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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/
Dtsch Arztebl Int. 2009 October; 106(40): 649655.
Published online 2009 October 2. doi: 10.3238/arztebl.2009.0649
PMCID: PMC2770229
Hand Hygiene for the Prevention of

Nosocomial Infections
Gnter Kampf, PD Dr. med.,1,2 Harald Lffler, Prof. Dr. med.,3 and Petra Gastmeier,
Prof. Dr. med
Abstract
Background
The WHO regards hand hygiene as an essential tool for the prevention of nosocomial infection,
but compliance in clinical practice is often low.
Methods
The relevant scientific literature and national and international evidence-based recommendations
(Robert Koch Institute [Germany], WHO) were evaluated.
Results
Hygienic hand disinfection has better antimicrobial efficacy than hand-washing and is the
procedure of choice to be performed before and after manual contact with patients. The hands
should be washed, rather than disinfected, only when they are visibly soiled. Skin irritation is
quite common among healthcare workers and is mainly caused by water, soap, and prolonged
wearing of gloves. Compliance can be improved by training, by placing hand-rub dispensers at
the sites where they are needed, and by physicians setting a good example for others.
Conclusions
Improved compliance in hand hygiene, with proper use of alcohol-based hand rubs, can reduce
the nosocomial infection rate by as much as 40%.
Keywords: hand hygiene, disinfection, compliance, nosocomial infection,
protective gloves
Healthcare workers hands represent the principal route of transmission of nosocomial

pathogens. They are colonized permanently by the physiological flora (resident flora) and
temporarily, depending on the precise nature of the employees duties, by various pathogens that
do not belong to the physiological flora (transient flora) (1). Staphylococcus aureus, for
example, can survive for over 2 h on the hands and is found in 10% to 78% of staff (table 1).
Table 1
Frequency and persistence of selected nosocomial pathogens on the hands
of healthcare workers (1)
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Clean Hands Campaign

Improvement of hand hygiene, with the aim of minimizing nosocomial infection, is a high
priority of the World Health Organization (WHO). The promotion of effective measures to
improve hand hygiene (e1) is therefore one of the five foremost goals of the WHOs current
worldwide Patient Safety Initiative (Announce Action on Patient Safety [High 5s] Initiative,
Washington, DC, 4 November 2006). By September 2008 114 countries had given written
undertakings to implement these goals. In Germany, the Clean Hands Campaign (Aktion
saubere Hnde) was launched on 1 January 2008 under the auspices of the Federal Ministry of
Health (e2). By 14 June 2009, 550 hospitals had signed up to the campaign, including two thirds
of the university hospitals. The goal is to establish hand disinfection as a decisive quality
parameter anchored firmly in clinical routine.
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Methods
We began by examining the scientific literature on the provisional WHO recommendation on
hand hygiene from the year 2006 (e3). For studies published from 2006 onward we performed a
selective review of the publications in the National Library of Medicine. Furthermore, we
evaluated the recommendations of the following institutions:
Commission for Hospital Hygiene and Prevention of Infection, Robert Koch

Institute (RKI) (2)
Association of the Scientific Medical Societies in Germany (AWMF) (e4)
WHO (final recommendation) (3)
Centers for Disease Control and Prevention (CDC) (e5).
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Importance of protective gloves

The wearing of protective gloves is a sensible precaution in various clinical situations in order to
prevent gross soiling or contamination (box 1). It may even break the chain of infection more
effectively than hand-washing or hand disinfection. A prospective, controlled intervention study
showed that a training session and the availability of gloves directly at the bedside can
significantly reduce the incidence of Clostridium difficileassociated diarrhea (CDAD) (4). The
hands should be disinfected when protective gloves are taken off, because in contrast to surgical
gloves, ordinary protective gloves are often permeable to pathogens even before use. Moreover,
the hands may have come into contact with the potentially contaminated outer surface of the
gloves during removal. In the case of vancomycin-resistant enterococci (VRE), a study showed
that despite the use of gloves the same pathogen could be found on the hands of staff involved in
treatment in 30% of cases (5).
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Box 1
Clinical situations in which the wearing of protective gloves is especially
indicated
Examination of incontinent patients
Examination or treatment of MRSA patients
Examination or treatment of patients with C. difficileassociated diarrhea
Endotracheal aspiration
Blood sampling
Removal of drains or bandages
Handling of secretions or excretions
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Hand-washing
Indications
Hand-washing should be an exception in clinical routine (2, 3). The point of washing the hands is
mainly to remove visible soiling and only occasionally to reduce the microbial colonization of
the skinfor example in contamination by spores of C. difficile. Hand-washing is therefore
indicated considerably less often than generally assumed. It makes sense to wash the hands
before starting work, after finishing work, and following visits to the bathroom. In all other
clinical situations in which hand hygiene measures are required, hand disinfection should be
preferred on grounds of efficacy and skin tolerability.
Efficacy
Washing with soap and water is much less effective than hygienic hand disinfection (1 3). Even
washing for several minutes reduces the skins resident flora hardly at all (table 2). Washing
reduces the transient flora (contaminating flora) by only 2 to 3 log10 levels. The same is true for
bacterial spores (6). Given the frequently short duration of washing, the efficacy of antimicrobial
soaps hardly exceeds that of ordinary soaps (6), so that normal soaps are generally perfectly
adequate for everyday clinical use.
Table 2
Effect of hand-washing and hand disinfection (1, 24)
Benefits and risks
The limited benefits of hand-washing are accompanied by the risk of cutaneous irritation and
hand eczema. Frequent washing of the hands can lead to dryness and impair the barrier function
of the skin (7). The skin thus continually loses fats and water-binding factors, and noxious
substances can more easily penetrate the epidermis. Clinically manifest irritant eczema of the
hand may gradually develop. Given the comparatively slight benefit, it swiftly becomes clear
that hand-washing should be seen as an exception. Merely in the case of contamination with
spore-forming bacteria, e.g., C. difficile, is it useful to wash the hands after disinfection, because
bacterial spores are naturally resistant to alcohol.
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Hygienic hand disinfection

