Alcohol handrubbing and chlorhexidine handwashing ... · • en aveugle concernant l’analyse...

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Alcohol handrubbing and chlorhexidine handwashing protocols for routine hospital practice : A randomized clinical trial of protocol efficacy and time effectiveness Angela Chow et al. American Journal of Infection Control, November 2012

Transcript of Alcohol handrubbing and chlorhexidine handwashing ... · • en aveugle concernant l’analyse...

Page 1: Alcohol handrubbing and chlorhexidine handwashing ... · • en aveugle concernant l’analyse bactériologique ... -après le soin mais avant l’hygiène des mains ... and protocol

Alcohol handrubbing and chlorhexidine handwashing protocols

for routine hospital practice :A randomized clinical trial of protocol

efficacy and time effectiveness

Angela Chow et al.

American Journal of Infection Control,November 2012

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Introduction : contexte

• 20 à 40 % des infections liées aux soins mettraient en cause les mains des soignants*, d’où l’importance de l’hygiène des mains

• augmentation de la consommation de savon et de SHA associée à une diminution des infections nosocomiales à C. difficile et SAMR

* WeberDJ,RutalaWA,MillerMB,HuslageK,Sickbert-BennettE.Roleofhospital surfaces in the transmission of emerging health care-associated pathogens: norovirus, Clostridium difficile, and Acinetobacter species. Am J Infect Control 2010;38(5 Suppl 1):S25-33.

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Introduction : contexte

• compliance à l’hygiène des mains de 50 %* (charge de travail et manque de temps)

• favoriser l’utilisation de SHA :

- meilleure compliance (facilité d’utilisation)

- meilleure efficacité antimicrobienne

* Pittet D, Hugonnet S, Harbarth S, Monronga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307-12.

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Introduction : rationnel

• une étude récente* a montré que la meilleure hygiène des mains était obtenue en laissant le soignant couvrir ses mains de SHA, sans protocole particulier

* Kampf G, Reichel M, Feil Y, Eggerstedt S, Kaulfers PM. Influence of rub-in technique on required application time and hand coverage in hygienic hand disinfection. BMC Infect Dis 2008;8:149.

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Introduction : objectifs

• objectif principal : comparer l’efficacité de 3 méthodes d’hygiène des mains (en conditions réelles) pour la réduction de la charge bactérienne manuelle

• objectif secondaire : évaluer le temps nécessaire moyen pour chacune de ces méthodes (en conditions réelles)

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Méthode : design

• essai contrôlé randomisé

• 3 groupes parallèles de même effectif : 1 groupe pour chaque méthode testée

• en aveugle concernant l’analyse bactériologique (2 bactériologistes ignorant la méthode d’hygiène des mains utilisée)

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Méthode : 3 méthodes

• méthode 1 (recommandations CDC) : SHA en quantité suffisante pour appliquer sur la totalité de la surface des 2 mains (sans étape ni ordre particulier)

• méthode 2 (recommandations OMS) : SHA en 7 étapes

• méthode 3 : lavage de mains à la chlorhexidine et à l’eau en 7 étapes

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Méthode : cadre spatial• Tan Tock Seng Hospital, Singapore

• 20 services d’aigu étudiés

• chaque service étant composé de 6 chambres comprenant 6 lits (soit 36 lits)

• SHA à disposition :

- à l’entrée du service

- à l’entrée de chaque chambre

- au pied de chaque lit

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Méthode : cadre temporel

• du 8 octobre 2007 au 7 novembre 2007, soit 1 mois

• étude menée pendant le tour du matin, entre 07h30 et 10h30, du lundi au vendredi (activité maximale)

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Méthode : recrutement• médecins et infirmières recrutés dans chaque service

• les investigateurs tournaient dans les différents services selon un ordre aléatoire déterminé à l’avance (eux seuls connaissaient cet ordre) (échantillonage aléatoire)

• observation de l’hygiène des mains réalisée lors de soins avec contact direct du patient (examen du patient, prise des constantes, changes...) sans gant (éligibilité)

• proposition de participation à l’étude de ces soignants

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Méthode : calcul du NSI

• NSI : 35 sujets par méthodes minimum

• choix de prendre 40 sujets par méthode

• soit 120 sujets :

- 60 médecins (30 % des médecins de l’hopital)

- 60 infirmières (15 % des infirmières de l’hopital)

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Méthode : assignation

• chaque participant était assigné aléatoirement à une des 3 méthodes d’hygiène des mains

• choix de la méthode d’hygiène des mains par tirage d’enveloppes préremplies et scellées, ouvertes juste avant la réalisation de l’hygiène des mains

• apprentissage préalable de la méthode des 7 étapes pour les participants concernés

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Méthode : recueil des données (efficacité AB)

• estimation de la charge bactérienne du soignant sur 2 échantillons réalisés sur la main dominante :

- après le soin mais avant l’hygiène des mains

- et après l’hygiène des mains

• technique du liquide de gant (cultures)

• identification et quantification des germes

Critère de jugement principal

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Méthode : recueil des données (durées)Critère de jugement secondaire

• observation pour chaque participant de :

- la durée du soin donné au patient

- la durée de l’hygiène des mains associée

- du respect de la méthode assignée

• utilisation d’un chronomètre

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Résultats : échantillonswith alcohol, using the 7-step technique they would normallyadopt for chlorhexidine handwashing.

Outcomes

A study number was assigned to each participant using pre-numbered data collection forms. Two research associates separatelyand independentlymonitored the time taken byeach participant forthe patient care activity and the assigned hand hygiene protocolusing stopwatches. The research associates followed a standardprotocol for time monitoring and had received prior training on theprocedure. The time durations as well as the type of patient careperformed were recorded by each research associate in the datacollection forms. The average of the times recorded by the researchassociates were used for analyses. In addition, each participant wasobserved for adherence to the allocated hand hygiene technique,without interference with their hand hygiene process.

Two samples for estimating bacterial load were taken from thedominant hand of each participant: (1) after patient contact butbefore hand hygiene and (2) after hand hygiene. The research asso-ciates, who had undergone training in the sampling technique, tookthe hand samples using amodification of the glove juice technique.14

Although more resource intensive, this technique was chosen overthe hand imprint technique because it was more effective in recov-ering the bacterial burden from thewhole hand andprovided amoreprecise measurement of bacterial contamination. With the glovejuice technique, the bacterial recovery process was also standard-ized. The participant’s dominant hand was first placed intoa powder-free, loose-fitting, sterile latex glove. Following that, 30mLof laboratory-prepared sterile nutrient broth was poured into theglove. Participants’ wrists were secured as they flexed their fingersaccording to a fixed protocol and research associates massaged theparticipants’ hands through the gloves in a uniform manner for 45seconds. The sterile gloves were then removed and the brothemptiedaseptically into a sterile specimen container,whichwas sentto the laboratory for cultures within 3 hours of collection.

