Japan Tsunami, 2011

Higienização das mãos: novas fronteiras Fernando Bellissimo Rodrigues

WHO Collaborating Centre on Patient Safety

Infection Control & Improving Practices

De novo???

Hand hygiene: a historical perspective

Trotula de Ruggiero, Medical School of Salerno, 12th century

J Matern Fetal Neonatal Med. 2015;28(14):1691-3.

Hand hygiene: a historical perspective

Oliver Wendell Holmes, 1809 - 1894

New England Quarterly Journal of Medicine and Surgery, 1843

Hand hygiene: a historical perspective

Ignaz Semmelweis, 1818 - 1865

Lancet 2011; 377:22-23

Hospital Geral de Viena

(1847)

Hand hygiene: a historical perspective

Hospital Geral de Viena (1847)

Hand hygiene: a historical perspective

N Engl J Med 2012; 366:1-7, January 5, 2012

Hand hygiene: a historical perspective

Hand Hygiene in the Infection Control Guidelines

Guidelines, year Infection(s) addressed Hand Hygiene

recommended? Level of

evidence

ATS/IDSA, 2005 SHEA/IDSA, 2008 Spanish Soc. of Intensive Care Medicine

Ventilator-associated pneumonia

Yes I Not ranked Moderate

SHEA/IDSA, 2008 Catheter-associated

urinary tract infection Yes A-III

CDC, 2011 SHEA/IDSA, 2014

Catheter-related blood stream infection

Yes IB II

SHEA/IDSA, 2014 Surgical site infections Yes II

Hand Hygiene in the Infection Control Bundles

First author, year Infection(s) addressed Hand Hygiene

included?

Tolentino, 2007 Zaydfudim, 2009 Righi, 2014 Al-Thaqafy, 2014 Azab, 2015 Talbot, 2015

Ventilator-associated pneumonia

Yes No Yes No Yes No

Rosenthal, 2012 Navoa, 2013 Leblebicioglu, 2013 Kanj, 2013 Davis, 2014

Catheter-associated urinary tract infection

Yes Yes Yes Yes Yes

Venkatram, 2010 Apisarnthanarak, 2010 Resende, 2011

Catheter-related blood stream infection

Yes Yes

Hand Hygiene in the Guidelines for controlling MDR pathogens

Guidelines, year Pathogen(s) addressed Hand Hygiene

recommended? Level of

evidence

SHEA, 2003 VRE Yes Not ranked

CDC, 2006 All MDR pathogens Yes IB

UK Hospital Infection Society, 2006 SHEA/IDSA, 2008

MRSA Yes 1b A-II

SHEA/IDSA, 2008 Clostridium difficile Yes A-II

CDC, 2012 Carbapenem-resistant

Enterobacteriaceae (CRE) Yes Not ranked

Prevalence of health-care associated infections in

high-income countries

Range: 3.6-12.0%

Range: 5.4-19.1%

Prevalence of health-care associated infections in

low- and middle-income countries

Risk of death comparisons

1

10

100

1.000

10.000

100.000

1 10 100 1.000 10.000 100.000 1.000.000 10.000.000

To

tal

live

s l

os

t p

er

ye

ar

Number of encounters for each fatality

REGULATED DANGEROUS (>1/1000)

ULTRA-SAFE (<1/100K)

Health

Care

Mountain

Climbing

Driving

Chemical

Manufacturing

Chartered

Flights

Scheduled

Airlines

European

Railroads

Nuclear

Power

Health-care associated infections:

clinical impact

Health-care associated infections:

clinical impact

Clin Inf Dis 2001; 33 (suppl. 2):S84-S93

Health-care associated infections:

clinical impact

Portilho online, 27.03.2014

“Uma paciente no Rio de Janeiro teve uma infecção

hospitalar e está com a barriga aberta”

19

Compliance with hand hygiene procedures

25 0

0

25

50

75

100

50 75 100

Opportunities for hand hygiene per hour of care

Com

plia

nce w

ith h

and

hygie

ne

(%

)

Pittet et al, Ann Intern Med 1999, 130:126

Time constraint is the main explanatory factor

Shifting to a new paradigm: from hand washing to hand rubbing with alcohol

Pittet et al, Lancet 2000; 356: 1307–12

70%

Duas décadas de promoção da higiene das mãos nos Hospitais Universitários de Genebra

