Thoughts on Handwashing, MRSA, and C. Difficile Colitis

Here are some recent thoughts on handwashing, MRSA, and C. Difficile. (I know -- handwashing is low-tech -- but it's absolutely critical for infection control.)

I recently cared for two patients with methicillin resistant Staphlococcal aureus (MRSA) infections. Both had acquired these infections from the community, not from a hospital. Ten years ago, this would have been unusual -- as most MRSA infections were picked up in the hospital, often related to lack of handwashing -- but now MRSA infections in the community are common.

What was unusual was the MRSA patients' response. Recently, the press has been filled with stories of killer MRSA infections contracted by otherwise healthy people. One of the patients initially acted as if he was diagnosed with AIDS. Both were worried they would transmit the infection to family or friends. They worried they would be shunned by their communities if word got out they had the bacteria.

Providing reassurance was difficult.

Also recently, Donald Landry, Acting Chair of Medicine at Columbia, emailed an essay on handwashing. His conclusion: "We must surrender." These words were thoughtfully chosen. They imply that no alternatives to or arguments against handwashing exist. It's a behavioral change. And it must happen.

For hospitalized patients, I routinely use an alcohol based hand rub before and after the physical exam. (To be absolutely honest, like most health care providers, I have had difficulty complying 100% of the time. But I'm trying.) Previously, I felt that the alcohol-based sanitizer alone was adequate -- and it probably is -- but recently I've become aware that alcohol-based hand sanitizers do not kill C. Difficile -- a major cause of colitis -- as well as soap and water.

So as an experiment, in the last few weeks I've taken a different approach. This routine has more steps, but surprisingly, seems easier. For hospitalized patients, this has become my routine:

• Wash with alcohol-based hand sanitizer (from a dispenser outside patient's room)
• Put on non-latex examining gloves (usually from a box in patient's room)
• Examine patient
• Discard gloves
• Wash again with alcohol-based hand sanitizer

This might seem like overkill, but I've personally found that I'm more compliant with this handwashing routine. Having to think about whether to wash your hands makes it less likely that it will actually happen. But creating a routine that you're comfortable with takes the thinking out of it, and therefore it just gets done, every time.

And the combination of wearing gloves and handwashing at least provides some additional reassurance that I'm doing everything I can to prevent the spread of MRSA, C. Difficile, and other infections.

As Landry's essay discusses, this is a difficult issue for both health care providers (and patients!). Comments are welcome.

(Also posted on The Efficient MD.)

Labels: clostridium difficile, handwashing, mrsa

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