Hand Hygiene Overview
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Hand Hygiene History
The 3 fathers of handwashing:
 Dr. Oliver Wendell Holmes
 Dr. Ignaz Semmelweis
 Louis Pasteur
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Hand Hygiene History
 Dr. Oliver Wendell Holmes advocated hand washing
to prevent childbed fever. He was horrified by the
prevalence in American hospitals of this fever which
he believed to be an infectious disease passed to
pregnant women by the hands of doctors. His ideas
were met with disdain.
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Hand Hygiene History
 In Vienna in 1846, Dr. Ignaz Semmelweis was
working in maternity wards where he observed the
mortality rate in the wards cared for by physicians
and medical students were as much as three times
greater than those wards where care was provided
by midwives.
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Hand Hygiene History
 Semmelweis found that the students were coming
straight from the pathology lab without washing their
hands. He believed that they were carrying infections
from the lab to their patients. When he implemented
a handwashing protocol, his mortality rate dropped
to less than 1%.
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Hand Hygiene History
 Louis Pasteur – contributed to the germ theory of
disease, developed pasteurization, and in 1879
debated his ideas at the Academy of Medicine in
Paris.
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Hand Hygiene Today
 According to the United States Centers of Disease
Control and Prevention (CDC):
“Handwashing is the single most
important means of preventing the
spread of infection.”
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Terms & Definitions
 Infection - An infection is the detrimental
colonization of a host organism by a foreign species.
In infection, the infecting organism seeks to utilize
the host’s resources in order to multiply (usually at
the expense of the host). The infecting organism, or
pathogen, interferes with the normal functioning of
the host
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Terms & Definitions
Infections can be caused by:
 A bacteria
 A virus
 A fungus
 A parasite
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Terms & Definitions
 Microbe – A microorganism that causes disease.
This term is no longer in technical use.
 Antimicrobial – Capable of destroying or inhibiting
the growth of microorganisms, e.g., antimicrobial
solutions or antimicrobial drugs
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Terms & Definitions
 Pathogen – A pathogen or infectious agent is a
biological agent that causes disease or illness to its
host. The term is most often used for agents that
disrupt the normal physiology of a multi-cellular
animal or plant.
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Terms & Definitions
Bacteria:
 Single-celled microorganisms which can exist either
as independent (free-living) organisms or as
parasites (dependent upon another organism for
life).
 Were the only life form on earth for 2 billion years
 May be beneficial or harmful
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Bacteria
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Terms & Definitions
 Virus – A virus is a microscopic particle that can
infect the cells of a biological organism. Viruses
can only replicate themselves by infecting a host
cell and therefore cannot reproduce on their own.
 It has been argued extensively whether viruses
are living organisms. Most virologists consider
them non-living, as they do not meet all the
criteria of the generally accepted definition of life
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Viruses
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Terms & Definitions
 Fungi (singular fungus) - are a kingdom of
eukaryotic organisms. They are heterotrophic (live
off others) and digest their food externally, absorbing
nutrient molecules into their cells. Yeasts, molds, and
mushrooms are examples of fungi. The branch of
biology involving the study of fungi is known as
mycology.
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Fungi
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Terms & Definitions
 Parasite - Parasitism is one version of symbiosis
("living together"), a phenomenon in which two
organisms which are phylogenetically unrelated coexist over a prolonged period of time, usually the
lifetime of one of the individuals.