Indications
Hand disinfection is indicated in almost all interactions of medical staff with patients (box 2) (2).
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Box 2
Hygienic hand disinfection benefits the patient in the following clinical
situations (2):
Before invasive procedures, even if gloves will be worn, e.g.
Insertion of a venous or bladder catheter
Angiography, bronchoscopy, endoscopy
Injections and punctures
Before contact with patients who are at particular risk of infection, e.g.
Leukemia patients
Polytrauma patients
Burns patients
Irradiated and other severely ill patients
Before exposure to potential contamination
Preparation of infusions
Mixing of combined infusions
Drawing up of syringes
Before and after any contact with
Wounds
Insertion sites of catheters or drains
After contact with
Blood, secretions, excrement, or infected regions of the body
Urine-collecting systems, aspirators, ventilators, ventilation masks,

tracheal tubes or drains
Potentially infectious patients, e.g., MRSA patients
After removal of protective gloves
After contact with a patient during a clinical round or in the consultation or

treatment room
For example, the hands should be disinfected after direct patient contact (measurement of vital
functions, auscultation, palpation) or after contact with potentially infectious materials, e.g.,
bandages. Hand disinfection is most important, however, in the case of potential nosocomial
infections (2, 3). The most frequent such infections in Germany are catheter-associated urinary
tract infection (ca. 42%), ventilator-associated pneumonia (ca. 21%), surgical site infection (ca.
16%), and catheter-associated bloodstream infection (ca. 8%) (8). Hygienic hand disinfection can
make a substantial contribution to preventing these infections if consistently performed at the
following junctures (2, 3):
Catheter-associated urinary tract infection: before placement of the urinary

catheter, before and after contact with the catheter
Ventilator-associated pneumonia: before and after intubation, before and
after aspiration
Surgical site infection: before and after contact with wounds, after removal of
a bandage
Catheter-associated bloodstream infection: before placement of vascular

catheters, before manipulation of vascular catheters, before preparation of
intravenous medication.
Efficacy
The commonly available hand rubs are considerably more effective than hand-washing with soap
(2, 3). Within 30 s, for example, the following bacteria are not only greatly reduced but
practically completely eliminated (e6):
Escherichia colimost frequent cause of catheter-associated urinary tract

infection
Pseudomonas aeruginosavery frequent cause of ventilator-associated

pneumonia
Staphylococcus aureusmost frequent cause of surgical site infection
Staphylococcus epidermidismost frequent cause of catheter-associated

bloodstream infection.
The same applies to yeasts such as Candida spp. or Rhodotorula spp. and to coated viruses such
as HBV, HCV, HIV, and the influenza viruses. Hand disinfection thus eliminates the majority of
agents known to cause nosocomial infections.
There are only a few pathogens against which the commonly available hand rubs are ineffective.
These include uncoated viruses such as noroviruses and the spores of spore-forming bacteria
such as C. difficile. In the case of the noroviruses special virucidal hand rubs are recommended
(see the RKIs list of disinfectant hand rubs [9]), because epidemiological studies have shown
that as part of a package of measures these preparations make a real contribution to the
containment of outbreaks. For spore-forming bacteria such as C. difficile, the recommendation is
first to disinfect the hands in order to kill off the vegetative form, then to wash them briefly but
thoroughly to reduce the number of spores as much as possible (e7).
Benefits and risks
Hand disinfection is key to the prevention of nosocomial infections. At Geneva University

Hospital, improvement of the compliance rate from 48% to 66% over a 5-year period lowered
the frequency of nosocomial infections by more than 40% (10). Over the same period the rate of
new infections by methicillin-resistant S. aureus (MRSA) was reduced by more than 50% (10).
In contrast to popular opinion, the irritant potential of alcohol-based hand rubs is very low.
Commercially available preparations are generally tolerated much better than the detergents in
hand-washing agents (7, 11). Even frequent, intensive hand disinfection detracts only minimally
from the skins barrier function and makes the skin only slightly drier. This is due partly to the
skin care substances usually found in hand rubs. Allergic reactions to the ingredients of hand-rub
preparations are extremely rare (1, 3).
For hand disinfection to be effective, both hands must be completely covered. To this end, an
adequate amount of the hand rub must be applied efficiently. The duration of application should
be 22 to 28 s. Shorter application times, e.g., 15 s, almost always fail to cover the hands
completely (12). Surprisingly, the best results are achieved when users are left to their own
devices, not with a strictly regulated procedure. Special attention must be paid to the fingertips
and thumbs, however; these parts of the hand are most likely to come into contact with the
patient, and the greatest proportion of the bacteria are found on the fingertips (13).
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Hand eczema
There can be no doubt that hygiene precautions are a risk factor for occupational hand eczema.
Consequently employment in nursing and related professions involves the risk of contracting
occupational dermatosis (14). Many consider rough, flaking skin on their hands as normal in
their line of work and fail to realize that this may be the first sign of hand eczema (figure 1). In a
survey carried out by the German Contact Allergy Group (Deutsche Kontaktallergiegruppe,
DKG), more than 70% of nursing staff reported irritant skin symptoms within a year, and 46%
considered them detrimental in their daily lives (15).
Figure 1
Early irritant skin changes between the digits
Most nurses still believe that alcohol-based hand rubs damage their skin more than hand-washing
(15). However, alcohol-based preparations are much kinder to the skin than hand-washing agents
because they are less harmful to the cutaneous barrier (as measured by transepidermal water loss)
and dry the skin out less (as measured by corneometry) (7, 11). Interestingly, the application of
alcohols after hand-washing can even reduce the irritation caused by the washing, probably by
elimination of residual detergent monomers (7). Nevertheless, many users think that hand rubs
harm their skin. One reason is the burning felt when the alcohols stimulate the pain receptors in
damaged areas of skin. The alcohol-based hand rub is then blamed for the symptoms (it only
burns with the alcohol) and hand disinfection is abandoned in favor of washing. The burning
stops, but the damage accelerates: a vicious circle begins, resulting in manifest hand eczema
(figure 2) and, in the worst case, inability to work (16).
Figure 2
Manifest irritant hand eczema
A burning sensation on use of a disinfecting hand rub is a warning of impairment of the skins
barrier function. Those affected should avoid activities harmful to the skinwashing, occlusion
(protective gloves), contact with soaps, direct contact with irritant disinfectantsand apply
copious quantities of skin protection and skin care products.
Some users state that alcohol-based hand rubs have a sensitizing effect. Nevertheless,
sensitization to an alcohol could be excluded in all 50 persons who were tested for allergic
reactions to an alcohol-based hand rub because of suspected intolerance. Oversensitivity to an
excipient (e.g., cetearyl octanoate) was demonstrated, however (15).
An intact cutaneous barrier is of more than just cosmetic and functional relevance. Eczematous
hands are also colonized to a greater degree by pathogens than are healthy hands (17, 18). The
principles of hand care and protection should therefore be taught to all healthcare workers and
should form part of every training program (19). They are also included in the Clean Hands
Campaign.
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Care and protection of the skin

