Healthcare Hygiene magazine December 2019 | Page 19

handwashing, there was no impact on the overall level of
diversity on the hands. Another study found no impact on
hand microbiome composition when handwashing occurred
within one hour of sampling. Frequency of handwashing
on the day prior to sampling did not correlate with changes
in bacterial composition. Use of other topical products
was not studied on hands but use of oral antibiotics had a
significant impact on the hand microbiome, with the largest
shift observable around the time of use.”
The mechanism of handwashing and handrubbing influ-
ences the cleanliness of the hands – or does it? There seems
to be some disagreement as to how effective technique can
be, and unlike the levels of cleanliness for medical devices that
can be established through sterility parameters, we are at a
disadvantage when it comes to microorganisms on skin and
ascertaining exactly
how “clean” hands
are after they have
been washed in the

The best answer
real-world setting.
“This is what

seems to be train-
the
guidelines and

ing our clinicians in
recommendations
proper technique, right from the
are for, so there is
start, how (including how long) to no reason to invent
another definition
wash their hands.”
of what “clean” is,”
— Paul Pottinger, MD, FACP, FIDSA says Didier Pittet, MD,
MS, CBE, professor
of medicine, hospital epidemiologist, and director of the
infection control program at the University of Geneva
Hospitals. “There is a standard that qualifies the log reduction
in bacteria needed to prevent cross transmission. In the U.S.
it’s ASTM standards, in Europe it’s the EN ones. We do not
need hands to be sterile (have zero bacteria on them) in
order to prevent cross transmission.”
“I am not aware of fast, reliable, easy-to-use point-of-
care technology to answer the fundamental question we
have for healthcare workers before and after each patient
encounter: Did you wash your hands, and did you do it
properly?” says Paul Pottinger, MD, FACP, FIDSA, professor
of medicine in the Division of Allergy & Infectious Diseases
at the University of Washington Medical Center in Seattle.
“The best answer seems to be training our clinicians in proper
technique, right from the start, how (including how long) to
wash their hands,” adds Pottinger, who is also director of
the Infectious Diseases Training Program, and co-director, of
the UWMC Antimicrobial Stewardship Program.
“Part of that training can include application of a
fluorescent hand-rub product that will reveal under special
light just how well someone has done,” he continues. “This
can have a real impact on getting everyone’s technique up
to snuff before they hit the wards. As for whether they
sustain this best practice... well, that’s another matter. For
us, success depends on a supportive healthcare environment,
where team members are encouraged, empowered, and
expected to call each other out if they forget to perform
diligent, effective hand hygiene.”
“In the real world, there are products like GloGerm to aid
www.healthcarehygienemagazine.com • december 2019
the visualization of washing technique, but is this enough?,”
asks Pittet. “Such products can help, but behavior change
is a complex field. So as long as hand hygiene compliance
remains suboptimal, I think the answer to everything will be
‘no, it’s not enough.’ But such innovations can be useful
tools in the WHO multimodal strategy (https://www.who.
int/gpsc/news/simple_guideline/en/).”
Pittet adds, “Hand hygiene, when performed correctly,
results in hands that are more than clean enough to prevent
cross-transmission from the hands of that person. The issue
is not making hand hygiene more effective microbiologically
— that part is okay. What is difficult is making sure people
perform hand hygiene well, and at all of the moments where
there is a risk of infecting the patient with contaminated
hands. That is why we developed the 5 moments for hand
hygiene for the World Health Organization (https://www.
who.int/gpsc/5may/background/5moments/en/).”
Pittet continues, “If we are talking about is it enough for
healthcare workers to ‘wash in’ and ‘wash out’ when they
go into and leave a patient room, the answer is absolutely
not. If we are talking about the WHO 5 Moments for Hand
Hygiene, they are enough if it is followed well (we aim for
80 percent compliance but even improvements resulting in
far lower levels of compliance have caused large reductions
in healthcare-associated infections).”
Pottinger emphasizes, “Current handwashing protocols
from CDC and APIC are excellent. They do not include
microbiological testing of hands to see just how clean they
are, probably because such testing is not practical and not
necessary, so long as hands are washed in the correct way and
at the correct opportunities. Specifically, hands should be clean
during patient encounters. Using an alcohol-based hand rub
is appropriate if hands are visibly clean before the product is
applied, but nothing replaces good old soap and water when
they are visibly soiled. Nothing too fancy is required to do a
great job: get hands wet, rub them together with plenty of
soap, make sure the entire hand is soaped up (including the
backs, between fingers... everywhere), and keep on scrubbing.
After 15-20 seconds, the bioburden should be so low that
risk of carrying or transmitting germs by hand is exponentially
reduced. If that protocol is followed, it is plenty robust.” 
References:
Edmonds-Wilson SL, et al. Review of human hand microbiome research.
J Derm Science. Vol. 80, No. 1. Pages 3-12. October 2015.
Fierer N, Hamady M, Lauber CL, and Knight R. The influence of sex,
handedness, and washing on the diversity of hand surface bacteria. PNAS. Nov.
18, 2008; 105 (46) 17994-17999. https://doi.org/10.1073/pnas.0807920105
Fredricks DN. Microbial Ecology of Human Skin in Health and Disease. J
Investigative Derm Symposium Proceedings. Vol. 6, No. 3, Pages 167-169.
December 2001.
Grice E, et al. (2008) A diversity profile of the human skin microbiota.
Genome Res 18:1043–1050.
Jain VM. Comparative assessment of antimicrobial efficacy of different
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Kumar, KV, et al. Co-aggregation of bacterial flora isolated from the human
skin surface. Microbial Pathogenesis. Vol. 135, October 2019.
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