Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study

The state of reporting context and implementation in peer-reviewed evaluations of water, sanitation, and hygiene interventions: A scoping review

INTRODUCTION

To accurately assess evidence from environmental and public health field trials, context and implementation details of the intervention must be weighed with trial results; yet these details are under and inconsistently reported for water, sanitation, and hygiene (WASH), limiting the external validity of the evidence.

METHODS

To quantify the level of reporting of context and implementation in WASH evaluations, we conducted a scoping review of the 40 most cited evaluations of WASH interventions published in the last 10 years (2012-2022). We applied criteria derived from a review of existing reporting guidance from other sectors including healthcare and implementation science. We subsequently reviewed main articles, supplements, protocols, and other associated resources to assess thoroughness of context and implementation reporting.

RESULTS

Of the final 25 reporting items we searched for, four-intervention name, approach, location, and temporality-were reported by all studies. Five items-theory, implementer qualifications, dose intensity, targeting, and measured fidelity-were not reported in over a third of reviewed articles. Only two studies (5%) reported all items in our checklist. Only 74% of items were found in the main article, while the rest were found in separate papers (7%) or not at all (19%).

DISCUSSION

Inconsistent reporting of WASH implementation illustrates a major challenge in the sector. It is difficult to know what interventions are actually being evaluated and how to compare evaluation results. This inconsistent and incomplete implementation reporting limits the ability of programmers and policy makers to apply the available evidence to their contexts. Standardized reporting guidelines would improve the application of the evidence for WASH field evaluations.

Unpacking nudge sensu lato: insights from a scoping review

Nudges may play an important role in improving infection prevention and control (IPC) in hospitals. However, despite the novelty of the framework, their objectives, strategies and implementation approaches are not new. This review aims to provide an overview of the methods typically used by nudge interventions in IPC in hospitals targeting healthcare workers (HCWs). The initial search in PubMed yielded nine hits. Consequently, the search criteria were broadened and a second search was conducted, introducing 'nudge sensu lato' which incorporates insights from sources beyond the traditional nudge framework while maintaining the same objectives, strategies and approaches. During the second search, PubMed, Epistemonikos, Web of Science and PsycInfo were searched in accordance with the PRISMA guidelines. Abstracts were screened, and reviewers from an interdisciplinary team read the full text of selected papers. In total, 5706 unique primary studies were identified. Of these, 67 were included in the review, and only four were listed as nudge sensu stricto, focusing on changing HCWs' hand hygiene. All articles reported positive intervention outcomes. Of the 56 articles focused on improving hand hygiene compliance, 71.4% had positive outcomes. For healthcare equipment disinfection, 50% of studies showed significant results. Guideline adherence interventions had a 66.7% significant outcome rate. The concept of nudge sensu lato was introduced, encompassing interventions that employ strategies, methods and implementation approaches found in the nudge framework. The findings demonstrate that this concept can enhance the scientific development of more impactful nudges. This may help clinicians, researchers and policy makers to develop and implement effective nudging interventions.

Clostridioides difficile infection leading to fulminant colitis with toxic megacolon

Clostridioidesdifficile infection (CDI) is the culprit of millions of nosocomial infections in the United States. Programs that successfully decrease its incidence, therefore, render cost savings for the healthcare system. Toxic megacolon and perforation are two of the most significant complications with increased mortality rates. We report a 23-year-old nursing home resident hospitalized for fever, cough, and green sputum. After 3 days of antibiotic therapy, he developed abdominal distension, diarrhea, and vomiting and underwent a total colectomy. The colon was dilated to a maximum of 11 cm with markedly edematous mucosa and yellow pseudomembranes. Qualitative PCR of the stool detected Clostridioides difficile toxin B gene. While there is no consensus for the required interval between antibiotic treatment and CDI, this presentation 3 days after starting the antibiotic therapy is earlier than most proposed ranges.

Increase in methicillin-susceptible Staphylococcus aureus bloodstream infections in Switzerland: a nationwide surveillance study (2008-2021)

PURPOSE

An increasing burden of Staphylococcus aureus bloodstream infections (BSI), despite a decrease in the percentage of methicillin-resistant S. aureus (MRSA), was described recently in other European countries. The main aim of this study was to analyse recent temporal trends of S. aureus, methicillin-susceptible S. aureus (MSSA) and MRSA BSI for Switzerland as well as the different linguistic regions within Switzerland. An additional aim was to estimate potential differences among patient-based and epidemiological risk factors.

METHODS

A retrospective observational study was conducted in Switzerland over a period of 14 years (2008-2021). Trends in S. aureus, MSSA and MRSA BSI were analysed by applying linear regression models.

RESULTS

Staphylococcus aureus BSI increased by + 30% from 19.7 to 25.6 cases per 100,000 inhabitants between 2008 and 2021 (P < 0.01) in Switzerland. Thereof, MSSA increased by + 37% from 17.8 to 24.4 cases per 100,000 inhabitants (P < 0.01). MRSA decreased from 1.9 to 1.2 cases per 100,000 inhabitants (P < 0.01), which was driven by decreasing incidence in the French-speaking region. MSSA BSI increased significantly (P < 0.01) in both linguistic regions. A further stratification revealed that incidence increased the most in male patients of the age group ≥ 80 years of the German-speaking region.

CONCLUSION

The increasing health burden of MSSA BSI in Switzerland indicates that not only proportions of resistant microorganisms but also total BSI incidences should be monitored. In addition, data stratification revealed that the increase was mainly driven by an increasing incidence in elderly males of the German-speaking region.

Comparing human to electronic observers to monitor hand hygiene compliance in an intensive care unit

Objective

We sought to determine whether an electronic hand hygiene (HH) system could monitor HH compliance at similar rates to direct human observation.

Methods

This 4-year proof-of-concept study was conducted in an intensive care unit (ICU) of a private tertiary-care hospital in São Paulo, Brazil, where electronic HH systems were installed in 2 rooms. HH compliance was reported respectively using direct observation and electronic counter devices with an infrared system for detecting HH opportunities.

Results

In phase 1, HH compliance by human observers was 56.3% (564 of 1,001 opportunities), while HH compliance detected by the electronic observer was 51.0% (515 of 1,010 opportunities). In phase 2, human observers registered 484 HH opportunities with a HH compliance rate of 64.7% (313 of 484) versus 70.6% (346 of 490) simultaneously detected by the electronic system. In addition, an enhanced HH electronic system monitored activity 24 hours per day and HH compliance without the presence of a human observer was 40.3% (10,642 of 26,421 opportunities), providing evidence for the Hawthorne effect.

Conclusions

The electronic HH monitoring system had good correlation with human HH observation, but compliance was remarkably lower when human observers were not present due to the Hawthorne effect (25%-30% absolute difference). Electronic monitoring systems can replace direct observation and can markedly reduce the Hawthorne effect.