Appropriate precautions when using potentially irritant substances can prevent harm to the skin.
Moreover, adequate protection and care of the skin are of paramount importance for the
maintenance of a functioning cutaneous barrier (e8). These precautions should be integrated in
the working routine and can, if properly implemented, protect the hands without compromising
disinfection. Skin protection plans should be drawn up with information about the available
products and their use (see Technical Rule for Hazardous Substances [TRGS] 401 of June 2008:
Risks resulting from skin contactdetermination, evaluation, measures) (20). Staff should have
access to data showing the efficacy of all preparations employed, as well as information on their
uses (see the Occupational Skin Preparations (Berufliche Hautmittel) guideline of the
German Working Group for Occupational and Environmental Dermatology [Arbeitsgemeinschaft
fr Berufs- und Umweltdermatologie, ABD]) (21). Skin protection products should be applied
before starting work and after every break, in order to minimize drying out and impairment of
the skins barrier function by wet work. After work, skin care creams help to accelerate
cutaneous regeneration. Because components of some of these preparations may promote
penetration of irritants, they should preferably be applied only when work is over (21).
Any member of staff exhibiting clinically manifest cutaneous irritation at work should be
referred to a dermatologist or occupational medicine specialist, who can then institute the
appropriate procedures, including reporting of the case to the accident insurance provider (22).
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Compliance
Unfortunately the overall rate of compliance in hand hygiene is poor, only 50% on average. In
other words, every second time hand disinfection is required, it is not carried out. The primary
goal of all initiatives to improve compliance in hand hygiene is optimization of the rate of hand
disinfection. As a secondary aim, of course, it is also important to reduce hand-washing to a
minimum.
Barriers
There are many different reasons why healthcare workers disinfect their hands much less often
than necessary for protection of their patients. These include:
Insufficient knowledge of the clinical situations in which the patient clearly

benefits
Lack of products or dispensers: unavailability of the disinfecting hand rub
right where it is needed
Lack of time: hand disinfection is frequently not carried out because of

increasing pressure of work, or when a ward is over-occupied or under-staffed
(23)
Cutaneous irritation: skin problems with use, e.g., dryness, irritation, or

burning combined with inadequate knowledge of the causes
Failure of high-ranking medical staff to set an example: junior doctors and

nurses will think that hand disinfection cannot be very important if senior
doctors dispense with it.
Measures to achieve improvement
Readily implementable measures can be drawn up to counter the above-mentioned factors and
improve compliance (box 3). Moreover, primary prevention by means of early education on hand
hygiene (e.g., during training, with explanation of the efficacy and cutaneous tolerance of hand
hygiene measures), accompanied by regular motivational campaigns, is effective. Furthermore,
skin protection and care products must be available to all employees at their workplace. One can
only appeal to all senior staff to set a proper example. It will then be much more difficult for
junior workers not to follow suit.
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Box 3
Measures to improve compliance
Staff training with regard to the clinical situations in which hand disinfection
is indicated
Inclusion of the goals in the training program, because behavior learned
during basic training is put into practice much more effectively than that
taught in later training sessions, when established routine behavior has to be
changed
Disinfecting hand rubs should be available where they are actually needed.
This can by achieved by simple means both in the hospital and the doctors
office. If wall dispensers cannot be mounted, the doctor may be able to carry
a bottle of hand rub in the pocket of his/her lab coat.
Reduction of hand-washing to a minimum in order to avoid unnecessary skin

irritation
Senior members of medical staff must recognize that they have to set an
example and act accordingly.
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Conclusion
Evidence-based hand hygiene can prevent transmission of the most important nosocomial
pathogens and also keep employees skin healthy. In most clinical situations hygienic
disinfection is indicated for hand decontamination on grounds of better efficacy and cutaneous
tolerance. Washing with soap and water is necessary only when the hands are visibly soiled, or
following disinfection in the case of contamination by spores of bacteria such as C. difficile.
Compliance could be improved by knowledge of the principal clinical circumstances in which
hand disinfection by healthcare workers genuinely benefits the patient.
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Key Messages
Hand disinfection eliminates the transient flora and is one of the most
important precautions for specific prevention of transmission of nosocomial
infections.
In practice, on average every second necessary disinfection of the hands is
not actually carried out. The WHO has therefore launched a worldwide
initiative to improve compliance.
The rate of nosocomial infections can be reduced by up to 40% by improved

compliance in hand disinfection.
Hand-washing damages the skin more than hand disinfection. It should

principally be restricted to visibly soiled hands and, following disinfection,
hands contaminated with spore-forming bacteria such as C. difficile.
A burning sensation on hand disinfection represents an important warning of

damage to the cutaneous barrier. Activities harmful to the skin, e.g., frequent
washing, must then be avoided and skin protection and care products applied
more intensively.
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Acknowledgments
Translated from the original German by David Roseveare.
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Footnotes
Conflict of interest statement

Dr. Kampf is an employee of Bode Chemie GmbH, Hamburg. Professor Lffler has received
honoraria for lectures given on behalf of Bode Chemie GmbH. Professor Gastmeier declares that
no conflict of interest exists according to the guidelines of the International Committee of
Medical Journal Editors.
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www.who.int/patientsafety/en/
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http://pmj.bmj.com/content/77/903/16.full
Postgrad Med J 2001;77:16-19 doi:10.1136/pmj.77.903.16
The health professional's role in preventing

nosocomial infections
1. H Saloojee,
2. A Steenhoff
+ Author Affiliations
1. Department of Paediatrics and Child Health, University of the Witwatersrand, PO Wits,
Johannesburg 2050, South Africa
1. Dr Saloojee092sal@chiron.wits.ac.za
Received 12 January 2000
Accepted 9 May 2000
Abstract
Despite their best intentions, health professionals sometimes act as vectors of disease,
disseminating new infections among their unsuspecting clients. Attention to simple preventive
strategies may significantly reduce disease transmission rates. Frequent hand washing remains
the single most important intervention in infection control. However, identifying mechanisms to
ensure compliance by health professionals remains a perplexing problem. Gloves, gowns, and
masks have a role in preventing infections, but are often used inappropriately, increasing service
costs unnecessarily. While virulent microorganisms can be cultured from stethoscopes and white
coats, their role in disease transmission remains undefined. There is greater consensus about
sterile insertion techniques for intravascular cathetersa common source of infectionsand
their care. By following a few simple rules identified in this review, health professionals may
prevent much unnecessary medical and financial distress to their patients.
Infection control programmes are cost-effective,1 2 but their implementation is often hindered by
a lack of support from administrators and poor compliance by doctors, nurses, and other health
workers. Some health professionals suffer from the Omo syndromea belief that they are
always super clean and sterile. Many are visibly upset when their poor hygiene practices are
exposed and are offended when it is suggested that they may be potential vectors of disease and
are spreading virulent microorganisms among their patients.
There is increasing concern worldwide about the rising prevalence of multiresistant, virulent
bacteria. Indeed, in one South African neonatal unit multi-antibiotic resistant klebsiellae are now
the commonest organisms cultured.3 While this neonatal unit, like many others, has resorted to
using more potent and expensive antibiotics to curb the threat these organisms pose to vulnerable
infants, it is clear that the focus of any efforts has to be on the prevention of nosocomial
infections.
Aetiology of nosocomial infections

