Hand Flora Research Articles

Glove punctures and postoperative skin flora of hands in cardiac surgery

Background. Surgical gloves are frequently perforated during operations, including heart operations. This infection risk factor is inadequately studied. Methods. After preoperative hand disinfection and at the end of 116 heart operations, bacterial samples from hands of surgeons, altogether 800 samples, were taken. Glove punctures were examined with water test. Results. Surgeons changed 70 gloves because of breakage during operations. Additionally, 154 of 400 (39%) gloves had holes in postoperative testing. The breakage rate of gloves increased from 30% in operations shorter than 3 hours to 65% when operations were longer than 5 hours. High bacterial counts of the hands were also more common after prolonged operations. Conclusions. Glove puncture rates and bacterial counts of hands increase with increasing operation time. We recommend changing of both gloves when a puncture is detected. Before donning new gloves, hands should be disinfected.

Clinical assay of N-duopropenide alcohol solution on hand application in newborn and pediatric intensive care units: Control of an outbreak of multiresistantKlebsiella pneumoniae in a newborn intensive care unit with this measure

Outbreaks of gram-negative colonization (generally by antibiotic-resistant enterobacteria) are common in newborn intensive care units (NICUs), and control methods are not always effective. We studied the effectiveness of an alcohol solution of N-duopropenide (NDP) in vivo (germicidal effect on flora of teams in the NICU and the pediatric intensive care unit vs handwashing with nonantiseptic soap) and its effect on the control of a multiresistant (MR) Klebsiella pneumoniae outbreak in our NICU that had persisted for 13 months, despite the use of classic control measures. For educational purposes, we also performed 4 prevalence studies of microbial hand flora in NICU staff (two before and two after introducing NDP). The alcohol solution of NDP was highly germicidal in vivo, destroying microorganisms better than classic handwashing on the hands of 69 health care staff of our NICU and PICU. The flora in both units was reduced from an average of 63% to an average of 95%. Application of this disinfectant to the hands of health care workers after handling newborns helped to eliminate the MR Klebsiella strain in our NICU, (relative risk compared with the period preceding use of the disinfectant: 8.6, with 95% confidence intervals, 4.8-145.5). Four prevalence studies of hand microbial contamination, before and after NDP introduction in the NICU, showed a significant reduction of enterobacteriaceae, mainly MR K pneumoniae , in health care workers. In conclusion, NDP in alcohol was very effective in vivo. It proved to be a useful complementary measure to handwashing and reduced exogenous microorganism transmission in a unit with a heavy patient-care workload. (Am J Infect Control 2001;29:162-7)

Double-blind, randomized trial of scheduled use of a novel barrier cream and an oil-containing lotion for protecting the hands of health care workers

Context: Many health care workers suffer severe hand irritation, with cracking and bleeding, as a consequence of frequent handwashing and glove use. Integumentary breakdown has major implications for nosocomial infection control and promotes the spread of bloodborne viruses. The potential benefits of scheduled use of hand-care agents—lotions or creams—in health care workers has not been established by controlled trial. Objective: To compare the value of an oil-containing lotion with a novel barrier skin cream in health care workers with severe hand irritation. Design: Prospective, randomized, double-blind trial. Setting: University medical center. Participants: Fifty-four health care workers from multiple departments with severe hand irritation, 74% with one or more full-thickness cracks or other integumentary breaks. Main Outcome Measures: Objective and subjective parameters for scaling, cracking, weeping, bleeding, and pain were scored by two blinded investigators weekly for 4 weeks, and the hands of subjects were cultured quantitatively at the onset and after 2 weeks and 4 weeks. Results: Subjects in both groups experienced marked improvement in overall hand condition (each, P <.02), particularly in scaling, cracking, and pain. Persons randomized to use of the oil-containing lotion showed greater improvement (mean score, from 6.5 to 2.7 vs 6.8 to 4.7, P =.006). In 18 (69%) of 26 persons who used the control lotion, all full-thickness integumentary breaks were healed and pain was totally resolved, compared with 14 (52%) of 27 persons who used the barrier cream (P =.26). Use of the two agents in a scheduled fashion had no effect on the levels or profile of the transient hand flora. However, by the fourth week of use, handwashing frequency was 50% higher in subjects randomized to use the control lotion than it was in subjects randomized to use the barrier cream (17.8 vs 11.7 times per day, P =.04). Conclusion: Use of an oil-containing lotion or a barrier cream on a scheduled basis can substantially protect the hands of vulnerable health care workers against drying and chemical irritation, preventing skin breakdown and promoting more frequent handwashing. (AJIC Am J Infect Control 2000;28:302-10)

