Est-ce que la désinfection des mains est un outil
efficace pour prévenir les transmissions croisées ?
Bertrand Souweine
1. Flore cutanée et contamination 2. Lavage des mains3. Frictions alcoolique
Efficacité microbiologiqueAspects pratiquesEfficacité clinique
4. Conclusion
Plan
1. Flore cutanée et contamination 2. Lavage des mains3. Frictions alcoolique
Efficacité microbiologiqueAspects pratiquesEfficacité clinique
4. Conclusion
Plan
Types of Skin Flora
• Transient flora• Resident flora• Infectious flora
Epiderme superficiel : stratum corneumeffet protecteur contre flore contaminante
squammes
lipides
•H20 assure plasticité, perméabilité // hydratation
•Une couche produite / 24 heures et qui disparaît en 15 jours
•102-103 ufc/cm2, enchâssés en profondeur
•107 particules libérées / j dans air dont 10% contiennent des germes
Resident Flora
• Deeper skin layers• Mainly CNS, coryneform bacteria and micrococci ;
fungi (Malassezia); virus usually not resident on the skin
• More resistant to mechanical removal and stable over time
• Lower pathogenic potential (not pathogens on intact skin)
• Colonization resistance • Very difficult to eliminate (< 50% decrease in
bacteril load after 6 min of handwashing)
Transient Flora
• Superficial layers; usually not multiply on the skin
• Acquired by contact with patient or environment
• Easily removed by mechanical means
• S. aureus, GNB or candida or virus
Infectious Flora
• The etiologic agents of actual infections such as abscess, panaritium, paronychia, and infected eczema on the hands
• S. aureus and β-hemolytic streptococci
You may not Realize You Have Germs on Your Hands!
• Nurses, doctors and other healthcare workers can contaminate their hands by doing simple tasks, including: – Taking a patient’s blood
pressure or pulse– Assisting patients with
mobility– Touching the patient’s gown
or bed sheets– Touching equipment,
including bedside rails, over bed tables, IV pumps http://www.handhygiene.org/
Acquisition de la flore transitoire ou contaminantetemps de soin dépendante
Pittet Arch Intern Med 1999
Durée de contact : 16 cfu /mn
Port de gants : 3 cfu /mn
Pittet Arch Intern Med 1999
Acquisition de la flore transitoire ou contaminantemême après simple contact patient
Type d’activité : 16-21 cfu /mn
Clin Microbiol Rev. 2004;17(4):863
Transmission of organisms
Transmission of organisms by hands of health care providers between two patients can result in health care associated infections (HAIs).
Adapted from the Swiss Hand Hygiene Campaign
Clin Microbiol Rev. 2004;17(4):863
Year Authors(s) Hospital setting Significant results
1977 Casewell and Phillips Adult ICU Reduced rates of HI due toendemic Klebsiella sp
1982 Maki Adult ICU Reduction in HI rates
1984 Massanari et Heirholzer Adult ICU Reduction in HI rates
1992 Doebelling et al. Adult ICU Significant diff. in rates of HIbetween 2 regimens
1994 Webster et al. NICU Elimination of MRSA
1995 Zafar et al. Newborn nursery Elimination of MRSA
2000 Larson et al. MICU/NICU Significant reduction of VRE
2000 Pittet et al. Hospital-wide Significant reduction in HI /MRSA cross transmission
CDC Guideline for HH in healthcare settingsCDC Guideline for HH in healthcare settings
Hygiène des mains et contrôle de l’infection
1. Flore cutanée et contamination 2. Lavage des mains3. Frictions alcoolique
Efficacité microbiologiqueAspects pratiquesEfficacité clinique
4. Conclusion
Plan
CID 2000;31:136
Soap
• Plain – Esterified fatty acids
