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Thanks for the feedback and background information Mathias.
Still leaves us with the question:
. Why in clinical areas of healthcare facilities do we recommend an
antiseptic agent (i.e. alcohol-based hand rub) for hand hygiene for “visibly
clean hands”, yet for “visibly soiled hands” an antiseptic agent is no
necessarily required?
As mentioned I would be interested to know how infection control
personnel/teams are overseeing, managing and monitoring this issue to
ensure transient microbial flora are being reduced or removed from
healthcare worker hands during handwashing (i.e. when hands are visibly
soiled/dirty).
Regards
Glenys
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
Of Matthias Maiwald (SingHealth – PATH)
hand washing with an antiseptic hand hygiene product in acute health
clinical areas
Dear Glenys,
You are touching upon two interesting questions:
(1) What is the role of plain versus antiseptic soap handwashing (as an
alternative to alcohol-based hand rubs) in healthcare facilities?
(2) What is the best method to clean or disinfect hands when they are
visibly soiled?
Re. (1). According to the literature (a bit too complex and convoluted to
give references here, but I summarized some of it in a 2009 review for the
then upcoming NHMRC guideline), the order of microbial elimination on hands
is roughly: plain soap < antiseptic soap << alcohol-based hand rubs. Most
antiseptic soaps/detergent are closer to plain soaps in terms of their
microbial elimination capacity, meaning they are usually not that great.
When I reviewed the literature on plain versus antiseptic soaps, it seemed
to me that there was no clear benefit of antiseptic soaps over plain ones in
general wards, but there seemed to be potential benefits of antiseptic soaps
in critical care areas. Among the antiseptic ingredients in soaps, triclosan
(mostly used in antiseptic household soaps) is very minimal in its
antimicrobial activity, whereas chlorhexidine (CHX) is somewhat better.
However, chlorhexidine is increasingly recognised as an agent of allergies
and contact dermatitis, and so one has to weigh the minimal benefit of
having an antiseptic ingredient with the potential downsides. We here are
phasing out CHX-containing antiseptic soaps in general ward areas and are
replacing CHX-containing ABHR with CHX-free ABHR (recent paper on CHX in
Re. (2). When I moved to Australia in 2002, I initially propagated what was
taught to me in medical school in the early 1980s, i.e. when hands are
visibly soiled, use ABHR first and then wash off the "dead bacterial
carcasses" (drastic wording used to teach us medical students so that it
would stick) with soap and water in a second step. That was consistent with
the "Vienna School" of hand hygiene (around Rotter) from the 1970s. However,
in 2002 I quickly gave up on this, because (a) no one believed me, and (b) I
realized that this was in contrast with what the then-upcoming CDC and WHO
HH guidelines would propagate, and I did not want to be discordant with
these, in order to avoid confusion and different teachings.
However, when examining things closely, it becomes clear that the
recommendation to only wash hands with soap and water when they are visibly
soiled is lacking a clear rationale and also data to support it. In
contrast, the Vienna school recommendation makes a lot of sense: (a) it has
been shown in earlier experiments in the 1960s and 70s that washing heavily
contaminated hands under running water above a sink creates heavily
contaminated splashes around the sink in about one metre plus diameter, and
(b) alcohol actually retains its antimicrobial killing capacity in the
presence of moderate organic soiling, i.e. the notion that alcohol does not
work in the presence of soiling is incorrect (e.g.
http://www.pubmed.gov/1629595). However, it must be emphasized that for this
to work, relatively larger-than-usual quantities of ABHR must be used,
meaning that a 1 ml or 2 ml portion of ABHR, as HCWs can often be observed
to be using, does not work. Liberal application is the key here.
Please don't misunderstand me, I am providing this mainly for clarification
and background information. I do NOT want to counteract the WHO
recommendation. Consistency (see statement above) is also an important
consideration.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women's and Children's Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387
Of Glenys Harrington
antiseptic hand hygiene product in acute health clinical areas
Dear all,
Hand washing with plain soap versus hand washing with an antiseptic hand
hygiene product in acute care facliity clinical areas
I understand some healthcare facilities have either replaced antiseptic hand
hygiene products in clinical areas of acute care facilities with plain soap
products or have added plain soap products as an option for handwashing
(i.e. when hands are visibly soiled/dirty).
Plain soap has minimal antimicrobial activity but after 30 seconds can
reduce counts by 1.8-2.8log10, however compliance with a 30sec hand wash is
poor.
Several studies of handwashing with plain soap have shown that plain soap
failed to remove pathogens from healthcare worker hands.
Standard handwashing with soap and water removes lipids and adhering dirt,
soil and various organic substances from the hands and remains a sensible
strategy for hand hygiene in non-healthcare settings.
Alcohol-based hand rubs are the most efficacious agents for reducing the
number of bacteria on the hands of personnel, however, there will be times
when healthcare worker hands are visibly soiled/dirty and they will need to
wash their hands rather than use an alcohol-based hand rub.
What is the issues?
My understanding is that in clinical areas staff should use an antiseptic
hand hygiene product when they need to wash their hands, not a plain soap
products?
Semmelweis demonstrated that hand antisepsis (i.e. the use of chlorinated
lime) was what stopped the infections in obstetric clinics not hand washing
with soap and water.
He noted that physicians and medical student who went from performing
autopsies to the delivery suite had a disagreeable odour on their hands
despite hand washing with soap and water before entering the clinic.
Infection control concerns
My concerns include the following:
. In clinical areas of organisations where antiseptic hand hygiene
products have been replaced with a plain soap product for hand washing (i.e.
when hands are visibly soiled/dirty) transient microbial flora are not being
reduced or removed from healthcare worker hands.
. In clinical areas of organisations where plain soap products have
been added as an option for hand washing (i.e. when hands are visibly
soiled/dirty), transient microbial flora are not being reduced or removed
from healthcare worker hands when they are using a plain soap product.
. Hand washing products are generally sourced from one supplier,
hence the dispensers (antiseptic & plain soap) are similar/same and usually
located adjacent to one another in clinical areas at hand washing
facilities/sinks.
o busy staff may not necessarily be aware of the difference in the
products
o Staff generally select what they will use based on smell, consistency,
feel and colour hence an antiseptic product may not be used at all when hand
washing.
Summary
This raises the following question:
. Why in clinical areas of healthcare facilities do we recommend an
antiseptic agent (i.e. alcohol-based hand rub) for hand hygiene for "visibly
clean hands", yet for "visibly soiled hands" an antiseptic agent is no
necessarily required?
I would be interested to know how infection control personnel/teams are
overseeing, managing and monitoring this issue to ensure transient
microbial flora are being reduced or removed from healthcare worker hands
during handwashing (i.e. when hands are visibly soiled/dirty).
Regards
Glenys
Definition of an Antiseptic agent
. An antimicrobial substance that inactivates microorganisms or
inhibits their growth on living tissues.
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
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