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:
1Est-ce que la désinfection des mains est un outil efficace pour prévenir les transmissions croisées ?Bertrand Souweine
2Plan Flore cutanée et contamination Lavage des mains Frictions alcooliqueEfficacité microbiologiqueAspects pratiquesEfficacité cliniqueConclusion
3Plan Flore cutanée et contamination Lavage des mains Frictions alcooliqueEfficacité microbiologiqueAspects pratiquesEfficacité cliniqueConclusion
4Types of Skin FloraTransient floraResident floraInfectious flora
5Epiderme superficiel : stratum corneum effet protecteur contre flore contaminantesquammeslipidesH20 assure plasticité, perméabilité // hydratationLa main joue un rôle important dans la transmission croisée car elle est le principal outil du soignant au contact du patient et de son environnement. La peau qui recouvre la main est une barrière anatomique bâtie comme un mur dont les squames seraient les briques et les lipides le mortier. L ’hydratation de la peau assure sa perméabilité et sa plasticité. Les lipides limitent l ’évaporation et sont indispensables au respect des propriétés fonctionnelles de l ’épiderme. Tous les jours l ’organisme élabore une couche de stratum et en disperse une dans l ’environnement libérant ainsi 107 particules contenant 10% de germes.Une couche produite / 24 heures et qui disparaît en 15 joursufc/cm2, enchâssés en profondeur107 particules libérées / j dans air dont 10% contiennent des germes
6Resident Flora Deeper skin layers Mainly CNS, coryneform bacteria and micrococci ; fungi (Malassezia); virus usually not resident on the skinMore resistant to mechanical removal and stable over timeLower pathogenic potential (not pathogens on intact skin)Colonization resistanceVery difficult to eliminate (< 50% decrease in bacteril load after 6 min of handwashing)
7Transient Flora Superficial layers; usually not multiply on the skin Acquired by contact with patient or environmentEasily removed by mechanical meansS. aureus, GNB or candida or virus
8Infectious FloraThe etiologic agents of actual infections such as abscess, panaritium, paronychia, and infected eczema on the handsS. aureus and β-hemolytic streptococci
9You 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 patient’s blood pressure or pulseAssisting patients with mobilityTouching the patient’s gown or bed sheetsTouching equipment, including bedside rails, over bed tables, IV pumpsThe photo shows a blood agar plate 24 hrs after an ICU nurse placed her hand on plate”
10Acquisition de la flore transitoire ou contaminante temps de soin dépendantePittet Arch Intern Med 1999Durée de contact : 16 cfu /mnPort de gants : 3 cfu /mnDans ce travail qui consiste à évaluer la densité microbienne sur les mains des soignants après activité de soins on voit que la contamination augmente avec la durée du contact et que le port de gants réduit significativement la contamination des mains.
11Acquisition de la flore transitoire ou contaminante même après simple contact patientPittet Arch Intern Med 1999Cette contamination survient pour tous les types d ’activité au contact des patient y compris des contact direct simpleType d’activité : cfu /mn
13Transmission 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
15Hygiène des mains et contrôle de l’infection CDC Guideline for HH in healthcare settingsHygiène des mains et contrôle de l’infectionRecently Mrs Larson published in a review a table with the 6 publications of hospital based studies which demonstrates significant results between the effect of hand hygiene and risk of infection.They are much methodologic limitations to conduct such a study but despite those problems, they are many evidences for an obvious link between hand hygiene and reduced risk of transmission of nosocomial pathogen
16Plan Flore cutanée et contamination Lavage des mains Frictions alcooliqueEfficacité microbiologiqueAspects pratiquesEfficacité cliniqueConclusion
19SoapPlainEsterified fatty acids with sodium or potassium hydroxideMechanical removal of dirt and loosely adherent flora (transient>resident)Antiseptic
20Chlorhexidine A cationic biguanide England in 1954; introduced into U.S. in 1970sChlorhexidine base only minimally soluble in water, but digluconate is water-solubleExists as acetate (diacetate), gluconate, and hydrochloride salts
21Mechanism of ActionAttach to bacterial cytoplasmic membrane (inner membrane)Precipitation or coagulation of protein and nucleic acidsAlso to the outer membrane in G(-) and the cell wall in G(+)Also damage the cytoplasmic membrane of yeasts
22Spectrum of Activity Depends on concentration Bacteria lower: bacteriostatic against GP bacteria, GNB and bacterial sporesBacteriaGood activity against G(+), less G(-) and fungi, not sporesDermatophytes: no activityMycobacteria: limitedVirus: good for most enveloped virus, low for naked viruses
23EfficacyReduce transient bacteria by 2.1 to 3 log10; smaller in resident flora (0.35 to 2.29 log10)Activity is greatly reduced in the presence of organic matter, natural corks, and hand creams containing anionic emulsifying agentsSubstantial residual activity
24Resistance If MIC greater than 50 mg/liter Mechanism Uncommon among G(+) bacteriaYes for G(-), such as E.coli, P.mirabilis (84.6%), P. stuartii, P. aeruginosa, P. cepacia and S. marcescensC. albicans (10.5%)Cross-resistance (+)MechanismAlternation of inner, outer membrane or the cell wall
25Adverse EffectTemperature greater than 70℃, chlorhexidine may degrade to para-chloraniline (carcinogenic)Conjunctivitis and corneal damage when contacted with eyeOtotoxicityDermatitis is concentration dependentAnaphylactic reactionsAvoid direct contact with brain tissue and the meninges
26Another reason why personnel don’t wash their hands often Frequent handwashing with soap and water often causes skin irritation and dryness.Skin irritation are more frequently reported when using antiseptic soapIn the winter months, some personnel may even develop cracks in their skin that cause bleeding, as seen in the adjacent figure.
