RUTALA HandHygCHGColumbia16

William A.
Rutala_Cali-Col
Hand Hygiene and Chlorhexidine

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

Clorox
Honoraria
3M
Grants
CDC, CMS
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Hand Hygiene recommendations and role in prevention

of HAIs
Chlorhexidine gluconate-role in prevention of HAIs
Hand hygiene
CHG showers prior to surgery
Perioperative skin antisepsis
Bathing
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Hand Hygiene
Hand Hygiene-a general term that applies to either
handwashing, antiseptic handwash, antiseptic handrub, or
surgical hand antisepsis
Main Results: alcohol-based handrubs reduce bacterial
bacterial counts on hands more effectively than plain
soaps, and in a majority of studies more effectively than
antimicrobial soaps.
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Hand Hygiene and Nosocomial Infections

Healthcare-associated infections (HAIs)-2 million cases
per year (U.S.); 80,000 deaths per year
$5-10 billion per year (U.S.)
Fraction of HAIs that are preventable with changes in
hand hygiene practices not known
38% due to cross-transmission

Increase in HW, reduction in HAIs
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Evidence of Transmission of Pathogens

on Hands
Transmission from patient-to-patient via HCW hands

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

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

(Lautenbach E, Woeltje KF, Malani PN, eds), 3rd ed, 2010.
Hand-borne Microorganisms
Presence bacterial counts on hands range from 104 to

106
resident microorganisms-attached to deeper layers of the skin

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

IN HEALTHCARE FACILITIES?
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90
80
70
60
50
40
30
20
10
0
Study
34
31
28
25
22
19
16
13
10
Average
The average adherence rate

was only 40%
Average Handwashing Adherence

of Personnel in 34 Studies
A review of 34 published
studies of handwashing
adherence among healthcare
workers found that adherence
rates varied from 5% to 81%
Percent Adherence
Hand Hygiene Practices in Healthcare
Hand hygiene has been reported to average 40% (34

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

Provide personnel with efficacious hand hygiene products
that have low irritancy potential. IB
To maximize acceptance, solicit input from HCW
regarding feel, fragrance, and skin tolerance. IB
Prior to purchasing, evaluate dispenser systems to ensure
function and delivery of appropriate volume. II
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Hand Hygiene Agents
Non-antimicrobial
Antimicrobial
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Chlorhexidine gluconate (CHG)

Triclosan
Quaternary Ammonium Compounds (QAC)
Parachlorometaxylenol (PCMX)
Alcohols (ethyl, isopropanol, n-propanol)
Iodine and Iodophors
Alcohol-Based Handrubs
Minimize factors adversely affecting adherence to hand hygiene

protocols
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Reduce bacterial counts more effectively than washing hands with

nonantimicrobial and antimicrobial soaps
Can be made much more accessible
Require less time to use
Produce less skin irritation and dryness
Improved adherence to hand hygiene policies and reduce NI rates
Studies Comparing Relative Efficacy of Plain Soap or

Antimicrobial Soap vs Alcohol-Based Antiseptics in
Reducing Counts on Hands
Alcohol more effective than plain soap (17 studies)

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

Apply alcohol-based handrub to one hand and rub hands
together, covering all surfaces. Follow manufacturers
recommendation on volume. IB
Soap and water-wet hands, apply amount of product
recommended, rub hands together for 15 sec, covering all
surfaces. Rinse with water and dry with disposable towel.
IB
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RATIONALE FOR HAND HYGIENE
Many infectious agents are acquired via hand contact with

contaminated surfaces
Contact transmission: healthcare (MRSA, VRE), day care (MRSA), home (MRSA,
cold viruses, herpes simplex)
Fecal-oral transmission: day care (Shigella, E. coli O157:H7), home (Salmonella,
E. coli O157:H7, Cryptosporidium)
Hand hygiene effective in reducing or eliminating transient flora

