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Authors:    Colleen Symanski-Sanders (RN) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)


This course presents current CDC guidelines regarding handwashing, so that practitioners can comply with the most recent recommendations.


At the completion of this module the learner will be able to do the five following things:

  1. discuss bacterial flora,
  2. describe the role of bacterial flora in transmissions of nosocomial infection,
  3. describe the latest handwashing guidelines recommended by the Centers for Disease Control (CDC),
  4. implement current hand hygiene and handwashing procedure recommendations into clinical practice, and
  5. evaluate a product for its intended and FDA-Approved purpose.

History of Handwashing and Hygiene

“Never forget to wash your hands after having touched a sick person” (Moses ben Maimon) Moses ben Maimon practiced and taught medicine in Egypt. He wrote the 2nd Law to Torah in 1199 in which he devoted a chapter just to the principles of hygiene. As early as 1199, the importance of hygiene in medicine was recognized. It has been written that there were physicians who would finish an autopsy and then attend to ill patients without ever washing their hands. From 1204-1843 there was no real support for Maimon’s words of wisdom. A Harvard Professor of Anatomy, Oliver Wendell Holmes, the father of the supreme court justice, in 1842 observed the transmission of puerperal fever, known as “childbed fever,” from patient to patient by the nurses and doctors who cared for them. Prudently, he wrote an essay on childbed cleanliness and much like Maimonides, found no support by his medical peers. Holmes re-addressed infection during a National Sanitary Association meeting in 1860 with these words, “What makes the healing art divine? The blazoned truth we hold so dear: To guard is better than to heal, the shield is nobler than the spear.”

A physician and Chairman of Obstetrics at the Allgemeines Krankenhaus (hospital) in Vienna, by the name of I.P. Semmelweis paid particular notice to infection (perhaps facilitated because a physician friend had died of fever symptoms after sustaining a puncture wound during an autopsy). Semmelweis observed infection rates in two of the hospitals wards.

Based on his findings, Semmelweis mandated in 1847 that both physicians and students wash their hands with chlorine water and lime solution after performing postmortem exams. The mortality rate dropped to 3% within seven months. Instead of receiving merit, Semmelweis was fired and died in 1865 in an insane asylum. He is well known today for his advancements in infection control.

The CDC was established in 1946 and later established that the simple most important procedure in preventing nosocomial infections is handwashing. The American Medical Association (AMA) published a resolution titled “Ten Dirty Digits" in the early 70’s. The CDC had estimated that the cost of nosocomial infections in hospital was 45 billion in 1992. In the Joint Commission’s 1998 Comprehensive Accreditation Manual for Hospitals: The Official Handbook a section was added which addressed surveillance, prevention and control of infections and included mandates adopted from the CDC on handwashing technique.

Normal Bacterial Flora

The human species is warm-blooded and host to numerous bacterial cells. This normal bacterial flora lives on the external body surfaces & in the stomach. The composition of the normal flora varies somewhat from individual to individual. To understand the importance of different hand cleansing procedures, knowledge of normal bacterial skin flora is required. Different areas of the body have different bacterial counts. Total bacterial counts on the hands of medical personnel also have different counts. The perineal/inguinal areas are frequently heavily colonized. The axillae, trunk, and upper extremities are usually colonized as well. The number of S. aureus, Proteus mirabilis, Klebsiella spp., and Acinetobacter spp. present on intact areas of the skin of certain patients can vary from a little to a lot. Persons with diabetes, undergoing dialysis and or patients with chronic dermatitis are likely to have areas of intact skin colonized with S. aureus.

Bacterial floras are categorized as either transient or resident. Transient flora, which colonize the superficial layers of the skin, are more susceptible to removal by routine handwashing. Health care workers often acquire them during direct patient contact or from contact with contaminated environmental surfaces. Transient flora are the organisms most frequently associated with health-care related infections. Resident flora are attached to deeper layers of the skin and are more resistant to removal than transient flora. The hands can be colonized with pathogenic flora such as S. aureus, gram-negative bacilli, or yeast. It is believed that normal flora is perhaps beneficial. Normal flora may prevent pathogenic microorganisms from gaining access to the body surfaces. This is referred to as colonization resistance. Normal flora may also produce essential nutrients such as vitamin K produced by stomach flora. Not all bacteria cause disease and most don’t. In fact, some species even play beneficial roles, like producing antibiotics.