Intravascular device related infections and infections acquired through the respiratory tract are
among the most common nosocomial infections in critically ill patients.4 Among the numerous
risk factors for acquiring a nosocomial infection, the length of hospital stay is the most
important. (box 1). Aetiological agents vary and include antibiotic resistant bacteria,
particularlyStaphylococcus aureus, Gram negative bacilli and enterococci, viruses (which
account for up to 20% of cases), and fungi.
Box 1: Risk factors for nosocomial infection
Duration of hospital stay

Indwelling catheters
Mechanical ventilation
Use of total parenteral nutrition
Antibiotic usage
Use of histamine (H2) receptor blockers (owing to relative bacterial overgrowth)
Agemore common in neonates, infants, and the elderly
Immune deficiency
Hand washing
The hands of staff are the commonest vehicles by which microorganisms are transmitted between
patients.5 Hand washing is accepted as the single most important measure in infection control.57 Not surprisingly, hospital staff believe that they wash their hands more often than they actually
do, and they also overestimate the duration of hand washing.8 In a study of nurses' practices,
hands were only cleaned after 30% of patient contacts and after 50% of activities likely to result
in heavy contamination. Poorer hand washing performance was related to increasing nursing
workload and the reduced availability of hand decontaminating agents.9 At many hospitals and
clinics, particularly in developing countries, handwash basins are poorly accessible and the
unavailability of soap, sprays, and hand towels is a regular, annoying occurrence.
Alcoholic hand disinfection is generally used in Europe, while hand washing with medicated
soap is more commonly practised in the United States.10 The superiority of one method over the
other is a moot point. Voss and Widmer argue that alcoholic hand disinfection, with its rapid
activity, superior efficacy, and minimal time commitment, allows easy and complete compliance
without interfering with the quality of patient care.10 They estimated that given 100%
compliance, soap hand washing would consume 16 hours of nursing time for a 24 hour shift,
whereas alcoholic hand disinfection from a bedside dispenser requires only three hours. Hand
washing using a spray can be accomplished in 20 seconds, compared with 4080 seconds for
soap.
Theatre staff are sometimes reluctant to remove their wedding rings when scrubbing up. Higher
microbial counts after washing are found in health workers who prefer not to remove rings,11
and may put the patient at risk for a nosocomial infection.12 The value of surgical scrubbing
using a brush is questioned. In one study, subjects who washed with an antiseptic soap alone had
a twofold greater reduction in bacterial counts than when they scrubbed with a brush.13
Continued monitoring and educational efforts can improve hand washing habits.14 15 Larson et
alreported that by providing feedback to staff regarding the frequency of hand washing,
compliance improved by 92%.14 Alas, when feedback was stopped compliance quickly returned
to baseline levels. The importance of constantly reminding staff of the need for hand washing,
and of senior staff setting a good example by their own hygienic practices, cannot be
overemphasised.
It is difficult to provide clear guidelines on how often hands should be washed. The
Handwashing Liaison Group is emphatic: an explicit standard [should] be set, that hands should
be decontaminated before each patient contact.16 We recommend the use of chlorhexidine
solution before the performance of invasive procedures. The thoroughness of application is more
important than the time spent on washing or the agent used.
Gloves
Gloves are a useful additional means of reducing nosocomial infection, but they supplement
rather than replace hand washing. Possible microbial contamination of hands and transmission of
infection has been reported despite gloves being worn.17 Not surprisingly, health care workers
who wash their hands more often are also more likely to wear gloves.5 Single use gloves should
never be washed, resterilised, or disinfected, and gloves must be changed after each patient
encounter.
Sterile gloves are much more expensive than clean gloves and need only be used for certain
procedures, such as when hands are going to make contact with normally sterile body areas or
when inserting a central venous or urinary catheter. Clean gloves can be used at all other times,
including during wound dressings. For gloves to be used appropriately they must be readily
available. Again, this is not always the case at many clinics and hospitals in poorer settings.
Gowning
Gowns help keep infectious materials off clothing, although in some centres they are used more
as reminders that the patient is isolated. Two recent studies confirm that staff gowning in the
neonatal intensive care unit is an unnecessary custom.18 19Wearing gowns did not reduce
neonatal colonisation, infection, or mortality rates. There was no change in traffic patterns in the
unit or in hand washing behaviour,18 and it was not cost-effective.19 The universal use of gloves
and gowns was found to be no better than the use of gloves alone in preventing rectal
colonisation by vancomicin resistant enterococci in a medical intensive care unit.20
Masks
It has never been shown that wearing surgical facemasks decreases postoperative wound
infections. When originally introduced, the primary function of the surgical mask was to prevent
the migration of microorganisms residing in the nose and mouth of members of the operating
team to the open wound of the patient. However, it is now recognised that most bacteria
dispersed by talking and sneezing are harmless to wounds.21 The prevailing opinion that masks
are useful in preventing surgical site infection has been challenged.22-24 Orr reported a 50%
decrease in wound infections when masks were not worn, but the study was criticised for lack of
proper controls.23 Tunevall, using better controls, confirmed the earlier findings of lack of clear
benefit from wearing masks24; after 1537 operations performed with face masks, 73 wound
infections were recorded (4.7%), while following 1551 operations performed without face
masks, 55 infections occurred (3.5%). The difference was not significant. Thus while masks may
be used to protect the operating team from drops of infected blood and from airborne infections,
they have not been proven to protect the patient.
Stethoscopes
Some health personnel have difficulty in accepting that the stethoscope, the symbol of their
professional status, may actually be a vector of disease. In a study of 150 health care workers (50
paramedics, 50 nurses, and 50 doctors), staphylococcus species (mostly coagulase negative) were
cultured from 89% of the participants' stethoscopes, the mean number of colony forming units
increasing the longer stethoscopes were not cleaned.25 Overall, 48% of health care providers
cleaned their stethoscopes daily or weekly, 37% monthly, 7% yearly, and 7% had never cleaned
them. Cleaning the stethoscope's diaphragm resulted in an immediate reduction in the bacterial
countby 94% with alcohol swabs, 90% with a non-ionic detergent, and 75% with antiseptic
soap.25
There are no studies on the beneficial effect of regularly cleaning stethoscopes on nosocomial
infection rates. Nevertheless, we suggest that regular disinfection should be carried out (at least
once daily), as the level of contamination rises from 0% to 69% after more than one day without
cleaning of the stethoscope.26 Isopropyl alcohol is an effective cleaning agent,27 but may dry
out the stethoscope's rubber seals and damage the tubing if used routinely.
White coats
Like the stethoscope, the white coat has long been a symbol of the medical professional. Many
institutions insist that junior doctors, in particular, wear a white coat as part of a mandatory dress
code. About half of all patients still prefer their doctor to wear one.28 However, they may be less
enthusiastic about this if they realised that white coats harbour potential pathogens and are
thereby a source of cross infection, particularly in surgical areas.29 The cuffs and pockets of the
coats are the most highly contaminated areas. The recommendation that the coat is removed and
a plastic apron is donned before wound examination is rarely followed in practice. While few
would challenge the sartorial elegance of the white coat, clearly its value needs to be critically
assessed. There is little microbiological evidence for recommending changing white coats more
often than once a week, or for excluding the wearing of white coats in non-clinical areas.29
Intravenous catheters
In critically ill patients, intravenous lines are responsible for at least one quarter of all
nosocomial blood stream infections, with a 25% reported mortality.30 Most causative organisms
originate from the skin: staphylococci cause two thirds of the infections, with Saureus
accounting for 515% of these. The insertion of an intravenous needle or cannula results in a
break in the body's natural defences. Organisms can enter the circulation from contaminated fluid
or a giving set, or can grow along the outer surface of the cannula.
Prevention of complications requires careful insertion practice and optimal catheter care.
Inserting a peripheral catheter demands the same precautions as for any surgical procedure. The
hands should be disinfected with alcohol and gloves should be worn. The skin of the insertion
site must be thoroughly disinfected with alcoholic chlorhexidine or 70% isopropyl alcohol for at
least 30 seconds and allowed to dry before inserting the cannula. The insertion site should not be
touched after disinfection. When 2% chlorhexidine, 10% povidone-iodine, and 70% alcohol were
compared as skin disinfectants, the rate of catheter associated bacteraemia was almost fourfold
lower in the patients who received chlorhexidine than in the two other groups.31
The use of a clear, adhesive, bacteria impermeable dressing to secure the cannula has become
popular. These dressings may be contraindicated as they allow accumulation of blood, sweat, and
exudate, which may promote growth on and in the underlying skin. Indeed, a meta-analysis
showed a significantly increased risk of catheter tip infection when transparent rather than gauze
dressings were used with either central or peripheral catheters.32 Recently, polyurethane
dressings, such as Tegaderm, have been produced which are several times more permeable than
standard dressings.33These should minimise the risk of moisture accumulation and reduce sepsis
rates.33
Routine replacement of the intravenous line every three to five days is common practice in the
USA but not in Europe. Guidelines developed by the Centers for Disease Control and Prevention
recommend that peripheral intravenous catheters be changed every three days. However, routine
replacement of central venous catheters was no longer supported in their latest update.34 A
recent Swiss study was unable to show an increased risk of catheter related complications
phlebitis, infections, and mechanical complicationsduring prolonged peripheral
catheterisation.35 Peripheral catheters can be safely maintained with adequate monitoring for up
to 144 hours (six days) in critically ill children.36
Containers of intravenous fluids are usually changed before significant growth occurs, but the
giving set does not need to be replaced more often than every 72 hours.37 Flagging each set
with a sticker displaying the time it had to be replaced resulted in a significant reduction in the
incidence of klebsiellae in a busy neonatal unit.38 There is no difference in the incidence of
septicaemia in children who have in-line bacterial filters fitted compared with those who do
not.39
Box 2: Practical methods for preventing nosocomial infection
What's in
Hand washing:
o as often as possible
o
use of alcoholic hand spray
removing jewellery before washing
Stethoscope: cleaning with an alcohol swab at least daily
Gloves: supplement rather than replace hand washing
Intravenous catheter:
o
thorough disinfection of skin before insertion
changing administration sets every 72 hours