Pulmonary function testing during SARS-CoV-2: An ANZSRS/TSANZ position statement

The Thoracic Society of Australia and New Zealand (TSANZ) and the Australian and New Zealand Society of Respiratory Science (ANZSRS) commissioned a joint position paper on pulmonary function testing during coronavirus disease 2019 (COVID-19) in July 2021. A working group was formed via an expression of interest to members of both organizations and commenced work in September 2021. A rapid review of the literature was undertaken, with a 'best evidence synthesis' approach taken to answer the research questions formed. This allowed the working group to accept findings of prior relevant reviews or societal document where appropriate. The advice provided is for providers of pulmonary function tests across all settings. The advice is intended to supplement local infection prevention and state, territory or national directives. The working group's key messages reflect a precautionary approach to protect the safety of both healthcare workers (HCWs) and patients in a rapidly changing environment. The decision on strategies employed may vary depending on local transmission and practice environment. The advice is likely to require review as evidence grows and the COVID-19 pandemic evolves. While this position statement was contextualized specifically to the COVID-19 pandemic, the working group strongly advocates that any changes to clinical/laboratory practice, made in the interest of optimizing the safety and well-being of HCWs and patients involved in pulmonary function testing, are carefully considered in light of their potential for ongoing use to reduce transmission of other droplet and/or aerosol borne diseases.

Nosocomial Outbreak of SARS-CoV-2 in a Non-COVID Zone of a Tertiary Care Hospital of North India: Need to Upgrade Infection Control Practices

BACKGROUND

Hospital acquired infections are preventable cause for morbidity and mortality worldwide. In the current pandemic era proper implementation of infection control measures can prevent the spread of such infections including SARS-CoV 2. The study was done to identified the source and reason for spread of COVID-19 infection and devise recommendations to halt the progress of infection in a non-COVID area.

METHODS

An outbreak in a non-COVID area of a tertiary care hospital was investigated by the infection control team along with the epidemiologist when they were notified about the rising cases of COVID-19 from Advanced Trauma Center's (ATC) disaster ward. The time, place and person distribution of the cases were studied. Recommendations based on gaps identified were developed onsite and implemented to control the outbreak.

RESULTS

The outbreak lasted from 19th December 2020 to 12th January 2021, affecting 34 people (25 patients and 9 health care workers). The attack rate was 9.2%. We identified the causes of current outbreak as compromises in infection prevention measures, high bed patient ratio, irregularities in the ventilation system, overcrowding by patient attendants and communication gaps between nursing officers and doctors. Measures required to control the outbreak were implemented and no cases were reported for 2 weeks following the last positive case.

CONCLUSION

Non-COVID areas of hospitals are also at risk of nosocomial outbreaks of SARS-CoV 2 and therefore strict infection prevention measures those designated to COVID areas should be followed in non-COVID zones also to prevent such outbreaks.

Methicillin-Resistant Staphylococcus aureus: An Update on Prevention and Control in Acute Care Settings

Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of health-care-associated infections. Controversies regarding the effectiveness of various control strategies have contributed to varying approaches to MRSA control. However, new evidence from large-scale studies has emerged, particularly concerning screening and decolonization. Importantly, implementation and outcomes of control measures in practice are not only influenced by scientific evidence, but also economic, administrative, and political factors, as demonstrated by decreasing MRSA rates in a number of countries after concerted and coordinated efforts at a national level. Flexibility to adapt measures based on local epidemiology and resources is essential for successful MRSA control.

Prevention of Infection due to Clostridium (Clostridioides) difficile

Clostridium (Clostridioides) difficile infection (CDI) causes significant morbidity and mortality in the United States every year. Prevention of CDI is difficult because of spore durability and requires implementation of multipronged strategies. Two categories of prevention strategies are infection control and prevention and risk factor reduction. Hand hygiene, contact precautions, patient isolation, and environmental decontamination are cornerstones of infection control and prevention. Risk factor reduction should focus on antibiotic stewardship to reduce unnecessary antibiotic use. If CDI incidence remains higher than the institution's goal despite these measures, then special measures should be considered.

Does high adherence to contact precautions lead to low in-hospital transmission of multi-drug-resistant micro-organisms in the endemic setting?

BACKGROUND

Conflicting results have been published on the impact of contact precautions (CPs) on reduction of transmission of multi-drug-resistant micro-organisms (MDROs) in the endemic setting. Ambiguous definitions coupled with low adherence partly explain these differences.

AIM

We prospectively monitored the level of adherence to CPs and aimed to relate it to in-hospital transmission of MDROs.

METHODS

Between January 2016 and March 2018, all patients under CPs underwent continuous monitoring of adherence to CPs by routine on-site visits on days 0, 3 and 7 after initiating CPs using a standardized checklist. The protocol included 10 interventions that were routinely checked such as CP sign at the door as well as wearing of gowns and gloves upon entry to the patient room. Patients requiring CPs were defined as colonized or infected with MDROs (meticillin-resistant Staphylococcus aureus (MRSA), non-Escherichia coli extended-spectrum beta lactamase (ESBL) Enterobacterales, vancomycin-resistant enterococci (VRE) and carbapenem-resistant Gram-negative micro-organisms (CRGN)) as well as patients infected with respiratory viruses, norovirus, scabies and hypervirulent strains of Clostridioides difficile.

FINDINGS

Overall, data from 13,756 CP records from 1378 visits of 812 patients were analysed. Adherence varied between 93% and 100% for each intervention, except for "separate space for contaminated material" with an adherence of 5.3-6.1%. The incidence of in-hospital transmission during the study period was extremely low for MRSA, VRE, non-E.coli ESBL Enterobacterales and CRGN with 0.00-0.064 cases/1000 patient days.

CONCLUSION

High adherence coupled with continuous monitoring of CPs correlated with a very low in-hospital transmission rate. These results indicate that CPs are highly effective if routine monitoring of adherence is implemented.

Knowledge of infection prevention and control among healthcare workers and factors influencing compliance: a systematic review

BACKGROUND

Knowledge of infection prevention and control (IPC) procedures among healthcare workers (HCWs) is crucial for effective IPC. Compliance with IPC measures has critical implications for HCWs safety, patient protection and the care environment.

AIMS

To discuss the body of available literature regarding HCWs' knowledge of IPC and highlight potential factors that may influence compliance to IPC precautions.

DESIGN

A systematic review. A protocol was developed based on the Preferred Reporting Items for Systematic reviews and Meta-Analysis [PRISMA] statement.

DATA SOURCES

Electronic databases (PubMed, CINAHL, Embase, Proquest, Wiley online library, Medline, and Nature) were searched from 1 January 2006 to 31 January 2021 in the English language using the following keywords alone or in combination: knowledge, awareness, healthcare workers, infection, compliance, comply, control, prevention, factors. 3417 papers were identified and 30 papers were included in the review.