with sodium or potassium hydroxide
– Mechanical removal of dirt and loosely adherent flora (transient>resident)
• Antiseptic
Chlorhexidine
• A cationic biguanide • England in 1954;
introduced into U.S. in 1970s
• Chlorhexidine base only minimally soluble in water, but digluconate is water-soluble
• Exists as acetate (diacetate), gluconate, and hydrochloride salts
Mechanism of Action
• Attach to bacterial cytoplasmic membrane (inner membrane)
– Precipitation or coagulation of protein and nucleic acids
– Also to the outer membrane in G(-) and the cell wall in G(+)
• Also damage the cytoplasmic membrane of yeasts
Spectrum of Activity
• Depends on concentration– lower: bacteriostatic against GP bacteria, GNB and
bacterial spores• Bacteria
– Good activity against G(+), less G(-) and fungi, not spores
• Dermatophytes: no activity • Mycobacteria: limited• Virus: good for most enveloped virus, low for
naked viruses
Efficacy
• Reduce transient bacteria by 2.1 to 3 log10; smaller in resident flora (0.35 to 2.29 log10)
• Activity is greatly reduced in the presence of organic matter, natural corks, and hand creams containing anionic emulsifying agents
• Substantial residual activity
Resistance
• If MIC greater than 50 mg/liter– Uncommon among G(+) bacteria
– Yes for G(-), such as E.coli, P.mirabilis (84.6%), P. stuartii, P. aeruginosa, P. cepacia and S. marcescens
– C. albicans (10.5%)
– Cross-resistance (+)
• Mechanism – Alternation of inner, outer membrane or the cell wall
Adverse Effect
• Temperature greater than 70 , chlorhexidine ℃may degrade to para-chloraniline (carcinogenic)
• Conjunctivitis and corneal damage when contacted with eye
• Ototoxicity • Dermatitis is concentration dependent • Anaphylactic reactions • Avoid direct contact with brain tissue and the
meninges
Frequent handwashing with soap and water often causes skin irritation and dryness. Skin irritation are more frequently reported when using antiseptic soap
In the winter months, some personnel may even develop cracks in their skin that cause bleeding, as seen in the adjacent figure.
Another reason why personnel don’t wash their hands often
OBSERVANCE / HYGIENE DES MAINS
Nb d’actions d’hygiène des mains
Nb d’indications à l’hygiène des mains
Observance basale
Soignants 30-40%
Médecins 10-20%
Autres 10-20%
Year author observation observed Opportunity HW %type No
1981 Albert masqued all HCWs a 1,212 494 41297 81 28
1986 Mayer masqued nurses b 142 89 6354 34 63
1987 Donowitz masqued all HCWs a 3226 863 271989 Conly masqued all HCWs c 184 39 211990 Dubbert overt nurses d 811990 Graham masqued all HCWs a 440 140 321990 Simmons masqued all HCWs e 86 10 12
91 29 321992 Larson overt all HCWs f 337 102 361992 Doebbeling overt all HCWs na 1,233 492 401993 Zimakoff masqued all HCWs g 1,025 351 34
607 305 501994 Gould overt nurses h 231994 Lund masqued all HCWs a 17 10 41
10 02 201994 Sproat na all HCWs* c 762 234 311994 Wurtz masqued all HCWs j 41 9 221996 Tibballs alterned physicians k 322 37 11
55 31 561997 Larson overt nurses l 151 85 56
310 172 551998 Watanakunakorn masqued all HCWs m 97 38 391999 Khatib masqued RCPs n 537 247 461999 Nishimura hidden camera everybody o 903 658 731999 Pittet overt all HCWs p 450 162 362000 Biscoff alterned all HCWs q 361 59 16
352 29 82000 Maury overt all HCWs r 621 263 422001 Harbarth masqued all HCWs q 2,811 946 39
Observance du lavage des mains : revue de la littérature
%
Trick, CID
07
Reasons Advocated for Poor Handwashing
