Review
Handwashing in the intensive care unit: a big measure with modest effects

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Summary

Handwashing is widely accepted as the cornerstone of infection control in the intensive care unit. Nosocomial infections are frequently viewed as an indicator of poor compliance of handwashing. The aim of this review is to evaluate the effectiveness of handwashing on infection rates in the intensive care unit, and to analyse the failure of handwashing. A literature search identified nine studies that evaluated the impact of handwashing or hand hygiene on infection rates, and demonstrated a low level of evidence for the efforts to control infection with handwashing. Poor compliance cannot be blamed as the only reason for the failure of handwashing to control infection. Handwashing on its own does not abolish, but only reduces transmission, as it is dependent on the bacterial load on the hand of healthcare workers. Finally, recent studies, using surveillance cultures of throat and rectum, have shown that, under ideal circumstances, handwashing can only influence 40% of all intensive care unit infections. A randomised clinical trial with the intensive care as randomisation unit is required to support handwashing as the cornerstone of infection control.

Introduction

Influential authorities including the Centers for Disease Control and Prevention and the American Hospital Association believe that ‘handwashing remains the single most important prevention strategy that reduces the risk of healthcare workers transmitting micro-organisms from one patient to another’.1, 2 Since the beginning of intensive care in the 1960s, handwashing has been an example of a procedure that must be religiously observed because of the belief that, if ignored, nosocomial infection will become an enormous problem. Infections occurring more than two days after admission to an intensive care unit (ICU) are attributed to micro-organisms originating within the unit and due to transmission from one patient to another via the unwashed hands of healthcare workers.3 Infections occurring within two days are deemed to be present or incubating at the time of entry to the ICU and not because of inadequate prophylactic handwashing. Thus 40 years after the inception of intensive care, handwashing has become a dogma,4 and nosocomial infections are viewed as a marker of poor compliance. The widely held belief is that handwashing works, and that it is an ‘all-or-nothing’ intervention.

However, are these assumptions fair? What evidence is there to support the views espoused by influential authorities and experts? One-third of critically ill adults on ICUs still die from their underlying disease and resultant immunoparalysis which is complicated by infection.5 Rates of pneumonia and septicaemia have not changed since the 1960s; an observation which could be interpreted as indicating that handwashing has failed. However, to undertake a randomized controlled trial (RCT) is likely to be considered unethical.

Section snippets

Re-assessing the failure of handwashing

Five years ago, an editorial entitled ‘Hand washing. A modest measure—with big effects’ was published by the Handwashing Liaison Group.6 We challenge the assertion of this editorial as we would argue that handwashing is actually the opposite; ‘a big measure—with modest effects’. This view is the result of our daily ICU experience that, despite genuine and vigorous attempts to comply with handwashing protocols, the number of methicillin-resistant Staphylococcus aureus (MRSA) cases continues to

Analysis of clinical trials on handwashing

We searched for clinical trials published from January 1976 to December 2003. Studies were identified through Medline (MeSH keywords: ‘handwashing’, ‘intensive care units’, ‘infection’, ‘cross infection’ and ‘antisepsis’). No language restriction was applied. Moreover, citations before November 1998 were also obtained from the only available potentially relevant review article.12 All trials that evaluated the effectiveness of handwashing or hand hygiene practices on infection rates in ICUs were

The definition of nosocomial infection is wrong: most ICU infections are not due to transmitted bacteria

The conventional approach to classifying infections on ICUs is based on the criterion of time,3 where infections occurring after 48 h are considered to be ‘nosocomial’. An alternative approach to classifying infections on the ICU is based upon the carrier state.25 In this classification, primary endogenous infections are caused by both normal, e.g. Streptococcus pneumoniae, and abnormal potentially pathogenic micro-organisms (PPMs), e.g. aerobic Gram-negative bacilli (AGNB) that are already

Is there a solution?

Handwashing may fail to control transmission, acquisition, infection and outbreaks for three reasons. Firstly, poor compliance has always been blamed for the failure of handwashing to control infection. Factors that contribute to this poor compliance include professional category, time of the day/week, and type and intensity of patient's care.4 This is why handwashing is not a simple or modest measure. The recognition that handwashing only reduces the level of contamination illustrates that it

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