Вы находитесь на странице: 1из 59

William A.

Rutala_Cali-Col

Hand Hygiene and Chlorhexidine


Gluconate: The Role in Reducing HAIs
William A. Rutala, PhD, MPH
Director, Hospital Epidemiology, Occupational Health and Safety;
Professor of Medicine and Director, Statewide Program for Infection
Control and Epidemiology
University of North Carolina at Chapel Hill, USA
CIDEIM

William A. Rutala_Cali-Col

DISCLOSURES

Consultation and Honoraria


Clorox
Honoraria
3M
Grants
CDC, CMS

CIDEIM

William A. Rutala_Cali-Col

Hand Hygiene and Chlorhexidine


Gluconate: The Role in Reducing HAIs

Hand Hygiene recommendations and role in prevention


of HAIs
Chlorhexidine gluconate-role in prevention of HAIs

Hand hygiene
CHG showers prior to surgery
Perioperative skin antisepsis
Bathing

CIDEIM

William A. Rutala_Cali-Col

Hand Hygiene
Hand Hygiene-a general term that applies to either
handwashing, antiseptic handwash, antiseptic handrub, or
surgical hand antisepsis
Main Results: alcohol-based handrubs reduce bacterial
bacterial counts on hands more effectively than plain
soaps, and in a majority of studies more effectively than
antimicrobial soaps.

CIDEIM

William A. Rutala_Cali-Col

CIDEIM

William A. Rutala_Cali-Col

CIDEIM

William A. Rutala_Cali-Col

Hand Hygiene and Nosocomial Infections


Healthcare-associated infections (HAIs)-2 million cases
per year (U.S.); 80,000 deaths per year
$5-10 billion per year (U.S.)
Fraction of HAIs that are preventable with changes in
hand hygiene practices not known

38% due to cross-transmission


Increase in HW, reduction in HAIs

CIDEIM

William A. Rutala_Cali-Col

Evidence of Transmission of Pathogens


on Hands

Transmission from patient-to-patient via HCW hands


requires four elements
Organisms on HCWs hands (via patient or environment)
Organisms must survive for several minutes on hands
Hand hygiene must be inadequate or agent inappropriate
Contaminated hands of HCW must come in contact with
another patient (or an inanimate object that will contact patient)

CIDEIM

TRANSMISSION MECHANISMS INVOLVING


THE SURFACE ENVIRONMENT

William A. Rutala_Cali-Col

CIDEIM

Rutala WA, Weber DJ. In:SHEA Practical Healthcare Epidemiology


(Lautenbach E, Woeltje KF, Malani PN, eds), 3rd ed, 2010.

William A. Rutala_Cali-Col

Hand-borne Microorganisms

Presence bacterial counts on hands range from 104 to


106

resident microorganisms-attached to deeper layers of the skin


and are more resistant to removal; less likely to be associated
with HAIs.
transient microorganisms-colonize the superficial layers of skin
and amenable to removable; acquired by direct contact with
patients or contaminated environment surfaces; frequently
associated with HAIs.

CIDEIM

William A. Rutala_Cali-Col

CIDEIM

William A. Rutala_Cali-Col

WHAT IS OUR TRACK RECORD ON HANDWASHING


IN HEALTHCARE FACILITIES?

CIDEIM

90
80
70
60
50
40
30
20
10
0

Study

34

31

28

25

22

19

16

13

10

Average

The average adherence rate


was only 40%

Average Handwashing Adherence


of Personnel in 34 Studies

A review of 34 published
studies of handwashing
adherence among healthcare
workers found that adherence
rates varied from 5% to 81%

Percent Adherence

William A. Rutala_Cali-Col

Hand Hygiene Practices in Healthcare

Hand hygiene has been reported to average 40% (34


studies)
Inaccessibility of hand hygiene supplies
Skin irritation from hand hygiene agents
Inadequate time for hand hygiene
Interference with patient care
Lack of knowledge of the guidelines
Lack of information on the importance of hand hygiene

CIDEIM

William A. Rutala_Cali-Col

CIDEIM

William A. Rutala_Cali-Col

Selection of Hand Hygiene Agents


Provide personnel with efficacious hand hygiene products
that have low irritancy potential. IB
To maximize acceptance, solicit input from HCW
regarding feel, fragrance, and skin tolerance. IB
Prior to purchasing, evaluate dispenser systems to ensure
function and delivery of appropriate volume. II

