Hand hygiene in the intensive care unit.

Abstract

Healthcare-associated infections affect 1.4 million patients at any time worldwide, as estimated by the World Health Organization. In intensive care units, the burden of healthcare-associated infections is greatly increased, causing additional morbidity and mortality. Multidrug-resistant pathogens are commonly involved in such infections and render effective treatment challenging. Proper hand hygiene is the single most important, simplest, and least expensive means of preventing healthcare-associated infections. In addition, it is equally important to stop transmission of multidrug-resistant pathogens. According to the Centers for Disease Control and Prevention and World Health Organization guidelines on hand hygiene in health care, alcohol-based handrub should be used as the preferred means for routine hand antisepsis. Alcohols have excellent in vitro activity against Gram-positive and Gram-negative bacteria, including multidrug-resistant pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, Mycobacterium tuberculosis, a variety of fungi, and most viruses. Some pathogens, however, such as Clostridium difficile, Bacillus anthracis, and noroviruses, may require special hand hygiene measures. Failure to provide user friendliness of hand hygiene equipment and shortage of staff are predictors for noncompliance, especially in the intensive care unit setting. Therefore, practical approaches to promote hand hygiene in the intensive care unit include provision of a minimal number of handrub dispensers per bed, monitoring of compliance, and choice of the most attractive product. Lack of knowledge of guidelines for hand hygiene, lack of recognition of hand hygiene opportunities during patient care, and lack of awareness of the risk of cross-transmission of pathogens are barriers to good hand hygiene practices. Multidisciplinary programs to promote increased use of alcoholic handrub lead to an increased compliance of healthcare workers with the recommended hand hygiene practices and a reduced prevalence of nosocomial infections.

Full text

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Specific Infection Control Topics
Hand hygiene in the intensive care unit
Sarah Tschudin-Sutter, MD; Hans Pargger, MD; Andreas F. Widmer, MD, MS
R
healthcare-associated infections (HCAIs)
at any time (1). HCAIs concern 5% to
15% of hospitalized patients in the devel-
oped countries and affect 9% to 37% of
those admitted to the intensive care unit
(ICU) (2). Approximately 5 million HCAIs
are estimated to occur in acute care hos-
pitals in Europe annually, causing an at-
tributable mortality of 1% or 50,000
deaths per year, leading to 25 million
extra days of hospital stay. In the United
States, the occurrence rate of HCAIs in
2002 was 4.5%, affecting 1.7 million pa-
tients and causing approximately 99,000
deaths (3).
ecently, the World Health Or-
ganization (WHO) estimated
that 1.4 million patients
worldwide are affected by
Burden of HCAI
In ICUs, the burden of HCAI is greatly
increased. In Europe, prevalence rates of
infections acquired on the ICU vary from
9.7% to 31.8% (4), and in the United States
from9%to37%,withcrudemortalityrates
ranging from 12% to 80% (2). The use of
invasive devices (e.g., central venous cath-
eters, mechanical ventilation, or urinary
catheters) is one of the most important risk
factors for acquiring HCAIs. In addition to
morbidity and mortality, multidrug-resis-
tant pathogens are commonly involved in
such infections and render effective treat-
ment challenging.
The hands of healthcare workers
(HCWs) are the primary mode of trans-
mission of nosocomial infections to pa-
tients (5). Therefore, hand hygiene is a
key component in the prevention of HCAI
(6–8) and is the primary component of
the WHO patient safety program (1).
Historical perspective of hand
hygiene
For centuries, handwashing with soap
andwaterhasbeenconsideredameasureof
personal hygiene and has been embedded
in religious and cultural habits. The link
between handwashing and the spread of
disease, however, was only established 2
centuries ago. That said, this can be con-
sidered as relatively early with respect to
the discoveries of Pasteur and Lister, which
occurred decades later.
