Participant selection (paragraf 1)HWC were enrolled in this study over 9 weekdays during December 2006 from 10 selected clinical department (ICU, surgical, pediatrics, emergency, gastroenterology, hepatobiliary, nephrology, poison center, cardiology, and infectious diseases) in which the study was conducted. A minimum of 3 HCWs ( 1 physician, 1 nurse, and 1 other HCW) were selected at random from each department. Infection control staff selected the first HCW encountered in the first patient room in the participating department. If no HCWs were present in the first patient room, the researcher would enter another patient room.

Statistical analysis (paragraf 1)All data were collected and managed using Epilnfo version 6.04b (Centers for Disease Control and Prevention, Atlanta, Georgia).Bacterial counts on hands were measured before and after hand hygiene. Log 10 bacteria counts were reported as mean counts for all HCW tested by all solutions and stratified by filtered/unfiltered water. Result from the 7 department studied ( emergency, gastroenterology, hepatobiliary, nephrology, poison center, cardiology, and infectious diseases) were aggregated owing to the small numbers of HCWs in each department participating. When analyzed separately, the pediatric department showed the highest hand contamination owing to frequent touching during in reactions with pediatric patients and the patient zones.

Ethical considerationsThe study protocol was reviewed and approved by Bach Mai Hospital's Ethics Committee, which waived the need for receipt of informed consent before the study. Verbal consent was obtained from each participant to allow the use of data obtained for analysis and reporting. No HCW participant refused to be involved in the study.

Result (paragraf 3)Analysis of each hand hygiene method for reduction in bacterial colony counts found that ABHR was associated with the greatest reduction (1,4 log ; P < .0001; table 2). CHG with filtered water was also associated with a significant reduction (1,3 log; P < .0001), but CHG with unfiltered water was not (P= .173). Bacterial counts were markedly reduced after hand hygiene with ABHR (1,4 log ; P < .0001) CHG with filtered water (0,8 log ; P < .0001), and plain soap and filtered water (0,8 log ; P < .0001). The use of unfiltered water was associated with minimal, nonsignificant bacterial reduction. Table 3 shows average reductions in bacterial hand contamination according to the different methods used for hand cleansing. Both commensals and pathogens commonly associated with HAIs were recovered from HCWs hands in all group. The mean bacterial count reduction was simiĺar among bacterial group for all hand hygiene formulations with the exception of ABHR and CHG with filtered water.

Discussion (paragraf 5 dan 6)In summary, the present study supports the fact that hand rubbing with alcohol-based formulations is superior to hand washing with soap irrespective of water quality or hand cleansing with CHG solution with unfiltered water. Although our sample of CHG and unfiltered water was small., the lack of CFU reduction was also observed when unfiltered water was used with plain soap. ABHR significantly reduced CFU counts, and we believe that our findings support the use of ABHR as an additional step after hand washing with unfiltered water for visibly dirty hands in clinical areas where filtered water is unavailable. In a future follow-up future study, all participant should be requested to perform all 5 hand hygiene methods in random order (on different days) to assess the quality of each method. Moreover, monitoring and feedback to HCWs on hand hygiene and glove use compliance should be implemented to emphasize that whereas gloves provide protection against hand contamination, especially, when handling or anticipating contact with blood and body fluids, gloves should never replace the need to perform hand hygiene.

Study limitations include the many nonsignificant findings, which could be related to sample size. In addition, there is reduced generalizability to the nondominant hand. However, the dominant hand is used more frequently during daily practice and is more likely to be associated with cross-transmision. We cannot fully appreciate the clinical implications of our finding, given that the threshold of bacterial hand contamination associated with an increased risk for HAI acquisition remains unknown and undocumented; nonetheless, the isolation of pathogens and the demonstrated efficacy of ABHR support their pivotal role in the control and prevention of HAIs.