Assessment of alternative hand hygiene regimens to improve skin health among neonatal intensive care unit nurses

The frequent handwashing and gloving required in high-risk, high-volume patient care areas such as critical care units damages skin of the hands. The purpose of this exploratory study was to compare 2 hand care regimens (traditional antiseptic wash with chlorhexidine-containing detergent versus mild soap wash with subsequent alcohol-based rinse for degerming as necessary) in a neonatal intensive care unit (NICU). Prospective, quasi-experimental, random assignment. One NICU (47 beds) in a New York City children's hospital. Sixteen full-time NICU nurses. Microbial flora and skin condition of hands. Nurses were randomly assigned to one of the 2 hand care regimens. No significant differences in microbial counts or types of organisms from hands of staff were found, but after 2 weeks nurses in the mild soap and alcohol group had significant improvements in their skin condition (P =.005). Use of a mild soap for cleaning and an alcohol-based product for degerming may offer an acceptable alternative to the traditional antiseptic handwash and may reduce skin damage to health care professionals' hands.

Handwashing patterns in primary pediatric community clinics.

Handwashing is acknowledged as a critical factor in the prevention of nosocomial infection. Nonetheless, health care personnel often wash their hands inadequately. The purpose of this study was to examine the flora of hands and the frequency of handwashing of physicians working in primary care pediatric community clinics. The fingers of the dominant hand of 55 physicians working in 12 clinics were sampled for bacterial cultures. Only 354/720 (49%) of the expected handwashings by 17 board-certified pediatricians were recorded as having been performed. None of them washed their hands after each contact with an examined child. All physicians' hands were found to be contaminated with microorganisms. Staphylococcus species were isolated from 47 (85.4%) of the physicians' hands. Methicillin-resistant Staphylococcus aureus was found on the hands of 9.1% of the physicians. Such contaminated hands may serve as a potential vector of community-acquired infection with highly resistant organisms. Compliance with handwashing recommendations among these physicians was low. An active educational infection control program must be introduced in ambulatory pediatric community clinics.

Do ‘chlorine covers’ exert a sustained bactericidal effect on the bacterial hand flora?

Treatment of skin with chlorine generates ‘chlorine covers’ which, in a previous study, exerted significant sustained bactericidal effects against transient skin flora on the upper arm and forearm. In this investigation, this effect was studied on both the transient and resident flora of the hands using test models for the evaluation of hand disinfectants as agreed upon in Austria and Germany. Chlorine covers were generated by bathing hands in a solution of 2% sodium tosylchloramide for 1 min. Subsequently, this cover was destroyed on one, randomly selected, hand by bathing it in a solution of 0·5% sodium thiosulphate for 15 s. The amount of chlorine on the fingertips of chlorinated hands was 2·2 ± 0·4 μg/cm 2; that on subsequently dechlorinated hands was 0·2 ± 0·1 μg/cm 2. In experiments with artificially contaminated hands ( Escherichia coli), the kinetics of bacterial die-off were the same on both hands. Also, in experiments with resident flora, the kinetics of bacterial die-off did not suggest bacterial reductions that increase with the duration of contact with the chlorine cover. It was concluded that with the test models used, a significant sustained antimicrobial effect of the chlorine cover could not he demonstrated on hands.

Handwashing practices and resistance and density of bacterial hand flora on two pediatric units in Lima, Peru

The handwashing practices and bacterial hand flora of 62 pediatric staff members of a teaching hospital in Lima, Peru, were studied. Handwashing followed patient contact 29.3% of the time (204/697 contacts). Mean duration was 14.5 seconds, and significant differences in practices were found by unit (rehydration or neonatal intensive care), type of staff member (nurses or physicians), and type and duration of patient contact. Mean count of colony-forming units was log10 5.87 +/- 0.41, with significant differences in density of flora found between patient care and kitchen staffs. There was no significant effect of handwashing on counts of colony-forming units. Significant differences were also found by unit and by staff position with regard to species isolated and antimicrobial resistance of isolates. A more efficacious and cost-effective form of hand hygiene and a more prudent use of antimicrobial agents are indicated.

