Performance feedback of hand hygiene, using alcohol gel as the skin decontaminant, reduces the number of inpatients newly affected by MRSA and antibiotic costs

Assessment of transparency of cost estimates in economic evaluations of patient safety programmes

OBJECTIVES

Transparency of costing is essential for decision-makers who require information on the efficiency of a health care programme, because effective decisions depend largely on applicability to their settings. The main objectives of this study were to assess published studies for transparency of cost estimates.

METHODS

We first developed criteria with two axes by reviewing publications dealing with economic evaluations and cost accounting studies: clarification of the scope of costing and accuracy of method evaluating costs. We then performed systematic searches of the literature for studies which estimated prevention costs and assessed the transparency and accuracy of costing based on our criteria.

RESULTS

Forty studies met the inclusion criteria. Half of the studies reported data for both the quantity and unit price of programmes in regard to prevention costs. Although 30 studies estimated costs of adverse events, 19 of these described the scope of costing only, and just five studies used a micro-costing method. Among 30 studies that estimated 'gross cost savings' and 'net cost savings', there was a huge discrepancy in labels.

CONCLUSIONS

Even if a cost study was conducted in accordance with existing techniques of economic evaluation which mostly paid attention to internal validity of cost estimates, without adequate explanation of the process of costing, reproducibility cannot be assured and the study may lose its value as scientific information. This study found that there is tremendous room for improvement.

A comparison of the antibacterial efficacy and cytotoxicity to cultured human skin cells of 7 commercial hand rubs and Xgel, a new copper-based biocidal hand rub

BACKGROUND

Hand cleanliness is important in hospital infection control, but skin irritation from frequent alcohol-based hand rub use reduces compliance. We have compared a new copper biocide/Aloe vera-based biocidal hand rub (Xgel) with 7 commercially available hand rubs.

METHODS

Hand rubs were cultured with human skin cells for 24 hours after which cytotoxicity was assessed using the sulforhodamine B assay. The EN 12054 bacterial suspension test protocol was used to assess biocidal activity of 2 of the least cytotoxic hand rubs (Xgel and Purell).

RESULTS

Hand rubs had 50% cytotoxic concentrations ranging from >10% to <0.1% vol/vol. In the EN12054 assay, Xgel reduced colony forming units (CFU) by >10(8) with methicillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter in 1 minute, whereas Purell only reduced CFU by 10(4) and 10(5), respectively. Purell was ineffective against C difficile spores, whereas Xgel produced a 3 x 10(3) reduction in CFU.

CONCLUSION

The hand rubs had a wide range of cytotoxicity values for human skin cells, with Xgel being the least cytotoxic to human skin cells. In the EN 12054 bacterial suspension test, Xgel was more effective than Purell against all organisms tested. It should be noted that these in vitro results may not translate into clinical differences.

Methicillin-resistant Staphylococcus aureus in orthopaedic trauma

We have conducted a case-control study over a period of ten years comparing both deep infection with methicillin-resistant staphylococcus aureus (MRSA) and colonised cases with a control group.

Risk factors associated with deep infection were vascular diseases, chronic obstructive pulmonary disease, admission to a high-dependency or an intensive-care unit and open wounds. Those for colonisation were institutional care, vascular diseases and dementia. Older age was a risk factor for any MRSA infection. The length of hospital stay was dramatically increased by deep infection.

These risk factors are useful in identifying higher-risk patients who may be more susceptible to MRSA infection. A strategy of early identification and isolation may help to control its spread in trauma units.

