Skin Hygiene

Commonly Used Antiseptic Agents

Alcohol Iodophor Chlorhexidine Advantage Broad Spectrum; Superior reduction in bacterial counts; Rapid Onset Broad Spectrum Residual activity ~ 6 hrs Disadvantage Little residual activity; Water-based solutions can irritate skin Slow onset; Can irritate skin Narrow spectrum

In all, the following recommendations should be observed – use antiseptic solutions to clean hands (rather than plain soap and water) which are visibly soiled. Then use alcohol gels on hands which are not visibly soiled, as these gels have superior antiseptic properties and do not irritate the skin as much (assuming a non-water based gel is used). [CDC]

Protective Barriers

Antiseptic handwashing is necessary before and after gloved surgical procedures because the long term use of gloves promotes moisture and growth, which can be a problem following broken gloves. ICU procedures, on the other hand, are brief, and thus handwashing before and after gloving is likely unnecessary [Crit Care Med 23: 1211, 1995]

Surgical masks have never been proven effective at preventing transmission of infection [Clin Chest Med 18: 1, 1997]. For M.tuberculosis or other agents < 5 m in diameter (measles, varicella), the N95 respirator is recommended.

Contact Precautions

[J Am Geriatr Soc. 52: 2003, 2004] Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. [email protected] OBJECTIVES: To compare routine glove use by healthcare workers for all residents, without use of contact-isolation precautions, with contact-isolation precautions for the care of residents who had vancomycin-resistant enterococci or methicillin-resistant Staphylococcus aureus isolated from a clinical culture. DESIGN: Random allocation of two similar sections of the skilled-care unit to one of the infection-control strategies during an 18-month study period. SETTING: Skilled-care unit of a 667-bed acute- and long-term care facility. PARTICIPANTS: All residents present or admitted to the skilled-care unit from June 1, 1998, through December 7, 1999. MEASUREMENTS: Resident acquisition of four antimicrobial-resistant organisms (methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, or extended-spectrum beta-lactamase-producing Klebsiella pneumoniae or Escherichia coli). All isolates were strain typed. The facility level costs associated with each strategy were estimated. RESULTS: Resident acquisition of antimicrobial-resistant organisms was no different in the glove-use and isolation-precautions sections (31 episodes (1.5 per 1,000 resident-days) vs 38 episodes (1.6 per 1,000 resident-days)). Acquisition of either of two prevalent K. pneumoniae strains was more likely (P=.06) in residents in the isolation-precautions section. The estimated costs of contact-isolation precautions were 40% greater than those of routine glove use. CONCLUSION: There was a similar frequency of transmission of antimicrobial-resistant bacteria in the two study sections; there was evidence for resident-to-resident K. pneumoniae transmission in the isolation-precautions section. Routine glove use for healthcare workers, which decreases resident social isolation and healthcare facility costs, may be preferable in many long-term care facilities.

[Infect Control Hosp Epidemol 23: 424, 2002] Division of Infectious Diseases, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-5425, USA. BACKGROUND: Vancomycin-resistant enterococci (VRE) remain a significant nosocomial pathogen. Current guidelines of the Hospital Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) recommend the use of gowns and gloves for some interactions with VRE-infected or -colonized patients to prevent nosocomial transmission of VRE. OBJECTIVE: To assess the effect of disposable cover gowns on preventing nosocomial transmission of VRE. DESIGN AND SETTING: Prospective study in a 16-bed medical intensive care unit of a university teaching hospital. PATIENTS: All patients who were at risk to acquire VRE, were admitted to the intensive care unit from August 1998 to January 1999, and had at least two perirectal cultures were included in the analysis of VRE acquisition. INTERVENTION: VRE isolation precautions were changed from gowns and gloves to gloves alone. MAIN OUTCOME risk factors for VRE acquisition. RESULTS: The VRE acquisition rate was 1.80 cases per 100 days at risk in the gown and gloves period compared with 3.78 in the gloves only period (P = .04). In a proportional hazards model adjusted for length of stay, gloves only precautions with a hazard ratio of 2.5 (P = .02; 95% confidence interval, 1.2 to 5.3) were the only independent risk factor for VRE acquisition. CONCLUSION: Our data lend support to current HICPAC recommendations for the use of cover gowns to decrease nosocomial transmission of VRE.