Administration of broad-spectrum antibiotics has a significant effect on the body’s normal flora and can result in colonization with antibiotic-resistant organisms. Antibiotic-mediated disruption of the normal flora can lead to fungal infections, such as superficial or, in the critically ill, invasive Candidiasis, or to antibiotic-associated colitis caused by Clostridium difficile. Bacterium that is usually part of the normal flora or is common in the environment may become a pathogen under certain conditions. Some bacteria that are part of the normal flora acquire extra virulence factors making them pathogenic such as strains of E. coli that cause diarrhea disease, urinary tract infections, or meningitis. Also, some bacteria that are part of the normal flora, like staphylococcus aureus, can cause disease if they gain entry to deep tissues by trauma, surgery, and/or insertion of intravascular lines. Patients who are immunocompromised can be exposed to Serratia marcescens if bacteria and components of normal flora are introduced into deep tissues.

So, What’s Bugging You? Fingernails, Artificial Nails & Bacteria

The CDC, Joint Commission, and the Association of Operating Room Nurses, to name a few, support studies which have documented that the subungual areas of the hand harbor high concentrations of bacteria, commonly coagulase-negative staphylococci, Pseudomonas spp., and yeasts. Conclusive evidence is needed whether or not artificial nails contribute to transmission of infections but, health care personnel who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing. Whether the length of natural or artificial nails is a substantial risk factor remains debatable because the majority of bacterial growth occurs along the proximal 1 mm of the nail adjacent to the subungual area. Long nails - both natural and artificial can facilitate colonization of bacteria on the hands by making handwashing less effective and the use of gloves less practical. The longer the nail the more likely it is that bacteria reside under its free edge. Less formal reports have implied that nurses who wear acrylic fingernails may become colonized or infected by Candida and, thus, become a possible risk to susceptible patients. Personnel wearing artificial nails have been epidemiologically implicated in several outbreaks of infection caused by gram-negative bacilli and yeast.

Researchers from Oklahoma City found that of 439 infants admitted to the NICU during a 15-month study, 46 or 11 % acquired P. aeruginosa and 16 or 35% of those infected died. Molecular typing confirmed that the genotypes isolated from the hands of two nurses were the same as those found in 90 % of their case patients, and that these genotypes differed from those found in patients in other parts of the hospital or in those who arrived in the NICU after the study period. They further assessed 92 of the 104 health care professionals for fingernail length and presence of artificial nails. The researchers found those with short or medium – length nails had a low risk of P. aeruginosa colonization (one in 80, whereas those with long natural or artificial nails had a much higher risk of two in 12).

The Association of Operating Room Nurses has responded to this problem by issuing a new practice statement. However, some health care professional feel they are subjective and somewhat arbitrary sounding. Taken from their website’s frequently asked questions, this is their posted response on the acceptance of fake nails: “Artificial nails of any type should not be worn in the perioperative setting. It does not matter whether the person is scrubbed or circulating, artificial nails are not acceptable in the operating room.” The AORN "Recommended practices for surgical hand scrubs" and "Recommended practices for surgical attire" in the Standards, Recommended Practices and Guidelines state, "Artificial nails should not be worn. Rationale: It has not been proven that artificial or acrylic nails on healthy hands increase the risk of surgical infection. Artificial nails, however, may harbor organisms and prevent effective hand washing. Higher numbers of gram-negative microorganisms have been cultured from the fingertips of personnel wearing artificial nails than from personnel with natural nails…" Whether it is the scrub person or the circulator, AORN believes that artificial nails should not be worn. The word should expresses obligation or tentative suggestion rather than a mandatory action and the implied passivity is concerning, but in time there will be enough policies prohibiting the use of artificial nails to make it a moot point.