After mixing the sample well, a 10-mL loop was used to inoculatean agar plate (5% blood agar; Oxoid, Cambridge, UK). Inoculatedagar plates were incubated at 37!C under aerobic conditions. Allcolonial morphotypes were counted, and the total bacterialcontamination of hands was recorded as the number of colony-forming units per milliliter (cfu/mL) after 48 hours of incubation.Species identification of bacteria present in the samples were alsoqualitatively identified using standard microbiologic procedures;antimicrobial susceptibility testing was performed for relevantisolates by disk diffusion on Mueller Hinton agar plates followingClinical and Laboratory Standards Institute guidelines.17

Sample size

To detect a difference of 35% in the median reduction of handbacteria load between hand hygiene protocols, at a significancelevel of 5% and a desired power of 80%, we calculated that wewouldrequire 35 participants per protocol. We expanded the sample sizeto 40 health care staff per protocol to take into account possiblelogistic difficulties in the study. We enrolled an equal proportion ofmedical (60 participants) and nursing staff (60 participants), rep-resenting approximately 30% of medical and 15% of nursing staffworking on the subsidized general wards.

Randomization

Block randomization with a block size of 6 was used to ensureequal numbers of study participants in each hand hygiene protocol.Pre-prepared sealed envelopes were used to conceal the protocol

allocation from the study team. Just as study participants wereabout to perform a clinical hand hygiene, the envelopes wereopened, and participants were assigned to the protocol enclosed inthe envelope.

Blinding

Both microbiologists reporting the cfu counts and the microbi-ologic results were blinded to the hand hygiene protocols used.

Statistical analysis

The primary objective of the study was to determine the effec-tiveness of the 3 hand hygiene protocols, in the reduction of handbacterial load. Based on the principle of intention-to-treat, theanalyseswere carried out with the population-averaged generalizedestimating equationswith identity link and gamma-distribution,18,19

in anticipation of the skewed nature of bacterial load. Each studyparticipant had 2 paired measurements of bacteria load recorded,before andafterhandhygiene. The unstructuredworking correlationmatrix was chosen a priori to facilitate the analyses. As the mostflexible specification, it made no assumption about the correlationalpattern of the paired measurements. Generalized linear mixedmodel20 was not chosen for analysis because there was no practicaladvantage in applying a subject-specific technique in answering thestudy question. The nonparametric Kruskal-Wallis test was alsoconducted to ascertain the difference in time spent on the 3 handhygiene protocols and Fisher exact test for comparison of proportionof participantswith reduction in bacterial load and clearance of handbacterial contamination. Analyzed with Stata Release 11.0 (StataCorporation, College Station, TX), all statistical tests were performedat 5% level of significance.

RESULTS

Sixty medical and 60 nursing staff were included in our study,with 40 participants block randomized into each of the 3 protocols(Fig 1). Medical staff had a higher hand bacterial load than nursingstaff post-patient contact and prior to hand hygiene (median, 37.5"102 vs 6.0" 102 cfu/mL, respectively) (Table 1). All medical staff hadperformed a patient physical examination involving direct contactwith the patient’s skin. Duration of the physical examinationsranged from 21.1 to 901.7 seconds (median, 79.1 s). Nursing staffwere involved with a variety of patient care activities, with themajority being assisting patient in positional change (47%), takingof vital parameters (35%), and changing of patient’s clothes (10%).Median duration of patient care activities was 92.5 seconds (range,23.8-536.7 s).

1. Alcohol handrubbing covering all surfaces

(n=40; 20Med, 20Nurs)

2. Alcohol handrubbing using 7-Step technique

(n=40; 20Med, 20Nurs)

3. Chlorhexidine handwashing using 7-Step technique (n=40; 20Med, 20Nurs)

Health care staff from all general surgical and medical wards

- Assessed for eligibility during morning rounds and routine inpatient work

- Medical staff (n=60) ; Nursing staff (n=60)

RANDOMIZED

Fig 1. Schematic schedule of participant selection and randomization to hand-hygieneprotocol.

A. Chow et al. / American Journal of Infection Control 40 (2012) 800-5802

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• toute méthode confondue, réduction significative de la charge bactérienne sur les mains de 77,65 x 102 UFC/mL (p < 0,01)

- méthode 1 : meilleure réduction de la charge bactérienne (médiane 24,5 x 102 UFC/mL)

- comparé à la méthode 1,

la méthode 2 (- 5,17 x 102 UFC/mL), p = 0,07

et la méthode 3 (- 5,06 x 102 UFC/mL), p = 0,08

ne réduisent pas davantage la charge bactérienne de manière significative

Résultats : charge bactérienne

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Protocol 1 resulted in a nonsignificant difference in proportionof staff with reduction in hand bacterial load, when compared withthe other 2 protocols (Fig 2) and was the least time-consuming.Protocol 1 appeared to have the largest proportion (82.5%; 95%confidence interval [CI]: 76.5%-88.5%) of staff with reduced bacte-rial load after hand hygiene compared with protocol 2 (75.0%; 95%CI: 68.2%-81.8%) and protocol 3 (75.0%; 95% CI: 68.2%-81.8%). Therewas no difference in protocol adherence (staff with bacterial loadreduction vs staff without reduction: odds ratio [OR], 0.98; 95% CI:0.29-3.27; P! .98) and patient contact time (staff with reduction vsstaff without reduction: median, 89.5 vs 73.2 seconds, respectively;P! .55) between staff who had a bacterial load reduction and thosewho had not.

Overall, hand hygiene resulted in a substantial reduction inbacterial load of 77.65 " 102 cfu/mL (P < .01) (Table 2). After handhygiene, medical staff had a larger bacterial load reduction(median, 24.5 " 102 cfu/mL) than nursing staff (6.0 " 102 cfu/mL)(P! .01). Protocol 1 had the largest reduction in hand bacterial load(median, 15.5 " 102 cfu/mL), followed by protocol 3 (12.0 " 102 cfu/mL) and protocol 2 (10.5 " 102 cfu/mL). Compared with protocol 1,protocol 2 (#5.17" 102 cfu/mL, P! .07) and protocol 3 (#5.06" 102

cfu/mL, P ! .08) resulted in slightly greater bacterial load reduc-tions, after adjusting for staff category. However, the differencesamong the protocols were nonsignificant. All staff had beencompliant with the assigned hand hygiene protocol. None of thestaff allocated to alcohol handrubbing protocols 1 and 2 had toswitch to chlorhexidine handwashing because of soiled hands.

