Hand Hygiene in Peritoneal Dialysis

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Peritonitis remains one of the most serious complications of peritoneal dialysis (PD) and a significant cause of transfer from the therapy. In peritonitis, analyses suggest that approximately 42% of episodes involve Staphylococcus species, organisms associated with touch contamination (1). To reduce the risk of touch contamination, patients are instructed on the importance of hand washing before performing a dialysis exchange. Hand washing to reduce the risk of infection has been advocated since the work of Semmelweis, who in 1847 proposed the use of chlorinated lime for hand hygiene (2). Maintenance of proper hand hygiene to reduce the risk of infection is a critical component of successful PD therapy. However, compliance with hand hygiene may be poor. In PD patients observed 6 months after initiation of dialysis, 51% were observed to wash their hands incorrectly (3). Hand hygiene practices are also noted to be poor in health care workers (4,5). Hand washing instructions given to patients may have significant variations. Little is known about the actual instructions given to patients on aspects of hand washing or alcohol hand rub techniques, such as method of washing, length of time, type of cleaning agent, and method of drying the hands, among others. The 2005 International Society of Peritoneal Dialysis (ISPD) update on PD-related infections recommendations states that “antibacterial soap and water are recommended by many centers” and suggests that if the water used to wash hands is thought to contain bacteria, an alcohol hand wash should be encouraged (6). The 2010 ISPD update of the recommendations does not discuss hand washing (7). In general, there appears to be scant discussion in the PD and related literature on hand washing techniques. This literature may be of interest to PD practitioners as they develop policies on exit-site care and exchange techniques. Are there certain ways of washing the hands that are more effective? If patients use soap, what types of soaps are recommended? If an alcohol gel is used, what preparations may be most effective? To address the foregoing issues, the existing and surprisingly rich science of hand washing is the subject of the present review. Studies of hand hygiene in health care workers provide the largest base of information from which evidence-based recommendations can be derived. The goal of our review was to expand on components of hand washing technique and to propose specific hand washing principles to the PD community.