In 1847, the Hungarian obstetrician
Ignaz Philipp Semmelweis (1818–1865)
was head of the Women’s Hospital in Vi-
enna, Austria, and noted that puerperal
fever was more common in a maternity
ward where physicians and medical stu-
dents provided care to women in labor
than it was on the ward where midwives
assisted at deliveries. Peripartum mortal-
ity in the former ward was as high as
18%, compared with only 3% in the latter
ward (9). Semmelweis postulated that
physicians and students were contami-
nating their hands at the same time per-
forming autopsies and subsequently in-
troducing a fatal etiological agent
(“cadaverous particles”) into the birth ca-
nal during vaginal examination. Washing
their hands with soap and water before
examining women in labor did not pre-
vent the epidemic of puerperal fever, and
the hands retained a disagreeable odor
from the autopsy rooms. On May 15,
1847, Semmelweis ordered that all stu-
dents and physicians scrub their hands
with a 4% chlorinated lime solution after
From the Division of Infectious Diseases and
Hospital Epidemiology, Department of Anesthesia
and Intensive Care Medicine, University Hospital
Basel, Switzerland.
The authors have not disclosed any potential con-
flict of interest.
For information regarding this article, E-mail:
Widmera@uhbs.ch
Copyright © 2010 by the Society of Critical Care
Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0b013e3181e6a23f
Healthcare-associated infections affect 1.4 million patients at
any time worldwide, as estimated by the World Health Organiza-
tion. In intensive care units, the burden of healthcare-associated
infections is greatly increased, causing additional morbidity and
mortality. Multidrug-resistant pathogens are commonly involved
in such infections and render effective treatment challenging.
Proper hand hygiene is the single most important, simplest, and
least expensive means of preventing healthcare-associated infec-
tions. In addition, it is equally important to stop transmission of
multidrug-resistant pathogens. According to the Centers for Dis-
ease Control and Prevention and World Health Organization guide-
lines on hand hygiene in health care, alcohol-based handrub
should be used as the preferred means for routine hand antisep-
sis. Alcohols have excellent in vitro activity against Gram-positive
and Gram-negative bacteria, including multidrug-resistant patho-
gens, such as methicillin-resistant Staphylococcus aureus and
vancomycin-resistant enterococci, Mycobacterium tuberculosis, a
variety of fungi, and most viruses. Some pathogens, however,
such as Clostridium difficile, Bacillus anthracis, and noroviruses,
may require special hand hygiene measures. Failure to provide
user friendliness of hand hygiene equipment and shortage of staff
are predictors for noncompliance, especially in the intensive care
unit setting. Therefore, practical approaches to promote hand
hygiene in the intensive care unit include provision of a minimal
number of handrub dispensers per bed, monitoring of compliance,
and choice of the most attractive product. Lack of knowledge of
guidelines for hand hygiene, lack of recognition of hand hygiene
opportunities during patient care, and lack of awareness of the
risk of cross-transmission of pathogens are barriers to good hand
hygiene practices. Multidisciplinary programs to promote in-
creased use of alcoholic handrub lead to an increased compliance
of healthcare workers with the recommended hand hygiene prac-
tices and a reduced prevalence of nosocomial infections. (Crit
Care Med 2010; 38[Suppl.]:S299–S305)
KEY WORDS: healthcare-associated infections; hand hygiene;
hand rubs; nosocomial infections
S299 Crit Care Med 2010 Vol. 38, No. 8 (Suppl.)

Page 2

dissecting cadavers and before examining
patients. Probably, Semmelweis had cho-
sen chlorinated lime because of its deodor-
izing characteristic, as microorganisms
were unknown to be the cause of infection
at that time. After introduction of the new
hand hygiene practice, the maternal mor-
tality rate dramatically decreased to ?3%
and remained low for years. Nevertheless,
Semmelweis’s recommendations were
strongly opposed by his co-workers, and his
appointment in Vienna ended prematurely.
He returned to Hungary, where he intro-
duced his antiseptic hand hygiene method
in two other hospitals, reducing their mor-
tality rates from ?10% to ?1%. Although
most physicians at that time ignored his
theory, Semmelweis opened a new era in
medical science by introducing hand anti-
sepsis in surgery and obstetrics.