During routine patient care, protocol 1 (median, 26.0 s) requiredless time than protocol 2 (median, 38.5 s; P ! .04) and protocol 3(median, 75.5 s; P< .001), respectively (Table 3). The Kruskal-Wallistest showed that there was a difference in time spent on handhygiene among the 3 protocols (P < .001). The Wilcoxon-Mann-Whitney tests confirmed further that there was significant differ-ence between protocol 1 and protocols 2 and 3 separately.

Coagulase-negative staphylococcus was the most commonorganism isolated among medical and nursing staff with hand

contamination (Fig 3). Hand hygiene reduced the proportion of staffwith coagulase-negative staphylococcus on their hands from 73.3%to 30.0% (P < .001). Post-hand hygiene, no bacteria could be isolatedfrom the hands of two-thirds (63.3%) of health care staff. In theremaining 44 staff that still carried bacteria, resident flora was iso-lated in the majority (91%) of them. In 4 staff, methicillin-resistantStaphylococcus aureus (MRSA) and Acinetobacter baumannii wereidentified. Hand hygiene reduced nosocomial gram-positive cocci(post-hand hygiene vs pre-hand hygiene, difference in proportion,0.14; 95% CI: 0.07-0.21) more than nosocomial gram-negative bacilli(difference in proportion, 0.07; 95% CI: 0.01-0.13).

MRSA was isolated in 8 staff members prior to hand hygiene.After hand hygiene, MRSA remained in only 1 staff member.Although MRSA was not completely removed from that nursingstaff member’s hand, hand hygiene had substantially reduced thebacterial load by 70%, from 2,100 cfu/mL to 600 cfu/mL.

Acinetobacter baumannii was present on the hands of 7 healthcare workers post-patient contact. After hand hygiene, it remainedin 3 staff members. However, substantial reductions in bacterialload were observed (staff A: 123,500 cfu/mL to 1,700 cfu/mL, staffB: 70,000 cfu/mL to 300 cfu/mL, staff C: 5,400 cfu/mL to 3,800 cfu/mL). Some of the bacterial load could have been contributed byresident flora, which were also observed in the post-hand hygienesamples from staff A and C.

Table 1Duration of patient care activities and bacterial counts on hands of health care workers pre-hand hygiene and post-hand hygiene

Duration of patientactivities (seconds)

Hand bacterial counts ("102 cfu/mL)

Pre-hand hygiene Post-hand hygiene

Median (range) Median (IQR) Mean (SD) Median (IQR) Mean (SD)

All staff (n ! 120) 88.4 (21.1-901.7) 19.0 (1.0-97.0) 90.6 (180.1) 0.0 (0.0-3.0) 11.3 (34.0)Medical staff (n ! 60) 79.1 (21.1-901.7) 37.5 (8.0-114.0) 103.1 (157.0) 0.0 (0.0-5.8) 20.2 (45.8)Nursing staff (n ! 60) 92.5 (23.8-536.7) 6.0 (0.0-68.0) 78.2 (201.2) 0.0 (0.0-1.0) 2.4 (8.8)

Cfu, colony-forming units; IQR, Interquartile range; SD, standard deviation.

Fig 2. Proportion (%) of staff with hand bacterial load reduction and time spent onhand hygiene (seconds), by hand-hygiene protocol. The bars represent the proportionof staff with bacterial load reduction and the line represents the median time spent onhand hygiene.

Table 2Analysis of reduction in bacterial load based on generalized estimating equationswith gamma-distribution, identity link and unstructuredworking correlationmatrix

Coefficient 95% CIP

value

OccasionPre-hand hygiene Reference - -Post-hand hygiene #77.65 #114.11-#41.18 <.01

Specific hand hygiene protocol*Protocol 1: Alcohol handrubbing

covering all surfaces inno particular order

Reference - -

Protocol 2: Alcohol handrubbing usingstandard 7-step technique

#5.17 #10.76-0.43 .07

Protocol 3: Chlorhexidine handwashingusing standard 7-step technique

#5.06 #10.66-0.54 .08

NOTE. Analysis of reduction in bacterial load: "102 colony-forming units/milliliter.*Adjusted for staff category.

Table 3Time spent in seconds on hand hygiene by protocol

Median (IQR) Mean (SD)

Protocol 1: Alcohol handrubbingcovering all surfaces inno particular order

26.0 (15.4-54.0) 33.4 (21.2)

Protocol 2: Alcohol handrubbingusing 7-step technique

38.5 (32.8-47.0) 40.3 (14.4)

Protocol 3: Chlorhexidine handwashingusing 7-step technique

75.5 (64.9-93.3) 80.3 (21.2)

IQR, interquartile range; SD, standard deviation.

A. Chow et al. / American Journal of Infection Control 40 (2012) 800-5 803

Résultats : charge bactérienne

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Protocol 1 resulted in a nonsignificant difference in proportionof staff with reduction in hand bacterial load, when compared withthe other 2 protocols (Fig 2) and was the least time-consuming.Protocol 1 appeared to have the largest proportion (82.5%; 95%confidence interval [CI]: 76.5%-88.5%) of staff with reduced bacte-rial load after hand hygiene compared with protocol 2 (75.0%; 95%CI: 68.2%-81.8%) and protocol 3 (75.0%; 95% CI: 68.2%-81.8%). Therewas no difference in protocol adherence (staff with bacterial loadreduction vs staff without reduction: odds ratio [OR], 0.98; 95% CI:0.29-3.27; P! .98) and patient contact time (staff with reduction vsstaff without reduction: median, 89.5 vs 73.2 seconds, respectively;P! .55) between staff who had a bacterial load reduction and thosewho had not.

Overall, hand hygiene resulted in a substantial reduction inbacterial load of 77.65 " 102 cfu/mL (P < .01) (Table 2). After handhygiene, medical staff had a larger bacterial load reduction(median, 24.5 " 102 cfu/mL) than nursing staff (6.0 " 102 cfu/mL)(P! .01). Protocol 1 had the largest reduction in hand bacterial load(median, 15.5 " 102 cfu/mL), followed by protocol 3 (12.0 " 102 cfu/mL) and protocol 2 (10.5 " 102 cfu/mL). Compared with protocol 1,protocol 2 (#5.17" 102 cfu/mL, P! .07) and protocol 3 (#5.06" 102

cfu/mL, P ! .08) resulted in slightly greater bacterial load reduc-tions, after adjusting for staff category. However, the differencesamong the protocols were nonsignificant. All staff had beencompliant with the assigned hand hygiene protocol. None of thestaff allocated to alcohol handrubbing protocols 1 and 2 had toswitch to chlorhexidine handwashing because of soiled hands.

