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Morbidity and Mortality Weekly ReportRecommendations and ReportsOctober 25, 2002 / Vol. 51 / No. RR-16Guideline for Hand Hygiene in Health-Care SettingsRecommendations of the Healthcare Infection Control PracticesAdvisory Committee and the HICPAC/SHEA/APIC/IDSAHand Hygiene Task ForceINSIDE: Continuing Education ExaminationCenters for Disease Control and PreventionSAFER HEALTHIERHEALTHIER TMPEOPLE

MMWRCONTENTSThe MMWR series of publications is published by theEpidemiology Program Office, Centers for DiseaseControl and Prevention (CDC), U.S. Department ofHealth and Human Services, Atlanta, GA 30333.Part I. Review of the Scientific Data RegardingHand Hygiene . 1Historical Perspective . 1Normal Bacterial Skin Flora . 2Physiology of Normal Skin . 2SUGGESTED CITATIONCenters for Disease Control and Prevention.Guideline for Hand Hygiene in Health-CareSettings: Recommendations of the HealthcareInfection Control Practices Advisory Committeeand the HICPAC/SHEA/APIC/IDSA HandHygiene Task Force. MMWR 2002;51(No. RR16):[inclusive page numbers].Definition of Terms . 3Evidence of Transmission of Pathogens on Hands . 4Models of Hand Transmission . 5Relation of Hand Hygiene and Acquisitionof Health-Care–Associated Pathogens . 5Methods Used To Evaluate the Efficacyof Hand-Hygiene Products . 6Centers for Disease Control and PreventionJulie L. Gerberding, M.D., M.P.H.DirectorDavid W. Fleming, M.D.Deputy Director for Science and Public HealthDixie E. Snider, Jr., M.D., M.P.H.Associate Director for ScienceEpidemiology Program OfficeStephen B. Thacker, M.D., M.Sc.DirectorOffice of Scientific and Health CommunicationsJohn W. Ward, M.D.DirectorEditor, MMWR SeriesSuzanne M. Hewitt, M.P.A.Managing EditorReview of Preparations Used for Hand Hygiene . 8Activity of Antiseptic Agents AgainstSpore-Forming Bacteria . 16Reduced Susceptibility of Bacteria to Antiseptics . 17Surgical Hand Antisepsis . 17Relative Efficacy of Plain Soap, AntisepticSoap/Detergent, and Alcohols . 18Irritant Contact Dermatitis Resulting fromHand-Hygiene Measures . 18Proposed Methods for Reducing AdverseEffects of Agents . 19Factors To Consider When SelectingHand-Hygiene Products . 20Hand-Hygiene Practices Among HCWs . 21Lessons Learned from Behavioral Theories . 25Methods Used To Promote Improved Hand Hygiene . 26Efficacy of Promotion and Impact of ImprovedRachel J. WilsonDouglas W. WeatherwaxProject EditorsMalbea A. HeilmanBeverly J. HollandVisual Information SpecialistsQuang M. DoanErica R. ShaverInformation Technology SpecialistsHand Hygiene . 27Other Policies Related to Hand Hygiene . 29Hand-Hygiene Research Agenda . 30Web-Based Hand-Hygiene Resources . 30Part II. Recommendations . 31Categories . 31Recommendations . 32Part III. Performance Indicators . 34References . 34Appendix . 45Continuing Education Activity . CE-1

Vol. 51 / RR-16Recommendations and Reports1Guideline for Hand Hygiene in Health-Care SettingsRecommendations of the Healthcare Infection Control Practices AdvisoryCommittee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task ForcePrepared byJohn M. Boyce, M.D.1Didier Pittet, M.D.21Hospital of Saint RaphaelNew Haven, Connecticut2University of GenevaGeneva, SwitzerlandSummaryThe Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promoteimproved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-caresettings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline forhandwashing and hospital environmental control, 1985. Infect Control 1986;7:231–43) and the 1995 APIC guideline(Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings.Am J Infect Control 1995;23:251–69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levelsof adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the invivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studiesdemonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubsin improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical handantiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.Part I. Review of the Scientific DataRegarding Hand HygieneHistorical PerspectiveFor generations, handwashing with soap and water has beenconsidered a measure of personal hygiene (1). The concept ofcleansing hands with an antiseptic agent probably emerged inthe early 19th century. As early as 1822, a French pharmacistdemonstrated that solutions containing chlorides of lime orsoda could eradicate the foul odors associated with humancorpses and that such solutions could be used as disinfectantsand antiseptics (2). In a paper published in 1825, this pharmacist stated that physicians and other persons attendingpatients with contagious diseases would benefit from moistening their hands with a liquid chloride solution (2).In 1846, Ignaz Semmelweis observed that women whosebabies were delivered by students and physicians in the FirstClinic at the General Hospital of Vienna consistently had aThe material in this report originated in the National Center forInfectious Diseases, James M. Hughes, M.D., Director; and the Divisionof Healthcare Quality Promotion, Steve Solomon, M.D., ActingDirector.higher mortality rate than those whose babies were deliveredby midwives in the Second Clinic (3). He noted that physicians who went directly from the autopsy suite to the obstetrics ward had a disagreeable odor on their hands despitewashing their hands with soap and water upon entering theobstetrics clinic. He postulated that the puerperal fever thataffected so many parturient women was caused by “cadaverous particles” transmitted from the autopsy suite to theobstetrics ward via the hands of students and physicians. Perhaps because of the known deodorizing effect of chlorine compounds, as of May 1847, he insisted that students andphysicians clean their hands with a chlorine solution betweeneach patient in the clinic. The maternal mortality rate in theFirst Clinic subsequently dropped dramatically and remainedlow for years. This intervention by Semmelweis represents thefirst evidence indicating that cleansing heavily contaminatedhands with an antiseptic agent between patient contacts mayreduce health-care–associated transmission of contagious diseases more effectively than handwashing with plain soap andwater.In 1843, Oliver Wendell Holmes concluded independentlythat puerperal fever was spread by the hands of health personnel (1). Although he described measures that could be takento limit its spread, his recommendations had little impact on

