Bertrand Souweine

1. Est-ce que la désinfection des mains est un outil efficace pour prévenir les transmissions croisées ? Bertrand Souweine

2. Plan • Flore cutanée et contamination • Lavage des mains • Frictions alcoolique • Efficacité microbiologique • Aspects pratiques • Efficacité clinique • Conclusion

3. Plan • Flore cutanée et contamination • Lavage des mains • Frictions alcoolique • Efficacité microbiologique • Aspects pratiques • Efficacité clinique • Conclusion

4. Types of Skin Flora • Transient flora • Resident flora • Infectious flora

5. Epiderme superficiel : stratum corneum effet protecteur contre flore contaminante squammes lipides • H20 assure plasticité, perméabilité // hydratation • Une couche produite / 24 heures et qui disparaît en 15 jours • 102-103 ufc/cm2, enchâssés en profondeur • 107 particules libérées / j dans air dont 10% contiennent des germes

6. Resident Flora • Deeper skin layers • Mainly CNS, coryneform bacteria and micrococci ; fungi (Malassezia); virus usually not resident on the skin • More resistant to mechanical removal and stable over time • Lower pathogenic potential (not pathogens on intact skin) • Colonization resistance • Very difficult to eliminate (< 50% decrease in bacteril load after 6 min of handwashing)

7. Transient Flora • Superficial layers; usually not multiply on the skin • Acquired by contact with patient or environment • Easily removed by mechanical means • S. aureus, GNB or candida or virus

8. Infectious Flora • The etiologic agents of actual infections such as abscess, panaritium, paronychia, and infected eczema on the hands • S. aureus and β-hemolytic streptococci

9. You may not Realize You Have Germs on Your Hands! • Nurses, doctors and other healthcare workers can contaminate their hands by doing simple tasks, including:  • Taking a patient’s blood  pressure or pulse • Assisting patients with mobility • Touching the patient’s gown  or bed sheets • Touching equipment,  including bedside rails, over  bed tables, IV pumps http://www.handhygiene.org/

10. Acquisition de la flore transitoire ou contaminante temps de soin dépendante Durée de contact : 16 cfu /mn Port de gants : 3 cfu /mn Pittet Arch Intern Med 1999

11. Acquisition de la flore transitoire ou contaminante même après simple contact patient Pittet Arch Intern Med 1999 Type d’activité : 16-21 cfu /mn

12. Clin Microbiol Rev. 2004;17(4):863

13. Transmission of organisms Transmission of organisms by hands of health care providers between two patients can result in health care associated infections (HAIs). Adapted from the Swiss Hand Hygiene Campaign

14. Clin Microbiol Rev. 2004;17(4):863

15. Hygiène des mains et contrôle de l’infection CDC Guideline for HH in healthcare settings

16. Plan • Flore cutanée et contamination • Lavage des mains • Frictions alcoolique • Efficacité microbiologique • Aspects pratiques • Efficacité clinique • Conclusion

17. CID 2000;31:136

19. Soap • Plain • Esterified fatty acids with sodium or potassium hydroxide • Mechanical removal of dirt and loosely adherent flora (transient>resident) • Antiseptic

20. Chlorhexidine • A cationic biguanide • England in 1954; introduced into U.S. in 1970s • Chlorhexidine base only minimally soluble in water, but digluconate is water-soluble • Exists as acetate (diacetate), gluconate, and hydrochloride salts

21. Mechanism of Action • Attach to bacterial cytoplasmic membrane (inner membrane) • Precipitation or coagulation of protein and nucleic acids • Also to the outer membrane in G(-) and the cell wall in G(+) • Also damage the cytoplasmic membrane of yeasts

22. Spectrum of Activity • Depends on concentration • lower: bacteriostatic against GP bacteria, GNB and bacterial spores • Bacteria • Good activity against G(+), less G(-) and fungi, not spores • Dermatophytes: no activity • Mycobacteria: limited • Virus: good for most enveloped virus, low for naked viruses

23. Efficacy • Reduce transient bacteria by 2.1 to 3 log10; smaller in resident flora (0.35 to 2.29 log10) • Activity is greatly reduced in the presence of organic matter, natural corks, and hand creams containing anionic emulsifying agents • Substantial residual activity

24. Resistance • If MIC greater than 50 mg/liter • Uncommon among G(+) bacteria • Yes for G(-), such as E.coli, P.mirabilis (84.6%), P. stuartii, P. aeruginosa, P. cepacia and S. marcescens • C. albicans (10.5%) • Cross-resistance (+) • Mechanism • Alternation of inner, outer membrane or the cell wall

25. Adverse Effect • Temperature greater than 70℃, chlorhexidine may degrade to para-chloraniline (carcinogenic) • Conjunctivitis and corneal damage when contacted with eye • Ototoxicity • Dermatitis is concentration dependent • Anaphylactic reactions • Avoid direct contact with brain tissue and the meninges

26. Another reason why personnel don’t wash their hands often Frequent handwashing with soap and water often causes skin irritation and dryness. Skin irritation are more frequently reported when using antiseptic soap In the winter months, some personnel may even develop cracks in their skin that cause bleeding, as seen in the adjacent figure.

