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Est-ce que la désinfection des mains est un outil efficace pour prévenir les transmissions croisées ? Bertrand Souweine.

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Présentation au sujet: "Est-ce que la désinfection des mains est un outil efficace pour prévenir les transmissions croisées ? Bertrand Souweine."— Transcription de la présentation:

1 Est-ce que la désinfection des mains est un outil efficace pour prévenir les transmissions croisées ? Bertrand Souweine

2 1.Flore cutanée et contamination 2.Lavage des mains 3.Frictions alcoolique Efficacité microbiologique Aspects pratiques Efficacité clinique 4.Conclusion Plan

3 1.Flore cutanée et contamination 2.Lavage des mains 3.Frictions alcoolique Efficacité microbiologique Aspects pratiques Efficacité clinique 4.Conclusion Plan

4 Types of Skin Flora Transient flora Resident flora Infectious flora

5 Epiderme superficiel : stratum corneum effet protecteur contre flore contaminante squammes lipides H 2 0 assure plasticité, perméabilité // hydratation Une couche produite / 24 heures et qui disparaît en 15 jours ufc/cm 2, enchâssés en profondeur 10 7 particules libérées / j dans air dont 10% contiennent des germes

6 Resident Flora Deeper skin layers Mainly CNS, coryneform bacteria and micrococci ; fungi (Malassezia); virus usually not resident on the skin More resistant to mechanical removal and stable over time Lower pathogenic potential (not pathogens on intact skin) Colonization resistance Very difficult to eliminate (< 50% decrease in bacteril load after 6 min of handwashing)

7 Transient Flora Superficial layers; usually not multiply on the skin Acquired by contact with patient or environment Easily removed by mechanical means S. aureus, GNB or candida or virus

8 Infectious Flora The etiologic agents of actual infections such as abscess, panaritium, paronychia, and infected eczema on the hands S. aureus and β-hemolytic streptococci

9 You may not Realize You Have Germs on Your Hands! Nurses, doctors and other healthcare workers can contaminate their hands by doing simple tasks, including: –Taking a patients blood pressure or pulse –Assisting patients with mobility –Touching the patients gown or bed sheets –Touching equipment, including bedside rails, over bed tables, IV pumps

10 Acquisition de la flore transitoire ou contaminante temps de soin dépendante Pittet Arch Intern Med 1999 Durée de contact : 16 cfu /mn Port de gants : 3 cfu /mn

11 Pittet Arch Intern Med 1999 Acquisition de la flore transitoire ou contaminante même après simple contact patient Type dactivité : cfu /mn

12 Clin Microbiol Rev. 2004;17(4):863

13 Transmission of organisms Transmission of organisms by hands of health care providers between two patients can result in health care associated infections (HAIs). Adapted from the Swiss Hand Hygiene Campaign

14 Clin Microbiol Rev. 2004;17(4):863

15 CDC Guideline for HH in healthcare settings Hygiène des mains et contrôle de linfection

16 1.Flore cutanée et contamination 2.Lavage des mains 3.Frictions alcoolique Efficacité microbiologique Aspects pratiques Efficacité clinique 4.Conclusion Plan

17 CID 2000;31:136

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19 Soap Plain –Esterified fatty acids with sodium or potassium hydroxide –Mechanical removal of dirt and loosely adherent flora (transient>resident) Antiseptic

20 Chlorhexidine A cationic biguanide England in 1954; introduced into U.S. in 1970s Chlorhexidine base only minimally soluble in water, but digluconate is water-soluble Exists as acetate (diacetate), gluconate, and hydrochloride salts

21 Mechanism of Action Attach to bacterial cytoplasmic membrane (inner membrane) –Precipitation or coagulation of protein and nucleic acids –Also to the outer membrane in G(-) and the cell wall in G(+) Also damage the cytoplasmic membrane of yeasts

22 Spectrum of Activity Depends on concentration –lower: bacteriostatic against GP bacteria, GNB and bacterial spores Bacteria –Good activity against G(+), less G(-) and fungi, not spores Dermatophytes: no activity Mycobacteria: limited Virus: good for most enveloped virus, low for naked viruses

23 Efficacy Reduce transient bacteria by 2.1 to 3 log 10 ; smaller in resident flora (0.35 to 2.29 log 10 ) Activity is greatly reduced in the presence of organic matter, natural corks, and hand creams containing anionic emulsifying agents Substantial residual activity

24 Resistance If MIC greater than 50 mg/liter –Uncommon among G(+) bacteria –Yes for G(-), such as E.coli, P.mirabilis (84.6%), P. stuartii, P. aeruginosa, P. cepacia and S. marcescens –C. albicans (10.5%) –Cross-resistance (+) Mechanism –Alternation of inner, outer membrane or the cell wall