CIDEIM

William A. Rutala_Cali-Col

Hand Hygiene Agents

Non-antimicrobial
Antimicrobial

CIDEIM

Chlorhexidine gluconate (CHG)


Triclosan
Quaternary Ammonium Compounds (QAC)
Parachlorometaxylenol (PCMX)
Alcohols (ethyl, isopropanol, n-propanol)
Iodine and Iodophors

William A. Rutala_Cali-Col

Alcohol-Based Handrubs

Minimize factors adversely affecting adherence to hand hygiene


protocols

CIDEIM

Reduce bacterial counts more effectively than washing hands with


nonantimicrobial and antimicrobial soaps
Can be made much more accessible
Require less time to use
Produce less skin irritation and dryness
Improved adherence to hand hygiene policies and reduce NI rates

Studies Comparing Relative Efficacy of Plain Soap or


Antimicrobial Soap vs Alcohol-Based Antiseptics in
Reducing Counts on Hands

William A. Rutala_Cali-Col

Alcohol more effective than plain soap (17 studies)


In all but two trials (15/17), alcohol-based solutions
reduced bacterial counts on hands to a greater extent
than washing with soaps or detergents containing
povidone-iodine, 4% CHG, or triclosan

CIDEIM

William A. Rutala_Cali-Col

Hand Hygiene Technique


Apply alcohol-based handrub to one hand and rub hands
together, covering all surfaces. Follow manufacturers
recommendation on volume. IB
Soap and water-wet hands, apply amount of product
recommended, rub hands together for 15 sec, covering all
surfaces. Rinse with water and dry with disposable towel.
IB

CIDEIM

William A. Rutala_Cali-Col

RATIONALE FOR HAND HYGIENE

Many infectious agents are acquired via hand contact with


contaminated surfaces

Contact transmission: healthcare (MRSA, VRE), day care (MRSA), home (MRSA,
cold viruses, herpes simplex)
Fecal-oral transmission: day care (Shigella, E. coli O157:H7), home (Salmonella,
E. coli O157:H7, Cryptosporidium)

Hand hygiene effective in reducing or eliminating transient flora


Hand hygiene demonstrated to be effective in preventing illness
(especially fecal-oral diarrheal illnesses) in healthcare facilities, child
care centers/homes, and households
~40% of healthcare-associated infections due to cross-transmission

CIDEIM

William A. Rutala_Cali-Col

ASSOCIATION BETWEEN HAND HYGIENE


COMPLIANCE AND HAI RATES
Author, year
Casewell, 1977
Maki, 1982
Massanari, 1984
Kohen, 1990
Doebbeling, 1992
Webster, 1994
Zafar, 1995
Larson, 2000
Pittet, 2000

Setting
Adult ICU
Adult ICU
Adult ICU
Adult ICU
Adult ICU
NICU
Newborn
MICU/NICU
Hospitalwide

Results
Reduction HAI due to Klebsiella
Reduction HAI rates
Reduction HAI rates
Trend to improvement
Different rates of HAI between 2 agents
Elimination of MRSA*
Elimination of MRSA*
85% reduction VRE
Reduction HAI & MRSA cross-transmission

HAI, healthcare-associated infections


*Other infection control measures also instituted
Boyce JM, Pitter D. MMWR 2002;51(RR-16)
CIDEIM

William A. Rutala_Cali-Col

Administrative Measures

Make improved hand hygiene adherence an institutional priority


and provide appropriate administrative support and financial
resources. IB
Implement a multidisciplinary program (e.g., education, feedback,
engineering controls, reminders in workplace, avoid understaffing)
designed to improve adherence of health personnel to recommend
hand hygiene practices. IB
As part of the multidisciplinary program, provide HCW with a
readily accessible alcohol-based handrub. IA

CIDEIM

William A. Rutala_Cali-Col

HCW Educational and Motivational


Programs

Educate staff regarding the types of patient care activities


that can result in hand contamination and the adv/disadv
of various methods used to clean their hands. II
Monitor HCW adherence with recommended hand
hygiene practices and provide personnel with information
regarding their performance. IA
Encourage patients and their families to remind HCW to
decontaminate their hands. II

CIDEIM

William A. Rutala_Cali-Col

Reducing Healthcare-Associated Infections


Via a Novel All Hands on Deck Approach for Hand
Hygiene Compliance

CIDEIM

William A. Rutala_Cali-Col

Simplify the Message:


