DIAGNOSIS AND TREATMENT

Handwashing Practices for the Prevention of Nosocomial Infections ALLEN C. STEERE, M.D., and GEORGE F. MALLISON, M.P.H., Atlanta, Georgia

Handwashing is generally considered the most important procedure in preventing nosocomial infections, because many types of these infections may be caused by organisms transmitted on the hands of personnel. Personnel should wash their hands before and after significant contact with any patient. The risk of personnel acquiring transient hand carriage of organisms is usually greatest after contact with excretions, secretions, or blood; patients at greatest risk are those undergoing surgery, those with catheters, and newborn infants. Although handwashing with an antiseptic agent between patient contacts is theoretically desirable, handwashing with soap, water, and mechanical friction are sufficient to remove most transiently acquired organisms. Antiseptic agents may produce excessively dry skin if used frequently, and any regimen of handwashing that leads to dermatitis negates the purpose of handwashing. We favor antiseptics for handwashing before surgery and other highrisk invasive procedures and in the care of newborn infants but prefer soap and water for other handwashing.

THE GREAT IMPORTANCE of handwashing by surgical and

obstetric personnel in the prevention of nosocomial wound infections was recognized by Semmelweiss over 100 years ago (1). Today, the sites of nosocomial infections are more diverse, and they commonly include urinary tract infections, lower respiratory tract infections, intravenous catheter-associated bacteremias, neonatal skin infections, and surgical wound infections (2). Organisms transmitted on the hands of physicians, nurses, and technicians may cause infections at these sites (3-12), and many outbreaks have occurred, particularly in nurseries, where this was thought to be the means of cross infection (13-15). Because many different types of nosocomial infections might be prevented by appropriate personnel handwashing, it is generally considered the most important single procedure in their prevention (16). Therefore, the Center for Disease Control and the American Hospital Association have recommended that personnel wash their hands before and after taking care of every patient (16, 17). However, it is doubtful that any hospital has been able to motivate • From the Bacterial Diseases Division, Bureau of Epidemiology, Center for Disease Control, Atlanta, Georgia. Annals of Internal Medicine 83:683-690, 1975

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its personnel to wash their hands consistently before and after all such contacts. Besides, the risk of transmitting organisms to or acquiring organisms from a given patient varies with the type of contact and the susceptibility of the patient. Thus, the real need for handwashing by personnel is before and after certain procedures and before caring for particularly susceptible patients. Although personnel frequently do not wash their hands when they should, the principal disagreement among physicians about handwashing involves which agent or agents should be used. Some believe that antiseptic agents (products used on the skin that kill microorganisms) should be used for all personnel handwashing, while others believe that they should be reserved for special purposes and that plain soap or detergent preparations (products that do not kill but suspend certain easily removable microorganisms, thereby allowing them to be washed off) should be used for routine handwashing. In a recent survey of the 82 hospitals in the Center for Disease Control's National Nosocomial Infections Study, 53% require handwashing with an antiseptic (usually an iodophor) between all patient contacts, while 47% require handwashing with only plain soap between routine patient contacts. Present studies do not completely resolve the disagreement regarding which method is better. Most studies have used the comparison of the microbe counts on the hands before and after handwashing as the single criterion for the effectiveness of the handwashing agent (18-23). These studies do not evaluate the effects of frequent handwashing over a long period of time on bacterial hand flora or on side effects such as dermatitis that influence personnel use and acceptance of an agent. More importantly, few studies have evaluated the effect of handwashing with a particular product on the infection rates in patients. Those that have are primarily studies of handwashing by nursery and operating room personnel using hexachlorophene-containing antiseptics, and, therefore, they may not be applicable to all parts of the hospital or to other agents (24-28). Although the available information is both limited and occasionally contradictory, we review here the studies on handwashing methods and agents, and from this information we outline an effective program of handwashing practices for hospital personnel. 683