[Am Surg 67: 1140, 2001] Burns and Allen Research Institute, Department of Surgery, Cedars-Sinai Medical Center and the UCLA School of Medicine, Los Angeles, California 90048, USA. Nosocomial pneumonia (NP) is the leading cause of death from hospital-acquired infection in intubated surgical intensive care unit (SICU) patients. To determine whether protective contact isolation would lower the incidence of NP in intubated patients we performed a prospective, randomized, and controlled study in two SICUs in a tertiary medical center. Over a period of 15 months two identical ten-bed SICUs alternated for 3-month periods between protective contact isolation (isolation group) and standard “universal precautions” (control group). In the isolation group all personnel and visitors donned disposable gowns and nonsterile gloves before entering an intubated patient’s room; handwashing was required before entry and on leaving the room. In the control group caregivers utilized only “standard precautions” including handwashing and nonsterile gloves for intubated patients. Respiratory cultures were obtained 48 hours after SICU admission and every 48 hours thereafter until extubation, transfer to floor care, or death. Airway colonization (AC) occurred in 72.7 per cent of isolated patients and 69.0 per cent of control patients (P = 0.61). The incidence of NP was significantly higher in the isolation group (36.4%) compared with the control group (19.5%) (P = 0.02). There was no statistically significant difference between groups in days from SICU admission to AC, days to NP, and mortality. We conclude that protective contact isolation with gowns, gloves, and handwashing is not superior to gloves and handwashing alone in the prevention of AC and NP in SICU patients and may in fact be detrimental.

[Crit Care Med 25:567, 1997] Randomized, controlled trial. Medical and surgical intensive care units in two university-affiliated teaching hospitals. 357 patients requiring mechanical ventilation, randomly assigned to receive either protocol-directed (n = 179) or physician-directed (n = 178) weaning from mechanical ventilation. Median duration of mechanical ventilation was 35 hrs for the protocol-directed group. Kaplan-Meier analysis demonstrated that patients randomized to protocol-directed weaning had significantly shorter durations of mechanical ventilation compared with patients randomized to physician-directed weaning (chi squared = 3.62, p = .057, log-rank test; chi squared = 5.12, p = .024, Wilcoxon test). Cox proportional-hazards regression analysis, adjusting for other covariates, showed that the rate of successful weaning was significantly greater for patients receiving protocol-directed weaning compared with patients receiving physician-directed weaning (risk ratio 1.31; 95% confidence interval 1.15 to 1.50; p = .039). The hospital mortality rates for the two treatment groups were similar (protocol-directed 22.3% vs. physician-directed 23.6%; p = .779). Hospital cost savings for patients in the protocol-directed group were $42,960 compared with hospital costs for patients in the physician-directed group.

[AIM 125: 448, 1996] Cook County Hospital, Chicago, Illinois, USA. OBJECTIVE: To determine the efficacy of the use of gloves and gowns compared with that of the use of gloves alone for the prevention of nosocomial transmission of vancomycin-resistant enterococci. DESIGN: Epidemiologic study and controlled, nonrandomized clinical trial. SETTING: University-affiliated, 900-bed, urban teaching hospital in which vancomycin-resistant enterococci are endemic. PATIENTS: 181 consecutive patients admitted to the medical intensive care unit for 48 hours or more. INTERVENTION: It was determined that all hospital employees would always use gloves and gowns when attending 8 particular beds in the medical intensive care unit and would always use gloves alone when attending 8 others. Compliance with precautions was monitored weekly. Rectal surveillance cultures were taken from patients daily. Cultures of environmental surfaces, such as those of bed rails, bedside tables, and other frequently touched objects in patient rooms and common areas, were taken monthly. Pulsed-field gel electrophoresis was used for molecular epidemiologic typing of vancomycin-resistant enterococci. MEASUREMENTS: The number of patients becoming colonized by vancomycin-resistant enterococci; the number of days to acquisition of vancomycin-resistant enterococci; and other measurements, including nosocomial infections, length of hospital stay, and mortality rates. RESULTS: The 93 patients in glove-and-gown rooms and the 88 patients in glove-only rooms had similar demographic and clinical characteristics. Fifteen (16.1%) patients in the glove-and-gown group and 13 (14.8%) in the glove-only group had vancomycin-resistant enterococci on admission to the medical intensive care unit. Twenty-four (25.8%) patients in the glove-and-gown group and 21 (23.9%) in the glove-only group acquired vancomycin-resistant enterococci in the medical intensive care unit. The mean times to colonization among the patients who became colonized were 8.0 days in the glove-and-gown group and 7.1 days in the glove-only group. None of these comparisons were statistically significant. Risk factors for acquisition of vancomycin-resistant enterococci induced length of stay in the medical intensive care unit, use of enteral feeding, and use of sucralfate. Compliance with precautions was 79% in glove-and-gown rooms and 62% in glove-only rooms (P < 0.001). Only 25 of 397 (6.3%) environmental cultures were positive for vancomycin-resistant enterococci. Nineteen types of vancomycin-resistant enterococci were documented by pulsed-field gel electrophoresis during the study period. CONCLUSIONS: Universal use of gloves and gowns was no better than universal use of gloves only in preventing rectal colonization by vancomycin-resistant enterococci in a medical intensive care unit of a hospital in which vancomycin-resistant enterococci are endemic. Because the use of gowns and gloves together may be associated with better compliance and may help prevent transmission of other infectious agents, this finding may not be applicable to outbreaks caused by single strains or hospitals in which the prevalence of vancomycin-resistant enterococci is low.