27. OBSERVANCE / HYGIENE DES MAINS Nb d’actions d’hygiène des mains Nb d’indications à l’hygiène des mains

28. Observance basale Soignants 30-40% Médecins 10-20% Autres 10-20%

29. Observance du lavage des mains : revue de la littérature %

30. Trick, CID 07

31. Reasons Advocated for Poor Handwashing Compliance Skin irritation from hand hygiene products Inaccessibility of hand hygiene supplies Wearing gloves Hands don’t look dirty Lack of information on the importance of hand hygiene Lack of knowledge of the guidelines Too busy/handwashing takes too long Risk factors for Poor Handwashing Compliance • Male vs female • Physician vs nurse • Wearing gloves • Working in ICU • Understaffing/overcrowding

32. It takes ICU nurses an average of 62 seconds to go to a sink, wash and dry their hands, and return to patient care activities

33. It takes ICU nurses an average of 62 seconds to go to a sink, wash and dry their hands, and return to patient care activities The time needed for hand hygiene before and after every contact is about 100 min/patient for direct contacts

34. DUREE DU LAVAGE SIMPLE DES MAINS Anne Simon

35. Hand as a Vectors of Transmission • Organisms present on the patient’s skin or on inanimate objects • Organism must be capable of surviving for at least several minutes on the hands of personnel • Handwashing is inadequate or omitted entirely • Come in direct contact with another patient, or with an inanimate object

36. Precaution • Recontaminated from faucets or by splashes from traps or sinks (P. aeruginosa in the tap water) or from plain soap (both bar and liquid soaps, bar soaps heavier; S. marcescens or Serratia liquefaciens) • Outside health care facilities (working hours, before eating, after using restroom), use of soap and water is recommended

37. Hand hygiene is the most important tool in NI control • Adherence to hand-washing practices remains unacceptable low, rarely exceeding 40%

38. Plan • Flore cutanée et contamination • Lavage des mains • Frictions alcoolique • Efficacité microbiologique • Aspects pratiques • Efficacité clinique • Conclusion

39. CID 2000;31:136

40. Poor Kolletchka

41. Ignaz Philipp Semmelweis (1818-65), a Hungarian obstetrician educated at the universities of Pest and Vienna, introduced antiseptic prophylaxis into medicine. Ignaz Philipp Semmelweis (1818-1865)

42. hand disinfection with a solution of 4% chlorinated Death of Kolletchka Curr Opin Infect Dis 1998; 11: 457-460

43. Ethanol, Isopropanol, and n-Propanol • Ethanol is introduced in 1888 isopropanol and n-propanol in 1904 • Vigorous friction, rinsing with water, and drying with a towel are unnecessary

44. Les produits hydro-alcooliques (PHA) • solutions ou gels • séchage rapide • désinfection des mains • alcool (60-70%) + émollient +/- autre antiseptique • péril hydrique • friction sans rinçage • friction sur mains • sèches +++ • non visiblement souillées (propres) • non poudrées • pas de friction de gants

45. Mechanism of Action • Killing not mechanically remove • Protein denaturation, rapid killing (sec)

47. Spectrum of Activity • Mycobacteria • Excellent in vitro activity against G(+) and G(-) bacteria • Virus • Good activity against enveloped viruese • Nonenveloped viruses require higher concentration (70-80%) • Against most fungi • Poor or no activity against spores, protozoal oocysts

48. Etudes expérimentales de l’activité des savons sur les mains contaminées par C. difficile(Barbut F. et coll., Hygiènes, 2003, 5, 449-55) Contamination expérimentale des mains de 14 volontaires Contamination initiale : 4.2 à 4.8 log10 UFC/ml Méthode du jus de gants log 0 1 2 3 1 min 30 sec 1 min 30 sec P<0.01 P=0.36 P<0.01 Diapositive empruntée a F Barbut

49. Quelle hygiène des mains ? • Faut il bannir les solutions hydro alcooliques? Boyce et al, ICHE 2006 Même constat, -Diminution de l’incidence des ERV et des SARM (1998-2000) vs (2001-2003) -Incidence stable pour Clostridium difficile Gordin et al ICHE 2006

50. Efficacy • The type of alcohol • Concentration • Contact time • Volume used • Whether the hands are wet when the alcohol applied • Temperature • Organic material