Hand Hygiene: Infection Control/Exposure Control Issues for Oral Healthcare Workers

Hand Hygiene: Infection Control/Exposure Control Issues for Oral Healthcare Workers Géza T. Terézhalmy, DDS, MA; Michaell A. Huber, DDS Continuing Education Units: 2 hours Online Course: www.dentalcare.com/en-us/dental-education/continuing-education/ce353/ce353.aspx Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy. This course presents the essential elements of an infection control/exposure control plan for the oral healthcare setting with emphasis on hand hygiene. Conflict of Interest Disclosure Statement Dr. Terézhalmy has done consulting work for Procter & Gamble and is a member of the dentalcare.com Advisory Board. Dr. Huber reports no conflicts of interest associated with this course. ADA CERP The Procter & Gamble Company is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at: http://www.ada.org/cerp Approved PACE Program Provider The Procter & Gamble Company is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and Membership Maintenance Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 8/1/2013 to 7/31/2017. 1

Overview The transmission of healthcare-associated pathogens most often occurs via the contaminated hands of healthcare workers (HCWs). Accordingly, hand hygiene is one of the most important infection control measures for preventing healthcare-associated infections. However, compliance by HCWs, including oral healthcare workers (OHCWs), with recommended hand hygiene practices remains low. The widespread availability of waterless, alcohol-based hand antiseptics is making this task easier. Alcohol-based hand hygiene products rapidly reduce bacterial counts on hands (with the exception of Clostridium difficile) and rapidly kill many fungi and viruses. Alcohol-based hand hygiene takes much less time than traditional hand washing and is gentler on the hands than the repeated use of soap and water. Oral healthcare facilities are accountable for establishing a system in which OHCWs have the knowledge, competence, time, and tools to practice hand hygiene; and OHCWs have the duty to perform hand hygiene - perfectly and every time. Learning Objectives Upon completion of this course, the dental professional should be able to: Discuss the physiology of normal skin. Discuss the normal bacterial flora of the skin. Discuss the relationship between hand hygiene and healthcare associated pathogens. Discuss issues related to infection control/exposure control in the oral healthcare setting: Hand hygiene Factors to consider when selecting hand hygiene products. Strategies to improving hand hygiene practices. Course Contents Introduction Physiology of Normal Skin Normal Microbial Flora of the Skin Acquisition and Transmission of Healthcareassociated Pathogens Issues Related to Infection Control/Exposure Control in the Oral Healthcare Setting Hand Hygiene Handwashing Hand Antisepsis and Surgical Hand Antisepsis Alcohol-based Handrub Antiseptic Handwash Surgical Hand Antisepsis Adverse Effects Associated with Hand-hygiene Products Irritant Contact Dermatitis Allergic Contact Dermatitis Other Factors to Consider in the Selection of Hand Hygiene products Strategies to Improve Hand Hygiene Practices Conclusion Course Test Preview References About the Authors Introduction In 2002, The Centers for Disease Control and Prevention published its most recent Guideline for Hand Hygiene in Health-Care Settings. 1 Yet, recent reports of outbreaks of HBV and HCV infections, primarily in medical settings outside of acute care hospitals, indicate a failure of HCWs to adhere to fundamental principles of infection control and aseptic technique (e.g., failure to wear gloves and perform hand hygiene). 2 The 2002 guidelines apply to oral healthcare settings. 3 Recent evidence also suggests low compliance with recommended hand hygiene practices by OHCWs as well. 4 It is axiomatic that wearing gloves during patient care is an essential element of standard precautions, yet gloves do not provide complete protection against hand contamination and the hands are also frequently contaminate after the gloves are removed. 5,6 However, it is documented that the acquisition of various healthcare-associated pathogens is reduced when hand hygiene is performed more frequently by HCWs and the prevalence of healthcare-associated infections is decreased as adherence to recommended hand hygiene practices is improved. 7,8 Physiology of Normal Skin The skin serves as a physiologic barrier to chemical penetration and microbial invasion from 2

