Hand hygiene.pdf

as lifting patients, taking the patient’s pulse, blood pressure or oral temperature; or touching
the patient’s hand, shoulder or groin. Similarly, Ehrenkranz and colleagues 44 cultured the
hands of nurses who touched the groin of patients heavily colonized with P. mirabilis and
found 10 to 600 colony forming units (CFU)/ml in glove juice samples.
Pittet and colleagues 28 studied contamination of HCWs’ hands before and after direct
patient contact, wound care, intravascular catheter care, respiratory tract care or handling
patient secretions. Using agar fingertip impression plates, they found that the number of
bacteria recovered from fingertips ranged from 0 to 300 CFU. Direct patient contact and
respiratory tract care were most likely to contaminate the fingers of caregivers. Gram-negative
bacilli accounted for 15% of isolates and S. aureus for 11%. Importantly, duration of
patient-care activity was strongly associated with the intensity of bacterial contamination of
HCWs’ hands in this study. A similar study of hand contamination during routine neonatal
care defined skin contact, nappy/diaper change and respiratory care as independent predictors
of hand contamination 29 . In the latter study, the use of gloves did not fully protect
HCWs’ hands from bacterial contamination, and glove contamination was almost as high as
ungloved hand contamination following patient contact. In contrast, the use of gloves during
procedures such as nappy/diaper change and respiratory care almost halved the average
increase of bacteria CFU/min on HCWs’ hands 29 .
Several other studies have documented that HCWs can contaminate their hands with
Gram-negative bacilli, S. aureus, enterococci or Clostridium difficile by performing “clean
procedures” or touching intact areas of skin of hospitalized patients 45,63,64,71 . A recent study
that involved culturing the HCWs’ hands after various activities showed that hands were contaminated
following patient contact and after contact with body fluids or waste 72 . McBryde
and colleagues 73 estimated the frequency of HCWs’ glove contamination with MRSA after
contact with a colonized patient. HCWs were intercepted after a patient-care episode and
cultures were taken from their gloved hands before handwashing had occurred; 17% (CI 95
9–25%) of contacts with patients, a patient’s clothing or a patient’s bed resulted in transmission
of MRSA from a patient to the HCWs’ gloves. Furthermore, HCWs caring for infants
with respiratory syncytial virus (RSV) infections have acquired it by performing activities
such as feeding infants, nappy/diaper change and playing with the infant 68 . Caregivers who
had contact only with surfaces contaminated with the infants’ secretions also acquired RSV.
In the above studies, HCWs contaminated their hands with RSV and inoculated their oral
or conjunctival mucosa. Other studies have also documented that the hands (or gloves) of
HCWs may be contaminated after touching inanimate objects in patient rooms 29,64,71-77 .
Similarly, laboratory-based studies have shown that touching contaminated surfaces can
transfer S. aureus or Gram-negative bacilli to the fingers 78 . Unfortunately, none of the studies
dealing with HCW hand contamination was designed to determine if the contamination
resulted in the transmission of pathogens to susceptible patients.
Many other studies have reported contamination of HCWs’ hands with potential pathogens,
but did not relate their findings to the specific type of preceding patient contact 34,35,79-85 . For
example, in studies conducted before glove use was common among HCWs, Ayliffe and
colleagues 82 found that 15% of nurses working in an isolation unit carried a median of 1 x
10 4 CFU of S. aureus on their hands. Twenty-nine per cent of nurses working in a general
hospital had S. aureus on their hands (median count, 3.8 x 10 3 CFU), while 78% of those
working in a hospital for dermatology patients had the organism on their hands (median
count, 14.3 x 10 6 CFU). The same survey revealed that 17% to 30% of nurses carried Gramnegative
bacilli on their hands (median counts ranged from 3.4 x 10 3 CFU to 38 x 10 3 CFU).
Daschner 80 found that S. aureus could be recovered from the hands of 21% of intensive
care unit (ICU) caregivers and that 21% of doctors and 5% of nurse carriers had >10 3 CFU