Artificial Nails and Infection

With the increased use of nail services and products in recent years has come growing concern about safety. According to Nails 1995 Fact Book, U.S. consumers will spend an estimated $5.2 billion on nail services in 1995, half a billion more than in 1994. The most requested service, according to the Fact Book, is artificial nails. Manicures are number two followed by other services such as nail jewelry and nail art. Nail products for both home and salon use are regulated by the Food and Drug Administration under the Federal Food, Drug, and Cosmetic Act, these products are considered cosmetics because they are "articles other than soap which are applied to the human body for cleansing, beautifying, promoting attractiveness, or altering the appearance." The FDA does not review or approve nail products and other cosmetics before they go on the market.

Common nail problems reported by dermatologists are infections from bacteria, such as Staphylococcus; fungi, such as Candida; and skin viruses, such as warts. Bacterial and fungal infections frequently result from artificial nails, whether applied at home or in a salon. A bump or knock to a long artificial nail may cause it to lift from the natural nail at the base, leaving an opening for dirt to get in. If the nail is reglued without proper cleaning, bacteria or fungi may grow between the nails and spread into the natural nail. Also, as the natural nail grows, an opening develops between the natural nail and artificial nail. If this space is not filled in regularly, it can increase the chances for infection. A fungal infection can take hold when an acrylic nail is left in place too long (such as three months or more) and moisture accumulates under the nail.

First do no harm vs. non-adherence

According to the CDC, Research has indicated some practices that are risk factors for proper hand cleanliness: 2

1. being male,
2. working in an intensive-care unit,
3. working during the week versus the weekend,
4. wearing gowns/gloves and beliefs that glove use obviates the need for hand hygiene,
5. automated sink or sinks that are inconveniently located or shortage of sinks,
6. activities with high risk of cross-transmission,
7. handwashing agents that cause irritation and dryness,
8. lack of soap and paper towels,
9. often too busy/insufficient time due to understaffing/overcrowding or patient needs take priority,
10. low risk of acquiring infection from patients,
11. lack of knowledge of guidelines/protocols,
12. not thinking about it/forgetfulness, and
13. no role model from colleagues or superiors.

In addition to the above risk factors and despite scientific evidence, disagreement with recommendations, and lack of scientific information of definitive impact of improved hand hygiene on health-care– associated infection rates are also cited. It reminds me of the early days of AIDS research – “what do we think, what do we know, and what can we prove?” Ethically, clinicians are obligated to first do no harm.

Transmission of Pathogens on Hands

Hand-transmission is a critical factor in the spread of bacteria, pathogens, viruses that cause disease, foodborne illness, and nosocomial infections. Everyone is vulnerable and over one-third of the population is at high risk, including the elderly, young children, pregnant women, and those with compromised immune systems. Each year, an alarming 2,400,000 plus nosocomial infections occur in the U.S. The Centers for Disease Control and Prevention (CDC) estimates that more than 2 million patients annually acquire an infection while hospitalized in U.S. hospitals for other health problems and that an astounding 88,000 die as a direct or indirect result of these infections. In addition the CDC reports that efforts to treat these infections add nearly $5 billion to health care costs every year. In health care, nurses and doctors wash only 30% of the required time between patient contacts and procedures. Health care personnel, through patient contact, are a leading cause of transmission of nosocomial infection.

In the 1960s, a clinical trial sponsored by the National Institutes of Health and the Office of the Surgeon General demonstrated that infants cared for by nurses who did not wash their hands after handling an index infant colonized with S. aureus acquired the organism more often and more rapidly than infants who were cared for by nurses who used hexachlorophene to clean their hands between infant contacts. Convincing evidence that when compared with no handwashing, washing hands with an antiseptic agent between patient contacts reduced transmission of health-care--associated pathogens.