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

COMPLIANCE AND HAI RATES
Author, year
Casewell, 1977
Maki, 1982
Massanari, 1984
Kohen, 1990
Doebbeling, 1992
Webster, 1994
Zafar, 1995
Larson, 2000
Pittet, 2000
Setting
Adult ICU
Adult ICU
Adult ICU
Adult ICU
Adult ICU
NICU
Newborn
MICU/NICU
Hospitalwide
Results
Reduction HAI due to Klebsiella
Reduction HAI rates
Reduction HAI rates
Trend to improvement
Different rates of HAI between 2 agents
Elimination of MRSA*
Elimination of MRSA*
85% reduction VRE
Reduction HAI & MRSA cross-transmission
HAI, healthcare-associated infections

*Other infection control measures also instituted
Boyce JM, Pitter D. MMWR 2002;51(RR-16)
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Administrative Measures
Make improved hand hygiene adherence an institutional priority

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

Programs
Educate staff regarding the types of patient care activities

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

Via a Novel All Hands on Deck Approach for Hand
Hygiene Compliance
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Simplify the Message:

Clean In, Clean Out
Diller T, AJIC 2014 June
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Expand the Pool of Observers
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Immediate Feedback
https://www.youtube.com/watch?v=nSek2nVUUxM
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FY15 Success of Clean In, Clean Out

99,151 observations of Clean In, Clean Out by 3703 unique
observers with compliance >90%
42,327 times hand hygiene feedback provided

Per month: 3300 inpatient, 1200 outpatient/procedural, 250 OR
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HAI Reductions and Associations with Hand Hygiene

Sickbert-Bennett, DiBiase, Weber, Rutala. 2015
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Over 17 months, we noted a significantly increased overall hand hygiene

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

Unique observers were predictor of hand hygiene within job class
(p=0.0096).
Each additional 10 observers was associated with an increase of 0.1

percentage points of hand hygiene compliance within that job class.
Feedback provided was predictor of hand hygiene within a job class

(p=0.0035).
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Each increase in percent feedback of ten percentage points was associated

with an increase in hand hygiene compliance of 0.21 percentage points within
that job class.
Chlorhexidine Gluconate Used to Prevent HAIs

Hand Hygiene
Preoperative showers
Surgical site preparation
Patient bathing
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Chlorhexidine
Cationic biguanide that alters membrane integrity
Broad-spectrum activity against gram-positive and gramnegative bacteria, yeasts, and some lipid-enveloped
viruses
Persistent activity on skin
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Milstone AM, et al. Chlorhexidine: Expanding the armamentarium for

infection control and prevention. Clin Infect Dis 2008;46:274-81
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Preoperative Shower
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SSI: Primary Risk Factors
Endogenous microorganisms
Skin-dwelling microorganisms
Most common source
S aureus most common isolate
Fecal flora (gnr) when incisions are near the perineum or groin
Exogenous microorganisms
Surgical personnel (members of surgical team)
OR environment (including air)
All tools, instruments, and materials
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Microbial Ecology of Skin Surface
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Scalp
6.0 Log10 cfu/cm2
Axilla
5.5 Log10 cfu/cm2
Abdomen
4.3 Log10 cfu/cm2
Forearm
4.0 Log10 cfu/cm2
Hands
4.0-6.6 Log10 cfu/cm2
Perineum 7.0-11.0 Log10 cfu/cm2
Surgical Microbiology Research Laboratory 2008 Medical College of Wisconsin
SSI: PATHOGENESIS
Risk of surgical site infections =
Microbial load x Virulence x Tissue injury x Foreign material x Antibiotic resistance
____________________________________________________________
Host resistance x Perioperative antibiotics
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SSI: Preoperative Issues

Modifiable Risks
Glucose control-in diabetic patients
Preoperative CHG shower

Appropriate hair removal
Hand hygiene
Skin antisepsis
Antimicrobial prophylaxis
Normothermia-hypo higher risks
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Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

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

showering with antiseptic1
CHG more effective than PI and
triclocarban
Lower rates of intraoperative wound
contamination
1. Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

2. Garibaldi RA. J Hosp Infect. 1988;11(suppl B):5-9.
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Chlorhexidine:
Preoperative Showers
Patients who had 2 preoperative

showers with CHG 24 hours before
surgery had reduced rates of wound
infection compared to patients who
showered with soap.
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Hayek LJ, et al. J Hosp Infect. 1987;10(2):165-172.
4% Chlorhexidine Gluconate (CHG) Shower Mean Skin Surface Concentration (N=60)