During routine patient care, protocol 1 (median, 26.0 s) requiredless time than protocol 2 (median, 38.5 s; P ! .04) and protocol 3(median, 75.5 s; P< .001), respectively (Table 3). The Kruskal-Wallistest showed that there was a difference in time spent on handhygiene among the 3 protocols (P < .001). The Wilcoxon-Mann-Whitney tests confirmed further that there was significant differ-ence between protocol 1 and protocols 2 and 3 separately.

Coagulase-negative staphylococcus was the most commonorganism isolated among medical and nursing staff with hand

contamination (Fig 3). Hand hygiene reduced the proportion of staffwith coagulase-negative staphylococcus on their hands from 73.3%to 30.0% (P < .001). Post-hand hygiene, no bacteria could be isolatedfrom the hands of two-thirds (63.3%) of health care staff. In theremaining 44 staff that still carried bacteria, resident flora was iso-lated in the majority (91%) of them. In 4 staff, methicillin-resistantStaphylococcus aureus (MRSA) and Acinetobacter baumannii wereidentified. Hand hygiene reduced nosocomial gram-positive cocci(post-hand hygiene vs pre-hand hygiene, difference in proportion,0.14; 95% CI: 0.07-0.21) more than nosocomial gram-negative bacilli(difference in proportion, 0.07; 95% CI: 0.01-0.13).

MRSA was isolated in 8 staff members prior to hand hygiene.After hand hygiene, MRSA remained in only 1 staff member.Although MRSA was not completely removed from that nursingstaff member’s hand, hand hygiene had substantially reduced thebacterial load by 70%, from 2,100 cfu/mL to 600 cfu/mL.

Acinetobacter baumannii was present on the hands of 7 healthcare workers post-patient contact. After hand hygiene, it remainedin 3 staff members. However, substantial reductions in bacterialload were observed (staff A: 123,500 cfu/mL to 1,700 cfu/mL, staffB: 70,000 cfu/mL to 300 cfu/mL, staff C: 5,400 cfu/mL to 3,800 cfu/mL). Some of the bacterial load could have been contributed byresident flora, which were also observed in the post-hand hygienesamples from staff A and C.

Table 1Duration of patient care activities and bacterial counts on hands of health care workers pre-hand hygiene and post-hand hygiene

Duration of patientactivities (seconds)

Hand bacterial counts ("102 cfu/mL)

Pre-hand hygiene Post-hand hygiene

Median (range) Median (IQR) Mean (SD) Median (IQR) Mean (SD)

All staff (n ! 120) 88.4 (21.1-901.7) 19.0 (1.0-97.0) 90.6 (180.1) 0.0 (0.0-3.0) 11.3 (34.0)Medical staff (n ! 60) 79.1 (21.1-901.7) 37.5 (8.0-114.0) 103.1 (157.0) 0.0 (0.0-5.8) 20.2 (45.8)Nursing staff (n ! 60) 92.5 (23.8-536.7) 6.0 (0.0-68.0) 78.2 (201.2) 0.0 (0.0-1.0) 2.4 (8.8)

Cfu, colony-forming units; IQR, Interquartile range; SD, standard deviation.

Fig 2. Proportion (%) of staff with hand bacterial load reduction and time spent onhand hygiene (seconds), by hand-hygiene protocol. The bars represent the proportionof staff with bacterial load reduction and the line represents the median time spent onhand hygiene.

Table 2Analysis of reduction in bacterial load based on generalized estimating equationswith gamma-distribution, identity link and unstructuredworking correlationmatrix

Coefficient 95% CIP

value

OccasionPre-hand hygiene Reference - -Post-hand hygiene #77.65 #114.11-#41.18 <.01

Specific hand hygiene protocol*Protocol 1: Alcohol handrubbing

covering all surfaces inno particular order

Reference - -

Protocol 2: Alcohol handrubbing usingstandard 7-step technique

#5.17 #10.76-0.43 .07

Protocol 3: Chlorhexidine handwashingusing standard 7-step technique

#5.06 #10.66-0.54 .08

NOTE. Analysis of reduction in bacterial load: "102 colony-forming units/milliliter.*Adjusted for staff category.

Table 3Time spent in seconds on hand hygiene by protocol

Median (IQR) Mean (SD)

Protocol 1: Alcohol handrubbingcovering all surfaces inno particular order

26.0 (15.4-54.0) 33.4 (21.2)

Protocol 2: Alcohol handrubbingusing 7-step technique

38.5 (32.8-47.0) 40.3 (14.4)

Protocol 3: Chlorhexidine handwashingusing 7-step technique

75.5 (64.9-93.3) 80.3 (21.2)

IQR, interquartile range; SD, standard deviation.

A. Chow et al. / American Journal of Infection Control 40 (2012) 800-5 803

Résultats : charge bactérienne

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Résultats : charge bactérienne• pas de différence significative dans la proportion de

soignants avec réduction de la charge bactérienne sur les mains entre les différentes méthodes

• diminution de la charge bactérienne :

• chez 82,5 % des soignants pour la méthode 1 (IC95 : 76,5 - 88,5 %)

• chez 75 % des soignants pour la méthode 2 (IC95 : 68,2 - 81,8 %)

• chez 75 % des soignants pour la méthode 3 (IC95 : 68,2 - 81,8 %)

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Résultats : durée passée à l’hygiène des mains

- la méthode 1 nécessite significativement moins de temps (médiane 26 s)

- que la méthode 2 (médiane 38,5 s, p = 0,04)

- et que la méthode 3 (médiane 75,5 s, p < 0,001)

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Protocol 1 resulted in a nonsignificant difference in proportionof staff with reduction in hand bacterial load, when compared withthe other 2 protocols (Fig 2) and was the least time-consuming.Protocol 1 appeared to have the largest proportion (82.5%; 95%confidence interval [CI]: 76.5%-88.5%) of staff with reduced bacte-rial load after hand hygiene compared with protocol 2 (75.0%; 95%CI: 68.2%-81.8%) and protocol 3 (75.0%; 95% CI: 68.2%-81.8%). Therewas no difference in protocol adherence (staff with bacterial loadreduction vs staff without reduction: odds ratio [OR], 0.98; 95% CI:0.29-3.27; P! .98) and patient contact time (staff with reduction vsstaff without reduction: median, 89.5 vs 73.2 seconds, respectively;P! .55) between staff who had a bacterial load reduction and thosewho had not.