In the 1980s, the first hand hygiene
guidelines were published in the English
literature (10–12). In 1995 and 1996, the
Centers for Disease Control and Preven-
tion/Healthcare Infection Control Practices
Advisory Committee (13, 14) in the United
States recommended that either antimicro-
bial soap or a waterless antiseptic agent be
used for cleaning hands upon leaving the
rooms of patients with multidrug-resistant
pathogens. In 2002, the Healthcare Infec-
tion Control Practices Advisory Committee
guidelines (15) defined alcohol-based han-
drub as the standard of care for hand hy-
giene in healthcare settings.
Normal bacterial flora and
transmission of pathogens by
hands
Bacteria recovered from hands can be
divided into two categories: resident and
transient flora (16). The resident flora con-
sists of microorganisms living under the
superficial cells of the stratum corneum
and can also be found on the skin’s surface
(17, 18). The dominant species is Staphy-
lococcus epidermidis (19). Other resident
bacteria include Staphylococcus hominis
and other coagulase-negative staphylo-
cocci, as well as Propionibacterium spp.,
Corynebacterium spp., and micrococci
(20). In general, resident flora is rarely as-
sociated with infections. Transient flora
colonizes the superficial layers of the skin
and is often acquired by HCWs during di-
rect contact with patients or by contami-
nated environmental surfaces. These or-
ganisms are most frequently associated
with nosocomial infections; luckily, they
are more amenable to removal by routine
hand hygiene than the resident flora. The
transmissibility of transient flora depends
on the species present, the number of bac-
teria on the surface, and the skin moisture
(21, 22). Hands of HCWs may become per-
sistently colonized by pathogenic flora,
such as S. aureus, Gram-negative bacilli, or
yeast(23).Thebacterialdensityoftransient
and resident flora, usually between 3.9 ?
104colony-forming units (CFU)/cm2and
4.6 ? 106CFU/cm2(16, 24–27) and is rel-
atively constant for any given individual.
HCWs can contaminate their hands
with Gram-negative bacilli S. aureus, en-
terococci, or C. difficile by performing
so-called “clean procedures,” such as lift-
ing a patient or taking the patient’s pulse,
blood pressure, or temperature, or by
touching intact areas of a hospitalized
patient’s skin (28–33). Pittet et al (34)
examined contamination of HCWs’ hands
before and after direct patient contact,
wound care, intravascular catheter care, re-
spiratory tract care, or handling of a pa-
tient’s secretions. They found that direct
patient contact and respiratory tract care
were most likely to contaminate the hands
of caregivers. Importantly, duration of pa-
tient care activity was strongly associated
with the intensity of bacterial contamina-
tion of HCWs’ hands. HCWs may also con-
taminate their hands after touching inani-
mate objects in patients’ rooms (31–36).
Hayden et al (37) reported that HCWs con-
taminated their hands with vancomycin-
resistant enterococcus after touching the
environment without touching the patient.
Several studies have shown the ability
of microorganisms to survive on hands
for prolonged periods. Both Enterococ-
cus faecalis and E. faecium survived for
at least 60 mins on fingertips (38).
Pseudomonas aeruginosa and Burkhold-
eria cepacia were transmissible by hand-
shake for up to 30 mins when the organ-
isms were suspended in saline and for up
to 180 mins when they were suspended in
sputum (39). People suffering from der-
matitis commonly remain colonized for
prolonged time periods (40).
Microbial transfer is likely to occur
when HCWs fail to clean their hands be-
tween patient contact or during patient
care, in particular, when hands move from
a microbiologically contaminated body site
toacleanersiteofthesamepatient.Several
outbreaks of nosocomial infections have
beenassociatedwithHCWs’hands(41–43).
Forexample,identicalstrainsofmultidrug-
resistant Acinetobacter baumannii from
patients, the hands of staff, and the envi-
ronment could be documented during an
outbreak investigation (43).
