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The Art and Science of Handwashing. Handwashing 80% of common infections spread by hands Most effective way of preventing the spread of respiratory tract.

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Presentation on theme: "The Art and Science of Handwashing. Handwashing 80% of common infections spread by hands Most effective way of preventing the spread of respiratory tract."— Presentation transcript:

1 The Art and Science of Handwashing

2 Handwashing 80% of common infections spread by hands Most effective way of preventing the spread of respiratory tract infections

3 Handwashing 1822 - Labarraque – French pharmacist chloride solutions published paper in 1825 1843 - Oliver Wendell Holmes decrease in puerperal fever 1846 - Ignaz Semmelweis chlorine/nail brush reduced deaths in obstetric wards 20%  1%

4 Improved Patient Outcomes Associated with Proper Hand Hygiene Ignaz Philipp Semmelweis (1818-65) Chlorinated lime hand antisepsis

5 Puerperal fever 19 th century physicians miasmas – bad air Semmelweis incontrovertible proof refused to publish logic behind his theory physician practice did not change Joseph Lister 20 years later published in Lancet

6 Handwashing 1975, 1985 CDC  Handwashing guidelines 1988, 1995 APIC  First to recommend alcohol based hand rubs 1995,1996 HICPAC  Antimicrobial soap/alcohol based agents 2002 HICPAC/SHEA/APIC/IDSA  Guidelines for Hand Hygiene in Health-Care

7 Health-Care Associated Infections USA 2 million infections/year  90,000 deaths  $ 4.5 billion / year  1/3 preventable

8 Resident Flora S. epidermidis / Micrococci / Diphtheroids Survive and multiply on skin Throughout skin layers Cultured repeatedly Low virulence Fingernails / crevices / hair follicles / sebaceous glands Not easily removed by scrubbing

9 Transient Flora E. coli, Klebsiella, Streptococci, Pseudomonas +/- S. aureus  Usually survive less than 24 hours  Do not multiply  Can be easily removed by handwashing

10 How easy is it to transmit germs?. 10 3 – 10 5 bacteria to hands Touching patient shoulder Measuring blood pressure Duckro AN et al. Arch Int Med 2005;165(3):302-7.

11 Rings: Trick et al, CID 2003:36  10 fold higher median skin organism count  stepwise increase with number of rings worn

12 Gloves: 1) reduce transmission from patient to HCW 2) prevent transmission of HCW flora to patient 3) reduce transient contamination of HCW hands

13 Impact of Hand Hygiene on Hospital Infections YearAuthorSettingImpact on Infection Rates 1977Casewell adult ICUKlebsiella decreased 1982Makiadult ICUdecreased 1984Massanariadult ICUdecreased 1990Simmonsadult ICUno effect 1992Doebbelingadult ICUdecreased 1994Webster NICUMRSA eliminated 1995ZafarnurseryMRSA eliminated 1999Pittet hospitalMRSA decreased Source: Pittet D: Emerg Infect Dis 2001;7:234-240

14 General hospital hand hygiene campaign Pittet, Lancet 2000

15 Post-surgical acute care unit hand hygiene program Pre- intervention Post- intervention Total infections per 100 patients12.78.9 Total infections per 1000 pt-days6.25.0 BSI per 1000 patient days9.38.9 RTI per 1000 patient days6.23.8 Swoboda Crit Care Med; 2004:32:358

16 Handwashing Compliance Intensive Care Units Profession % Handwashing UniversityPrivate Physicians2814 Nurses4328 Respiratory therapists7648 Radiology technicians4425 Albert RK, Condie F. NEJM 1981;304(24):1465-6

17 Lack of knowledge Nursing students at some schools in Ontario: no classroom training in infection prevention SARS outbreak: fewer than 60% of quarantined HCWs accurately identified why they were being quarantined

18 How Dirty Are Things? University of Arizona study: Tucson Chicago San Francisco Tampa LocationContamination (%) Playground44 Bus Rails35 Public Restrooms25 Pens (shared)16 Vending Machines14 Public phones*13 *home phones more contaminated

19 How easy is it to transmit germs? 10 million E. coli 0157.H7 Patting contaminated ground beef Wachtel MR et al. J Food Prot 2003;66(7):1176-83. 10 3 – 10 5 bacteria to hands Touching patient shoulder Measuring blood pressure Hayden MK et al. ICCAC 2001, abstract K-1334

20 American Society for Microbiology Survey and Observational Study Study Year Say they wash* Actually wash* WomenMen 2000 8,000 people 5 cities 95%75%58% 2005 6,336 people 4 cities 91%90%75% NOTE: 2003 Post SARS @ Toronto Airport – 96% actually washed *After using public washroom

21 Travellers Percent who did NOT wash hands JFK NYC – 29% San Francisco – 26% Chicago – 26% Miami – 26% Dallas Forth Worth -19% Toronto – 4%

22 School 22 million school days lost annually to common cold (CDC 1996) Am J Infect Control 2000 school with handwashing policy 2.42 days missed/student/year school not using proper hand hygiene 3.02 days missed/student/year