the environment, as well as a barrier to fluid and solute loss from within. 9 The basic structure of the skin includes the stratum corneum or horny layer, which is about 10 to 20 µm thick; the viable epidermis, 50 to 100 µm thick; the dermis, 1 to 2 mm; and the hypodermis, 1 to 2 mm thick. 10 The stratum corneum is a semipermeable laminated surface aggregate of corneocytes (horny cells). Corneocytes are flat polyhedral-shaped nonnucleated remnants of terminally differentiated keratinocytes derived from the viable epidermis. Corneocytes are composed primarily of insoluble bundled keratin surrounded by a cell envelop stabilized by cross-linked proteins and covalently bound lipids. Interconnecting the corneocytes are corneodesmosomes, which contribute to stratum corneum cohesion. The intercellular lipids, which are generated during the terminal differentiation of keratinocytes, form the only continuous domain of the skin and are essential for a competent barrier function. 9 It is of interest to note that hand hygiene products and procedures can decrease skin-barrier function by extracting skin lipids, chemically inducing irritation, and physically stripping the stratum corneum. 1 Under the stratum corneum is the viable epidermis, which is composed primarily of keratinizing epithelial cells, i.e., keratinocytes. 11 This layer also contains melanocytes involved in skin pigmentation; Langerhans cells, which are important for antigen presentation and immune responses; and Merkel cells, which contain neuroendocrine peptides and appear to have a sensory function. The viable epidermis does not contain a vascular network and the keratinocytes obtain nutrients from the dermis by passive diffusion through the interstitial fluid. The barrier function of the skin is under homeostatic control and the rate of keratinocyte proliferation directly influences the integrity of the skin barrier. Under basal conditions, differentiated keratinocytes require about 2 weeks to exit the nucleated compartment and an additional 2 weeks to move through the stratum corneum. 12 However, keratinocytes have the capacity for increased rates of proliferation and maturation to levels far greater than this when stimulated by injury or infection. In such cases, the return to normal barrier function is biphasic: 50 to 60% of barrier recovery typically occurs within 6 hours with complete normalization of barrier function in 5 to 6 days. Normal Microbial Flora of the Skin One of the largest human-associated microbial habitats is the skin. To understand the objectives of different approaches to hand hygiene and associated adverse effects, knowledge of the normal bacterial flora of the skin is essential. Different areas of normal human skin are colonized variably primarily by aerobic bacteria and bacterial density may be as high as 107 cells per square centimeter. 13 Total bacterial counts on the hands of HCWs have been reported to range from 3.9 x 104 to 4.6 x 106 colony-forming units per cubic centimeter. 14-16 A typical hand surface harbors >150 unique species-level bacterial phylotypes and a total of 4,742 unique phylotypes have been identified across all hands examined. 17 The most abundant genera (Propionibacterium, Streptococcus, Staphylococcus, Corynebacterium, and Lactobacillus) were found on nearly all palm surfaces. Although there appears to be a core set of bacterial taxa commonly found on palm surfaces, pronounced interpersonal variation in bacterial community composition was noted: women appear to have significantly higher diversity than men, and community composition is further affected by handedness and time since the last hand washing. 17 Acquisition and Transmission of Healthcare-associated Pathogens Organisms recovered from hands can be divided into two categories: transient and resident. The number of transient and resident organisms may vary greatly from HCW to HCW, yet it is often relatively constant for any one individual. 17 Transient organisms are often acquired by HCWs during: 1. contact with a patient s intact skin (e.g., when taking a pulse or blood pressure), 2. contact with nonintact skin and mucous membranes, 3. direct contact with blood and other potentially infectious material; and 4. contact with contaminated instruments, equipment, and environmental surfaces. Transient organisms tend to colonize the superficial layers of skin and while they are amenable to removal by washing hands with plain (i.e., 3

non-antimicrobial) soap and water, they are responsible for most healthcare-associated infections. Resident organisms are attached to deeper layers of the skin and while they are more resistant to removal, they are less likely to be associated with healthcare-associated infections. However, the hands of HCWs may become persistently colonized with transient pathogenic organisms (e.g., S. aureus, gram-negative bacilli, or yeast), which subsequently may be transmitted to patients. It is of interest to note that organisms are transferred in much larger numbers (i.e., >104 cell) from wet hands than from hands that have been thoroughly dried. 18 The acquisition and transmission of healthcareassociated pathogens from one patient to another via the hands of HCWs must meet 4 criteria: 1,3 Organisms present on the patient s skin or mucous membranes, or on contaminated instruments, equipment, and environmental surfaces must be transferred to the hands of HCWs. The organisms transferred must then be capable of surviving for at least several minutes on the hands of HCWs. Hand hygiene by HCWs must be inadequate or omitted entirely, or the agent used for hand hygiene must be inappropriate. The contaminated hands of HCWs must come in direct contact with another patient, or with an inanimate object that will come into direct contact with the patient. Issues Related to Infection Control/ Exposure Control in the Oral Healthcare Setting Historically, infection control/exposure control guidelines focused primarily on the risk of transmission of bloodborne pathogens among healthcare workers and patients and the use of Universal Precautions to reduce the risk. 19 Universal Precautions were based on the concept that patients with bloodborne infections can be asymptomatic and unaware that they are infectious; therefore all blood and body fluids contaminated with blood were treated as infectious. The CDC expanded Universal Precautions into the concept of Standard Precautions. 3 Standard Precautions were intended to apply not only to contact with blood and body fluids contaminated with blood; but also to contact with all body fluids, secretions and excretions, nonintact skin, and mucous membranes. Today, there are two tiers of precautions to prevent the transmission of infectious agents in healthcare settings, Standard Precautions (expanded by new components as may be necessary, e.g., Respiratory Hygiene/Cough Etiquette, Safe Injection Practices) and Transmission-Based Precautions (e.g., Contact Precautions, Droplet Precautions, Airborne Precautions). 20 Standard Precautions apply to the care of all patients in all healthcare settings, regardless of the suspected or confirmed presence of an infectious agent and constitutes the primary strategy for the prevention of healthcare-associated transmission of infectious agents (Table 1). Transmission-Based Precautions are for patients who are known or are suspected to be infected with certain pathogens, which require additional control measures to effectively prevent transmission. When Contact, Droplet, or Airborne Precautions are specified Standard Precautions also apply. 3 To prevent or reduce the risk of occupational exposure, the standard of care mandates that HCWs wear gloves (Personal Protective Equipment). 1,3,19 However, as noted earlier, gloves do not provide complete protection against cross-infection. Bacterial flora colonizing patients have been recovered from the hands of 30% of HCWs who wore gloves during patient contact. 21,22 It has also been documented that wearing gloves does not provide complete protection against the acquisition of infections caused by the hepatitis B, hepatitis C, and herpes simplex viruses in healthcare settings. 2,5,6 In such instances, pathogens presumably gain access to the caregiver s hands via small defects in gloves or by contamination of the hands during glove removal. 5,6,21,23 It is also important to note that at least 70% of the population shed HSV-1 asymptomatically at least once a month and many individuals appear to shed the virus more than 6 times a month. 24 HSV-1 can also survive for several hours in a variety of fluids, on dental charts, and environmental surfaces. Clearly, wearing gloves does not eliminate the need for appropriate hand hygiene practices (Work Practice Controls). 4