Genetic similarity between staphylococcus sp isolated from human and hospital settings, and susceptibility to different antimicrobials

One hundred and forty-three samples from human hands and hospital beds were collected at a teaching hospital in the city of Ribeirão Preto/SP by swabs, and placed in BHI broth. Following a 24 h incubation period at 37°C, they were seeded on Petri dishes containing Agar “Staphylococcus Medium 110”. Colonies typical of the genus Staphylococcus were collected and stored at 4°C until tested for catalase, mannitol, hemolysis, DNAse and coagulase. Strains were analyzed by RAPD-PCR to verify their similarity, and tested for sensitivity to ten different antibiotics. From the ninety-two isolated strains, 67 (72,8%) were coagulase- negative and 25 (27,2%) coagulase-positive. Similarity analysis showed a great heterogeneity among strains, but some presented 100% similarity. Resistance to oxacilin was encountered in 39 (42%) of the strains. Two coagulase-negative strains were resistant to vancomycin, and eleven (12%) were considered multiresistant. Measures such as hand disinfection of the staff and hospital beds and rationalization of antibiotic use could contribute to decrease pathogen transmission and selection pressure, diminishing the frequency and lethality of nosocomial infections.

The effect of posters and displays on the use of alcohol gel

Introduction: Hand cleansing with alcohol gel is important in reducing health care associated infection (HCAI). HCAI affects 8% of acute hospital admissions in the UK costing the NHS an estimated ®1 billion per annum1. The aim of this study was to determine the effect of posters and placement of alcohol dispensers on use of alcohol dispensers by staff and visitors passing through hospital foyers.

Method: We noted the use of alcohol gel for hand cleansing in pedestrians entering through the hospital foyers. Three scenarios were noted:

■ Display 1. Poster and gel dispenser in the centre of the foyer.

■ Display 2. Poster and gel dispenser on the wall of the foyer.

■ Display 3. No poster with a gel dispenser on the wall of the foyer.

Results: For display 1 uptake of alcohol gel was 38.4%, for display 2 it was 8.6% and for display 3 it was 2.7%. There was a significant increase in uptake of alcohol hand cleansing when a display was used (p > 0.001). Regarding gender, males were better users of alcohol hand gel overall. Employment group: the highest use was amongst female visitors with display 1 (51.6%). Displays had least influence on male doctors (44% with display 1, 10% with display 3).

Conclusion: We recommend the use of prominently placed posters and gel dispensers in hospital foyers.

Methicillin-resistant Staphylococcus aureus--positive surgical site infections in face-lift surgery

OBJECTIVES

To determine the incidence of methicillin-resistant Staphylococcus aureus (MRSA)-positive surgical site infections after face-lift surgery and to discuss the screening, prevention, and treatment of such infections.

METHODS

The patient charts of 780 patients who underwent a deep-plane rhytidectomy between 2001 and 2007 were reviewed for postoperative wound infections. Culture results and sensitivities were recorded. To our knowledge, this is the first study that documents MRSA-positive surgical site infections after face-lift surgery.

RESULTS

Five of 780 patients (0.6%) who underwent face-lift surgery by the senior surgeon had postoperative surgical site infections. Four of the 5 patients had cultures that were positive for MRSA. Two of these patients (0.3%) required hospitalization and had collections that had to be opened or drained and developed wound breakdown. Both patients eventually responded to wound care along with intravenous and then oral antibiotic therapy. The other 2 MRSA-infected patients responded to oral antibiotic therapy and local wound care alone. The 2 complicated infections occurred on postoperative days 5 and 8. These 2 patients were the only ones among the 5 patients with positive cultures who had known recent contact with another physician or a hospital. All infections occurred in the year 2006, with 3 patients experiencing infection in the last 4 months of the year. Herein, we describe the incidence and sequelae of MRSA infections and colonization. The 2 major different subsets of MRSA are community-acquired MRSA and health care-associated MRSA. Surgical site infections that are positive for MRSA blur this division, which affects many aspects of the course of disease and treatment. We also discuss strategies for screening, preventing, and treating MRSA surgical site infections.

CONCLUSIONS

Methicillin-resistant S aureus-positive surgical site infection is an increasingly problematic issue in all surgical fields. In the future, MRSA-positive infections will be more prevalent and will require well-developed screening, prevention, and treatment strategies.

An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections

BACKGROUND

The objectives of this integrative review were to critically examine the overall state of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections (HCAIs) in acute care and long-term care settings, and offer recommendations for future directions in the field based on our findings.

