1. Is handwashing so effective? Prof Bertrand SOUWEINE Medical ICU Clermont-Ferrand FRANCE ISICEM March 2009

2. The technique used for hand cleansing before patient care affected the amount of bacterial contamination Handwashing with plain soap Handwashing with antiseptic detergent Alcohol-based handrub (ABH)

3. Handwashing compliance rates are poor (40%) Nurses: 30-40% Physicians: 10-20% Others: 10-20%

4. Reasons Advocated for Poor Handwashing Compliance Skin irritation from hand hygiene products Inaccessibility of hand hygiene supplies Wearing gloves Hands don’t look dirty Lack of information on the importance of hand hygiene Lack of knowledge of the guidelines Too busy/handwashing takes too long Male vs female Physician vs nurse Wearing gloves Working in ICU Understaffing/overcrowding Risk factors for Poor Handwashing Compliance

5. The time needed for hand hygiene before and after every contact is about 100 min/patient for direct contacts

7. Handwashing with plain soap Alcohol-based handrub Before After Handwashing with antiseptic detergent

10. Before / after study Single centre No period randomization Overt observations Differences in the type of opportunities recorded Hawthorne effect Handwashing still performed during the ABH period Multifaceted programme on hand hygiene practice Several Limitations in Hand Hygiene Compliance Studies

12. Epidermal water content Self-reported skin score Dry Healthy Dry Healthy Effect of Alcohol Handrub on Skin Condition Alcohol-based handrub is less damaging to the skin Boyce, Infection Control and Hospital Epidemiology 2000;21:438-41.

13. Larson EL CCM 2001

15. ABH introduction

16. baseline Education programme ABH

17. Infection due to MRSA: from 1.67 to 2.77 per 1.000 patient-days Infections due to VRE from 0.35 to 1.36 per 1.000 patient-days

18. Is mproving hand hygiene compliance with ABH gel effective in decreasing NI rates?

19. Cannot detect a change is not absence of change Was a training programme carried out? Very low baseline rates of nosocomial infection Even if improvements in hand hygiene compliance were able to decrease NI rates by 50%, this study would have only a 20% chance of demonstrating the effect Absence of surveillance cultures to detect MRSA/VRE colonization No data on the rates of MRSA/VRE importation

20. 6 urban sites

22. ABH is effective in decreasing NI rates The causal role of microorganisms on hands in the pathogenesis of NI is extremely well established Traditional soap-and-water hand hygiene is less effective than hand antisepsis Handwashing as frequent as recommended is often impractical and leads to inflammatory skin reactions

23. ABH is the simplest and less expensive way of achieving good hand hygiene practice and so of preventing health care associated infections and the spread of antimicrobial resistance Multifaceted campaign with education programme, meetings, introduction of ABH, training in application of ABH, reminders, monitoring of compliance, monitoring of NI rate, and surveillance feedback are required to promote hand hygiene and reduce cross transmission in ICUs ABH is effective in decreasing NI rates