Table 1. Standard precautions: A hierarchy of preventive strategies Hand Hygiene The term hand hygiene is a general term that applies to (1) handwashing (2) hand antisepsis, and (3) surgical hand antisepsis. 1 Products used for hand hygiene in healthcare settings represent various types of detergents (i.e., surfactants; the term soaps is often used to refer to such detergents). Detergents are compounds that possess cleaning action and are composed of both hydrophilic and lipophilic parts. An antimicrobial soap is a soap that contains an antiseptic agent. Antiseptic agents (e.g., alcohols, chlorhexidine, iodophors, chlorhexidine, hexachlorophene, chloroxylenol, triclosan, quaternary ammonium compounds, and others) are substances that are applied to the skin to reduce the microbial flora. Handwashing Handwashing is defined as washing hands with plain soap (esterified fatty acids and sodium or potassium hydroxide) and water, i.e., a detergent that does not contain an antimicrobial agent or contains low concentrations of antimicrobial agents that are effective solely as preservatives. The cleaning activity of plain soap is attributed to its detergent properties, which result in removal of dirt, soil, and various organic substances from the hands. Handwashing (Figure 1) removes loosely adherent transient microorganisms. 1,25 It is indicated when (1) hands are visible dirty or contaminated with proteinaceous material, or are visibly soiled with blood or other potentially infectious material, (2) before eating, (3) after using a restroom, (4) after caring for patients colonized with Clostridium difficile, (5) following suspected or proven exposure to Bacillus anthraces (the physical action of washing and rinsing hands under such circumstances is recommended because alcohols and other antiseptic agents have poor activity against spoors), and (6) as part of two-stage surgical hand antisepsis, i.e., handwashing followed by the application of an alcohol-based hand scrub. 1,25 Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an acceptable alternative to handwashing. However, the use of towelettes is not an acceptable alternative to hand antisepsis or surgical hand antisepsis. When done with handwashing, dry hands thoroughly with a single use towel. Organisms are transferred in much larger numbers (i.e., >104 cell) from wet hands than from hands that are thoroughly dried. 18 Multipleuse cloth towels of the hanging or roll type are not recommended for use in healthcare settings. 5

Figure 1. How to Handwash when hands are visibly soiled? Image source: World Health Organization (WHO) 6

The frequent use of plain soap and hot water can cause considerable skin irritation and dryness (irritant contact dermatitis). When performing handwashing, wet hands with warm water. Follow the manufacturer s recommendations regarding the volume of soap use. Bar, liquid, leaflet, or powdered forms of plain soap are acceptable. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used. Occasionally, plain soaps have become contaminated with gram-negative bacilli and have caused outbreaks of nosocomial infections. 26 Hand Antisepsis and Surgical Hand Antisepsis Hand antisepsis refers to either (1) antiseptic handwash or (2) antiseptic handrub performed by HCWs. Antiseptic handwash is defined as washing hands with soap containing an antiseptic agent and water. Antiseptic handrub is defined as applying an antiseptic handrub product or waterless antiseptic agent (i.e., an antiseptic agent that does not require use of exogenous water) to the hands. In the United States, all such preparations approved for use in healthcare settings contain ethanol alone or in combination with isopropyl alcohol (i.e., alcohol-based hand rub). Surgical hand antisepsis is defined as either (1) a surgical antiseptic handwash or (2) a two-stage surgical hand antisepsis performed preoperatively by surgical personnel (see Table 4). Antiseptic agents are regulated by the FDA s Division of Over-the-Counter (OTC) Drug Products. Requirement for in vitro and in vivo testing and criteria for the classification of such products are outlined in the FDA Tentative Final Monograph for Healthcare Antiseptic Drug Products (TFM). 27 The FDA TFM of 1994 classifies antiseptic agents as Category I, i.e., generally recognized as safe and effective and not misbranded; as Category II, i.e., not generally recognized as safe and effective or misbranded; or as Category III, available data are insufficient to classify as safe and effective, and further testing is required. Based on available evidence, the FDA TFM 1994 concluded that only ethanol, 60 to 95%, and povidone iodine, 5 to 10%, formulations have meet the test and product labeling requirements as antiseptic agents for hand antisepsis and surgical hand antisepsis in healthcare settings (Table 2). 27 Hand hygiene products used in healthcare settings should have a broad spectrum, be fast acting, have persistent activity, and reduce the number of microorganisms on intact skin to an initial baseline level (i.e., by 2-log10 or 99% on each hand within 5 minute after the first use of a product and by 3-log10 or 99.9% on each hand within 5 minutes after the tenth use) after adequate washing, rinsing and/or rubbing and drying (Table 3). 1,27 Persistent activity is characterized by a prolonged or extended Table 2. The FDA TFM 1994 classification of healthcare antiseptic active ingredients 7