CHG Shower
Group 1A
Evening (PM)
150
CHG Concentration (PPM)
125
Group 2A
Morning (AM)
100
Group 3A
Both (AM and PM)
75
p <0.05
NS
P<0.001
50
25
MIC90 = 4.8 ppm
Left
Elbow
Right
Elbow
Abdominal
Left
Knee
Right
Knee
Skin Sites
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Edmiston et al, J Am Coll Surg 2008;207:233-239
Perioperative Skin Antisepsis
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Surgical Site Preparation

N = 849 surgical patients: 409 Alc-CHG vs 440 PI (ITT)
1:1 randomization
Patients monitored for 30 days post-op
Overall rate of SSI was significantly reduced in Alc-CHG vs PI groups:
9.5% vs 16.1%, p=0.004
Significant difference for both superficial incisional site rate: 4.2% A-CHG
vs 8.6% PI (p=0.008) and deep incisional: 1% A-CHG vs 3% PI (p=0.05)
No significant adverse events noted during the study in either group
Alc-CHG superior to PI in reducing the risk of SSI in clean-contaminated
procedures
Darouiche RO, et al. New England Journal of Medicine 2010;362:18-26
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Chlorhexidine Baths
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Impact of Chlorhexidine-Impregnated
Cloths/Baths in Preventing Infections and
Reducing Environmental Contamination and
Skin Burden: A Review of the Literature
Curtis Donskey, M.D.
Louis Stokes VA Medical Center
Cleveland, Ohio
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Objective
To review the evidence that daily bathing with chlorhexidine is
effective in reducing colonization and infection with
healthcare-associated infections
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Transmission of Healthcare-Associated Pathogens
Infected
Patient
Susceptible
Patient
Environment
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Contamination of Hands with MRSA

Skin contact
Environmental contact
Donskey CJ, Eckstein B. The hands give it away. NEJM 2009;360:e3; Stiefel U, et al. Contamination of hands
with methicillin-resistant Staphylococcus aureus after contact with environmental surfaces versus skin of
CIDEIMcolonized patients. Infect Control Hosp Epidemiol 2011;32:185-7.
Source control
Skin disinfection
Infected
Patient
Susceptible
Patient
Environment
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Environmental
Cleaning
Daily Bathing with Chlorhexidine Cloths

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

Contamination and Acquisition
Decreased hand
contamination
-56% vs 37% in VRE rooms
-16% vs 8% in common areas
Decreased skin
contamination
-47% vs 94%
-2.5 log reduction
on inguinal skin
Decreased VRE
acquisition
20% vs 8%
Decreased environmental
contamination
34% vs 11%
Vernon MO. CHG to cleanse patients in a medical ICU: Effectiveness of source

CIDEIM control to reduce the bioburden of VRE. Arch Int Med 2006;166:306-12
Impact of Daily Bathing with Chlorhexidine on

Colonization and Infection with Pathogens
Ref
Setting
Design
Effect
MICU
Quasiexperimental
Decreased VRE on patients skin, healthcare workers

hands, and environment
Reduced acquisition of VRE colonization
MICU
Quasiexperimental
Decreased Acinetobacter baumannii skin colonization and

bloodstream infections
2 MICU wards
2 arm crossover trial
Decreased primary BSI
MICU
Quasiexperimental
Decreased CLABSI and blood culture contamination
6 ICUs in 4 hospitals
Quasiexperimental
Decreased acquisition of MRSA and VRE

Decreased VRE bacteremia
Long-term acute
care hospital
Quasiexperimental
Decreased CLABSI
No change in ventilator associated pneumonia
2 ICUs
Quasiexperimental
Decreased acquisition of MRSA (non-qacA/B strains)
1. Vernon MO. Arch Int Med 2006;166:306-12; 2. Borer A. J Hosp Infect 2007;67:149-55;
3. Bleasdale SC. Arch Intern Med 2007;167:2073-9; 4. Popovich KJ. ICHE 2009;30:2959-63; 5. Climo MW. Crit Care Med
2009;37:1858-65; 6. Munoz-Price LS. ICHE 2009;30:1031-5; 7. Batra R. Clin Infect Dis 2010;50:210-2.
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Impact of Daily Bathing with Chlorhexidine on

