WHO Hand Hygiene

8/18/2019 WHO Hand Hygiene

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WHO Guidelineson Hand Hygiene in Health Care

First Global Patient SafetyChallenge Clean Care is Safer Care


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WHO Library Cataloguing-in-Publication Data

WHO guidelines on hand hygiene in health care.

1.Hand ash - standards. !.Hygiene. ".Cross infection - #re$entionand control. %.Patient care - standards. &.Health facilities -standards. '.Guidelines. (.World Health Organi)ation. ((.World *lliance for Patient Safety.

(S+, / ! % 1&0 ' ,L2 classification3 W+ "004

5 World Health Organi)ation !00

*ll rights reser$ed. Publications of the World Health Organi)ationcan be obtained fro6 WHO Press7 World Health Organi)ation7 !0 *$enue *##ia7 1!11 Gene$a !7 Sit)erland tel.3 8%1 !! 1 "!'%9fa:3 8%1 !! 1 %/&9 e-6ail3 boo;ordersuests for#er6ission to re#roduce or translate WHO #ublications ? hether

for sale or for nonco66ercial distribution ? should be addressed toWHO Press7 at the abo$e address fa:3 8%1 !! 1 %/0'9 e-6ail3#er6issions


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Printed in


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WHO Guidelineson Hand Hygiene in Health Care

First Global Patient SafetyChallenge Clean Care is Safer Care


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CO,@B,@S

CONTENTS

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1. Definition of ter6s !

!. Guideline #re#aration #rocess %

2.1 Pre#aration of the *d$anced Draft

2.2 Pilot testing the *d$anced Draft

2.3 Finali)ation of the WHO Guidelines on Hand Hygiene in Health Care

". @he burden of health care-associated infection '

".1 Health care-associated infection in de$elo#ed countries

".! +urden of health-care associated infection in de$elo#ing countries

%. Historical #ers#ecti$e on hand hygiene in health care

&. ,or6al bacterial flora on hands 10

'. Physiology of nor6al s;in 11

. @rans6ission of #athogens by hands 1!

7.1 Organis6s #resent on #atient s;in or in the inani6ate en$iron6ent

7.2 Organis6 transfer to health-care or;ersA hands

7.3 Organis6 sur$i$al on hands

7.4 Defecti$e hand cleansing7 resulting in hands re6aining conta6inated

7.5 Cross-trans6ission of organis6s by conta6inated hands

/. 2odels of hand trans6ission !!

/.1 B:#eri6ental 6odels

/.! 2athe6atical 6odels

. =elationshi# beteen hand hygiene and the ac>uisition of !%

health care-associated #athogens

10. 2ethods to e$aluate the anti6icrobial efficacy of handrub and !&

handash agents and for6ulations for surgical hand #re#aration

10.1 Current 6ethods

10.2 Shortco6ings of traditional test 6ethods

10.3 @he need for better 6ethods

11. =e$ie of #re#arations used for hand hygiene "0

11.1 Water

11.2 Plain non-anti6icrobial4 soa#

11.3 *lcohols

11.4 Chlorhe:idine

11.5 Chloro:ylenol

11.6 He:achloro#hene

11.7 (odine and iodo#hors

11.8 uaternary a66oniu6 co6#ounds

11.9 @riclosan

11.10 Other agents

11.11 *cti$ity of antise#tic agents against s#ore-for6ing bacteria

11.12 =educed susce#tibility of 6icrorganis6s to antise#tics

11.13 =elati$e efficacy of #lain soa#7 antise#tic soa#s anddetergents7 and alcohols


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(


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WHO G(DBL(,BS O, H*,D HEG(B,B (, HB*L@H C*=B

1!. WHO-reco66ended handrub for6ulation %

12.1 General re6ar;s

12.2 Lessons learnt fro6 local #roduction of the WHO-reco66ended handrub for6ulations in

different settings orldide

1". Surgical hand #re#aration3 state-of-the-art &%

1".1 B$idence for surgical hand #re#aration

1".! Obecti$e of surgical hand #re#aration

1"." Selection of #roducts for surgical hand #re#aration

1".% Surgical hand antise#sis using 6edicated soa#

1".& Surgical hand #re#aration ith alcohol-based handrubs

1".' Surgical hand scrub ith 6edicated soa# or surgical hand #re#aration

ith alcohol-based for6ulations

1%. S;in reactions related to hand hygiene '1

1%.1 Fre>uency and #atho#hysiology of irritant contact der6atitis

1%.! *llergic contact der6atitis related to hand hygiene #roducts1%." 2ethods to reduce ad$erse effects of agents

1&. Factors to consider hen selecting hand hygiene #roducts '%

1&.1 Pilot testing

1&.! Selection factors

1'. Hand hygiene #ractices a6ong health-care or;ers ''

and adherence to reco66endations

16.1 Hand hygiene #ractices a6ong health-care or;ers

16.2 Obser$ed adherence to hand cleansing

16.3 Factors affecting adherence

1. =eligious and cultural as#ects of hand hygiene /

1.1 (6#ortance of hand hygiene in different religions

1.! Hand gestures in different religions and cultures

1." @he conce#t of $isibly dirtyI hands

1.% se of alcohol-based handrubs and alcohol #rohibition by so6e religions

1.& Possible solutions

1/. +eha$ioural considerations /&

1/.1 Social sciences and health beha$iour

1/.! +eha$ioural as#ects of hand hygiene

1. Organi)ing an educational #rogra66e to #ro6ote hand hygiene /

19.1 Process for de$elo#ing an educational #rogra66e hen i6#le6enting guidelines19.2 Organi)ation of a training #rogra66e

19.3 @he infection control lin; health-care or;er

!0. For6ulating strategies for hand hygiene #ro6otion "

20.1 Ble6ents of #ro6otion strategies

20.2 De$elo#ing a strategy for guideline i6#le6entation

20.3 2ar;eting technology for hand hygiene #ro6otion

!1. @he WHO 2ulti6odal Hand Hygiene (6#ro$e6ent Strategy

21.1 Jey ele6ents for a successful strategy

21.2 Bssential ste#s for i6#le6entation at heath-care setting le$el21.3 WHO tools for i6#le6entation

21.4 2y fi$e 6o6ents for hand hygieneI

21.5 Lessons learnt fro6 the testing of the WHO Hand Hygiene(6#ro$e6ent Strategy in #ilot and co6#le6entary sites

!!. (6#act of i6#ro$ed hand hygiene 1!%


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((


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CO,@B,@S

!". Practical issues and #otential barriers to o#ti6al hand hygiene #ractices 1!/

!".1 Glo$e #olicies

!".! (6#ortance of hand hygiene for safe blood and blood #roducts

!"." Keellery

!".% Fingernails and artificial nails!".& (nfrastructure re>uired for o#ti6al hand hygiene

!".' Safety issues related to alcohol-based #re#arations

!%. Hand hygiene research agenda 1%'

P*=@ ((. CO,SB,SS =BCO22B,D*@(O,S 1&1

1. =an;ing syste6 for e$idence

!. (ndications for hand hygiene

". Hand hygiene techni>ue

%. =eco66endations for surgical hand #re#aration

&. Selection and handling of hand hygiene agents'. S;in care

. se of glo$es

/. Other as#ects of hand hygiene

. Bducational and 6oti$ational #rogra66es for health-care or;ers

10. Go$ern6ental and institutional res#onsibilities

11. For health-care ad6inistrators

1!. For national go$ern6ents

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1. Hand hygiene as a #erfor6ance indicator 1&/

1.1 2onitoring hand hygiene by direct 6ethods1.2 @he WHO-reco66ended 6ethod for direct obser$ation

1.3 (ndirect 6onitoring of hand hygiene #erfor6ance

1.4 *uto6ated 6onitoring of hand hygiene

!. Hand hygiene as a >uality indicator for #atient safety 1'%

". *ssessing the econo6ic i6#act of hand hygiene #ro6otion 1'/

3.1 ,eed for econo6ic e$aluation

3.2 Cost?benefit and cost?effecti$eness analyses

3.3 =e$ie of the econo6ic literature

3.4 Ca#turing the costs of hand hygiene at institutional le$el3.5 @y#ical cost-sa$ings fro6 hand hygiene #ro6otion #rogra66es

3.6 Financial strategies to su##ort national #rogra66es

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1. (ntroduction 1&

!. Obecti$es 1&

". Historical #ers#ecti$e 1'

%. Public ca6#aigning7 WHO7 and the 6ass 6edia 1

4.1 ,ational ca6#aigns ithin health care

&. +enefits and barriers in national #rogra66es 1/

'. Li6itations of national #rogra66es 1


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(((


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. @he rele$ance of social 6ar;eting and social 6o$e6ent theories 1/0

7.1 Hand hygiene i6#ro$e6ent ca6#aigns outside of health care/. ,ationally dri$en hand hygiene i6#ro$e6ent in health care 1/1

. @oards a blue#rint for de$elo#ing7 i6#le6enting and e$aluating a 1/!

national hand hygiene i6#ro$e6ent #rogra66e ithin health care

10. Conclusion 1/!

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1. O$er$ie and ter6inology 10

!. Patient e6#oer6ent and health care 10

". Co6#onents of the e6#oer6ent #rocess 11

3.1 Patient #artici#ation

3.2 Patient ;noledge

3.3 Patient s;ills

3.4 Creation of a facilitating en$iron6ent and #ositi$e de$iance

%. Hand hygiene co6#liance and e6#oer6ent 1!

%.1 Patient and health-care or;er e6#oer6ent

&. Progra66es and 6odels of hand hygiene #ro6otion7 including #atient 1%

and health-care or;er e6#oer6ent

5.1 B$idence

5.2 Progra66es

'. WHO global sur$ey of #atient e:#eriences 1&

. Strategy and resources for de$elo#ing7 i6#le6enting7 and e$aluating 1'

a #atienthealth-care or;er e6#oer6ent #rogra66e in a health-care

facility or co66unity

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1. Definitions of health-care settings and other related ter6s !%0

! Guide to a##ro#riate hand hygiene in connection ith Clostridiu6 difficile s#read !%!

