Infection Control Hotline

By Jean Fleming, R.N.

Just how significantly can you decrease the potential for bloodstream infections when using a combination skin prepping antiseptic of chlorhexidine gluconate and 70 percent isopropyl alcohol? What departments would benefit most from using this combination skin prepping antiseptic? Should patients have regular access to alcohol-based hand sanitizers? Get answers to these questions and more.

Q: What are the advantages of a combination skin prepping antiseptic CHG/70 percent isopropyl alcohol versus other skin prepping antiseptics?

With a combination skin-prepping antiseptic chlorhexidine gluconate (CHG) and 70 percent isopropyl alcohol (IPA), there is an immediate bactericidal action against both the skin’s resident and transient microbial flora. Alcohol is rapid acting and dries fast, thus producing the rapid kill time of microbes. Chlorhexidine gluconate has excellent residual, persistent activity. With CHG there is activity retention in the presence of blood or bodily fluids. When combined with 70 percent IPA, there is rapid action, fast drying plus a persistent activity that prevents the re-growth of skin microorganisms even in the presence of blood.

A number of studies published have shown that a combination of CHG/70 percent IPA has reduced the incidence of bloodstream infections in patients with central venous catheters. A meta-analysis by Chalyakaunapruk et. al. published in the Annals of Internal Medicine, 2002, Vol. 132. No. 11, (“Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care; a meta-analysis”), suggested that the incidence of bloodstream infections was reduced significantly  in patients with central vascular catheters who received chlorhexidine gluconate versus povidone-iodine for insertion site disinfection.

Over the past several years, clinicians have favored the combination of CHG/70 percent IPA antiseptics over single antiseptics for skin prepping.

Q: What specific departments within a hospital would benefit from using a CHG/70 percent isopropyl alcohol skin prepping antiseptic?

Departments that would benefit are those in which antiseptic skin prepping is performed for operative or injection procedures. Such departments may include: emergency rooms, operating rooms, out-patient surgery, anesthesia, intravenous or vascular access teams, laboratory phlebotomy or blood culture services, blood bank donor facilities, special procedure areas (endoscopy), medical imaging (radiology), cardiology, ICUs/critical care units and general nursing units.

Q: What are the recommended methods/products for disinfecting surfaces in Clostridium difficile patient rooms, and why is bleach so often cited as the recommended method?

Clostridium difficile is a spore-forming microorganism. Spores are killed by sterilization or high-level disinfection. C. difficile spores are more resistant than vegetative cells to commonly used surface disinfectants and the environment may be an important source of C. difficile spores. Because there are no EPA-registered products specific for inactivating C. difficile spores, the use of a diluted hypochlorite (1:10 dilution of bleach) should be considered in units with high endemic C. difficile rates or in an outbreak setting. Diluted sodium hypochlorite prevents the spores from replicating or reproducing. Many published studies have shown the reduction of C. difficile infection rates when sodium hypochlorite is used routinely to disinfect of rooms of patients with C. difficile diarrhea. Studies also have shown that person-to-person transmission is the principle means of transmission between patients. It is important to stress that hand washing, use of barrier precautions and meticulous environmental cleaning are key measures for preventing the spread of C. difficile.

Q: What is the rationale behind selecting chemical germicides for disinfecting critical items, semicritical items and noncritical items?

The rationale behind selecting chemical germicides for disinfection and sterilization of patient care items or equipment is based on a logical approach devised by Earle H. Spaulding, Ph.D., more than 35 years ago. Spaulding’s classification scheme has been used successfully by infection control professionals and others when planning methods for disinfection or sterilization. The classification scheme is divided into three categories based on the degree of risk of infection involved in the use of the items.

The three categories are: critical, semicritical and noncritical. Items are called critical because of the high risk of infection if such an item is contaminated with any microorganism, including bacterial spores. Items or objects that enter sterile tissue or the vascular system must be sterile because any microbial contamination could result in disease transmission.

These include surgical instruments, cardiac and urinary catheters, implants and ultrasound probes used in sterile body cavities. Items in this category should be purchased as sterile or be sterilized by steam sterilization, ETO, hydrogen peroxide gas plasma or liquid chemical sterilants.

Semicritical items are those that come in contact with mucous membranes or broken skin. These medical items should be free of microorganisms, although small numbers of spores may be present. Mucous membranes of the lungs and gastrointestinal tract are generally more susceptible to infection by such bacteria as mycobacteria and viruses than common bacterial spores. Respiratory therapy and anesthesia equipment, some endoscopes, laryngoscope blades, diaphragm fitting rings are examples of semicritical items. These items require minimal, high-level disinfection using FDA-approved chemical disinfectants, e.g., glutaraldehyde, hydrogen peroxide, orthophthalaldehyde and peracetic acid.

Noncritical items are those that come in contact with intact skin but not mucous membranes. Intact skin is the most effective barrier to most microorganisms. Therefore, items that come in contact with intact skin are not considered critical. Noncritical items are divided into patient care items and environmental items. Examples of noncritical patient care items include blood pressure cuffs, stethoscopes, IV poles and IV pumps.

Examples of noncritical environmental items include bed rails, bedside tables, patient furniture and countertops. Noncritical items frequently are touched items in the patient environment or shared by patients and potentially can contribute to secondary transmission. Such items and surfaces are disinfected with hospital germicides that are EPA-approved as intermediate or low-level surface disinfectants.

Q: Is it important to have alcohol-based hand sanitizers for patient use?

Patient hand hygiene should be a part of all infection prevention and control initiatives, and alcohol-based hand sanitizers should be offered to both patients and health care workers.

Infection transmission from patients exists in all health care settings. Patients may be bedridden, have a limited ability to ambulate or are unaware of the risk of infection transmission and importance of hand hygiene. We must ask: Who is providing hand hygiene to these patients? Is it done? If so, how is it done? Patients may be infected or colonized with pathogenic microorganisms (e.g., MRSA; viruses), thus a contamination source to the environment.

Patients who are alert can be involved in their own care to reduce the risk of infection. Shouldn’t patients and family members be reminded about clean hands when touching a wound, IV or vent? Patients carry transient microorganisms on their hands—they touch bedrails, telephones, call bells, chair arms, light switches, etc., and children play with toys in the playroom or sit in chairs, swings, etc.

Does anyone offer patients hand hygiene before leaving a room for testing or returning to a room, before eating or after using a bedpan/commode chair or assisting to the bathroom?

With increasing infection rates associated with the spread of resistant organisms and viral outbreaks reported in health care and the community, a hand sanitizer is needed that has good antimicrobial efficacy against hard-to-kill and common nosocomial pathogens.

Alcohol-based hand wipes that contain 65 percent ethanol alcohol with emollients is ideal for patient use because they create the friction to remove soil from hands and provide the antimicrobial efficacy against pathogenic microorganisms found in a hospital environment. It is easier for a caregiver, family member or visitor to wipe a patient’s hands using an alcohol-based hand wipe than to rub in a gel, foam or liquid alcohol-based hand rub. Patient hand hygiene should be at the bedside within reach of a patient.

In today’s environment, with emerging pathogens and problem pathogens in health care, alcohol-based hand sanitizers with more than 60 percent ethanol alcohol are more effective than non-alcohol or low-alcohol hand sanitizers for patient use.

Hand hygiene for patients should be a key element of a hospital’s patient safety and hand hygiene programs.  

About this column

This column presents answers and practical guidance to some of the most commonly asked questions of suppliers and educators in the infection control and sterile processing communities. To submit a question to the column, e-mail Bob Kehoe, associate pubisher, at [email protected].

This article first appeared in the January 2008 issue of Materials Management in Health Care.

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