Most of them can be found on the superficial layer of the skin and under the most superficial cells of the stratum corneum. On intact skin they usually do not cause any infection but in sterile body tissue or on nonintact skin they may well cause infections. Resident microorganisms can survive longer on the skin in comparison to transient gram-negative rods (Lowbury, 1969). All kinds of microorganisms that colonize the skin for a limited period of time belong to the transient flora. Colonization rates with transient microorganisms on hands of health care workers are summarized in Table 1. Up to 75% of health care workers' (HCW) hands can be colonized or contaminated with pathogens such as S. aureus,
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Table 1. Frequency of colonization of health care workers' hands with various transient microorganisms. Year and reference
Investigated health care workers (n)
Type of microorganism
Colonization on hands (%)
1985 1977 1990 1982 1981 1977 1989 1996 1998 1994 2000
328 163 112 255 103 28 35 73 146 36 240 samples
S. aureus S. aureus S. aureus Gram-negative bacteria Gram-negative bacteria Klebsiella spp. C. difficile C. difficile Yeasts Yeasts HCV
20.5% 15.1% 16.1% 31.3% 21% 17% 59% 14% 46% 75% Range: 3.3% to 23.8%
( Daschner) ( Gr‰f and Mˆnius) ( Opal et al.) ( Adams and Marrie) ( Larson) ( Casewell and Phillips) ( McFarland et al.) ( Samore et al.) ( Huang et al.) ( Strausbaugh et al.) ( Alfurayh et al.)
gram-negative bacteria, yeasts, Clostridium difficile or HCV (hepatitis C virus), depending on the clinical setting, the department and the activity prior to the sampling. The number of microorganisms steadily increases with the duration of patient care, on average 16 microorganisms per minute on the non-gloved hand (Pittet et al., 1999). More microorganisms are found on the hands after specific patient care activities such as direct patient contact, respiratory care, contact with body fluids and after interrupting patient care (Pittet et al., 1999). A simple hand wash alone leads to a significantly higher number of microorganisms on the hands (Pittet et al., 1999). A third group of microorganisms on hands can be described as the infectious flora. This type of flora is not commonly found on healthcare workers' hands. But if a healthcare worker suffers from any infection of the skin or nails, or from predamaged skin, psoriasis or atopic eczema, the infectious flora may well contribute to or even predominate the overall skin flora on hands. A common example in this respect is S. aureus.
Nursing activities with a high risk of contamination of hands During patient care there is always a risk for the health care worker to contaminate the own hands. But the risk depends on the type of nursing activity. Only limited data is available that actually describes the level of contamination of health care workers' hands after specific patient care activities. ™Clean activities∫ have been described as handling sterile material or objects, shaking hands or taking a pulse; ™dirty activities∫ are, for example, contact with secretions, urine, faeces or infected sites (e.g. wounds) (Rotter, 1999). Some specific nursing
activities, however, have been described to lead to a significant contamination of the hands, which is quite surprising because these activities would have to be classified as ™clean∫, such as lifting patients, taking a patient's pulse, blood pressure or oral temperature or touching the patient's hand, shoulder or groin. All these activities may result in an additional hand contamination of up to 1000 colony-forming units per hand as shown with Klebsiella spp. (Casewell et al., 1977). It is easy to imagine that other patient care activities such as washing incontinent patients or a wound dressing change probably results in even higher contamination of the hands.
Prevention of contamination Two basic principles exist to prevent contamination of the hands during nursing activities: performing ™non-touch techniques∫ and wearing gloves. The non-touch technique is, for example, changing dressings with a forceps and thereby not touching the wound. The primary aim is to avoid transmission of organisms from the health care worker's hands to the patient. At the same time, hand contamination from a potentially contaminated wound is prevented. For a long time the non touch technique has been a standard procedure in surgical patient care. Wearing gloves is recommended when contamination of the hands is expected, e.g., during respiratory care of ventilated patients, care of incontinent patients, manipulation of urinary catheters etc. Contamination of hands can be reduced by gloves. But up to 85% of gloves have leaks after use and do not provide complete prevention of contamination (Kralj et al., 1999; Yangco and Yangco, 1989). Hands are contaminated despite wearing gloves in up to 29.4% (Tenorio et al., 2001). It is therefore absolutely necessary to carry out a hygienic hand
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disinfection after gloves are taken off (Anonymous, 2001). Gloves should not be worn too long in order not to enhance dermal irritation although one may be tempted to leave the protective glove on the hands as long as possible. In community medicine, however, it is unlikely that gloves are worn too long.
years. In the USA, for example, alcohols are now considered to be the first choice hand antiseptic for the post contamination treatment of hands (Anonymous, 2001). There are many scientific reasons for this change in hand hygiene as outlined below. Antimicrobial activity and efficacy
Treatment of contamination There are in general 3 different methods to treat contaminated hands: * *
*
Social hand wash (rinse-off products): washing hands with non-medicated soap and water. Hygienic hand wash (rinse-off products): washing hands with medicated soap and water (according to prEN 12054, EN 1499) (DIN EN 1499, 1997; prEN 12054, 1997). Active ingredients such as chlorhexidine or triclosan are often found in medicated soaps. Hygienic hand disinfection (leave-on products): rubbing hands with an alcoholic liquid or gel (according to prEN 12054, EN 1500) (DIN EN 1500, 1997; prEN 12054, 1997). The active ingredients are usually ethanol, n-propanol or iso-propanol. Some rubs contain some additional active ingredients such as chlorhexidine or mecetronium etil sulphate (quaternary ammonium compound).