". Hand and s;in self-assess6ent tool !%'

% 2onitoring hand hygiene by direct 6ethods !%

&. B:a6#le of a s#readsheet to esti6ate costs !&0

'. WHO global sur$ey of #atient e:#eriences in hand hygiene i6#ro$e6ent !&1

*++=B(*@(O,S !&/

*CJ,OWLBDGB2B,@S !&

(


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@he WHO Guidelines on Hand Hygiene in Health Care #ro$ide health-care or;ers HCWs47 hos#italad6inistrators and health authorities ith a thorough re$ie of e$idence on hand hygiene in health care ands#ecific reco66endations to i6#ro$e #ractices and reduce trans6ission of #athogenic 6icroorganis6s to #atientsand HCWs. @he #resent Guidelines are intended to be i6#le6ented in any situation in hich health care isdeli$ered either to a #atient or to a s#ecific grou# in a #o#ulation. @herefore7 this conce#t a##lies to all settingshere health care is #er6anently or occasionally #erfor6ed7 such as ho6e care by birth attendants. Definitions ofhealth-care settings are #ro#osed in *##endi: 1. @hese Guidelines and the associated WHO 2ulti6odal HandHygiene (6#ro$e6ent Strategy and an (6#le6entation @ool;it htt#3.ho.intg#scen4 are designed to offerhealth-care facilities in 2e6ber States a conce#tual fra6eor; and #ractical tools for the a##lication ofreco66endations in #ractice at the bedside. While ensuring consistency ith the GuidelinesA reco66endations7indi$idual ada#tation according to local regulations7 settings7 needs7 and resources is desirable.

@he de$elo#6ent of the Guidelines began in autu6n !00% and

the #re#aration #rocess is thoroughly described in Part (7 Section

!. (n brief7 the #resent docu6ent is the result of the u#date and

finali)ation of the *d$anced Draft7 issued in *#ril !00'7 according

to the literature re$ie and data and lessons learnt fro6 #ilot

testing. * Core Grou# of e:#erts coordinated the or; of

re$ieing the a$ailable scientific e$idence7 riting

the docu6ent7 and fostering discussion a6ong authors9 6ore

than 100 international e:#erts contributed to #re#aring the

docu6ent. *uthors7 technical contributors7 e:ternal re$ieers7

and #rofessionals ho acti$ely #artici#ated in the or; #rocess

u# to final #ublication are listed in the *c;noledge6ents at the

end of the docu6ent.

@he WHO Guidelines on Hand Hygiene in Health Care #ro$ide a

co6#rehensi$e re$ie of scientific data on hand hygiene

rationale and #ractices in health care. @his e:tensi$e re$ie

includes in one docu6ent sufficient technical infor6ation

to su##ort training 6aterials and hel# #lan i6#le6entation

strategies. @he docu6ent co6#rises si: #arts9 for con$enience7 the

figures and tables are nu6bered to corres#ond to the #art and the

section in hich they are discussed3

1• Part ( re$ies scientific data on hand hygiene #ractices inhealth care and in health-care settings in #articular.

2• Part (( re#orts consensus reco66endations of the

international #anel of

e:#erts 6andated by

WHO together ith

grading of the e$idence

and #ro#oses

guidelines that could be

used orldide.

3• Part ((( discusses#rocess and outco6e6easure6ents.

4• Part ( #ro#oses the

#ro6otion of handhygiene on a large

scale.

5• Part co$ers theas#ect of #atient

#artici#ation in handhygiene #ro6otion.

6• Part ( re$ies e:istingnational and sub-nationalguidelines for hand

hygiene.

*n B:ecuti$e Su66ary of the

*d$anced Draft of the

Guidelines is a$ailable as a

se#arate docu6ent7 in

Chinese7 Bnglish7 French7

=ussian and S#anish $ersions

htt#3.ho.

intg#sctoolsen4. *n

B:ecuti$e Su66ary of the

#resent Guidelines ill be

translated into all WHO official

languages.

(t is antici#ated that the

reco66endations in theseGuidelines ill re6ain $alid

until !011. @he Patient Safety

De#art6ent (nfor6ation7

B$idence and =esearch

Cluster4 at WHO

head>uarters is co66itted to

ensuring that the WHO

Guidelines on Hand Hygiene

in Health Care are u#dated

e$ery to to three years.


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P*=@ (.

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1.

Definition of ter6s

Hand hygiene. * general ter6 referring to any action of hand cleansingsee belo Hand hygiene #racticesI4.

Hand hygiene #roducts

*lcohol-based hand4 rub. *n

alcohol-containing#re#aration li>uid7 gel or

foa64 designed fora##lication to the hands

to inacti$ate

6icroorganis6s andorte6#orarily su##ress their

groth. Such #re#arations

6ay contain one or 6ore

ty#es of alcohol7 other

acti$e ingredients ith

e:ci#ients7 and

hu6ectants.

*nti6icrobial 6edicated4

soa#. Soa# detergent4

containing an antise#tic agent

at a concentration sufficient to

inacti$ate 6icroorganis6s

andor te6#orarily su##ress

their groth. @he detergentacti$ity of such soa#s 6ay

also dislodge transient

6icroorganis6s or other

conta6inants fro6 the s;in to

facilitate their subse>uent

re6o$al by ater.

*ntise#tic agent. *n

anti6icrobial substance that

inacti$ates 6icroorganis6sor inhibits their groth on

li$ing tissues. B:a6#lesinclude alcohols7

chlorhe:idine gluconate

CHG47 chlorine deri$ati$es7

iodine7 chloro:ylenol

PC2M47 >uaternary

a66oniu6 co6#ounds7

and triclosan.

*ntise#tic hand i#e. *

#iece of fabric or #a#er #re-

etted ith an antise#tic

used for i#ing hands to

inacti$ate andor re6o$e6icrobial conta6ination.

@hey 6ay be considered as

an alternati$e to ashing

hands ith non-

anti6icrobial soa# and

ater but7 because they are

not as effecti$e at reducing

bacterial counts on HCWsA

hands as alcohol-

based handrubs or

ashing hands ith

an anti6icrobial

soa# and ater7

they are not a

substitute for using

an alcohol-based

handrub or

anti6icrobial soa#.

Detergent

surfactant4.

Co6#ounds that

#ossess a cleaning

action. @hey are

co6#osed of a

hydro#hilic and a

li#o#hilic #art and

can be di$ided into

four grou#s3 anionic7

cationic7 a6#hoteric7

and non-ionic.

*lthough #roducts

used for

handashing or

antise#tic handash

in health care

re#resent

$arious ty#es ofdetergents7 the ter6

soa#I ill be used torefer to such

detergents in these

guidelines.

Plain soa#.

Detergents thatcontain no added

anti6icrobial

agents7 or 6ay

contain these

solely as

#reser$ati$es.

Waterless antise#tic

agent. *n antise#tic

agent li>uid7 gel or

foa64 that does not

re>uire the use of

e:ogenous ater. *fter a##lication7 the

indi$idual rubs the

hands together until

the s;in feels dry.

Hand hygiene#ractices

*ntise#tichandashing.

Washing hands ithsoa# and ater7 or

other detergentscontaining an

antise#tic agent.


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*ntise#tic handrubbing

or handrubbing4.

*##lying an antise#tic

handrub to reduce or

inhibit the groth of

6icroorganis6s ithout the

need for an e:ogenous

source of ater and

re>uiring no rinsing or drying

ith toels or other de$ices.

Hand

antise#sisdeconta6inationdeg

er6ing. =educing or inhibiting

the groth of 6icroorganis6s

by the a##lication of an

antise#tic handrub or by

#erfor6ing an antise#tic

handash.

Hand care. *ctions to

reduce the ris; of s;inda6age or irritation.

Handashing. Washinghands ith #lain or

anti6icrobial soa# and ater.

Hand cleansing. *ction of

#erfor6ing hand hygiene

for the #ur#ose of

#hysically or 6echanically

re6o$ing dirt7 organic

6aterial7 andor

6icroorganis6s.

Hand disinfection is e:tensi$ely

used as a ter6 in so6e #arts of

the orld and can refer to

antise#tic handash7 antise#tic

handrubbing7 hand

antise#sisdeconta6inationdeg

er6ing7 handashing

ith an anti6icrobial

soa# and ater7

hygienic hand

antise#sis7 or hygienic

handrub. Since

disinfection refers

nor6ally to the

deconta6ination of

inani6ate surfaces

and obects7 this ter6

is not used in these

Guidelines.

Hygienic hand

antise#sis.

@reat6ent of

hands ith either

an antise#tichandrub or

antise#tic

handash to

reduce the

transient 6icrobial

flora ithout

necessarilyaffecting the

resident s;in flora.

Hygienic handrub.

@reat6ent of hands

ith an antise#tic

handrub to reduce

the transient floraithout necessarily

affecting the


@hese #re#arations

are broad s#ectru6and fast-acting7 and

#ersistent acti$ity is

not necessary.

Hygienic handash.

@reat6ent of hands

ith an antise#tic

handash andater to reduce the

transient flora

ithout necessarily

affecting the

resident s;in flora. (t

is broad s#ectru67

but is usually less

efficacious and acts

6ore sloly than

the hygienic

handrub.

Surgical hand

antise#sissurgical

hand #re#aration

#resurgical hand

#re#aration.

*ntise#tic handash

or antise#tic handrub

#erfor6ed

#reo#erati$ely by the

surgical tea6 toeli6inate transient

flora and reduce


Such antise#tics

often ha$e #ersistent

anti6icrobial acti$ity.

Surgicalhandscrubbing4#res

urgical scrub refer to

surgical hand

#re#aration ith

anti6icrobial soa#

and ater. Surgicalhandrubbing4 refers

to surgical hand

#re#aration ith a

aterless7 alcohol-

based handrub.!


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P*=@ (. =B(BW OF SC(B,@(F(C D*@* =BL*@BD @O H*,D HEG(B,B

*ssociatedter6s

Cu6ulati$e

effect. (ncreasinganti6icrobialeffect ith

re#eateda##lications of a

gi$en antise#tic.

Bfficacyefficace

ous. @he#ossible4 effect

of the a##lication

of a hand

hygiene

for6ulation hentested in

laboratory or in

$i$o situations.

Bffecti$enesseff

ecti$e. @he

clinical

conditions under

hich a hand

hygiene #roduct

has been tested

for its #otential to

reduce the

s#read of

#athogens7 e.g.field trials.

B:ci#ient. (nertsubstance

included in a#roduct

for6ulation toser$e as a

$ehicle for theacti$e

substance.

