university of iowa hospitals and clinics artificial nails/nail enhancements the evidence sherry...

University of Iowa Hospitals and Clinics

Artificial Nails/Nail EnhancementsTHE EVIDENCE

Sherry David ICP

Contact

Program of Hospital Epidemiology

356-1606


7th National Patient Safety Goal

JCAHO 2004 National Patient Safety Goal• 7.) Reduce the risk of health care-acquired infections.

a.) Comply with the current hand hygiene guidelines.

JCAHO requires hospitals to comply with all category I recommendations and encourages hospitals to comply with category II recommendations.


Guideline for Hand Hygiene inHealth-Care Settings 2002

Section 6. 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) (1A)• Category 1A. Strongly recommended for

implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.


Section 6. B.- Keep natural tips less than ¼ inch long (II)• Category II. Suggested for implementation and

supported by suggestive clinical or epidemiologic studies or a theoretical rationale.


Let’s look at the evidence……….


Effects of Nail Polish on Microbial Counts of Fingernails

Clinical trial: 26 volunteers One hand polished: one

hand left unpolished Nail cultures:

• Baseline

• Daily for four days

Results: 24 of 26 completed 23/24 had chipped polish

by fourth day No statistically significant

difference in colony forming units (cfu) between polished and unpolished nails

Baumgardner, C. et al. (1993). American Operating Room Nurses Journal. 58(1): 84-88.


Pseudomonas Corneal Ulcers after Artificial Fingernail Injuries

Case 1 28 yo hit in her right eye

with a piece of nail debris while manicuring her artificial nails• Corneal culture grew PSA

Case 2 37 yo scratched her L eye

with a sculptured fingernail• Corneal culture grew PSA

Case 3 20 yo brushed across her L

eye with the tip of her artificial nail• Corneal culture grew PSA

Parker, AV et al (1989). American Journal of Ophthalmology. 107(5), 548-549.


ESBL-producing Klebsiella pneumoniae in a NICU linked to artificial nails

Case-Control Study April to June 2001,

outbreak of ESBL K pneumoniae in NICU in a NYC hospital

Typed by PFGE: 13/19 case infants harbored the outbreak Clone A

Method: Cx of GI tract of pts, HCW hands, and the environment

Attack rate - 45%: 9/19 developed invasive disease

Serious Morbidity• 6 case of sepsis

• 2 BSI

Clone A found on 2 HCW’s• 1 wore artificial nails - RN 53

• one with natural nail length > ¼ inch - RN 23

Gupta, A. et al. (2004). Infection Control Hospital Epidemiology. 25(3):210-5.


Results: Risk Factors for Acquisition Not Significant

• Transfer from local hosp

• Surgery

• Chest tube, UAC

• Bed location

• ATB treatment

• Type of enteral feeding

Significant (univariate)• Very low birth weight,

Intubation, CVC, Intra-lipids, LOS, Exposure to RN 53

Significant (multivariate)• LOS, Exposure to RN 53

Cost of outbreak $350,000 (estimated)

Results: Institution-wide ban on wearing of artificial nails


Prolonged Outbreak of Pseudomonas aeruginosa (PSA) in an NICU

Jan 1997- Mar 1998 in an Oklahoma NICU 46 pts. developed BSI with PSA - 16 deaths (35%)

15 of 20 pts. had genotype A & 3 had genotype B

HCW Cultures • 3 Nurses had PSA isolated

from hands;

• Nurse A1 (Long natural nails) and A2 (short natural nails) had genotype A on their hands

• Nurse B (Long artificial nails) had genotype B on her hands

Moolenaar, R. et al. (2000). Infection Control Hospital Epidemiology. 21(2), 80-85.


Results

Case Control Study Exposure to Nurse A1 (long natural nails) and

Nurse B (long artificial nails) were significantly associated for acquiring PSA

Index strain of PSA was cultured from both of these nurses’ hands

Investigators suggest both artificial and long nails can facilitate colonization of bacteria making hand hygiene less effective and use of gloves less practical


Candida Osteomyelitis and Diskitis after Spinal Surgery: An Outbreak that Implicates Artificial Nails

Case Control Study 1997, 3 pts. post-laminectomy

with deep wound infections due to Candida albicans (CA)

PFGE revealed identical isolates

One OR tech scrubbed in on all 3 cases and the same CA strain was isolated in her throat

3 mos prior she removed her artificial nails. The nails were present during the 3 surgeries. She was treated and removed from duty for 14 days

No difference for:

• Age, sex, time of surgery,

• Intra-op radiology, skin prep, pre-op ATB, pre-op shower, etc.