Indications for hand hygiene
According to the Centers for Disease
Control and Prevention and WHO guide-
lines on hand hygiene in health care, alco-
hol-based handrub is the preferred means
for routine hand antisepsis. As exceptions,
hands that are visibly dirty or soiled with
bloodorotherbodyfluidsorafterusingthe
toilets should be washed with soap and wa-
ter. Hands should also be washed with soap
and water if alcohol-based handrub is not
obtainable.
Hand hygiene should be performed in
the following situations (Fig. 1):
● Before and after touching the pati-
ent (IB);
● Before handling an invasive device for
patient care, regardless of whether or
not gloves are used (IB);
● After contact with body fluids or excre-
tions, mucous membranes, nonintact
skin, or wound dressings (IA);
● If moving from a contaminated body
site to another body site during care of
the same patient (IB);
● After contact with inanimate surfaces
and objects (including medical equip-
ment) in the immediate vicinity of the
patient (IB);
● After removing sterile or nonsterile
gloves (IB).
A palmful of alcohol-based handrub
should be applied to cover all surfaces of
the hands. Hands should then be rubbed
until they are dry. The technique for han-
drubbing is illustrated in Figure 2, adapted
from WHO guidelines 1. Applying the
proper technique for using handrub, as
outlined in the guidelines, can significantly
improve the degree of bacterial killing (44).
Preparations used for hand
hygiene and relative efficacy of
plain soap and alcohols
The purpose of routine handwashing
in patient care is to remove dirt and or-
ganic material. Handwashing refers to
the application of a plain (nonantimicro-
bial) or antiseptic (antimicrobial) soap.
The cleaning activity is attributed to de-
tergent properties that result in mechan-
ical removal of dirt (soil and organic sub-
stances) and loosely adherent flora (most
transient flora and a small portion of the
resident flora) from the hands. Plain
soaps have minimal or no antimicrobial
activity, reducing bacterial counts from
hands by 0.6 to 1.1 log10CFU in 15 secs,
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Page 3

1.8 to 2.8 log10CFU in 30 secs, and 2.7 to
3.0 log10CFU in 1 min (9).
The alcohol handrub procedure in-
volves the use of alcohol rather than
water. In contrast to handwashing, the
objective of this procedure is a more
effective and rapid reduction of skin
flora by killing, not mechanically re-
moving, microorganisms (all transient
flora and most resident flora). The an-
timicrobial activity of alcohols is due to
their ability to denature proteins (45).
Alcohol solutions containing 60% to
80% ethanol are most effective. Higher
concentrations are less effective, be-
cause proteins are more difficult to de-
nature in the absence of water. Alcohols
have excellent in vitro activity against
Gram-positive and Gram-negative bac-
teria, including multidrug-resistant
pathogens, such as methicillin-resis-
tant Staphylococcus aureus and vanco-
mycin-resistant enterococcus, M. tu-
berculosis, and a variety of fungi (45–
47). However, they have no activity
against bacterial spores or protozoan
oocysts and very poor activity on some
nonenveloped viruses. The virucidal ac-
tivity of alcohol against enveloped vi-
ruses (such as influenza virus or human
immunodeficiency virus) is excellent, ex-
cept for rabies virus. Certain nonenveloped
viruses (such as enteroviruses, rotaviruses,
or norovirus) may require higher ethanol
concentrations (?90%). The properties of
antiseptics used in hand hygiene, as well as
their antimicrobial activities, are summa-
rized in Table 1.
A systematic review of publications be-
tween 1992 and 2002 on the effectiveness
of alcohol-based solutions for hand hy-
giene showed that alcohol-based han-
drubs remove organisms more effec-
tively, require less time, and irritate the
skin less than handwashing with soap or
other antiseptic agents and water (48).
Hand hygiene technique
The perfect hand hygiene technique
has never been evaluated in prospective
clinical trials. However, the WHO-
proposed technique allows the handrub
to get to all parts of the hand. The prop-
erly applied technique has been shown to
improve antimicrobial killing (49). Addi-
tional training of HCWs further improved
the technique and antimicrobial killing
(44). At the University of Basel, all med-
ical students are trained in this tech-
nique; advanced students significantly
improve their skills as they are exposed to
multiple training sessions during medical
school (50). On average, 3 mL of handrub
should be applied (WHO protocol) (Fig.