The Skin Flora

To determine an effective handwashing policy, one must know something about the skin's inhabitants. In 1938, Price (18) described the existence of two kinds of organisms on the hands: resident and transient flora. Resident flora were described as organisms that survived and multiplied on the skin and could be cultured repeatedly. Transient flora were described as organisms that did not survive and multiply and could be cultured for only a short time. Though the resident flora differ qualitatively and quantitatively on different parts of the body and on different people (29, 30), everyone has aerobic staphylococci (Staphylococcus epidermidis and micrococci) and diphtheroids in all skin areas (31, 32). However, anaerobic diphtheroids (Proprionobacterium acnes) are found mainly on areas such as the face that produce large amounts of sebum (30). Gram-positive organisms are much more common on the skin than Gram-negative ones, although in moist areas such as the axilla and groin, Acinetobacter (Mimae) may be resident flora (30). The hair, face, axilla, and groin usually harbor the greatest number of bacteria, while the arms and hands generally have far fewer (33). The greatest number of organisms on hands are found around and under the fingernails (31). Most resident organisms are found on the superficial skin surface, but 10% to 20% of total flora are concentrated in skin crevices, where lipid and superficial cornified epithelium make their removal difficult (19, 34) and make complete sterilization of the skin impossible (29). Fortunately, resident flora are usually of low virulence and rarely cause infections other than skin infections, except when introduced into the body through invasive procedures such as surgery or catheterization. They are not easily removed by scrubbing (18) but can be inactivated by antiseptics. Transient flora may consist of many different pathogenic organisms (including those that commonly cause nosocomial infections) such as streptococci, Escherichia coli, and pseudomonas. These organisms applied to the skin usually survive less than 24 hours (35). Transient flora are not firmly attached to the skin and can usually be removed quickly and almost as effectively by handwashing for about 30 seconds with a soap or detergent and water instead of with an antiseptic (36). In fact, friction and water alone are almost as effective as soap and water (36, 37). Apparently, depending on the person, some organisms including Staphylococcus aureus and various Gram-negative organisms can be either resident or transient flora. In 4 % to 4 7 % of persons, S. aureus can be cultured from hands (38, 39). Although these organisms are rarely dominant or plentiful, they apparently may be resident flora (38, 40). More commonly, S. aureus is a resident flora in the anterior nares or perineal area, or both, but are transient flora on the hands (38, 41, 42). In two instances, greater numbers of S. aureus often exist on the skin: in the newborn infant, S. aureus seems frequently to replace micrococci (43), and in persons with eczematous, dermatitic skin, S. aureus and Gram-negative organisms frequently colonize these areas (44). Periods of resident 684

carriage of Gram-negative organisms have been reported in nursery personnel (45). However, it remains unclear whether these personnel acquire resident carriage of Gramnegative organisms because of repeated exposure to such organisms or because of the frequent use of antiseptics that destroy much of the normal resident flora thereby allowing colonization with Gram-negative organisms. Transient Hand Contamination During Patient Care Activities

The purpose of most handwashing in patient care is simply to remove transient microbial contamination that has been acquired by recent contact with infected or colonized patients or environmental sources. The risk of such acquisition varies with the type of contact. Personnel who have contact with patient excretions, secretions, or blood, whether directly or through contaminated objects, may acquire transient carriage of microorganisms from such contact. Activities with this risk include a physical examination where the examiner has contact with the mouth, nose, vagina, urethra, or rectum of a patient and nursing duties such as catheter care and emptying bed pans or urinals. Nurses and aides may have more such contact with patients than physicians. In an investigation of cross-infection with antibiotic-resistant E. coli and Klebsiella organisms, a higher percentage of hand cultures in nurses and aides were positive for the epidemic strains than in physicians ( 4 ) . The majority of patient care usually involves minimal patient contact. The risk of causing infections or acquiring organisms from patients because of shaking hands, taking a pulse, auscultating a heart, palpating the abdomen, percussing the chest, or administering medications is probably minimal. One study suggested that 7 5 % of ward nursing duties were of minimal contact types (46), and the percentage is probably higher for physicians. If transiently acquired organisms are not removed from the hands of personnel by appropriate handwashing, the patients who are most likely to acquire infections because of this are those with catheters or other invasive devices (this includes the majority of patients in intensive care units), those with depressed host resistance, and newborn infants (3-15). Handwashing Agents