25 Adverse Effect Temperature greater than 70, chlorhexidine may degrade to para-chloraniline (carcinogenic) Conjunctivitis and corneal damage when contacted with eye Ototoxicity Dermatitis is concentration dependent Anaphylactic reactions Avoid direct contact with brain tissue and the meninges

26 Frequent handwashing with soap and water often causes skin irritation and dryness. Skin irritation are more frequently reported when using antiseptic soap In the winter months, some personnel may even develop cracks in their skin that cause bleeding, as seen in the adjacent figure. Another reason why personnel dont wash their hands often

27 OBSERVANCE / HYGIENE DES MAINS Nb dactions dhygiène des mains Nb dindications à lhygiène des mains

28 Observance basale Soignants 30-40% Médecins 10-20% Autres 10-20%

29 Observance du lavage des mains : revue de la littérature %

30 Trick, CID 07

31 Reasons Advocated for Poor Handwashing Compliance Skin irritation from hand hygiene products Inaccessibility of hand hygiene supplies Wearing gloves Hands dont 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

32 It takes ICU nurses an average of 62 seconds to go to a sink, wash and dry their hands, and return to patient care activities

33 The time needed for hand hygiene before and after every contact is about 100 min/patient for direct contacts It takes ICU nurses an average of 62 seconds to go to a sink, wash and dry their hands, and return to patient care activities

34 Anne Simon DUREE DU LAVAGE SIMPLE DES MAINS

35 Hand as a Vectors of Transmission Organisms present on the patients skin or on inanimate objects Organism must be capable of surviving for at least several minutes on the hands of personnel Handwashing is inadequate or omitted entirely Come in direct contact with another patient, or with an inanimate object

36 Precaution Recontaminated from faucets or by splashes from traps or sinks (P. aeruginosa in the tap water) or from plain soap (both bar and liquid soaps, bar soaps heavier; S. marcescens or Serratia liquefaciens) Outside health care facilities (working hours, before eating, after using restroom), use of soap and water is recommended

37 Hand hygiene is the most important tool in NI control Adherence to hand- washing practices remains unacceptable low, rarely exceeding 40%

38 1.Flore cutanée et contamination 2.Lavage des mains 3.Frictions alcoolique Efficacité microbiologique Aspects pratiques Efficacité clinique 4.Conclusion Plan

39 CID 2000;31:136

40 Poor Kolletchka

41 Ignaz Philipp Semmelweis ( ) Ignaz Philipp Semmelweis ( ), a Hungarian obstetrician educated at the universities of Pest and Vienna, introduced antiseptic prophylaxis into medicine.

42 Curr Opin Infect Dis 1998; 11: Death of Kolletchka hand disinfection with a solution of 4% chlorinated

43 Ethanol, Isopropanol, and n-Propanol Ethanol is introduced in 1888 isopropanol and n-propanol in 1904 Vigorous friction, rinsing with water, and drying with a towel are unnecessary

44 Les produits hydro-alcooliques (PHA) solutions ou gels séchage rapide désinfection des mains alcool (60-70%) + émollient +/- autre antiseptique péril hydrique friction sans rinçage friction sur mains sèches +++ non visiblement souillées (propres) non poudrées pas de friction de gants

45 Mechanism of Action Killing not mechanically remove Protein denaturation, rapid killing (sec)

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47 Spectrum of Activity Mycobacteria Excellent in vitro activity against G(+) and G(-) bacteria Virus –Good activity against enveloped viruese –Nonenveloped viruses require higher concentration (70-80%) Against most fungi Poor or no activity against spores, protozoal oocysts

48 log Etudes expérimentales de lactivité des savons sur les mains contaminées par C. difficile (Barbut F. et coll., Hygiènes, 2003, 5, ) Contamination expérimentale des mains de 14 volontaires Contamination initiale : 4.2 à 4.8 log 10 UFC/ml Méthode du jus de gants P=0.36 P< min 30 sec 1 min 30 sec Diapositive empruntée a F Barbut

49 Quelle hygiène des mains ? Faut il bannir les solutions hydro alcooliques? Boyce et al, ICHE 2006 Même constat, -Diminution de lincidence des ERV et des SARM ( ) vs ( ) -I ncidence stable pour Clostridium difficile Gordin et al ICHE 2006

50 Efficacy The type of alcohol Concentration Contact time Volume used Whether the hands are wet when the alcohol applied Temperature Organic material

51 Henri Mondor, Efficacite de lhygiène des mains sur la flore

52 Clin Microbiol Rev. 2004;17(4):863

53 Time-Course of Efficacy of Unmedicated Soap and Water and Alcohol-Based Handrub in Reducing the Release of Test Bacteria from Artificially Contaminated Hands Curr Opin Infect Dis Aug;16(4):327