METHODS

We searched for original research and reviews of research published between January 1, 1996, and July 31, 2006. Studies were identified through the electronic databases Medline, CINAHL, EMBASE, PUBMED, the Cochrane Library, and through expert consultation. Our comprehensive search strategy included all English articles for which hand hygiene or handwashing-related terms were combined with HCAIs. All studies that investigated a relationship between hand hygiene practices and HCAIs in acute care facilities were considered. These hand hygiene practices included the initiation of multimodal hand hygiene initiatives, the introduction of alcohol sanitizers, the implementation or changes of the infection control practices or infection control policies, and other organizational interventions. Studies only examining hand hygiene compliance, efficacy of alcohol hand gels, plain soap, and antimicrobial soap in reducing bacteria count recovered from hands were excluded.

RESULTS

Of the 1120 articles retrieved, 35 publications, including 4 reviews of research discussed at the outset of this article, met our inclusion criteria. The remaining 31 eligible original studies included 18 (58.07%) before and after studies without control groups, 4 (12.90%) before and after studies with a control group, 3 (9.68%) cohort studies with no control group, 4 (12.90%) cohort studies with a control group, and 2 (6.45%) randomized trials. Over 50% (16 or 31) of the studies were conducted in the U.S. Two independent reviewers conducted independent evaluations of all eligible studies, critiquing and scoring each study using a rating scale for examining the fatal flaws of quasi-experimental and before and after studies.

CONCLUSIONS

There is a lack of rigorous evidence linking specific hand hygiene interventions with the prevention of HCAIs. The varied nature of the interventions used and the diverse factors affecting the acquisition of HCAIs make it difficult to show the specific effect of hand hygiene alone. The most frequent methodologies currently used in this research area are before and after observational studies without a control comparison group. Based on these findings, we recommend that researchers used a modified version of Larson's 2005 criteria to guide the design and conduct of future before and after observational studies in this area. We also argue that as we accumulate stronger evidence of which interventions are most effective, we need to develop additional research approaches to study how organizations succeed and fail in fostering the uptake of evidence-based hand hygiene interventions.

Impact of rapid screening tests on acquisition of meticillin resistant Staphylococcus aureus: cluster randomised crossover trial

OBJECTIVE

To determine whether introducing a rapid test for meticillin resistant Staphylococcus aureus (MRSA) screening leads to a reduction in MRSA acquisition on hospital general wards.

DESIGN

Cluster randomised crossover trial.

SETTING

Medical, surgical, elderly care, and oncology wards of a London teaching hospital on two sites.

MAIN OUTCOME MEASURE

MRSA acquisition rate (proportion of patients negative for MRSA who became MRSA positive).

PARTICIPANTS

All patients admitted to the study wards who were MRSA negative on admission and screened for MRSA on discharge.

INTERVENTION

Rapid polymerase chain reaction based screening test for MRSA compared with conventional culture.

RESULTS

Of 9608 patients admitted to study wards, 8374 met entry criteria and 6888 had full data (82.3%); 3335 in the control arm and 3553 in the rapid test arm. The overall MRSA carriage rate on admission was 6.7%. Rapid tests led to a reduction in median reporting time from admission, from 46 to 22 hours (P<0.001). Rapid testing also reduced the number of inappropriate pre-emptive isolation days between the control and intervention arms (399 v 277, P<0.001). This was not seen in other measurements of resource use. MRSA was acquired by 108 (3.2%) patients in the control arm and 99 (2.8%) in the intervention arm. When predefined confounding factors were taken into account the adjusted odds ratio was 0.91 (95% confidence interval 0.61 to 1.234). Rates of MRSA transmission, wound infection, and bacteraemia were not statistically different between the two arms.

CONCLUSION

A rapid test for MRSA led to the quick receipt of results and had an impact on bed usage. No evidence was found of a significant reduction in MRSA acquisition and on these data it is unlikely that the increased costs of rapid tests can be justified compared with alternative control measures against MRSA.