To determine an effective handwashing policy, one must also evaluate handwashing agents. The following section lists the pros and cons of most of the agents currently available. SOAPS AND DETERGENTS

As stated earlier, soap is effective in removing the transient flora (36, 37). It comes in many forms: bar, liquid, granule, leaflet, or soap-impregnated tissues. All seem to be acceptable, with the caution that contaminated liquid soap dispensers have been associated with nosocomial outbreaks ( 4 7 , 4 8 ) . Therefore, such dispensers should be emptied, thoroughly cleaned, and refilled with a new solution on a regular basis. To our knowledge, no outbreaks caused by contaminated bar soap have been reported, and one study suggested that organisms inocu-

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lated on bar soap die quickly (49). However, bars of soap frequently remain in pools of water that might support the growth of organisms. Thus, if bar soap is used, small bars that can be changed frequently and soap racks that allow drainage of water should be used. Because of the problems of maintenance, many hospitals have preferred a form of soap that remains dry before use. Soap leaflets or soap-impregnated paper tissues are more expensive than bar soap, but they require 10 to 15 seconds of handwashing before the leaflet completely dissolves or the tissue wets to permit lathering. In addition, it is difficult to remove granular soap from the hands in less than 15 seconds. Thus, the use of a dry soap preparation may provide a mechanism for reminding personnel of an adequate length of time for routine handwashing. ALCOHOL

Alcohol has been used as an antiseptic for years, and, although many new agents have been introduced, it is still one of the most effective. In 1946, Gardner and Seddon (22) showed that 70% alcohol would "virtually disinfect" the skin in 15 to 20 seconds. Similarly, Dineen and Hildick-Smith (23) showed that handwashing with ethyl alcohol for 1 to 3 minutes reduced bacterial counts an average of 9 2 % . At 70% concentration by weight, both ethyl and isopropyl alcohol are effective antiseptics, although Spaulding (50) believes that ethyl alcohol is generally a better viricidal agent. The disadvantages of alcohol are that it is volatile and may be flammable or explosive, it evaporates quickly, and it dries the skin. However, Walter (51) has combined isopropyl alcohol with a quaternary ammonium compound and other ingredients to make an emollient mixture that is still an effective antiseptic but is reported to cause less chapping. Various other agents including chlorhexidine and glycerol have been combined with alcohol, and they seem to maintain or improve the antibacterial efficacy of alcohol while also causing less chapping (52, 53). IODINE

As with alcohol, iodine has been used as an antiseptic for many years. Outstanding in its range of action, it kills vegetative organisms, spores, viruses, and fungi. The combination of iodine and alcohol (tincture of iodine, 1.8 to 2.2 g iodine, 2.1 to 2.6 g sodium iodide in each dl of 44% to 50% ethyl alcohol) is a most effective antiseptic (54), with the hands becoming 80% to 90% free of bacteria after a 2-minute exposure to the solution (55-58). However, because of possible adverse effects such as burning, chapping, allergic reactions, and skin discoloration, this preparation is used only as a preoperative skin disinfectant and not as a routine handwashing agent. IODOPHORS

The iodophors are water-soluble complexes of iodine with organic compounds. Because the iodine is bound and released slowly, the iodophors seem to alleviate or reduce the problems of adverse skin reactions and staining caused by iodine (59-61), but the binding also may reduce the

antibacterial potency, since its effectiveness depends on free iodine. Lowbury, Lilly, and Bull (21) reported that bacterial counts were reduced by approximately 60% after 2 minutes of handwashing with iodophors, although others have reported a greater reduction of approximately 90% (62). Despite the popularity of iodophors, the Food and Drug Administration (FDA) has recently published several warnings about their effectiveness and safety (63). First, although it has been reported that iodophors have a longacting germicidal action caused by the sustained release of iodine as long as the color of the product remains on the skin (36), they usually do not have a substantive effect (that is, a continued reduction in microbial counts caused by the retention and binding of a chemical in the stratum corneum after rinsing) once the product is washed off (62). Second, the rate of release and the stability of the complexed iodine may vary with time. Third, in many cases, the toxicity of the various carrier molecules has been only superficially characterized. Finally, many infection control personnel have reported to us that iodophor preparations, if used frequently for handwashing, are considerably more drying to the skin than other antiseptic handwashing agents, including hexachlorophene preparations and agents containing emollients. HEXACHLOROPHENE PREPARATIONS