RESULTS

Overall, the level of HCW knowledge of IPC appears to be adequate, good, and/or high concerning standard precautions, hand hygiene, and care pertaining to urinary catheters. Acceptable levels of knowledge were also detected in regards to IPC measures for specific diseases including TB, MRSA, MERS-CoV, COVID-19 and Ebola. However, gaps were identified in several HCWs' knowledge concerning occupational vaccinations, the modes of transmission of infectious diseases, and the risk of infection from needle stick and sharps injuries. Several factors for noncompliance surrounding IPC guidelines are discussed, as are recommendations for improving adherence to those guidelines.

CONCLUSION

Embracing a multifaceted approach towards improving IPC-intervention strategies is highly suggested. The goal being to improve compliance among HCWs with IPC measures is necessary.

Hand Areas Which Are Commonly Missed during Hand Disinfection by Nursing Students Who Completed a Basic Educational Course in Hand Hygiene

BACKGROUND

Teaching nursing students how to correctly perform hand hygiene procedures may guarantee a reduction in transmitting pathogens through direct contact and, thus, it may lead to a decrease in the number of hospital infections. The aim of the study, which was conducted in low fidelity simulation conditions, was to assess the performance and the efficiency of a hand-rubbing disinfection technique among nursing students on the last day of their course.

MATERIALS AND METHODS

The study was conducted in a group of 190 nursing students studying at the Jagiellonian University and it focused on the performed hand-rubbing disinfection procedure. The accuracy of the task performance was assessed by measuring the percentage of the amount of Fluo-Rub (B. Braun) fluorescent alcohol-based gel remaining on students' hands after disinfection. The gel was rubbed into particular hand parts including four surfaces (left palm, right palm, left back and right back) divided into thirteen areas (I-XIII) and each surface was examined separately. The results were then dichotomized based on the cut-off point of 10% and two categories: "clean" and "dirty" were established. Additionally, the range of negligence in the disinfection procedure was assessed by counting the total number of the areas classified as "dirty". The comparison of continuous and categorical variables was conducted by means of Friedman's and Cochrane's tests, respectively.

RESULTS

It was found out that the palm surfaces that were commonly missed during hand disinfection included the whole thumb (I and VI), the fingertip of the little finger (V) and the midpalm (XIII), whereas in the case of back surfaces (on both right and left hand) the most commonly missed areas were the fingertips and the whole thumb I-VI. Only 30 students (13%) had all 52 areas of both hands completely clean, whereas more than one third-66 students (33%)-failed to disinfect properly more than 10 areas out of all assessed ones on the surfaces of both hands.

CONCLUSIONS

In the examined group of nursing students, a significant lack of compliance with hand disinfection procedures was observed and it was related mainly to thumbs and back parts of both hands. Therefore, it is essential to conduct systematic training sessions and assessment of hand hygiene procedures for nursing students at the end of every educational stage as it can lead to their developing these skills properly.

Association of Visitor Contact Precautions With Estimated Hospital-Onset Clostridioides difficile Infection Rates in Acute Care Hospitals

IMPORTANCE

Visitor contact precautions (VCPs) are commonly used to reduce the transmission of Clostridioides difficile at health care institutions. Implementing VCPs requires considerable personnel and personal protective equipment resources. However, it is unknown whether VCPs are associated with reduced hospital-onset C difficile infection (HO-CDI) rates.

OBJECTIVE

To estimate the association between VCPs and HO-CDI rates using simulation modeling.

DESIGN, SETTING, AND PARTICIPANTS

This simulation study, conducted between July 27, 2020, and August 11, 2020, used an established agent-based simulation model of C difficile transmission in a 200-bed acute care adult hospital to estimate the association between VCPs and HO-CDI while varying assumptions about factors such as patient susceptibility, behavior, and C difficile transmission. The model simulated hospital activity for 1 year among a homogeneous, simulated adult population.

INTERVENTIONS

No VCP use vs ideal use of VCPs under different hospital configurations.

MAIN OUTCOMES AND MEASURES

The rate of HO-CDI per 10 000 patient-days according to the Centers for Disease Control and Prevention's definition of HO-CDI.

RESULTS

With use of the simulation model, the baseline rate of HO-CDI was 7.94 10 000 patient-days (95% CI, 7.91-7.98 per 10 000 patient-days) with no VCP use compared with 7.97 per 10 000 patient-days (95% CI, 7.93-8.01 per 10 000 patient-days) with ideal VCP use. Visitor contact precautions were not associated with a reduction of more than 1% in HO-CDI rates in any of the tested scenarios and hospital settings. Independently increasing the hand-hygiene compliance of the average health care worker and environmental cleaning compliance by no more than 2% each was associated with greater HO-CDI reduction compared with all other scenarios, including VCPs.

CONCLUSIONS AND RELEVANCE

In this simulation study, the association between VCPs and HO-CDI was minimal, but improvements in health care worker hand hygiene and environmental cleaning were associated with greater reductions in estimated HO-CDI. Hospitals may achieve a higher rate of reduction for HO-CDI by focusing on making small improvements in compliance with interventions other than VCP.

Methicillin-resistant Staphylococcus aureus in hip fracture

AIMS

Infection after surgery increases treatment costs and is associated with increased mortality. Hip fracture patients have historically had high rates of methicillin-resistant Staphylococcus aureus (MRSA) colonization and surgical site infection (SSI). This paper reports the impact of routine MRSA screening and the "cleanyourhands" campaign on rates of MRSA SSI and patient outcome.

METHODS

A total of 13,503 patients who presented with a hip fracture over 17 years formed the study population. Multivariable logistic regression was performed to determine risk factors for MRSA and SSI. Autoregressive integrated moving average (ARIMA) modelling adjusted for temporal trends in rates of MRSA. Kaplan-Meier estimators were generated to assess for changes in mortality.

RESULTS

In all, 6,189 patients were identified before the introduction of screening and 7,314 in the post-screening cohort. MRSA infection fell from 69 cases to 15 in the post-screening cohort (p < 0.001). The ARIMA confirmed a significant reduction in MRSA SSI post-screening (p = 0.043) but no significant impact after hand hygiene alone (p = 0.121). Overall SSI fell (2.4% to 1.5%), however deep infection increased slightly (0.89% to 1.06%). ARIMA showed neither intervention affected overall SSI ("cleanyourhands" -0.172% (95% confidence interval (CI) -0.39% to 0.21); p = 0.122, screening -0.113% per year, (95% CI -0.34 to 0.12); p = 0.373). One-year mortality after deep SSI was unchanged after screening (50% vs 45%; p = 0.415). Only warfarinization (OR 3.616 (95% CI 1.366 to 9.569); p = 0.010) and screening (OR 0.189 (95% CI 0.086 to 0.414); p < 0.001) were significant covariables for developing MRSA SSI.

CONCLUSION

While screening and decolonization may reduce MRSA-associated SSI, the benefit to patient outcome remains unclear. Overall deep SSI remains an unsolved problem that has seen little improvement over time. Preventing other hospital-associated infections should not be forgotten in the fight against MRSA. Cite this article: Bone Joint J 2021;103-B(1):170-177.