For many decades the social hand wash as well as the hygienic hand wash were regarded in many countries such as the USA and the UK as the method of choice to eliminate the contamination from the HCW's hands. Due to a better understanding of the scientific background and recent studies, new recommendations have been developed over the last
Alcohols such as ethanol, 1-propanol or 2-propanol have a broad spectrum of antimicrobial activity. They are bactericidal, virucidal (coated viruses and some naked viruses), mycobactericidal and fungicidal, but there is practically no sporicidal activity (Hared et al., 1963; Heuzenroeder and Johnson, 1958). A detailed description of the spectrum of virucidal activity of the different alcohols is shown in Table 2. Other active ingredients such as chlorhexidine or triclosan have a smaller spectrum of antimicrobial activity (Pittet and Boyce, 2001). In addition, alcohols are very fast acting and exhibit their full activity within 15 to 30 s. It has been shown that other active ingredients such as chlorhexidine act much slower (Kampf et al., 1999). For decades alcohol-based hand rubs are available as liquids. Since the first commercially available liquid products introduced in the early 1960s (e.g., Sterillium) they where regarded to be the standard for hand disinfection mainly because of their fast and immediate antimicrobial activity. During the last years alcohol-based gels have been found in some countries. Although many HCWs favored this type of hand rub, it was repetitively shown that the antimicrobial activity of most gels is significantly lower in comparison to liquid products (Kramer et al., 2002b; Pietsch, 2001). Those gels are considered not to be suitable for the post contamination treatment of hands in health care settings due to their limited antimicrobial activity (Kramer, et al. 2002b). So far
Table 2. Virucidal activity of different types of alcohols at various concentrations, adapted from (Rudolf and Kampf, 2003). Type of alcohol Coated viruses and concentration HSV, HSV, Vaccinia- BVDV* HIV type 1 type 2 virus Ethanol (60% ± 80%) Ethanol (95%) 1-Propanol (60% ± 80%) 2-Propanol (60% ± 85%)
Naked viruses HBV** Rotavirus Norovirus Papova- PolioAdeno- HAV virus virus*** virus***
±
±
±
±
unknown
±
±
±
±
unknown
comprehensive and immediate activity (15 ± 30 sec); comprehensive and fast activity (up to 2 min); comprehensive and slow activity (> 2 min); ± no activity. * Surrogate virus for HCV; ** antigen test, *** test viruses according to prEN 14476.
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only one gel meets the efficacy standard (EN 1500 within 30 s) which is set by liquid products and which is valid for community medicine, too (Kampf et al., 2002b). Time A HCW has only limited time for patient care activities. That is why time is another topic with influence on hand hygiene practices. To ask busy HCWs to walk away from the patient in order to reach a wash basin gives raise to non-compliance with hand hygiene recommendations (Pittet and Boyce, 2001). For a hand wash, the HCW will have to walk to the next available sink, wash the hands, dry them and walk to the next patient. This may take up to one minute (Voss and Widmer, 1997). Hygienic hand disinfection with an alcohol-based product requires only about 30 seconds because a dispenser may be available next to the patient's bed or a pocket bottle may be available so that no further walking away from the patient is necessary. The hand disinfection may be done during a conversation with the patient which is only possible if the HCW does not have to leave the patient. The use of alcohol-based hand rubs solves two problems often associated with hand washing: lack of facilities (no sinks required) and lack of time (Pittet and Boyce, 2001). Both aspects are particularly important in community medicine especially due to the unique environment during home care activities. Skin care and dermal tolerance Chronic irritative dermatitis of HCWs is an important issue in occupational dermatology. Up to 70% of HCWs were reported to have occupational hand dermatitis, e.g., those reporting a frequency of hand washing exceeding 35 times per shift (Forrester and Roth, 1998). This is mainly explained by the observation that washing hands dries out the skin (Boyce et al., 2000). Rub-in products do not wash off the superficial fat layer of the skin. They may well solve the fat layer but leave it on the skin. In addition, alcohol-based hand rubs usually contain emollients. The effect of the emollients has been well established (Rotter et al., 1991). That is why hand disinfectants are in comparison to hand wash products better tolerated by the HCW (Boyce et al., 2000; Kramer et al., 2002a; 2003; Sauermann et al., 1995; Winnefeld et al., 2000). The ideal hand hygiene product would increase the skin hydration after repetitive use and help the HCW to improve the skin condition. This has been described for an alcohol-based liquid product (Rigaud et al., 2002) and for one alcohol-