27OBSERVANCE / HYGIENE DES MAINS Nb d’actions d’hygiène des mainsNb d’indications à l’hygiène des mains
31Reasons Advocated for Poor Handwashing Compliance Risk factors for Poor Handwashing ComplianceSkin irritation from hand hygiene productsInaccessibility of hand hygiene suppliesWearing glovesHands don’t look dirtyLack of information on the importance of hand hygieneLack of knowledge of the guidelinesToo busy/handwashing takes too longMale vs femalePhysician vs nurseWearing glovesWorking in ICUUnderstaffing/overcrowding
32It takes ICU nurses an average of 62 seconds to go to a sink, wash and dry their hands, and return to patient care activities
33It takes ICU nurses an average of 62 seconds to go to a sink, wash and dry their hands, and return to patient care activities.In this study the authors measured the contact rates between health care workers and patients in a general ICU and estimated that if handwashing was undertaken for every patient contact, 3 to 4 hours during every 24 h of care would be needed for every patient in the ICU for this activity. If an alcohol-based handrub (ABH) is available at each patient’s bedside, it takes nurses about 15 seconds to clean their hands.It takes ICU nurses an average of 62 seconds to go to a sink, wash and dry their hands, and return to patient care activitiesThe time needed for hand hygiene before and after every contact is about 100 min/patient for direct contacts
35Hand as a Vectors of Transmission Organisms present on the patient’s skin or on inanimate objectsOrganism must be capable of surviving for at least several minutes on the hands of personnelHandwashing is inadequate or omitted entirelyCome in direct contact with another patient, or with an inanimate object
36PrecautionRecontaminated 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
37Hand hygiene is the most important tool in NI control Adherence to hand-washing practices remains unacceptable low, rarely exceeding 40%
38Plan Flore cutanée et contamination Lavage des mains Frictions alcooliqueEfficacité microbiologiqueAspects pratiquesEfficacité cliniqueConclusion
41Ignaz Philipp Semmelweis (1818-1865) Ignaz Philipp Semmelweis ( ), a Hungarian obstetrician educated at the universities of Pest and Vienna, introduced antiseptic prophylaxis into medicine.In the 1840s, puerperal or childbirth fever, a bacterial infection of the female genital tract after childbirth, was taking the lives of up to 30% of women who gave birth in hospitals. Women who gave birth at home remained relatively unaffected. As assistant professor on the maternity ward of the Vienna General Hospital, Semmelweis observed that women examined by student doctors who had not washed their hands after leaving the autopsy room had very high death rates. When a colleague who had received a scalpel cut died of infection, Semmelweis concluded that puerperal fever was septic and contagious. He ordered students to wash their hands with chlorinated lime before examining patients; as a result, the maternal death rate was reduced from 12% to 1% in 2 years. Nevertheless, Semmelweis encountered strong opposition from hospital officials and left Vienna in 1850 for the University of Pest.As a professor of obstetrics at the University of Pest Hospital, he enforced antiseptic practices and reduced the death rate from puerperal fever to 0.85%. However, Semmelweis findings and publications were resisted by hospital and medical authorities in Hungary and abroad. After a breakdown, he entered a mental hospital in Vienna, where he died of an infection contracted during an operation he had performed.Ignaz Philipp Semmelweis ( )
42hand disinfection with a solution of 4% chlorinated Death of Kolletchka(Mean) maternal mortality at the First ([white circle]) and Second (•) Imperial Royal Obstetric Departments of the General Hospital in Vienna, A: before the introduction of autopsies; B: after the introduction of autopsies; C: after the establishment of a second department, medical and midwifery students trained jointly at both departments; D: medical students trained only at the first department, where deliveries were directed by doctors; midwifery students trained only at the second department, where deliveries were conducted mainly by midwives; E: introduction of hand disinfection with a solution of 4% chlorinated lime by Semmelweis in May 1847 at both departments; F: maternal mortality after the introduction of hand disinfection.Curr Opin Infect Dis 1998; 11:
43Ethanol, Isopropanol, and n-Propanol Ethanol is introduced in 1888isopropanol and n-propanol in 1904Vigorous friction, rinsing with water, and drying with a towel are unnecessary
44Les produits hydro-alcooliques (PHA) solutions ou gelsséchage rapidedésinfection des mainsalcool (60-70%) + émollient +/- autre antiseptiquepéril hydriquefriction sans rinçagefriction sur mainssèches +++non visiblement souillées (propres)non poudréespas de friction de gants