2). Very large hands may require higher
volume, whereas a smaller amount of
hand alcohol may suffice for tiny hands.
The goal is that the hands are wet at all
parts during the process, independent of
the volume required. The last two steps of
the WHO protocol are very important:
wetting the thumb and the fingertips.
These parts of the hands are frequently
forgotten but are the body parts that
come in closest contact with the patient.
Special situations
C. difficile. Concerns about the activ-
ity of antiseptic agents against spores
have been raised by the increasing prev-
alence of C. difficile-associated infection
in healthcare facilities, as well in outpa-
tients, and by the occurrence of human
Bacillus anthracis infections related to
contaminated items sent through the
postal system in the United States. The
emergence of new, more virulent strains
of C. difficile (ribotype 027) has led to
increasing morbidity and mortality of C.
difficile-associated infection in the United
States, Canada, and Europe (51).
Alcohol, as well as other agents used
for antiseptic handwash or antiseptic
handrub (including chlorhexidine, hexa-
chlorophene, chloroxylenol, and tri-
closan), is not reliably sporicidal against
Clostridium spp. or Bacillus spp. (45, 52).
Mechanical friction while washing hands
with soap and water may help physically
remove spores from the surface of con-
taminated hands (53). This effect is not
enhanced when using medicated soap
(53). Because alcohol preserves spores
and is used in the laboratory to select C.
difficile spores from stool, the widespread
use of alcohol-based handrubs was
thought to be associated with the in-
crease of C. difficile-associated infection.
However, C. difficile infections began to
rise in the United States long before the
widespread use of alcohol handrub (54).
Figure 1. The patient zone, healthcare area, and critical sites with inserted time-space representation
of “My five moments for hand hygiene.” (Available at http://www.who.int/gpsc/5may/background/
5moments/en/index.html).
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B. anthracis. Pathogens for biological
warfare have been classified by the Cen-
ters for Disease Control and Prevention
with B. anthracis as a key pathogen.
Washing hands with soap and water re-
duced the amount of B. atrophaeus (a
surrogate for B. anthracis) on hands; this
is the recommended procedure for HCWs
with suspected or documented exposure
to B. anthracis (55). In contrast to what
is known for C. difficile, alcohol handrubs
are not an option, and handwashing is
deemed mandatory in such situations.
Norovirus. Noroviruses are one of the
major causes for nonbacterial gastroenter-
itis throughout the world and are respon-
sible for multiple outbreaks in hospitals
and nursing homes. As mentioned previ-
ously, certain nonenveloped viruses (such
as enteroviruses, rotaviruses, or norovirus)
may require different alcoholic com-
pounds for optimal killing, such as levels
of ethanol higher (?90%) than those op-
timal for killing bacteria. The virus may
contaminate inanimate surfaces, food, or
the hands and thus be transmitted to
other people. Airborne transmission is
likely when individuals vomit. Chemical
disinfection of hands and surfaces is con-
sidered to be a key to breaking the chain
of transmission (56). Kampf et al (57)
investigated the efficacy of three ethanol-
based handrubs (Sterillium Virugard,
95% ethanol; Sterillium Rub, 80% etha-
nol; Desderman N, 75.1% ethanol) against
feline calicivirus, the surrogate virus for
norovirus, on artificially contaminated
hands of healthy volunteers. They found
that the handrub based on 95% ethanol
was more effective than those based on
lower concentrations of ethanol, so they
concluded that the transmission of norovi-
ruses by hands is best controlled using
hand disinfectants with ethanol at a high
concentration (e.g., 95%) for the postcon-
tamination treatment of hands.