0.0

20.0

40.0

60.0

0%

20%

40%

60%

80%

100%

44.6 l‰

HH compliance %

HH Campaign

The five moments

H1N1 National HH

campaign Swiss Noso

Hand rub solution consumption

l/‰ days of hospitalization

« Patient participation »

Countries committed to addressing HAI

Countries committed in 2005-2006

Countries planning to commit in 2006

Launch of the

Clean Care is Safer Care campaign WHO HeadQuarters, 13 October 2005

From modern health care settings

©

To settings with limited resources

©

Turmi, Ethiopia

Local clinic in Turmi, Ethiopia

The Hamlin Fistula Hospital in Addis

Bethesda Hospital

PLoS One 9(9): e105866.

Quantidade x Qualidade

Higiene das mãos:

Quando e Como

Avaliação da qualidade da higiene das mãos

através de marcadores indiretos

Volume de álcool?

Avaliação da qualidade da higiene das mãos

através de marcadores indiretos

Should Alcohol-Based Handrub Use Be Customized to

Health-care Workers’ Hand Size?

Should Alcohol-Based Handrub Use Be Customized to

Health-care Workers’ Hand Size?

• Objective: To evaluate the association between the volume of ABHR

taken by HCWs performing hand hygiene and the reduction of the

bacterial load in their hands, depending on their hands size.

• Design/setting: experimental, microbiological laboratory;

• Participants: 15 healthy HCWs with different hand sizes;

• Study protocol (EN 1500 standard):

Measurement of all health-care workers’ hand sizes;

Hand contamination with E. coli ATCC 10536;

Application of isopropanol 60%, from 0mL to 3mL, following the WHO

standard technique;

Fingertips culture.

Infect. Control Hosp. Epidemiol. 2016;37(2):219–221

Infect. Control Hosp. Epidemiol. 2016;37(2):219–221

Should Alcohol-Based Handrub Use Be Customized to

Health-care Workers’ Hand Size?

Infect. Control Hosp. Epidemiol. 2016;37(2):219–221

Should Alcohol-Based Handrub Use Be Customized to

Health-care Workers’ Hand Size?

• There is a direct association between the volume of alcohol-based

handrub taken by healthcare workers performing hand hygiene and the

reduction of the concentration of bacteria in their hands.

• The healthcare workers’ hand size significantly affects that

association.

• These results suggest the need of customizing the volume of alcohol-

based handrub used for hand hygiene, according to the size of the

healthcare workers' hands, for ensure appropriate hand antisepsis and

patient safety.

Infect. Control Hosp. Epidemiol. 2016;37(2):219–221

Should Alcohol-Based Handrub Use Be

Customized to Health-care Workers’ Hand Size?

Por quê pessoas com mãos grandes não conseguem descontaminar

suas mãos mesmo usando 3mL de solução alcóolica?

Revisiting the WHO “How to handrub” standard

technique

ECCMID 2016, Amsterdam, submitted.

WHO fingertips first technique

WHO “How to handrub”:

standard technique x fingertips first

• Objective: To evaluate whether modifying the sequence of the WHO “How to

handrub” standard technique to clean the fingertips first would lead to a

greater bacterial load reduction in hands;

• Design/setting: experimental, microbiological laboratory;

• Participants: 15 healthy HCWs with different hand sizes;

• Study protocol (EN 1500 standard):

Hand contamination with E. coli ATCC 10536;

Application of 3mL of isopropanol 60%, for 30 seconds, on a random order,

once using the WHO standard technique and once using the WHO fingertips-

first technique;

Fingertips culture.

ECCMID 2016, Amsterdam, submitted.

Presented as an oral session at the ECCMID 2016 In press in the Infection Control and Hospital Epidemiology

WHO “How to handrub”:

standard technique x fingertips first

ECCMID 2016, Amsterdam, submitted.

Baseline

(n=16)

Standard technique

(n=16)

Fingertips first

(n=16) P-value

Globally (log10) 6.2 (±0.9) 3.5 (±1.4) 2.7 (±1.3) <0.001a

By hand size

Small (log10) 5.3 (±0.8) 1.9 (±1.3) 1.3 (±1.1) <0.001b

Medium (log10) 6.2 (±0.8) 3.6 (±1.0) 3.1 (±1.2) <0.001b

Large (log10) 6.7 (±0.4) 4.4 (±1.1) 3.3 (±0.8) 0.001b

aFrom a mixed linear model with a random effect on the intercept; bFrom a mixed linear model with a random effect on the intercept and an interaction between the sequence and category of hand size.