Antiseptics containing hexachlorophene, if used at least once a day, are, after 3 to 5 days, approximately as effective as the iodophors in reducing the resident skin flora ( 2 1 , 3 6 , 5 2 ) . They have a substantive effect and reduce the number of inoculated S. aureus able to survive on the skin ( 3 3 , 6 4 ) . Thus, they may be superior to iodophors in duration of action (62). Bathing infants with hexaclorophene has been shown to be effective in reducing the incidence of S. aureus infections (25), and, therefore, handwashing with hexachlorophene or an iodophor has been recommended for all nursery personnel between infant contacts (26). However, Forfar, Gould, and Maccabe (44) found that hexachlorophene handwashing was insufficient to reduce the incidence of staphylococcal infections in infants. Light and co-workers (27) found that the incidence of S. aureus colonization of infants in a nursery was 50% when hexachlorophene handwashing was required in the nursery, but that it dropped to 4% after the addition of hexachlorophene bathing of infants. A study by Mortimer, Wolinsky, and Rammelkamp (28) showed no difference in staphylococcal colonization between two nursery populations, one cared for by nurses who washed their hands with a hexachlorophene antiseptic and the other by nurses who washed their hands with soap and water. Furthermore, in a study of surgical patients, Bruun (24) found no significant difference between the rates of S. aureus surgical wound infections in two groups of patients—one cared for by personnel who washed their hands with hexachlorophene antiseptics, and the other by personnel who washed their hands with soap and water. Thus, even though hexachlorophene reduces S. aureus colonization of hands, there seems to be little benefit in hexachlorophene handwashing in Steere and Mallison • Handwashing Practices

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comparison with soap and water handwashing by personnel in reducing S. aureus infections in patients. Hexachlorophene preparations have several marked disadvantages. First, the film that causes the substantive effect can be broken by alcohol (57). Second, one study showed that adults who washed their hands five times a day with 3 % hexachlorophene had blood hexachlorophene levels of 0.5 /yg/ml or higher after 10 days ( 6 5 ) ; while no known adverse effects have resulted in adults, blood levels this high in some infants and laboratory animals have occurred in association with marked vacuolization of the gray and white matter of the brain ( 6 6 , 6 7 ) . Further, hexachlorophene preparations have minimal activity against Gram-negative bacteria and fungi and may even enhance their growth ( 2 7 , 4 4 , 6 8 , 6 9 ) ; Pseudomonas aeruginosa, Serratia marcescens, and Alcaligenes fecalis have been found to grow in these preparations (47, 70). In addition, Bruun and Solberg (71) reported that the hand carriage rate of Gram-negative bacteria was significantly higher for hospital personnel using hexachlorophene antiseptics ( 2 1 % ) than for those using plain soap ( 1 4 % ) . Knittle, Eitzman, and Baer (45) reported that Gram-negative bacteria were isolated from about 80% of all hand cultures of nursery personnel when hexachlorophene antiseptics were used, while this number was reduced to about 50% when povidone-iodine was used. However, in 36 nurseries surveyed by the Center for Disease Control in 1972, infants bathed with hexachlorophene did not have a higher incidence of Gram-negative infections than infants bathed with soap and water (68). CHLORHEXIDINE PREPARATIONS

The British have had considerable experience with various products containing chlorhexidine and have found some of them approximately as effective as iodophors and hexachlorophene preparations in reducing the resident flora ( 5 2 , 7 2 ) . Unfortunately, chlorhexidine solutions can become contaminated with Gram-negative organisms and have been responsible for infections in the nursery ( 7 3 ) . Products containing chlorhexidine are not yet approved by the F D A for use in the United States. AQUEOUS BENZALKONIUM CHLORIDE

These products have enjoyed some popularity as handwashing agents but are relatively ineffective antiseptics (74-76). In addition, they are rapidly inactivated by contact with protein, cellulose fibers, and other organic materials ( 7 7 , 7 8 ) . Furthermore, Pseudomonas and Enterobacter organisms have frequently been noted to grow in them (77, 79, 80). ANTISEPTIC FOAMS

