Medical Journal of Dr. D.Y. Patil Vidyapeeth

: 2018  |  Volume : 11  |  Issue : 3  |  Page : 201--202

Hand hygiene and hospital-acquired infections

Sarit Sharma 
 Department of Community Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Correspondence Address:
Sarit Sharma
Department of Community Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab

How to cite this article:
Sharma S. Hand hygiene and hospital-acquired infections.Med J DY Patil Vidyapeeth 2018;11:201-202

How to cite this URL:
Sharma S. Hand hygiene and hospital-acquired infections. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2020 Sep 24 ];11:201-202
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Full Text

Hospital-acquired infection (HAI) or health care-associated infection is an infection occurring in a patient during the process of care in a hospital or other health-care facility which was not present or incubating at the time of admission. Hand hygiene (HH) is a simple yet effective way to prevent HAIs. Studies have shown that there is knowledge about the importance of HH, but implementation of these guidelines in practice is poor. This is evident from the high incidence of HAIs both in developed and developing countries. According to the Centers for Disease Control and Prevention (CDC) data, approximately one in 25 patients acquire HAI during their hospital care in the USA, adding up to about 722,000 infections a year, out of which, 75,000 patients die of their infections.[1]

In developed countries, HAIs continue to account for complications in 5%–10% of admissions to acute-care hospitals. In developing countries, the impact of HAI is far greater, approximately two- to twenty-fold higher than those in the developed countries. Although the surveillance is poor in developing countries, the prevalence studies report hospital-wide infection rates usually higher than 15%.[2]

 The Link between Hospital-Acquired Infections and Hand Hygiene Practices

Since Semmelweis' observation regarding the importance of handwashing, there have been many studies to confirm the role that health-care workers' (HCW) hands play in transmission of pathogens in the health-care settings. Various organizations, including the CDC and WHO, have published guidelines on appropriate HH practices for HCWs. Sustained hospital-wide compliance improvement associated with the reduction of overall HAI prevalence and methicillin-resistant Staphylococcus aureus (MRSA) cross-transmission was shown in a study by Pittet et al.[3] Another study showed that when HH compliance increased from poor (<60%) to excellent (90%), it was associated with a 24% reduction in the risk of MRSA acquisition. Furthermore, lower incidence rates of MRSA, resistant Escherichia coli, and carbapenem-resistant Pseudomonas aeruginosa in wards have been seen with compliance levels higher than 70%.[4],[5]


Transmission of health care-associated pathogens from one patient to another occurs through hands of HCWs if the organisms are present on the patient's skin or have been shed onto inanimate objects immediately surrounding the patient. There are five moments of HH as outlined by the WHO: before patient contact, before aseptic task, after bodily fluid exposure, after patient contact, and after contact with patient surroundings.[6] Alcohol-based hand sanitizers are the preferred way to clean hands in health-care facilities as these are more effective and cause less drying than using soap and water. However, sanitizers do not kill Clostridium difficile, a common health care-associated infection that causes severe diarrhea. Patients with C. difficile should wash their hands with soap and water and make sure that their health-care providers always wear gloves when caring for them.[7] Care should be taken that glove use is not a substitute for handwashing.

Several barriers have been reported that lead to overall low HH compliance. The reasons reported in literature are skin irritation, inaccessible supplies, interference with worker–patient relation, patient needs perceived as priority, wearing gloves, forgetfulness, ignorance of guidelines, insufficient time, high workload and understaffing, and lack of scientific information demonstrating the impact of improved HH on hospital infection rates.[7] CDC's “Clean Hands Count” campaign, started in May 2017, aims to improve health-care provider adherence to HH recommendations. This campaign encourages and empowers patients to play a role in their own care by asking or reminding health-care providers to clean their hands before caring for them.[8]

 Monitoring of Hand Hygiene

The gold standard of monitoring HH compliance is direct observation, but the reliability of this method to measure true, actual compliance with HH is questionable. HH compliance increases in front of the observers. It is the classic Hawthorne effect, where people change their behavior when they know they are being watched.[9] Another issue is that it is difficult to observe all the HH opportunities that a health-care provider should undergo. Health-care providers might need to clean their hands as many as 100 times per 12-h shift, depending on the number of patients and intensity of care. However, studies show that on an average, health-care providers clean their hands less than half of the times they should.[8]

Another novel intervention for monitoring HH that has been tried in Brazil involve using electronic surveillance system with radiofrequency devices with censors placed at patient bedside, hand rub dispenser, and employee's ID badge.[10] Such newer interventions for better monitoring and encouraging HH among HCWs can go a long way in decreasing HAIs' prevalence in the health-care settings.


1CDC. HAI Data and Statistics. Health Care Associated Infections. Available from: [Last accessed on 2018 Feb 11].
2WHO. Clean Care is Safer Care. Available from: [Last accessed on 2018 Feb 11].
3Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection control programme. Lancet 2000;356:1307-12.
4Girou E, Legrand P, Soing-Altrach S, Lemire A, Poulain C, Allaire A, et al. Association between hand hygiene compliance and methicillin-resistant Staphylococcus aureus prevalence in a French rehabilitation hospital. Infect Control Hosp Epidemiol 2006;27:1128-30.
5Trick WE, Vernon MO, Welbel SF, Demarais P, Hayden MK, Weinstein RA, et al. Multicenter intervention program to increase adherence to hand hygiene recommendations and glove use and to reduce the incidence of antimicrobial resistance. Infect Control Hosp Epidemiol 2007;28:42-9.
6WHO. Cleaner Care is Safer Care. Available from: [Last accessed on 2018 Feb 11].
7Pittet D. Improving adherence to hand hygiene practice: A multidisciplinary approach. Emerg Infect Dis 2001;7:234-40.
8Clean Hands Count Campaign. Available from: [Last accessed on 2018 Feb 11].
9Hagel S, Reischke J, Kesselmeier M, Winning J, Gastmeier P, Brunkhorst FM, et al. Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring. Infect Control Hosp Epidemiol 2015;36:957-62.
10de França SR, Sant'Ana EA, Nunes Mafra AC, Prado M, Gagliardi GM, Edmond MB, et al. The impact of isolation precautions on hand hygiene frequency by healthcare workers. Infect Control Hosp Epidemiol 2018;39:245-7.