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Parasites
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Measuring Antimicrobial Efficacy
 Antimicrobial properties are measured in their ability
to kill or eliminate pathogens
 Testing protocols consist of sampling the hands
before and after a “treatment” of an antimicrobial
 The labs count the number of “Colony Forming
Units” (CFU’s) before and after a treatment by an
antimicrobial
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Colony Forming Units
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Units of Measurement
 The two most common “units of measurement” for
the reduction of CFU’s are:
 A percent reduction, e.g., “kills 99.9% of bacteria”
 A log10 reduction
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Log Reductions
 As mnemonic for converting log reductions into
percent reductions is the number of the log, e.g., 1,
2, 3, 4 etc. equates to the number of “nines” (9’s) in
the percent reduction:
 1-log = 90% reduction
 2-logs = 99% reduction
 3-logs = 99.9% reduction
 4 logs = 99.99% reduction
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HAIs
Cost of Health Care Associated Infections
 Approximately 1 in 10 patients acquire a HAI after admission, totaling
more than 2 million cases each year. At least one-third of these
infections are preventable, and hand washing is the single most
important procedure for prevention. (CDC)
 Nearly 100,000 deaths a year result from HAI’s, and this number
continues to grow. (APIC)
 In the United States, HAIs add an estimated $30.5 billion in annual
costs to the nation’s health care system. (Committee to Reduce
Infection Deaths)
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HAIs
Cost of Health Care Associated Infections
 The average stay for patients with HAIs diagnosed in the hospital is
23 days; the average stay for patients without infections is 5 days.
(American Journal of Medical Quality)
 Patients who acquire infections average healthcare costs of
approximately $185,000, compared with less than $32,000 for those
who do not acquire infections. (Pennsylvania Health Care Cost
Containment Council)
 HAIs are among the top five causes of death in the United States.
(HealthNews Digest)
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HAIs
Cost of Health Care Associated Infections
 Approximately 3 million cases of Clostridium difficile are reported
each year in the US, costing more than $1.3 billion. (Washington
University School of Medicine, CDC)
 In 2005, there were about 368,600 cases of MRSA infection in US
hospitals. In 1993, there were fewer than 2,000 MRSA infections
recorded in US hospitals. (Agency for Healthcare Research and
Quality)
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Food Borne Illness
 The CDC estimates that 76 million Food Borne illness, or food
poisoning, cases occur in the United States every year, which
means that one in four Americans contracts a Food Borne
illness annually after eating foods contaminated with such
pathogens.
 Approximately 325,000 people are hospitalized with a
diagnosis of food poisoning, and 5,000 die. The estimated
costs in terms of medical expenses and lost wages or
productivity are between $6.5 and $34.9 billion
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Food Borne Illness
While most Food Borne illness cases go unreported to
health departments, nearly 13.8 million cases are
reported and diagnosed by their cause:
 Viruses cause 67% of cases
 Bacteria cause 30% of cases
 Parasites cause 3% of cases
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Top Bugs
Clostridium Difficile
 This organism is a growing
problem in healthcare
settings. C. diff causes
serious diarrheal disease
and colitis and most often
affects patients that are
seriously ill or undergoing
antibiotic treatment. In its
spore form, Clostridium
difficile must be removed
from the hands with soap
and water.
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Top Bugs
MRSA
 Methicillin-resistant
Staphylococcus aureus,
both healthcare associated
and community associated,
is a type of bacteria that is
resistant to certain
antibiotics. Typically starting
as a skin infection, MRSA
now accounts for nearly
70% of staph infections.
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Top Bugs
Norovirus
 This virus is the leading
cause of gastroenteritis in the
United States. Noroviruses
are relatively resistant to
environmental challenge, are
often food borne, and can be
spread through contaminated
surfaces and hands. This bug
must be removed from the
hands through mechanical
action during handwashing.
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Top Bugs
VRE
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 Enterococci are bacteria
normally found in the intestinal
track and in the environment.
These bacteria can sometimes
cause infections of the urinary
track, skin wounds or
bloodstream, and can be
spread through skin to skin
contact. Enterococci can
become resistant to antibiotics,
including Vancomycin, resulting
in VRE.
Top Bugs
Influenza
 Influenza Type A and
Type B viruses are
responsible for seasonal
flu epidemics. Influenza
viruses are constantly
changing through
antigenic drift. Each year,
5 to 20% of the
population will come
down with the flu.
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Top Bugs
Acinetobacter
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 Acinetobacter bacteria can
be found in soil, water and
the skin of healthy people.
It can cause a variety of
diseases, from pneumonia
to serious blood or wound
infections. Acinetobactor
outbreaks most often
occur in intensive care
units or healthcare settings
with seriously ill patients.
