Skip directly to site content Skip directly to page options Skip directly to A-Z link Skip directly to A-Z link Skip directly to A-Z link
Volume 7, Number 2—April 2001
THEME ISSUE
4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections
Prevention is Primary

Hygiene of the Skin: When Is Clean Too Clean?

Elaine LarsonComments to Author 
Author affiliation: Columbia University School of Nursing, New York, New York, USA

Main Article

Table

Microbial flora colonizing hands of health-care professionals

A. Microbial counts
Year (reference) Sample (# subjects) Mean log10 CFUa
1986 (62) Staff of bone marrow transplant unit (n = 22) 4. 89
1992 (63) Pediatric staff, Peru (n = 62) 5.88
1997 (64) Nurses in acute care unit (n = 40) 5.61
B. Resistance of coagulase-negative staphylococcal flora
Resistant (%) to
Year (reference) Sample (no. of isolates) methicillin tetracycline
1986 (62) Staff of bone marrow transplant unit (50) 68.0 23.0
1988 (65) oncology, dermatology staff (152) 50.7 30.7
1992 (63) Pediatric staff, Peru (279) 40.9 45.4
1997 (64) Acute care nurses (122) 59.0 10.5

aCFU = Colony-forming unit

Main Article

References
  1. Sattar  SA, Tetro  J, Springthorpe  VS. Impact of changing societal trends on the spread of infections in American and Canadian homes. Am J Infect Control. 1999;27:S421. DOIPubMed
  2. Green  VW. Cleanliness and the health revolution. New York: Soap and Detergent Association; 1984. Available from: URL: http://www.sdahq.org/about/order_formjs.html
  3. Larson  E. Social and economic impact of infectious diseases--United States. Clin Perform Qual Health Care. 1997;5:317.PubMed
  4. Ekanem  EE, Akitoye  CO, Adedeji  OT. Food hygiene behaviour and childhood diarrhoea in Lagos, Nigeria: a case-control study. J Diarrhoeal Dis Res. 1991;9:21926.PubMed
  5. Alam  N, Wojtyniak  B, Henry  FJ, Rahaman  MM. Mothers' personal and domestic hygiene and diarrhoea incidence in young children in rural Bangladesh. Int J Epidemiol. 1989;18:2427. DOIPubMed
  6. Feachem  RG. Interventions for the control of diarrhoeal diseases among young children: promotion of personal and domestic hygiene. Bull World Health Organ. 1984;62:46776.PubMed
  7. Haggerty  PA, Muladi  K, Kirkwood  BR, Ashworth  A, Manunebo  M. Community-based hygiene education to reduce diarrhoeal disease in rural Zaire: impact of the intervention on diarrhoeal morbidity. Int J Epidemiol. 1994;23:10509. DOIPubMed
  8. Manun'ebo  MN, Haggerty  PA, Kalengaie  M, Ashworth  A, Kirkwood  BR. Influence of demographic, socioeconomic and environmental variables on childhood diarrhoea in a rural area of Zaire. J Trop Med Hyg. 1994;97:318.PubMed
  9. Keswick  BH, Berge  CA, Bartolo  RG, Watson  DD. Antimicrobial soaps: their role in personal hygiene. In: Aly R, Beutner KR, Maibach H, editors. Cutaneous infection and therapy. New York: Marcel Dekker, Inc.; 1997. p. 49-82.
  10. Speers  R, Bernard  H, O'Grady  F, Shooter  RA. Increased dispersal of skin bacteria into the air after shower-baths. Lancet. 1965;1:47883. DOIPubMed
  11. Hall  GS, Mackintosh  CA, Hoffman  PN. The dispersal of bacteria and skin scales from the body after showering and after application of a skin lotion. J Hyg (Camb). 1986;97:28998. DOIPubMed
  12. Ulrich  JA. Dynamics of bacterial skin populations. In: Maibach HI, Hildick-Smith G, editors. Skin bacteria and their role in infection. New York: McGraw-Hill; 1965. p. 219-34.
  13. Evans  CA. Persistent individual differences in the bacterial flora of the skin of the forehead: numbers of propionibacteria. J Invest Dermatol. 1975;64:426. DOIPubMed
  14. Leyden  JJ, McGinley  KJ, Nordstrom  KM, Webster  GF. Skin microflora. J Invest Dermatol. 1987;88:65s72. DOIPubMed
  15. Hartmann  AA. Daily bath and its effect on the normal human skin flora quantitative: and qualitative investigations of the aerobic skin flora. Arch Dermatol Res. 1979;265:15364. DOIPubMed
