dgkh000676 10.3205/dgkh000676 urn:nbn:de:0183-dgkh0006761 Position Paper Ausstattung medizinischer Handwaschplätze mit kaltem Wasser in Trinkwasserqualität – ein Beitrag zur Nachhaltigkeit Scheithauer Scheithauer Simone S Prof Dr. med. habil.

Department of Infection Control and Infectious Diseases, University Medical Center Göttingen (UMG), Georg-August University Göttingen, Göttingen, Robert-Koch-Straße 40, 37075 Göttingen, Germany; Phone: +49 5513962092Department of Infection Control and Infectious Diseases, University Medical Center Göttingen (UMG), Georg-August University Göttingen, Göttingen, GermanyMember of the Commission for Infection Prevention and Hygiene in Healthcare and Nursing (KRINKO) at the Robert Koch Institute (RKI), Berlin, Germany

simone.scheithauer@med.uni-goettingen.de author Lexow Lexow Franziska F

Robert Koch Institute (RKI), Department for Infectious Diseases, Unit 14 Hospital Hygiene, Infection Prevention and Control, Berlin, Germany

author Hepner Hepner Britta B

Robert Koch Institute (RKI), Department for Infectious Diseases, Unit 14 Hospital Hygiene, Infection Prevention and Control, Berlin, Germany

author Exner Exner Martin M

Member of the Commission for Infection Prevention and Hygiene in Healthcare and Nursing (KRINKO) at the Robert Koch Institute (RKI), Berlin, Germany

author von Baum von Baum Heike H

Member of the Commission for Infection Prevention and Hygiene in Healthcare and Nursing (KRINKO) at the Robert Koch Institute (RKI), Berlin, Germany Institute of Medical Microbiology and Hygiene, University Clinic Ulm, Ulm, Germany

author Thanheiser Thanheiser Marc M

Robert Koch Institute (RKI), Department for Infectious Diseases, Unit 14 Hospital Hygiene, Infection Prevention and Control, Berlin, Germany

author Kramer Kramer Axel A

Member of the Commission for Infection Prevention and Hygiene in Healthcare and Nursing (KRINKO) at the Robert Koch Institute (RKI), Berlin, Germany Institute of Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany

author German Medical Science GMS Publishing House

Düsseldorf

610 cold-water handwashing carbon footprint hygiene/infection prevention and control benefits Händewaschung Kaltwasser CO2-Fußabdruck Hygienevorteile 20260910 engl This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 2196-5226 21 GMS Hygiene and Infection Control GMS Hyg Infect Control 67 00010101Typo Aus folgenden Gründen wird die Standardaussattung medizinischer Handwaschplätze mit Reihung nur mit kaltem Wasser empfohlen: Beitrag zur Nachhaltigkeit durch Reduzierung des CO2-Fußabdrucks, Reduzierung des Risikos der Vermehrung von Legionella spp. in der Trinkwasserinstallation, Entfallen der Untersuchung von Warmwasser auf Legionellen, Vermeidung akzidenteller Verbrühung bei gleicher Abreicherung der transienten Hautflora wie durch Warmwasser, Reduzierung der Hautirritation und Kostenreduktion. Equipping medical handwashing stations with cold water only as a standard is recommended for the following reasons: contribution to sustainability through a reduced carbon footprint, reduced risk of Legionella spp. proliferation in the drinking water system, elimination of the need to test hot water for Legionella spp., prevention of accidental scalding, reduced skin irritation, and cost savings – all while achieving the same reduction of transient skin flora as with warm water. IntroductionPrevious German recommendations stated that medical handwashing stations for employees must be equipped with inlets for both hot an cold water , . Recent updates recommend “water of drinking-water quality” without the need to provide hot water .This is in line with the general assessment by the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC), that the effects of water temperature on effective depletion of pathogens from the hands are negligible , recently conformed in an in vitro study . Benefit and risk assessmentThe elimination of the obligation to provide hot water offers opportunities for proportionate solutions for a wide variety of facilities and functions for reasons of resource and environmental conservation as well as cost savings. Benefits are summarized in the infographic. Additionally, in times of climate crisis, hybrid attacks, and war, a power outage must always be expected. In such situations, you can only wash with cold water. This needs to be taken into account more when weighing risks. Climate change has been identified as the greatest global threat to human health in the 21st century and has been described by the Intergovernmental Panel on Climate Change (IPCC) as an existential threat to humanity . Globally, the healthcare sector itself contributes significantly to the climate crisis, being responsible for 4.4% of total climate-damaging emissions . The WHO sees significant potential for the healthcare sector to actively contribute to climate protection through more sustainable structures and processes . The carbon dioxide balance (CO2 footprint) can be reduced safely from an infection prevention point of view by promoting the use of cold water. If, for example, 100 handwashing activities per day were carried out in a hospital over one year using only cold water, between 1.5 and 2.1 tonnes of CO2 could be saved, depending on the proportion of fossil fuels (e.g. gas, oil, electricity). In Germany, one litre of hot water costs about 2.5 to 4 times as much as a litre of cold water, depending on the type of energy source. Thus, this intervention is part of the national infection prevention and control (IPC) recommendations, making IPC more sustainable .Not providing hot water can also reduce the risk of accidental scalding. With regard to water temperature, the comfort aspect of a pleasant water temperature probably increasing adherence to hand washing needs to be taken into account. However, the most important single measure of hand hygiene in medical and nursing care is hand antisepsis using alcohol-based hand rubs. Handwashing is primarily used for mechanical cleaning of the hands such as at the start of the day of surgery and for certain indications, e.g. the care of patients with Clostridioides (C.) difficile infections (CDI). The effectiveness of handwashing on the transient flora correlates with the duration of handwashing, the technique, the quality of the water used and the handwashing preparations, but not with temperature , , . The experimental comparison of rinsing the hands with cold vs. warm water regarding the reduction of contamination with Escherichia (E.) coli K 12 showed no difference using EN 1499 as method . The authors conclude that avoiding hot water is a safe and resource-saving method . Even more, skin irritation by washing hands and especially using hot water , can have a negative impact on the implementation of hygienic hand antisepsis and thus increase the likelihood of pathogen transmission and infection among the employees themselves, respectively.Education about the benefits of resource conservation can help ensure acceptance. Furthermore, the removal of the obligation to provide hot water is not to be equated with a ban. However, using only cold water could – especially with regard to climate change – reduce the risk of the