Overall, hand hygiene resulted in a substantial reduction inbacterial load of 77.65 " 102 cfu/mL (P < .01) (Table 2). After handhygiene, medical staff had a larger bacterial load reduction(median, 24.5 " 102 cfu/mL) than nursing staff (6.0 " 102 cfu/mL)(P! .01). Protocol 1 had the largest reduction in hand bacterial load(median, 15.5 " 102 cfu/mL), followed by protocol 3 (12.0 " 102 cfu/mL) and protocol 2 (10.5 " 102 cfu/mL). Compared with protocol 1,protocol 2 (#5.17" 102 cfu/mL, P! .07) and protocol 3 (#5.06" 102

cfu/mL, P ! .08) resulted in slightly greater bacterial load reduc-tions, after adjusting for staff category. However, the differencesamong the protocols were nonsignificant. All staff had beencompliant with the assigned hand hygiene protocol. None of thestaff allocated to alcohol handrubbing protocols 1 and 2 had toswitch to chlorhexidine handwashing because of soiled hands.

During routine patient care, protocol 1 (median, 26.0 s) requiredless time than protocol 2 (median, 38.5 s; P ! .04) and protocol 3(median, 75.5 s; P< .001), respectively (Table 3). The Kruskal-Wallistest showed that there was a difference in time spent on handhygiene among the 3 protocols (P < .001). The Wilcoxon-Mann-Whitney tests confirmed further that there was significant differ-ence between protocol 1 and protocols 2 and 3 separately.

Coagulase-negative staphylococcus was the most commonorganism isolated among medical and nursing staff with hand

contamination (Fig 3). Hand hygiene reduced the proportion of staffwith coagulase-negative staphylococcus on their hands from 73.3%to 30.0% (P < .001). Post-hand hygiene, no bacteria could be isolatedfrom the hands of two-thirds (63.3%) of health care staff. In theremaining 44 staff that still carried bacteria, resident flora was iso-lated in the majority (91%) of them. In 4 staff, methicillin-resistantStaphylococcus aureus (MRSA) and Acinetobacter baumannii wereidentified. Hand hygiene reduced nosocomial gram-positive cocci(post-hand hygiene vs pre-hand hygiene, difference in proportion,0.14; 95% CI: 0.07-0.21) more than nosocomial gram-negative bacilli(difference in proportion, 0.07; 95% CI: 0.01-0.13).

MRSA was isolated in 8 staff members prior to hand hygiene.After hand hygiene, MRSA remained in only 1 staff member.Although MRSA was not completely removed from that nursingstaff member’s hand, hand hygiene had substantially reduced thebacterial load by 70%, from 2,100 cfu/mL to 600 cfu/mL.

Acinetobacter baumannii was present on the hands of 7 healthcare workers post-patient contact. After hand hygiene, it remainedin 3 staff members. However, substantial reductions in bacterialload were observed (staff A: 123,500 cfu/mL to 1,700 cfu/mL, staffB: 70,000 cfu/mL to 300 cfu/mL, staff C: 5,400 cfu/mL to 3,800 cfu/mL). Some of the bacterial load could have been contributed byresident flora, which were also observed in the post-hand hygienesamples from staff A and C.

Table 1Duration of patient care activities and bacterial counts on hands of health care workers pre-hand hygiene and post-hand hygiene

Duration of patientactivities (seconds)

Hand bacterial counts ("102 cfu/mL)

Pre-hand hygiene Post-hand hygiene

Median (range) Median (IQR) Mean (SD) Median (IQR) Mean (SD)

All staff (n ! 120) 88.4 (21.1-901.7) 19.0 (1.0-97.0) 90.6 (180.1) 0.0 (0.0-3.0) 11.3 (34.0)Medical staff (n ! 60) 79.1 (21.1-901.7) 37.5 (8.0-114.0) 103.1 (157.0) 0.0 (0.0-5.8) 20.2 (45.8)Nursing staff (n ! 60) 92.5 (23.8-536.7) 6.0 (0.0-68.0) 78.2 (201.2) 0.0 (0.0-1.0) 2.4 (8.8)

Cfu, colony-forming units; IQR, Interquartile range; SD, standard deviation.

Fig 2. Proportion (%) of staff with hand bacterial load reduction and time spent onhand hygiene (seconds), by hand-hygiene protocol. The bars represent the proportionof staff with bacterial load reduction and the line represents the median time spent onhand hygiene.

Table 2Analysis of reduction in bacterial load based on generalized estimating equationswith gamma-distribution, identity link and unstructuredworking correlationmatrix

Coefficient 95% CIP

value

OccasionPre-hand hygiene Reference - -Post-hand hygiene #77.65 #114.11-#41.18 <.01

Specific hand hygiene protocol*Protocol 1: Alcohol handrubbing

covering all surfaces inno particular order

Reference - -

Protocol 2: Alcohol handrubbing usingstandard 7-step technique

#5.17 #10.76-0.43 .07

Protocol 3: Chlorhexidine handwashingusing standard 7-step technique

#5.06 #10.66-0.54 .08

NOTE. Analysis of reduction in bacterial load: "102 colony-forming units/milliliter.*Adjusted for staff category.

Table 3Time spent in seconds on hand hygiene by protocol

Median (IQR) Mean (SD)

Protocol 1: Alcohol handrubbingcovering all surfaces inno particular order

26.0 (15.4-54.0) 33.4 (21.2)

Protocol 2: Alcohol handrubbingusing 7-step technique

38.5 (32.8-47.0) 40.3 (14.4)

Protocol 3: Chlorhexidine handwashingusing 7-step technique

75.5 (64.9-93.3) 80.3 (21.2)

IQR, interquartile range; SD, standard deviation.

A. Chow et al. / American Journal of Infection Control 40 (2012) 800-5 803

Résultats

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Protocol 1 resulted in a nonsignificant difference in proportionof staff with reduction in hand bacterial load, when compared withthe other 2 protocols (Fig 2) and was the least time-consuming.Protocol 1 appeared to have the largest proportion (82.5%; 95%confidence interval [CI]: 76.5%-88.5%) of staff with reduced bacte-rial load after hand hygiene compared with protocol 2 (75.0%; 95%CI: 68.2%-81.8%) and protocol 3 (75.0%; 95% CI: 68.2%-81.8%). Therewas no difference in protocol adherence (staff with bacterial loadreduction vs staff without reduction: odds ratio [OR], 0.98; 95% CI:0.29-3.27; P! .98) and patient contact time (staff with reduction vsstaff without reduction: median, 89.5 vs 73.2 seconds, respectively;P! .55) between staff who had a bacterial load reduction and thosewho had not.