45Mechanism of Action Killing not mechanically remove Protein denaturation, rapid killing (sec)
46The cell viability of biofilms of S The cell viability of biofilms of S. epidermidis was determined by staining the bacteria within biofilm with CTC and DAPI. The absence of red cells indicates the loss of respiratory activity by most cells in ethanol treated biofilm.At this point we see that on the basis of in vitro study results, concentrated ethanol is effective for treating experimental biofilm. However, extrapolating these results in clinical practice might be questionable since blood components such as fibrin, or other proteins may interfere with the ability of ethanol to kill biofilm in vivo.
47Spectrum of Activity Mycobacteria Excellent in vitro activity against G(+) and G(-) bacteriaVirusGood activity against enveloped virueseNonenveloped viruses require higher concentration (70-80%)Against most fungiPoor or no activity against spores, protozoal oocysts
48Etudes expérimentales de l’activité des savons sur les mains contaminées par C. difficile (Barbut F. et coll., Hygiènes, 2003, 5, )Contamination expérimentale des mains de 14 volontairesContamination initiale : 4.2 à 4.8 log10 UFC/mlMéthode du jus de gantslog1 min30 secP<0.01P=0.36P<0.01Diapositive empruntée a F Barbut
49Quelle hygiène des mains ? Faut il bannir les solutions hydro alcooliques?Boyce et al, ICHE 2006Même constat,-Diminution de l’incidence des ERV et des SARM ( ) vs ( )-Incidence stable pour Clostridium difficileGordin et al ICHE 2006
50Efficacy The type of alcohol Concentration Contact time Volume used Whether the hands are wet when the alcohol appliedTemperatureOrganic material
51Efficacite de l’hygiène des mains sur la flore Henri Mondor, 1996
55Handwashing with plain soap Handwashing with antiseptic detergent Alcohol-based handrubBeforeAfterAlcohol is an established disinfectant. Many in vitro studies have demonstrated that ABH is more effective than either plain soap or antibacterial soaps in reducing the bacterial counts on hands.On this slide you can see culture plates showing growth of germs 24 hours after a nurse placed her hand on the plate, having used three different techniques of hand hygiene. ABH reduced the bacterial counts on hands to a greater extent than washing with plain soaps or detergents containing povidone-iodine.One noticeable exception is clostridium difficile since the spores cannot be destroyed by standard ABH. When caring for a patient harbouring c difficile, handwashing is mandatory for mechanical removal of spores and should be followed by alcoholic hand disinfection after hands have been dried.d’après Pr Bientz, Institut d’hygiène de Strasbourg
56The technique used for hand cleansing before patient care affected the amount of bacterial contaminationHandwashing with plain soapHandwashing with antiseptic detergentOn this slide we see that the bacterial contamination of ungloved hands during patient care increased linearly with time and depended on the method of hand cleansing performed before patient care. HCWs who washed their hands with only unmedicated soap and water had higher bacterial counts than those who used hand antisepsisAlcohol-based handrub (ABH)
57Plan Flore cutanée et contamination Lavage des mains Frictions alcooliqueEfficacité microbiologiqueAspects pratiquesEfficacité cliniqueConclusion
58Temps économisé par l’utilisation de la Friction Hydro-Alcoolique Lavage simple des mains :quitter le lit du patientaller au lavabo, se mouiller les mainsse laver les mains (= 30 secondes)se sécher les mainsretourner au lit du patientTotal 1 min 30 s Friction avec une SHA :au lit du maladedurée de friction pour séchageTotal 30 s
59PLUS RAPIDE Lavage des mains sol. alcoolique 40 à 80 secondes pour effectuer le lavage des mains contre seulement 20 secondes pour une désinfection avec la solution hydro-alcooliquePour une équipe de 12 personnes en réanimation au cours d ’une journée de 8h de travail :Lavage des mains sol. alcooliqueTemps requis 16h 4hForce de travail 17% < 5%Voss A & Widmer AF ICHE 1997;18:205-8
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67Aviat Space Environ Med. 2007 number of duty days lost 200420052006N=56N=210 ; 2.4%N=78 ; 0.9%N=61number of duty days lost
68Effet des SHA sur l’observance Service de réanimation médicale, 6 moisObservance à l’hygiène des mainsAu début: l’observance ne dépasse pas 22%. Cela a permis d’augmenter l’observance d’environ 20%Bischoff et al., Arch Intern Med, 2000
69Effet des SHA sur l’observance Évolution selon la catégorie de personnel soignantMaury et al.AJRCCM, 2000
70There is a negative relationship between hand hygiene compliance and the number of hand hygiene opportunities per hour of patient care when handwashing is used, which is not found when ABH is used.