Practical approach for ICUs
Pocket bottles versus dispensers. Lack
of user friendliness of hand hygiene
equipment and lack of time are predictors
for noncompliance (58). Deficiencies in
structural layout of hand hygiene re-
sources that hinder their usage include
poor visibility, difficulty of access, place-
ment at undesirable height, and wide spa-
tial separation of resources that are used
sequentially (59). Individual pocket bot-
tles have been proposed (60). This ap-
proach may be suitable for wards where
HCWs wear coats with pockets. However,
multiple installed dispensers are pre-
ferred in ICUs. At the surgical ICU of the
University Hospital Basel, we recommend
at least one dispenser per bed, one at the
nursing station, and at each entrance to a
bay. HCWs should be forced to walk ?15
feet to the closest dispenser.
Monitoring compliance. Compliance
is crucial to prevent transmission of
pathogens by hands of HCWs. Therefore,
measurement of compliance is impor-
tant. The WHO and the Institute for
Healthcare Improvement provide proto-
cols and tools on how to measure and
how to monitor compliance (1, 61). The
optimal tool—manual observation—is
time consuming. Continuous measure-
ment is rarely feasible; audits can be done
as prevalence survey. An alternative mon-
itor as a minimum is the monthly report
on the use of the alcohol handrub. Pub-
lished studies (62) reported an average
use of 68–73 mL per patient day. Careful
evaluation should be applied when such
data are used to extrapolate purchased
bottles of dispensers or bottles and com-
pliance. Frequently, purchasing uses dif-
ferent accounts not necessarily repre-
senting the actual use of the ICU bay.
Choice of the product. The choice of
the product is one of the most difficult
tasks: HCWs may or may not prefer a
product with a strong perfume. All com-
mercially available products contain
emollients for skin care. However, in the
cold season, additional ointments are
necessary to avoid dermatitis from the
use of the alcohol handrub. These oint-
ments should undergo careful testing by
the manufacturers to avoid neutralizing
the alcoholic compound and antagoniz-
ing or hampering the antimicrobial effect
of the alcohol. Many companies provide
compatible handrubs and lotions.
Fluid versus gel. Alcohol-based han-
drubs are available as solutions (with low
viscosity), gels, and foams. Few data are
available regarding the relative efficacy of
the various formulations. Some studies
(63) have demonstrated that solutions have
reduced bacterial counts on the hands of
HCWs to a significantly higher extent than
gels. New generations of gel formulations
with higher antibacterial efficacy than pre-
Figure 2. Technique for using handrub.
S302Crit Care Med 2010 Vol. 38, No. 8 (Suppl.)

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vious products have, however, been proposed
since. Gels may be used more frequently
than solutions, because they are perceived
as less skin drying; hence, compliance with
hand hygiene may be possibly better.
Skin reactions related to hand
hygiene
Two major types of skin reactions are
associated with hand hygiene: irritant
contact dermatitis and allergic contact
dermatitis. Irritant contact dermatitis is
extremely common, ranging from 25% to
55% in prevalence studies of nurses (64).
Its cause is the frequent use of hand hy-
giene products, which can damage the
skin by causing denaturation of stratum
corneum proteins, changes in intercellu-
lar lipids, and decreased stratum cor-
neum water-binding capacity. Damage to
the skin can change skin flora, resulting
in more frequent colonization by staphy-
lococci and Gram-negative bacteria. In
general, alcohols are safer than deter-
gents but can still cause dryness and skin
irritation. One strategy for reducing ex-
posure of HCWs to irritating soaps and
detergents is to promote the use of alco-
hol-based handrubs containing humec-
tants. These products are well tolerated
and are associated with a better skin con-
dition when compared with either plain
or antimicrobial soap (65).
Allergic contact dermatitis caused by al-
cohol-based handrubs is very uncommon.
Surveillance at a hospital in Switzerland
where a commercial alcohol-based han-
drub has been used for ?10 yrs failed to
identify a single case of documented allergy
to the product (66). Allergic reactions to
products applied to the skin may present as
a delayed type reaction (allergic contact
dermatitis) or less commonly as immediate
reactions (contact urticaria). The most
common causes of contact allergies are fra-
grances and preservatives.
The occurrence of irritant contact der-
matitis can be reduced by avoiding soap-
and-water handwashing before or after an
alcohol-based product was used and by
using moisturizing skin care products.