Table 3. The relative effectiveness of various antiseptic agents* antimicrobial activity that prevents or inhibits the proliferation or survival of microorganisms after application of the product. This property also has been referred to as residual activity. Substantivity is an attribute of certain active ingredients in antiseptic products that adhere to the stratum corneum (i.e., remain on the skin after rinsing or drying) to provide an inhibitory effect on the growth of microorganisms remaining on the skin. However, both substantive and nonsubstantive active ingredients can show a persistent effect if they substantially lower the number of bacteria following hand hygiene. Alcohol-based Handrub As noted in Table 2, the FDA TFM of 1994 classified ethanol, 60 to 95%, as a Category I agent, i.e., generally safe and effective for use in antiseptic handwash or HCW handwash products. 27 The antiseptic activity of alcohols is attributed to their ability to denature proteins. 28 Alcohol solutions, 60-95% (expressed as percent by volume) are more effective than higher concentrations because proteins are not denatured easily in the absence of water. Although alcohols are not considered to have residual antimicrobial activity, microorganisms appear to reproduce slowly on hands after the use alcohol-based products (presumably because of the sublethal antimicrobial effect of alcohols) and microbial counts on hands after wearing gloves for 1 to 3 hours seldom exceed baseline values. 1 Alcohol-based handrub (Figure 2) removes or destroys transient microorganisms and reduce the resident hand flora. 1,25 Based on available evidence, the FDA, the CDC, and the WHO concluded that alcohol-based handrub is more effective than plain and antiseptic soaps and water (see Table 3) for HCW handwash. 1,25,27 Alcohol-based hand antisepsis is indicated for routine hand hygiene in clinical situations when the hands are not visibly soiled. 1,25 When performing alcohol-based handrub, follow the manufacturer s recommendations regarding the volume of product to use. Liquids, gels, or foam formulations are all acceptable. The concomitant use of an alcohol-based handrub and an iodophor-based antimicrobial soap is contraindicated. The frequent use of alcohol-based hand-rubs can cause skin irritation and dryness (irritation contact dermatitis) unless emollients, humectants, or other skin-conditioning agents are added to the formulation (solicit information from manufacturers regarding any known interactions between hand hygiene products, skin care products, and the type of gloves used). Formulations with strong fragrances may be poorly tolerated by HCWs 8

Figure 2. How to Handrub when hands are not visibly soiled? Image source: World Health Organization (WHO) 9

and patients with respiratory allergies. Allergic contact dermatitis or contact urticaria syndrome to alcohols or to various additives present in certain formulations is rare. 29,30 Contamination of alcoholbased products is remote. 31 Alcohol-based hand rubs are flammable and should be stored away from high temperatures (flash points range from 210C to 240C) or flames. 32 Antiseptic Handwash As noted in Table 2, the FDA TFM of 1994 classified povidone iodine, 5 to 10%, as a Category I agent, i.e., generally safe and effective for use in antiseptic hand wash or HCW handwash products. 27 Povidone iodine is an iodophor composed of elemental iodine, iodide or triiodide, and a polymer carrier or complexing agent. The amount of free iodine determines the level of antimicrobial activity of iodophors. 33 Iodine molecules rapidly penetrate the microbial cell wall and inactivate cells by forming complexes with amino acids and unsaturated fatty acids, resulting in impaired protein synthesis and alteration of cell membranes. The extent to which iodophors exhibit persistent antimicrobial activity is unclear. 1 Antiseptic handwash (follow handwashing recommendations in Figure 1) with povidone iodine removes or destroys transient microorganisms and reduces the resident hand flora. 1 It is an acceptable method of hand antisepsis when the hands are visibly soiled and it is an acceptable alternative to handwashing. However, when the hands are not visibly soiled, the CDC and the WHO recommend the use of an alcohol-based handrub (see Figure 2) for routine hand hygiene. 1,25,27 The concomitant use of an alcohol-based handrub and an iodophor-based antimicrobial soap is contraindicated and the use of antimicrobial-impregnated wipes (i.e., towelettes) are not acceptable for antiseptic handwash. The antimicrobial activity of iodophors can be affected by both organic (e.g., blood and sputum) and inorganic compounds (e.g., alcohols and detergents). 34 Iodophors cause less skin irritation (irritant contact dermatitis) and fewer allergic contact dermatitis than iodine, but more irritant contact dermatitis than other antiseptic agents. 35,36 Occasionally, povidone iodine antiseptic agents have become contaminated with gram-negative bacilli and have caused outbreaks of nosocomial infection. 33 Surgical Hand Antisepsis As noted in Table 2, the FDA TFM of 1994 classified both ethanol, 60 to 95%, and povidone iodine, 5-10%, as Category I agents, i.e., generally safe and effective for use in surgical hand antisepsis. 27 The FDA, the CDC, and the WHO recommend surgical hand antisepsis (Table 4) using either an antimicrobial soap and water or two-stage surgical hand antisepsis, i.e., handwashing with plain soap and water followed by the application of an alcohol-based handrub with (preferably) persistent activity (alcohol-based preparations containing 0.5% to 1% chlorhexidine gluconate have persistent activity). 1,25,27 Traditionally, surgical staff has been required to scrub hands for 10 minutes with an antiseptic agent. The CDC concluded that scrubbing with a brush for 10 minutes can damage skin and result in increased shedding of microorganisms from the hands; scrubbing for 5 minutes reduces microbial counts as effectively as a 10 minute scrub; and scrubbing for 2 to 3 minutes reduces microbial counts to acceptable level; and scrubbing with a disposable sponge reduces microbial counts on the hands as effectively as scrubbing with a brush. 1 However, neither a brush nor a sponge is necessary to reduce microbial counts on the hands of surgical personnel to acceptable levels. 1 Adverse Effects Associated with Handhygiene Products Irritant Contact Dermatitis The most common reaction associated with the frequent and repeated use of handhygiene products is irritant contact dermatitis (ICD). ICD is a non-immunologically mediated dermatitis characterized by dryness, itchiness, or burning; the skin may feel rough ; and appear erythematous, scaly, or fissured. These signs and symptoms are similar to those associated with allergic contact dermatitis, which can be ruled out by allergy testing. The irritation may be caused by the antimicrobial agent or by other ingredients of the formulation. Detergents damage skin by causing denudation of the stratum corneum proteins, changes in intercellular lipids (either depletion or reorganization of lipid moieties), decreased corneocyte cohesion, and decreased stratum corneum water-binding capacity. 36 10