Because running water and sinks are not always conveniently located, antiseptic foams have been developed that can be kept at the patients' bedsides or carried in the pockets of personnel and sprayed on the hands when needed. One such product containing quaternary ammonium compounds, 50% ethyl alcohol, and emollients has been reported to be approximately as effective as alcohol alone in reducing bacterial counts but is somewhat less 686

drying to the skin than alcohol ( 2 7 , 8 1 ) . Unfortunately, such a product is not now commercially available. A similar product that does not contain alcohol has been reported to reduce the numbers of pathogenic organisms from the hands of personnel for periods of up to 4 hours (82). However, no investigator has compared the reduction in organisms inoculated after the application of the foam with the reduction of organisms obtained by soap and water handwashing. Furthermore, although no outbreaks caused by the use of this antiseptic foam have been reported, contamination of a solution that contains neither iodine nor alcohol would seem a possible danger. Handwashing Recommendations

From this information on the skin flora and handwashing agents, we believe that an adequate handwashing policy for hospital personnel should include handwashing with antiseptics before doing surgery or certain other invasive procedures such as catheterizations, but handwashing with only soap and water between more routine patient contacts. This policy might be criticized because some personnel may have S. aureus or various Gram-negative organisms as a part of their resident hand flora, and such organisms would require antiseptics for their inactivation (38, 40, 45). Furthermore, antiseptics may have a sustained suppressant action on the skin flora (36, 53, 62, 64). Therefore, antiseptic handwashing in all circumstances may be desirable. The problem with this policy is that all available antiseptics have some adverse effects (83), and even those that are ordinarily safe may, with repeated use, cause excessive dryness, cracking, and dermatitis. Continual use of antiseptics may do more harm than good, because bacteria counts on dermatitic skin cannot be reduced appreciably even with antiseptics (29, 51, 71, 84), colonization with S. aureus and Gram-negative organisms may become more common (43, 44), and personnel with dermatitic hands may tend to avoid handwashing altogether. In some persons, frequent handwashing with soap and water can cause the skin to be excessively dry, but reports given to us suggest that dermatitis occurs more often with antiseptics, particularly with iodophors, than with soap. Thus, we favor a handwashing policy that reserves the use of antiseptics for special situations where the risk of infection is greatest and where resident as well as transient flora on the hands of personnel may cause infections in patients, and a policy that allows handwashing with soap and water for routine patient care. HANDWASHING IN PATIENT CARE AREAS

The handwashing procedure itself is simple. The hands should be vigorously lathered and rubbed together for at least 15 seconds under a moderate-sized stream of water at a comfortably warm temperature. Then, the hands should be rinsed and dried with a paper towel, and the towel used to turn off the faucet. In cases where sinks are not available, scrubbing with alcohol swabs or alcohol with emollients may be acceptable, but excessive drying may result if this method is used often. Consequently, there is no good substitute for routine handwashing with soap and running water.

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Rings and cracked or chipped nail polish make the removal of organisms more difficult (85). Therefore, personnel should not wear rings or nail polish while on duty, although many hospitals permit personnel to wear a single wedding band. Personnel who have contact with patient excretions, secretions, or blood, whether directly or through contaminated objects, should wash their hands with soap and water after such contact. This should avoid contamination of the employee, other patients, or the environment. However, some hospitals prefer to have personnel wash their hands with an antiseptic after contact with secretions or excretions from patients in isolation and before special dressing changes (86) of infected wounds. Personnel should also wash their hands with soap and water before inserting or caring for intravenous, urinary, or peritoneal catheters, or other invasive devices. Patients with such devices are frequently the most likely ones to acquire nosocomial infections because of the carriage of pathogenic organisms on the hands of personnel. Gloves are usually worn before the insertion of catheters and certainly minimize the risk of personnel hand contamination causing infections in patients. However, gloves are often not worn before the insertion of intravenous catheters. Therefore, handwashing with an antiseptic agent, preferably an iodophor, is recommended before this procedure, since the resident flora on the hands of personnel may cause infections at this site. In addition, personnel should wash their hands before activities that require touching a large skin area or mucous membranes. However, patient care activities with minimal contact such as taking a pulse or giving a medication usually do not require handwashing before the activity; however, if gross contamination occurs during the activity, handwashing is indicated afterwards. Although personnel can identify procedures and patients with the greatest risk of infection, they may not always know when they have acquired hand carriage of pathogenic organisms from either patients or the inanimate environment, and they cannot always identify patients by the presence of invasive devices that may acquire nosocomial infections. Furthermore, although personnel may expect to have only minimal contact while caring for a given patient, unexpected happenings at the bedside may require the handling of catheters or more extensive contact. Thus, the discipline of washing one's hands before taking care of all patients is to be encouraged. INTENSIVE CARE UNIT