Clean In, Clean Out

Diller T, AJIC 2014 June

CIDEIM

William A. Rutala_Cali-Col

Expand the Pool of Observers

CIDEIM

William A. Rutala_Cali-Col

Immediate Feedback

https://www.youtube.com/watch?v=nSek2nVUUxM

CIDEIM

William A. Rutala_Cali-Col

FY15 Success of Clean In, Clean Out


99,151 observations of Clean In, Clean Out by 3703 unique
observers with compliance >90%

42,327 times hand hygiene feedback provided


Per month: 3300 inpatient, 1200 outpatient/procedural, 250 OR
CIDEIM

William A. Rutala_Cali-Col

HAI Reductions and Associations with Hand Hygiene


Sickbert-Bennett, DiBiase, Weber, Rutala. 2015

CIDEIM

Over 17 months, we noted a significantly increased overall hand hygiene


compliance rate (p<0.001) and significantly decreased overall HAI rate
(p=0.0066) with 197 fewer infections.
The association of hand hygiene compliance and HAIs adjusting for unit-level data
was p=0.086 with a 10% improvement in HH associated with a 6% reduction in
overall HAI.
The association of hand hygiene compliance and C. difficile adjusting for unit-level
data was p=0.070 with a 10% improvement in HH associated with a 14%
reduction in C. difficile HAI.

William A. Rutala_Cali-Col

Success of All Hands On Deck Approach


Unique observers were predictor of hand hygiene within job class
(p=0.0096).

Each additional 10 observers was associated with an increase of 0.1


percentage points of hand hygiene compliance within that job class.

Feedback provided was predictor of hand hygiene within a job class


(p=0.0035).

CIDEIM

Each increase in percent feedback of ten percentage points was associated


with an increase in hand hygiene compliance of 0.21 percentage points within
that job class.

William A. Rutala_Cali-Col

Chlorhexidine Gluconate Used to Prevent HAIs


Hand Hygiene
Preoperative showers
Surgical site preparation
Patient bathing

CIDEIM

William A. Rutala_Cali-Col

Chlorhexidine
Cationic biguanide that alters membrane integrity
Broad-spectrum activity against gram-positive and gramnegative bacteria, yeasts, and some lipid-enveloped
viruses
Persistent activity on skin

CIDEIM

Milstone AM, et al. Chlorhexidine: Expanding the armamentarium for


infection control and prevention. Clin Infect Dis 2008;46:274-81

William A. Rutala_Cali-Col

CIDEIM

William A. Rutala_Cali-Col

Preoperative Shower

CIDEIM

William A. Rutala_Cali-Col

SSI: Primary Risk Factors

Endogenous microorganisms
Skin-dwelling microorganisms
Most common source
S aureus most common isolate
Fecal flora (gnr) when incisions are near the perineum or groin
Exogenous microorganisms
Surgical personnel (members of surgical team)
OR environment (including air)
All tools, instruments, and materials

CIDEIM

William A. Rutala_Cali-Col

Microbial Ecology of Skin Surface

CIDEIM

Scalp

6.0 Log10 cfu/cm2

Axilla

5.5 Log10 cfu/cm2

Abdomen

4.3 Log10 cfu/cm2

Forearm

4.0 Log10 cfu/cm2

Hands

4.0-6.6 Log10 cfu/cm2

Perineum 7.0-11.0 Log10 cfu/cm2

Surgical Microbiology Research Laboratory 2008 Medical College of Wisconsin

William A. Rutala_Cali-Col

SSI: PATHOGENESIS
Risk of surgical site infections =
Microbial load x Virulence x Tissue injury x Foreign material x Antibiotic resistance

____________________________________________________________
Host resistance x Perioperative antibiotics

CIDEIM

William A. Rutala_Cali-Col

SSI: Preoperative Issues


Modifiable Risks

Glucose control-in diabetic patients

Preoperative CHG shower


Appropriate hair removal
Hand hygiene
Skin antisepsis
Antimicrobial prophylaxis
Normothermia-hypo higher risks

CIDEIM

Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.


5 Million lives. Institute for Healthcare Improvement. Available at:
http://ihi.org/IHI/Programs/Campaign/Campaign.htm. Accessed on February 8, 2007.

William A. Rutala_Cali-Col

Chlorhexidine:
Preoperative Showers

CDC recommends preoperative


showering with antiseptic1
CHG more effective than PI and
triclocarban
Lower rates of intraoperative wound
contamination

1. Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.