Prevention of Clostridioides difficile in hospitals: A position paper of the International Society for Infectious Diseases

Clostridioides difficile infection is an increasing presence worldwide. Prevention is multipronged, reflecting a complex and evolving epidemiology. Multiple guidelines exist regarding the prevention of C. difficile infection in healthcare settings; however, existing guidelines do not address C. difficile in low- and middle-income countries (LMIC). Nevertheless, the prevalence of C. difficile in LMIC likely parallels, if not exceeds, that of high-income countries, and LMIC may experience additional challenges in C. difficile diagnosis and control. A panel of experts was convened by the International Society for Infectious Diseases (ISID) to review the current state of C. difficile infections globally and make evidence-based recommendations for infection prevention that are broadly applicable.

A behaviour change package to prevent hand dermatitis in nurses working in health care: the SCIN cluster RCT

BACKGROUND

Although strategies have been developed to minimise the risk of occupational hand dermatitis in nurses, their clinical effectiveness and cost-effectiveness remain unclear.

OBJECTIVES

The Skin Care Intervention in Nurses trial tested the hypothesis that a behaviour change package intervention, coupled with provision of hand moisturisers, could reduce the point prevalence of hand dermatitis when compared with standard care among nurses working in the NHS. The secondary aim was to assess the impact of the intervention on participants' beliefs and behaviour regarding hand care, and the cost-effectiveness of the intervention in comparison with normal care.

DESIGN

Cluster randomised controlled trial.

SETTING

Thirty-five NHS hospital trusts/health boards/universities.

PARTICIPANTS

First-year student nurses with a history of atopic tendency, and full-time intensive care unit nurses.

INTERVENTION

Sites were randomly allocated to be 'intervention plus' or 'intervention light'. Participants at 'intervention plus' sites received access to a bespoke online behaviour change package intervention, coupled with personal supplies of moisturising cream (student nurses) and optimal availability of moisturising cream (intensive care unit nurses). Nurses at 'intervention light' sites received usual care, including a dermatitis prevention leaflet.

MAIN OUTCOME MEASURE

The difference between intervention plus and intervention light sites in the change of point prevalence of visible hand dermatitis was measured from images taken at baseline and at follow-up.

RANDOMISATION

Fourteen sites were randomised to the intervention plus arm, and 21 sites were randomised to the intervention light arm.

BLINDING

The participants, trial statistician, methodologist and the dermatologists interpreting the hand photographs were blinded to intervention assignment.

NUMBERS ANALYSED

An intention-to-treat analysis was conducted on data from 845 student nurses and 1111 intensive care unit nurses.

RESULTS

The intention-to-treat analysis showed no evidence that the risk of developing dermatitis was greater in the intervention light group than in the intervention plus group (student nurses: odds ratio 1.25, 95% confidence interval 0.59 to 2.69; intensive care unit nurses: odds ratio 1.41, 95% confidence interval 0.81 to 2.44). Both groups had high levels of baseline beliefs about the benefits of using hand moisturisers before, during and after work. The frequency of use of hand moisturisers before, during and after shifts was significantly higher in the intensive care unit nurses in the intervention plus arm at follow-up than in the comparator group nurses. For student nurses, the intervention plus group mean costs were £2 lower than those for the comparator and 0.00002 more quality-adjusted life-years were gained. For intensive care unit nurses, costs were £4 higher and 0.0016 fewer quality-adjusted life-years were gained.

HARMS

No adverse events were reported.

LIMITATIONS

Only 44.5% of participants in the intervention plus arm accessed the behaviour change package.

CONCLUSION

The intervention did not result in a statistically significant decrease in the prevalence of hand dermatitis in the intervention plus group.

FUTURE WORK

Participants had a high level of baseline beliefs about the importance of using hand moisturisers before, during and after work. Future research should focus on how workplace culture can be changed in order for that knowledge to be actioned.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN53303171.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 58. See the NIHR Journals Library website for further project information.

Association between hospital outbreaks and hand hygiene: Insights from electronic monitoring

BACKGROUND

Hand hygiene (HH) is an important patient safety measure linked to prevention of healthcare-associated infection yet how outbreaks affect HH performance has not been formally evaluated.

METHODS

A controlled interrupted time series was performed across five acute-care academic hospitals using group electronic monitoring. This system captures 100% of all hand sanitizer and soap dispenser activations via a wireless signal to a wireless hub divided by a previously validated estimate of the number of daily HH opportunities per patient bed multiplied by the hourly census of patients on the unit. Daily HH adherence 60 days prior and 90 days following outbreak on inpatient units was compared to control units not in outbreak over the same period, using a Poisson regression model adjusting for correlation within hospitals and units. Predictors of HH improvement were assessed in this multivariate model.

RESULTS

In the 60 days prior to outbreak, units destined for outbreak had significantly lower HH adherence compared to control units (IRR of 0.91 (95% CI 0.90-0.93; p <0.0001). Following outbreak, the HH adherence among outbreak units increased above controls (IRR 1.04, 95% CI = 1.02-1.06; p <0.0001). Greater improvements were noted for outbreaks on surgical units, involving antibiotic-resistant organisms and enteric outbreaks, as well as those where healthcare workers became ill.

CONCLUSIONS

Hospital outbreaks tend to occur on units with lower HH adherence and are associated with rapid improvements in HH performance. Group electronic monitoring of HH could be used to develop novel prospective feedback interventions designed to avert hospital outbreaks.

Resistance of Gram-Positive Bacteria to Current Antibacterial Agents and Overcoming Approaches

The discovery of antibiotics has created a turning point in medical interventions to pathogenic infections, but unfortunately, each discovery was consistently followed by the emergence of resistance. The rise of multidrug-resistant bacteria has generated a great challenge to treat infections caused by bacteria with the available antibiotics. Today, research is active in finding new treatments for multidrug-resistant pathogens. In a step to guide the efforts, the WHO has published a list of the most dangerous bacteria that are resistant to current treatments and requires the development of new antibiotics for combating the resistance. Among the list are various Gram-positive bacteria that are responsible for serious healthcare and community-associated infections. Methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus faecium, and drug-resistant Streptococcus pneumoniae are of particular concern. The resistance of bacteria is an evolving phenomenon that arises from genetic mutations and/or acquired genomes. Thus, antimicrobial resistance demands continuous efforts to create strategies to combat this problem and optimize the use of antibiotics. This article aims to provide a review of the most critical resistant Gram-positive bacterial pathogens, their mechanisms of resistance, and the new treatments and approaches reported to circumvent this problem.