Table 4. Surgical Hand Antisepsis 11

Table 4. Surgical Hand Antisepsis (continued) Other factors that contribute to ICD include using hot water, low relative humidity (winter months), the quality of paper towels used, and shear forces associated with wearing and removing gloves. Damage to the skin frequently leads to colonization by staphylococci and gram-negative bacilli, which contributes to further irritation. ICD is most commonly reported with iodophors. Other antiseptic agents that can cause ICD, in order of decreasing frequency, include chlorhexidine, phenolic derivatives, and triclosan. Following an exhaustive review of available data, the CDC concluded that alcohol-based preparations are the safest antiseptics available and ethanol is usually less irritating than isopropanol. 37 Allergic Contact Dermatitis Allergic contact dermatitis (ACD) is a T cellmediated delayed hypersensitivity reaction (Gell and Coombs Type IV) caused primarily by fragrances and preservatives; and less commonly by emulsifiers found in hand-hygiene products. 38,39 ACD is characterized by a rash, redness, and itching, which usually begins 24 to 48 hours after contact with offending products and may progress to oozing skin blisters and spread to areas of 12

skin untouched by the product. The reaction is similar to those caused by nickel and poison ivy. A skin rash may be the first sign that a person has become allergic to a hand-hygiene product and more serious reactions could occur with continued exposure. Skin damage associated with ICD increases the potential for allergic sensitization and allergy to latex proteins increases the likelihood of ICD. Since the clinical signs and symptoms of ACD are similar to ICD, it is necessary to confirm the allergic nature of the reaction in order to avoid further sensitization. ACD has been reported with chlorhexidine, phenolic derivatives, iodine and iodophors, triclosan, and quaternary ammonium compounds. ACD with alcohol-based products is uncommon, but such reactions may represent true allergy to alcohol, allergy to an impurity or aldehyde metabolites, or allergy to another constituent of the product. 29,32 Other Factors to Consider in the Selection of Hand Hygiene products HCWs should be provided with efficacious hand hygiene products that have low irritability potential and with hand lotions to minimize the occurrence of irritant contact dermatitis. To maximize acceptance solicit input from HCWs regarding fragrance (smell), consistency, (i.e., feel ), skin tolerance, and color. Washing hands with soap and water after each use of alcohol-based handrub is not necessary and is not recommended, because it may lead to dermatitis. 2 However, because personnel may feel a build-up of emollients on the hands after repeated use, washing hands with soap and water after 5 to 10 applications has been recommended by some manufacturers. When selecting plain soaps, antimicrobial soaps, or alcohol-based hand rubs, solicit information from manufacturers regarding any known interactions between the hand hygiene products; skin care products; the type of gloves used in the healthcare setting; and ask about the risk of product contamination (do not add soap to a partially empty dispenser, topping off dispensers can lead to bacterial contamination of soap). Before making purchasing decisions evaluate the dispenser system to make sure that it functions reliably, delivers an appropriate volume of product, and that the dispenser for alcohol-based formulations is approved for flammable materials. The cost of hand hygiene products should not be the primary factor influencing product selection; however, it has been shown that the routine use of an alcohol-based hand rub is more cost effective than the use of an antimicrobial soap and water. 40 Strategies to Improve Hand Hygiene Practices The Institute for Healthcare Improvement in its How-to Guide: Improving Hand Hygiene recommends a multidimensional approach (i.e., introduction of alcohol-based hand rub, and educational and behavioral initiatives) to improve compliance with hand hygiene guidelines in healthcare settings. 41 The science supporting a multidimensional hand hygiene program (glove use is included in this strategy because proper glove use is inextricably linked to effective hand hygiene) is sufficiently established to be considered a standard and consist of four components (Table 5). While these four components of best practices individually improve hand hygiene compliance, when applied together they are substantially more effective. Recently, a novel strategy of video surveillance of hand hygiene coupled with real-time compliance feedback has been reported. 42 The study was conducted in a 17-bed intensive care unit. Cameras were placed with views of every sink and hand sanitizer dispenser to record hand hygiene of HCW. Sensors in the doorways identified when an individual entered/exited. When video auditors observed a HCW performing hand hygiene upon entering/exiting, they assigned a pass; if not, a fail was assigned. Hand hygiene was measured during a 16-week period without feedback and a 91-week period with feedback. During a 16-week pre-feedback period, hand hygiene rates were less than 10%. In the 16-week post-feedback period compliance improved to 81.6% and, subsequently, was maintained through 75 weeks at 87.9%. While quality of hand hygiene and healthcare-associated infection data were not presented, this approach for improving to improve compliance merits consideration. 13

Table 5. Multidimensional approach to improve compliance with hand hygiene guidelines 14