presence, multiplication and cross-contamination of Legionella spp. and thus the risk of infection. The growth of virulent Legionella is favoured in the temperature range of 25°C–50°C, which is why the hot water temperature should be at least 55°C and the cold water temperature below 25°C according to technical regulations. Ensuring a hot water temperature of 55°C at least requires a huge amount of energy. There is no alternative to temperature for safely controlling Legionella in hot water, as chemical disinfection methods in hot water are not sufficiently reliable, and there are always reports of outbreaks despite adequately high disinfectant concentrations. Therefore, the strategy of focusing hot water supply only on areas where it is truly needed from a hygienic-medical perspective, is sensible and represents a significant contribution to energy efficiency.When considering a change to cold-water supply only in existing buildings, caution is required. If existing hot water inlets are not or seldom used, a regular flushing of the hot water pipe must be included in the facility's internal water safety plan . Alternatively, a professional dismantling of the hot water pipes can be considered. The intervention perfectly fits to new buildings helping to decrease risks, the carbon footprint and costs by one single intervention. NotesWe want to acknowledge all other KRINKO members and the KRINKO office members at the RKI as well as the secretary office of the Department of Infection Control and Infectious Diseases, UMG.Authors’ ORCIDs Scheithauer S: https://orcid.org/0000-0003-0773-4739Lexow F: https://orcid.org/0000-0003-3463-2842Hepner B: https://orcid.org/0009-0002-5660-157XExner M: https://orcid.org/0000-0002-6383-7866Thanheiser M: https://orcid.org/0009-0005-4139-6544Kramer A: https://orcid.org/0000-0003-4193-2149FundingNone. Competing interestsThe authors declare that they have no competing interests.AI usage statement No artificial intelligence (AI) tools were used. All aspects of the work were carried out solely by the authors. Anonym TRBA 250: Biologische Arbeitsstoffe im Gesundheitsdienst und in der Wohlfahrtspflege. GMBl Nr. 34-37 vom 10.11.2025, 1. Änderung vom 14.11.2025, GMBl Nr. 38 TRBA 250: Biologische Arbeitsstoffe im Gesundheitsdienst und in der Wohlfahrtspflege. GMBl Nr. 34-37 vom 10.11.2025, 1. Änderung vom 14.11.2025, GMBl Nr. 38. Baua. [last access 2026 Jun 03]. Available from: https://www.baua.de/DE/Angebote/ Regelwerk/TRBA/TRBA-250 https://www.baua.de/DE/Angebote/ Regelwerk/TRBA/TRBA-250 Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Institut Händehygiene in Einrichtungen des Gesundheitswesens, Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut (RKI) 2016 Bgbl Gesundheitsforsch Gesundheitssch 1189–220 Kommission für Krankenhaushygiene und Infektionsprävention beim Robert Koch-Institut. Händehygiene in Einrichtungen des Gesundheitswesens, Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut (RKI). Bgbl Gesundheitsforsch Gesundheitssch. 2016; 59:1189–220. DOI: 10.1007/s00103-016-2416-6 https://doi.org/10.1007/s00103-016-2416-6 Kommission für Infektionsprävention in medizinischen Einrichtungen und in Einrichtungen und Unternehmen der Pflege und Eingliederungshilfe (KRINKO) beim Robert Koch-Institut (RKI) Änderung der Empfehlung „Händehygiene in Einrichtungen des Gesundheitswesens“ bezüglich der Temperatur des Wassers an medizinischen Handwaschplätzen 2026 Epid Bull 3-7 Kommission für Infektionsprävention in medizinischen Einrichtungen und in Einrichtungen und Unternehmen der Pflege und Eingliederungshilfe (KRINKO) beim Robert Koch-Institut (RKI). Änderung der Empfehlung „Händehygiene in Einrichtungen des Gesundheitswesens“ bezüglich der Temperatur des Wassers an medizinischen Handwaschplätzen. Epid Bull. 2026 Aug 6;32:3-7. World Health Organization 2009 WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge. Clean Care is Safer Care 1-270 World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge. Clean Care is Safer Care. 2009. p. 1-270. Available from: https://iris.who.int/server/api/core/bitstreams/b7cdc469-d662-4958-adfd-949a750e5ad9/content https://iris.who.int/server/api/core/bitstreams/b7cdc469-d662-4958-adfd-949a750e5ad9/content CDC 2024 About Hand Hygiene for Patients in Healthcare Settings CDC. About Hand Hygiene for Patients in Healthcare Settings. 2024 Feb 27 [last access 2026 Aug 09]. Available from: https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html Kordasiewicz-Stingler R Reiter M Kampf G Gebel J Ilschner C Suchomel M Equivalent reduction of Escherichia coli by rinsing hands with cold and warm water 2024 GMS Hyg Infect Control Doc72 Kordasiewicz-Stingler R, Reiter M, Kampf G, Gebel J, Ilschner C, Suchomel M. Equivalent reduction of Escherichia coli by rinsing hands with cold and warm water. GMS Hyg Infect Control. 