Colonization and Infection with Pathogens
Ref
Setting
Design
Effect
Trauma ICU
Quasiexperimental
Decreased MRSA and Acinetobacter colonization

Decreased CLABSI
SICU
Quasiexperimental
No decrease in CLABSI
10
Trauma center
SICU
Quasiexperimental
Decreased CLABSI
11
4 medical wards
Quasiexperimental
Decreased MRSA & VRE infections

No change in C. difficile infection rate
12
Hospital-wide
Quasiexperimental
Decreased C. difficile infection

No change in other hospital-associated infections
13
Oncology
patients
Quasiexperimental
Decreased acquisition of VRE colonization
14,15
4 LTACHs
Stepped wedge
bundle
Decreased KPC colonization and infection, all-cause

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

Bathing in the ICU
Multicenter, cluster-randomized, nonblinded crossover trial

9 ICUs and bone marrow transplant units in 6 hospitals
Chlorhexidine 2% cloths or nonantimicrobial washcloths for
6 months followed by 6 months with the alternative product
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Climo MW. NEJM 2013;368:533-42
Randomized Trial of Daily Chlorhexidine

Bathing in the ICU
Decreased MDRO (VRE and MRSA) acquisition (23%

reduction)
Decreased hospital-acquired BSI (28% reduction)
Decreased CLABSI
Gram-positive organisms
Fungi
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Climo MW. NEJM 2013;368:533-42

Hand Hygiene recommendations and role in prevention

of HAIs
Chlorhexidine gluconate-role in prevention of HAIs
Hand Hygiene
CHG showers prior to surgery
Perioperative skin antisepsis
Bathing
CIDEIM

Improved hand hygiene reduces HAIs

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

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William A.

Hand Hygiene and Chlorhexidine

Consultation and Honoraria

Hand Hygiene and Chlorhexidine

Hand Hygiene recommendations and role in prevention

Hand Hygiene and Nosocomial Infections

38% due to cross-transmission

Evidence of Transmission of Pathogens

Transmission from patient-to-patient via HCW hands

TRANSMISSION MECHANISMS INVOLVING

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

Presence bacterial counts on hands range from 104 to

resident microorganisms-attached to deeper layers of the skin

WHAT IS OUR TRACK RECORD ON HANDWASHING

The average adherence rate

Average Handwashing Adherence

Hand Hygiene Practices in Healthcare

Hand hygiene has been reported to average 40% (34

Selection of Hand Hygiene Agents

Hand Hygiene Agents

Chlorhexidine gluconate (CHG)

Minimize factors adversely affecting adherence to hand hygiene

Reduce bacterial counts more effectively than washing hands with

Studies Comparing Relative Efficacy of Plain Soap or

Alcohol more effective than plain soap (17 studies)

Hand Hygiene Technique

RATIONALE FOR HAND HYGIENE

Many infectious agents are acquired via hand contact with

Hand hygiene effective in reducing or eliminating transient flora

ASSOCIATION BETWEEN HAND HYGIENE

HAI, healthcare-associated infections

Make improved hand hygiene adherence an institutional priority

HCW Educational and Motivational

Educate staff regarding the types of patient care activities

Reducing Healthcare-Associated Infections

Simplify the Message:

Diller T, AJIC 2014 June

Expand the Pool of Observers

FY15 Success of Clean In, Clean Out

42,327 times hand hygiene feedback provided

HAI Reductions and Associations with Hand Hygiene

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

Success of All Hands On Deck Approach

Each additional 10 observers was associated with an increase of 0.1

Feedback provided was predictor of hand hygiene within a job class

Each increase in percent feedback of ten percentage points was associated

Chlorhexidine Gluconate Used to Prevent HAIs

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

SSI: Primary Risk Factors

Microbial Ecology of Skin Surface

6.0 Log10 cfu/cm2

5.5 Log10 cfu/cm2

4.3 Log10 cfu/cm2

4.0 Log10 cfu/cm2

4.0-6.6 Log10 cfu/cm2

Perineum 7.0-11.0 Log10 cfu/cm2

Surgical Microbiology Research Laboratory 2008 Medical College of Wisconsin

SSI: Preoperative Issues

Glucose control-in diabetic patients

Preoperative CHG shower

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

CDC recommends preoperative

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