The effect of a 5-year hand hygiene initiative based on the WHO multimodal hand hygiene improvement strategy: an interrupted time-series study

Background

A World Health Organization (WHO) guideline-based multimodal hand hygiene (HH) initiative was introduced hospital-wide to a nonteaching Japanese hospital for 5 years. The objective of this study was to assess the effect of this initiative in terms of changes in alcohol-based hand rub (ABHR) consumption and the Hand Hygiene Self-Assessment Framework (HHSAF) score.

Methods

The consumption of monthly hospital-wide ABHR was calculated in L per 1000 patient days (PDs). The change in ABHR consumption was analysed by an interrupted time series analysis with a pre-implementation period of 36 months and an implementation period of 60 months. The correlation between annual ABHR consumption and the HHSAF score was estimated using Pearson’s correlation coefficients.

Results

The annual ABHR consumption was 4.0 (L/1000 PDs) to 4.4 in the pre-implementation period and 10.4 to 34.4 in the implementation period. The HHSAF score was 117.5 (out of 500) in the pre-implementation period and 267.5 to 445 in the implementation period. A statistically significant increase in the monthly ABHR consumption (change in slope: + 0.479 L/1000 PDs, p <  0.01) was observed with the implementation of the initiative. Annual ABHR consumption was strongly correlated with the annual HHSAF score (r = 0.971, p <  0.01).

Conclusions

A 5-year WHO-based HH initiative significantly increased ABHR consumption. Our study suggested that the HHSAF assessment can be a good process measure to improve HH in a single facility, as ABHR consumption increased with the HHSAF score.

Sustained effects of a multimodal campaign aiming at hand hygiene improvement on compliance and healthcare-associated infections in a large gynaecology/obstetrics tertiary-care centre in Vietnam

Background

Hung Vuong Hospital (HVH) is a 900-bed maternity hospital in Ho-Chi-Minh-City, Vietnam. Due to low compliance, a quasi-experimental, observational study was conducted with the aim to improve hand hygiene.

Methods

A multimodal promotion strategy was established in 2010 and further developed towards ongoing, repetitive and inventive campaigns including patient participation. Hand hygiene compliance was monitored by direct observation and healthcare-associated infections (HAIs) by applying standard definitions.

Results

Between 2010 and 2018, a total of 43,711 hand hygiene opportunities were observed. Compliance improved from 21.5% (95%CI: 20.2–22.8%) in 2010 to 75.1% (73.9–76.2%) in 2018 (incidence rate ratio, IRR , 1.10; 95%CI, 1.10–1.11). This was achieved through increasing recourse to alcohol-based hand rubbing. A total of 554,720 women were admitted to HVH during the study period for 353,919 deliveries (198,679 vaginal; 155,240 by C-section) and 257,127 surgical procedures. The HAI-incidence decreased significantly from 1.10 episodes per 1000 patient-days in 2010 to 0.45 per 1000 patient-days in 2018 (IRR 0.85; 95%CI, 0.79–0.90). Significant improvement was observed also for surgical site infections after gynaecological surgery (IRR 0.95; 95%CI, 0.92–0.99) and endometritis after abortion (IRR 0.80; 95%CI, 0.68–0.93).

Conclusions

A multimodal strategy aiming at behaviour change significantly improved and sustained hand hygiene, which contributed to the reduction of healthcare-associated infections.

Impact of improved observed hand hygiene on bloodstream infection rates in Ireland. A prospective segmented regression analysis, 2009-2016

Participation in European surveillance for bloodstream infection (BSI) commenced in Ireland in 1999 with all laboratories (n = 39) participating by 2014. Observational hand hygiene auditing (OHHA) was implemented in 2011. The aim of this study was to evaluate the impact of OHHA on hand hygiene compliance, alcohol hand rub (AHR) procurement and the incidence of sensitive and resistant Staphylococcus aureus and Enterococcus faecium and faecalis BSI. A prospective segmented regression analysis was performed to determine the temporal association between OHHA and outcomes. Observed hand hygiene improved from 74.7% (73.7-75.6) in 2011 to 90.8% (90.1-91.3) in 2016. AHR procurement increased from 20.1 l/1000 bed days used (BDU) in 2009 to 33.2 l/1000 BDU in 2016. A pre-intervention reduction of 2% per quarter in the ratio of methicillin sensitive Staphylococcus aureus BSI/BDU stabilized in the time period after the intervention (P < 0.01). The ratio of Methicillin resistant Staphylococcus aureus (MRSA) BSI/BDU was decreasing by 5% per quarter pre-intervention, this slowed to 2% per quarter post intervention, (P < 0.01). There was no significant change in the ratio of vancomycin sensitive (P = 0.49) or vancomycin resistant (P = 0.90) Enterococcus sp. BSI/BDU post intervention. This study shows national OHHA increased observed hand hygiene compliance and AHR procurement, however there was no associated reduction in BSI.

Hospital Infection Control: Clostridioides difficile

Clostridioides difficile remains a leading cause of healthcare-associated infection. Efforts at C. difficile prevention have been hampered by an increasingly complex understanding of transmission patterns and a high degree of heterogeneity among existing studies. Effective prevention of C. difficile infection requires multimodal interventions, including contact precautions, hand hygiene with soap and water, effective environmental cleaning, use of sporicidal cleaning agents, and antimicrobial stewardship. Roles for probiotics, avoidance of proton pump inhibitors, and isolation of asymptomatic carriers remain poorly defined.

Behavioural Determinants of Hand Washing and Glove Recontamination before Aseptic Procedures at Birth: A Time-and-Motion Study and Survey in Zanzibar Labour Wards

Recent research calls for distinguishing whether the failure to comply with World Health Organisation hand hygiene guidelines is driven by omitting to rub/wash hands, or subsequently recontamination of clean hands or gloves prior to a procedure. This study examined the determinants of these two behaviours. Across the 10 highest-volume labour wards in Zanzibar, we observed 103 birth attendants across 779 hand hygiene opportunities before aseptic procedures (time-and-motion methods). They were then interviewed using a structured cross-sectional survey. We used mixed-effect multivariable logistic regressions to investigate the independent association of candidate determinants with hand rubbing/washing and avoiding glove recontamination. After controlling for confounders, we found that availability of single-use material to dry hands (OR:2.9; CI:1.58–5.14), a higher workload (OR:29.4; CI:12.9–67.0), more knowledge about hand hygiene (OR:1.89; CI:1.02–3.49), and an environment with more reminders from colleagues (OR:1.20; CI:0.98–1.46) were associated with more hand rubbing/washing. Only the length of time elapsed since donning gloves (OR:4.5; CI:2.5–8.0) was associated with avoiding glove recontamination. We identified multiple determinants of hand washing/rubbing. Only time elapsed since washing/rubbing was reliably associated with avoiding glove recontamination. In this setting, these two behaviours require different interventions. Future studies should measure them separately.