Compliance• Skin irritation from hand
hygiene products
• Inaccessibility of hand hygiene supplies
• Wearing gloves
• Hands don’t look dirty
• Lack of information on the importance of hand hygiene
• Lack of knowledge of the guidelines
• Too busy/handwashing takes too long
• Male vs female
• Physician vs nurse
• Wearing gloves
• Working in ICU
• Understaffing/overcrowding
Risk factors for Poor Handwashing Compliance
It takes ICU nurses an average of 62 seconds to go to a sink, wash and dry their hands, and return to patient care activities
The time needed for hand hygiene before and after every contact is about 100 min/patient for direct contacts
It takes ICU nurses an average of 62 seconds to go to a sink, wash and dry their hands, and return to patient care activities
Anne Simon
DUREE DU LAVAGE SIMPLE DES MAINS
Hand as a Vectors of Transmission
• Organisms present on the patient’s skin or on inanimate objects
• Organism must be capable of surviving for at least several minutes on the hands of personnel
• Handwashing is inadequate or omitted entirely • Come in direct contact with another patient, or
with an inanimate object
Precaution
• Recontaminated from faucets or by splashes from traps or sinks (P. aeruginosa in the tap water) or from plain soap (both bar and liquid soaps, bar soaps heavier; S. marcescens or Serratia liquefaciens)
• Outside health care facilities (working hours, before eating, after using restroom), use of soap and water is recommended
• Hand hygiene is the most important tool in NI control
• Adherence to hand-washing practices remains unacceptable low, rarely exceeding 40%
1. Flore cutanée et contamination 2. Lavage des mains3. Frictions alcoolique
Efficacité microbiologiqueAspects pratiquesEfficacité clinique
4. Conclusion
Plan
CID 2000;31:136
Poor Kolletchka
Ignaz Philipp Semmelweis (1818-1865)
• Ignaz Philipp Semmelweis (1818-65), a Hungarian obstetrician educated at the universities of Pest and Vienna, introduced antiseptic prophylaxis into medicine.
Curr Opin Infect Dis 1998; 11: 457-460
Death of Kolletchka
hand disinfection with a solution of 4% chlorinated
Ethanol, Isopropanol, and n-Propanol
• Ethanol is introduced in 1888
isopropanol and n-propanol in 1904• Vigorous friction, rinsing with water, and
drying with a towel are unnecessary
Les produits hydro-alcooliques (PHA)
solutions ou gels séchage rapidedésinfection des mainsalcool (60-70%) + émollient +/- autre antiseptique
péril hydriquefriction sans rinçage friction sur mains
sèches +++non visiblement souillées (propres)non poudrées
pas de friction de gants
Mechanism of Action
• Killing not mechanically remove
• Protein denaturation, rapid killing (sec)
Spectrum of Activity
• Mycobacteria• Excellent in vitro activity against G(+) and G(-)
bacteria• Virus
– Good activity against enveloped viruese– Nonenveloped viruses require higher concentration
(70-80%)• Against most fungi• Poor or no activity against spores, protozoal
oocysts
0 1 2 3
Sterillium®
Hibiscrub®
savon doux
Betadine scrub®
99%90% 99,9%
log 0 1 2 3
Etudes expérimentales de l’activité des savons sur les mains contaminées par C. difficile
(Barbut F. et coll., Hygiènes, 2003, 5, 449-55)
Contamination expérimentale des mains de 14 volontaires
Contamination initiale : 4.2 à 4.8 log10 UFC/ml
Méthode du jus de gants
P=0.36
P<0.01
P<0.01
1 min
30 sec
1 min
30 sec
Diapositive empruntée a F Barbut
Quelle hygiène des mains ?
• Faut il bannir les solutions hydro alcooliques?
