Course Access
Dear colleagues,
An interesting discussion. In SA we have always taught staff that if their hands are visibly soiled they should wash with soap and water, followed by alcohol-based hand rub. This has always seemed very logical to me, so I was surprised by Matthias’ comment that this may in fact be the wrong way around!
Irene
Irene Wilkinson BSc(Hons) MPH
Manager, Infection Control Service
Communicable Disease Control Branch
System Peformance and Service Delivery
SA Health
Government of South Australia
http://www.sahealth.sa.gov.au/infectionprevention
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
This e-mail may contain confidential information, which also may be legally privileged. Only the intended recipient(s) may access, use, distribute or copy this e-mail. If this e-mail is received in error, please inform the sender by return e-mail and delete the original. If there are doubts about the validity of this message, please contact the sender by telephone. It is the recipient’s responsibility to check the e-mail and any attached files for viruses.
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
E: infexion@ozemail.com.au
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 ABHR: http://www.pubmed.gov/28924473).
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
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
E: infexion@ozemail.com.au
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.
You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au
[cid:image7f3f1a.GIF@efae345d.41acad2b]shstagl1
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.
You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.
You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.
You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au