Because of the high susceptibility to nosocomial infections of most patients in intensive care units, personnel working in these units will need to wash their hands more often than personnel in many other areas. Although antiseptic agents should be available as in other areas for handwashing before certain invasive procedures, handwashing with soap and water should suffice before most contacts. NURSERY

Because of the high susceptibility of newborn infants to

skin infections, handwashing between infant contacts is particularly important for nursery personnel. After the widespread discontinuation of hexachlorophene bathing of infants in 1971, the F D A and the American Academy of Pediatrics recommended that nursery personnel wash their hands with either an iodophor or an antiseptic containing 3 % hexachlorophene between each infant contact and for 2 minutes at the beginning of each working day (26, 83, 87). Unfortunately, there is little data to suggest that antiseptic handwashing is of greater benefit than soap and water handwashing in the nursery ( 2 7 , 2 8 , 4 4 ) , and we would encourage physicians who study the effects of iodophors and hexachlorophene-antiseptic handwashing in the nursery to also study the effects of soap. Of the two antiseptic agents recommended, hexachlorophene preparations may still be better for routine use because they have a substantive effect against S. aureus organisms (36, 64, 88), which cause the greatest number of nursery-acquired infections (68). Also, reports to us suggest that hexachlorophene antiseptics are less drying to the hands than iodophors. However, because increased colonization and numbers of infections with Gram-negative organisms have been reported with hexachlorophene antiseptics, alternating their use with iodophors on a regular basis may be preferable. The American Academy of Pediatrics also recommends that both antiseptic agents be available, but they encourage the use of iodophors for routine use (87). As reported frequently by other authors, personnel who are staphylococcal nasal carriers may cause S. aureus nursery outbreaks (41). However, because 20% to 70% of personnel may be colonized at some time with S. aureus and because the majority do not cause staphylococcal infections in infants, it has been impractical to remove all such personnel from nursery duties during periods of carriage (41). In addition, the organisms seem to be spread to the infant predominantly by the hands of the nasal carrier rather than by droplets or droplet nuclei expired during speaking or coughing (7-12,42). Thus, unless staphylococcal nasal carriers are shown to cause infections in others, we believe that they may work in the nursery and, like other personnel, should wash their hands before each infant contact. PERSONNEL WITH DERMATITIS

Personnel with dermatitis caused by frequent handwashing may be a greater risk to patients. Because colonization of dermatitic skin with virulent organisms is common (44), handwashing does not appreciably reduce bacteria counts (29, 51, 71, 84), and such personnel tend to avoid handwashing. Using hand creams, alternating the agent used, or wearing gloves may all help alleviate the problem. However, hand creams are not necessarily sterile and, therefore, should not be applied after handwashing while on duty, but they could be applied during nonworking hours such as lunch breaks or at home. Hand creams contaminated with bacteria and fungi have been the source of several outbreaks (89-92). Personnel with dermatitis may wear gloves during duty, which allows protection to them from the handwashing agent and also offers protection to patients. Transient flora may be washed Steere and Mallison

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away more easily from gloved hands than from nongloved hands ( 3 6 ) . However, if the dermatitis persists, employees should report to the employee health service for evaluation and treatment. SURGICAL, OBSTETRIC, AND MAJOR CATHETERIZATION PROCEDURES