Health-care

area. Conce#t

related to the

geogra#hicalI

$isuali)ation

of ;ey

6o6ents for

hand hygiene.

(t contains all

surfaces in

the health-

care setting

outside the#atient )one

of #atient M7i.e. other

#atients and

their #atient

)ones and the

health-care

facility

en$iron6ent.

Hu6ectant.

(ngredients4added to hand

hygiene#roducts to

6oisturi)e thes;in.

2edical

glo$es.Dis#osable

glo$es used

during

6edical

#rocedures9

they include

e:a6ination

sterile or

non-sterile4

glo$es7

surgical

glo$es7 and

6edicalglo$es for

handlingche6othera

#y agents

che6other

a#y glo$es4.

Patient )one.

Conce#t related

to the

geogra#hicalI

$isuali)ation of

;ey 6o6ents forhand hygiene. (t

contains the

#atient M and

hisheri66ediate

surroundings.

@his ty#ically

includes the

intact s;in of the

#atient and all

inani6ate

surfaces that are

touched by or in

direct #hysical

contact ith the

#atient such as

the bed rails7

bedside table7

bed linen7

infusion tubing

and other

6edical

e>ui#6ent. (t

further contains

surfaces

fre>uently

touched byHCWs hile

caring for the

#atient such as

6onitors7 ;nobs

and buttons7 and

other high

fre>uencyI touch

surfaces.

Persistent

acti$ity. @he#rolonged or

e:tended

anti6icrobial

acti$ity that

#re$ents the

groth or

sur$i$al of

6icroorganis6

s aftera##lication of a

gi$en

antise#tic9 also

called

residualI7

sustainedI or

re6nantI

acti$ity. +oth

substanti$e

and non-

substanti$e

acti$e

ingredients cansho a

#ersistent

effect

significantly

inhibiting the

groth of

6icroorganis6

s after

a##lication.

Point of care.

@he #lace here

three ele6entsco6e together3

the #atient7 the

HCW7 and care

or treat6ent

in$ol$ing contact

ith the #atient

or hisher

surroundings

ithin the

#atient )one4.1

@he conce#t

e6braces the

need to #erfor6

hand hygiene at

reco66ended

6o6ents e:actly

here care

deli$ery ta;es

#lace. @his

re>uires that a

hand hygiene

#roduct e.g.

alcohol-based

handrub7 if

a$ailable4 be

easily accessible

and as close as

#ossible ? ithin

ar6As reach of

here #atient

care or treat6ent

is ta;ing #lace.

Point-of-care

#roducts should

be accessible


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ithout ha$ing to

lea$e the #atient

)one.

=esident flora

resident

6icrobiota4.

2icroorganis6s

residing under

the su#erficial

cells of the

stratum corneum

and also found

on the surface of

the s;in.

Substanti$ity.

*n attribute ofso6e acti$e

ingredients that

adhere to the

stratum

corneum and#ro$ide an

inhibitory effect

on the groth

of bacteria by

re6aining on

the s;in after

rinsing or

drying.

Surrogate6icroorganis6. *

6icroorganis6

used tore#resent a gi$en

ty#e or category

of nosoco6ial

#athogen hen

testing the

anti6icrobial

acti$ity of

antise#tics.

Surrogates are

selected for their

safety7 ease ofhandling7 and

relati$e

resistance to

anti6icrobials.

@ransient

flora

transient

6icrobiota4.

2icroorganis6s that

coloni)e the

su#erficial

layers of

the s;in

and are

6ore

a6enable

to re6o$al

by routine

handashin

g.

isibly soiledhands. Hands

on hich dirtor body fluids

are readily$isible.

"


18/527


2.

GuidelinesA #re#aration #rocess

@he #re#aration #rocess of the WHO Guidelines on Hand Hygiene in Health Care in$ol$ed the ste#s that arebriefly described in this section.

!.1 Pre#aration of the *d$anced Draft

@he #resent guidelines ere de$elo#ed by the Clean

Care is Safer CareI tea6 Patient Safety De#art6ent7

(nfor6ation7 B$idence and =esearch Cluster4.

* Core Grou# of international e:#erts in the field of

infection control7 ith s#ecific e:#ertise in hand hygiene7

#artici#ated in the riting and re$ision of the docu6ent.@he grou# as constituted at WHO Head>uarters in

Gene$a in Dece6ber !00%. During its first 6eeting7 the

e:#erts discussed the a##roach to be e6#hasi)ed in these

guidelines and their content and dre u# a #lan for their

#re#aration. @he obecti$es identified ere to de$elo# a

docu6ent including a co6#rehensi$e o$er$ie of

essential as#ects of hand hygiene in health care and

e$idence- and consensus-based reco66endations for

o#ti6al hand hygiene #ractices and

successful hand hygiene #ro6otion. sers ere 6eant to be

#olicy-6a;ers7 6anagers and HCWs in different settings and

geogra#hical areas. (t as decided to ado#t the CDC

Guideline for Hand Hygiene in Health-Care Settings issued in

!00! as

a basis for the #resent docu6ent but to introduce 6any

ne to#ics. * distincti$e feature of the #resent Guidelines

is the fact that they ere concei$ed ith a global

#ers#ecti$e9 therefore7 they are not targeted at only

de$elo#ing or de$elo#ed countries7 but at all countries

regardless of the resources a$ailable see also Part (4.

arious tas; forces ere established @able (.!.14 to

e:a6ine different contro$ersial to#ics in de#th and reach

consensus on the best a##roach to be included in the

docu6ent for both i6#le6entation and research #ur#oses.

*ccording to their

e:#ertise7 authors ere assigned $arious cha#ters7 thecontent of hich had to be based on the scientific literature

and their e:#erience. * syste6atic re$ie of the literature as

#erfor6ed through Pub2ed nited States ,ational Library of

2edicine47 O$id7 2BDL(,B7 B2+*SB7 and the Cochrane

Library7 and secondary #a#ers ere identified fro6 reference

lists and e:isting rele$ant guidelines. (nternational and

national infection control guidelines and te:tboo;s ere also

consulted. *uthors #ro$ided the list of ;eyords that they

used for use in the ne:t u#date of the Guidelines.

(n *#ril !00& and 2arch !00'7 the Core Grou# recon$ened

at WHO Head>uarters in Gene$a for tas; force 6eetings7

final re$ision7 and consensus on the first draft.=eco66endations ere for6ulated on the basis of the

e$idence described in the $arious sections9 their ter6inology

and consistency ere

discussed in de#th during the e:#ert consultations. (n

addition to e:#ert consensus7 the criteria de$elo#ed by the

Healthcare (nfection Control Practices *d$isory Co66ittee

H(CP*C4 of the nited States Centers for Disease Control

and Pre$ention CDC47 *tlanta7 G*7 ere used to categorise

the consensus

reco66endations in the

WHO Guidelines for Hand

Hygiene

in Health Care @able (.!.!4. (n

the case of difficulty in

reaching consensus7 the

$oting syste6 as ado#ted.

@he final draft as sub6itted

to a list of e:ternal and

internal re$ieers hose

co66ents ere considered

during the 2arch !00' Core

Grou# consultation. @he *d$anced Draft of the WHO

Guidelines on Hand Hygiene

in Health Care as #ublished

in *#ril !00'.

!.! Pilot testing the *d$anced Draft

*ccording to WHO

reco66endations for

guideline #re#aration7 a

testing #hase of theguidelines as underta;en.

(n #arallel ith the *d$anced

Draft7 an i6#le6entation

strategy

WHO 2ulti6odal Hand

Hygiene (6#ro$e6ent

Strategy4 as

de$elo#ed7 together ith

a ide a range of tools

Pilot

(6#le6entation Pac;4 to

hel# health-care settings to

translate the guidelines into

#ractice see also Part (7

Sections !1.1?%4. @he ai6s

of this testing ere3 to

#ro$ide local data on the

resources re>uired to carry

out the reco66endations9 to

generate infor6ation on

feasibility7 $alidity7 reliability7

and cost? effecti$eness of

the inter$entions9 and toada#t and refine #ro#osed

i6#le6entation strategies.

Bight #ilot sites fro6 se$en

countries re#resenting thesi: WHO regions ere

selected for #ilot testing and

recei$ed technical and7 in

so6e cases7 financial

su##ort fro6 the First Global

Patient Safety Challenge

tea6 see also Part (7

Section !1.&4. Other health-


19/527

care settings around the orld $olunteered to #artici#ate

autono6ously in the testing #hase7 and these ere na6ed

co6#le6entary test sitesI. *nalysis of data and e$aluation

of the lessons learnt fro6 #ilot and co6#le6entary sitesere underta;en and are re#orted in Part (7 Section !1.&.

!." Finali)ation of the WHO Guidelines onHand Hygiene in Health Care

(n *ugust !007 the e:#ert Core Grou# recon$ened in Gene$a

to start the #rocess of guideline finali)ation. *uthors ere

as;ed to u#date their te:t according to rele$ant ne

#ublications u# to October !00 and to return the or; by

Dece6ber !009 so6e authors ere as;ed to rite ne

cha#ters by the sa6e

deadline. @he First Global

Patient Safety Challenge

tea6 and the Guidelines’

editor contributed ith the

content of se$eral cha#ters

and too; the res#onsibility to

re$ise the u#dated and ne

6aterial7 to #erfor6 technical

editing7 and to add any further

rele$ant reference #ublished

beteen October !00 and

Kune !00/. Si: ne cha#ters7

11 additional #aragra#hs7 and

three ne a##endices ere

added in the #resent final

$ersion co6#ared ith the

*d$anced Draft. B:ternal and

internal

re$ieers ere as;ed again

to co66ent on the ne

#arts of the guidelines.

(n Se#te6ber !00/7 the last

Core Grou# consultation too;

#lace in Gene$a. @he final

draft of the Guidelines as

circulated

%


20/527


ahead of the 6eeting7 including rele$ant co66ents fro6 the

re$ieers. * s#ecific session of the 6eeting as dedicated to

the e$aluation of data and lessons learnt fro6 the testing sites

and ho to integrate these as#ects into the te:t. Final

discussion too; #lace about the content of the final $ersion of the docu6ent ith a #articular focus on the

reco66endations and the research agenda7 and re$ieersA

co66ents and >ueries9 a##ro$al as obtained by

consensus. Folloing the consultation7 the final a6end6ents

and insertions ere 6ade and7 at the latest stage7 the

docu6ent as sub6itted to a WHO reference editor.

