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Artificial Nails/Nail Enhancements THE 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.

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Artificial Nails/Nail EnhancementsTHE EVIDENCE

Sherry David ICP


Program of Hospital Epidemiology


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7th National Patient Safety Goal

  • JCAHO 2004 National Patient Safety Goal

    • 7.) Reduce the risk of health care-acquired


      a.) Comply with the current hand hygiene


  • 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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Clinical trial:

26 volunteers

One hand polished: one hand left unpolished

Nail cultures:


Daily for four days


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

Effects of Nail Polish on Microbial Counts of Fingernails

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

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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

Pseudomonas Corneal Ulcers after Artificial Fingernail Injuries

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

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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


Clone A found on 2 HCW’s

1 wore artificial nails - RN 53

one with natural nail length > ¼ inch - RN 23

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

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

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Not Significant

Transfer from local hosp


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: Risk Factors for Acquisition

Results: Institution-wide ban on wearing of artificial nails

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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

Prolonged Outbreak of Pseudomonas aeruginosa (PSA) in an NICU

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

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Results with PSA -

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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Case Control Study with PSA -

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

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

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

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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.


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!

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

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

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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

Endemic Pseudomonas aeruginosaInfection in an NICU

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

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Cultures of fingertips taken before and after handwashing with Clone A

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

Bacterial Carriage by Artificial vs. Natural Nails

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

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Results: Number of Nurses with Organisms with Clone A

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

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Results: Type of Organisms Found with Clone A

  • 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

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Novice Guide to Nail Technology with Clone A

  • 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 with Clone A

  • 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 with Clone A

  • 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 with Clone A

  • 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… with Clone A

But can harbor bacteria!

Pseudomonas nail infection

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CDC Website with Clone A

CORM Website