Overall, hand hygiene resulted in a substantial reduction inbacterial load of 77.65 " 102 cfu/mL (P < .01) (Table 2). After handhygiene, medical staff had a larger bacterial load reduction(median, 24.5 " 102 cfu/mL) than nursing staff (6.0 " 102 cfu/mL)(P! .01). Protocol 1 had the largest reduction in hand bacterial load(median, 15.5 " 102 cfu/mL), followed by protocol 3 (12.0 " 102 cfu/mL) and protocol 2 (10.5 " 102 cfu/mL). Compared with protocol 1,protocol 2 (#5.17" 102 cfu/mL, P! .07) and protocol 3 (#5.06" 102

cfu/mL, P ! .08) resulted in slightly greater bacterial load reduc-tions, after adjusting for staff category. However, the differencesamong the protocols were nonsignificant. All staff had beencompliant with the assigned hand hygiene protocol. None of thestaff allocated to alcohol handrubbing protocols 1 and 2 had toswitch to chlorhexidine handwashing because of soiled hands.

During routine patient care, protocol 1 (median, 26.0 s) requiredless time than protocol 2 (median, 38.5 s; P ! .04) and protocol 3(median, 75.5 s; P< .001), respectively (Table 3). The Kruskal-Wallistest showed that there was a difference in time spent on handhygiene among the 3 protocols (P < .001). The Wilcoxon-Mann-Whitney tests confirmed further that there was significant differ-ence between protocol 1 and protocols 2 and 3 separately.

Coagulase-negative staphylococcus was the most commonorganism isolated among medical and nursing staff with hand

contamination (Fig 3). Hand hygiene reduced the proportion of staffwith coagulase-negative staphylococcus on their hands from 73.3%to 30.0% (P < .001). Post-hand hygiene, no bacteria could be isolatedfrom the hands of two-thirds (63.3%) of health care staff. In theremaining 44 staff that still carried bacteria, resident flora was iso-lated in the majority (91%) of them. In 4 staff, methicillin-resistantStaphylococcus aureus (MRSA) and Acinetobacter baumannii wereidentified. Hand hygiene reduced nosocomial gram-positive cocci(post-hand hygiene vs pre-hand hygiene, difference in proportion,0.14; 95% CI: 0.07-0.21) more than nosocomial gram-negative bacilli(difference in proportion, 0.07; 95% CI: 0.01-0.13).

MRSA was isolated in 8 staff members prior to hand hygiene.After hand hygiene, MRSA remained in only 1 staff member.Although MRSA was not completely removed from that nursingstaff member’s hand, hand hygiene had substantially reduced thebacterial load by 70%, from 2,100 cfu/mL to 600 cfu/mL.

Acinetobacter baumannii was present on the hands of 7 healthcare workers post-patient contact. After hand hygiene, it remainedin 3 staff members. However, substantial reductions in bacterialload were observed (staff A: 123,500 cfu/mL to 1,700 cfu/mL, staffB: 70,000 cfu/mL to 300 cfu/mL, staff C: 5,400 cfu/mL to 3,800 cfu/mL). Some of the bacterial load could have been contributed byresident flora, which were also observed in the post-hand hygienesamples from staff A and C.

Table 1Duration of patient care activities and bacterial counts on hands of health care workers pre-hand hygiene and post-hand hygiene

Duration of patientactivities (seconds)

Hand bacterial counts ("102 cfu/mL)

Pre-hand hygiene Post-hand hygiene

Median (range) Median (IQR) Mean (SD) Median (IQR) Mean (SD)

All staff (n ! 120) 88.4 (21.1-901.7) 19.0 (1.0-97.0) 90.6 (180.1) 0.0 (0.0-3.0) 11.3 (34.0)Medical staff (n ! 60) 79.1 (21.1-901.7) 37.5 (8.0-114.0) 103.1 (157.0) 0.0 (0.0-5.8) 20.2 (45.8)Nursing staff (n ! 60) 92.5 (23.8-536.7) 6.0 (0.0-68.0) 78.2 (201.2) 0.0 (0.0-1.0) 2.4 (8.8)

Cfu, colony-forming units; IQR, Interquartile range; SD, standard deviation.

Fig 2. Proportion (%) of staff with hand bacterial load reduction and time spent onhand hygiene (seconds), by hand-hygiene protocol. The bars represent the proportionof staff with bacterial load reduction and the line represents the median time spent onhand hygiene.

Table 2Analysis of reduction in bacterial load based on generalized estimating equationswith gamma-distribution, identity link and unstructuredworking correlationmatrix

Coefficient 95% CIP

value

OccasionPre-hand hygiene Reference - -Post-hand hygiene #77.65 #114.11-#41.18 <.01

Specific hand hygiene protocol*Protocol 1: Alcohol handrubbing

covering all surfaces inno particular order

Reference - -

Protocol 2: Alcohol handrubbing usingstandard 7-step technique

#5.17 #10.76-0.43 .07

Protocol 3: Chlorhexidine handwashingusing standard 7-step technique

#5.06 #10.66-0.54 .08

NOTE. Analysis of reduction in bacterial load: "102 colony-forming units/milliliter.*Adjusted for staff category.

Table 3Time spent in seconds on hand hygiene by protocol

Median (IQR) Mean (SD)

Protocol 1: Alcohol handrubbingcovering all surfaces inno particular order

26.0 (15.4-54.0) 33.4 (21.2)

Protocol 2: Alcohol handrubbingusing 7-step technique

38.5 (32.8-47.0) 40.3 (14.4)

Protocol 3: Chlorhexidine handwashingusing 7-step technique

75.5 (64.9-93.3) 80.3 (21.2)

IQR, interquartile range; SD, standard deviation.

A. Chow et al. / American Journal of Infection Control 40 (2012) 800-5 803

Résultats

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Protocol 1 resulted in a nonsignificant difference in proportionof staff with reduction in hand bacterial load, when compared withthe other 2 protocols (Fig 2) and was the least time-consuming.Protocol 1 appeared to have the largest proportion (82.5%; 95%confidence interval [CI]: 76.5%-88.5%) of staff with reduced bacte-rial load after hand hygiene compared with protocol 2 (75.0%; 95%CI: 68.2%-81.8%) and protocol 3 (75.0%; 95% CI: 68.2%-81.8%). Therewas no difference in protocol adherence (staff with bacterial loadreduction vs staff without reduction: odds ratio [OR], 0.98; 95% CI:0.29-3.27; P! .98) and patient contact time (staff with reduction vsstaff without reduction: median, 89.5 vs 73.2 seconds, respectively;P! .55) between staff who had a bacterial load reduction and thosewho had not.