Table I.2.1

Task forces for discussion and expert consensus on critical issues related to hand hygiene in health care

Task forces on hand hygiene in health care

1• +eha$ioural changes

2• Bducationtrainingtools

3• WHO-reco66ended hand antise#sis for6ulations

4• Glo$e use and reuse

5• Water >uality for handashing

6• Patient in$ol$e6ent

7• =eligious and cultural as#ects of hand hygiene

8• (ndicators for ser$ice i6#le6entation and 6onitoring

9• =egulation and accreditation

10• *d$ocacyco66unicationca6#aigning

11• ,ational guidelines on hand hygiene

12• Fre>uently as;ed >uestionsI de$elo#6ent

Table I.2.2

odified C!C"#IC$%C ranking syste& for e'idence

C%TE(O)* C)ITE)I%

(* Strongly reco66ended for i6#le6entation and strongly su##orted by ell-designed e:#eri6ental7 clinical7 or e#ide6iological studies.

(+ Strongly reco66ended for i6#le6entation and su##orted by so6e e:#eri6ental7 clinical7 or e#ide6iologicalstudies and a strong theoretical rationale.

(C =e>uired for i6#le6entation7 as 6andated by federal andor state regulation or standard.

(( Suggested for i6#le6entation and su##orted by suggesti$e clinical or e#ide6iological studies or a theoreticalrationale or a consensus by a #anel of e:#erts.

&


21/527


+.

@he burden of health care-associated infection

@his section su66ari)es the e#ide6iological data and rele$ant issues related to the global burden of healthcare-associated infection HC*(4 and e6#hasi)es the i6#ortance of #re$enting HC*( by gi$ing #riority to the#ro6otion of hand hygiene best #ractices in health care. When a$ailable7 national or 6ulticentre sur$eys ere#referred to single hos#ital sur$eys7 and only studies or re#orts #ublished in Bnglish ere considered. @hiso$er$ie of a$ailable data on HC*( is therefore not to be considered e:hausti$e7 but rather as an infor6ati$e7e$idence-based introduction to the to#ic of hand hygiene in health care.

HC*( is a 6aor #roble6 for #atient safety and its sur$eillance

and #re$ention 6ust be a first #riority for settings and

institutions co66itted to 6a;ing health care safer. @he i6#act

of HC*( i6#lies #rolonged hos#ital stay7 long-ter6 disability7

increased resistance of 6icroorganis6s to anti6icrobials7

6assi$e additional financial burden7 high costs for #atients and

their fa6ilies7 and e:cess deaths. *lthough the ris; of ac>uiring

HC*( is uni$ersal and #er$ades e$ery health-care facility

and syste6 around the orld7 the global burden is un;non

because of the difficulty of gathering reliable diagnostic

data. O$erall esti6ates indicate that 6ore than 1.% 6illion

#atients orldide in de$elo#ed and de$elo#ing countries are

affected at any ti6e.2 *lthough data on the burden of diseases

orldide that are #ublished in WHOAs World Health Reports

infor6 HCWs7 #olicy-6a;ers7 and the #ublic of the 6ost

i6#ortant diseases in ter6s of 6orbidity and 6ortality7 HC*(

does not a##ear on the list of the 1"' diseases e$aluated. @he

6ost li;ely reason is that the diagnosis of HC*( is co6#le:7

relying on 6ulti#le criteria and not on a single laboratory test. (n

addition7 although national sur$eillance syste6s e:ist in 6any

industriali)ed countries7! e.g. the ,ational ,osoco6ial (nfection

Sur$eillance ,,(S4 syste6 in the nited States of *6erica

S*4 htt#3.cdc.go$ncidoddh>#nnis.ht6l47 they often

use different diagnostic criteria and 6ethods7 hich render

international co6#arisons difficult due to bench6ar;ing

obstacles. (n de$elo#ing countries7 such syste6s are seldo6 in

#lace. @herefore7 in 6any settings7 fro6 hos#itals to

a6bulatory and long-ter6 care7 HC*( a##ears to be a

hidden7 cross-cutting concern that no institution or country

can clai6 to ha$e sol$ed as yet.

For the #ur#ose of this re$ie on the HC*( burden orldide7countries are ran;ed as de$elo#edI and de$elo#ingI

according to the World +an; classification based on their

esti6ated #er ca#ita inco6e htt#3siteresources.orldban;.

orgD*@*S@*@(S@(CS=esourcesCL*SS.MLS4.

!& 6illion e:tra days of

hos#ital stay and a

corres#onding econo6ic

burden of N1"?!% billion. (n

general7 attributable 6ortality

due to HC*( in Buro#e isesti6ated to be 1 &0 000

deaths #er year47 but HC*(

contributes to death in at

least !. of cases 1"& 000

deaths #er year4. @he

esti6ated HC*( incidence

rate in the S* as %.& in

!00!7 corres#onding to ."

infections #er 1000 #atient-

days and 1. 6illion affected

#atients9 a##ro:i6ately

000 deaths ere attributed to

HC*(." @he annual econo6ic

i6#act of HC*( in the S*

as a##ro:i6ately S '.&

billion in !00%.1#

(n the S*7 si6ilar to the

#osition in other

industriali)ed countries7

the 6ost fre>uent ty#e of

infection hos#italide is

urinary tract infection

@(4 "'47 folloed by

surgical site infection

SS(4 !047 bloodstrea6

infection +S(47 and#neu6onia both 114." (t

is noteorthy7 hoe$er7

that so6e infection ty#es

such as +S( and

$entilator-associated

#neu6onia ha$e a 6ore

se$ere i6#act than others

in ter6s of 6ortality and

e:tra-costs. For instance7

the 6ortality rate

directly attributable to +S(s in

(C #atients has been

esti6ated to be 1'?%0 and

#rolongation of the length of

stay .&?!& days.1$%1"

Further6ore7 nosoco6ial +S(7

esti6ated to account for !&0

000 e#isodes e$ery year in

the S*7 has shon a trend

toards increasing fre>uency

o$er the last decades7

#articularly in cases due to

antibiotic-resistant

organis6s.1&

@he HC*( burden is greatly

increased in high-ris;

#atients such as those

ad6itted to (Cs.

Pre$alence rates ofinfection ac>uired in (Cs

$ary fro6 .?"1./ in

Buro#e1' and ?" in the

S*7 ith crude 6ortality

rates ranging fro6 1! to

/0(.# (n the S*7 the

national infection rate in

(Cs as esti6ated to be

1" #er 1000 #atient-days in

!00!." (n (C settings

#articularly7 the use of

$arious in$asi$e de$ices

e.g. central $enous

catheter7 6echanical

$entilation or urinary

catheter4 is one of the 6osti6#ortant ris; factors for ac>uiring HC*(. De$ice-associated infection rates#er 1000 de$ice-daysdetected through the ,,(SSyste6 in the S* are

su66ari)ed in @able (.".1.2)

".1 Health care-associatedinfection in de$elo#ed countries

(n de$elo#ed countries7 HC*( concerns &?1& of hos#itali)ed #atients and can

affect ?" of those ad6itted to

intensi$e care units (Cs4.2%# =ecent

studies conducted in Buro#e re#orted

hos#ital-ide #re$alence rates of #atients

affected by HC*( ranging fro6 %.' to

.".$-1! *ccording to data #ro$ided by

the Hos#ital in Buro#e Lin; for (nfection

Control through

Sur$eillance

HBL(CS4

htt#3helics.uni$-lyon1.frhelicsho6e

. ht647

a##ro:i6ately &

6illion HC*(s are

esti6ated to occur

in acute care

hos#itals in Buro#e

annually7

re#resenting

around(n sur$eillance

studies conducted

in de$elo#ed

countries7 HC*(diagnosis relies

6ostly on

6icrobiological

andor laboratory

criteria. (n large-

scale studies

conducted in the

S*7 the

#athogens 6ost

fre>uently

detected in HC*(

are re#orted byinfection site both

hos#italide and

in (Cs.21%22

Further6ore7 in

high-inco6e

countries ith

6odern and


22/527

so#histicated health-care #ro$ision7

6any factors ha$e been shon to be

associated ith the ris; of ac>uiring an

HC*(. @hese

factors can be

related to the

infectious agent

e.g. $irulence7

ca#acity to

sur$i$e in the

en$iron6ent7

anti6icrobial

'


23/527


resistance47 the

host e.g.

ad$anced age7

lo birtheight7

underlyingdiseases7 state

of debilitation7

i66unosu##re

ssion7

6alnutrition47

and the

en$iron6ent

e.g. (C

ad6ission7

#rolonged

hos#itali)ation7in$asi$e

de$ices and

#rocedures7

anti6icrobial

thera#y4.

".! +urdenof healthcare-associatedinfection in de$elo#ingcountries

While HC*(

sur$eillance is

already a

challenging tas;

in highly

resourced

settings7 it 6ay

often a##ear an

unrealistic goal in

e$eryday care in

de$elo#ing

countries. (naddition to the

usual difficulties

to define the

diagnosis of

HC*( 6ust be

added the #aucity

and unreliability

of laboratory

data7 lac; of

standardi)ed

infor6ation fro6

6edical records7

and scarceaccess to

radiological

facilities. Li6ited

data on HC*(

fro6 these

settings are

a$ailable fro6 the

literature. @his is

ell

de6onstrated by

an electronic

search of the

#eriod 1&?

!00/7 hich

alloed the

retrie$al of

around !00

scientific #a#ers

#ublished in

Bnglish anda##ro:i6ately

100 in other

languages.2

O$erall7 no 6ore

than /0 of these

#a#ers featured

rigorous7 high

>uality7

6ethodological

characteristics.