What's out
Hand washing: using a brush

Mask:
o
routine use in theatre
during wound dressing
Gowning: routine use in neonatal units
White coats: enforced use in clinical units
Intravenous catheter:
o
routine removal of peripheral catheters after 72 hours
use of impermeable, transparent dressings
in-line bacterial filters
Conclusions
Methods for preventing nosocomial infections are summarised in box 2. Nosocomial infections
are worth preventing in terms of benefits in morbidity, mortality, duration of hospital stay, and
cost. Educational interventions promoting good hygiene and aseptic techniques have generally
proved to be successful, but these practices are often not sustainable. Greater efforts are being
made in some countries to ensure the application of the infection control evidence base into
practice.40 In the end, constant vigilance and attention by the individual to what are rather
simple measures is demanded.
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Dtsch Arztebl Int. 2009 October; 106(40): 649655.

Published online 2009 October 2.
Hand Hygiene for the Prevention of

Nosocomial Infections
Gnter Kampf, PD Dr. med.,1,2 Harald Lffler, Prof. Dr. med.,3 and Petra Gastmeier,
Prof. Dr. med
Abstract
Background
The WHO regards hand hygiene as an essential tool for the prevention of nosocomial infection,
but compliance in clinical practice is often low.
Methods
The relevant scientific literature and national and international evidence-based recommendations
(Robert Koch Institute [Germany], WHO) were evaluated.
Results
Hygienic hand disinfection has better antimicrobial efficacy than hand-washing and is the
procedure of choice to be performed before and after manual contact with patients. The hands
should be washed, rather than disinfected, only when they are visibly soiled. Skin irritation is
quite common among healthcare workers and is mainly caused by water, soap, and prolonged
wearing of gloves. Compliance can be improved by training, by placing hand-rub dispensers at
the sites where they are needed, and by physicians setting a good example for others.
Conclusions
Improved compliance in hand hygiene, with proper use of alcohol-based hand rubs, can reduce
the nosocomial infection rate by as much as 40%.
Keywords: hand hygiene, disinfection, compliance, nosocomial infection,
protective gloves
Healthcare workers hands represent the principal route of transmission of nosocomial

pathogens. They are colonized permanently by the physiological flora (resident flora) and
temporarily, depending on the precise nature of the employees duties, by various pathogens that
do not belong to the physiological flora (transient flora) (1). Staphylococcus aureus, for
example, can survive for over 2 h on the hands and is found in 10% to 78% of staff (table 1).
Table 1
Frequency and persistence of selected nosocomial pathogens on the hands
of healthcare workers (1)
Go to:
Clean Hands Campaign