  16. Paulson  DS. Efficacy evaluation of a 4% chlorhexidine gluconate as a full-body shower wash. Am J Infect Control. 1993;21:2059. DOIPubMed
  17. Kaiser  AB, Kernodle  DS, Barg  NL, Petracek  MR. Influence of preoperative showers on staphylococcal skin colonization: a comparative trial of antiseptic skin cleansers. Ann Thorac Surg. 1988;45:358. DOIPubMed
  18. Byrne  DJ, Napier  A, Cuschieri  A. Rationalizing whole body disinfection. J Hosp Infect. 1990;15:1837. DOIPubMed
  19. Mackenzie  I. Preoperative skin preparation and surgical outcome. J Hosp Infect. 1988;11(Suppl B):2732. DOIPubMed
  20. Rotter  ML, Larsen  SO, Cooke  EM, Dankert  J, Daschner  F, Greco  D, A comparison of the effects of preoperative whole-body bathing with detergent alone and with detergent containing chlorhexidine glucontate on the frequency of wound infections after clean surgery. J Hosp Infect. 1988;11:31020. DOIPubMed
  21. Ayliffe  GAJ, Noy  MF, Babb  JR, Davies  JG, Jackson  J. A comparison of pre-operative bathing with chlorhexidine-detergent and non-medicated soap in the prevention of wound infection. J Hosp Infect. 1983;4:23744. DOIPubMed
  22. Meberg  A, Schoyen  R. Bacterial colonization and neonatal infections. Effects of skin and umbilical disinfection in the nursery. Acta Paediatr Scand. 1985;74:36671. DOIPubMed
  23. Tuffnell  DJ, Croton  RS, Hemingway  DM, Hartley  MN, Wake  PN, Garvey  RJ. Methicillin resistant Staphylococcus aureus; the role of antisepsis in the control of an outbreak. J Hosp Infect. 1987;10:2559. DOIPubMed
  24. Bartzokas  CA, Paton  JH, Gibson  MF, Graham  F, McLoughlin  GA, Croton  RS. Control and eradication of methicillin-resistant Staphylococcus aureus on a surgical unit. N Engl J Med. 1984;311:14225. DOIPubMed
  25. Sempertegui  F, Estrella  B, Correa  E, Aguirre  L, Saa  B, Torres  M, Risk of diarrheal disease in Ecuadorian day-care centers. Pediatr Infect Dis. 1995;14:60612. DOIPubMed
  26. Shahid  NS, Greenough  WB, Samadi  AR, Huq  MI, Rahman  N. Hand washing with soap reduces diarrhoea and spread of bacterial pathogens in a Bangladesh village. J Diarrhoeal Dis Res. 1996;14:859.PubMed
  27. Rudland  S, Little  M, Kemp  P, Miller  A, Hodge  J. The enemy within: diarrheal rates among British and Australian troops in Iraq. Mil Med. 1996;161:72831.PubMed
  28. Larson  E. A causal link between hand washing and risk of infection? Examination of the evidence. Infect Control Hosp Epidemiol. 1988;9:2836. DOIPubMed
  29. Bryan  JL, Cohran  J, Larson  EL. Hand washing: a ritual revisited. Crit Care Nurs Clin North Am. 1995;7:61726.PubMed
  30. Gwaltney  JM, Moskalski  PB, Hendley  JO. Hand-to-hand transmission of rhinovirus colds. Ann Intern Med. 1978;88:4637.PubMed
  31. ASM inagurates nationwide public education effort. ASM News. 1996;62:5478.
  32. Russell  AD, Hammond  SA, Morgan  JR. Bacterial resistance to antiseptics and disinfectants. J Hosp Infect. 1986;7:21325. DOIPubMed
  33. APIC position statement. The use of antimicrobial household products. APIC News 1997;(Nov/Dec):13.
  34. Sasatsu  M, Shimizu  K, Noguchi  N, Kong  M. Triclosan-resistant Staphylococcus aureus [letter]. Lancet. 1993;342:248. DOIPubMed
  35. Moken  MC, McMurry  LM, Levy  SB. Selection of multiple-antibiotic-resistant (mar) mutants of Escherichia coli by using the disinfectant pine oil: roles of the mar and acrAB loci. Antimicrob Agents Chemother. 1997;41:27702.PubMed
  36. Ehrenkranz  NJ, Taplin  D, Butt  P. Antibiotic-resistant bacteria on the nose and skin: colonization and cross-infection. Proceedings from Sixth Interscience Conference on Antimicrobial Agents and Chemotherapy. Philadelphia: American Society for Microbiology. Antimicrob Agents Chemother; 1966. p. 255-64.
  37. Bruun  JN, Solberg  CO. Hand carriage of gram negative bacilli and Staphylococcus aureus. BMJ. 1973;2:5802. DOIPubMed