23 Hand hygiene products Regular soap Antibacterialx Antiseptic Alcohol based

24 Hand hygiene products Product Antimicrobial Activity Sustained Activity Potential for Resistance Skin Shedding Soap + none +++ Antibacterial* Intermittent ++ Continuous +++ Alcohol +++ none + Adapted from CID 1999;29:1287-94 * triclosan, hexachlorophene, chlorhexidine gluconate

25 Antibacterial soaps Not needed in the community Not needed routinely in hospital Promote antibacterial resistance

26 Antibacterial soaps Levy S S. aureus resistance to triclosan Schweizer et al AAC. 2001,45:428-432 exposure of P. aeruginosa to Triclosan  MIC to tetracycline, erythromycin 500X  MIC to ciprofloxacin 94X

27 Triclosan: mechanism of action Triclosan : Inhibits fatty acid synthesis (fab I gene) Target = enoyl reductase E. coli mutants easily selected with exposure S. pneumoniae, Enterococcus, lack fab I and are not susceptible Yazhankhah SP, et al. Microb Drug Resist 2006;12(2):83-90.

28 Triclosan and antibiotic resistance Resistance to triclosan: Mutation in fab I gene fab I potential site for development of new antibiotics Activation / upregulation of efflux pumps Multi-drug efflux = cross resistance Other resistance mechanisms not well understood Co-resistance to other antibiotics Thorrold CA, et al.Int J Food Microbiol 2007;113(3):315-20. Seaman PF, et al. J Antimicrob Chemother 2007;59(1):43-50.

29 Akimitsu et al. Antimicrob Agents Chemother 1999;43:3042-3 Methicillin Resistant S. aureus (MRSA): Link: antimicrobial soap and community acquired MRSA

30 Antibacterial Household Products: Cause for Concern Stuart B. Levy Emerging Infectious Diseases, 2001;7(3):512-515 Antimicrobial Resistance Allergy Link

31 Cause for Concern Allergy Link Too much hygiene and increased allergy  children on farms < allergies than children in cities Braun-Fahrlander. Clin Exp Allergy 1999;29:28-34 Excessive hygiene may interfere with immune system  maturation of T helper cells eliminate stimulation from commensal microflora immune system not confronted with enough antigens Folkerts et al. Immunol Today 2000;21:118-20

32 Antibacterial products > 700 different products toothbrushes plastic containers/chopsticks sheets, towels, beds window cleaner No demonstrated health benefit in the household

33 Bacteria Good or Bad Germs? 60% of earth biomass 2-3 billion microbial species < 0.5% have been identified Preceded plants / animals > 3 billion years Essential to life Both internal / external environments

34 Antibacterial soaps Not needed in the community Not needed routinely in hospital No enhanced activity against viruses, fungi Promote antibacterial resistance

35 Antiseptic soaps Not needed in the community for general hand hygiene Have a role in hospital setting May promote antibacterial resistance

36 Alcohol Based Waterless Agents Advantages - no water required - fast to use Voss, Widmer. Infect Control Hosp Epidemiol 1997 - less drying time - less skin shedding Meers, Yeo. J Hyg 1978 - broad spectrum efficacy kill bacteria (fungi, viruses - do not promote resistance

37 Alcohol Based Waterless Agents Disadvantages:  not effective in presence of organic material  will kill resident flora SHOULD NOT REPLACE SOAP AND WATER

38 When to Wash Hands Before eating or preparing food After using the toilet or helping a child use the toilet Before and after diapering After handling shared objects such as toys After wiping your nose or helping a child wipe his / her nose

39 Handwashing Not long enough  average 9.5 seconds  need 15-20 seconds

40 Use soap and water (water alone does not get rid of germs) Rub hands together for 20 seconds Sing Twinkle, Twinkle Little Star Song Rinse for 10 seconds Dry with a towel How to Wash Hands

41 Hand Drying Removes 42% more germs than washing alone Use towels and avoid sharing towels Hot air dryers promote bacterial growth because hands are left warm and moist

42 Does Handwashing Work? Ryan M. Health Naval Research Center, San Diego Recruits ordered to wash hands at least 5 times /day  45% reduction in respiratory illness Ryan MA et al. Am J Prev Med 2001;21(2):79-83 Lee M. Canadian Journal of Infection, Toronto Nurses - at least 7 handwashing episodes/day  Decreased number of enteric / respiratory infections Lee MB. Can J Infect Control 2000;19:89-91

43 Effect of Antibacterial Home Cleaning and Handwashing Products on Infectious Diseases Larson et al Annals of Internal Medicine 2004 Randomized double blind clinical trial 238 inner city homes with at least 1 preschool aged child - NY Conclusion Antibacterial products did not reduce the risk for symptoms of viral infectious diseases in households of healthy people fever/sore throat/runny nose/vomiting/diarrhea

44 The Effect of Hand Hygiene on Illness Rate Among Students in University Residence Halls AJIC 2003;31:364-70 College dorms randomized : Alcohol hand rubs in various locations vs. not. Alcohol hand rub groups:  14.8% -39.9% reduction in respiratory illness symptoms  43% fewer sick days

45 Effect of Handwashing on Child Health: A Randomised Controlled Trial Squatter settlements in Karachi 50% reduction in pneumonia 53% reduction in diarrhea 34% reduction in impetigo No difference between plain soap and antibacterial soap Lancet 2005;366:225-233



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