Top Bugs
Campylobacter
 Common bacterial cause
of diarrhea in the United
States; Sources: raw and
undercooked meat and
poultry, raw milk and
untreated water.
Campylobacter infections
cause also be caused by
contact with sickened
animals, including
household pets.
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Top Bugs
Escherichia coli O157:H7
 A common food borne
bacterium that can
produce a deadly toxin
and causes approximately
73,000 cases of Food
Borne illness each year in
the U.S.; Sources: meat,
especially undercooked or
raw hamburger, produce
and raw milk.
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Top Bugs
Listeria monocytogenes
 Causes listeriosis, a
serious disease for
pregnant women,
newborns and adults
with a weakened
immune system.
Symptoms include
nausea, fever and
gastroenteritis. Sources:
soil and water. Listeria
is often found in drains.
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Top Bugs
Pseudomonas
 Pseudomonas is a
bacterium with many
dangerous strains,
including
Pseudomonas
fluorescens and
Pseudomonas
aeruginosa. Sources:
soil and water. Listeria
is often found in drains
due to biofilm buildup.
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Top Bugs
Salmonella
 Most common cause of
Food Borne deaths.
Responsible for millions of
cases of Food Borne
illness a year; Sources:
raw and undercooked
eggs, undercooked
poultry and meat, dairy
products, seafood, fruits
and vegetables.
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Top Bugs
Shigella
 Causes an estimated
300,000 cases of
diarrheal illnesses. Poor
hygiene causes Shigella
to be easily passed
from person to person.
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Top Bugs
Toxoplasma gondii
 A parasite that causes
toxoplasmosis, a very
severe disease that can
produce central nervous
system disorders
particularly mental
retardation and visual
impairment in children.
Pregnant women and
people with weakened
immune systems are at
higher risk.
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Top Bugs
Vibrio vulnificus
 This gram-negative
bacterium causes
gastroenteritis or a
syndrome known as
primary septicemia.
People with liver
diseases are especially
at high risk.
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Top Bugs
Hepatitis A
 Food contaminated with
the virus is the most
common vehicle
transmitting Hepatitis A.
The food preparer or
cook is the individual
most often
contaminating the food.
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Copyright © 2014 Meritech / Resurgent Health and Medical
Quiz Time
 What is the body’s largest organ?
 How much skin does the average person have?
 What are some of the main functions of skin?
 How often does our skin replace itself?
 How are skin health and hygiene related?
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Skin Fun Facts
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Skin Fun Facts
 Skin is the body’s largest organ; the average adult
has 1.75 M2 of skin
 The epidermis has 5 layers; the outermost layer is
the stratum corneum
 The stratum corneum itself has 15 layers and
replaces itself every 2 weeks, or 1 layer of skin / day
 Healthy skin loses roughly 10 million particles of skin
per day
Source: “Hygiene of the Skin: When is Clean Too Clean?” by Elaine Larson, Columbia School of Nursing
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Skin Fun Facts
 10%, or 1 million of these skin particles contain
viable bacteria
 Males disperse more organisms than females
 Amount varies between persons using the same
hygienic regimen by as much as fivefold
 70% of house dust is dead skin
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Skin Fun Facts
The epidermis has three principal functions:



Protecting the body from the environment,
particularly the sun
Preventing excessive water loss from the body
Protecting the body from infection.
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Skin Contaminants
Two major groups of microorganisms are found on the
skin:
 Resident flora (organisms that usually reside on skin)
 Transient flora (contaminant microorganisms)
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Skin Contaminants
 Resident flora - Unless introduced into body tissues
by trauma or medical devices such as intravenous
catheters, the pathogenic potential of the resident
flora is low
 Transient flora - are easily removed by handwashing,
cause most infections resulting from crosstransmission
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Effect of Soap on Skin
 Soaps and detergents have been described as the
most damaging of all substances routinely applied to
skin.
 Each time the skin is washed it undergoes profound
changes, most of which are temporary.
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Effect of Soap on Skin
 In an investigation of the effect on skin of repeated
use of two washing agents, all skin function tests
were markedly changed after a single wash
Grunewald AM, Gloor M, Gehring W, Kleesz P. Damage to the skin by repetitive washing. Contact Dermatitis 1995;32:225-32.