TRIAL REGISTRATION

Clinical controlled trials ISRCTN75590122 [controlled-trials.com].

Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people

BACKGROUND

Nursing homes for older people provide an environment likely to promote the acquisition and spread of meticillin-resistant Staphylococcus aureus (MRSA), putting residents at increased risk of colonisation and infection. It is recognised that infection control strategies are important in preventing and controlling MRSA transmission.

OBJECTIVES

The objective of this review was to determine the effects of infection control strategies for preventing the transmission of MRSA in nursing homes for older people.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2007, Issue 1), the Cochrane Wounds Group Specialised Register (searched April 2007); the Infectious Diseases Group and EPOC also searched their Specialised Registers for this review (both May 2006). We also searched MEDLINE (from 1966 to March Week 3 2007), EMBASE (1980 to 2007 Week 13), CINAHL (1982 to March Week 3 2007), British Nursing Index (1985 to March 2007), DARE (1992 to March 2007), Web of Science (1981 to March 2007), and the Health Technology Assessment (HTA) database (1988 to March 2007). Research in progress was identified through the National Research Register, Current Clinical Trials (www.controlled-trials.com), Medical Research Council Register, Current Research in Britain (CRIB), and HSRPRoj (current USA projects). SIGLE was also searched in order to identify atypical material which was not accessible through more conventional sources.

SELECTION CRITERIA

All randomised and controlled clinical trials, controlled before and after studies and interrupted time series studies of infection control interventions in nursing homes for older people were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the results of the searches.

MAIN RESULTS

Since no studies met the selection criteria, neither a meta-analysis nor a narrative description of studies was possible.

AUTHORS' CONCLUSIONS

The lack of studies in this field is surprising. Nursing homes for older people provide an environment likely to promote the acquisition and spread of infection, with observational studies repeatedly reporting that being a resident of a nursing home increases the risk of MRSA colonisation. Much of the evidence for recently-issued United Kingdom guidelines for the control and prevention of MRSA in health care facilities was generated in the acute care setting. It may not be possible to transfer such strategies directly to the nursing home environment, which serves as both a healthcare setting and a resident's home. Rigorous studies should be conducted in nursing homes, to test interventions that have been specifically designed for this unique environment.

Reduction of health care associated infection risk in neonates by successful hand hygiene promotion

OBJECTIVES

Hand hygiene promotion interventions rarely result in sustained improvement, and an assessment of their impact on individual infection risk has been lacking. We sought to measure the impact of hand hygiene promotion on health care worker compliance and health care-associated infection risk among neonates.

METHODS

We conducted an intervention study with a 9-month follow-up among all of the health care workers at the neonatal unit of the Children's Hospital, University of Geneva Hospitals, between March 2001 and February 2004. A multifaceted hand hygiene education program was introduced with compliance assessed during successive observational surveys. Health care-associated infections were prospectively monitored, and genotypic relatedness of bloodstream pathogens was assessed by pulsed-field gel electrophoresis. A comparison of observed hand hygiene compliance and infection rates before, during, and after the intervention was conducted.

RESULTS

A total of 5325 opportunities for hand hygiene were observed. Overall compliance improved gradually from 42% to 55% across study phases. This trend remained significant after adjustment for possible confounders and paralleled the measured increase in hand-rub consumption (from 66.6 to 89.2 L per 1000 patient-days). A 9-month follow-up survey showed sustained improvement in compliance (54%), notably with direct patient contact (49% at baseline vs 64% at follow-up). Improved compliance was independently associated with infection risk reduction among very low birth weight neonates. Bacteremia caused by clonally related pathogens markedly decreased after the intervention.

CONCLUSIONS

Hand hygiene promotion, guided by health care workers' perceptions, identification of the dynamics of bacterial contamination of health care workers' hands, and performance feedback, is effective in sustaining compliance improvement and is independently associated with infection risk reduction among high-risk neonates.

