AAOS Bulletin - April, 2006

Hand hygiene guidelines for orthopaedists

Hand washing is the single most important means to prevent the spread of infection

By David B. Carmack, MD

The concept of cleansing hands with an antiseptic agent probably emerged in the early 19th century. As early as 1822, a French pharmacist demonstrated that solutions containing chlorides of lime or soda could eradicate the foul odors associated with human corpses and that such solutions could be used as disinfectants and antiseptics.

In 1961, the U.S. Public Health Service produced a training film that demonstrated hand washing techniques recommended for use by health-care workers (HCW). In 1988 and 1995, guidelines for hand washing and hand antisepsis were published by the Association for Professionals in Infection Control (APIC). In 1995 and 1996, the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended that either antimicrobial soap or a waterless antiseptic agent be used for cleaning hands upon leaving the rooms of patients infected with multidrug-resistant pathogens.

Although the APIC and HICPAC guidelines have been adopted by the majority of hospitals, adherence of HCWs to recommended hand washing practices has remained low.

Defining terms

• Alcohol-based hand rub: An alcohol-containing preparation designed for application to the hands for reducing the number of viable microorganisms on the hands. In the United States, such preparations usually are 60 percent to 95 percent ethanol or isopropanol.

• Antimicrobial soap: Soap (detergent) containing an antiseptic agent.

• Antiseptic agent: Antimicrobial substances that are applied to the skin to reduce the number of microbial flora.

• Antiseptic hand rub: Applying an antiseptic hand-rub product to all surfaces of the hands to reduce the number of microorganisms present.

• Detergent: Detergents (surfactants) are compounds that possess a cleaning action.

• Waterless antiseptic agent: An antiseptic agent that does not require use of exogenous water. After applying such an agent, the hands are rubbed together until the agent has dried.

Transmission of pathogens

Transmission of health-care-associated pathogens from one patient to another via the hands of HCWs requires the following sequence of events:

• Organisms present on the patient’s skin, or that have been shed onto inanimate objects in close proximity to the patient, must be transferred to the hands of HCWs.

• These organisms must then be capable of surviving for at least several minutes on the HCW’s hands.

• Handwashing or hand antisepsis by the worker must be inadequate or omitted entirely, or the agent used for hand hygiene must be inappropriate.

• The HCW’s contaminated hands must come in direct contact with another patient, or with an inanimate object that will come into direct contact with the patient.

Health-care-associated pathogens can be recovered not only from infected or draining wounds, but also from frequently colonized areas of normal, intact patient skin. The perineal or inguinal areas are usually most heavily colonized, but the axillae, trunk and upper extremities (including the hands) also are frequently colonized. The number of organisms (Staphylococcus aureus, Proteus mirabilis, Klebsiella species and Acinetobacter species) present on intact areas of the skin of certain patients can vary from 100/cm2 to 106/cm2.

Patients with diabetes, those undergoing dialysis for chronic renal failure and those with chronic dermatitis are likely to have areas of intact skin colonized with S. aureus. In one study, Agar fingertip impression plates were used to culture bacteria; the number of bacteria recovered from fingertips ranged from 0 to 300 colony-forming units (CFUs). Duration of patient-care activity was strongly associated with the intensity of bacterial contamination of HCWs’ hands. HCWs can contaminate their hands with gram-negative bacilli, S. aureus, enterococci, or Clostridium difficile by performing “clean procedures” or touching intact areas of the skin of hospitalized patients.

Other studies also have documented that HCWs may contaminate their hands (or gloves) merely by touching inanimate objects in patient rooms. One study found that S. aureus could be recovered from the hands of 21 percent of intensive-care-unit personnel and that 21 percent of physician carriers and 5 percent of nurse carriers had more than 1,000 CFUs of the organism on their hands. Serial cultures revealed that 100 percent of HCWs carried gram-negative bacilli at least once, and 64 percent carried S. aureus at least once.

Preparations for hand hygiene

Plain (non-antimicrobial) soap: The cleaning activity of these agents can be attributed to their detergent properties, which result in removal of dirt, soil and various organic substances from the hands. Plain soaps have minimal, if any, antimicrobial activity.

• Alcohols: The antimicrobial activity of alcohols can be attributed to their ability to denature proteins. The ideal volume of product to apply to the hands is not known.

• Chlorhexidine: The antimicrobial activity of chlorhexidine is likely attributable to attachment to—and subsequent disruption of—cytoplasmic membranes, resulting in precipitation of cellular contents.

• Chloroxylenol: The antimicrobial activity of para-chloro-meta-xylenol (PCMX) may be attributable to inactivation of bacterial enzymes and alteration of cell walls.

• Hexachlorophene: Hexachlorophene can inactivate essential enzyme systems in microorganisms. It is bacteriostatic.

• Iodine and iodophors: Iodine molecules rapidly penetrate the cell wall of microorganisms and inactivate cells by forming complexes with amino acids and unsaturated fatty acids, resulting in impaired protein synthesis and alteration of cell membranes.

• Quaternary ammonium compounds: These compounds are primarily bacteriostatic and fungistatic, although they are microbicidal against certain organisms at high concentrations.

• Triclosan: Triclosan enters bacterial cells and affects the cytoplasmic membrane and synthesis of RNA, fatty acids and proteins.

Hand hygiene by HCWs

Adherence of HCWs to recommended hand-hygiene procedures has been poor, with mean baseline rates of 5 percent to 81 percent (overall average: 40 percent).


1. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51

David B. Carmack, MD, is a member of the AAOS Infections Committee. He can be reached at dcarmack@emh.org


1. Indications for handwashing and hand antisepsis

• Hands that are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids should be washed with either a non-antimicrobial soap and water or an antimicrobial soap and water.

• If hands are not visibly soiled, an alcohol-based hand rub should be used for routine decontamination in all other clinical situations.

• Decontaminate hands before having direct contact with patients.

• Decontaminate hands after contact with a patient’s intact skin (such as when taking a pulse or blood pressure or lifting a patient).

• Even if hands are not visibly soiled, they should be decontaminated after contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings.

• Decontaminate hands if moving from a contaminated body site to a clean body site during patient care.

• Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

• Decontaminate hands after removing gloves.

• Wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water before eating and after using a restroom.

• No recommendation can be made regarding the routine use of non-alcohol-based hand rubs for hand hygiene in health-care settings. This is an unresolved issue.

2. Hand hygiene techniques

• When decontaminating hands with an alcohol-based hand rub, apply the product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer’s recommendations regarding the volume of product to use.

• When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet.

• Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care settings.

3. Surgical hand antisepsis

• Remove rings, watches and bracelets before beginning the surgical hand scrub.

• Remove debris from underneath fingernails using a nail cleaner under running water.

• Use either an antimicrobial soap or an alcohol-based hand rub with persistent activity before donning sterile gloves to perform a surgical procedure.

• When using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 2 to 6 minutes. Long scrub times (10 minutes) are not necessary.

• When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer’s instructions. Before applying the alcohol solution, prewash hands and forearms with a non-antimicrobial soap and dry them completely. After applying the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves.

4. Other aspects of hand hygiene

• Do not wear artificial fingernails or extenders if you will have direct contact with patients at high risk (those in intensive-care units or operating rooms).

• Keep natural nails tips less than 1/4” long.

• Wear gloves when you could come into contact with blood or other potentially infectious materials, mucous membranes and non-intact skin.

• Change gloves during patient care if you are moving from a contaminated body site to a clean body site.

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