Improvement of hand hygiene, with the aim of minimizing nosocomial infection, is a high
priority of the World Health Organization (WHO). The promotion of effective measures to
improve hand hygiene (e1) is therefore one of the five foremost goals of the WHOs current
worldwide Patient Safety Initiative (Announce Action on Patient Safety [High 5s] Initiative,
Washington, DC, 4 November 2006). By September 2008 114 countries had given written
undertakings to implement these goals. In Germany, the Clean Hands Campaign (Aktion
saubere Hnde) was launched on 1 January 2008 under the auspices of the Federal Ministry of
Health (e2). By 14 June 2009, 550 hospitals had signed up to the campaign, including two thirds
of the university hospitals. The goal is to establish hand disinfection as a decisive quality
parameter anchored firmly in clinical routine.
Go to:
Methods
We began by examining the scientific literature on the provisional WHO recommendation on
hand hygiene from the year 2006 (e3). For studies published from 2006 onward we performed a
selective review of the publications in the National Library of Medicine. Furthermore, we
evaluated the recommendations of the following institutions:
Commission for Hospital Hygiene and Prevention of Infection, Robert Koch

Institute (RKI) (2)
Association of the Scientific Medical Societies in Germany (AWMF) (e4)
WHO (final recommendation) (3)
Centers for Disease Control and Prevention (CDC) (e5).
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Importance of protective gloves

The wearing of protective gloves is a sensible precaution in various clinical situations in order to
prevent gross soiling or contamination (box 1). It may even break the chain of infection more
effectively than hand-washing or hand disinfection. A prospective, controlled intervention study
showed that a training session and the availability of gloves directly at the bedside can
significantly reduce the incidence of Clostridium difficileassociated diarrhea (CDAD) (4). The
hands should be disinfected when protective gloves are taken off, because in contrast to surgical
gloves, ordinary protective gloves are often permeable to pathogens even before use. Moreover,
the hands may have come into contact with the potentially contaminated outer surface of the
gloves during removal. In the case of vancomycin-resistant enterococci (VRE), a study showed
that despite the use of gloves the same pathogen could be found on the hands of staff involved in
treatment in 30% of cases (5).
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Box 1
Clinical situations in which the wearing of protective gloves is especially
indicated
Examination of incontinent patients
Examination or treatment of MRSA patients
Examination or treatment of patients with C. difficileassociated diarrhea
Endotracheal aspiration
Blood sampling
Removal of drains or bandages
Handling of secretions or excretions
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Hand-washing
Indications
Hand-washing should be an exception in clinical routine (2, 3). The point of washing the hands is
mainly to remove visible soiling and only occasionally to reduce the microbial colonization of
the skinfor example in contamination by spores of C. difficile. Hand-washing is therefore
indicated considerably less often than generally assumed. It makes sense to wash the hands
before starting work, after finishing work, and following visits to the bathroom. In all other
clinical situations in which hand hygiene measures are required, hand disinfection should be
preferred on grounds of efficacy and skin tolerability.
Efficacy
Washing with soap and water is much less effective than hygienic hand disinfection (1 3). Even
washing for several minutes reduces the skins resident flora hardly at all (table 2). Washing
reduces the transient flora (contaminating flora) by only 2 to 3 log10 levels. The same is true for
bacterial spores (6). Given the frequently short duration of washing, the efficacy of antimicrobial
soaps hardly exceeds that of ordinary soaps (6), so that normal soaps are generally perfectly
adequate for everyday clinical use.
Table 2
Effect of hand-washing and hand disinfection (1, 24)
Benefits and risks
The limited benefits of hand-washing are accompanied by the risk of cutaneous irritation and
hand eczema. Frequent washing of the hands can lead to dryness and impair the barrier function
of the skin (7). The skin thus continually loses fats and water-binding factors, and noxious
substances can more easily penetrate the epidermis. Clinically manifest irritant eczema of the
hand may gradually develop. Given the comparatively slight benefit, it swiftly becomes clear
that hand-washing should be seen as an exception. Merely in the case of contamination with
spore-forming bacteria, e.g., C. difficile, is it useful to wash the hands after disinfection, because
bacterial spores are naturally resistant to alcohol.
Go to:
Hygienic hand disinfection

Indications
Hand disinfection is indicated in almost all interactions of medical staff with patients (box 2) (2).
Go to:
Box 2
Hygienic hand disinfection benefits the patient in the following clinical
situations (2):
Before invasive procedures, even if gloves will be worn, e.g.
Insertion of a venous or bladder catheter
Angiography, bronchoscopy, endoscopy
Injections and punctures
Before contact with patients who are at particular risk of infection, e.g.
Leukemia patients
Polytrauma patients
Burns patients
Irradiated and other severely ill patients
Before exposure to potential contamination
Preparation of infusions
Mixing of combined infusions
Drawing up of syringes
Before and after any contact with
Wounds
Insertion sites of catheters or drains
After contact with
Blood, secretions, excrement, or infected regions of the body
Urine-collecting systems, aspirators, ventilators, ventilation masks,

tracheal tubes or drains
Potentially infectious patients, e.g., MRSA patients
After removal of protective gloves
After contact with a patient during a clinical round or in the consultation or

treatment room
For example, the hands should be disinfected after direct patient contact (measurement of vital
functions, auscultation, palpation) or after contact with potentially infectious materials, e.g.,
bandages. Hand disinfection is most important, however, in the case of potential nosocomial
infections (2, 3). The most frequent such infections in Germany are catheter-associated urinary
tract infection (ca. 42%), ventilator-associated pneumonia (ca. 21%), surgical site infection (ca.
16%), and catheter-associated bloodstream infection (ca. 8%) (8). Hygienic hand disinfection can
make a substantial contribution to preventing these infections if consistently performed at the
following junctures (2, 3):
Catheter-associated urinary tract infection: before placement of the urinary

catheter, before and after contact with the catheter
Ventilator-associated pneumonia: before and after intubation, before and
after aspiration
Surgical site infection: before and after contact with wounds, after removal of
a bandage
Catheter-associated bloodstream infection: before placement of vascular

catheters, before manipulation of vascular catheters, before preparation of
intravenous medication.
Efficacy
The commonly available hand rubs are considerably more effective than hand-washing with soap
(2, 3). Within 30 s, for example, the following bacteria are not only greatly reduced but
practically completely eliminated (e6):
Escherichia colimost frequent cause of catheter-associated urinary tract

infection
Pseudomonas aeruginosavery frequent cause of ventilator-associated

pneumonia
Staphylococcus aureusmost frequent cause of surgical site infection
Staphylococcus epidermidismost frequent cause of catheter-associated

bloodstream infection.
The same applies to yeasts such as Candida spp. or Rhodotorula spp. and to coated viruses such
as HBV, HCV, HIV, and the influenza viruses. Hand disinfection thus eliminates the majority of
agents known to cause nosocomial infections.
There are only a few pathogens against which the commonly available hand rubs are ineffective.
These include uncoated viruses such as noroviruses and the spores of spore-forming bacteria
such as C. difficile. In the case of the noroviruses special virucidal hand rubs are recommended
(see the RKIs list of disinfectant hand rubs [9]), because epidemiological studies have shown
that as part of a package of measures these preparations make a real contribution to the
containment of outbreaks. For spore-forming bacteria such as C. difficile, the recommendation is
first to disinfect the hands in order to kill off the vegetative form, then to wash them briefly but
thoroughly to reduce the number of spores as much as possible (e7).
Benefits and risks
Hand disinfection is key to the prevention of nosocomial infections. At Geneva University