Clinical effectiveness of alcohol-based products in increasing hand hygiene compliance and reducing infection rates: a systematic review

Reducing the incidence of healthcare-associated infection represents a major challenge. This systematic review of the evidence base considers the clinical effectiveness of incorporating an alcohol-based hand hygiene product into procedures aimed at improving compliance with hand hygiene guidelines, and thereby reducing the incidence of healthcare-associated infections. Multi-component interventions that included alcohol-based products were as effective as those that did not, both in achieving sustained hand hygiene compliance and in reducing infection rates. However, a number of difficulties were encountered in assessing hand hygiene studies: the problem of attributing efficacy to an alcohol-based product when used in a multi-component intervention; the variability inherent in the design of such studies; and how to use data from uncontrolled, unblinded studies in the assessment.

Electronic surveillance of wall-mounted soap and alcohol gel dispensers in an intensive care unit

We describe a battery-powered recording device incorporating a force-sensitive resistor and a microcontroller that records depressions of wall-mounted soap and alcohol gel dispensers. The device has a two-second (2 s) lockout built into it, so that a single record is associated with a single hand-hygiene episode. Recorders were implanted within the wall-mounted dispensers found in two bed areas and the entrance of a 16-bedded intensive care unit. The use of the bed area dispensers was correlated (r) with the dependency of the patient in the open bed area (r=0.5, P<0.01), as assessed using the UK Department of Health critical care minimum data set. Both bed areas and the entrance dispensers showed wide but different fluctuations in use throughout the 24h day. The recording device may help in feedback about soap and gel use for hand-hygiene quality improvement and educational initiatives.

epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001. These guidelines describe the precautions healthcare workers should take in three areas: standard principles for preventing HCAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; preventing infections associated with the use of short-term indwelling urethral catheters; and preventing infections associated with central venous catheters. The evidence for these guidelines was identified by multiple systematic reviews of experimental and non-experimental research and expert opinion as reflected in systematically identified professional, national and international guidelines, which were formally assessed by a validated appraisal process. In 2003, we developed complementary national guidelines for preventing HCAI in primary and community care on behalf of the National Collaborating Centre for Nursing and Supportive Care (National Institute for Healthand Clinical Excellence). A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective in preventing HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. Consequently, the DH commissioned a review of new evidence published following the last systematic reviews. We have now updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the original epic guidelines published in 2001 remain robust, relevant and appropriate but that adjustments need to be made to some guideline recommendations following a synopsis of the evidence underpinning the guidelines. These updated national guidelines (epic2) provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. Because this is not always the best possible evidence, we have included a suggested agenda for further research in each section of the guidelines. National evidence-based guidelines are broad principles of best practice which need to be integrated into local practice guidelines. To monitor implementation, we have suggested key audit criteria for each section of recommendations. Clinically effective infection prevention and control practice is an essential feature of protecting patients. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of healthcare in NHS hospitals in England can be minimised.

Novel ways of preventing antibiotic-resistant infections: what might the future hold?

Most antibiotic-resistant bacteria are opportunistic pathogens; they colonize the skin and mucosal surfaces and only cause infection when the opportunity arises. Thus, the processes that lead to an infection attributable to antibiotic-resistant bacteria can be broadly divided into those processes that lead to acquisition of antibiotic-resistant bacteria and those that lead to the development of an infection with that organism. We review the processes that lead to the development of infections attributable to antibiotic-resistant bacteria. We then discuss options that may become available to interrupt these processes and, thus, may reduce the rate of infections attributable to antibiotic-resistant bacteria in the future.

Evidence-based model for hand transmission during patient care and the role of improved practices

Hand cleansing is the primary action to reduce health-care-associated infection and cross-transmission of antimicrobial-resistant pathogens. Patient-to-patient transmission of pathogens via health-care workers' hands requires five sequential steps: (1) organisms are present on the patient's skin or have been shed onto fomites in the patient's immediate environment; (2) organisms must be transferred to health-care workers' hands; (3) organisms must be capable of surviving on health-care workers' hands for at least several minutes; (4) handwashing or hand antisepsis by the health-care worker must be inadequate or omitted entirely, or the agent used for hand hygiene inappropriate; and (5) the caregiver's contaminated hand(s) must come into direct contact with another patient or with a fomite in direct contact with the patient. We review the evidence supporting each of these steps and propose a dynamic model for hand hygiene research and education strategies, together with corresponding indications for hand hygiene during patient care.

