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

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<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE of QACs, e.g. didecyldimethyl ammonium chloride (DDAC), have stronger antimicrobial activity and good performance in the presence of hard water and organic soiling, but their activity has been studied on inanimate surfaces only. In 1994, the FDA TFM tentatively classified benzalkonium chloride and benzethonium chloride as Category IIISE active agents (insufficient data to classify as safe and effective for use as an antiseptic handwash). 198 Further evaluation of these agents by the FDA is in progress. In general, QACs are relatively well tolerated. Unfortunately, because of weak activity against Gram-negative bacteria, benzalkonium chloride is prone to contamination by these organisms and a number of outbreaks of infection or pseudoinfection have been traced to QACs contaminated with Gramnegative bacilli. 386-388 For this reason, these compounds have seldom been used for hand antisepsis during the last 15–20 years in the USA. More recently, newer hand hygiene products containing benzalkonium chloride or benzethonium chloride have been introduced for use by HCWs. A recent clinical study performed among surgical ICU HCWs found that cleaning hands with antimicrobial wipes containing a QAC was almost as effective as handwashing with plain soap and water, and that both were significantly less effective than decontaminating hands with an alcohol-based handrub. 389 One laboratorybased study reported that an alcohol-free handrub product containing a QAC was efficacious in reducing microbial counts on the hands of volunteers. 390 Further studies of such products are needed to determine if newer formulations are effective in health-care settings. QACs have been used as antiseptics to reduce the bioburden on skin (e.g. for wound cleansing and on mucous membrane as mouthwashes for the control of dental plaque). They are also extensively used as disinfectants (“spray & wipe”) for household, industrial, and health-care surfaces, as well as for food surface disinfection, as most formulations do not require to be rinsed off with water after application. 391 The presence of low-level residues may allow the selective development of bacterial strains with greater tolerance of QACs over time; intrinsic and acquired resistance mechanisms have been described. 392,393 In general, QACs are relatively well tolerated and have low allergenic potential. In higher concentrations, though, they can cause severe irritation to skin and mucous membranes. 11.9 Triclosan Triclosan (chemical name 2,4,4’–trichloro-2’-hydroxydiphenyl ether) is known commercially as Irgasan DP-300. It is a nonionic, colourless substance developed in the 1960s; it is poorly soluble in water, but dissolves well in alcohols. Concentrations ranging from 0.2% to 2% have antimicrobial activity. Triclosan has been incorporated in detergents (0.4% to 1%) and in alcohols (0.2% to 0.5%) used for hygienic and surgical hand antisepsis or preoperative skin disinfection; it is also used for antiseptic body baths to control MRSA. This agent is incorporated into some soaps (at a 1% w/v concentration) and a variety of other consumer products (deodorants, shampoos, lotions, etc.), as well as being integrated also into various dressings and bandages for release over time onto the skin. Triclosan enters bacterial cells and affects the cytoplasmic membrane and synthesis of RNA, fatty acids, and proteins. 394 Recent studies suggest that this agent’s antibacterial activity is attributable in large part to binding to the active site of enoylacyl carrier protein reductase. 395,396 Triclosan has a fairly broad range of antimicrobial activity (Table I.11.7), but tends to be bacteriostatic. 48 Minimum inhibitory concentrations (MICs) range from 0.1 to 10 μg/ ml, while minimum bactericidal concentrations are 25–500 μg/ml. Triclosan’s activity against Gram-positive organisms (including MRSA) is greater than against Gram-negative bacilli, particularly P. aeruginosa. 48,394 The agent possesses reasonable activity against mycobacteria and Candida spp., but has little activity against filamentous fungi and most viruses of nosocomial significance. Triclosan (0.1%) reduces bacterial counts on hands by 2.8 log 10 after a 1-minute hygienic handwash. 48 In a number of studies, log reductions achieved have been lower than with chlorhexidine, iodophors or alcoholbased products. 48,137,223,354,397 / In 1994, the FDA TFM tentatively classified triclosan up to 1% as a Category IIISE active agent (insufficient data to classify as safe and effective for use as an antiseptic handwash). 198 Further evaluation of this agent by the FDA is under way. Similar to chlorhexidine, triclosan has persistent activity on the skin. Its activity in hand-care products is affected by pH, the presence of surfactants or humectants, and the ionic nature of the particular formulation. 48,394 Triclosan’s activity is not substantially affected by organic matter, but may be inhibited by sequestration of the agent in micelle structures formed by surfactants present in some formulations. Most formulations containing less than 2% triclosan are well tolerated and seldom cause allergic reactions. A few reports suggest that providing HCWs with a triclosan-containing preparation for hand antisepsis has led to decreased infections caused by MRSA. 181,182 Triclosan’s lack of potent activity against Gram-negative bacilli has resulted in occasional reports of contaminated triclosan. 398 A recent study compared an antibacterial soap containing triclosan with a non-antibacterial soap and concluded that the former did not provide any additional benefit. 399 Concerns have been raised about the use of triclosan, because of the development of bacterial resistance to low concentrations of biocide and cross-resistance to some antibiotics. For example, Mycobacterium smegmatis mutations in inhA gene leading to triclosan resistance are known to carry resistance also to isoniazid. 400 Increased tolerance (i.e increased MICs) to triclosan due to mutations in efflux pumps has been reported in E. coli and P. aerugninosa. 401 Laboratory studies involving exposure of some microorganisms to subinhibitory concentrations of triclosan have resulted in increased triclosan MICs. However, the clinical relevance of increased triclosan MICs generated in the laboratory is unclear, since affected strains remain susceptible to in-use concentrations of triclosan. 401,402 Further research dealing with the relationship between triclosan use and antimicrobial resistance mechanisms is warranted, and surveillance for triclosan-resistant pathogens in clinical and environmental settings is needed. 36
PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE 11.10 Other agents More than 100 years after Semmelweis demonstrated the impact of rinsing hands with a solution of chlorinated lime on maternal mortality related to puerperal fever, Lowbury and colleagues 403 studied the efficacy of rubbing hands for 30 seconds with an aqueous hypochlorite solution. They found that the solution was no more effective than rinsing with distilled water. Rotter 404 subsequently studied the regimen used by Semmelweis, which called for rubbing hands with a 4% hypochlorite solution 405 until the hands were slippery (approximately 5 minutes). He found that the regimen was 30 times more effective than a 1-minute rub using 60% isopropanol. However, because hypochlorite solutions tend to be very irritating to the skin when used repeatedly and have a strong odour, they are seldom used for hand hygiene today. A number of other agents are being evaluated by the FDA for use in antiseptics related to health care. 198 However, the efficacy of these agents has not been evaluated adequately for use in hand hygiene preparations intended for use by HCWs. Further evaluation of some of these agents may be warranted. Products that utilize different concentrations of traditional antiseptics (e.g. low concentrations of iodophor) or contain novel compounds with antiseptic properties are likely to be introduced for use by HCWs. For example, preliminary studies have demonstrated that adding silver-containing polymers to an ethanol carrier (Surfacine) results in a preparation that has persistent antimicrobial activity on animal and human skin. 406 A unique chlorhexidine-loaded, nanocapsule-based gel showed immediate bactericidal effect, comparable to isopropanolol 60% v/v against aerobic bacteria; surviving anaerobic bacteria were significantly lower compared with ethanol-based gel 62% v/v. Persistant bactericidal effect was observed throughout the 3-hour test period. The immediate and sustained antibacterial effect was explained by an efficient chlorhexidine carrier system which improved the drug targeting to bacteria. 407 The clinical significance of these findings deserves further research. New compounds with good in vitro activity must be tested in vivo to determine their abilities to reduce transient and resident skin flora on the hands of caregivers. 11.11 Activity of antiseptic agents against sporeforming bacteria The increasing incidence of C. difficile-associated diarrhoea in health-care facilities in several countries, and the occurrence in the USA of human Bacillus anthracis infections related to contaminated items sent through the postal system, have raised concerns about the activity of antiseptic agents against spores. The increasing morbidity and mortality of C. difficile-associated disease in the USA, Canada, and some European countries since 2001 has been especially attributed to more frequent outbreaks and the emergence of a new, more virulent strain (ribotype 027). 408 Epidemic strains differ among countries: for instance, while in Canada and the Netherlands ribotype 027 is predominant, the United Kingdom detected three different strains (ribotype 001, 027 and 106) responsible for 70% of C. difficile-associated diarrhoea. 409-417 Apart from iodophors, but at a concentration remarkably higher than the one used in antiseptics, 373 none of the agents (including alcohols, chlorhexidine, hexachlorophene, chloroxylenol, and triclosan) used in antiseptic handwash or antiseptic handrub preparations is reliably sporicidal against Clostridium spp. or Bacillus spp. 287,339,418,419 Mechanical friction while washing hands with soap and water may help physically remove spores from the surface of contaminated hands. 110,420,421 This effect is not enhanced when using medicated soap. 420 Contact precautions are highly recommended during C. difficileassociated outbreaks, in particular, glove use (as part of contact precautions) and handwashing with a non-antimicrobial or antimicrobial soap and water following glove removal after caring for patients with diarrhoea. 422,423 Alcohol-based handrubs can then be exceptionally used after handwashing in these instances, after making sure that hands are perfectly dry. Moreover, alcohol-based handrubs, now considered the gold standard to protect patients from the multitude of harmful resistant and non-resistant organisms transmitted by HCWs’ hands, should be continued to be used in all other instances at the same facility. Discouraging their widespread use, just because of the response to diarrhoeal infections attributable to C. difficile, will only jeopardize overall patient safety in the long term. The widespread use of alcohol-based handrubs was repeatedly given the major blame for the increase of C. difficile-associated disease rates because alcohol preserves spores and is used in the laboratory to select C. difficile spores from stools. 424,425 Although alcohol-based handrubs may not be effective against C. difficile, it has not been shown that they trigger the rise of C. difficile-associated disease. 426-429 C. difficile-associated disease rates began to rise in the USA long before the wide use of alcohol-based handrubs. 430,431 One outbreak with the epidemic strain REA-group B1 (≃ribotype 027) was successfully managed while introducing alcohol-based handrub for all patients other than those with C. difficile-associated disease. 427 Furthermore, abandoning alcohol-based handrub for patients other than those with C. difficile-associated disease would do more harm than good, considering the dramatic impact on overall infection rates observed through the recourse to handrubs at the point of care. 320 A guide on how to deal with C. difficile outbreaks, including frequently asked questions on hand hygiene practices, is provided in Appendix 2. A recent study demonstrated that washing hands with either non-antimicrobial soap or antimicrobial soap and water reduced the amount of B. atrophaeus (a surrogate for B. anthracis) on hands, whereas an alcohol-based handrub was not effective. 432 Accordingly, HCWs with suspected or documented exposure to B. anthracis-contaminated items should wash their hands with a non-antimicrobial or antimicrobial soap and water. 11.12 Reduced susceptibility of microorganisms to antiseptics Reduced susceptibility of bacteria to antiseptic agents can be an intrinsic characteristic of a species, or can be an acquired trait. 433 A number of reports have described strains of bacteria that appear to have acquired reduced susceptibility to antiseptics such as chlorhexidine, QAC, or triclosan when defined by MICs established in vitro. 433-436 However, since “in-use” concentrations of antiseptics are often substantially 37
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REFERENCES 35. Jroundi I et al. Pre
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