Hospital, improvement of the compliance rate from 48% to 66% over a 5-year period lowered
the frequency of nosocomial infections by more than 40% (10). Over the same period the rate of
new infections by methicillin-resistant S. aureus (MRSA) was reduced by more than 50% (10).
In contrast to popular opinion, the irritant potential of alcohol-based hand rubs is very low.
Commercially available preparations are generally tolerated much better than the detergents in
hand-washing agents (7, 11). Even frequent, intensive hand disinfection detracts only minimally
from the skins barrier function and makes the skin only slightly drier. This is due partly to the
skin care substances usually found in hand rubs. Allergic reactions to the ingredients of hand-rub
preparations are extremely rare (1, 3).
For hand disinfection to be effective, both hands must be completely covered. To this end, an
adequate amount of the hand rub must be applied efficiently. The duration of application should
be 22 to 28 s. Shorter application times, e.g., 15 s, almost always fail to cover the hands
completely (12). Surprisingly, the best results are achieved when users are left to their own
devices, not with a strictly regulated procedure. Special attention must be paid to the fingertips
and thumbs, however; these parts of the hand are most likely to come into contact with the
patient, and the greatest proportion of the bacteria are found on the fingertips (13).
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Hand eczema
There can be no doubt that hygiene precautions are a risk factor for occupational hand eczema.
Consequently employment in nursing and related professions involves the risk of contracting
occupational dermatosis (14). Many consider rough, flaking skin on their hands as normal in
their line of work and fail to realize that this may be the first sign of hand eczema (figure 1). In a
survey carried out by the German Contact Allergy Group (Deutsche Kontaktallergiegruppe,
DKG), more than 70% of nursing staff reported irritant skin symptoms within a year, and 46%
considered them detrimental in their daily lives (15).
Figure 1
Early irritant skin changes between the digits
Most nurses still believe that alcohol-based hand rubs damage their skin more than hand-washing
(15). However, alcohol-based preparations are much kinder to the skin than hand-washing agents
because they are less harmful to the cutaneous barrier (as measured by transepidermal water loss)
and dry the skin out less (as measured by corneometry) (7, 11). Interestingly, the application of
alcohols after hand-washing can even reduce the irritation caused by the washing, probably by
elimination of residual detergent monomers (7). Nevertheless, many users think that hand rubs
harm their skin. One reason is the burning felt when the alcohols stimulate the pain receptors in
damaged areas of skin. The alcohol-based hand rub is then blamed for the symptoms (it only
burns with the alcohol) and hand disinfection is abandoned in favor of washing. The burning
stops, but the damage accelerates: a vicious circle begins, resulting in manifest hand eczema
(figure 2) and, in the worst case, inability to work (16).
Figure 2
Manifest irritant hand eczema
A burning sensation on use of a disinfecting hand rub is a warning of impairment of the skins
barrier function. Those affected should avoid activities harmful to the skinwashing, occlusion
(protective gloves), contact with soaps, direct contact with irritant disinfectantsand apply
copious quantities of skin protection and skin care products.
Some users state that alcohol-based hand rubs have a sensitizing effect. Nevertheless,
sensitization to an alcohol could be excluded in all 50 persons who were tested for allergic
reactions to an alcohol-based hand rub because of suspected intolerance. Oversensitivity to an
excipient (e.g., cetearyl octanoate) was demonstrated, however (15).
An intact cutaneous barrier is of more than just cosmetic and functional relevance. Eczematous
hands are also colonized to a greater degree by pathogens than are healthy hands (17, 18). The
principles of hand care and protection should therefore be taught to all healthcare workers and
should form part of every training program (19). They are also included in the Clean Hands
Campaign.
Go to:
Care and protection of the skin

Appropriate precautions when using potentially irritant substances can prevent harm to the skin.
Moreover, adequate protection and care of the skin are of paramount importance for the
maintenance of a functioning cutaneous barrier (e8). These precautions should be integrated in
the working routine and can, if properly implemented, protect the hands without compromising
disinfection. Skin protection plans should be drawn up with information about the available
products and their use (see Technical Rule for Hazardous Substances [TRGS] 401 of June 2008:
Risks resulting from skin contactdetermination, evaluation, measures) (20). Staff should have
access to data showing the efficacy of all preparations employed, as well as information on their
uses (see the Occupational Skin Preparations (Berufliche Hautmittel) guideline of the
German Working Group for Occupational and Environmental Dermatology [Arbeitsgemeinschaft
fr Berufs- und Umweltdermatologie, ABD]) (21). Skin protection products should be applied
before starting work and after every break, in order to minimize drying out and impairment of
the skins barrier function by wet work. After work, skin care creams help to accelerate
cutaneous regeneration. Because components of some of these preparations may promote
penetration of irritants, they should preferably be applied only when work is over (21).
Any member of staff exhibiting clinically manifest cutaneous irritation at work should be
referred to a dermatologist or occupational medicine specialist, who can then institute the
appropriate procedures, including reporting of the case to the accident insurance provider (22).
Go to:
Compliance
Unfortunately the overall rate of compliance in hand hygiene is poor, only 50% on average. In
other words, every second time hand disinfection is required, it is not carried out. The primary
goal of all initiatives to improve compliance in hand hygiene is optimization of the rate of hand
disinfection. As a secondary aim, of course, it is also important to reduce hand-washing to a
minimum.
Barriers
There are many different reasons why healthcare workers disinfect their hands much less often
than necessary for protection of their patients. These include:
Insufficient knowledge of the clinical situations in which the patient clearly

benefits
Lack of products or dispensers: unavailability of the disinfecting hand rub
right where it is needed
Lack of time: hand disinfection is frequently not carried out because of

increasing pressure of work, or when a ward is over-occupied or under-staffed
(23)
Cutaneous irritation: skin problems with use, e.g., dryness, irritation, or

burning combined with inadequate knowledge of the causes
Failure of high-ranking medical staff to set an example: junior doctors and