World Health Organization Framework: Multimodal Hand Hygiene Strategy in Piedmont (Italy) Health Care Facilities

OBJECTIVES

In 2009, the World Health Organization (WHO) introduced the "Hand Hygiene Self-Assessment Framework" (HHSAF) to evaluate the level of the application of the Multimodal Hand Hygiene Improvement Strategy (MHHIS), which defines preventive interventions, standards, and tools conceived to improve hand hygiene in healthcare facilities. The aim of our study was to evaluate the implementation of the MHHIS in Piedmont healthcare units in 2014 using the HHSAF document.

METHODS

Our surveillance was performed through collection and analysis of the data from 50 Piedmont healthcare facilities recorded through the HHSAF in 2014. The HHSAF describes the hand hygiene level evaluating the following 5 parameters: system changes, education/staff training, evaluation and feedback, reminders in the workplace, and promotion of an institutional safety climate.

RESULTS

We reported that 70.4% of the healthcare facilities involved in the study achieved the intermediate hand hygiene level, 19% the advanced level, and 11% the basic level. No facility exhibited an inadequate level of WHO multimodal implementation. Only 55% of the healthcare units provided information about hand hygiene to patients, and only 15% actively involved patients and their families.

CONCLUSIONS

The implementation of the MHHIS has achieved important results all over the world in terms of hand hygiene. Piedmont has reached an overall good level, particularly in terms of the supply and availability of hand washing products and staff education. Our results revealed, however, some critical issues related to direct and indirect monitoring of hand hygiene, providing reminders and the active involvement of patients, family members, and caregivers.

Sterilization efficiency of pathogen-contaminated cottons in a laundry machine

Pathogenic bacteria on abiotic surfaces such as fabrics, bedding, patient wears, and surgical tools are known to increase the risk of bacterial diseases in infants and the elderly. The desiccation tolerance of bacteria affects their viability in cotton. Thus, washing and drying machines are required to use conditions that ensure the sterilization of bacteria in cotton. The objective of this study is to determine the effects of various sterilization conditions of washing and drying machines on the survival of three pathogenic bacteria (Acinetobacter baumannii, Pseudomonas aeruginosa, and Staphylococcus aureus) commonly presented in contaminated cotton and two non-pathogenic bacteria (Bacillus subtilis and Escherichia coli) in cotton. High survival rates of A. baumannii and S. aureus in desiccated cotton were observed based on scanning electron microscope and replicate organism direct agar contact assay. The survival rates of A. baumannii and S. aureus exposed in desiccated cotton for 8 h were higher (14.4 and 5.0%, respectively) than those of other bacteria (< 0.5%). All tested bacteria were eradicated at low-temperature (< 40°C) washing with activated oxygen bleach (AOB). However, bacterial viability was shown in low temperature washing without AOB. High-temperature (> 60°C) washing was required to achieve 99.9% of the sterilization rate in washing without AOB. The sterilization rate was 93.2% using a drying machine at 60°C for 4 h. This level of sterilization was insufficient in terms of time and energy efficiency. High sterilization efficiency (> 99.9%) at 75°C for 3 h using a drying machine was confirmed. This study suggests standard conditions of drying machines to remove bacterial contamination in cotton by providing practical data.

The effectiveness of alcohol-based gel for hand sanitising in infection control

This article aims to evaluate the evidence relating to the effectiveness of alcohol-based gel for hand sanitising, or 'handrub', in infection control in healthcare settings with particular reference to renal nursing, as this has become pertinent due to the increasing reliance on evidence-based practice. There is a need to implement better infection control strategies and education, to reinforce knowledge among the public, health professionals and those at high risk of infection not only in renal nursing, but also in other areas of practice. Healthcare-associated infections (HCAIs) put patients' safety at risk, increase morbidity and mortality, extend the length of hospital admission and increase the cost to the NHS. There is evidence that the prevalence of HCAIs in England can be minimised through the use of different infection control measures. For example, alcohol-based handrub has been found to be associated with minimising the spread of gastrointestinal infections not only in hospital settings, but also in childcare centres. In addition, the UK national guidelines recommend regular handwashing (implementing the right technique) when hands are visibly dirty and hand disinfection with alcohol-based handrub when they are not visibly dirty. This should be before, in between and after different healthcare activities are performed.

Effects of Antibiotic Cycling Policy on Incidence of Healthcare-Associated MRSA and Clostridioides difficile Infection in Secondary Healthcare Settings

This quasi-experimental study investigated the effect of an antibiotic cycling policy based on time-series analysis of epidemiologic data, which identified antimicrobial drugs and time periods for restriction. Cyclical restrictions of amoxicillin/clavulanic acid, piperacillin/tazobactam, and clarithromycin were undertaken over a 2-year period in the intervention hospital. We used segmented regression analysis to compare the effect on the incidence of healthcare-associated Clostridioides difficile infection (HA-CDI), healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA), and new extended-spectrum β-lactamase (ESBL) isolates and on changes in resistance patterns of the HA-MRSA and ESBL organisms between the intervention and control hospitals. HA-CDI incidence did not change. HA-MRSA incidence increased significantly in the intervention hospital. The resistance of new ESBL isolates to amoxicillin/clavulanic acid and piperacillin/tazobactam decreased significantly in the intervention hospital; however, resistance to piperacillin/tazobactam increased after a return to the standard policy. The results question the value of antibiotic cycling to antibiotic stewardship.

The influence of observational hand hygiene auditing on consultant doctors' hand hygiene behaviors: A qualitative study

BACKGROUND

Compliance with hand hygiene guidelines reduces the risk of health care-associated infection, yet doctors are less compliant than other health care workers. Use of observational hand hygiene auditing with targeted individualized feedback was implemented, with improved hand hygiene of consultant doctors; however, the factors that influenced this were not explained by previous quantitative data. The aim was to explore consultant doctors' opinions about the influence of observational hand hygiene auditing with individualized feedback on hand hygiene behavior.

METHODS

Using the Theoretical Domains Framework, we conducted 12 semi-structured in-depth interviews with consultant doctors who experienced the observational hand hygiene audit and feedback intervention. Data were analyzed using a thematic analysis approach.

RESULTS

Analysis identified 8 domains of the Theoretical Domains Framework, with 5 dominant domains: (1) behavioral regulation: receiving written individualized audit feedback positively influenced practice; (2) knowledge: provision of specific individualized feedback improved performance; (3) reinforcement: audit highlighted substandard practices; (4) social professional role and identity: audit reports triggered profession-associated competitive motivation; and (5) environmental context and resources: auditing was perceived to be synonymous with strong organizational safety culture.

CONCLUSIONS

In this study, provision of individualized targeted feedback was a critical component of observational hand hygiene auditing.

Control of MSSA and MRSA in the United States: protocols, policies, risk adjustment and excuses

Data released by the U.S. Centers for Disease Control and Prevention (CDC) on March 5, 2019 showed that Staph aureus infections are a major problem in the United States, with 119,000 infections and almost 20,000 deaths in 2017. Rates of decline for hospital-onset MRSA have slowed since 2012 and the United States is not on track for meeting the 2015 U.S. Dept. of Health and Human Services’ goal of a 50% reduction by 2020. There is a need for improved standards for control of dangerous pathogens. Currently, the World Health Organization’s recommendation of preoperatively screening patients for Staph aureus has not become a standard of care in the United States.

