Hospital-acquired infections (HAIs), also called nosocomial infections, are infections contracted in a hospital setting and not present before the patient’s admission to the hospital. These infections often manifest 48 hours after hospital admission and may show multidrug resistance, especially in patients with a history of recent antibiotic use.¹ Catheter-associated urinary tract infections, central line-associated bloodstream infections, surgical site infections, ventilator-associated or other hospital-acquired pneumonia, and Clostridium difficile infection are examples of common HAIs.¹

According to the World Health Organization, 7 of every 100 hospitalized patients in high-income countries and 15 of every 100 hospitalized patients in low- and middle-income countries will contract an HAI during their hospital stay.² Known risk factors include older age, comorbidities, immunosuppression, long or frequent hospital stays, invasive procedures and devices, and mechanical ventilation. However, HAI risk also depends on the hospital’s infection control protocols, the patient’s immune status, and the microbial pathogens prevalent in the community.¹

Common methods to prevent HAIs include hand hygiene, maintenance of a clean hospital environment, sorting of patients into cohorts, contact precautions as indicated, public health surveillance, antibiotic stewardship, patient positioning, avoidance of aspiration, strict asepsis as indicated, removal of catheters as soon as appropriate, and chlorhexidine cleansing in intensive care unit patients.^1,3 In addition, certain patient safety programs have been developed to prevent HAIs. For example, the Comprehensive Unit-based Safety Program(CUSP) combines improvements in safety culture, teamwork, and communications with a checklist of practices for preventing harms.⁴

This discussion focuses on hand hygiene techniques and protocols for the prevention of HAIs.

Hand Hygiene Background

Hand hygiene—ie, cleaning one’s hands—revolutionized modern medical care, but not without a fight. Even before the microbiology of infection was understood, Hungarian physician Ignaz Semmelweis in the 1840s and English nurse Florence Nightingale in the 1850s independently made the connection between clean hands and lower infection rates.^5,6 Semmelweis realized that the high infant and maternal mortality rates from puerperal fever (also known as postpartum or childbed fever) at his hospital, in contrast to the much lower mortality rates in women and infants cared for by midwives, were directly related to the hospital physicians’ practice of making maternity rounds with dirty hands immediately after dissecting cadavers. Semmelweis initially met with resistance to his well-researched report on hand hygiene in infection prevention, but his view gradually became accepted, and puerperal fever rates began to decline.⁵ When caring for wounded soldiers during the Crimean War, Nightingale insisted that the nurses she supervised wash their hands repeatedly during the day, and she found decreased rates of infection among nurses and their patients as a result.⁶

Despite the clear evidence provided by the work of Nightingale and Semmelweis, hand hygiene was slow to be adopted on a global level. Finally, in the 1980s, in response to outbreaks of foodborne illness and HAIs, the essential role of hand hygiene was formally recognized when the Centers for the Disease Control and Prevention (CDC) declared hand hygiene to be an important means of preventing the spread of infection.⁶

Hand Hygiene Rationale and Indications

Hand hygiene is vitally important, because it protects both health care personnel and patients by reducing the potential spread of microbial pathogens to patients, inhibiting dissemination of antimicrobial-resistant microorganisms, and lowering the risk of infection transmission from patients to health care workers.⁷

As for indications, hand hygiene should be implemented at the following times^8,9:

·      Immediately before touching a patient

·      Before performing an aseptic task (eg, catheter insertion) or handing invasive medical devices

·      Before moving from a soiled body site to a clean body site on the same patient

·      After touching a patient or a patient’s environment

·      After contact with contaminated surfaces, blood, or other bodily fluids

·      Immediately after glove removal

Hand Hygiene Categories

For health care workers, the type or degree of hand hygiene depends on the clinical setting. It can mean cleansing with an antiseptic hand rub (alcohol-based foam or gel hand sanitizer), handwashing with water and soap (plain soap or with an antiseptic), or surgical hand antisepsis.^7,8,10 Various facilities and institutions will have their own policies on which method is appropriate in which scenarios so consult your facility’s guidance to confirm best practices.

 Hand Hygiene With an Alcohol-Based Hand Sanitizer

This method is commonly preferred in office or nonsurgical hospital settings. The following procedure is recommended^8,9:

·      Dispense a palm-sized amount of sanitizer, enough to cover all hand surfaces.

·      Rub the palms together.

·      Rub between the fingers and rotate around the thumbs.

·      Rub the fingertips in each palm.

·      Ensure that hands stay wet with the sanitizer for at least 15 seconds.

Hand Hygiene With Soap and Water

Washing hands with soap (or an antiseptic) and water is indicated when hands are visibly soiled, before eating or assisting a patient with eating, after using the restroom, or after helping a patient with toileting or a diaper change.^8,9 Handwashing procedure is as follows^8,9:

·      Wet hands with warm water (not hot water, to avoid possible dermatitis).

·      Rub soap lather into the palms and then onto the backs of the hands.

·      Scrub between the fingers.

·      Scrub the thumbs and fingertips.