Alcohol for Surgical Scrubbing?

AbstractTo test the effects of four surgical scrub products on colonizing hand flora, 60 healthy adult volunteers were assigned by block randomization (12 subjects per group) to use one of the following formulations: 70% ethyl alcohol with 0.5% chlorhexidine gluconate (ALC); a liquid detergent base containing 1% triclosan (TRI); a liquid detergent base containing 4% chlorhexidine gluconate (CHG); a liquid detergent base containing 7.5% povidone-iodine (PI); or a nonantimicrobial liquid soap (control). Using standard protocol, subjects performed a surgical scrub daily for five consecutive days. Hand cultures were obtained at baseline and on test days 1 and 5 immediately after the scrub and following four hours of gloving. After the first and last scrubs, ALC, CHG and PI resulted in significant reductions in colonizing flora when compared to the control. Additionally, by day 5 ALC was associated with an almost 3-log reduction as compared to an approximate 1.5-log reduction for CHG and PI and less than a l-log reduction of TRI and the control (p = .009). After four hours of gloving on both days 1 and 5, microbial counts on hands of subjects using ALC, TRI and CHG were significantly lower than counts for the control (p &lt; .001), whereas there was no significant difference in counts between the PI and control groups (p = .41). Skin assessment by study subjects rated products from least to most harsh as follows: control, TRI, CHG, ALC and PI (p = .00001). It was concluded that ALC could be an efficacious and acceptable alternative for surgical scrubbing.

Alcohol for Surgical Scrubbing?

To test the effects of four surgical scrub products on colonizing hand flora, 60 healthy adult volunteers were assigned by block randomization (12 subjects per group) to use one of the following formulations: 70% ethyl alcohol with 0.5% chlorhexidine gluconate (ALC); a liquid detergent base containing 1% triclosan (TRI); a liquid detergent base containing 4% chlorhexidine gluconate (CHG); a liquid detergent base containing 7.5% povidone-iodine (PI); or a nonantimicrobial liquid soap (control). Using standard protocol, subjects performed a surgical scrub daily for five consecutive days. Hand cultures were obtained at baseline and on test days 1 and 5 immediately after the scrub and following four hours of gloving. After the first and last scrubs, ALC, CHG and PI resulted in significant reductions in colonizing flora when compared to the control. Additionally, by day 5 ALC was associated with an almost 3-log reduction as compared to an approximate 1.5-log reduction for CHG and PI and less than a 1-log reduction of TRI and the control (p = .009). After four hours of gloving on both days 1 and 5, microbial counts on hands of subjects using ALC, TRI and CHG were significantly lower than counts for the control (p less than .001), whereas there was no significant difference in counts between the PI and control groups (p = .41). Skin assessment by study subjects rated products from least to most harsh as follows: control, TRI, CHG, ALC and PI p = .00001). It was concluded that ALC could be an efficacious and acceptable alternative for surgical scrubbing.

Influence of two handwashing frequencies on reduction in colonizing flora with three handwashing products used by health care personnel

Four handwashing products (containing either 2% chlorhexidine gluconate, 0.6% parachlorometaxylenol, 0.3% triclosan, or a nonantimicrobial control) at two handwashing frequencies (6 or 18 times/day) were compared with regard to their effectiveness in reducing colonizing hand flora. Eighty adult volunteers were assigned by block randomization to one of the four products and one of the two frequency schedules ( n = 10/group) and washed their hands under supervision for 5 consecutive days. There were no significant differences between products in mean log 10 colony-forming units after the initial wash ( p = 0.61), nor were there significant differences in products after 5 days among subjects washing six times per day. For those who washed 18 times per day, however, the effectiveness of all three antimicrobial soaps was significantly better than that of the control soap ( p < 0.05). Chlorhexidine gluconate produced significantly greater reductions than triclosan or parachlorometaxylenol ( p < 0.05), which were not significantly different from each other. On the basis of these findings an antimicrobial soap is recommended when handwashing frequency is high and a long-term reduction in colonizing flora is desirable. When handwashing frequency is low (6 times/day), there seems to be less advantage of one product over another, although the use of chlorhexidine gluconate resulted in greater reductions at both high and low handwashing frequencies.