Preventing nosocomial infections: improving compliance with standard precautions in an Indonesian teaching hospital

Standard precautions can prevent transmission of micro-organisms. This study investigated hand hygiene, handling of needles and use of personal protective equipment in an Indonesian teaching hospital, and performed a multi-faceted intervention study to improve compliance. An intervention was performed in an internal medicine ward and a paediatric ward, consisting of development of a protocol for standard precautions, installation of washstands, educational activities and performance feedback. Before, during and after the intervention, observers monitored compliance with hand hygiene, safe handling of needles and use of gloves, gowns and masks. A gynaecology ward served as the control. Unobtrusive observations were performed to check for an influence of the observers on the overt observations. In total, 7,160 activities were observed. Compliance with hand hygiene increased from 46% to 77% in the internal medicine ward and from 22% to 62% in the paediatric ward. Before the intervention, no safe recapping of needles was recorded in either ward. After the intervention, 20% of needles were recapped safely. Inappropriate gown use decreased in the internal medicine ward. There were no significant changes in use of gloves and masks. There may have been an effect of the overt observations in the paediatric ward, but there was no effect in the internal medicine ward. There were no significant changes in the control ward, except for a decrease in the use of gloves. In conclusion, compliance with hand hygiene procedures improved significantly due to an intervention project focused on education and improved facilities. Compliance with safe handling of needles improved slightly due to introduction of the one-handed method for safe recapping of used needles.

Improving hand-washing performance - a crossover study of hand-washing in the orthopaedic department

INTRODUCTION

Effective hand-washing is essential for reducing the spread of infection in hospitals. We aimed to evaluate hand-washing performance of hospital personnel and to determine if this could be improved by education.

MATERIALS AND METHODS

A total of 55 personnel working in the orthopaedic department were asked to clean their hands using an alcohol gel containing a clear fluorescent substance. They were unaware of the assessment method. Performance was assessed by examining their hands under UV light to identify areas that had been neglected. Subjects could visualise which areas they had missed and were then educated regarding hand-washing technique and retested after 7 days.

RESULTS

Of the 55 subjects, 53 completed the study. Individual performance varied widely. Following a simple educational intervention, 49 out of 53 subjects improved from an average of 7.8% to 2.3% area missed (P < 0.001).

CONCLUSIONS

We suggest that hand-washing effectiveness needs to be improved and that a simple educational intervention can be effective.

The role of gowns in preventing nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA): gown use in MRSA control

During a 2-year period, a standard isolation protocol for control of methicillin-resistant Staphylococcus aureus was compared with a similar protocol in which gowns were not used but the availability of alcohol-based hand disinfectant was increased. Intervention wards had 0.10 fewer new MRSA transmissions per ward per month, compared with control wards (P was not significant).

Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units

BACKGROUND

The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC's emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement.

OBJECTIVE

To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO.

DESIGN

Six Sigma Project with pre-post design.

PARTICIPANTS

Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals.

MEASUREMENTS

Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire.

RESULTS

Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products.

CONCLUSIONS

The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC's evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use.

Improving adherence to hand hygiene among health care workers

Increased adherence to hand hygiene is widely acknowledged to be the most important way of reducing infections in health care facilities. Despite evidence of benefit, adherence to hand hygiene among health care professionals remains low. Several behavioral and organizational theories have been proposed to explain this. As a whole, the success of interventions to improve adherence to hand hygiene among health care professionals has been limited. Recent data suggest that a multifaceted intervention, including the use of feedback, education, the introduction of alcohol-based hand wash, and visual reminders, may increase adherence to hand-hygiene recommendations. Although the "active ingredient" of such an intervention is unknown, there is evidence that the use of feedback may be the key to increasing adherence. In this article, we review the theoretical basis for interventions and provide an overview of the evidence for interventions. Coherent and methodologically sound research is required to better understand the factors contributing to hand-hygiene behavior among health care professionals.

