A recent survey reveals hygiene gaps in the cleaning of dispensers in hospitals, but good alternatives do exist.
Thorough hand hygiene is essential for comprehensive patient safety, as people are increasingly paying attention to hygiene standards when choosing a hospital.
Healthcare standards for washing and hand disinfection requires staff to have access to appropriate hygiene dispensers at multiple locations, particularly in the immediate vicinity of patients. Permanently installed disinfectant dispensers ensure that alcohol-based disinfection can be conveniently achieved without having to travel long distances. This offers many advantages, particularly when dealing with high volumes of people as normal workflows need not be disrupted. In addition to regular hand hygiene, thorough dispenser hygiene plays an important role in infection control. This is because dispenser reprocessing (cleaning and maintenance) not only goes a long way to ensuring normal functionality of the device, but also effectively prevents possible contamination.
Critical points during reprocessing
A closer look at the individual components of a hygiene dispenser quickly reveals that the dosing pump is a focal point for reprocessing. In many dispensers, the pump stays in permanent contact with the product, and product residues often stick to the inside of the suction pipe and at the pump outlet, which can impact dosing and contaminate new products. Additives, such as moisturizers, often increase build up.
When looking at the exterior of a hygiene dispenser, the operating lever is another “hot spot” that requires attention. Constant contact with the user’s hands, forearms and elbows can quickly lead to cross-contamination and, in the worst case scenario, acquired pathogens can reach patients throughout the facility.
Contaminated hand wash soaps
But how high is the real risk of microbial contamination of the contents? A team led by Dr. Sabine Gleich investigated this question as part of a scientific project at a German university hospital. The researchers found that ten percent of the one hundred liquid soap dispensers tested were contaminated with bacteria. However, none of the samples had more than 2 colony-forming units. 
Further studies show that the risk of contamination is particularly high with refilled soap and can lead to outbreaks.  And even with dispenser systems that are operated with disposable bottles, undesirable contamination of the soap can occur if the soap is improperly prepared. 
Disinfectant or sanitizer dispensers are less vulnerable to microbial colonization than soap dispensers. Nevertheless, failure to clean and care for the dispensers means that the alcohol-based hand care solutions can no longer be dosed correctly. This undoubtedly has a negative effect on hand hygiene compliance.
The KRINKO perspective
Section 23 of the German Infection Protection Act, the Commission for Hospital Hygiene and Infection Prevention (KRINKO) – lists detailed recommendations for the prevention of nosocomial infections. The published guidelines apply to all healthcare institutions in Germany and are highly regarded around the world. Their recommendations on hand hygiene were updated in 2016, and describe the requirements for dispenser reprocessing.
The KRINKO has set specific requirements for the dispenser’s exterior as well, such as at the outlet and removing visible impurities on the housing with disinfectant. According to KRINKO, the operating lever should also be wiped and disinfected daily.
With regard to the scope and frequency of hygiene dispenser cleaning, KRINKO provides some flexibility for healthcare institutions to define their own cleaning intervals, regardless of whether soap or disinfectant dispensers are used. The individually defined cycles should be put on paper with the in-house hygiene plans, which should be accessible to staff and and reinforced. Manufacturers typically recommend a thorough reprocessing every six months for disinfectant dispensers and with each bottle change for soap dispensers.
When looking at dispenser reprocessing there are two types; manual and mechanical. Manual reprocessing involves numerous steps, from cleaning the pump with hot water, to disinfecting the housing and assembling the dispenser. Mechanical reprocessing involves the use of autoclaves that heat the dispensers above temperatures that bacteria can survive, or medical dishwashers that use a combination of disinfecting chemicals and heat.
Cost: Beyond good and evil
A published statement of costs by Dr. Dr. Otto-Karg from the Klinikum Fulda shows that a 6-month cycle of manually cleaning 4,000 dispensers can cost 6,800€, a figure that would be considered at the very low-end of the cost spectrum. Logistical processes such as removing and replacing the dispensers, daily surface cleaning and other processes are not taken into account and will significantly inflate the cost. In another publication by Stefan Drees from the St. Elisabeth Hospital in Cologne-Hohenlind, costs for proper dispenser preparation were estimated to lie around € 125,000 per year for a 700-bed hospital. Despite these costs, manual and mechanical processes can also be subject to human and logistical errors.