  38. Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Am J Infect Control. 1996;24:2452. DOIPubMed
  39. Larson  E. the 1992, 1993, and 1994 APIC Guideline Committees. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control. 1995;23:25169. DOIPubMed
  40. Doebbeling  BN, Stanley  GL, Sheetz  CT, Pfaller  MA, Houston  AK, Annis  L, Comparative efficacy of alternative handwashing agents in reducing nosocomial infections in intensive care units. N Engl J Med. 1992;327:8893. DOIPubMed
  41. Zafar  AB, Butler  RC, Reese  DJ, Gaydos  LA, Mennonna  PA. Use of 0.3% triclosan (Bacti-Stat*) to eradicate an outbreak of methicillin-resistant Staphylococcus aureus in a neonatal nursery. Am J Infect Control. 1995;23:2008. DOIPubMed
  42. Webster  J, Faoagali  JL, Cartwright  D. Elimination of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit after hand washing with triclosan. J Paediatr Child Health. 1994;30:5964. DOIPubMed
  43. Jarrett  A, ed. The physiology and pathophysiology of the skin. New York: Academic Press; 1978.
  44. Schaefer  H, Redelmeier  TE. Skin barrier: principles of percutaneous absorption. Basel: Karger; 1996.
  45. Noble  WC, Davies  RR. Studies on the dispersal of staphylococci. J Clin Pathol. 1965;18:1620. DOIPubMed
  46. Noble  WC. Dispersal of skin microorganisms. Br J Dermatol. 1975;93:47785. DOIPubMed
  47. Holbrook  KA, Odland  GF. Regional differences in the thickness (cell layers) of the human stratum: an ultra-structural analysis. J Invest Dermatol. 1974;62:415. DOIPubMed
  48. Blank  IH. Factors which influence the water content of the stratum corneum. J Invest Dermatol. 1952;18:433.PubMed
  49. Maki  DG. The use of antiseptics for handwashing by medical personnel. J Chemother. 1989;1(Suppl):311.PubMed
  50. Klauder  JV, Gross  BA. Actual causes of certain occupational dermatoses. III. a further study with special reference to effect of alkali on the skin, effect of soap on pH of skin, modern cutaneous detergents. Arch Dermatol Symp 1951;63:1-23.
  51. Hoffler  U, Gloor  M, Peters  G, Ko  HL, Brautigam  A, Thurn  A, Qualitative and quantitative investigations on the resident bacterial skin flora in healthy persons and in the non-affected skin of patients with seborrheic eczema. Arch Dermatol Res. 1980;268:297312. DOIPubMed
  52. Grunewald  AM, Gloor  M, Gehring  W, Kleesz  P. Damage to the skin by repetitive washing. Contact Dermat. 1995;32:22532. DOIPubMed
  53. Wilhelm  KP, Freitag  G, Wolff  HH. Surfactant-induced skin irritation and skin repair. Evaluation of the acute human irritation model by noninvasive techniques. J Am Acad Dermatol. 1994;30:9449. DOIPubMed
  54. Dugard  PH, Scheuplein  RJ. Effect of ionic surfactants on the permeability of human epidermis: an electrometric study. J Invest Dermatol. 1973;60:2635. DOI
  55. Scheuplein  RJ, Ross  L. Effects of surfactants and solvents on the permeability of epidermis. J Soc Cosmet Chem. 1970;21:8536.
  56. Larson  E, Friedman  C, Cohran  J, Treston-Aurand  J, Green  S. Prevalence and correlates of skin damage on hands of nurses. Heart Lung. 1997;26:40412. DOIPubMed
  57. Sproat  LJ, Uveges  RE. Epidemiology of hand dermatitis in dental personnel. Mil Med. 1995;160:3358.PubMed
  58. Stingeni  L, Lapomarda  V, Lisi  P. Occupational hand dermatitis in hospital environments. Contact Dermat. 1995;33:1726. DOIPubMed
  59. Meers  PD, Yeo  GA. Shedding of bacteria and skin squames after handwashing. J Hyg (Camb). 1978;81:99105. DOIPubMed
  60. Ojajarvi  J. Effectiveness of hand washing and disinfection methods in removing transient bacteria after patient nursing. J Hyg (Camb). 1980;85:193203. DOIPubMed
  61. Parry  MF, Hutchinson  JH, Brown  NA, Wu  CH, Estreller  L. Gram-negative sepsis in neonates: a nursery outbreak due to hand carriage of Citrobacter diversus. Pediatrics. 1980;65:11059.PubMed