Overall, hand hygiene resulted in a substantial reduction inbacterial load of 77.65 " 102 cfu/mL (P < .01) (Table 2). After handhygiene, medical staff had a larger bacterial load reduction(median, 24.5 " 102 cfu/mL) than nursing staff (6.0 " 102 cfu/mL)(P! .01). Protocol 1 had the largest reduction in hand bacterial load(median, 15.5 " 102 cfu/mL), followed by protocol 3 (12.0 " 102 cfu/mL) and protocol 2 (10.5 " 102 cfu/mL). Compared with protocol 1,protocol 2 (#5.17" 102 cfu/mL, P! .07) and protocol 3 (#5.06" 102

cfu/mL, P ! .08) resulted in slightly greater bacterial load reduc-tions, after adjusting for staff category. However, the differencesamong the protocols were nonsignificant. All staff had beencompliant with the assigned hand hygiene protocol. None of thestaff allocated to alcohol handrubbing protocols 1 and 2 had toswitch to chlorhexidine handwashing because of soiled hands.

During routine patient care, protocol 1 (median, 26.0 s) requiredless time than protocol 2 (median, 38.5 s; P ! .04) and protocol 3(median, 75.5 s; P< .001), respectively (Table 3). The Kruskal-Wallistest showed that there was a difference in time spent on handhygiene among the 3 protocols (P < .001). The Wilcoxon-Mann-Whitney tests confirmed further that there was significant differ-ence between protocol 1 and protocols 2 and 3 separately.

Coagulase-negative staphylococcus was the most commonorganism isolated among medical and nursing staff with hand

contamination (Fig 3). Hand hygiene reduced the proportion of staffwith coagulase-negative staphylococcus on their hands from 73.3%to 30.0% (P < .001). Post-hand hygiene, no bacteria could be isolatedfrom the hands of two-thirds (63.3%) of health care staff. In theremaining 44 staff that still carried bacteria, resident flora was iso-lated in the majority (91%) of them. In 4 staff, methicillin-resistantStaphylococcus aureus (MRSA) and Acinetobacter baumannii wereidentified. Hand hygiene reduced nosocomial gram-positive cocci(post-hand hygiene vs pre-hand hygiene, difference in proportion,0.14; 95% CI: 0.07-0.21) more than nosocomial gram-negative bacilli(difference in proportion, 0.07; 95% CI: 0.01-0.13).

MRSA was isolated in 8 staff members prior to hand hygiene.After hand hygiene, MRSA remained in only 1 staff member.Although MRSA was not completely removed from that nursingstaff member’s hand, hand hygiene had substantially reduced thebacterial load by 70%, from 2,100 cfu/mL to 600 cfu/mL.

Acinetobacter baumannii was present on the hands of 7 healthcare workers post-patient contact. After hand hygiene, it remainedin 3 staff members. However, substantial reductions in bacterialload were observed (staff A: 123,500 cfu/mL to 1,700 cfu/mL, staffB: 70,000 cfu/mL to 300 cfu/mL, staff C: 5,400 cfu/mL to 3,800 cfu/mL). Some of the bacterial load could have been contributed byresident flora, which were also observed in the post-hand hygienesamples from staff A and C.

Table 1Duration of patient care activities and bacterial counts on hands of health care workers pre-hand hygiene and post-hand hygiene

Duration of patientactivities (seconds)

Hand bacterial counts ("102 cfu/mL)

Pre-hand hygiene Post-hand hygiene

Median (range) Median (IQR) Mean (SD) Median (IQR) Mean (SD)

All staff (n ! 120) 88.4 (21.1-901.7) 19.0 (1.0-97.0) 90.6 (180.1) 0.0 (0.0-3.0) 11.3 (34.0)Medical staff (n ! 60) 79.1 (21.1-901.7) 37.5 (8.0-114.0) 103.1 (157.0) 0.0 (0.0-5.8) 20.2 (45.8)Nursing staff (n ! 60) 92.5 (23.8-536.7) 6.0 (0.0-68.0) 78.2 (201.2) 0.0 (0.0-1.0) 2.4 (8.8)

Cfu, colony-forming units; IQR, Interquartile range; SD, standard deviation.

Fig 2. Proportion (%) of staff with hand bacterial load reduction and time spent onhand hygiene (seconds), by hand-hygiene protocol. The bars represent the proportionof staff with bacterial load reduction and the line represents the median time spent onhand hygiene.

Table 2Analysis of reduction in bacterial load based on generalized estimating equationswith gamma-distribution, identity link and unstructuredworking correlationmatrix

Coefficient 95% CIP

value

OccasionPre-hand hygiene Reference - -Post-hand hygiene #77.65 #114.11-#41.18 <.01

Specific hand hygiene protocol*Protocol 1: Alcohol handrubbing

covering all surfaces inno particular order

Reference - -

Protocol 2: Alcohol handrubbing usingstandard 7-step technique

#5.17 #10.76-0.43 .07

Protocol 3: Chlorhexidine handwashingusing standard 7-step technique

#5.06 #10.66-0.54 .08

NOTE. Analysis of reduction in bacterial load: "102 colony-forming units/milliliter.*Adjusted for staff category.

Table 3Time spent in seconds on hand hygiene by protocol

Median (IQR) Mean (SD)

Protocol 1: Alcohol handrubbingcovering all surfaces inno particular order

26.0 (15.4-54.0) 33.4 (21.2)

Protocol 2: Alcohol handrubbingusing 7-step technique

38.5 (32.8-47.0) 40.3 (14.4)

Protocol 3: Chlorhexidine handwashingusing 7-step technique

75.5 (64.9-93.3) 80.3 (21.2)

IQR, interquartile range; SD, standard deviation.

A. Chow et al. / American Journal of Infection Control 40 (2012) 800-5 803

Résultats

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Résultats

• tous les participants ont respecté la

méthode qui leur a été assignée

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Résultats

DISCUSSION

Our study has shown that alcohol handrubbing covering allhand surfaces in no particular order was just as effective as alcoholhandrubbing using the 7-step technique and chlorhexidine hand-washing. Of note, alcohol handrubbing covering all hand surfaces inno particular order required significantly less time (median 26.0 s)than the other 2 protocols (alcohol handrubbing using 7-steptechnique: median, 38.5 s, P ! .04; chlorhexidine handwashing:median, 75.5 s, P < .001).