Surgical and obstetric procedures require the greatest degree of hand antisepsis, since these procedures may be prolonged and since both the resident and transient flora introduced into wounds on the hands of personnel can cause infections in patients. Since gloves are worn for these procedures and since bacteria grow faster under gloved than ungloved hands ( 1 8 ) , hand antisepsis becomes important if gloves puncture or tear. This occurs most often because of handling the suture needle with a gloved hand rather than with forceps, handling wire sutures, or touching sharp bone edges*. Several studies have reported that 5% to 60% of operations are accompanied by glove punctures ( 8 4 , 9 3 , 9 4 ) . Cruse and Foord (95) reported that in their hospital the clean wound infection rate was three times higher after operations that were accompanied by glove tears than after those that were not. The surgical hand scrub should begin by cleaning the fingernails with a plastic or orange-wood stick. After this, the hands should be scrubbed for 4 to 5 minutes with either an iodophor or a hexachlorophene antiseptic (96, 97), although 70% alcohol may be used instead (29, 9 6 ) . An iodophor is probably the best agent to use because of its broad antibacterial effect; however, a hexachlorophene antiseptic, because of its substantive effect, may allow a longer period with low bacterial counts (62). Cruse and Foord (95) found that the antiseptic agent (Betadine® or pHisoHex®) used in the preoperative hand scrub made no significant difference in the subsequent clean wound infection rates in patients. Scrubbing with a sterile brush seems to offer no advantage over scrubbing with a sterile sponge in reducing bacterial counts (98, 9 9 ) . Internists are increasingly doing invasive procedures such as cardiac catheterizations, bronchoscopies, needle biopsies, and aspirations that, like surgical procedures, are associated with a risk of infection. The risk of glove tears during these procedures seems minimal, and the length of many of these procedures is short. Furthermore, no data are available to confirm that handwashing with either soap or an antiseptic agent before these procedures lowers infection rates in patients. Nevertheless, we think it is advisable for personnel to wash their hands before these procedures with an antiseptic agent for 15 seconds if the procedure is short and for 2 to 4 minutes if the procedure lasts for an hour or more, since glove tears and breaks in gloving method may occur. ACKNOWLEDGMENTS: The authors thank John V. Bennett, M.D., Walter E. Stamm, M.D., Stephen C. Schimpff, M.D., T. Grace Emori, R.N., M.S., and Deborah Jones for reviewing this manuscript. Doctor Steere is presently in the Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut. Received 30 June 1975; accepted 5 August 1975. * WALTER CW, COLE WR: Communication to the authors, June 1975. 688

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disease related to hospital nursery bathing practices—a nationwide epidemiologic investigation. Pediatrics 51:418-429, 1973 26. Hexachlorophene in newborns. FDA Drug Bull, December 1971. Copies may be obtained from the Bureau of Drugs, FDA, Washington, D.C. 27. LIGHT IJ, SUTHERLAND JM, COCHRAN L, et al: Ecologic rela-

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36. LOWBURY EJL, LILLY HA, BULL JP: Disinfection of hands:

removal of transient organisms. Br Med J 2:230-233, 1964 37. SPRUNT K, REDMAN W, LEIDY G: Antibacterial effectiveness of

routine handwashing. Pediatrics 52:264-21 \, 1973 38. WILLIAMS REO: Pathogenic bacteria on the skin, in Skin Bacteria and Their Role in Infection, edited by MAIBACK HIt HILDICK-SMITH G. New York, McGraw-Hill, 1965, p. 50 39. WILLIAMS REO: Healthy carriage of Staphylococcus aureus: its prevalence and importance. Bacteriol Rev 27:56-71, 1963 40. WILLIAMS REO: Pathogenic bacteria on the skin, in Skin Bacteria and Their Role in Infection, edited by MAIBACH HI, HILDICK-SMITH G. New York, McGraw-Hill, 1965, p. 54 41. NAHMIAS

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Lea & Fibiger, 1968, pp. 329-347 59. POSTLETHWAIT RW, DILLON ML: Iodophor for presurgical skin antisepsis. Arch Surg 89:462-465, 1964 60. MANNIX H, DINEEN P: "Germicides" for skin preparation before surgery. Arch Surg 83:752-757, 1961 61. HUGO WB, NEWTON JM: The antibacterial activity of a complex of iodine and a non-ionic surface active agent. J Pharm Pharmacol 16:189-197, 1964 62. MICHAUD RN, MCGRATH