2. Garibaldi RA. J Hosp Infect. 1988;11(suppl B):5-9.

CIDEIM

William A. Rutala_Cali-Col

Chlorhexidine:
Preoperative Showers

Patients who had 2 preoperative


showers with CHG 24 hours before
surgery had reduced rates of wound
infection compared to patients who
showered with soap.

CIDEIM

Hayek LJ, et al. J Hosp Infect. 1987;10(2):165-172.

William A. Rutala_Cali-Col

4% Chlorhexidine Gluconate (CHG) Shower Mean Skin Surface Concentration (N=60)


CHG Shower
Group 1A
Evening (PM)

150

CHG Concentration (PPM)

125

Group 2A
Morning (AM)

100

Group 3A
Both (AM and PM)

75

p <0.05
NS
P<0.001

50
25

MIC90 = 4.8 ppm

Left
Elbow

Right
Elbow

Abdominal

Left
Knee

Right
Knee

Skin Sites
CIDEIM

Edmiston et al, J Am Coll Surg 2008;207:233-239

William A. Rutala_Cali-Col

Perioperative Skin Antisepsis

CIDEIM

William A. Rutala_Cali-Col

CIDEIM

William A. Rutala_Cali-Col

Surgical Site Preparation


N = 849 surgical patients: 409 Alc-CHG vs 440 PI (ITT)
1:1 randomization
Patients monitored for 30 days post-op
Overall rate of SSI was significantly reduced in Alc-CHG vs PI groups:
9.5% vs 16.1%, p=0.004
Significant difference for both superficial incisional site rate: 4.2% A-CHG
vs 8.6% PI (p=0.008) and deep incisional: 1% A-CHG vs 3% PI (p=0.05)
No significant adverse events noted during the study in either group
Alc-CHG superior to PI in reducing the risk of SSI in clean-contaminated
procedures
Darouiche RO, et al. New England Journal of Medicine 2010;362:18-26

CIDEIM

William A. Rutala_Cali-Col

Chlorhexidine Baths

CIDEIM

William A. Rutala_Cali-Col

Impact of Chlorhexidine-Impregnated
Cloths/Baths in Preventing Infections and
Reducing Environmental Contamination and
Skin Burden: A Review of the Literature
Curtis Donskey, M.D.
Louis Stokes VA Medical Center
Cleveland, Ohio

CIDEIM

William A. Rutala_Cali-Col

Objective
To review the evidence that daily bathing with chlorhexidine is
effective in reducing colonization and infection with
healthcare-associated infections

CIDEIM

William A. Rutala_Cali-Col

Transmission of Healthcare-Associated Pathogens

Infected
Patient

Susceptible
Patient

Environment
CIDEIM

William A. Rutala_Cali-Col

Contamination of Hands with MRSA


Skin contact

Environmental contact

Donskey CJ, Eckstein B. The hands give it away. NEJM 2009;360:e3; Stiefel U, et al. Contamination of hands
with methicillin-resistant Staphylococcus aureus after contact with environmental surfaces versus skin of
CIDEIMcolonized patients. Infect Control Hosp Epidemiol 2011;32:185-7.

William A. Rutala_Cali-Col

Source control
Skin disinfection
Infected
Patient

Susceptible
Patient

Environment
CIDEIM

Environmental
Cleaning

William A. Rutala_Cali-Col

Daily Bathing with Chlorhexidine Cloths


Reduces Skin Contamination

Popovich KJ, et al. Relationship of CHG skin concentration to microbial density on skin of
CIDEIM critically ill patients bathed daily with CHG. ICHE 2012;33:889-96.

William A. Rutala_Cali-Col

Effect of Chlorhexidine Bathing on VRE


Contamination and Acquisition
Decreased hand
contamination
-56% vs 37% in VRE rooms
-16% vs 8% in common areas

Decreased skin
contamination
-47% vs 94%
-2.5 log reduction
on inguinal skin

Decreased VRE
acquisition
20% vs 8%

Decreased environmental
contamination
34% vs 11%

Vernon MO. CHG to cleanse patients in a medical ICU: Effectiveness of source


CIDEIM control to reduce the bioburden of VRE. Arch Int Med 2006;166:306-12

William A. Rutala_Cali-Col

Impact of Daily Bathing with Chlorhexidine on


Colonization and Infection with Pathogens

Ref

Setting

Design

Effect

MICU

Quasiexperimental

Decreased VRE on patients skin, healthcare workers


hands, and environment
Reduced acquisition of VRE colonization

MICU

Quasiexperimental

Decreased Acinetobacter baumannii skin colonization and


bloodstream infections

2 MICU wards

2 arm crossover trial

Decreased primary BSI

MICU

Quasiexperimental

Decreased CLABSI and blood culture contamination

6 ICUs in 4 hospitals

Quasiexperimental

Decreased acquisition of MRSA and VRE


Decreased VRE bacteremia

Long-term acute
care hospital

Quasiexperimental

Decreased CLABSI
No change in ventilator associated pneumonia

2 ICUs

Quasiexperimental

Decreased acquisition of MRSA (non-qacA/B strains)