@he 6agnitude of

the #roble6 is#articularly

rele$ant in

settings here

basic infection

control 6easures

are $irtually non-

e:istent. @his is

the result of the

co6bination of

nu6erous

unfa$ourable

factors such as

understaffing7#oor hygiene

and sanitation7

lac; or shortageof basic

e>ui#6ent7 and

inade>uatestructures and

o$ercroding7al6ost all of

hich can beattributed to

li6ited financial

resources. (n

addition to theses#ecific factors7an unfa$ourable

socialbac;ground and

a #o#ulationlargely affected

by 6alnutritionand other ty#es

of infectionandor diseases

contribute toincrease the ris;

of HC*( inde$elo#ing

countries.2!%2#

nder theseconditions7

thousands ofinfections ? in

#articular due tohe#atitis + and C

$iruses and

hu6ani66unodeficienc

y $irus H(4trans6ission ?

are still ac>uiredfro6 #atients7

but also fro6HCWs through

unsafe use ofinections7

6edical de$icesand blood

#roducts7inade>uate

surgical#rocedures7 and

deficiencies in

bio6edical aste

6anage6ent.2!

When

referring to

ende6ic

HC*(7 6any

studies

conducted in

de$elo#ing

countries

re#ort

hos#italide

rates higher

than in

de$elo#ed

countries.

,e$ertheless7

it is i6#ortant

to note that

6ost of thesestudies

concern single

hos#itals and

therefore 6ay

not be

re#resentati$e

of the #roble6

across the

hole

country.2$-$

For e:a6#le7

in one-day

#re$alence

sur$eysrecently

carried out in

single

hos#itals in

*lbania7$

2orocco7#

@unisia7! and

the nited

=e#ublic of

@an)ania7

HC*( #re$alence

rates ere

1.17 1./71.7 and

1%./7

res#ecti$ely.

Gi$en the

difficulties to

co6#ly ith the

S* Centers for

Disease Control

2"%)%-#%!-!"


24/527

and Pre$ention

CDC4 definitions

of nosoco6ial

infection7" the

6ost fre>uently

sur$eyed ty#e of

infection is SS(7

hich is the

easiest to define

according to

clinical criteria.@he ris; for

#atients tode$elo# SS( inde$elo#ingcountries issignificantlyhigher than inde$elo#edcountries e.g."0. in a#aediatrichos#ital in

,igeria7& !" in

general surgery

in a hos#ital inthe nited=e#ublic of

@an)ania7 and

1 in a6aternity unit in

Jenya' 4.

@he burden

of HC*( is

also 6uch

6ore

se$ere in

high-ris;

#o#ulations

such as

adults

housed in

(Cs and

neonates7

ith general

infection

rates7

#articularly

de$ice-

associated

infection rates7

se$eral-fold

higher than in

de$elo#ed

countries. *s an

e:a6#le7 in

@able (.".17de$ice-

associated

infection rates

re#orted fro6

6ulticentre

studies

conducted in

adult and

#aediatric (Cs

are co6#ared

ith the S*

,,(S

syste6rates.2)%!)%!1 (n

a syste6aticre$ie of the

literature7neonatalinfectionsere re#orted

to be "?!0ti6es highera6onghos#ital-born

babies in

de$elo#ingthan inde$elo#ed

countries.!2

* $ery li6ited

nu6ber of

studies fro6

de$elo#ing

countries

assessed

HC*( ris;

factors by

6ulti$ariate

analysis. @he6ost

fre>uently

identified

ere

#rolonged

length of

stay7 surgery7

intra$ascular

and urinary

catheters7

and sedati$e

6edication.

@he 6agnitude

and sco#e of the

HC*( burden

orldide

a##ears to be

$ery i6#ortant

and greatly

underesti6ated.

2ethods to

assess the si)e

and nature of the

#roble6 e:ist and

can contribute to

correct 6onitoring

and to finding

solutions.

,e$ertheless7

these tools need

to be si6#lified

and ada#ted

so as to beaffordable in

settings here

resources and

data sources

are li6ited.

Si6ilarly7

#re$enti$e

6easures

ha$e been

identified and

#ro$en

effecti$e9 they

are oftensi6#le to

i6#le6ent7

such as hand

hygiene.

Hoe$er7

based on an

i6#ro$ed

aareness of

the #roble67

infection

control 6ust

reach a higher

#ositiona6ong the

first #riorities

in national

health

#rogra66es7

es#ecially in

de$elo#ing

countries.


25/527


Table I.+.1

!e'ice,associated infection rates in IC-s in de'eloping countries co&pared ith NNIS rates

Sur'eillance netork/ Setting No. of patients C),0SI %$ C),-TI

study period/ country

(,(CC7 !00"?!00&7 P(C 17&! 1'.1 10.' &."

& de$elo#ing countriesQ!1

,,(S7 !00!?!00%7 S*2) P(C R '.' !. %.0

(,(CC7 !00!?!00&7 *dult !170' 1!.& !%.1 /./ de$elo#ing countriesT (C

,,(S7 !00!?!00%7 S*2) *dult R %.0 &.% ".(C

T O$erall #ooled 6ean4 infection rates1000 de$ice-days.

(,(CC U (nternational ,osoco6ial (nfection Control Consortiu69 ,,(S U ,ational ,osoco6ial (nfection Sur$eillance syste69 P(C U

#aediatric intensi$e care unit9 C=-+S( U cather-related bloodstrea6 infection9 *P U $entilator-associated #neu6onia9 C=-@( U catheter-

related urinary tract infection.

Q*rgentina7 Colo6bia7 2e:ico7 Peru7 @ur;ey

*rgentina7 +ra)il7 Colo6bia7 (ndia7 2e:ico7 2orocco7 Peru7 @ur;ey

=e#roduced fro6 Pittet7 !00/2# ith #er6ission fro6 Blse$ier.

/


26/527


3.

Historical #ers#ecti$eon hand hygiene in health care

Handashing ith soa# and ater has been considered a 6easure of #ersonal hygiene for centuries !&%!' and hasbeen generally e6bedded in religious and cultural habits see Part (7 Section 14. ,e$ertheless7 the lin; beteenhandashing and the s#read of disease as established only to centuries ago7 although this can be consideredas relati$ely early ith res#ect to the disco$eries of Pasteur and Lister that occurred decades later.

(n the 6id-1/00s7 studies by (gna) Se66eleis in ienna7 *ustria7

and Oli$er Wendell Hol6es in +oston7 S*7 established that

hos#ital-ac>uired diseases ere trans6itted $ia the hands of

HCWs. (n 1/%7 Se66eleiss as a##ointed as a house officer in

one of the to obstetric clinics at the ni$ersity

of ienna *llge6eine Jran;enhaus General Hos#ital4. He

obser$ed that 6aternal 6ortality rates7 6ostly attributable to

#uer#eral fe$er7 ere substantially higher in one clinic co6#ared

ith the other 1' $ersus (*.#) He also noted that doctors and

6edical students often ent directly to the deli$ery suite after

#erfor6ing auto#sies and had a disagreeable odour on their hands

des#ite handashing ith soa# and ater before entering the clinic.

He hy#othesi)ed therefore that cada$erous #articlesI ere

trans6itted $ia the hands of doctors and students fro6 the auto#sy

roo6 to the deli$ery theatre and caused the #uer#eral fe$er. *s a

conse>uence7 Se66eleis reco66ended that hands be scrubbed

in a chlorinated li6e solution before e$ery #atient contact and

#articularly after lea$ing the auto#sy roo6. Folloing the

i6#le6entation of this 6easure7 the 6ortality rate fell dra6atically

to " in the clinic 6ost affected and re6ained lo thereafter.

*#art fro6 #ro$iding the first e$idence that cleansing hea$ily

conta6inated hands ith an antise#tic agent can reduce

nosoco6ial trans6ission of ger6s 6ore effecti$ely than

handashing ith #lain soa# and ater7 this a##roach includes all

the essential ele6ents for a successful infection control

inter$ention3 recogni)e-e:#lain-actI.#1 nfortunately7 both Hol6es

and Se66eleis failed to obser$e a sustained change in their

colleaguesA beha$iour. (n #articular7 Se66eleis e:#erienced great

difficulties in con$incing his colleagues and ad6inistrators of the

benefits of this #rocedure. (n the light of the #rinci#les of social

6ar;eting today7 his 6aor error as that he i6#osed a syste6change the use of the chlorinated li6e solution4 ithout consulting

the o#inion of his collaborators. Des#ite these drabac;s7 6any

lessons ha$e been learnt

fro6 the Se66eleis inter$ention9 the recogni)e-e:#lain-actI

a##roach has dri$en 6any in$estigators and #ractitioners since

then and has also been re#licated in different fields and settings.

Se66eleis is considered not only the father of hand

hygiene7 but his inter$ention is also a 6odel of

e#ide6iologically dri$en strategies to #re$ent infection.

* #ros#ecti$e controlled trial conducted in a hos#ital nursery#2

and 6any other in$estigations conducted o$er the #ast %0

years ha$e confir6ed the i6#ortant role that conta6inatedHCWsA hands #lay in the trans6ission of health care-associated#athogens see Part (7 Sections ?4.

@he 1/0s re#resented a

land6ar; in the e$olution ofconce#ts of hand hygiene in

health care. @he first nationalhand hygiene

guidelines ere #ublished in the 1/0s7 folloed by se$eral

others in 6ore recent years in

different countries. (n 1& and

1'7 the CDCHealthcare

(nfection Control Practices

*d$isory Co66ittee H(CP*C4

in the S* reco66ended that

either anti6icrobial soa# or a

aterless antise#tic agent be

used#$%#" for cleansing hands

u#on lea$ing the roo6s of

#atients ith 6ultidrug-

resistant #athogens. 2ore

recently7 the H(CP*Cguidelines issued in !00!#&

defined alcohol-based

handrubbing7 here a$ailable7

as the standard of care for

hand hygiene #ractices in

health-care settings7 hereas

handashing is reser$ed for

#articular situations only.#' @he

#resent guidelines are based

on this #re$ious docu6ent and

re#resent the 6ost e:tensi$e

re$ie of the e$idence related

to hand hygiene in the

literature. @hey ai6 to e:#andthe sco#e of reco66endations

to a global #ers#ecti$e7 foster

discussion and e:#ert

consultation on contro$ersial

issues related to hand hygiene

in health

care7 and to #ro#ose

a #ractical a##roachfor successful

i6#le6entation seealso Part (4.

*s far as the i6#le6entationof reco66endations on

hand hygiene i6#ro$e6ent

is concerned7 $ery

significant #rogress has

been achie$ed since the

introduction and $alidation of

the conce#t that #ro6otional

strategies 6ust be

6ulti6odal to

achie$e any degree of

success. (n !0007 Pittet et al.

re#orted the e:#erience of

the Gene$aAs ni$ersity

Hos#itals ith

the i6#le6entation of a

strategy based on se$eral

essential co6#onents and

not only the introduction of

an alcohol-based handrub.