Conclusion An unintended result of seeking care is healthcare-associated infections. These infections can lead to serious illness, prolonged hospital stays, and long-term disability. The transmission of healthcare-associated pathogens most often occurs via the contaminated hands of healthcare workers (HCWs). Many factors can contribute to poor hand hygiene practices among HCWs including (1) lack of knowledge about the importance of hand hygiene, i.e., how hands become contaminated with microorganisms and spread infection, (2) lack of understanding of correct hand hygiene techniques, (3) lack of access to appropriate hand hygiene products, (4) irritant contact dermatitis associated with frequent use of soap and water, and (5) lack of institutional commitment to good hand hygiene practices. A major goal of institutional hand hygiene strategies should be to encourage a culture of safety and to create a blame-free environment in which errors are seen as a by-product of poor systems, not as caused by irresponsible or incompetent people. The simplest and most effective hand hygiene technique, if the hands are not visibly soiled, is the routine use of an alcohol-based hand rub. Alcohol-based had rubs have been shown to be more effective in reducing the number of viable bacteria, viruses, and fungi on hands than plain soap and water or an antimicrobial soap and water; require less time to use; can be made available at the point of care; cause less hand irritation and dryness with repeated use; and, consequently, improve compliance with hand hygiene standards. 15

Course Test Preview To receive Continuing Education credit for this course, you must complete the online test. Please go to: www.dentalcare.com/en-us/dental-education/continuing-education/ce353/ce353-test.aspx 1. All of the following statements regarding hand hygiene in healthcare settings are true except which one? a. The overall adherence of HCWs to fundamental principles of infection control and aseptic technique (e.g., failure to wear gloves and perform hand hygiene) is low. b. Poor adherence to hand hygiene practices is a primary contributor to healthcare-associated infection. c. Hand hygiene is not necessary if gloves are worn. d. The prevalence of healthcare-associated infections is decreased as adherence to recommended hand hygiene practices is improved. 2. Intercellular lipids, which form the only continuous domain of the skin essential for a complete barrier function, e.g., to minimize microbial invasion from the environment, are a basic component of the. a. stratum corneum b. viable epidermis c. dermis d. hypodermis 3. Hand hygiene products and procedures can decrease the barrier function of skin by. a. extracting skin lipids b. chemically inducing irritation c. physically stripping the stratum corneum d. All of the above. 4. Which of the following statements is correct in relation to homeostatic control and the rate of keratinocyte proliferation? a. Under basal conditions, differentiated keratinocytes require 2 weeks to exit the nucleated compartment and an additional 2 weeks to move through the stratum corneum. b. When stimulated by injury or infection, keratinocytes have the capacity for increased rates of proliferation and maturation, and 50 to 60% of barrier recovery typically occurs within 6 hours. c. When stimulated by injury or infection, keratinocytes have the capacity for increased rates of proliferation and maturation, and complete normalization of barrier function occurs in 5 to 6 days. d. All of the above. 5. Which of the following statement in relation to the normal skin flora and the acquisition and transmission of healthcare-associated pathogens is incorrect? a. One of the largest human-associated microbial habitats is the skin. b. Transient organisms tend to colonize the superficial layers of skin and since they are amenable to removal by washing hands with plain soap and water, they are less likely to cause healthcareassociated infections than resident pathogens. c. Organisms are transferred in much larger numbers from wet hands than from hands that are thoroughly dried. d. Resident organisms are attached to deeper layers of skin and they are more resistant to removal than transient pathogens. 16

6. Which of the following infections can be potentially transmitted from patients to HCWs if appropriate glove use and hand hygiene are not performed? a. Herpes simplex virus infections b. Colonization or infection Staphylococcus aureus c. Hepatitis B and C virus infection d. All of the above. 7. Hand hygiene refers to. a. handwashing, i.e., washing hands with plain soap and water b. hand antisepsis, i.e., antiseptic hand wash or antiseptic hand rub c. surgical hand antisepsis d. All of the above. 8. Handwashing is an inappropriate hand hygiene procedure. a. when the hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids b. to remove or destroy transient microorganisms and reduce the resident hand flora c. before eating d. after using the bathroom 9. Antimicrobial-impregnated wipes, i.e., towelettes. a. might be considered as an alternative to washing hands with plain soap and water b. are as effective as alcohol-based hand rubs c. are as effective as washing hands with antimicrobial soap and water d. B and C 10. Alcohol-based hand rubs have good or excellent antimicrobial activity against which of the following microorganisms? a. Viruses and fungi b. Mycobacteria c. Gram-positive and gram-negative bacteria d. All of the above. 11. Each of the following statements regarding alcohol-based hand rubs is true except which one? Alcohol-based hand rubs. a. reduce bacterial counts on the hands of HCWs more effectively than plain and antiseptic soap and water b. kill microorganisms more rapidly than iodophors and other antiseptic containing soaps c. are only effective if they are applied for 60 seconds d. have been demonstrated to cause less skin irritation and dryness than repeated handwashing (i.e., washing hands with plain soap and water) or antiseptic handwash (i.e., washing hands with antimicrobial soap and water) 12. If hands are not visibly soiled or visibly contaminated with blood or other proteinaceous material, which of the following regimens is the most effective for reducing the number of pathogenic organisms on the hands of HCWs? a. Handwashing, i.e., washing hands with plain soap and water. b. Antiseptic handwash, i.e., washing hands with an antimicrobial soap and water. c. Hand antisepsis, i.e., applying an appropriate amount of alcohol-based hand rub to the hands and rubbing hands together until they feel dry. d. Using an antimicrobial impregnated wipe, i.e., towelettes. 17