Efficacy of alcohol-based hand rinses under frequent-use conditions

Fifty volunteers randomly assigned to one of five hand washing agents (10 subjects per agent)--a nonantiseptic liquid soap (control), an antiseptic hand rinse containing 60% isopropyl alcohol (IPA) with emollients (Alc A), an antiseptic hand rinse containing 70% IPA and 0.5% chlorhexidine gluconate with emollients (Alc B), an antiseptic containing 4% chlorhexidine gluconate and 4% IPA (CHG), and 70% IPA--washed their hands 15 times per day for 5 days under supervision by using a standardized technique and measured amounts of test agent. Microbiologic samples of hand flora were obtained at base line and after hand washes 1 and 15 on test days 1 and 5. After the initial hand wash there were significant reductions over base line in aerobic and anaerobic log CFU among those using Alc A, CHG, and IPA. By the end of the first day of hand washing (15 washes), there were 2-log or greater reductions in aerobic counts among subjects using all antiseptics, but no significant reductions in controls. By the end of day 5, all agents produced significant reductions in aerobic (P = 0.0002) and anaerobic (P = 0.002) counts over control soap. Subject assessment of effects of hand washing on the skin and overall satisfaction varied significantly by product (P = 0.04 and 0.05, respectively). We conclude that alcohol-based hand rinses are highly efficacious, and such products are recommended as a health care personnel hand wash, particularly when sink and running water are inaccessible.

Effects of handwashing agent, handwashing frequency, and clinical area on hand flora

Six hundred twenty-two isolates from 554 samples taken from hands of 103 perpital personnel and 50 controls were obtained over a mean period of 35 days. Eighty-five were obtained immediately before and after handwashing (HW), the remainder after HW only. The relationship of HW agent used, clinical area and job, and frequency of HW to rates of bacterial colonization and numbers and types of organisms isolated, particularly gram-negative bacteria, were evaluated. The HW agent used (nonantiseptic, hexachlorophene-based, chlorhexidine-based, or iodophor) was significantly correlated with the number of isolates obtained from each sample. Control subjects, all of whom used nonantiseptic soaps, had 1.42 mean isolates per sample; hospital personnel who used nonantiseptic soap had a mean of 1.00 isolates per sample. Other means were 1.25, hexachlorophene; 1.43, iodophor; 0.79, chlorhexidine; and 0.67 for those who used several different antiseptics, p < 0.0001. The agent was also correlated with the type of organisms isolated (p = 0.002), but not with the counts of colony-forming units (CFU). Frequency of HW was significantly correlated with CFU counts before (p = 0.03) and after (p = 0.001) HW. In general, numbers decreased with increasing HW frequency, but at the higher HW frequencies there was a slight rise. There were significant differences in numbers of isolates per sample according to clinical area, with personnel working in obstetrics and nonpatient areas having the greatest number and those working on neonatal and medical-surgical units having the least (p < 0.0001). CFU counts also varied significantly by clinical unit in samples obtained before HW (p = 0.004), but not after (p < 0.28). We recommend that further study be conducted to investigate why bacterial counts tended to increase at high HW frequencies and to differentiate between the quality of HW and other factors such as frequency and agent used and their separate combined effects on hand flora.

Hand carriage of aerobic Gram-negative rods by health care personnel.

A quantitative culture technique (hand washed in a glove containing broth for 30 s) was used to determine the frequency of hand carriage of aerobic Gram-negative rods by various groups of health care workers and 104 control subjects. Overall, 31% of health care workers carried aerobic Gram-negative rods on their hands compared to 59% of control subjects (P < 0.001). Enterobacter agglomerans accounted for 40% of the isolates, and other Enterobacter spp. 7%. Other organisms included Acinetobacter calcoaceticus 21%, Serratia spp. 11%, Klebsiella spp. 10%, Moraxella spp. 3%, Pseudomonas spp. 3%, Proteus spp. 1.5%, Escherichia coli 1%; Morganella morganii, Citrobacter freundii, Aeromonas sp. and an isolate that was not speciated accounted for 0.5% each. We conclude that endemic hand carriage of aerobic Gram-negative rods by health care personnel is common, but significantly less than that of control subjects. Enterobacter agglomerans is found so frequently on the hands of control subjects that it must be considered part of the normal hand flora.