@he study shoed

re6ar;able results in ter6s

of

an i6#ro$e6ent in hand

hygiene co6#liancei6#ro$e6ent and HC*(

reduction.$) @a;ing ins#iration

fro6 this inno$ati$e

a##roach7 the results of hich

ere also de6onstrated to be

long-lasting7$1 6any other

studies including further

original as#ects ha$e

enriched the scientific

literature see @able (.!!.14.

Gi$en its $ery solid e$idence

base7 this 6odel has been

ado#ted by the First GlobalPatient Safety Challenge to

de$elo# the WHO Hand

Hygiene (6#ro$e6ent Strategy

ai6ed at translating into

#ractice the reco66endations

included in the #resent

guidelines. (n this final $ersion

of the guidelines7 e$idence

generated fro6 the #ilot testing

of the strategy during !00?

!00/ is included see also Part

(7 Section !1.&4.$2

#-##


27/527


4.

,or6al bacterial flora on hands

(n 1"/7 Price$ established that bacteria reco$ered fro6 the hands could be di$ided into to categories7 na6elyresident or transient. @he resident flora resident 6icrobiota4 consists of 6icroorganis6s residing under thesu#erficial cells of the stratum corneum and can also be found on the surface of the s;in.$!%$# Staphylococcus epidermidis is the do6inant s#ecies7$$ and o:acillin resistance is e:traordinarily high7 #articularly a6ong HCWs.$" Other resident bacteria include S. hominis and other coagulase-negati$e sta#hylococci7 folloed by corynefor6bacteria propioni+acteria7 coryne+acteria7 der6obacteria7 and 6icrococci4.$& *6ong fungi7 the 6ost co66ongenus of the resident s;in flora7 hen #resent7 is ,ityrosporum alasseia4 s##.$'. =esident flora has to 6ain#rotecti$e functions3 6icrobial antagonis6 and the co6#etition for nutrients in the ecosyste6.") (n general7 residentflora is less li;ely to be associated ith infections7 but 6ay cause infections in sterile body ca$ities7 the eyes7 or onnon-intact s;in."1

@ransient flora transient 6icrobiota47 hich coloni)es the

su#erficial layers of the s;in7 is 6ore a6enable to re6o$al byroutine hand hygiene. @ransient 6icroorganis6s do not usually

6ulti#ly on the s;in7 but they sur$i$e and s#oradically 6ulti#ly on

s;in surface.") @hey are often ac>uired by HCWs during direct

contact ith #atients or conta6inated en$iron6ental surfaces

adacent to the #atient and are the organis6s 6ost fre>uently

associated ith HC*(s. So6e ty#es of contact during routine

neonatal care are 6ore fre>uently associated ith higher le$els of

bacterial conta6ination of HCWsA hands3 res#iratory secretions7

na##ydia#er change7 and direct s;in contact."2%" @he

trans6issibility of transient flora de#ends on the s#ecies #resent7

the nu6ber of 6icroorganis6s on the surface7 and

the s;in 6oisture."!%"# @he hands of so6e HCWs 6aybeco6e #ersistently coloni)ed by #athogenic flora such as

S. aureus7 Gra6-negati$e bacilli7 or yeast."$

,or6al hu6an s;in is

coloni)ed by bacteria7 ith total

aerobic bacterial countsranging fro6 6ore than 1 : 10'

colony for6ing units CF4c6!

on the scal#7 & : 10& CFsc6!

in the a:illa7 and % : 10%

CFc6! on the abdo6en to 1

: 10% CFc6! on the

forear6."" @otal bacterial

counts on the hands of HCWs

ha$e ranged fro6 ". : 10% to

%.' : 10' CFc6!. $%"&-&)

Fingerti# conta6ination ranged

fro6 0 to "00 CF hen

sa6#led by agar contact6ethods."2 Price and

subse>uent in$estigators

docu6ented that although the

count of transient and resident

flora $aries considerablya6ong indi$iduals7 it is often

relati$ely constant for any

gi$en indi$idual.$%&1

10


28/527


5.

Physiology of nor6al s;in

The skin is composed of three layers, the epidermis (50–100 μm), dermis (1–2 mm) and hypodermis(1–2 mm) (Figure !"!1)! The #arrier to percutaneous a#sorption lies $ithin the stratum corneum, themost super%cial layer of the epidermis! The function of the stratum corneum is to reduce $ater loss,pro&ide protection against a#rasi&e action and microorganisms, and generally act as a permea#ility#arrier to the en&ironment!

The stratum corneum is a 10–20 μm thick, multilayer stratum of flat,polyhedral'shaped, 2 to μm thick, non'nucleated cells namedcorneocytes. Corneocytes are composed primarily

of insolu#le #undled keratins surrounded #y a cellen&elope sta#ilied #y cross'linked proteins andco&alently #ound lipids! *orneodesmosomes aremem#rane +unctions interconnecting corneocytes andcontri#uting to stratum corneum cohesion! Theintercellular space #et$een corneocytes is composed oflipids primarily generated from the eocytosis oflamellar #odies during the terminal di-erentiation of thekeratinocytes! These lipids are re.uired for a competentskin #arrier function!

The epidermis is composed of 10–20 layers of cells! This pluristrati%ed epithelium also containsmelanocytes in&ol&ed in skin pigmentation, and/angerhans cells, in&ol&ed in antigen presentationand immune responses! The epidermis, as for anyepithelium, o#tains its nutrients from the dermal&ascular net$ork!

6igure I.5.1

The anato&ical layers of the cutaneous tissue

The epidermis is adynamic structureand the rene$al ofthe stratum corneum iscontrolled #ycomple regulatorysystems of cellulardi-erentiation!*urrent kno$ledge of the function of thestratum corneum has

come from studies ofthe epidermalresponses topertur#ation of theskin #arrier such as(i) etraction of skinlipids $ith apolarsol&ents (ii)physical stripping of thestratum corneum usingadhesi&e tape and (iii)chemically'inducedirritation! 3ll sucheperimentalmanipulations lead to atransient decrease ofthe skin #arrier e4cacyas determined #ytransepidermal $ater

loss! These alterations of the stratum corneum generate an increase ofkeratinocyteproliferation anddi-erentiation inresponse to thisaggression6 in order torestore the skin #arrier!

This increase in thekeratinocyteproliferation rate coulddirectly in7uencethe integrity of the skin#arrier #y pertur#ing (i)the uptake of nutrients,such as essential fattyacids (ii) the synthesis of proteins and lipids or (iii) theprocessing of precursormolecules re.uired for skin#arrier function!

%nato&ical layersB#ider6is

Der6is

Subcutaneous tissue

Su#erficial fascia

Subcutaneous tissue

Dee#fascia

2uscle

11


29/527


7.

@rans6ission of #athogens by hands

@rans6ission of health care-associated #athogens fro6 one #atient to another $ia HCWsA hands re>uires fi$ese>uential ste#s Figures (..1?'43 i4 organis6s are #resent on the #atientAs s;in7 or ha$e been shed ontoinani6ate obects i66ediately surrounding the #atient9 ii4 organis6s 6ust be transferred to the hands of HCWs9iii4 organis6s 6ust be ca#able of sur$i$ing for at least se$eral 6inutes on HCWsA hands9 i$4 handashingor hand antise#sis by the HCW 6ust be inade>uate or entirely o6itted7 or the agent used for hand hygieneina##ro#riate9 and $4 the conta6inated hand or hands of the caregi$er 6ust co6e into direct contact ithanother #atient or ith an inani6ate obect that ill co6e into direct contact ith the #atient. B$idencesu##orting each of these ele6ents is gi$en belo.

.1 Organis6s #resent on #atient s;in or in the inani6ate en$iron6ent

Health care-associated #athogens can be reco$ered not only fro6

infected or draining ounds7 but also fro6 fre>uently coloni)ed

areas of nor6al7 intact #atient s;in.&2-'$ @he #erineal or inguinal

areas tend to be 6ost hea$ily coloni)ed7 but the a:illae7 trun;7 and

u##er e:tre6ities including the hands4 are also fre>uently

coloni)ed.%&$%&&%&'%'1%'%'" @he nu6ber of organis6s such as S.

aureus7 ,roteus mira+ilis7 /le+siella s##. and

0cineto+acter s##. #resent on intact areas of the s;in of so6e #atients

can $ary fro6 100 to 10' CFc6!.&$%&&%'2%'& Diabetics7 #atients

undergoing dialysis for chronic renal failure7 and those ith chronic

der6atitis are #articularly li;ely to ha$e s;in areas coloni)ed ith S.

aureus.''-1)$ . +ecause nearly 10' s;in s>ua6es containing $iable

6icroorganis6s are shed daily fro6 nor6al s;in71)" it is not sur#rising

that #atient gons7 bed linen7 bedside furniture and other obects in the

i66ediate en$iron6ent of

the #atient beco6e conta6inated ith #atient flora.

Such conta6ination is 6ost li;ely to be due to

sta#hylococci7 enterococci or Clostridium difficile hich are 6ore

resistant to desiccation. Conta6ination of the inani6ate

en$iron6ent has also been detected on ard handash station

surfaces and 6any of the organis6s isolated ere

sta#hylococci.11# @a# faucet handles ere 6ore li;ely to be

conta6inated and to be in e:cess of bench6ar; $alues than other

#arts of the station. @his study e6#hasi)es the #otential

i6#ortance of en$iron6ental conta6ination on 6icrobial cross

conta6ination and #athogen s#read.11# Certain Gra6-negati$e

rods7 such as 0cineto+acter +aumannii 7 can also #lay an i6#ortantrole in en$iron6ental conta6ination due to their long-ti6e sur$i$al

ca#acities.11$-11'

.! Organis6 transfer to health-care or;ersA hands

=elati$ely fe data are a$ailable regarding the ty#es of #atient-

care acti$ities that result in trans6ission of #atient flora to

HCWsA hands."2%&'%11)%111%12)-12 (n the #ast7 atte6#ts ha$e been

6ade to stratify #atient-care acti$ities into those 6ost li;ely to

cause hand conta6ination712! but such stratification sche6es

ere ne$er $alidated by >uantifying the le$el of bacterial

conta6ination that occurred. Caseell V Philli#s121 de6onstrated that nurses could conta6inate their hands ith

100?1000 CF of /le+siella s##. during cleanI acti$ities such

as lifting #atients9 ta;ing the #atientAs #ulse7 blood #ressure or

oral te6#erature9 or touching the #atientAs hand7 shoulder or

groin. Si6ilarly7 Bhren;ran) and colleagues&& cultured the hands

of nurses ho touched the groin of #atients hea$ily

coloni)ed ith ,. mira+ilis

and found 10?'00 CF6l in

glo$e uice sa6#les. Pittet

and colleagues"2

studiedconta6ination of HCWsA

hands before and after direct

#atient contact7 ound care7

intra$ascular catheter care7

res#iratory tract care or

handling #atient secretions.

sing agar fingerti#

i6#ression #lates7 they found

that the nu6ber of bacteria

reco$ered fro6 fingerti#s

ranged fro6 0 to "00 CF.