13. All of the following statements regarding surgical hand antisepsis are true except which one? a. Antimicrobial counts on hands are reduced as effectively with a 5-minute scrub as with a 10-minute scrub. b. A brush or sponge must be used when applying the antiseptic agent to adequately reduce bacterial counts on hands. c. The FDA, CDC, and the WHO recommend surgical hand antisepsis using an antimicrobial soap and water or two-stage surgical hand antisepsis. d. Handwashing with plain soap and water followed by the application of an alcohol-based hand rub is an acceptable method of surgical hand antisepsis. 14. According to the CDC, which antiseptic agent is least likely to produce irritant contact dermatitis or allergic contact dermatitis? a. Chlorhexidine b. Ethanol c. Triclosan d. Iodophors 15. Compliance with hand hygiene guidelines is substantially improved when a multidimensional strategy includes. a. introduction of alcohol-based hand rub b. educational and behavioral initiatives c. institutional verification of compliance and feedback d. All of the above. 18

References 1. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002 Oct 25;51(RR-16):1-45. 2. Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med. 2009 Jan 6;150(1):33-39. 3. Kohn WG, Collins AS, Cleveland JL, et al. Centers for Disease Control and Prevention (CDC). Guidelines for infection control in dental health-care settings--2003. MMWR Recomm Rep. 2003 Dec 19;52(RR-17):1-61. 4. Myers R, Larson E, Cheng B, et al. Hand hygiene among general practice dentists: A survey of knowledge, attitudes and practices. J Am Dent Assoc. 2008 Jul;139(7):948-957. 5. Kotilainen HR, Brinker JP, Avato JL, Gantz NM. Latex and vinyl examination gloves: quality control procedures and implications for health care workers. Arch Intern Med. 1989 Dec;149(12):2749-2753. 6. Reingold AL, Kane MA, Hightower AW. Failure of gloves and other protective devices to prevent transmission of hepatitis B virus to oral surgeons. JAMA. 1988 May 6;259(17):2558-2560. 7. Larson EL, Early E, Cloonan P, Sugrue S, Parides M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med. 2000 Spring;26(1):14-22. 8. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000 Oct 14;356(9238): 1307-1312. 9. Elias PM, Choi EH. Interactions among stratum corneum defensive functions. Exp Dermatol. 2005 Oct;14(10):719-726. 10. Corcuff P, Fiat F, Minondo AM: Ultrastructure of the human stratum corneum. Skin Pharmacol Appl Skin Physiol. 2001;14 Suppl 1:4-9. 11. Fuchs E. Beauty is skin deep: the fascinating biology of the epidermis and its appendages. Harvey Lect. 1998-1999;94:47-77. 12. Bergstresser PR, Taylor JR. Epidermal turnover time --a new examination. Br J Dermatol. 1977 May;96(5):503-509. 13. Fredricks DN. Microbial ecology of human skin in health and disease. J Investig Dermatol Symp Proc. 2001 Dec;6(3):167-169. 14. Larson E. Effects of handwashing agent, handwashing frequency, and clinical area on hand flora. Am J Infect Control. 1984 Apr;12(2):76-82. 15. Larson EL, Hughes CA, Pyrek JD, et al. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control. 1998 Oct;26(5):513-521. 16. Maki D. Control of colonization and transmission of pathogenic bacteria in the hospital. Ann Intern Med. 1978 Nov;89(5 Pt 2 Suppl):777-780. 17. Fierer N, Hamady M, Lauber CL, Knight R. The influence of sex, handedness, and washing on the diversity of hand surface bacteria. Proc Natl Acad Sci U S A. 2008 Nov 18;105(46):17994-17999. 18. Patrick DR, Findon G, Miller TE. Residual moisture determines the level of touch-contact-associated bacterial transfer following hand washing. Epidemiol Infect. 1997 Dec;119(3):319-325. 19. U.S. Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to bloodborne pathogens; needlesticks and other sharps injuries; final rule. Federal Register 2001;66:5317-5325. As amended from and includes 29 CRF Part 1910.1030. Occupational exposure to bloodborne pathogens; final rule Federal Register 1991;56:64174-64182. Accessed July 20, 2013. 20. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 guidelines for isolation precautions: preventing transmission of infectious agents in healthcare settings. Accessed July 20, 2013. 19