Boyce et al, ICHE 2006
Même constat,
-Diminution de l’incidence des ERV et des SARM (1998-2000) vs (2001-2003)
-Incidence stable pour Clostridium difficile
Gordin et al ICHE 2006
Efficacy
• The type of alcohol • Concentration • Contact time• Volume used• Whether the hands are wet when the alcohol
applied• Temperature • Organic material
Henri Mondor, 1996 51
Efficacite de l’hygiène des mains sur la flore
Clin Microbiol Rev. 2004;17(4):863
Time-Course of Efficacy of Unmedicated Soap and Water and Alcohol-Based Handrub in Reducing the Release of Test Bacteria
from Artificially Contaminated Hands
Curr Opin Infect Dis. 2003 Aug;16(4):327
PREVALUES
99.9 3.0
90.0 1.0
99.0 2.0
0 60 180 min
LIQUID SOAP
POVIDONE-IODINELIQUID SOAP 0.8%
CHLORHEXIDINE-DETERGENT 4%
POVIDONE-IODINEAQU. SOLUTION 10%
ISO-PROPANOL 60%
HEXACHLOROPHENE-DETERGENT 3%
ISO-PROPANOL 70%
N-PROPANOL 60%
ISO-PROPANOL 70%+CHLORHEXIDINE 0.5%
% Iog 10
0.0 0.0
Handwashing with plain soap
Alcohol-based handrub
Before
After
Handwashing with antiseptic detergent
d’après Pr Bientz, Institut d’hygiène de Strasbourg
The technique used for hand cleansing before patient care affected the amount of bacterial contamination
Handwashing with plain soap
Handwashing with antiseptic detergent
Alcohol-based handrub (ABH)
1. Flore cutanée et contamination 2. Lavage des mains3. Frictions alcoolique
Efficacité microbiologiqueAspects pratiquesEfficacité clinique
4. Conclusion
Plan
Temps économisé par l’utilisation de la Friction Hydro-Alcoolique
• Lavage simple des mains :• quitter le lit du patient• aller au lavabo, se mouiller les mains• se laver les mains (= 30 secondes)• se sécher les mains• retourner au lit du patient Total 1 min 30 s
Total 30 s
• Friction avec une SHA :• au lit du malade• durée de friction pour séchage
PLUS RAPIDEPLUS RAPIDEPLUS RAPIDEPLUS RAPIDE
• 40 à 80 secondes pour effectuer le lavage des mains contre seulement 20 secondes pour une désinfection avec la solution hydro-alcoolique
• Pour une équipe de 12 personnes en réanimation au cours d ’une journée de 8h de travail :
Lavage des mains sol. alcoolique
Temps requis 16h 4hForce de travail 17% < 5%
Voss A & Widmer AF ICHE 1997;18:205-8
Widmer CID 2007
Widmer CID 2007
Mayo Clin Proc. 2004;79(1):109
15 Jan 2007 ... Michelle Manhart nude photos are now online. Air Force staff sergeant Michelle Manhart was relieved of her duties for
posing nude in Playboy
2004 2005 2006
N=56
N=61
number of duty days lost
N=210 ; 2.4%
N=78 ; 0.9%
Aviat Space Environ Med. 2007
Effet des SHA sur l’observance
Bischoff et al., Arch Intern Med, 2000
0
20
40
60
Base Après form. SHA 1/4 lits SHA 1/lit
LdM avant soins
LdM après soins
0
20
40
60
Base Après form. SHA 1/4 lits SHA 1/lit
LdM avant soins
LdM après soins
Service de réanimation médicale, 6 mois
Observance à l’hygiène des mains
Maury et al.AJRCCM, 2000 69
Effet des SHA sur l’observance
Évolution selon la catégorie de personnel soignant
bef
ore
pat
ien
t co
nta
ctb
efor
ep
atie
nt
con
tact
afte
rp
atie
nt
con
tact
afte
rp
atie
nt
con
tact
afte
rre
mov
ing
glov
esaf
ter
rem
ovin
ggl
oves
bef
ore
pat
ien
t co
nta
ctb
efor
ep
atie
nt
con
tact
afte
rp
atie
nt
con
tact
afte
rp
atie
nt
con
tact
afte
rre
mov
ing
glov
esaf
ter
rem
ovin
ggl
oves
• Before / after study
• Single centre
• No period randomization
• Overt observations
• Differences in the type of opportunities recorded
• Hawthorne effect
• Handwashing still performed during the ABH period
• Multifaceted programme on hand hygiene practice
Several Limitations in Hand Hygiene Compliance Studies
0
1
2
3
4
5
6
Baseline 2 weeks
Alcohol rub Soap and water
15
17
19
21
23
25
27
Baseline 2 weeks
Alcohol rub Soap and water
Epidermal water contentSelf-reported skin score
Dry
Healthy Dry
Healthy
Effect of Alcohol Handrub on
Skin Condition
Alcohol-based handrub is less damaging to the skin
Boyce, Infection Control and Hospital Epidemiology 2000;21:438-41.