·      Take a minimum of 15 seconds to scrub (the entire process may take up to 1 minute).

·      Rinse with warm water.

·      Pat hands dry with a disposable towel and use the towel to turn off the water.

Surgical Hand Antisepsis

Strict adherence to the following steps decreases the risk of HAI transmission in surgical settings^8-10:

·      Remove all jewelry, including watches, from hands and arms.

·      Keep fingernails short, without nail polish or artificial nails.

·      Inspect hands for cuts, damaged cuticles, open lesions, or abrasions.

·      Don surgical shoe covers, hats, caps, masks, and eye protection.

·      Turn on water to a warm temperature with foot or knee controls.

·      Prerinse to ensure that soap reaches 2 inches above the elbows (hands must always remain above the elbows during surgical hand antisepsis).

·      Remove debris from under fingernails with a nail pick used under running water.

·      When using an antimicrobial agent, scrub hands, fingers, and forearms for 2 to 6 minutes or according to the manufacturer’s instructions or individual hospital procedures.

·      When rinsing, let the water run off at the elbows to keep the hands clean.

·      Use foot or knee controls to turn off the water.

·      Keep hands elevated and away from the body.

·      Approach the sterile field, grab a towel if appropriate, or accept the towel from the scrub nurse, prevent excess water from dripping on the sterile field, and dry 1 hand.

·      Grab or accept a new sterile towel (or reverse the first towel) and dry the other hand.

·      Drop the towel into a hamper, or hand it to another team member without contaminating yourself.

·      After applying an alcohol-based product or antiseptic hand rub as recommended, let the hands and forearms dry completely before donning sterile gloves.

Glove Removal and Hand Hygiene

Glove use does not replace hand cleaning. In fact, it is sometimes necessary to remove gloves and carry out hand hygiene before performing a patient care task because that task requires hand cleaning. Hand hygiene is also important after routine glove removal.^8,9 To remove gloves^8,9:

·      Pinch the outside of the glove near your wrist.

·      Peel the first glove downward and inside out.

·      Put a finger of your ungloved hand inside the wrist of the second glove.

·      Peel downward until the second glove is inside out.

Training in Hand Hygiene and Ensuring Program Adherence

The risk and incidence of HAIs are reduced by ensuring that health care workers follow hospital protocols for hand hygiene. Proper training of staff in hand hygiene techniques is key, and a program’s success begins with and depends on active engagement of all participants.⁸

For example, the CDC, in partnership with the American Hospital Association, developed the 4 E’s, a video-based hand hygiene training program for health care workers that is founded on the following principles⁹:

Through the use of observation and respectful feedback, as well as automated data collection systems, the 4 E’s program promotes adherence to hand hygiene, which in turn lowers the risk of HAIs in both patients and health care workers.⁹

Conclusion

HAIs are here to stay, especially given the rise of multidrug-resistant pathogens, but fortunately, we have a strong and tested ally on our side: hand hygiene.

References

1. Monegro AF, Muppidi V, Regunath H. Hospital-acquired infections [updated 2023] In: StatPearls. StatPearls Publishing; 2025. Accessed April 24, 2025. https://www.ncbi.nlm.nih.gov/books/NBK441857/

2. Hand hygiene. World Health Organization. 2025. Accessed April 24, 2025. https://www.who.int/teams/integrated-health-services/infection-prevention-control/hand-hygiene

3. Haque M, McKimm J, Sartelli M, et al. Strategies to prevent healthcare-associated infections: a narrative overview. Risk Manag Healthc Policy. 2020;13:1765-1780. doi:10.2147/RMHP.S269315

4. Tools & resources to prevent healthcare-associated infections. Agency for Healthcare Research and Quality. 2016. Accessed April 24, 2025. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/hais-tools.pdf

5. Paul S, Salunkhe S, Sravanthi K, Mane SV. Pioneering hand hygiene: Ignaz Semmelweis and the fight against puerperal fever. Cureus. 2024;16(10):e71689. doi:10.7759/cureus.71689

6. Martini M, Lippi D. SARS-CoV-2 (COVID-19) and the teaching of Ignaz Semmelweis and Florence Nightingale: a lesson of public health from history, after the “introduction of handwashing” (1847). J Prev Med Hyg. 2021;62(3):E621-E624. doi:10.15167/2421-4248/jpmh2021.62.3.2161

7. Clinical safety: hand hygiene for healthcare workers. Centers for Disease Control and Prevention. 2024. Accessed April 24, 2025. https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html

8. WHO Guidelines on Hand Hygiene in Health Care. World Health Organization. 2009. Accessed April 28, 2025. https://www.who.int/publications/i/item/9789241597906

9. Clean hands in healthcare training [video series]. Centers for Disease Control and Prevention. 2024. Accessed April 28, 2025. https://www.cdc.gov/clean-hands/hcp/training/index.html

10. Toney-Butler TJ, Gasner A, Carver N. Hand hygiene [updated 2023]. In: StatPearls. StatPearls Publishing; 2025. Accessed April 24, 2025. https://www.ncbi.nlm.nih.gov/books/NBK470254/