21. Olsen RJ, Lynch P, Coyle MB, et al. Examination gloves as barriers to hand contamination in clinical practice. JAMA. 1993 Jul 21;270(3):350-353. 22. Tenorio AR, Badri SM, Sahgal NB, et al. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care. Clin Infect Dis. 2001 Mar 1;32(5):826-829. 23. Doebbeling BN, Pfaller MA, Houston AK, Wenzel RP. Removal of nosocomial pathogens from the contaminated glove. Implications for glove reuse and handwashing. Ann Intern Med. 1988 Sep 1;109(5):394-398. 24. Miller CS, Danaher RJ. Asymptomatic shedding of herpes simplex virus (HSV) in the oral cavity. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Jan;105(1):43-50. 25. World Health Organization. WHO guidelines on hand hygiene in health care (advanced draft): a summary. Accessed July 20, 2013. 26. Sartor C, Jacomo V, Duvivier C, et al. Nosocomial Serratia marcescens infections associated with extrinsic contamination of a liquid nonmedicated soap. Infect Control Hosp Epidemiol. 2000 Mar;21(3):196-199. 27. Department of Health and Human Services. Food and Drug Administration. Topical antimicrobial drug products for over-the-counter human use; tentative final monograph for health-care antiseptic drug products. Federal Register 1994;59:31402-31452. Accessed July 20, 2013. 28. Larson EL, Morton HE. Alcohols. In: Block SS, ed. Disinfection, sterilization and preservation. 4th ed. Philadelphia, PA: Lea and Febiger, 1991:642-54. 29. Ophaswongse S, Maibach HI. Alcohol dermatitis: allergic contact dermatitis and contact urticaria syndrome. A review. Contact Dermatitis. 1994 Jan;30(1):1-6. 30. Rilliet A, Hunziker N, Brun R. Alcohol contact urticaria syndrome (immediate-type hypersensitivity). Case report. Dermatologica. 1980;161(6):361-364. 31. Hsueh PR, Teng LJ, Yang PC, et al. Nosocomial pseudoepidemic caused by Bacillus cereus traced to contaminated ethyl alcohol from a liquor factory. J Clin Microbiol. 1999 Jul;37(7):2280-2284. 32. Widmer AF. Replace hand washing with use of a waterless alcohol hand rub? Clin Infect Dis. 2000 Jul;31(1):136-143. 33. Anderson RL. Iodophor antiseptics: intrinsic microbial contamination with resistant bacteria. Infect Control Hosp Epidemiol. 1989 Oct;10(10):443-446. 34. Larson EL. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control. 1995 Aug;23(4):251-269. 35. Larson E, Leyden JJ, McGinley KJ, et al. Physiologic and microbiologic changes in skin related to frequent handwashing. Infect Control. 1986 Feb;7(2):59-63. 36. Wilhelm KP. Prevention of surfactant-induced irritant contact dermatitis. Curr Probl Dermatol. 1996;25:78-85. 37. Rotter ML, Simpson RA, Koller W. Surgical hand disinfection with alcohols at various concentrations: parallel experiments using the new proposed European standards method. Infect Control Hosp Epidemiol. 1998 Oct;19(10):778-781. 38. Rastogi SC, Heydorn S, Johansen JD, Basketter DA. Fragrance chemicals in domestic and occupational products. Contact Dermatitis. 2001 Oct;45(4):221-225. 39. Schnuch A, Uter W, Geier J, Frosch PJ, Rustemeyer T. Contact allergies in healthcare workers. Results from the IVDK. Acta Derm Venereol. 1998 Sep;78(5):358-363. 40. Huber MA, Holton RH, Terezhalmy GT. Cost analysis of hand hygiene using antimicrobial soap and water versus an alcohol-based hand rub. J Contemp Dent Pract. 2006 May 1;7(2):37-45. 41. Institute for Healthcare Improvement. How-to guide: improving hand hygiene. A guide for improving practices among health care workers. 2006. Accessed July 20, 2013. 42. Armellino D, Hussain E, Schilling ME, Senicola W, et al. Using high-technology to enforce lowtechnology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis. 2012 Jan 1;54(1):1-7. 20

About the Authors Géza T. Terézhalmy, DDS, MA Professor and Dean Emeritus School of Dental Medicine Case Western Reserve University Dr. Terézhalmy is Professor and Dean Emeritus, School of Dental Medicine, Case Western Reserve University. In addition, he is a Consultant, Naval Postgraduate Dental School, National Naval Medical Center; and Civilian National Consultant for Dental Pharmacotherapeutics, Department of the Air Force. Dr. Terézhalmy earned a B.S. degree from John Carroll University; a D.D.S. degree from Case Western Reserve University; an M.A. in Higher Education and Human Development from The George Washington University; and a Certificate in Oral Medicine from the National Naval Dental Center. Dr. Terézhalmy is certified by the American Board of Oral Medicine and the American Board of Oral and Maxillofacial Radiology (Life). Dr. Terézhalmy has many professional affiliations and over the past 40 years, has held more than 30 positions in professional societies. He has served as editor or contributing editor for several publications, co-authored or contributed chapters for several books and has had over 200 papers and abstracts published. Dr. Terézhalmy has accepted invitations to lecture before many local, state, national, and international professional societies. Email: TEREZHALMY@uthscsa.edu Michaell A. Huber, DDS Associate Professor Head, Oral Medicine Division Department of Dental Diagnostic Science The University of Texas Health Science Center at San Antonio, Dental School Dr. Huber is an Associate Professor, Head, Division of Oral Medicine, Department of Dental Diagnostic Science, the University of Texas Health Science Center at San Antonio, Dental School, San Antonio, Texas. Dr. Huber received his DDS from the University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas in 1980 and a Certificate in Oral Medicine from the National Naval Dental Center, Bethesda, Maryland in 1988. He is certified by the American Board of Oral Medicine as an officer of the Dental Corps, United States Navy. Dr. Huber s assignments included numerous ships and shore stations and served as Chairman, Department of Oral Medicine and Maxillofacial Radiology and Director, Graduate Program in Oral Medicine, National Naval Dental Center, Bethesda, Maryland. In addition he served as Specialty Leader for Oral Medicine to the Surgeon General of the United States Navy, Washington, DC; and Force Dental Officer, Naval Air Force Atlantic, Norfolk, Virginia. He has many professional affiliations and over the past 24 years, he has held a variety of positions in professional organizations. Since joining the faculty in 2002, Dr. Huber has been teaching both pre-doctoral and graduate dental students at the University of Texas Health Science Center Dental School, San Antonio, Texas, and is the Director of the school s Oral Medicine Tertiary Care Clinic. He is currently serving as the Public Affairs Chairman for the American Academy of Oral Medicine. Dr. Huber has accepted invitations to lecture before many local, state, and national professional organizations. He has been published in numerous 21

journals including: Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology; Dental Clinics of North America, Journal of the American Dental Association, and Quintessence International. Email: huberm@uthscsa.edu 22