Research data on which types of patient-care activities result in transmission of patient flora to the hands of personnel needs further study. Direct patient contact and respiratory-tract care appear to be most likely to contaminate the fingers of caregivers. Research found Gram-negative bacilli accounted for 15% of isolates and S. aureus for 11%. The amount of time that a patient-care activity requires is also associated with the intensity of bacterial contamination. Personnel caring for infants with respiratory syncytial virus (RSV) infections have acquired RSV by performing activities like feeding infants, changing their diapers, and playing with infants. Even personnel who only had contact with surfaces that were contaminated with the infants' secretions acquired RSV by contaminating their hands with RSV and inoculating their oral or conjunctival mucosa.

Though invisible to the naked eye, pathogens can be transmitted from one patient to another via the hands of health care personnel. The following sequence of events as modes of transmission have been identified by the CDC:

1. Organisms present on the patient's skin, or that has been shed onto inanimate objects in close proximity to the patient, must be transferred to the hands of health care workers. These organisms must then be capable of surviving for at least several minutes on the hands of personnel.
2. Next, handwashing or hand antisepsis by the worker must be inadequate or omitted entirely, or the agent used for hand hygiene must be inappropriate.
3. Finally, the contaminated hands of the caregiver must come in direct contact with another patient, or with an inanimate object that will come into direct contact with the patient.

Case Study

Nurse E was a student attached to the Surgical Unit of a District General Hospital. Shortly after she was posted to the Unit, an increased number of patients were found to be suffering from post-operative wound infections. Analysis of the culture reports indicated that most cases were caused by methicillin-resistant Staphylococcus aureus (MRSA).

Because of the increased incidence of wound infections, and because they were caused by MRSA's, the hospital Infection Control Team initiated an investigation. Sub-typing showed that all of the MRSA's were clonal, that is they all belonged to the same strain, as far as could be determined with the techniques available. Despite initiating a surveillance program on the Unit, no source could be found for the MRSA’s.

A monitoring program to check the efficacy of hand washing was then initiated. After each time that they washed their hands, staff on the Unit were requested to make fingertip impressions on mannitol salt agar, a medium selective for staphylococci. No MRSAs were isolated for five days, during which MRSA wound infections continued on the Unit. Then, when collecting the impression plates one afternoon, one of the Hospital Infection Control Team observed that after she had made her fingertip impression, Nurse E rubbed her hands with a moisturizing cream, she said it was "...because of the roughening of my skin". She suffered from intermittent bouts of eczema, and had just recovered from an episode before starting on the surgical Unit.

The Infection Control Officer asked if she could sample the hand cream, and it yielded a culture of MRSA, indistinguishable from the clone that was isolated from patients on the Unit. Use of the moisturizing cream on the Unit was banned, and all staff were required to wash their hands using alcohol-based chlorhexidine. Monitoring of handwashing with fingertip impression plates continued for a week, but following the introduction of control measures, no further cases of MRSA wound infection were seen on the Unit.

CDC Hand Hygiene Guidelines Fact Sheet

The fact statements below are taken directly from the CDC hand hygiene fact sheet with the following notation “These guidelines should not be construed to legalize product claims that are not allowed by an FDA product approval by FDA's Over-the-Counter Drug Review. The recommendations are not intended to apply to consumer use of the products discussed. “2