54 PREVALUES min LIQUID SOAP POVIDONE-IODINE LIQUID SOAP 0.8% CHLORHEXIDINE- DETERGENT 4% POVIDONE-IODINE AQU. SOLUTION 10% ISO-PROPANOL 60% HEXACHLOROPHENE- DETERGENT 3% ISO-PROPANOL 70% N-PROPANOL 60% ISO-PROPANOL 70%+ CHLORHEXIDINE 0.5% % Iog

55 Handwashing with plain soap Alcohol-based handrub Before After Handwashing with antiseptic detergent daprès Pr Bientz, Institut dhygiène de Strasbourg

56 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)

57 1.Flore cutanée et contamination 2.Lavage des mains 3.Frictions alcoolique Efficacité microbiologique Aspects pratiques Efficacité clinique 4.Conclusion Plan

58 Temps économisé par lutilisation de la Friction Hydro-Alcoolique Lavage simple des mains : quitter le lit du patient aller au lavabo, se mouiller les mains se laver les mains (= 30 secondes) se sécher les mains retourner au lit du patient Total 1 min 30 s Total 30 s Friction avec une SHA : au lit du malade durée de friction pour séchage

59 PLUS RAPIDE 40 à 80 secondes pour effectuer le lavage des mains contre seulement 20 secondes pour une désinfection avec la solution hydro-alcoolique Pour une équipe de 12 personnes en réanimation au cours d une journée de 8h de travail : Lavage des mains sol. alcoolique Temps requis16h 4h Force de travail17%< 5% Voss A & Widmer AF ICHE 1997;18:205-8

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61 Widmer CID 2007

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63 Mayo Clin Proc. 2004;79(1):109

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66 15 Jan Michelle Manhart nude photos are now online. Air Force staff sergeant Michelle Manhart was relieved of her duties for posing nude in Playboy

67 N=56 N=61 number of duty days lost N=210 ; 2.4%N=78 ; 0.9% Aviat Space Environ Med. 2007

68 Effet des SHA sur lobservance Bischoff et al., Arch Intern Med, 2000 Service de réanimation médicale, 6 mois Observance à lhygiène des mains

69 Maury et al.AJRCCM, Effet des SHA sur lobservance Évolution selon la catégorie de personnel soignant

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75 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

76 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: * * *, P<0.001 RCT: HW vs HR 29 nurses

77 Larson EL CCM 2001

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79 1.Flore cutanée et contamination 2.Lavage des mains 3.Frictions alcoolique Efficacité microbiologique Aspects pratiques Efficacité clinique 4.Conclusion Plan

80 Impact de lutilisation des SHA sur les taux dIN Pittet et al., Lancet 2000

81 Impact de lutilisation des SHA sur lincidence des SARM Pittet et coll., Lancet 2000

82 ABH introduction

83 baseline Education programme ABH

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

85 Cannot detect a change is not absence of change Absence of training programme Very low baseline rates of nosocomial infection Absence of surveillance cultures to detect MRSA/VRE colonization No data on the rates of MRSA/VRE importation

86 Baseline 59.5% 26% 21% 22.5% Overall compliance Before patient contact After patient contact Correctly performed Intervention 65% 45% 56% 42.6% P 0.46 <0.01 <0.001 <0.01

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88 6 urban sites

89 a total of 65 fewer patients developping MRSA bacteremia during the 24-month intervention period

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92 Acceptability of hand hygiene procedures in the 7 units

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95 P=0.06

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97 Cannot detect a change is not absence of change

98 1.Flore cutanée et contamination 2.Lavage des mains 3.Frictions alcoolique Efficacité microbiologique Aspects pratiques Efficacité clinique 4.Conclusion Plan

99 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

100 ABH is the simplest and least 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

101 Plus efficace que le lavage avec un savon. Action rapide et réalisation rapide. Ne nécessite pas de lavabo. Actif sur les pathogènes nosocomiaux. Toujours à portée de la main. Moins irritant pour la peau. Moins polluant pour l environnement. Favorise l observance. Boyce JM.Infect Control Hosp Epidemiol 2000;21: Daschner Fr. Am J Infect Control 2000;28: 386 Avantages de la friction alcoolique

102 avant tout contact avec un malade, que des gants aient été portés ou non après tout contact avec un malade, que des gants aient été portés ou non entre les soins pour un même malade, que des gants aient été portés ou non après lablation des gants Quand utiliser les SHA?

103 AttentionAttention L'alcool ne contient pas d'agent nettoyant Si mains souillées, lavage des mains impératif Si C difficile la FHA est précédée dun lavage avec séchage

104 MODE DEMPLOI Délivrer une dose (3ml) dans le creux de la main Friction des mains jusquà évaporation (30 sec.) Paume / paume et paume/dos mains Espaces interdigitaux, ongles, pouce…

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106 Hand Hygiene Clean Care is Safer Care

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