71In this study the author reported the effect on adherence to hand hygiene of a multifaceted programme. ABH was available all over the study. Observed hand hygiene practice was measured at baseline in grey and after intervention in blue. On the x axis are shown 8 indications to hand hygiene. As we can see baseline values of hndhygiene complinace with ABH differed widely according to the indications for hand hygiene. The multifaceted programm was asociated with a significant improvement in the adherence to hand hygiene from 40 to 80%, But the effect differed with the opportunities observed.
73What about ABH for preventing cross transmission? Despite the paucity of appropriate RCTs there is substantial evidence that hand antisepis reduces the incidence of health care associated infections.Numerous recent studies reported that when dealing with outbreaks related to VRE or other multiresistant organisms, the re-inforcement of ABH use in combination with establishment or re-inforcement of other barrier precautions halted the outbreak.Despite the limitations of these studies, most reports showed a temporal relation between improvement in hand hygiene practices and reduced infection rates.
74Handwashing is in grey boxes and ABH in black boxes Handwashing is in grey boxes and ABH in black boxes. The increase in hand hygiene compliance when ABH is available is not related to an increase in handwashing but to the addition of hand hygiene actions undertaken with ABH
75Several Limitations in Hand Hygiene Compliance Studies Before / after studySingle centreNo period randomizationOvert observationsDifferences in the type of opportunities recordedHawthorne effectHandwashing still performed during the ABH periodMultifaceted programme on hand hygiene practiceHowever, several points must be taken into account when assessing the results of these studies. Most of these studies are before / after studies, performed in one centre without period randomization. The observations are overt, the opportunities recorded differ, and the novelty effect cannot be fully excluded since the study periods and follow-up are often short. During the intervention period with ABH introduction, handwashing is still performed, and, in most cases, ABH is introduced in combination with a multifaceted programme for improving hand hygiene practice. Taken together these factors make it difficult to measure the specific impact of ABH on hand hygiene compliance.
76Effect of Alcohol Handrub on Skin Condition RCT: HW vs HR29 nursesSelf-reported skin scoreEpidermal water contentDryHealthy**HealthyDrySeveral studies showed that ABH is associated with a better skin tolerance than handwashing. This was found in self-report questionnaire surveys and in studies where skin condition was assessed by external observers and biometric tests. It has been suggested that among alcohol-based handrubs, gels might be associated with better skin care properties and dermal tolerance.Alcohol-based handrub is less damaging to the skin* , P<0.001Boyce, Infection Control and Hospital Epidemiology 2000;21:
77The better skin tolerance observed with ABH compared to handwashing probably contributes to the better acceptability of ABH.As you can seen in this prospective randomized clinical trial, healthcare workers assigned to ABH reported they preferred ABH to handwashing with chlorhexidine. They reported that ABH was easier and faster than handwashing. However, no differences between the two techniques were reported with gloving.Larson EL CCM 2001
78It has been suggested that among alcohol-based handrubs, gels might be associated with better skin care properties and dermal tolerance. In this study performed in an MICU, self-reported and observed skin tolerance was better in the period when the ABH used was a gel.
