2. HCAI – rate, mortality, cost
Rate – hospitalized pts = 5-15%
- ICU pts = 9-37%
- Europe = 5 millions HCAI/yr
- USA = 1.7 million HCAI/yr
Mortality = 1-2.7% ( death/yr)
= ICU pts = 12-80%
Cost – Europe = € billion
- USA = $ 6.5 billion
- 25 million extra days of hospital stay

3. Most common infection types
UTI = 36%
SSI = 20%
BSI = 11
Pneumonia = 11%
Mortality from BSI & ventilator associated pneumonia = 16-40%

5. Transient flora
colonizes the superficial layers of the skin
do not usually multiply on the skin, but they survive and sporadically multiply on skin surface
often acquired by HCWs during direct contact with patients or contaminated environmental surfaces
the organisms most frequently associated with HCAIs
Total aerobic count on normal skin:
Scalp > colony forming units (CFU)/cm2
Axilla
Abdomen
Forearm
Hands of HCWs to

12. Water Remove dirt, organic materials, microbes
Cannot remove fats & oils (soap/detergent)
Alone not suitable
Tap water contain a variety of microorg including human pathogens.

13. Bacteria
Health significance
Persistence in water
Relative infectivity
Campylobacter jejuni, C. coli
High
Moderate
Pathogenic Escherichia coli
Low
Enterohaemorrhagic E. coli
Legionella spp.
Multiply
Non-tuberculosis mycobacteria
Pseudomonas aeruginosa
May Multiply
Salmonella typhi
Other salmonellae
Short
Shigella spp.
Vibrio cholerae
Burkholderia pseudomallei
Yersinia enterocolitica
Long

14. Viruses
Health significance
Persistence in water
Relative infectivity
Adenoviruses
High
Long
Enteroviruses
Hepatitis A
Hepatitis E
Noroviruses and sapoviruses
Rotaviruses
Helminths
Dracunculus medinensis
Moderate
Schistosoma spp.
Short

15. Protozoa
Health significance
Persistence in water
Relative infectivity
Acanthamoeba spp.
High
Long
Cryptosporidium parvum
Cyclospora cayetanensis
Entamoeba histolytica
Moderate
Giardia lamblia
Naegleria fowleri
May multiply

17. Medicated (antiseptic) soap
Various antimicrobials are added to soap:
- Chlorhexidine
- Chloroxylenol
- Hexachlorophene
- Triclosan

18. Chlorhexidine (Savlon)
Antimicrobial spectrum:
Gram +ve bacteria, enveloped viruses*
Minimal on Gram-ve bacteria,TB, fungi & non-enveloped viruses**
No on spores
* herpes simplex virus, HIV, CMV, influenza, RSV
** rotavirus, adenovirus, enteroviruses
Advantages:
Effect persists for 6 hours (Good residual activity)
Its effective is not reduced by blood

19. Chlorhexidine (Savlon)
Disadvantages:
Effectiveness is reduced by hard water, hand creams, natural soap
Irritation esp. in genital area, eye (conjunctivitis, corneal damage), inner/middle ear (ototoxic), brain tissue & meninges
Slow immediate activity
Preparations:
Medicated soap - 0.5%, 0.75% , 1%
Antiseptic prep – 4%
With alcohol-based prep – 0.5%-1% (↑ residual activity of alcohol)

20. Chloroxylenol (Dettol)
Antimicrobial spectrum:
 Gram +ve bacteria
 Fair on most others
Advantages:
 Effectiveness is minimally reduced by blood
Disadvantages:
 Slow immediate activity
 Low residual activity
Preparations:
 Antiseptic, disinfectant, medicated soap (0.4-4%)
FDA - insufficient data to classify as safe and effective for use as antiseptic handwash

21. Hexachlorophene Antimicrobial spectrum:  Good on S aureus
 Poor on most others
Advantages:
 Effect persists for at least 6 hours & with repeated use (cumulative effect)
Disadvantages:
 Significant dermal absorption
 Neurotoxic
 Rebound increase in bacterial growth if stopped after long-term use
 Slow immediate activity
Preparations:
 Antiseptic, bathe solution (3%)
FDA - not safe, nor effective
Banned worldwide

22. Iodophors (Povidone iodine = Betadine)
Iodophors = elemental iodine, iodide or triiodide, and a polymer carrier
Polymers:
 Polyvinyl pyrrolidone (povidone)
 Ethoxylated nonionic detergents (poloxamers)
(↑ solubility of iodine, promotes sustained-release of iodine, & reduces skin irritation)
Antimicrobial spectrum:
 Wide spectrum, some spores

23. Iodophors
Advantages:
 Less skin irritation than iodine
 Can be used on mucous membrane - Best antiseptic for use in genital area, vagina, cervix
 Effect persists for 1-6 hours
Disadvantages:
 Effectiveness is moderately reduced by blood
 Effective after 1-2 minutes, wait several minutes for optimal effectiveness
Preparations:
0.5-10%

24. Quaternary ammonium compounds
Alkyl benzalkonium chlorides, benzethonium chloride, cetrimide, cetylpyridium chloride
Antimicrobial spectrum:
 Bacteriostatic & fungistatic
 Gram-positive bacteria, viruses
 Weak against Gram-negative, fungi, TB
Disadvantages:
 Effectiveness is highly reduced by hard water, fatty materials
 Slow immediate action
 No residual activity
FDA - insufficient data to classify as safe & effective for use as antiseptic handwash