The U.S. Veterans Health Administration also released data which found a much larger decrease in hospital-onset MRSA infections as opposed to hospital-onset MSSA using various infectious disease bundles that all included universal MRSA surveillance and isolation for MRSA carriers. These results mirror the results obtained by the United Kingdom’s National Health Service. These findings support the contention that the marked decline in hospital-onset MRSA infections observed in these studies is due to interventions which are specifically targeted towards MRSA.

A case is made that concerns with the integrity of healthcare policy research, along with industrial conflicts-of-interest have inhibited effective formulation of infectious disease policy in the United States. Because MRSA has become endemic in the general U.S. population (approximately 2%), the author advocates that universal facility-wide screening of MRSA on admission be included in infection prevention bundles used at U.S. hospital.

Effects of the implementation of a hand hygiene education program among ICU professionals: an interrupted time-series analysis

Objective:

To evaluate the effects that a hand hygiene education program has on the compliance of health professionals in an ICU.

Methods:

This was a quasi-experimental study with an interrupted time-series design, conducted over a 12-month period: the 5 months preceding the implementation of a hand hygiene education program (baseline period); the 2 months of the intensive (intervention) phase of the program; and the first 5 months thereafter (post-intervention phase). Hand hygiene compliance was monitored by one of the researchers, unbeknownst to the ICU team. The primary outcome measure was the variation in the rate of hand hygiene compliance. We also evaluated the duration of mechanical ventilation (MV), as well as the incidence of ventilator-associated pneumonia (VAP) at 28 days and 60 days, together with mortality at 28 days and 60 days.

Results:

On the basis of 959 observations, we found a significant increase in hand hygiene compliance rates-from 31.5% at baseline to 65.8% during the intervention phase and 83.8% during the post-intervention phase, corresponding to prevalence ratios of 2.09 and 2.66, respectively, in comparison with the baseline rate (p < 0.001). Despite that improvement, there were no significant changes in duration of MV, VAP incidence (at 28 or 60 days), or mortality (at 28 or 60 days).

Conclusions:

Our findings indicate that a hand hygiene education program can increase hand hygiene compliance among ICU professionals, although it appears to have no impact on VAP incidence, duration of MV, or mortality.

Observation of stethoscope sanitation practices in an emergency department setting

BACKGROUND

Stethoscopes harbor pathogens that can be transferred to patients when proper sanitary measures are not taken. Our aim was to assess medical provider stethoscope cleaning and hand hygiene in an emergency department setting.

METHODS

The frequency and methods of stethoscope cleaning during and after provider-patient encounters were observed anonymously in an emergency department of the VA San Diego Healthcare System.

RESULTS

Among the total of 426 encounters, 115 (26.9%) involved the use of a personal stethoscope. In 15 of these 115 encounters (13.0%), the provider placed a glove over the stethoscope before patient contact. In 13 of these 115 encounters (11.3%), the provider cleaned the stethoscope with an alcohol swab after patient interaction. Stethoscope hygiene with water and a hand towel before patient interaction was observed in 5 of these 115 encounters (4.3%). Hand sanitizer use or handwashing was observed in 213 of the 426 encounters (50.0%) before patient interaction. Gloves were used before patient interaction in 206 of these 426 encounters (48.4%). Hand sanitizer or handwashing was used in 332 of the 426 encounters (77.9%) after patient interaction.

CONCLUSIONS

Rates of stethoscope and hand hygiene performance were lower than expected. Further investigation of stethoscope contamination and the associated risk of nosocomial infection are needed. Perhaps clearer guidelines on proper stethoscope cleaning would reduce this risk.

The neglected element of hand hygiene - significance of hand drying, efficiency of different methods and clinical implication: A review

Hand hygiene is a fundamental strategy for controlling the spread of infection. Careful hand drying is integral to the process of hand hygiene, which aims to optimise the removal of potentially pathogenic microorganisms. Ineffective hand drying results in wet hands that are an infection risk increasing the potential for cross-infection, occupational contact dermatitis for healthcare practitioners, harm to patients and environmental contamination. Evidence indicates that there has been limited research regarding the significance of hand drying and the efficacy and clinical impact of different drying methods. The purpose of this review paper was to scope and evaluate the existing literature pertaining to hand drying; to examine the clinical consequences associated with wet hands for patients, healthcare practitioners and the clinical environment; to assess the efficacy of different drying methods; to consider the impact on patient safety; and to progress the research, debate and practice relating to hand drying. The methodological framework applied in this review was that of Arksey and O'Malley (2007). Twenty-one papers identified from 112 abstracts screened were included in the review. Analysis identified three primary themes emerging from the literature: (1) efficacy of hand drying methods; (2) drying method and microbial translocation, dispersion and environmental contamination; and (3) drying methods and environmental sustainability. This review highlights the equal importance of hand drying in the process of hand hygiene and suggests that the efficacy of hand drying is a critical factor in the prevention of the transfer of microorganisms to the environment, and from person to person following hand washing. In conclusion, this paper argues that greater attention needs to be given to hand drying in terms of practice, policy and research and its importance in clinical settings given greater focus.

Epidemiology of Clostridium difficile infection in Portugal: Experience at a tertiary care hospital

BACKGROUND

Clostridium difficile is the main cause of healthcare-associated diarrhoea. Its incidence, severity and relapse rates increased over the past two decades.

AIM

To study epidemiologic characteristics and treatment of Clostridium difficile infection (CDI) and compare with a previous cohort from the same hospital.

METHOD

Retrospective analysis of clinical records of CDI diagnosed from 2010 to 2015 and comparison with data from 2004 to 2009.

RESULTS

259 cases were diagnosed, compared to 83 in 2004-2009. There was no difference in mean annual incidence (8.66 versus 7.11 per 1000 patients; p = .116), but a dramatic increase was observed in 2009/2010 (peak incidence: 21.63 cases per 1000 admissions). Females were more affected (61.4% versus 69.9%; p = .177). Median age was 80 and 83 (p = .097). We observed an increase in median number of antibiotics previously used (2 versus 3; p = .147) and in community-associated CDI (6% versus 19.7%; p = .003). There was a continued increase in the use of carbapenems and quinolones until 2010 and a high percentage of refractory cases in 2010. Female gender (p = .043), long-term care facility (LTCF) residency (p = .022) and a higher number of previous antibiotics (median of 3; p = .025) were independent predictors for refractory and recurrent CDI.

CONCLUSIONS

CDI incidence achieved a peak in 2009/2010 coinciding with the introduction of alcohol-based hand products, increase in quinolone and carbapenem prescription and a possible outbreak of an epidemic strain. Female gender, LTCF residency and exposure to three or more antibiotics are risk factors for refractory and recurrent CDI. We emphasize the need to restrict use of large spectrum antibiotics.