In vitro activity of a novel compound, the metal ion chelating agent AQ+, against clinical isolates of Staphylococcus aureus

OBJECTIVES

To determine the efficacy of a novel antimicrobial compound, AQ+, against a genetically heterogeneous collection comprising 213 Staphylococcus aureus isolates from global sources. AQ+ is an aqueous preparation containing 0.5% 8-hydroxyquinoline.

METHODS

MICs were found for all the isolates tested using the BSAC microdilution method. Time-kill studies were performed according to NCCLS guidelines. Transmission electron microscopy (TEM) was used to view the ultrastructural effects of AQ+.

RESULTS

AQ+ was shown to strongly inhibit the growth of all isolates with a median MIC of 0.25% at a pH optimum of 9.2. Lowering the pH to 7.5 gave an approximately 4-fold reduction in efficacy and at pH 5.5 there was an approximately 8-fold reduction in efficacy. Methicillin-resistant S. aureus (MRSA) as well as vancomycin-intermediate S. aureus were shown to be as equally susceptible to AQ+ as methicillin-susceptible S. aureus. Time-kill curves for AQ+ were similar to those for gentamicin. TEM showed that AQ+ actively disrupts the cell wall of S. aureus leading to cell lysis.

CONCLUSIONS

These results suggest that AQ+ has strong antimicrobial activity and may be useful in preparations to reduce nasal and skin carriage of MRSA.

A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home

OBJECTIVE

Good hand hygiene may reduce the spread of infections in families with children who are in out-of-home child care. Alcohol-based hand sanitizers rapidly kill viruses that are commonly associated with respiratory and gastrointestinal (GI) infections. The objective of this study was to determine whether a multifactorial campaign centered on increasing alcohol-based hand sanitizer use and hand-hygiene education reduces illness transmission in the home.

METHODS

A cluster randomized, controlled trial was conducted of homes of 292 families with children who were enrolled in out-of-home child care in 26 child care centers. Eligible families had > or =1 child who was 6 months to 5 years of age and in child care for > or =10 hours/week. Intervention families received a supply of hand sanitizer and biweekly hand-hygiene educational materials for 5 months; control families received only materials promoting good nutrition. Primary caregivers were phoned biweekly and reported respiratory and GI illnesses in family members. Respiratory and GI-illness-transmission rates (measured as secondary illnesses per susceptible person-month) were compared between groups, adjusting for demographic variables, hand-hygiene practices, and previous experience using hand sanitizers.

RESULTS

Baseline demographics were similar in the 2 groups. A total of 1802 respiratory illnesses occurred during the study; 443 (25%) were secondary illnesses. A total of 252 GI illnesses occurred during the study; 28 (11%) were secondary illnesses. The secondary GI-illness rate was significantly lower in intervention families compared with control families (incidence rate ratio [IRR]: 0.41; 95% confidence interval [CI]: 0.19-0.90). The overall rate of secondary respiratory illness was not significantly different between groups (IRR: 0.97; 95% CI: 0.72-1.30). However, families with higher sanitizer usage had a marginally lower secondary respiratory illness rate than those with less usage (IRR: 0.81; 95% CI: 0.65-1.09).

CONCLUSIONS

A multifactorial intervention emphasizing alcohol-based hand sanitizer use in the home reduced transmission of GI illnesses within families with children in child care. Hand sanitizers and multifaceted educational messages may have a role in improving hand-hygiene practices within the home setting.