  • Improved adherence to hand hygiene (i.e. hand washing or use of alcohol-based hand rubs) has been shown to terminate outbreaks in health care facilities, to reduce transmission of antimicrobial resistant organisms (e.g. methicillin resistant staphylococcus aureus) and reduce overall infection rates.
  • CDC is releasing guidelines to improve adherence to hand hygiene in health care settings. In addition to traditional handwashing with soap and water, CDC is recommending the use of alcohol-based hand rubs by health care personnel for patient care because they address some of the obstacles that health care professionals face when taking care of patients.
  • Handwashing with soap and water remains a sensible strategy for hand hygiene in non-health care settings and is recommended by CDC and other experts.
  • When health care personnel's hands are visibly soiled, they should wash with soap and water.
  • The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70 percent to 80 percent, prevent cross-contamination and protect patients and health care personnel from infection. Handrubs should be used before and after each patient just as gloves should be changed before and after each patient.
  • When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product.
  • Alcohol-based hand rubs significantly reduce the number of microorganisms on skin, are fast acting and cause less skin irritation.
  • Health care personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long if they care for patients at high risk of acquiring infections (e.g. Patients in intensive care units or in transplant units).
  • When evaluating hand hygiene products for potential use in health care facilities, administrators or product selection committees should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of a product that can affect acceptance and therefore usage include its smell, consistency, color and the effect of dryness on hands.
  • As part of these recommendations, CDC is asking health care facilities to develop and implement a system for measuring improvements in adherence to these hand hygiene recommendations. Some of the suggested performance indicators include: periodic monitoring of hand hygiene adherence and providing feedback to personnel regarding their performance, monitoring the volume of alcohol-based hand rub used/1000 patient days, monitoring adherence to policies dealing with wearing artificial nails, and focused assessment of the adequacy of health care personnel hand hygiene when outbreaks of infection occur.
  • Allergic contact dermatitis due to alcohol hand rubs is very uncommon. However, with increasing use of such products by health care personnel, it is likely that true allergic reactions to such products will occasionally be encountered.
  • Alcohol-based hand rubs take less time to use than traditional hand washing. In an eight-hour shift, an estimated one hour of an ICU nurse's time will be saved by using an alcohol-based hand rub.

Physiology of Normal Skin and Fingernails

The primary function of the skin is to reduce water loss, provide protection against abrasive action and microorganisms, and act as a permeability barrier to the environment. The basic structure of skin includes the epidermis, the dermis and the subcutaneous layer. The epidermis is the tougher, protective outer layer about as thick as a sheet of paper over most parts of the body and has four layers of cells. These cells are constantly flaking off and being renewed. In these four layers there are three special types of cells:

  • Melanocytes which produce melanin, the pigment that gives skin its color;
  • Keratinocytes which produce keratin, the basic component of nails; and
  • Langerhans cells, which help protect the body against infection.

Underneath, the dermis nourishes the epidermis. It consists of blood vessels, nerve endings, and connective tissue. The outer portion of the dermis has tiny projections called papillae that fit the dermis to the epidermis. Sensitive to touch, these papillae are especially numerous on the palms, soles, and fingertips. They are patterned and provide a person's unique set of fingerprints and footprints. The third layer, the subcutaneous tissue, is made up of connective tissue, blood vessels, and cells that store fat. This layer provides protection from injuries and helps the body retain body heat.

Nails are a type of modified skin. They are formed from the epidermis and consist of hardened skin cells that contain keratin. The skin below the nail is called the matrix. The larger part of the nail, the nail plate, is pink due to its nourishment from the blood supply in the underlying dermis. The whitish crescent-shaped area behind the pink part is called the lunula.

Consequences of Frequent Handwashing

The skin is a dynamic structure that has the ability to act as a barrier under a homeostatic environment. Circumstantial evidence indicates that the rate of keratinocyte proliferation directly influences the integrity of the skin barrier. A general increase in the rate of proliferation results in a decrease in the time available for intake of nutrients, protein and lipid synthesis, and processing of molecules required for skin-barrier function. It is still not clear whether chronic but quantitatively smaller increases in the rate of epidermal proliferation also lead to changes in skin-barrier function. Similarly, it is unclear to what extent the decreased barrier function caused by irritants result in an increased epidermal proliferation. Hand Detergents can act like acetone on intercellular lipids; thus frequent handwashing results in dry chapped hands. The return to normal barrier function typically occurs within 6 hours, but complete normalization of barrier function requires five to six days. It is this irritation that had been cited by clinicians for non-adherence to handwashing policies.