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based hand gel (Kampf et al., 2002a). There is a lot of evidence to suggest that alcohol-based hand rubs are significantly better tolerated by HCWs and their skin than antiseptic soaps based on chlorhexidine or triclosan (Kramer et al., 2002a; Pittet and Boyce, 2001). In contrast to hand rub products, liquid soaps (plain or antimicrobial) often reduce skin hydration and therefore predispose chronic irritative dermatitis of the HCWs hands (Sauermann et al., 1995). Mildness of an antiseptic soap is therefore very important and has been shown only for few products (Kampf et al., 2001). Compliance Non-compliance with hand hygiene remains a major problem in infection control. Compliance rates among health care workers were described to be between 16% and 81% with an estimated average of about 50% (Dubbert et al., 1990; Preston et al., 1981). Nurses seem to comply better with hand hygiene in comparison to doctors (Pittet, 2000; 2001; Pittet and Boyce, 2001) but nevertheless even among nurses the compliance remains too low. Noncompliance was described to be higher during procedures that carry a high risk of bacterial contamination and when the intensity of patient care was high (Pittet et al., 1999). Besides lack of time, skin irritation is one important factor for noncompliance. Soaps and detergents can damage skin when used on a regular basis. Alcohol-based hand rubs, however, have been shown to significantly improve compliance with hand hygiene. Two examples are described in further detail. On a 14-bed medical intensive care unit an alcohol-based hand rub was introduced for hand disinfection in addition to hand washing with soap and water. In a first study period without hand disinfection, the compliance was found (by observation) to be 42.2% among 621 opportunities for hand hygiene. In the second study period with Sterillium the compliance was found to be 60.9% among 905 opportunities for hand hygiene. This was found to be a significant increase of compliance (p < 0.001). This improvement was observed among all subgroups of medical staff such as nurses (45.3% versus 66.9%, p < 0.001), senior physicians (37.2% versus 55.5%, p < 0.001) and residents (46.9% versus 59.1%, p 0.03). Even three months after the second study period, compliance remained better than during the first study period (51.3% versus 42.2%, p 0.007) although it is known that compliance decreases quickly at the end of such a study. In addition rubbing with the product was described
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by all health care workers as an easy procedure (Maury et al., 2000). In another hospital in France, the influence of the introduction of an alcohol-based hand rub on the compliance of hand disinfection was investigated, too. The initial compliance with hand disinfection was very high with 62.6%. Nevertheless, an increase to 66.5% was observed after the introduction of the product. The overall conclusion of the authors was that this introduction (with educational and equipment program) is efficient both for compliance and skin condition (Girard et al., 2001). Improvement of compliance will not only depend on the hand disinfectant itself. A promotion campaign for hand hygiene has been described to substantially improve compliance with hand hygiene (Pittet et al., 2000). If i) health care workers are well educated about all aspects of hand hygiene and the benefit of a high compliance for the patient, and if ii) products with a high antimicrobial activity and a proven skin tolerance are available in the clinical situation where it is needed, and if iii) occupational dermatology can help the health care workers to come up with a skin protection plan which will eventually help to improve compliance, it should be possible to further reduce preventable nosocomial infections. Although all these data were obtained in hospitals they nevertheless provide important and helpful general information for community medicine, too.
observed reduction in infection rates is attributable to improved hand hygiene, the intervention might have prevented more than 900 infections indicating that the whole campaign was largely cost effective (Pittet et al., 2000). The time saved by applying alcohol-based hand rubs will in addition help to reduce costs and to lower the spread of antibioticresistant bacteria.
State-of-the-art hand hygiene State-of-the-art hand hygiene in community medicine is hygienic hand disinfection before and after patient care activities with an alcohol-based hand rub or an alcohol-based hand gel. Gels can only be recommended if they show an antimicrobial activity equal to the liquid preparations. The hand rub is usually applied for 30 s. Hands should be completely dry before the hand rub is applied. The correct technique of rubbing the preparation into the hands will help to prevent untreated skin areas with remaining microorganisms. Washing hands should be limited to situations in which hands are visibly soiled. An increasing awareness among HCWs for the best hand hygiene in community medicine will certainly help to reduce cross infections in the community and may thereby help to limit the spread of multi-drug resistant bacteria outside the hospital.
Cost effectiveness Cost effectiveness is difficult to determine in hand hygiene and has not been studied in community medicine yet. Only limited data from hospitals is available. In one study it has been calculated that the cost of using an alcohol-based hand rub was half as much as the use of an antimicrobial soap for hand washing (Larson et al., 2001). So far only one study has been carried out in which a significant reduction of nosocomial infection due to the promotion of hand hygiene was observed, and in which cost effectiveness calculation was attempted. Over a period of 4 years compliance among HCWs with hand hygiene increased from 48% to 66% (p < 0.001) mostly as a result of enhanced recourse to alcohol-based hand disinfection. The intervention was also associated with a significant reduction in MRSA cross transmission (Pittet et al., 2000). The total cost of the campaign was estimated to be 380.000 SFr. Using a conservative estimate of SFr 3500 saved per hospital-acquired infection, prevention of 108 infections would have offset the whole program costs. And assuming that only 1³4 of the
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