WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
Should we remove alcohol-based handrubs from
areas where there is Clostridium difficile infection?
No. Alcohol-based handrubs are required at the point of care
for a number of reasons:
• They are easy to use and therefore more likely to result
in greater compliance with the need for hand hygiene by
health-care workers.
• They are proven to be effective in killing a range of
pathogens and therefore reducing patients’ risk of
acquiring health care-associated infection.
• They are effective in killing the non-spore form of C. difficile
which may be present in higher numbers than the spores.
• Sinks for handwashing are not always readily available
and, even if they were made available right next to a
patient, washing takes at least twice as much time than
rubbing – all factors that mitigate against full compliance
with hand hygiene. Relying on promoting handwashing
only in health care is thought to result in lower compliance,
lower efficacy and greater risk of continued spread of
pathogens.
• Evidence-based research reinforces the need for the
presence of alcohol-based handrubs to ensure maximum
patient safety.
• There is no evidence to suggest that their use has been
connected with increased C. difficile infections.
Thus, alcohol-based handrubs should NOT be removed
from health-care settings; to remove them would be likely to
result in greater risk to patients from health care-associated
infections.
Are visibly clean (not soiled) hands still at risk for
cross-transmission?
It is very unlikely. Because handwashing with soap and water
is recommended when exposure to potential spore-forming
pathogens is strongly suspected or proven (this includes
outbreaks of C. difficile), it is very unlikely that using alcoholbased
handrubs on visibly clean hands will put patients at risk
of cross-infection. In fact alcohol-based handrubs are effective
in killing the non-spore form of C. difficile that can also be
present. Therefore, appopriate glove use and adopting either
means of performing hand hygiene on non-soiled hands will
ensure clean, safe hands.
The bottom line is to remember the message that hands
should be washed thoroughly with soap and water when they
are visibly dirty or visibly soiled with blood or other body fluids.
How often will the spores be present when patients
have Clostridium difficile infection?
When patients with C .difficile have severe diarrhoea, large
amounts of spores can be present. This is the basis of all the
recommendations featured here. This is also true of specific
strains of C. difficile, including those that are epidemic in certain
countries. Effective hand hygiene at the point of care, together
with other well-accepted control measures (in particular, glove
use and gowning as part of contact precautions, and individual
rooms), helps to manage the problem.
Clostridium difficile figures are very high is some
countries, and seem to have become worse. Is this
because of alcohol-based handrubs?
There is published evidence that the extensive use of alcoholbased
handrubs in hospitals has not led to an increase in C.
difficile.
Does the promotion of alcohol-based handrubs
imply the “downgrading” of sinks and handwashing?
No. Guidance usually highlights the fact that handwashing is
essential in specific situations (as described above). Although
washing hands with soap and water remains an accepted
method for routine hand antisepsis, alcohol-based handrubs
should be promoted as the gold standard for hand hygiene
considering, in particular, their dramatic impact on improving
compliance with hand hygiene and ensuring clean, safe hands.
What other key measures should be taken to prevent
and control Clostridium difficile?
There are several measures, including performing hand hygiene,
that should be applied to prevent and control C. difficile
infection, and these have been published widely. The following
is a brief description of these key steps, which should be in
place when C. difficile infection is present.
• Antimicrobial prescribing is a crucial part of preventing,
controlling and managing C. difficile infection. Guidance is
widely available on this. Antibiotic stewardship is therefore
an important part of health-care services to control C.
difficile, as is the appropriate prescribing of other drugs
including antacids and perhaps proton pump inhibitors.
• Patients with, or strongly suspected of having, C. difficile
infection should be cared for in a single room with a toilet or
dedicated commode and other dedicated care equipment
until they are symptom-free for at least 48 hours. If single
rooms are not available, cohorting of patients with C.
difficile infection should be considered in conjunction with
risk assessment and infection control expertise.
• Patients with C. difficile infection should have their
surroundings and other areas of concern, e.g. toilet areas,
cleaned at least daily using clean equipment and a freshlymade
solution containing at least 1000 ppm available
chlorine (this can be done by cleaning areas as normal
and then using a “bleach” to clean afterwards or by using
a combined detergent and chlorine-based solution). It
should be noted that non-chlorine-based cleaning agents
can promote the formation of C. difficile spores. Air drying
should be allowed following cleaning.
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