79Plan Flore cutanée et contamination Lavage des mains Frictions alcooliqueEfficacité microbiologiqueAspects pratiquesEfficacité cliniqueConclusion
80Impact de l’utilisation des SHA sur les taux d’IN Pittet et al., Lancet 2000
81Impact de l’utilisation des SHA sur l’incidence des SARM Pittet et coll., Lancet 2000
82In this prospective observational study carried out by Lucet and coll in Paris over a-6 year period in ICUs with high colonization pressure, we can see a relationship between intoduction of ABH and control of MRSA acquisitionABH introduction
83Education programme Education programme Here the results of a prospective controlled cross-over trial performed in two adult ICUs assessing the impact of ABH introduction on the rates of nosocomial infections.Concerning compliance,At baseline nurses exhibited greater hand hygiene compliance than physicians. After the educational programme, in unit A, where ABH was not available, nurses had a higher rate of hand hygiene compliance than physicians. In both units there was a significant increase in hand hygiene compliance during periods when ABH was available. During the periods with ABH, most of hand hygiene actions were performed with ABH. There was a close correlation between hand hygiene compliance and the patient care activities.baselinebaselineABHABHEducation programmeEducation programme
84Infection due to MRSA: from 1.67 to 2.77 per 1.000 patient-days Concerning nosocomial infection,Baseline rates were very low and there was no correlation between hand hygiene compliance and the nosocomial infection rates. The rates of nosocomial infections due to resistant organisms: VRE, MRSA and P aeruginosa were low during the study without significant change over time.Infection due to MRSA: from 1.67 to 2.77 per patient-daysInfections due to VRE from 0.35 to 1.36 per patient-days
85Cannot detect a change is not absence of change Absence of training programmeVery low baseline rates of nosocomial infectionAbsence of surveillance cultures to detect MRSA/VRE colonizationNo data on the rates of MRSA/VRE importationDoest it mean that improving compliance with ABH is not efficious for decreasing NI rates?Many reasons may have contributed to this negative resultsConcerns exist on the bactericidal effect of the hand hygiene gel used. There are ongoing debate on about the efficacy of ABH gel with a an ethnol concentration lower than 80%We don’t know if training in the application of ABH gel was performedThe very low baseline rate of NI may have jeopardized the possibilidy of detecting the clinical effect of introducing the gel. Rough calculation were performed and have suggested that even if improvements in hand hygiene compliance were able to decrease NI rates of 50%, this study would have only 20% of chance of demonstrating the effectThe acquisition of nosocomial infection represents an accurate surrogate but did not actually reflect cross transmission. Surveillance cultures were not performed and therefore data on ICU acquired colonization are lacking. Such information is needed to estimate the risk for acquiring MRSA since the rates of MRSA/VRE importation are a major determinant of MRSA/VRE transmission.
886 urban sitesHere the results of a large australian study aiming at measuring the effect of a multisite multifaceted programme to improve hand hygiene practice in 22 institutions. ABH was available all over the study. The study duration was 2 years. The authors measured hand hygiene complinace, ABH consumption, and the rates of MRSA bcteremia and of MRSA isolated from clinical samples. There was no screening for MRSA colonization.
89a total of 65 fewer patients developping MRSA bacteremia during the 24-month intervention period The number of patients with MRSA bacteremia fell significantly from a mean baseline rate of 0.05/per 100 patients discharge per month 24 months before the intervention to 0.02 in the last 3 month of the intervention. This represented a total of 65 fewer patients developping MRSA bacteremia during the 24-month intervention periodSimilarly was observed a significant decrease in the rates of clinical sample positive to MRSA representing 716 fewer clinical MRSA isolates identified during the 24-month intervention period.Similar findings were observed in the australian statewide roll-out including 75 hospitals with an increase in hand hygiene compliance from 20% to 55% and a reduction in the rates of MRSA isolates and bacteremia.
98Plan Flore cutanée et contamination Lavage des mains Frictions alcooliqueEfficacité microbiologiqueAspects pratiquesEfficacité cliniqueConclusion
99ABH is effective in decreasing NI rates The causal role of microorganisms on hands in the pathogenesis of NI is extremely well establishedTraditional soap-and-water hand hygiene is less effective than hand antisepsisHandwashing as frequent as recommended is often impractical and leads to inflammatory skin reactions
100ABH is effective in decreasing NI rates 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 resistanceMultifaceted 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
101Avantages de la friction alcoolique 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
102Quand utiliser les SHA?avant tout contact avec un malade, que des gants aient été portés ou nonaprès tout contact avec un malade, que des gants aient été portés ou nonentre les soins pour un même malade, que des gants aient été portés ou nonaprès l’ablation des gants
103Attention L'alcool ne contient pas d'agent nettoyant Si mains souillées, lavage des mains impératifSi C difficile la FHA est précédée d’un lavage avec séchage
104MODE D’EMPLOI Délivrer une dose (3ml) dans le creux de la main Friction des mains jusqu’à évaporation (30 sec.)Paume / paume et paume/dos mainsEspaces interdigitaux, ongles, pouce…