Direct #atient contact and

res#iratory tract care ere

6ost li;ely to conta6inate

the fingers of caregi$ers.

Gra6-negati$e bacilli

accounted for 1& of isolates

and S. aureus for 11.

(6#ortantly7 duration of #atient-

care acti$ity as strongly

associated ith the intensity of

bacterial conta6ination of

HCWsA hands in this study. *

si6ilar study of hand

conta6ination during routine

neonatal care defined s;in

contact7 na##ydia#er change7and res#iratory care as

inde#endent #redictors of hand

conta6ination." (n the latter

study7 the use of glo$es did not

fully #rotect HCWsA hands fro6

bacterial conta6ination7 and

glo$e conta6ination as

al6ost as high as unglo$ed

hand conta6ination folloing

#atient contact. (n contrast7 the

use of glo$es during

#rocedures such as na##y

dia#er change and res#iratorycare al6ost hal$ed the a$erage

increase of bacteria CF6in

on HCWsA hands."

Se$eral other studies ha$e

docu6ented that HCWs can

conta6inate their hands or

glo$es ith Gra6-negati$e

bacilli7 S. aureus7 enterococci

or C. difficile by #erfor6ing

clean #roceduresI or

touching intact areas of s;in

of hos#itali)ed

#atients.&'%'#%11)%111%12#%12$ *

recent study that in$ol$ed

culturing HCWsA hands after

$arious acti$ities shoed that

hands ere conta6inated

folloing #atient contact and

after contact ith body fluids

or aste.12" 2c+ryde and

colleagues12& esti6ated the

fre>uency of HCWsA glo$e

conta6ination ith

6ethicillin-resistant S.

aureus 2=S*4 after contact

ith a coloni)ed #atient.

HCWs ere interce#ted after

a #atient-care e#isode and

cultures ere ta;en fro6

their glo$ed hands before

handashing had occurred9

1 confidence inter$al C(4

& ?!&4 of contacts ith

#atients7 a #atientAs clothing

or a #atientAs bed resulted in

trans6ission of 2=S* fro6 a

#atient to the HCWsA glo$es.

(n another study in$ol$ing

HCWs caring for #atientsith $anco6ycin-resistant

enterococci =B47 0 of

HCWs conta6inated their

hands or glo$es by touching

the #atient and the #atientAs

en$iron6ent.11! Further6ore7

HCWs caring for infants ith

res#iratory syncytial $irus

=S4 infections ha$e

ac>uired infection by

#erfor6ing acti$ities such as

feeding infants7 na##ydia#er

change7 and #laying iththe infant.122 Caregi$ers

ho had contact only ith

surfaces conta6inated ith

the infantsA secretions also

ac>uired =S. (n the abo$e

studies7 HCWs

conta6inated their hands

ith =S and inoculated

'-'$%1)&-11!


30/527

their oral or conuncti$al 6ucosa. Other 1!


31/527


studies ha$ealso

docu6entedthat the hands

or glo$es4 ofHCWs 6ay be

conta6inated

after touchinginani6ate

obects in#atientsA

roo6s."%111%112%12

#-1)

Further6ore7 arecent to-#art

study conductedin a non-health-

care settingfound in theinitial #hase that

#atients ithnatural

rhino$irusinfections often

conta6inated6ulti#le

en$iron6entalsites in their

roo6s. (n thesecond #art of

the study7conta6inated

nasal secretionsfro6 the sa6e

indi$iduals ereused to

conta6inatesurfaces in

roo6s7 andtouching

conta6inatedsites 1?1/

hours laterfre>uently

resulted in thetransfer of the

$irus to thefingerti#s of the

indi$iduals.11

+halla and

colleagues

studied #atients

ith s;in

coloni)ation by

S. aureus

including

2=S*4 andfound that the

organis6 as

fre>uently

transferred to

the hands of

HCWs ho

touched both

the s;in of

#atients and

surrounding

en$iron6ental

surfaces.'$ Hayd

en and

colleagues

found that

HCWs seldo6

enter #atient

roo6s ithout

touching the

en$iron6ent7and that &! of

HCWs hose

hands ere free

of =B u#on

entering roo6s

conta6inated

their hands or

glo$es ith

=B aftertouching theen$iron6entithout touching

the #atient.

11!

Laboratory-based studiesha$e shon thattouchingconta6inatedsurfaces cantransfer S.aureus or Gra6-negati$e bacilli

to the fingers.12 nfortunately7none of thestudies dealing

ith HCW handconta6inationas designed todeter6ine if theconta6inationresulted in thetrans6ission of#athogens tosusce#tible#atients.

2any other

studies ha$e

re#orted

conta6ination of

HCWsA hands

ith #otential

#athogens7 but

did not relate their

findings to the

s#ecific ty#e of

#receding #atient

contact."&%"'%'!%12-

1!2 For e:a6#le7

in studies

conducted before

glo$e use as

co66on a6ongHCWs7 *yliffe and

colleagues1"

found that 1& of

nurses or;ing in

an isolation unit

carried a 6edian

of 1: 10% CF of

S. aureus on their

hands9 ! of

nurses or;ing in

a general hos#ital

had S. aureus on

their hands

6edian count7

3.8 : 10" CF47 hile /

of those or;ing

in a hos#ital for

der6atology

#atients had theorganis6 on

their hands

6edian

count7 1%." : 10'

CF4. @he sa6e

sur$ey re$ealed

that 1?"0 of

nurses carried

Gra6-negati$e

bacilli on their

hands 6ediancounts ranged fro6

".% : 10" CF to

"/ : 10" CF4.

Daschner 1# found

that S. aureus

could be reco$ered

fro6 the hands of

!1 of (Ccaregi$ers andthat !1 of doctors and &ofnurse carriers

had 10" CF of

the organis6 ontheir hands.

2a;i&) found

loer le$els ofcoloni)ation onthe hands ofHCWs or;ing ina neurosurgeryunit7 ith ana$erage of "CF of

S. aureus and

11 CF of

Gra6-negati$e

bacilli. Serial

cultures

re$ealed that

100 of HCWs

carried Gra6-

negati$e bacilli

at least once7

and '%

carried S.

aureus at least

once. * study

conducted in

to neonatal

(Cs re$ealed

that Gra6-negati$e bacilli

ere reco$ered

fro6 the hands

of "/ of

nurses.1&

7.3Organis6


32/527

sur$i$al onhands

Se$eral studies

ha$e shon the

ability of

6icroorganis6s to

sur$i$e on hands

for differing ti6es.

2usa and

colleagues

de6onstrated in a

laboratory study

that 0cineto+acter

calcoaceticus

sur$i$ed better

than strains of 0.

loffi at '0

6inutes after an

inoculu6 of 10%

CFfinger.1! *

si6ilar study by

Fry;lund and

colleagues using

e#ide6ic and

non-e#ide6ic

strains of

scherichia coli

and /le+siella

s##. shoed a

&0 ;illing to be

achie$ed at '

6inutes and !

6inutes7

res#ecti$ely.1!!

,os;in and

colleagues

studied the

sur$i$al of =B on

hands and the

en$iron6ent3 both

nterococcusfaecalis and .

faecium sur$i$ed

for at least '0

6inutes on glo$ed

and unglo$ed

fingerti#s.1!#

Further6ore7

Doring and

colleagues

shoed that

,seudomonas

aeruginosa and

3ur4holderiacepacia ere

trans6issible by

handsha;ing for

u# to "0 6inutes

hen the

organis6s ere

sus#ended in

saline7 and u# to

1/0 6inutes

hen they ere

sus#ended in

s#utu6.1!$ @he

study by (sla6

and colleaguesith Shigella

dysenteriae ty#e

1 shoed its

ca#acity to

sur$i$e on hands

for u# to 1

hour.1!" HCWs

ho ha$e hand

der6atitis 6ay

re6ain coloni)ed

for #rolonged

ti6e #eriods. For

e:a6#le7 the

hands of a HCW

ith #soriatic

der6atitis

re6ained

coloni)ed ith

Serratia

marcescens for

6ore than three

6onths.1!& *nsari

and

colleagues1!'%1#)

studied

rota$irus7 hu6an

#arainfluen)a$irus "7 andrhino$irus 1%sur$i$al onhands and#otential forcross-transfer.Sur$i$al#ercentages for

rota$irus at !0

6inutes and '06inutes afterinoculation ere1'.1 and 1./7

res#ecti$ely.iability at 1 hour for hu6an#arainfluen)a

$irus " andrhino$irus 1% asX1 and "./7

res#ecti$ely.

@he abo$e-

6entioned

studies clearly

de6onstrate that

conta6inated

hands could be

$ehicles for the

s#read of certain

$iruses and

bacteria. HCWsA

hands beco6e

#rogressi$elycoloni)ed ith

co66ensal flora

as ell as ith

#otential

#athogens during

#atient care."2%"

+acterial

conta6ination

increases linearly

o$er ti6e."2 (n

the absence of

hand hygiene

action7 the longer

the duration ofcare7 the higher

the degree

of hand

conta6ination.

Whether care

is #ro$ided to

adults or

neonates7

both the

duration and

the ty#e of

#atient care

affect HCWsAhand

conta6ination."2%" @he

dyna6ics of

hand

conta6ination

are si6ilar on

glo$ed $ersus

unglo$ed

hands9

glo$es reducehand

conta6ination7

but do not fully#rotect fro6ac>uisition of

bacteria during

#atient care.