Safety issues related to alcohol-
based preparations
Alcohols are flammable. Flashpoints
of commonly used alcohol-based han-
drubs range from 17.5°C to 24.5°C, de-
pending on the type and concentration
of alcohol present. After using handrub,
the hands should be completed dry be-
fore contacting electrical outlets or
plugs. Alcohol-based handrubs should
be stored away from high temperatures
or flames. In the United States, fire
safety codes may require mounting an
alcohol handrub container at a specified
distance from electrical outlets. Con-
sult the safety officer at the institution
for specific guidelines.
The risk of fires associated with such
products is very low. In the United
States, none of 798 healthcare facilities
surveyed reported a fire related to an
alcohol-based handrub dispenser (67).
In Europe, where alcohol-based han-
drubs have been used for years, the
prevalence of fires related to such prod-
ucts has been extremely low (66). In
Germany, the annual incidence of fires
related to alcohol-based products was
0.0000475% per hospital (68).
Use of alcohol-based handrubs
and alcohol prohibition by some
religions
Alcohol use is prohibited in some re-
ligions. Consequently, the adoption of al-
cohol-based formulations for hand hy-
giene may cause difficulties for some
HCWs, either due to their reluctance to
have contact with alcohol or because of
their concern about alcohol ingestion or
absorption via the skin. In general, reli-
gions with an alcohol prohibition demon-
strate a pragmatic vision leading to ac-
ceptance of alcohol-based products for
hand hygiene. In the Islamic tradition,
which generally poses the toughest chal-
lenge to alcohol use, the Qur’an permits
any substance that man can manufacture
or develop to alleviate illness or contrib-
ute to better health, and this includes
alcohol as a medical agent (69). The WHO
has had success in overcoming this chal-
lenge by partnering with the local reli-
gious leaders in some areas.
Hand hygiene practices among
HCWS, adherence to
recommendations, and potential
barriers to optimal hand
hygiene practices
Adherence of HCWs to recommended
hand hygiene procedures has been re-
ported with very variable figures, with
mean baseline rates ranging from as low
as 5% to 89%, representing an overall
average of 38.7% (70). Rates of compli-
ance with handwashing rarely exceed
40% under study conditions (71). Switch-
ing hand hygiene from handwashing to
alcohol-based handrub improved the
overall compliance rate (60).
Several observational studies or inter-
ventions to improve adherence have tried
to determine risk factors for poor com-
pliance with hand hygiene. Nonadher-
ence was higher in ICUs, compared with
internal medicine, during procedures
that carried a high risk of bacterial con-
tamination and when intensity of patient
care was high. In other words, the higher
the demand for hand hygiene, the lower
the adherence. The lowest adherence rate
(36%) was found in ICUs, where indica-
tions were typically more frequent (on
Table 1. Properties of antiseptics used in hand hygiene and antimicrobial activity
Antiseptics
Concentration
(%)
Speed of
Action
Residual
Activity
Gram-Positive
Bacteria
Gram-Negative
Bacteria
Viruses
Enveloped
Viruses
Nonenveloped Mycobacteria Fungi Spores
Alcohols
Chlorhexidine
Hexachlorophene
Triclosan
Quaternary ammonium
compounds
60–95
0.5–4
3
0.1–2
Variable
???
??
?
??
?
?
??
?
?
?
???
???
???
???
??
???
??
?
??
?
???
??
??
?
???
?
?
?
?
???
?
?
?
?
?
?
?
?
??
Variable
?, no activity; ?, poor; ?, fair; ??, good; ???, excellent.
Ethanol at ?95% is highly effective against viruses; isopropanol has limited effectiveness against small or nonlipid viruses. Reprinted with permission
from Widmer AF, Frei R: Decontamination, disinfection, and sterilization. In: Manual of Clinical Microbiology. Ninth Edition. Murray PR (Ed in Chief);
Baron EJ, Jorgensen JH, Landry ML, Pfaller MA (Eds). Washington, DC, American Society of Microbiology Press, 2007.
S303Crit Care Med 2010 Vol. 38, No. 8 (Suppl.)