Although there is growing evidence from experimental studiesthat alcohol-based products are more effective than soap or anti-microbial soaps, there have been very few randomized trials donein clinical settings comparing the effectiveness of alcohol han-drubbing with antiseptic handwashing in health care workersduring routine inpatient care in patient care units. Girou et aldemonstrated the superior antimicrobial efficacy of alcohol han-drubbing compared with chlorhexidine handwashing duringroutine patient care in intensive care units in a French tertiary carehospital.12 The median percentage reduction in bacterial contami-nationwas significantly higher with alcohol handrubbing thanwithhandwashing (83% vs 58%, respectively, P ! .012). However, themedian duration of handwashing was only 30 seconds. In ourstudy, we observed similar reductions in hand bacterial load withalcohol handrubbing and chlorhexidine handwashing protocols.This could be due to the adequacy of time spent in handwashing byour study participants (median, 75.5 s); previous studies haveshown that 40 to 80 seconds of handwashing was required forbacterial clearance.21

In another published randomized clinical trial involving 4general wards and 3 intensive care units in a large Barcelonahospital, Zaragoza et al reported an average reduction in handbacterial load of 88.2% with alcohol handrub, compared with 49.6%with regular liquid soap. However, the time taken for hand hygienewas not measured.13

To our knowledge, there has been no published clinical trialcomparing the effectiveness of different alcohol handrubbingprotocols.4,14 Our study provides important information on thecomparative effectiveness of alcohol handrubbing using the 2protocols during everyday hospital practice. Although medical andnursing staff took significantly less time (median, 26.0 s) to complete

covering their hands with the alcohol handrubbing solution andrubbing till dry, as compared with alcohol handrubbing with the 7-step technique (median, 38.5 s), both groups had similar reductionsin hand bacterial load. Kampf et al had similarly demonstrated thatthe best hand coverage with alcohol handrubbing occurred whenhealth care workers were left to their own devices to ensurecomplete coverage of both hands (“responsible application”).16 Themedian time taken for “responsible application” by health careworkers in their study was 25.5 s, which is very similar to ourfindings. In general wards of large tertiary care hospitals, a fast andeffective hand hygiene protocol would improve hand hygienecompliance among time-strapped medical and nursing staff.

Furthermore, our study has provided data on the actual timespent on hand hygiene during routine patient care activities. Themedian time spent by health care workers on chlorhexidinehandwashing (all: 75.5 s, medical: 74.5 s, nursing: 79.7 s) was inreality close to the median time spent on a physical examination(79.1 s) by a medical staff during busy morning rounds. Hence, it isnot surprising that hand hygiene compliance among medical staffwas low (unpublished hospital data 2007: 50%). Alcohol handrub-bing covering all hand surfaces in no particular order (26.0 s) takesup just one-third of that time. Knowing that it is fast yet effectivewould encourage the practice of alcohol handrubbing amonghealth care staff.

Our study had several strengths. It was a randomizedcontrolled trial with a high participation rate. Almost all medicaland nursing staff (99%) approached during the study periodparticipated in the study. The high participation rate was likelydue to the reassurance given to staff that their identity would bestrictly protected and that only study numbers were included indata collection forms. There were no withdrawals from the study,although staff could contact the principal investigator if theywanted to withdraw from the study at any point in time. Althoughthe study team followed a planned schedule and moved system-atically from one ward to another, staff in the ward were notinformed prior to the arrival of the team. Hence, it was unlikelythat hand hygiene practices and patient care activities could havechanged during the study period. Furthermore, each ward wasvisited only once by the study team.

All staff adhered to the assigned hand hygiene protocol andfollowed the techniques closely. The study team merely observed

73

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Fig 3. Types of bacteria isolated from health care workers’ hands, prehand hygiene, and posthand hygiene.

A. Chow et al. / American Journal of Infection Control 40 (2012) 800-5804

• SCN retrouvé chez 73 % des soignants avant hygiène des mains et chez 30 % après, avec une différence significative (p < 0,001)

• aucun germe retrouvé sur les mains des soignants pour 63,3 % d’entre eux. Parmis les autres, il s’agissait de la flore résidente dans 91 % des cas

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Discussion : comparaison bibliographique

• une étude française* a montré l’efficacité supérieure de la SHA, mais avec une différence significative pour la réduction de la charge bactérienne des mains entre l’hygiène avec la SHA et celle avec le savon, en faveur de la SHA

• l’explication serait une durée trop courte de lavage des mains au savon dans l’étude française (30 s contre 75,5 s dans notre étude), ne permettant pas une hygiène suffisante des mains

* GirouE,LoyeauS,LegrandP,OppeinF,Brun-BuissonC.Efficacyofhandrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ 2002;325:362.

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• autre étude*, évaluant le temps nécessaire à une hygiène des mains avec de la SHA, sans contrainte particulière d’ordre ou d’étape

• résultat (médiane à 25,5 s) très proche de la médiane de notre étude (26 s)

* Kampf G, Reichel M, Feil Y, Eggerstedt S, Kaulfers PM. Influence of rub-in technique on required application time and hand coverage in hygienic hand disinfection. BMC Infect Dis 2008;8:149.

Discussion : comparaison bibliographique

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Discussion :limites de la méthodologie

• utilisation de la technique du liquide de gant pour les prélèvements bactériologiques

• sans étude de la surface enduite de SHA ou savon (pouce et extrémité des doigts connus pour être plus à risque de mauvaise hygiène)

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Discussion :limites des résultats

• certains soignants n’avait pas de diminution significative de la charge bactérienne des mains

• cependant, les germes restants étaient, pour la plupart des soignants, la flore résidente

• l’objectif de l’hygiène des mains pour les soins est d’éliminer la flore pathogène

• donc la persistance de la flore résidente ne parait pas être un problème majeur

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Discussion : généralisation

• résultats généralisables à tout service d’aigu de par le monde

• participants réprésentatifs de l’ensemble des soignants en général

• activité de soins comparable à la plupart des services d’aigu

• conditions réelles dans lesquelles l’étude a été menée (charge de travail, manque de temps...)

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Conclusion

• les 3 méthodes apparaissaient donc aussi efficaces pour diminuer la charge bactérienne des mains

• mais la méthode 1 (SHA sans étape ni ordre particulier) était la plus rapide

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Conclusion

• ces résultats poussent à poursuivre la promotion de l’utilisaiton de la SHA pour l’hygiène des mains, en utilisant la méthode du CDC (couverture de la totalité de la surface des 2 mains sans ordre particulier)

• cette technique permettrait, par le gain de temps et son efficacité, d’améliorer l’hygiène des mains et donc de diminuer le risque d’infection nosocomiale

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Bibliographie disponible sur le site des Internes de Santé Publique de Rouen