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Rutala_Cali-Col
William A. Rutala_Cali-Col
DISCLOSURES
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William A. Rutala_Cali-Col
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-borne Microorganisms
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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
A review of 34 published
studies of handwashing
adherence among healthcare
workers found that adherence
rates varied from 5% to 81%
Percent Adherence
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Non-antimicrobial
Antimicrobial
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Alcohol-Based Handrubs
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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)
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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
William A. Rutala_Cali-Col
Administrative Measures
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Immediate Feedback
https://www.youtube.com/watch?v=nSek2nVUUxM
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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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Preoperative Shower
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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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Scalp
Axilla
Abdomen
Forearm
Hands
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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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Chlorhexidine:
Preoperative Showers
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Chlorhexidine:
Preoperative Showers
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150
125
Group 2A
Morning (AM)
100
Group 3A
Both (AM and PM)
75
p <0.05
NS
P<0.001
50
25
Left
Elbow
Right
Elbow
Abdominal
Left
Knee
Right
Knee
Skin Sites
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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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Infected
Patient
Susceptible
Patient
Environment
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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.
William A. Rutala_Cali-Col
Source control
Skin disinfection
Infected
Patient
Susceptible
Patient
Environment
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Environmental
Cleaning
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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.
William A. Rutala_Cali-Col
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%
William A. Rutala_Cali-Col
Ref
Setting
Design
Effect
MICU
Quasiexperimental
MICU
Quasiexperimental
2 MICU wards
MICU
Quasiexperimental
6 ICUs in 4 hospitals
Quasiexperimental
Long-term acute
care hospital
Quasiexperimental
Decreased CLABSI
No change in ventilator associated pneumonia
2 ICUs
Quasiexperimental
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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Ref
Setting
Design
Effect
Trauma ICU
Quasiexperimental
SICU
Quasiexperimental
No decrease in CLABSI
10
Trauma center
SICU
Quasiexperimental
Decreased CLABSI
11
4 medical wards
Quasiexperimental
12
Hospital-wide
Quasiexperimental
13
Oncology
patients
Quasiexperimental
14,15
4 LTACHs
Stepped wedge
bundle
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.)
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Gram-positive organisms
Fungi
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Hand Hygiene
CHG showers prior to surgery
Perioperative skin antisepsis
Bathing
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THANK YOU!
www.disinfectionandsterilization.org
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