A survey carried out in October 2018 among hygiene specialist staff during the Freiburg Infectious Diseases and Hygiene Congress in Germany, provided interesting insights into the cleaning behaviour of German clinics and hospitals. The results published in the Journal Infection Control & Hospital Epidemiology demonstrate that only one in three healthcare institutions cleans visibly contaminated disinfectant dispensers adequately. This carries the risk that dispensers and dosing pumps are rated as clean from the outside while hiding contamination on the inside. 15 percent stated they never to reprocess. 
Practical alternatives to reprocessing
As we have learned, in practice the lack of cleaning of soap dispensers can have a negative effect on hygiene. The Krinko therefore endorses the use of disposable pumps, which are aimed at those who feel they are unable to provide the logistical support of a thorough reprocessing program.
“For soap dispensers, it is therefore advantageous to use disposable pumps on the container that are discarded with each refill.Excerpt from the KRINKO recommendation, 2016
The German Society for Hospital Hygiene’s (DGKH) goes even further than the KRINKO, in their reprocessing recommendations for dispensers in healthcare facilities. The DGKH also advocates for using disposable pumps, or cartridge solutiosn in disinfectant dispensers. 
“Soap and hand disinfectant dispensers with disposable pump heads that are disposed of with the empty container are preferred. If the pump heads are used for subsequent containers, the manufacturer must provide detailed reprocessing instructions”.Extract from the DGKH recommendation, 2011
This recommendation from two well-known institutions is being promoted by more and more hospitals. One example is the Oberammergau Clinic, where innovative Disposable Hygiene Pumps (DHP) have been used since the beginning of the year in all patient rooms in acute care areas, as well as in heavily frequented therapy areas. Another example is a North Rhine-Westphalian clinic which relies on the advantages of the practical DHP disposable pumps, particularly in hygiene-sensitive intensive care units.
The DHP is a recyclable, product-neutral pump that is compatible with all Euro Bottle conforming soaps and sanitizers. The Euro bottle standard guarantees the user the greatest possible flexibility and is recommended by KRINKO and DGKH for safe and hygienic dispensing.
In other markets, products like the KX and Neptune cartridge systems offered by OPHARDT hygiene already offer maximum hygiene security, through a closed system. At OPHARDT hygiene all disposable dispenser pumps are made of recyclable plastics and manufactured without a metal spring which enables seamless recycling.
 Gleich, S., Vieweg, C., & von Baum, H. (2015). Untersuchung der mikrobiellen Kontamination von Waschlotionsspendern aus unterschiedlichen Risikobereichen. Hyg Med, 40(6), 236-241.
 Buffet-Bataillon, S., Rabier, V., Bétrémieux, P., Beuchée, A., Bauer, M., Pladys, P., … & Jolivet-Gougeon, A. (2009). Outbreak of Serratia marcescens in a neonatal intensive care unit: contaminated unmedicated liquid soap and risk factors. Journal of Hospital Infection, 72(1), 17-22.
 Trautmann, M., Notburga, P., & Bobic, R. (2013). Reinigungs-und Desinfektionsleistung eines Aufbereitungsprogramms für die routinemäßige Reinigung von Dosierspendern im Krankenhaus. Hyg Med, 38(11), 468-472.
 Spender für Händedesinfektionsmittel und Seifenlösungen ein Hygienerisiko? Empfehlungen : Klare Rahmenbedingungen und deren Umsetzung? Dr. Dr. I. Otto-Karg. Krankenhaushygiene Klinikum Fulda gAG Universitätsmedizin Marburg. Presentation.
 Aufbereitung von Händedesinfektionsmittel- und Seifenspendern aus Sicht der Hygienefachkraft. Stefan Drees. St. Elisabeth-Krankenhaus Köln-Hohenlind. Presentation.
 Schulz-Stübner, S., Volkmann, A., Ebner, W., & Hauer, T. (2019). Practice and attitudes toward alcohol-based hand disinfection among German infection control teams. Infection Control & Hospital Epidemiology, 40(5), 609-612.
 Assadian, O., Kramer, A., Christiansen, B., Exner, M., Martiny, H., Sorger, A., & Suchomel, M. (2011). Empfehlung zu Anforderungen an Seifen-und Händedesinfektionsmittelspender in Einrichtungen des Gesundheitswesens. Hygiene und Medizin, 36(10), 407.