Only one common factor…the OR tech who had artificial nails

Parry, M. et al. (2001) Clinical Infectious Diseases. (32), 352-357.


Postoperative Serratia marcescens Wound Infections Traced to an Out-of Hospital Source

Aug-Sept 1994, 7 cardio-vascular surgery patients at a California hospital with post-op wound infections; one death

No difference for:

• Age, race, gender, wt. BMI, and number of discharge dx.

Associations

• Exposure to scrub nurse A (wore artificial nails), was significant in all stratified analyses; hand cultures were negative

Environmental Home Culture

• Isolates from the exfoliant cream had the same PFGE pattern as the outbreak strain; the exfoliant was identified as the reservoir!

Passaro, K. et al. (1997). Journal of Infectious Disease. 175(4): 992-995.


Endemic Pseudomonas aeruginosa Infection in an NICU

August 1998, 9 infants colonized/infected with PSA – 7 with Clone A

Surveillance cx of environment were negative

10/165 HCW had PSA on hands

Case Control Study indicate:

• Risk factors were care by older nurses & nurses with artificial nails

Foca, M. et al. (2000). NEJM. (343), 695-700.


Bacterial Carriage by Artificial vs. Natural Nails

Cultures of fingertips taken before and after handwashing• 56 nurses with artificial

nails and • 56 nurses with natural

nails Nurses were paired from

the same patient care area and were free of active infection

No difference in both groups for:

• Type of soap used

• Number of handwashings

• Time between handwashings and collection of cultures

Pottinger, J. et al. (1989). American Journal of Infection Control. 17(6): 340-344.


Results: Number of Nurses with Organisms

Artificial nails

(N = 56):

No. (%)

Natural nails

(N = 56):

No. (%)

Gram-negative rods

Before handwashing

After handwashing

20 (36%)

23 (41%)

3 (5%)

5 (9%)

Gram-positive cocci

Before handwashing

After handwashing

4 (7%)

4 (7%)

4 (7%)

3 (5%)

Number of Nurses with gram-negative rods and gram-positive cocci before and after handwashing


Results: Type of Organisms Found

Natural nail group

• Klebsiella and Enterobacter Artificial nail group

• Klebsiella and Enterobacter plus

• Serratia, Acinetobacter and Pseudomonas

• One nurse had a pure culture of Pseudomonas > 500 cfu before and after handwashing (NICU)

Discussion

• Nails should be considered a potential source of transmission in an outbreak of GNR

• Nails could have a role in transmitting pathogenic bacteria


What is “nail art”?


Novice Guide to Nail Technology

Nail Capping or over lay• Gel applied to natural nails, is cured by UV light to

secure the bond. Allows nails to grow. Nail Extenders

• Artificial nail tips added to existing nails. Artificial nails are applied with resin. A fiberglass mesh may be used as a strengthener.

Wraps• Fiberglass pre-trimmed application used with resin.

These can be a nail extension or a nail strengthener.


More

Infills, refills or backfills• Nail extensions require regular maintenance, usually q

2 wks. Fiberglass resin is added over existing nail to fill in the growth area or damaged area.

Nail art/Jewelry/Sculptured • Applying paint which is sealed in enamel. Rhinestones, glitter, pearls, etc. may be added. • Rings which cover the nail & pierce the nail. • 3-D art with shaping and sizing the nail extension.


Important Concerns Infection control in nail salons

• Potential for cross contamination with supplies

• Use of individual manicure sets

• Non-disposable scissors need to be sterilized!

Obtaining & maintaining nails is an expensive endeavor• Impossible for quick removal

• After removal nail beds may be damaged

• Can take weeks to months to return to normal conditions


More Concerns

Difficult work performance with long nails• Reduced grip

• Speed of manipulation

• Glove puncture

• Catching nails in devices or bedding is a risk

• More reluctant to comply with hand hygiene standards

Developing nail & nail bed conditions• Infection – bacterial and fungal

• Loosening


Artificial nails can be pretty…

But can harbor bacteria!

Pseudomonas nail infection


CDC Website

http://www.cdc.gov/handhygiene/

www.uihc.uiowa.edu/corm/corm.htm

CORM Website

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