FDA Regulation of Healthcare Antiseptics

The FDA’s “Tentative Final Monograph for Healthcare Antiseptics (TFM)” published in the Federal Register, Friday, June 17, 1994, is the current guideline for manufacturers to follow when seeking approval of new antiseptic solutions for skin preparation. The TFM sets forth specific criteria for manufacturers to use when conducting clinical studies to evaluate the new antiseptic agent for safety and effectiveness. The FDA‘s role is to assure the safety and efficacy of medical devices and drug products. 3 The clinician’s role is to assure safe medical practices such as proper use of products. Review the warnings and contraindications that are listed. Warnings are issued for review and consideration before use; contraindication is an absolute definitive statement that applies to non- uses.

The Tentative Final Monograph has identified minimum bacterial reduction that products must demonstrate before being granted approval. Europe uses different standards for efficacy of alcohol-based hand products than the United States; therefore, alcohol-based hand rubs that meet Tentative Final Monograph criteria for efficacy may not meet European criteria for efficacy. In addition, it appears that scientific studies have not established the extent to which counts of bacteria/ microorganisms on the hands need to be reduced to minimize transmission of pathogens in health-care facilities by health care workers.

FDA Antiseptic Product Categories

The 1994 FDA Tentative Final Monograph for Health-Care Antiseptic Drug Products divided products into three categories and defined them as follows. Hand hygiene is a general term that applies to handwashing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis.

FDA Antiseptic Product Categories

1. Antiseptic handwash or HCW handwash. An antiseptic-containing preparation designed for frequent use; it reduces the number of microorganisms on intact skin to an initial baseline level after adequate washing, rinsing, and drying; it is broad-spectrum, fast-acting, and if possible, persistent.

CDC Product Definitions

CDC Definitions Types of Handrubs

Antiseptic agent. Antimicrobial substances that are applied to the skin to reduce the number of microbial flora. Examples include alcohols, chlorhexidine, chlorine, hexachlorophene, iodine, chloroxylenol (PCMX), quaternary ammonium compounds, and triclosan.


Antimicrobial soap (i.e., detergent) containing an antiseptic agent.





Plain soap refers to detergents that do not contain antimicrobial agents or contain low concentrations of antimicrobial agents that are effective solely as preservatives.




Detergents are compounds that possess a cleaning action. They are composed of both hydrophilic and lipophilic parts and can be divided into four groups: anionic, cationic, amphoteric, and nonionic detergents. Although products used for handwashing or antiseptic handwash in health-care settings represent various types of detergents, the term "soap" is used to refer to such detergents in this guideline.

Antiseptic hand rub. Applying an antiseptic hand-rub product to all surfaces of the hands to reduce the number of microorganisms present.

Antiseptic handwash. Washing hands with water and soap or other detergents containing an antiseptic agent.

Hand antisepsis. Refers to either antiseptic handwash or antiseptic hand rub

Handwashing. Washing hands with plain (i.e., non-antimicrobial) soap and water


Waterless antiseptic agent. An antiseptic agent that does not require use of exogenous water. After applying such an agent, the hands are rubbed together until the agent has dried.

Alcohol-based hand rub. An alcohol-containing preparation designed for application to the hands for reducing the number of viable microorganisms on the hands. In the United States, such preparations usually contain 60%--95% ethanol or isopropanol.

FDA Antiseptic Product Categories

2. Surgical hand scrub. An antiseptic-containing preparation that substantially reduces the number of microorganisms on intact skin; it is broad-spectrum, fast-acting, and persistent

CDC Product Definitions

CDC Definitions Types of Handrubs

Surgical hand antisepsis. Antiseptic detergent preparations often have persistent antimicrobial activity.

Antiseptic handwash or antiseptic hand rub performed preoperatively by surgical personnel to eliminate transient and reduce resident hand flora.

Decontaminate hands. To Reduce bacterial counts on hands by performing antiseptic hand rub or antiseptic handwash.

FDA Antiseptic Product Categories

3. Patient preoperative skin preparation. A fast-acting, broad-spectrum, and persistent antiseptic-containing preparation that substantially reduces the number of microorganisms on intact skin.