 In a study of irritant skin reactions induced by 3
surfactants, damage lasted for several days;
complete skin repair was not achieved for 17 days
Wilhelm KP, Freitag G, Wolff HH. Surfactant-induced skin irritation and skin repair. Evaluation of the acute human irritation model
by noninvasive techniques. J Am Acad Dermatol 1994;30:944-9.
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Effect of Soap on Skin
 Washing with plain soap may actually increase the
potential for microbial transmission because of a 17fold increase in the dispersal of bacterial colonies
from the skin of the hands
Meers PD, Yeo GA. Shedding of bacteria and skin squames after handwashing. J Hyg (Camb) 1978;81:99-105.
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Effect of Soap on Skin
 The numbers of organisms spread from the hands of
nurses who washed frequently with an antimicrobial
soap actually increased after a period of time; this
increase is associated with declining skin health
Ojajarvi J, Makela P, Rantsalo I. Failure of hand disinfection with frequent hand washing: a need for prolonged field studies.
J Hyg (Camb) 1977;79:107-19.
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Effect of Scrubbing on Skin Shedding
 Study comparing alcohol to surgical scrub showed
that CFU’s were reduced satisfactorily with both
 No increase in skin shedding after alcohol
 18-fold increase after scrub
 Conclusion “prolonged vigorous scrubbing is
unnecessary.”
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Skin Health
 As skin dries out and becomes unhealthy it develops
more cracks and crevices
 The cracks and crevices are breeding grounds for
bacteria
 Unhealthy skin “flakes off” far more than healthy skin
 Skin health and skin hygiene cannot be separated
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Antimicrobial Products
There are 5 basic antimicrobial formulations:





Alcohols
Triclosans
Chlorhexidine Gluconate (CHGs)
Iodophors (iodine formulations)
Parachlorometaxylenols (PCMXs)
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Antimicrobials Compounds
Are evaluated for effectiveness in 3 areas:



Immediate – occur within 1 minute of application
Persistent – prevents recolonization for hours after
application
Residual - antimicrobial properties persist for days
even after product discontinued
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Persistence
 Q: Why is persistence important?
 A: Persistence is the ability of the
agent to continue to reduce the
number of bacteria after the initial
application period is over
 A: Because alcohol doesn’t have it!
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Instant Hand Sanitizers
 One study showed that the application of instant
hand sanitizers resulted in a significant increase in
bacterial numbers on the surface of the hands
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Instant Hand Sanitizers
 The human skin is composed of multiple layers
with bacteria attached to the pores of each layer
 Alcohol is a powerful drying agent
 Even though alcohol may kill the organisms on
the surface of the skin it appears to
simultaneously dry the skin and may pull the
bacteria residing in the various skin layers
beneath the surface, to the surface
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Bacteria / Pores / Skin Layers
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Instant Hand Sanitizers
 “Since no rinsing occurs after the application of
these instant hand sanitizers, there is no mechanical
washing away of the bacteria that has been drawn to
the skin surface. The end result is an increase in
resident bacterial numbers on the surface of the
hands.”
Source: Dairy, Food, and Environmental Sanitation / March 1994
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Alcohol Formulations
Emollients:
 Emollients are ingredients that lubricate the skin and
give the product a soft, smooth feeling.
 Emollients sit on the surface of the skin and impede
water loss or dehydration. They are generally made
up of large molecules that help prevent water from
leaving the surface of the skin.
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Alcohol Formulations
 Emollients build up over time, unless there is some
mechanical action / washing away of the emollients
 Emollients become a barrier against alcohol
reaching the bacteria that is on the skin
 The layer of emollients actually become a breeding
ground for bacteria
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Alcohol Formulations
 Meritech’s study showed how alcohol’s efficacy
decreases drastically over time:
 1st application with alcohol had 3.72 log reduction
 1 hour post-wash after 11th application (without
washing emollients off between applications) had 0.41
log reduction
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Copyright © 2014 Meritech / Resurgent Health and Medical