2024;19:Doc72. DOI: 10.3205/dgkh000527 https://doi.org/10.3205/dgkh000527 Watts N Amann M Arnell N Ayeb-Karlsson S Belesova K Berry H Bouley T Boykoff M Byass P Cai W Campbell-Lendrum D Chambers J Daly M Dasandi N Davies M Depoux A Dominguez-Salas P Drummond P Ebi KL Ekins P Montoya LF Fischer H Georgeson L Grace D Graham H Hamilton I Hartinger S Hess J Kelman I Kiesewetter G Kjellstrom T Kniveton D Lemke B Liang L Lott M Lowe R Sewe MO Martinez-Urtaza J Maslin M McAllister L Mikhaylov SJ Milner J Moradi-Lakeh M Morrissey K Murray K Nilsson M Neville T Oreszczyn T Owfi F Pearman O Pencheon D Pye S Rabbaniha M Robinson E Rocklöv J Saxer O Schütte S Semenza JC Shumake-Guillemot J Steinbach R Tabatabaei M Tomei J Trinanes J Wheeler N Wilkinson P Gong P Montgomery H Costello A The 2018 report of the Lancet Countdown on health and climate change: shaping the health of nations for centuries to come 2018 Lancet 2479-514 Watts N, Amann M, Arnell N, Ayeb-Karlsson S, Belesova K, Berry H, Bouley T, Boykoff M, Byass P, Cai W, Campbell-Lendrum D, Chambers J, Daly M, Dasandi N, Davies M, Depoux A, Dominguez-Salas P, Drummond P, Ebi KL, Ekins P, Montoya LF, Fischer H, Georgeson L, Grace D, Graham H, Hamilton I, Hartinger S, Hess J, Kelman I, Kiesewetter G, Kjellstrom T, Kniveton D, Lemke B, Liang L, Lott M, Lowe R, Sewe MO, Martinez-Urtaza J, Maslin M, McAllister L, Mikhaylov SJ, Milner J, Moradi-Lakeh M, Morrissey K, Murray K, Nilsson M, Neville T, Oreszczyn T, Owfi F, Pearman O, Pencheon D, Pye S, Rabbaniha M, Robinson E, Rocklöv J, Saxer O, Schütte S, Semenza JC, Shumake-Guillemot J, Steinbach R, Tabatabaei M, Tomei J, Trinanes J, Wheeler N, Wilkinson P, Gong P, Montgomery H, Costello A. The 2018 report of the Lancet Countdown on health and climate change: shaping the health of nations for centuries to come. Lancet. 2018 Dec 8;392(10163):2479-514. DOI: 10.1016/S0140-6736(18)32594-7 https://doi.org/10.1016/S0140-6736(18)32594-7 Keil M Frehse L Hagemeister M Knieß M Lange O Kronenberg T Rogowski W Carbon footprint of healthcare systems: a systematic review of evidence and methods 2024 BMJ Open e078464 Keil M, Frehse L, Hagemeister M, Knieß M, Lange O, Kronenberg T, Rogowski W. Carbon footprint of healthcare systems: a systematic review of evidence and methods. BMJ Open. 2024 Apr 30;14(4):e078464. DOI: 10.1136/bmjopen-2023-078464 https://doi.org/10.1136/bmjopen-2023-078464 Watts N Campell-Lendrum D Maiero M Montoya LF Lao K 2015 Strengthening health resilience to climate change. Technical Briefing for the World Health Organization Conference on Health and Climate Watts N, Campell-Lendrum D, Maiero M, Montoya LF, Lao K. Strengthening health resilience to climate change. Technical Briefing for the World Health Organization Conference on Health and Climate. 2015 [last access 2026 Aug 08]. Available from: https://cdn.who.int/media/docs/default-source/climate-change/technical-briefing---health-resilience-to-climate-change815e9934-be34-4cdd-9734-ba6d1fcf8c25.pdf?sfvrsn=b0772759_1&download=true https://cdn.who.int/media/docs/default-source/climate-change/technical-briefing---health-resilience-to-climate-change815e9934-be34-4cdd-9734-ba6d1fcf8c25.pdf?sfvrsn=b0772759_1&download=true. Last access: 8.9.2026 Michaels B Gangar V Schultz A Arenas M Curiale M Ayers T Paulson D Water temperature as a factor in handwashing efficacy 2002 Food Service Technology 139–49 Michaels B, Gangar V, Schultz A, Arenas M, Curiale M, Ayers T, Paulson D. Water temperature as a factor in handwashing efficacy. Food Service Technology. 2002;2(3):139–49. DOI: 10.1046/j.1471-5740.2002.00043.x https://doi.org/10.1046/j.1471-5740.2002.00043.x Jensen DA Macinga DR Shumaker DJ Bellino R Arbogast JW Schaffner DW Quantifying the effects of water temperature, soap volume, lather time, and antimicrobial soap as variables in the removal of Escherichia coli ATCC 11229 from hands 2017 J Food Prot 1022-31 Jensen DA, Macinga DR, Shumaker DJ, Bellino R, Arbogast JW, Schaffner DW. Quantifying the effects of water temperature, soap volume, lather time, and antimicrobial soap as variables in the removal of Escherichia coli ATCC 11229 from hands. J Food Prot. 2017 Jun; 80(6):1022-31. DOI: 10.4315/0362-028X.JFP-16-370 https://doi.org/10.4315/0362-028X.JFP-16-370 Emilson A Lindberg M Forslind B The temperature effect on in vitro penetration of sodium lauryl sulfate and nickel chloride through human skin 1993 Acta Derm Venereol 203-7 Emilson A, Lindberg M, Forslind B. The temperature effect on in vitro penetration of sodium lauryl sulfate and nickel chloride through human skin. Acta Derm Venereol. 1993 Jun;73(3):203-7. DOI: 10.2340/0001555573203207 https://doi.org/10.2340/0001555573203207 Ohlenschlaeger J Friberg J Ramsing D Agner T Temperature dependency of skin susceptibility to water and detergents 1996 Acta Derm Venereol 274-6 Ohlenschlaeger J, Friberg J, Ramsing D, Agner T. Temperature dependency of skin susceptibility to water and detergents. Acta Derm Venereol. 1996 Jul;76(4):274-6. DOI: 10.2340/0001555576274276 https://doi.org/10.2340/0001555576274276 Dyck A Exner M Kramer A Experimental based experiences with the introduction of a water safety plan for a multi-located university clinic and its efficacy according to WHO recommendations 2007 BMC Public Health 34 Dyck A, Exner M, Kramer A. Experimental based experiences with the introduction of a water safety plan for a multi-located university clinic and its efficacy according to WHO recommendations. BMC Public Health. 2007 Mar 13;7:34. DOI: 10.1186/1471-2458-7-34 https://doi.org/10.1186/1471-2458-7-34 0 0 0 0