@herefore7 the

glo$e surface is

conta6inated7

6a;ing cross-


33/527

trans6ission

through

conta6inated

glo$ed handsli;ely.

.%Defecti$ehandcleansing7 resultingin hands re6ainingconta6inated

Studies shoing

the ade>uacy or

inade>uacy of

hand cleansing by

6icrobiological

#roof are fe.

Fro6 these fe

studies7 it can be

assu6ed thathands re6ain

conta6inated ith

the ris; of

trans6itting

organis6s $ia

hands. (n a

laboratory-based

study7 Larson and

colleagues1#1

found that using

only 1 6l of li>uid

soa# or alcohol-

based handrub

yielded loer log

reductions

greater nu6ber

of bacteria

re6aining on

hands4 than using

" 6l of #roduct to

clean hands. @he

findings ha$e

clinical rele$ance

since so6e HCWsuse as little as 0.%

6l of soa# to

clean their hands.

Jac and

colleagues1#2

conducted a

co6#arati$e7

cross-o$er study

of 6icrobiological

efficacy of

handrubbing ith

an alcohol-based

solution andhandashing ith

an un6edicated

soa#. @he study

results ere3 1&

of HCWsA hands

ere

conta6inated ith

transient

#athogens before

hand hygiene9

no transient

#athogens ere

reco$ered after

handrubbing7

hile to cases

ere found

after

handashing.

@ric; and

colleagues1#

did a

co6#arati$e

study of three

hand hygiene

agents '!

ethyl alcohol

handrub7

6edicated

handi#e7 and

handashing

ith #lain soa#

and ater4 in a

grou# of

surgical (Cs.

@hey also

studied the

i6#act of ring

earing onhand

conta6ination.

@heir results

shoed that

hand

conta6ination

ith transient

organis6s as

significantly

less li;ely after

the

1"


34/527


use of an

alcohol-

based

handrub

co6#aredith the

6edicated

i#e or soa#

and ater.

=ing

earing

increased

the

fre>uency of

hand

conta6inatio

n ith

#otential

health care-

associated

#athogens.

Wearing

artificial

acrylic

fingernails

can also

result in

hands

re6aining

conta6inate

d ith

#athogensafter use

of eithersoa# oralcohol-based handgel1#! andhas beenassociatedithoutbrea;s of infection1## see alsoPart (7

Section!".%4.

Sala and

colleagues1#

$

in$estigated

an outbrea;

of food

#oisoning

attributed to

noro$irus

genogrou# 1

and traced

the inde:

case to a

food handler

in the

hos#ital

cafeteria.

2ost of the

foodstuffs

consu6ed in

the outbrea;

ere

hand6ade7

thus

suggesting

inade>uate

hand hygiene.

,os;in and

colleagues1!#

shoed that a

&-second

handash ithater alone

#roduced no

change in

conta6ination

ith =B7 and

!0 of the

initial inoculu6

as reco$ered

on unashed

hands. (n the

sa6e study7 a

&-second ash

ith to soa#s

did not re6o$e

the organis6s

co6#letely

ith

a##ro:i6ately

a 1 reco$ery9

a "0-second

ash ith

either soa#

as necessary

to re6o$e the

organis6s

co6#letely

fro6 thehands.

Ob$iously7

hen HCWs

fail to clean

their hands

beteen

#atient contact

or during the

se>uence of

#atient care ?

in #articular

hen hands6o$e fro6 a

6icrobiologica

llyconta6inated

body site to a

cleaner site in

the sa6e

#atient ?

6icrobial

transfer is

li;ely to occur.

@o a$oid

#rolonged

hand

conta6ination7

it is not only

i6#ortant to

#erfor6 hand

hygiene hen

indicated7 but

also to use the

a##ro#riate

techni>ue and

an ade>uate

>uantity of the

#roduct to

co$er all s;in

surfaces for

thereco66ended

length of ti6e.

.& Cr oss-tr

ans6ission of

or ganis6s by conta6inated

hands

Cross-

trans6ission of

organis6s


35/527

occurs

through

conta6inate

d hands.

Factors that

influence the

transfer of

6icroorganis

6s fro6

surface to

surface and

affect cross-

conta6ination rates are

ty#e of

organis67

source and

destination

surfaces7

6oisture

le$el7 and

si)e of

inoculu6.

Harrison and

colleagues1#

" shoedthat

conta6inate

d hands

could

conta6inate

a clean

#a#er toel

dis#enser

and $ice

$ersa. @he

transfer

rates ranged

fro6 0.01to 0.'%

and 1!.%

to 1".17

res#ecti$ely.

* study

by

+ar;er

and

colleagu

es1#&

shoed

that

fingers

conta6i

nated

ith

noro$iru

s could

se>uenti

ally

transfer

$irus to

u# to

se$en

clean

surfaces7 and

fro6

conta6i

nated

cleaning

cloths to

clean

hands

and

surfaces.

Conta6ina

ted

HCWsA hands

ha$e been

associated

ith ende6ic

HC*(s.1#'%1$)

Sartor and

colleagues1$)

#ro$ided

e$idence thatende6ic

S.

marces

cens

as

trans6it

ted fro6

conta6i

nated

soa# to

#atients

$ia the

hands

ofHCWs.

During

an

outbrea

;

in$estigation of

S. li5uefaciens7

+S(7 and

#yrogenic

reactions in a

hae6odialysis

centre7

#athogens ere

isolated fro6

e:trinsically

conta6inated

$ials of

6edication

resulting fro6

6ulti#le dose

usage7

antibacterial

soa#7 and hand

lotion.1$1

Duc;ro and

colleagues12$

shoed that=B could be

transferred fro6

a conta6inated

en$iron6ent or

#atientsA intact

s;in to clean

sites $ia the

hands of HCWs

in 10.' of

contacts.

Se$eral

HC*(outbrea;s

ha$e been

associated

ith

conta6inate

d HCWsA

hands.1$2-1$!

Bl Shafie

and

colleagues1$

!


36/527

in$estigate

d an

outbrea; of

6ultidrug-

resistant 0.

+aumannii

anddocu6ente

d identical

strains fro6

#atients7

hands of

staff7 and

the

en$iron6en

t. @he

outbrea;

as

ter6inated

henre6edial

6easures

ere ta;en.

Conta6inated

HCWsA hands

ere clearly

related to

outbrea;s

a6ong

surgical1!&%1$2

and

neonatal1$%1$#

%1$$ #atients.

Finally7se$eral

studies ha$e

shon that

#athogens

can be

trans6itted

fro6 out-of-

hos#ital

sources to

#atients $ia

the hands of

HCWs. For

e:a6#le7 an

outbrea; of

#osto#erati$e

S.

marcescens

ound

infections as

traced to a

conta6inated

ar of e:foliant

crea6 in a

nurseAs

ho6e.1$" *n

in$estigation

suggested thatthe organis6

astrans6itted to

#atients $iathe hands of

the nurse7 hoore artificial

fingernails. (nanother

outbrea;7alasseia

pachydermatis

as #robably

trans6ittedfro6 a nurseAs

#et dogs to

infants in anintensi$e carenursery $ia the

hands of the

nurse.1$&

1%


37/527


6igure I.7.1

Organis&s present on patient skin or the i&&ediate en'iron&ent

* bedridden #atient coloni)ed ith Gra6-#ositi$e cocci7 in #articular at nasal7 #erineal7 and inguinal areas not shon47 as ell as a:illae and

u##er e:tre6ities. So6e en$iron6ental surfaces close to the #atient are conta6inated ith Gra6-#ositi$e cocci7 #resu6ably shed by the

#atient. =e#rinted fro6 Pittet7 !00'& ith #er6ission fro6 Blse$ier.

1&


38/527


6igure I.7.2

Organis& transfer fro& patient to #C8s9 hands

Contact beteen the HCW and the #atient results in cross-trans6ission of 6icroorganis6s. (n this case7 Gra6-#ositi$e cocci fro6 the

#atientAs on flora transfer to HCWAs hands. =e#rinted fro6 Pittet7 !00'& ith #er6ission fro6 Blse$ier.

1'


39/527


6igure I.7.+

Organis& sur'i'al on #C8s9 hands

% 0

C

(1) 2icroorganis6s in this case Gra6-#ositi$e cocci4 sur$i$e on hands. =e#rinted fro6 Pittet7 !00'& ith #er6ission fro6 Blse$ier.

(2) When groing conditions are o#ti6al te6#erature7 hu6idity7 absence of hand cleansing7 or friction47 6icroorganis6s can continue togro. =e#rinted fro6 Pittet7 !00'& ith #er6ission fro6 Blse$ier.

(3) +acterial conta6ination increases linearly o$er ti6e during #atient contact. *da#ted ith #er6ission fro6 Pittet7 1.1!

T @he figure intentionally shos that long-slee$ed hite coats 6ay beco6e conta6inated by 6icroorganis6s during #atient care. *lthough e$idence to for6ulate it as a reco66endation is li6ited7 long slee$es should be a$oided.

1


40/527


6igure I.7.3

Incorrect hand cleansing

(na##ro#riate handashing can result in hands re6aining conta6inated9 in this case7 ith Gra6-#ositi$e cocci. =e#rinted fro6 Pittet7

!00'& ith #er6ission fro6 Blse$ier.

T @he figure intentionally shos that long-slee$ed hite coats 6ay beco6e conta6inated by 6icroorganis6s during #atient care.

*lthough e$idence to for6ulate it as a reco66endation is li6ited7 long slee$es should be a$oided.

1/


41/527


6igure I.7.4a

6ailure to cleanse hands results in beteen,patient cross,trans&ission

%

*4 @he doctor had a #rolonged contact ith #atient * coloni)ed ith Gra6-#ositi$e cocci and conta6inated his hands. =e#rinted fro6

Pittet7 !00'& ith #er6ission fro6 Blse$ier.

T @he figure intentionally shos that long-slee$ed hite coats 6ay beco6e conta6inated by 6icroorganis6s during #atient care.

*lthough e$idence to for6ulate it as a reco66endation is li6ited7 long slee$es should be a$oided.

1


42/527


6igure I.7.4b

6ailure to cleanse hands

WHO Hand Hygiene

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