CDC Hand Hygiene Guidelines

The hand hygiene guidelines were developed by the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC), in collaboration with the Society for Healthcare Epidemiology of America (SHEA), the Association of Professionals in Infection Control and Epidemiology (APIC), and the Infectious Disease Society of America (IDSA). The hand hygiene guidelines are part of an overall CDC strategy to reduce infections in health care settings to promote patient safety.

In this guideline, washing hands with soap and water is replaced by rubbing hands with an alcohol hand rub as the primary means of hand hygiene to be used by healthcare personnel involved in routine patient care. The rationale behind this is the documented increased antimicrobial efficacy of alcohol hand rubs over washing hands with either plain soap and water or an antimicrobial soap. In addition, there is the potential for increased compliance with hand hygiene because hand rubbing requires less time, results in less skin irritation, and does not require proximity to a sink. The only qualification is that the hands must be free from visible soiling prior to the use of an alcohol hand rub.

The CDC/HICPAC system for categorizing recommendations is as follows and is found at the end of each recommendation statement. 2

  • Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiological studies.
  • Category IB. Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiological studies and a strong theoretical rationale.
  • Category IC. Required for implementation, as mandated by federal or state regulation or standard.
  • Category II. Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale.
  • No recommendation. Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exist.

Indications for handwashing and hand antisepsis

A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water (IA).
B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C--J (IA). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C--J (IB).
C. Decontaminate hands before having direct contact with patients (IB).
D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter (IB).
E. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure (IB).
F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) (IB).
G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA).
H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care (II).
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (II).
J. Decontaminate hands after removing gloves (IB).
K. Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water (IB).
L. Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of HCWs, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap (IB).
M. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis is suspected or proven. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores (II).
N. No rommendation can be made regarding the routine use of nonalcohol-based hand rubs for hand hygiene in health-care settings. Unresolved issue.

Hand-hygiene technique

A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry (IB). (Follow the manufacturer's recommendations regarding the volume of product to use.
B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB). Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis (IB).
C. Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a non-antimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used (II).
D. Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care settings (II).

Surgical hand antisepsis

A. Remove rings, watches, and bracelets before beginning the surgical hand scrub (II).volume of product to use.
B. Remove debris from underneath fingernails using a nail cleaner under running water (II).
C. Surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures (IB).
D. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 2--6 minutes. Long scrub times (e.g., 10 minutes) are not necessary (IB).
E. When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer's instructions. Before applying the alcohol solution, prewash hands and forearms with a non-antimicrobial soap and dry hands and forearms completely. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves (IB).

Other Aspects of Hand Hygiene

A. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms) (IA).
B. Keep natural nail tips less than 1/4-inch long (II).
C. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur (IC).
D. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients (IB).
E. Change gloves during patient care if moving from a contaminated body site to a clean body site (II).
F. No recommendation can be made regarding wearing rings in health-care settings. Unresolved issue.

Health-care worker educational and motivational programs

A. As part of an overall program to improve hand-hygiene practices of HCWs, educate personnel regarding the types of patient-care activities that can result in hand contamination and the advantages and disadvantages of various methods used to clean their hands (II).
B. Monitor HCWs' adherence with recommended hand-hygiene practices and provide personnel with information regarding their performance (IA).
C. Encourage patients and their families to remind HCWs to decontaminate their hands (II).


In 1855, Holmes republished his paper in the American Journal of the Medical Sciences where it was well received this time. Holmes referred to nosocomial infections as “professional homicide” and believed that" voluntary blindness, any interested oversight, any culpable negligence” should not be acceptable. It is hard to image that in 148 years the homicide that Holmes referred to still occurs. Despite advancements in scientific understanding and evidence, some healthcare workers and professionals still challenge the life-saving benefit of handwashing. Ironically, we expect food handlers to wash their hands and wear hairnets because we fear their hair in our foods- thus requiring hairnets. The shield of prevention is more provocative and we hold that power in our hands.


1. Baran R. Nail beauty therapy: an attractive enhancement or a potential hazard? Journal of Cosm Dermatol 2002; 1:24-29

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