2MMWRobstetric practices at the time. However, as a result of the seminal studies by Semmelweis and Holmes, handwashing gradually became accepted as one of the most important measuresfor preventing transmission of pathogens in health-care facilities.In 1961, the U. S. Public Health Service produced a training film that demonstrated handwashing techniques recommended for use by health-care workers (HCWs) (4). At thetime, recommendations directed that personnel wash theirhands with soap and water for 1–2 minutes before and afterpatient contact. Rinsing hands with an antiseptic agent wasbelieved to be less effective than handwashing and was recommended only in emergencies or in areas where sinks were unavailable.In 1975 and 1985, formal written guidelines onhandwashing practices in hospitals were published by CDC(5,6). These guidelines recommended handwashing with nonantimicrobial soap between the majority of patient contactsand washing with antimicrobial soap before and after performing invasive procedures or caring for patients at high risk. Useof waterless antiseptic agents (e.g., alcohol-based solutions)was recommended only in situations where sinks were notavailable.In 1988 and 1995, guidelines for handwashing and handantisepsis were published by the Association for Professionalsin Infection Control (APIC) (7,8). Recommended indicationsfor handwashing were similar to those listed in the CDC guidelines. The 1995 APIC guideline included more detailed discussion of alcohol-based hand rubs and supported their use inmore clinical settings than had been recommended in earlierguidelines. In 1995 and 1996, the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommendedthat either antimicrobial soap or a waterless antiseptic agentbe used for cleaning hands upon leaving the rooms of patientswith multidrug-resistant pathogens (e.g., vancomycin-resistantenterococci [VRE] and methicillin-resistant Staphylococcusaureus [MRSA]) (9,10). These guidelines also provided recommendations for handwashing and hand antisepsis in otherclinical settings, including routine patient care. Although theAPIC and HICPAC guidelines have been adopted by themajority of hospitals, adherence of HCWs to recommendedhandwashing practices has remained low (11,12).Recent developments in the field have stimulated a reviewof the scientific data regarding hand hygiene and the development of new guidelines designed to improve hand-hygienepractices in health-care facilities. This literature review andaccompanying recommendations have been prepared by aHand Hygiene Task Force, comprising representatives fromHICPAC, the Society for Healthcare Epidemiology of America(SHEA), APIC, and the Infectious Diseases Society of America(IDSA).October 25, 2002Normal Bacterial Skin FloraTo understand the objectives of different approaches to handcleansing, a knowledge of normal bacterial skin flora is essential. Normal human skin is colonized with bacteria; differentareas of the body have varied total aerobic bacterial counts(e.g., 1 x 106 colony forming units (CFUs)/cm2 on the scalp,5 x 105 CFUs/cm2 in the axilla, 4 x 104 CFUs/cm2 on theabdomen, and 1 x 104 CFUs/cm2 on the forearm) (13). Totalbacterial counts on the hands of medical personnel have rangedfrom 3.9 x 104 to 4.6 x 106 (14–17). In 1938, bacteria recovered from the hands were divided into two categories: transient and resident (14). Transient flora, which colonize thesuperficial layers of the skin, are more amenable to removal byroutine handwashing. They are often acquired by HCWs during direct contact with patients or contact with contaminatedenvironmental surfaces within close proximity of the patient.Transient flora are the organisms most frequently associatedwith health-care–associated infections. Resident flora, whichare attached to deeper layers of the skin, are more resistant toremoval. In addition, resident flora (e.g., coagulase-negativestaphylococci and diphtheroids) are less likely to be associatedwith such infections. The hands of HCWs may become persistently colonized with pathogenic flora (e.g., S. aureus), gramnegative bacilli, or yeast. Investigators have documented that,although the number of transient and resident flora varies considerably from person to person, it is often relatively constantfor any specific person (14,18).Physiology of Normal SkinThe primary function of the skin is to reduce water loss,provide protection against abrasive action and microorganisms, and act as a permeability barrier to the environment.The basic structure of skin includes, from outer- to innermost layer, the superficial region (i.e., the stratum corneum orhorny layer, which is 10- to 20-µm thick), the viable epidermis (50- to 100-µm thick), the dermis (1- to 2-mm thick),and the hypodermis (1- to 2-mm thick). The barrier to percutaneous absorption lies within the stratum corneum, the thinnest and smallest compartment of the skin. The stratumcorneum contains the corneocytes (or horny cells), which areflat, polyhedral-shaped nonnucleated cells, remnants of theterminally differentiated keratinocytes located in the viableepidermis. Corneocytes are composed primarily of insolublebundled keratins surrounded by a cell envelope stabilized bycross-linked proteins and covalently bound lipid. Interconnecting the corneocytes of the stratum corneum are polar structures (e.g., corneodesmosomes), which contribute to stratumcorneum cohesion.

Vol. 51 / RR-16Recommendations and ReportsThe intercellular region of the stratum corneum is composed of lipid primarily generated from the