  62. Larson  E, McGinley  K, Grove  G, Leyden  J, Talbot  G. Physiologic, microbiologic, and seasonal effects of handwashing on the skin of health care personnel. Am J Infect Control l986;l4:5l-9.
  63. Larson  E, McGinley  K, Foglia  A, Leyden  J, Boland  N, Larson  J, Handwashing practices and resistance and density of bacterial hand flora on two pediatric units in Lima, Peru. Am J Infect Control. 1992;20:6572. DOIPubMed
  64. Larson  EL, Norton Hughes  CA, Pyrek  JD, Sparks  SM, Cagatay  EU, Bartkus  JM. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control. 1998;26:51321. DOIPubMed
  65. Horn  W, Larson  E, McGinley  K, Leyden  JJ. Microbial flora on the hands of health care personnel: differences in composition and antibacterial resistance. Infect Control Hosp Epidemiol. 1988;9:18993. DOIPubMed
  66. Lilly  HA, Lowbury  EJL, Wilkins  MD. Limits to progressive reduction of resident skin bacteria by disinfection. J Clin Pathol. 1979;32:3825. DOIPubMed
  67. Ojajarvi  J, Makela  P, Rantsalo  I. Failure of hand disinfection with frequent hand washing: a need for prolonged field studies. J Hyg (Camb). 1977;79:10719. DOIPubMed
  68. Voss  A, Widmer  AF. No time for handwashing? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol. 1997;28:2058. DOIPubMed
  69. Lauharanta  J, Ojajarvi  J, Sarna  S, Makela  P. Prevention of dryness and eczema of the hands of hospital staff by emulsion cleansing instead of washing with soap. J Hosp Infect. 1991;17:20715. DOIPubMed
  70. Morrison  AJ, Gratz  J, Cabzudo  I, Wenzel  RP. The efficacy of several new handwashing agents for removing non-transient bacterial flora from hands. Infect Control. 1986;7:26872.PubMed
  71. Rotter  ML, Koller  W. Test models for hygienic handrub and hygienic handwash: the effects of two different contamination and sampling techniques. J Hosp Infect. 1992;20:16371. DOIPubMed
  72. Hobson  DW, Woller  W, Anderson  L, Guthery  E. Development and evaluation of a new alcohol-based surgical hand scrub with persistent antimicrobial characteristics and brushless application. Am J Infect Control. 1998;26:50712. DOIPubMed
  73. Larson  E, Eke  P, Laughon  B. Efficacy of alcohol-based hand rinses under frequent use conditions. Antimicrob Agents Chemother. 1986;30:5424.PubMed
  74. Larson  E, Silberger  M, Jakob  K, Whittier  S, Lai  L, DellaLatta  P, Assessment of alternative hand hygiene regimens to improve skin health among neonatal ICU nurses. Heart Lung. 2000;29:13642. DOIPubMed
  75. Murray  J, Calman  RM. Control of cross-infection by means of an antiseptic hand cream. BMJ. 1955;1:813. DOIPubMed
  76. Zelickson  AS, Zelickson  BD, Zelickson  BM. Measurements by transmission electron microscopy of "dry" skin before and after application of a moisturizing cream. Am J Dermatopathol. 1982;4:2058. DOIPubMed
  77. Grunewald  AM, Gloor  M, Gehring  W, Kleesz  P. Efficacy of barrier creams. In: Elsner P, Maibach HI, editors. Irritant dermatitis: new clinical and experimental aspects. Curr Probl Dermatol. 1995;23:187-97.
  78. Loden  M. Barrier recovery and influence of irritant stimuli in skin treated with a moisturinzing cream. Contact Dermat. 1997;36:25660. DOI
  79. Schluter-Wigger  W, Elsner  P. Efficacy of four commercially available protective creams in the repetitive irritation test (RIT). Contact Dermat. 1996;34:27883. DOI
  80. Frantz  SW, Haines  KA, Azar  CG, Ward  JI, Homan  SM, Roberts  RB. Chlorhexidine gluconate activity against clinical isolates of vancomycin-resistant Enterococcus faecium (VREF) and the effects of moisturizing agents on CGH residue accumulation on the skin. J Hosp Infect. 1997;37:15764. DOIPubMed
  81. Larson  E. Skin hygiene and infection prevention: more of the same or different approaches? Clin Infect Dis. 1999;29:128794. DOIPubMed

Main Article

Page created: May 10, 2011
Page updated: May 10, 2011
Page reviewed: May 10, 2011
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
file_external