*
*
* , P<0.001
RCT: HW vs HR29 nurses
Larson EL CCM 2001
ACCEPTABILITYNo participants
mak
es i
t ea
sier
to
don
glo
ves
Number of participants who preferred
alcohol
chlorhexidine
neither
Number of participants who preferred
alcohol
chlorhexidine
neither
1. Flore cutanée et contamination 2. Lavage des mains3. Frictions alcoolique
Efficacité microbiologiqueAspects pratiquesEfficacité clinique
4. Conclusion
Plan
Impact de l’utilisation des SHA sur les taux d’IN
Pittet et al., Lancet 2000
0
20
40
60
80
1994 1995 1996 1997 1998
Ob
serv
ance
(%
)
0
5
10
15
20
25
Pré
vale
nce
des
IN
Observance Prévalence des IN
Impact de l’utilisation des SHA sur l’incidence des SARM
0
20
40
60
80
1993 1994 1995 1996 1997 1998
Po
urc
enta
ge
d'o
bse
rvan
ce
0
0,2
0,4
0,6
0,8
Inci
denc
e de
s S
AR
M/1
00 a
dmis
Observance Incidence des SARM
Pittet et coll., Lancet 2000
ABH introduction
bas
elin
e
bas
elin
e
Education programme
Education programme
AB
H
AB
H
Infection due to MRSA: from 1.67 to 2.77 per 1.000 patient-days
Infections due to VRE from 0.35 to 1.36 per 1.000 patient-days
Cannot detect a change is not absence of change
Absence of training programme
Very low baseline rates of nosocomial infection
Absence of surveillance cultures to detect MRSA/VRE colonization
No data on the rates of MRSA/VRE importation
Baseline
59.5%
26%
21%
22.5%
Overall compliance
Before patient contact
After patient contact
Correctly performed
Intervention
65%
45%
56%
42.6%
P
0.46
<0.01
<0.001
<0.01
P=0,02
Grayson et al.
6 urban sites
Grayson et al.
a total of 65 fewer patients developping MRSA bacteremia during the 24-month intervention period
Acceptability of hand hygiene procedures in the 7 units
P=0.06
Cannot detect a change is not absence of change
1. Flore cutanée et contamination 2. Lavage des mains3. Frictions alcoolique
Efficacité microbiologiqueAspects pratiquesEfficacité clinique
4. Conclusion
Plan
ABH is effective in decreasing NI rates
The causal role of microorganisms on hands in the pathogenesis of NI is extremely well established
Traditional soap-and-water hand hygiene is less effective than hand antisepsis
Handwashing as frequent as recommended is often impractical and leads to inflammatory skin reactions
ABH is the simplest and least expensive way of achieving good hand hygiene practice and so of preventing health care associated infections and the spread of antimicrobial resistance
Multifaceted campaign with education programme, meetings, introduction of ABH, training in application of ABH, reminders, monitoring of compliance, monitoring of NI rate, and surveillance feedback are required to promote hand hygiene and reduce cross transmission in ICUs
ABH is effective in decreasing NI rates
• Plus efficace que le lavage avec un savon.
• Action rapide et réalisation rapide.
• Ne nécessite pas de lavabo.
• Actif sur les pathogènes nosocomiaux.
• Toujours à portée de la main.
• Moins irritant pour la peau.
• Moins polluant pour l ’environnement.
• Favorise l ’observance.
Boyce JM.Infect Control Hosp Epidemiol 2000;21:438-441
Daschner Fr. Am J Infect Control 2000;28: 386
Avantages de la friction alcooliqueAvantages de la friction alcoolique
• avant tout contact avec un malade, que des gants aient été portés ou non
• après tout contact avec un malade, que des gants aient été portés ou non
• entre les soins pour un même malade, que des gants aient été portés ou non
• après l’ablation des gants
Quand utiliser les SHA?
AttentionAttentionAttentionAttention
L'alcool ne contient pas d'agent nettoyant
Si mains souillées, lavage des mains impératif
Si C difficile la FHA est précédée d’un lavage avec séchage
MODE D’EMPLOI• Délivrer une dose (3ml) dans le creux de la
main
• Friction des mains jusqu’à évaporation (30 sec.)Paume / paume et paume/dos mainsEspaces interdigitaux, ongles, pouce…
Hand Hygiene
Clean Care is Safer Care