1. Vernon MO. Arch Int Med 2006;166:306-12; 2. Borer A. J Hosp Infect 2007;67:149-55;
3. Bleasdale SC. Arch Intern Med 2007;167:2073-9; 4. Popovich KJ. ICHE 2009;30:2959-63; 5. Climo MW. Crit Care Med
2009;37:1858-65; 6. Munoz-Price LS. ICHE 2009;30:1031-5; 7. Batra R. Clin Infect Dis 2010;50:210-2.

CIDEIM

William A. Rutala_Cali-Col

Impact of Daily Bathing with Chlorhexidine on


Colonization and Infection with Pathogens

Ref

Setting

Design

Effect

Trauma ICU

Quasiexperimental

Decreased MRSA and Acinetobacter colonization


Decreased CLABSI

SICU

Quasiexperimental

No decrease in CLABSI

10

Trauma center
SICU

Quasiexperimental

Decreased CLABSI

11

4 medical wards

Quasiexperimental

Decreased MRSA & VRE infections


No change in C. difficile infection rate

12

Hospital-wide

Quasiexperimental

Decreased C. difficile infection


No change in other hospital-associated infections

13

Oncology
patients

Quasiexperimental

Decreased acquisition of VRE colonization

14,15

4 LTACHs

Stepped wedge
bundle

Decreased KPC colonization and infection, all-cause


bacteremia, and blood culture contamination

8. Evans HI. Arch Surg 2010;145:240-6; 9. Popovich KJ. Intensive Care Med 2010;36:854-8; 10. Dixon JM. AJIC 2010;38:817-21; 11.
Kassakian SZ. ICHE 2011;32:238-43; 12. Rupp ME. ICHE 2012;33:1094-1100; 13. Bass P. AJIC 2013;41:345-8; 14. Hayden MK. Clin
Infect Dis 2015;60:1153-61; 15. Lin MY. ICHE 2014;35:440-2 (CHG reduced KPC on skin particularly when the CHG skin
CIDEIM
concentration was 128 mcg/mL or higher.)

William A. Rutala_Cali-Col

Randomized Trial of Daily Chlorhexidine


Bathing in the ICU

Multicenter, cluster-randomized, nonblinded crossover trial


9 ICUs and bone marrow transplant units in 6 hospitals
Chlorhexidine 2% cloths or nonantimicrobial washcloths for
6 months followed by 6 months with the alternative product

CIDEIM

Climo MW. NEJM 2013;368:533-42

William A. Rutala_Cali-Col

Randomized Trial of Daily Chlorhexidine


Bathing in the ICU

Decreased MDRO (VRE and MRSA) acquisition (23%


reduction)
Decreased hospital-acquired BSI (28% reduction)
Decreased CLABSI

Gram-positive organisms
Fungi

CIDEIM

Climo MW. NEJM 2013;368:533-42

William A. Rutala_Cali-Col

Hand Hygiene and Chlorhexidine


Gluconate: The Role in Reducing HAIs

Hand Hygiene recommendations and role in prevention


of HAIs
Chlorhexidine gluconate-role in prevention of HAIs

Hand Hygiene
CHG showers prior to surgery
Perioperative skin antisepsis
Bathing

CIDEIM

William A. Rutala_Cali-Col

Hand Hygiene and Chlorhexidine


Gluconate: The Role in Reducing HAIs

Improved hand hygiene reduces HAIs


CHG showers before surgery reduces contamination and may reduce SSIs
Chlorhexidine bathing reduces levels of pathogens on skin, environment and
reduces SSIs
Alc-CHG superior to povidone-iodine in reducing the risk of SSI in cleancontaminated procedures
Chlorhexidine bathing is effective in reducing levels of healthcare-associated
pathogens on skin. A majority of quasi-experimental and randomized trials
suggest that chlorhexidine bathing can be effective in reducing colonization and
infection with pathogens.

CIDEIM

William A. Rutala_Cali-Col

THANK YOU!
www.disinfectionandsterilization.org

CIDEIM