0.6

0.5

1.1

Presented as an oral session at the ECCMID 2016 In press in the Infection Control and Hospital Epidemiology

WHO “How to handrub”:

standard technique x fingertips first

In conclusion, WHO fingertips-first technique proved to be significantly more

efficient in cleaning hands than the WHO standard technique.

ECCMID 2016, Amsterdam, submitted.

Presented as an oral session at the ECCMID 2016 In press in the Infection Control and Hospital Epidemiology

What about the duration of handrubbing?

Duration of handrubbing

ECCMID 2016, Amsterdam, submitted.

• Objective: To evaluate the association between the duration of handrubbing by

HCWs and the reduction of the bacterial load in their hands;

• Design/setting: experimental, microbiological laboratory;

• Participants: 15 healthy HCWs with different hand sizes;

• Study protocol (EN 1500 standard):

Hand contamination with E. coli ATCC 10536;

Application of 3mL of isopropanol 60% following the WHO standard

technique, each one with a different duration of handrubbing, from 10 to 60

seconds;

Fingertips culture.

Presented as an oral session at the ECCMID 2016

Duration of handrubbing

ECCMID 2016, Amsterdam, submitted.

0

.5

1

1.5

2

2.5

3

3.5

4

4.5

5

5.5

6

6.5

7

7.5

8

Ba

cte

ria

l cou

nt m

easu

red

(lo

g10

UF

C)

Baseline 10sec 15sec 20sec 30sec 45sec 60sec

Duration of hand hygiene

Presented as an oral session at the ECCMID 2016

But after all, what is the minimum bacterial reduction to be

accomplished with the hand hygiene procedure to avoid

bacterial transmission?

The transmission study

Presented as an oral session in the ASM - Microbe 2016

The transmission study

• Objective: To evaluate what is the minimum bacterial load in hands to efficiently

accomplish cross transmission skin-to-skin;

• Design/setting: experimental, microbiological laboratory;

• Participants: 6 healthy HCWs with different hand sizes (2 in each category of

small, medium and large);

• Study protocol:

Hand contamination with E. coli ATCC 10536, in growing concentrations;

Hand holding with another HCW whose hands are clean, for 1 minute;

Fingertips culture of both.

Presented as an oral session in the ASM - Microbe 2016

The transmission study

Presented as an oral session in the ASM - Microbe 2016

The transmission study

Presented as an oral session in the ASM - Microbe 2016

The transmission study

• The idea was to evaluate what was the minimum bacterial load in

hands to accomplish cross-transmission skin-to-skin (1 log10);

• Then to compare that number with the average contamination

burden on HCWs hands in clinical practice (± 1-3 log10);

• Then, realize what is the minimum bacterial reduction (2 log10) to be

accomplished with the hand hygiene procedure to avoid bacterial

transmission (“microbiological concept of safe hands”).

• Then, suggest the revision of the norms EN 1500 and ASTM E2755-10.

Presented as an oral session in the ASM - Microbe 2016

Impact of using a device providing individual feedback on health-care

workers hand hygiene behavior: a cluster-randomized clinical trial

On going study, funded by the Swiss National Research Foundation

Impact of using a device providing individual feedback on health-care

workers hand hygiene behavior: a cluster-randomized clinical trial

On going study, funded by the Swiss National Research Foundation

It could be you in this bed...

...so, give the patients the same care you would like to have, perform hand hygiene before touching them!

Em síntese...

• A higienização das mãos ainda é a medida mais simples, segura e efetiva para

a prevenção de todas as infecções hospitalares;

• Enquanto a adesão à higienização das mãos têm aumentado, a qualidade do

gesto ainda têm muito a melhorar;

• Para uma adequada descontaminação de suas mãos:

Use 2-4 mL de solução alcóolica de acordo com o tamanho da sua mão

Friccione todas as partes de suas mãos, mas, sobretudo, não se esqueça das

pontas dos dedos

Friccione suas mãos por pelo menos 15 segundos

Em cada um dos 5 momentos, como você gostaria que fosse feito com você!

Proteja seus pacientes como a quem você quer bem... Use álcool gel antes de tocá-los!