Infections associated with medical devices: pathogenesis, management and prophylaxis

The insertion or implantation of foreign bodies has become an indispensable part in almost all fields of medicine. However, medical devices are associated with a definitive risk of bacterial and fungal infections. Foreign body-related infections (FBRIs), particularly catheter-related infections, significantly contribute to the increasing problem of nosocomial infections. While a variety of micro-organisms may be involved as pathogens, staphylococci account for the majority of FBRIs. Their ability to adhere to materials and to promote formation of a biofilm is the most important feature of their pathogenicity. This biofilm on the surface of colonised foreign bodies is regarded as the biological correlative for the clinical experience with FBRI, that is, that the host defence mechanisms often seem to be unable to handle the infection and, in particular, to eliminate the micro-organisms from the infected device. Since antibacterial chemotherapy is also frequently not able to cure these infections despite the use of antibacterials with proven in vitro activity, removal of implanted devices is often inevitable and has been standard clinical practice. However, in specific circumstances, such as infections of implanted medical devices with coagulase-negative staphylococci, a trial of salvage of the device may be justified. All FBRIs should be treated with antibacterials to which the pathogens have been shown to be susceptible. In addition to systemic antibacterial therapy, an intraluminal application of antibacterial agents, referred to as the 'antibiotic-lock' technique, should be considered to circumvent the need for removal, especially in patients with implanted long-term catheters. To reduce the incidence of intravascular catheter-related bloodstream infections, specific guidelines comprising both technological and nontechnological strategies for prevention have been established. Quality assurance, continuing education, choice of the catheter insertion site, hand hygiene and aseptic techniques are aspects of particular interest. Furthermore, all steps in the pathogenesis of biofilm formation may represent targets against which prevention strategies may be directed. Alteration of the foreign body material surface may lead to a change in specific and nonspecific interactions with micro-organisms and, thus, to a reduced microbial adherence. Medical devices made out of a material that would be antiadhesive or at least colonisation resistant would be the most suitable candidates to avoid colonisation and subsequent infection. Another concept for the prevention of FBRIs involves the impregnation of devices with various substances such as antibacterials, antiseptics and/or metals. Finally, further studies are needed to translate the knowledge on the mechanisms of biofilm formation into applicable therapeutic and preventive strategies.

Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs

The etiology of nosocomial infections, the frequency of contaminated hands with the different nosocomial pathogens, and the role of health care workers' hands during outbreaks suggest that a hand hygiene preparation should at least have activity against bacteria, yeasts, and coated viruses. The importance of efficacy in choosing the right hand hygiene product is reflected in the new Centers for Disease Control and Prevention guideline on hand hygiene (J. M. Boyce and D. Pittet, Morb. Mortal. Wkly. Rep. 51:1-45, 2002). The best antimicrobial efficacy can be achieved with ethanol (60 to 85%), isopropanol (60 to 80%), and n-propanol (60 to 80%). The activity is broad and immediate. Ethanol at high concentrations (e.g., 95%) is the most effective treatment against naked viruses, whereas n-propanol seems to be more effective against the resident bacterial flora. The combination of alcohols may have a synergistic effect. The antimicrobial efficacy of chlorhexidine (2 to 4%) and triclosan (1 to 2%) is both lower and slower. Additionally, both agents have a risk of bacterial resistance, which is higher for chlorhexidine than triclosan. Their activity is often supported by the mechanical removal of pathogens during hand washing. Taking the antimicrobial efficacy and the mechanical removal together, they are still less effective than the alcohols. Plain soap and water has the lowest efficacy of all. In the new Centers for Disease Control and Prevention guideline, promotion of alcohol-based hand rubs containing various emollients instead of irritating soaps and detergents is one strategy to reduce skin damage, dryness, and irritation. Irritant contact dermatitis is highest with preparations containing 4% chlorhexidine gluconate, less frequent with nonantimicrobial soaps and preparations containing lower concentrations of chlorhexidine gluconate, and lowest with well-formulated alcohol-based hand rubs containing emollients and other skin conditioners. Too few published data from comparative trials are available to reliably rank triclosan. Personnel should be reminded that it is neither necessary nor recommended to routinely wash hands after each application of an alcohol-based hand rub. Long-lasting improvement of compliance with hand hygiene protocols can be successful if an effective and accessible alcohol-based hand rub with a proven dermal tolerance and an excellent user acceptability is supplied, accompanied by education of health care workers and promotion of the use of the product.