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longed effect of antiseptic scrubs on the bacterial flora of the hands. Can Med Assoc J 99:402-407, 1968 65. U.S. GENERAL SERVICES ADMINISTRATION: O-T-C topical anti-

microbial products and drug and cosmetic products. Federal Register 39 (179), part 2:p. 33US, 1974 66. INNES JRM: Stratum spongiosus and hexachlorophene toxicity in children, experimental monkeys, rats and other species. Bull Soc Pharmacol Environ Pathol 2:8-9, 1973 67. KOPELMAN AE: Cutaneous absorption of hexachlorophene in low-birth-weight infants. J Pediatr 82:972-975, 1973 68. Nosocomial infections in nurseries and their relationship to hospital infant bathing practices—a preliminary report. National Nosocomial Infections Study Quarterly Report, Fourth Quarter 1972. Atlanta, Center For Disease Control, 1974, pp. 9-17 69. MILLER JM, JACKSON DA, COLLIER CS: The microbial property

of pHisoHex. Milit Med 127:576-578, 1962 70. SANFORD JP: Disinfectants that don't. Ann Intern Med 72:282283, 1970 71. BRUUN JN, SOLBERG CO: Hand carriage of gram-negative bacilli and staphylococcus aureus. Br Med J 2:580-582, 1973 72. LAWRENCE CA: Antimicrobial activity in vitro of chlorhexidine. / Am Pharm Assoc 49:731, 1960 73. BURDON DW, WHITBY JL: Contamination of hospital disinfectants with Pseudomonas species. Br Med J 2:153-156, 1967 74. ADAIR FW, GEFTIC SG, GELZER J: Resistance of pseudomonas

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"Fetus" or "Foetus"? Fetus was a word frequently used in classical Latin to indicate the recognizable prenatal form of a viviparous animal, a definition which generally still holds. Because it was a noun of the fourth declension, its plural spelling was identical to that of its nominative singular, but a diacritical mark was placed over the final vowel to indicate a change in its pronunciation to a long u (i.e., fetus; however, to eliminate the need of the diacritic, the anglicized fetuses is acceptable). The Latin derivation of the word was based on an Indo-European root fe, which meant to bear or bring forth. This stem is recognizable in other cognate forms such as /eminine, /emale and /emur. Since the term was taken directly from early classical Latin in both meaning and spelling, the source of the permutations foetus and more rarely faetus is somewhat of a mystery. That these are erroneous forms is readily admitted in the Oxford English Dictionary where it is stated that the "etymologically preferable spelling with the e in this word and its cognates is adopted in some dictionaries, but its actual use is almost unknown." It is obvious that this quote is primarily indicative of British writings, for the e form is now widely used in the United States. Nevertheless, the origin of the oe spelling is most intriguing, for it has enjoyed considerable antiquity. LaPrimaud (French Academy. 11.397. 1594) used it in the 16th century, and William Cowper (1666 to 1709) in the 17th and 18th centuries. The latter showed extended consistency in this when labeling a female stillborn as a foetus foeminae. Although the literature fails to reveal the exact origin of the double vowel spelling, Harper*s Latin Dictionary (1884) lists an early variation of the Latin root as feo (possibly a verb form?) which by simple vowel transposition could lead to the erroneous foe-. However, since the use of the oe form seems to have gained acceptance after the 15th century, a more probable source of the error may lie in the advent of printing. The early common usage of a single character of type for the JE and CE ligatures in Latin and Greek texts may have tempted the typesetters with an inclination toward elaborating manuscripts to substitute these for the single vowel. Despite the present extensive use of the more complex oe spelling, it must be recognized as historically incorrect, and the shorter, true Latin version should be used exclusively. WESLEY W. PARKE

Photographic Atlas of Fetal Anatomy Baltimore, University Park Press, 1975, pp. xvii-xviii

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Handwashing practices for the prevention of nosocomial infections.

Handwashing is generally considered the most important procedure in preventing nosocomial infections, because many types of these infections may be ca...
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