25. Triclosan Antimicrobial spectrum:  Bacteriostatic
 Good on Gram-positive & negative bacteria
 Fair on TB, candida
 Poor on fungi, viruses
Advantages:
 Effectiveness not reduced by blood
 Good residual activity
Disadvantages:
 Effectiveness is reduced by humectants
 Intermediate immediate activity

26.  Alcohol-based handrub – 0.2-0.5%
Triclosan
Preparations:
 Detergent, soap – 0.4-1%
 Alcohol-based handrub – %
 Body baths, deodorants, shampoos, lotions, dressings, bandages
FDA - insufficient data to classify as safe & effective for use as an antiseptic handwash

27. Alcohols Ethanol, isopropanol, n-propanol, combination of two of these
Antimicrobial spectrum:
 Wide, Gram-positive & negative bacteria, TB, fungi, enveloped viruses (HSV, HIV, influenza, RSV, vaccinia, HBV, HCB), non-enveloped viruses (rotavirus, adenovirus, rhinovirus, HAV, enterovirus – poliovirus)
 Poor on some noneveloped viruses
 No on spores, protozoa

28.  Very rarely become contaminated Disadvantages:
Alcohols
Advantages:
 Rapid action
 High compliance
 Very rarely become contaminated
Disadvantages:
 No residual activity
 No cleaning effect (not used on dirty / visibly contaminated with blood hands)
 Dryness of the skin (humectants – glycerol 1-3%), contact dermatitis & respiratory allergy – rare
 Stinging sensation (abrasions, cuts)
 Not used on mucous membranes

29. Flammable (precautions), volatile (closed containers)
Alcohols
Addition of chlorhexidine, quaternary ammonium compounds, octenidine or triclosan, humectant (glycerine) can result in persistent activity.
Flammable (precautions), volatile (closed containers)
Efficacy – type, concentration(60-95%), contact time(3-5 min, must dry completely), volume, wet hands
Preparation – solutions > gels, foams

30. Antiseptics
G+ve B
G-ve B
V- enveloped
V-non
enveloped
Mycob
Fungi
Spores
Alcohols
+++ ++ -
Chloroxylenol +
Chlorhexidine
Hexachlorophene ?
Iodophors
Triclosan
Q Ammonium compounds

31. Antiseptics
Concentration %
Speed of action
Residual activity
Use
Alcohols
60-70%
Fast No HR
Chloroxylenol
0.5-4%
Slow
Contradictory HW
Chlorhexidine
Intermediate
Yes
HR,HW
Hexachlorophene 3%
HW, but not recommended
Iodophors
0.5-10%
Triclosan
0.1-2%
HW; seldom
Q Ammonium compounds
HR,HW;seldom; + alcohols

32. Types of handwashing Surgical handscrub & handrub
Routine handwashing – with plain soap & running water
Handwashing with an antiseptic & running water
Alcohol handrub
Surgical handscrub & handrub

33. Routine handwashing – with plain soap & running water
Remove transient microorganisms & soil (dirt, blood, feces, remnants from food)
Appropriate
immediately after arriving at work
before & after contact with a client
after handling specimens or potentially contaminated items
after using a toilet
before leaving work

34. Handwashing with an antiseptic & running water
Removes transient microorganisms & soil
Kills & inhibits resident microorganisms
Appropriate
 High-risk situations – before invasive procedures (insertion of CVP, chest tube, angiography, spinal tap)
 Contact with client at high risk of infections (newborns, immunosuppressed)

35. Alcohol handscrub
Kills or inhibits transient & resident microorganisms
Does not remove microorganisms or soil
Appropriate when handwashing with soaps & running water is not possible, provided no visible soil on the hands

37. Routine handwashing 1
Wet hands with warm running water

38. Routine handwashing 2
Apply soap

39. Routine handwashing 3
Rub hands vigorously with soap & lather for seconds. Make sure to rub all parts of your hands
See you later

40. Routine handwashing 4
Rinse hands

41. Routine handwashing 5 Dry
Dry hands with a clean towel or allow hands to air-dry

42. Turn off taps with towel
Routine handwashing 6
Turn off taps with towel

43. Concentrate on your hands

44. Palm to palm

45. Right palm over left dorsum, left palm over right dorsum

46. Palm to palm, fingers interlaced

47. Back of fingers to opposing palms with fingers interlocked

48. Rotational rubbing of right thumb clasped in left palm & vice versa

49. Rotational rubbing backwards & forwards with tops of fingers & thumb of right hand in left palm & vice versa

50. 1 Remove all jewelry. Wet hands with warm running water
Surgical Handscrub 1
Remove all jewelry Wet hands with warm running water

51. Surgical Handscrub 2
Clean under each fingernail with a stick or brush

52. Surgical Handscrub 3
Holding your hands up above the level of your elbow, apply the antiseptic. Using a circular motion, begin at the fingertips of one hand & lather & wash between the fingers, continuing from fingertip to elbow. Repeat this for the second hand & arm. Do not forget your 5 fingers. Wash for 5 minutes.

53. Surgical Handscrub 4
Rinse each arm separately, fingertips first, holing your hands above the level of your elbow to allow the water to flow from hands to forearms.

54. Surgical Handscrub 5
Dry arm from fingertips to elbow with a sterile towel (dry hands first then forearms). Use one side of the towel to dry the first hand & the other side of the towel to dry the second hand.

55. Surgical Handscrub 6
Keep your hands above the level of your waist & do not touch anything.

56. 5 5 5
5 cm above elbow
5 minutes
5 fingers

59. Thank You