nurses will think that hand disinfection cannot be very important if senior
doctors dispense with it.
Measures to achieve improvement
Readily implementable measures can be drawn up to counter the above-mentioned factors and
improve compliance (box 3). Moreover, primary prevention by means of early education on hand
hygiene (e.g., during training, with explanation of the efficacy and cutaneous tolerance of hand
hygiene measures), accompanied by regular motivational campaigns, is effective. Furthermore,
skin protection and care products must be available to all employees at their workplace. One can
only appeal to all senior staff to set a proper example. It will then be much more difficult for
junior workers not to follow suit.
Go to:
Box 3
Measures to improve compliance
Staff training with regard to the clinical situations in which hand disinfection
is indicated
Inclusion of the goals in the training program, because behavior learned
during basic training is put into practice much more effectively than that
taught in later training sessions, when established routine behavior has to be
changed
Disinfecting hand rubs should be available where they are actually needed.
This can by achieved by simple means both in the hospital and the doctors
office. If wall dispensers cannot be mounted, the doctor may be able to carry
a bottle of hand rub in the pocket of his/her lab coat.
Reduction of hand-washing to a minimum in order to avoid unnecessary skin

irritation
Senior members of medical staff must recognize that they have to set an
example and act accordingly.
Go to:
Conclusion
Evidence-based hand hygiene can prevent transmission of the most important nosocomial
pathogens and also keep employees skin healthy. In most clinical situations hygienic
disinfection is indicated for hand decontamination on grounds of better efficacy and cutaneous
tolerance. Washing with soap and water is necessary only when the hands are visibly soiled, or
following disinfection in the case of contamination by spores of bacteria such as C. difficile.
Compliance could be improved by knowledge of the principal clinical circumstances in which
hand disinfection by healthcare workers genuinely benefits the patient.
Go to:
Key Messages
Hand disinfection eliminates the transient flora and is one of the most
important precautions for specific prevention of transmission of nosocomial
infections.
In practice, on average every second necessary disinfection of the hands is
not actually carried out. The WHO has therefore launched a worldwide
initiative to improve compliance.
The rate of nosocomial infections can be reduced by up to 40% by improved

compliance in hand disinfection.
Hand-washing damages the skin more than hand disinfection. It should

principally be restricted to visibly soiled hands and, following disinfection,
hands contaminated with spore-forming bacteria such as C. difficile.
A burning sensation on hand disinfection represents an important warning of

damage to the cutaneous barrier. Activities harmful to the skin, e.g., frequent
washing, must then be avoided and skin protection and care products applied
more intensively.
Go to:
Acknowledgments
Translated from the original German by David Roseveare.
Go to:
Footnotes
Conflict of interest statement

Dr. Kampf is an employee of Bode Chemie GmbH, Hamburg. Professor Lffler has received
honoraria for lectures given on behalf of Bode Chemie GmbH. Professor Gastmeier declares that
no conflict of interest exists according to the guidelines of the International Committee of
Medical Journal Editors.
Go to:
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Emerg Infect Dis. 2001 Mar-Apr; 7(2): 295298.
PMCID: PMC2631724
Feeding back surveillance data to prevent

hospital-acquired infections.
R. Gaynes, C. Richards, J. Edwards, T. G. Emori, T. Horan, J. Alonso-Echanove, S.
Fridkin, R. Lawton, G. Peavy, and J. Tolson
Abstract
We describe the Centers for Disease Control and Prevention's National Nosocomial Infections
Surveillance system. Elements of the system critical for successful reduction of nosocomial
infection rates include voluntary participation and confidentiality; standard definitions and
protocols; identification of populations at high risk; site-specific, risk- adjusted infection rates
comparable across institutions; adequate numbers of trained infection control professionals;
dissemination of data to health-care providers; and a link between monitored rates and
prevention efforts.
Full Text
The Full Text of this article is available as a PDF (47K).
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http://ocw.usu.ac.id/course/download/1125-INFECTION-AND-TROPICALPEDIATRICS/mk_itps_slide_infeksi_nosokomial.

Hand Hygiene for the Prevention of

Healthcare workers hands represent the principal route of transmission of nosocomial

Clean Hands Campaign

Commission for Hospital Hygiene and Prevention of Infection, Robert Koch

WHO (final recommendation) (3)

Centers for Disease Control and Prevention (CDC) (e5).

Importance of protective gloves

Examination or treatment of patients with C. difficileassociated diarrhea

Removal of drains or bandages

Handling of secretions or excretions

Benefits and risks

Hygienic hand disinfection

Angiography, bronchoscopy, endoscopy

Injections and punctures

Irradiated and other severely ill patients

Before exposure to potential contamination

Mixing of combined infusions

Before and after any contact with

Insertion sites of catheters or drains

After contact with

Blood, secretions, excrement, or infected regions of the body

Urine-collecting systems, aspirators, ventilators, ventilation masks,

Potentially infectious patients, e.g., MRSA patients

After removal of protective gloves

After contact with a patient during a clinical round or in the consultation or

Catheter-associated urinary tract infection: before placement of the urinary

Catheter-associated bloodstream infection: before placement of vascular

Escherichia colimost frequent cause of catheter-associated urinary tract

Pseudomonas aeruginosavery frequent cause of ventilator-associated

Staphylococcus aureusmost frequent cause of surgical site infection

Staphylococcus epidermidismost frequent cause of catheter-associated

Hand disinfection is key to the prevention of nosocomial infections. At Geneva University

Care and protection of the skin

Insufficient knowledge of the clinical situations in which the patient clearly

Lack of time: hand disinfection is frequently not carried out because of

Cutaneous irritation: skin problems with use, e.g., dryness, irritation, or

Failure of high-ranking medical staff to set an example: junior doctors and

Measures to achieve improvement

Reduction of hand-washing to a minimum in order to avoid unnecessary skin

The rate of nosocomial infections can be reduced by up to 40% by improved

Hand-washing damages the skin more than hand disinfection. It should

A burning sensation on hand disinfection represents an important warning of

Conflict of interest statement

und Stufenverfahren Haut der gesetzlichen Unfallversicherung. Der Hautarzt.

Postgrad Med J 2001;77:16-19 doi:10.1136/pmj.77.903.16

The health professional's role in preventing

Received 12 January 2000

Accepted 9 May 2000

Aetiology of nosocomial infections

Duration of hospital stay

Use of total parenteral nutrition

Use of histamine (H2) receptor blockers (owing to relative bacterial overgrowth)

Agemore common in neonates, infants, and the elderly

use of alcoholic hand spray

removing jewellery before washing

Stethoscope: cleaning with an alcohol swab at least daily

Gloves: supplement rather than replace hand washing

thorough disinfection of skin before insertion

changing administration sets every 72 hours

Hand washing: using a brush

routine use in theatre

during wound dressing

Gowning: routine use in neonatal units