Artificial Nails/Nail Enhancements THE EVIDENCE Sherry David

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Artificial Nails/Nail EnhancementsTHE EVIDENCE

• Sherry David ICP
• Contact
• Program of Hospital Epidemiology
• 356-1606

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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.

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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.

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• 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.

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Lets look at the evidence.
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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.
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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.
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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 HCWs
• 1 wore artificial nails - RN 53
• one with natural nail length gt ¼ inch - RN 23

Gupta, A. et al. (2004). Infection Control
Hospital Epidemiology. 25(3)210-5.
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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
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Prolonged Outbreak of Pseudomonas aeruginosa
(PSA) in an NICU

• 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

• 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

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

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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 factorthe OR tech who had
  artificial nails

Parry, M. et al. (2001) Clinical Infectious
Diseases. (32), 352-357.
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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.
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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.
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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.
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Results Number of Nurses with Organisms
Number of Nurses with gram-negative rods and
gram-positive cocci before and after handwashing
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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 gt 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

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What is nail art?
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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.

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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.

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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

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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

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Artificial nails can be pretty
But can harbor bacteria!
Pseudomonas nail infection
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CDC Website
http//www.cdc.gov/handhygiene/
CORM Website
www.uihc.uiowa.edu/corm/corm.htm