Comparative study on the antimicrobial effect of 0.5% chlorhexidine gluconate and 70% isopropyl alcohol on the normal flora of hands

A gloved-hand wash method was used to compare the antimicrobial effect of chlorhexidine gluconate alcohol emollient hand wash (HIBISTAT) with that of 70% isopropyl alcohol on the normal flora of the hands (81 subjects) under conditions designed to mimic use by surgeons. Results of the immediate postwash effects on the bacterial counts for all 3 tests days showed that chlorhexidine significantly reduced the normal flora of the hands. When compared with the base line bacterial counts, there was 85, 96, and 98% reduction with chlorhexidine treatment and 84, 93, and 90% reduction with alcohol treatment on days 1,2, and 5, respectively. The difference between chlorhexidine and alcohol treatments was not statistically significant on days 1 and 2, but was significant on day 5 (P less than 0.01). For delayed postwash bacterial counts (for persistent antimicrobial effects), the overall log means were 4.9943 and 5.4684 for chlorhexidine and alcohol treatments, respectively. The difference between the two treatments was significant (P less than 0.01). After the chlorhexidien treatment, there was no significant growth of bacteria over a period of 6 h when compared with the base line bacterial counts.

Microbial flora of nurses' hands. III. The relationship between staphylococcal skin populations and persistence of carriage.

The hands of 50 nurses and 50 controls were tested for coagulase-positive staphylococcus. Twenty-eight percent of both groups were carriers. The mean staphylococcal count on the palm of the hand was 13.7 per 16 cm-2 in nurses as compared to 442.7 per 16 cm-2 in the control group. The number of persistent carriers was the same for each group, but 25 percent of all cultures from nurses were positive for Staphylococcus aureus as compared to 14.2 percent of the cultures from the control group. It was concluded that there was no direct correlation between high staphylococcal counts and persistence of carriage. The skin as a site of carriage of Staphylococcus aureus was found to be of greater importance in nurses than in control subjects.

Microbial flora of nurses' hands. I. Quantitative differences in bacterial population between nurses and other occupational groups.

Microbial flora of nurses' hands. I. Quantitative differences in bacterial population between nurses and other occupational groups.

Experience with an iodine-detergent preoperative scrub solution

An iodine detergent preoperative scrub solution is evaluated under laboratory and operating room conditions. It has been found to be nonirritating and extremely effective in reducing the bacterial flora of the surgeon's hands. Its use recommended as one way in which to reduce the ever present threat of infection to surgical patients.

Disinfection of the hands of surgeons and nurses.

The hands of the nurse and the surgeon are undoubtedly two of the chief vectors of hospital infection. They often carry pathogenic organisms, in particular Staphylococcus aurelus, which may be present in large numbers. Price (1938) has shown that scrubbing with soap and water for six minutes will reduce the numbers Df bacteria on the hands by only about 50'. Devenish and Miles (1939) and others have found that about 30', of the rubber gloves worn at operations become punctured without the surgeon's knowledge, and bacteria can readily escape through the small holes which appear. Though these facts about hand scrubbing and gloves are quite well known, additional safeguards against manual contamination of wounds are not often used by surgeons ; nurses, for their part, are generally not expected to do anything more to control their hand flora than washing with soap and water after certain ward duties. Various antiseptics have been found to reduce the numbers of bacteria on the hands. Hexachlorophane soap (Traub, Newhall, and Fuller, 1944; Seastone, 1947) and phisohex (Hufnagel, Walter, and Howard, 1948) have been used for some years by surgeons in the United States, and a British paper in support of the latter has recently appeared (Smylie, Webster, and Bruce, 1959). Price (1951) has stressed the limitations of hexachlorophane soap when used irregularly, and finds that a conventional scrub with soap and water followed by three minutes' rinse in 70') alcohol before putting on gloves is more effective. The regular use of a hand cream containing chlorhexidine has been found to reduce the skin flora (Murray and Calman, 1955; Laurell, 1959), and its use by nurses in surgical and obstetric wards has been associated with some reduction in the incidence of cross-infection (Cook, Parrish, and Shooter, 1958; Gillespie, Simpson, and Tozer, 1958). In this paper we describe experiments on the relative merits of several pre-operative antiseptic applications to the surgeon's hands, with particular reference to the numbers of bacteria emerging through holes in gloves. We also describe a study on the routine use of hexachlorophane soap and some other methods by nurses working in accident and burns wards.

Bacterial flora of the surgeon's hands and operating field during aseptic operations

In the study of hand and operative field cultures at different moments of preparation for surgery and during the operation, the author observed that the data from the operative field cultures are identical to the data from the hands after surgery.