Improving hand hygiene compliance with patient zone demarcation: More than just lines on the floor

Background

Hand hygiene compliance can be difficult to improve as this prospective activity may not come to mind easily during busy clinical operations. Clinicians are often driven by clinical goals under time pressure, and the sudden recall to clean hands can either be disruptive or too late. Using patient zones as a reference has been known to be helpful. A low-tech solution of taping patient zones on the floor was introduced in a children’s intensive care unit. Coupled with this demarcation is a simplified protocol that uses patient zones for “just-in-time” reminders. Clinicians now clean their hands whenever they cross zone lines, namely “ before patient zone” and “ after patient zone”, along with “ before aseptic procedure” and “ after bodily fluids exposure”.

Methods

The mandatory national quarterly hand hygiene surveillance data for children’s intensive care unit and the entire hospital was tracked. Seven pre-intervention and seven post-intervention quarters were compared for improvement and sustainability.

Results

Overall, children’s intensive care unit hand hygiene compliance rose from an average of 77% to 90%, as well as physicians' hand hygiene compliance rates from 72% to 86%, and these differences are statistically significant. Hand Hygiene Moment 1 as defined by World Health Organization benefited the most from this intervention.

Discussion

Patient zone demarcation, along with more intuitive hand hygiene guidelines, is a cost-effective, operationally sensitive intervention that can improve hand hygiene compliance. The bundled solution taps on human factors science in understanding the cognitive challenges faced by clinicians. The positive effects are most profound in multi-bed cubicles where patient zones and infection control barriers are not clearly visible.

Cost-effectiveness of interventions to improve hand hygiene in healthcare workers in middle-income hospital settings: a model-based analysis

BACKGROUND

Multi-modal interventions are effective in increasing hand hygiene (HH) compliance among healthcare workers, but it is not known whether such interventions are cost-effective outside high-income countries.

AIM

To evaluate the cost-effectiveness of multi-modal hospital interventions to improve HH compliance in a middle-income country.

METHODS

Using a conservative approach, a model was developed to determine whether reductions in meticillin-resistant Staphylococcus aureus bloodstream infections (MRSA-BSIs) alone would make HH interventions cost-effective in intensive care units (ICUs). Transmission dynamic and decision analytic models were combined to determine the expected impact of HH interventions on MRSA-BSI incidence and evaluate their cost-effectiveness. A series of sensitivity analyses and hypothetical scenarios making different assumptions about transmissibility were explored to generalize the findings.

FINDINGS

Interventions increasing HH compliance from a 10% baseline to ≥20% are likely to be cost-effective solely through reduced MRSA-BSI. Increasing compliance from 10% to 40% was estimated to cost US$2515 per 10,000 bed-days with 3.8 quality-adjusted life-years (QALYs) gained in a paediatric ICU (PICU) and US$1743 per 10,000 bed-days with 3.7 QALYs gained in an adult ICU. If baseline compliance is not >20%, the intervention is always cost-effective even with only a 10% compliance improvement.

CONCLUSION

Effective multi-modal HH interventions are likely to be cost-effective due to preventing MRSA-BSI alone in ICU settings in middle-income countries where baseline compliance is typically low. Where compliance is higher, the cost-effectiveness of interventions to improve it further will depend on the impact on hospital-acquired infections other than MRSA-BSI.

Healthcare-acquired infections: prevention strategies

Healthcare-acquired infections (HAI) impact on patient care and have cost implications for the Australian healthcare system. The management of HAI is exacerbated by rising rates of antimicrobial resistance (AMR). Health-care workers and a contaminated hospital environment are increasingly implicated in the transmission and persistence of multi-resistant organisms (MRO), as well as other pathogens, such as Clostridium difficile. This has resulted in a timely focus on a range of HAI prevention actions. Core components include antimicrobial stewardship, to reduce overuse and ensure evidence-based antimicrobial use; infection prevention strategies, to control MRO - particularly methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE) and, more recently, multi-resistant Gram-negative bacteria; enhanced institutional investment in hand hygiene; hospital cleaning and disinfection; and the development of prescribing guidelines and standards of care. AMR surveillance and comparisons of prescribing are useful feedback activities once effectively communicated to end users. Successful implementation of these strategies requires cultural shifts at local hospital level and, to tackle the serious threat posed by AMR, greater co-ordination at a national level. HAI prevention needs to be multi-modal, requires broad healthcare collaboration, and the strong support and accountability of all medical staff.

Methicillin-resistant Staphylococcus aureus

Since the 1960s, methicillin-resistant Staphylococcus aureus (MRSA) has emerged, disseminated globally and become a leading cause of bacterial infections in both health-care and community settings. However, there is marked geographical variation in MRSA burden owing to several factors, including differences in local infection control practices and pathogen-specific characteristics of the circulating clones. Different MRSA clones have resulted from the independent acquisition of staphylococcal cassette chromosome mec (SCCmec), which contains genes encoding proteins that render the bacterium resistant to most β-lactam antibiotics (such as methicillin), by several S. aureus clones. The success of MRSA is a consequence of the extensive arsenal of virulence factors produced by S. aureus combined with β-lactam resistance and, for most clones, resistance to other antibiotic classes. Clinical manifestations of MRSA range from asymptomatic colonization of the nasal mucosa to mild skin and soft tissue infections to fulminant invasive disease with high mortality. Although treatment options for MRSA are limited, several new antimicrobials are under development. An understanding of colonization dynamics, routes of transmission, risk factors for progression to infection and conditions that promote the emergence of resistance will enable optimization of strategies to effectively control MRSA. Vaccine candidates are also under development and could become an effective prevention measure.

'And you'll suddenly realise 'I've not washed my hands': medical students', junior doctors' and medical educators' narratives of hygiene behaviours

OBJECTIVE

Compliance to hygiene behaviours has long been recognised as important in the prevention and control of healthcare associated infections, but medical doctors still display some of the lowest rates of compliance of all healthcare workers. We aim to understand compliance to hygiene behaviours by analysing medical students', junior doctors' and medical educators' narratives of these behaviours to identify their respective attitudes and beliefs around compliance and how these are learnt during training. Such an understanding can inform future interventions to improve compliance targeted to areas of greatest need.

DESIGN

A qualitative study, using narrative interviews (nine focus groups and one individual interview). Data were analysed thematically using inductive framework analysis.

SETTING

Teaching hospitals in the UK.

PARTICIPANTS

Convenience sample of 25 participants: third-year medical students in their first clinical year (n=13), junior doctors (n=6) and medical educators (n=6).

RESULTS

We identified four main themes: (1) knowledge, (2) constraints, (3) role models/culture and (4) hygiene as an added extra. Knowledge varied across participant groups and appeared to influence behaviours; medical students relied on what they have been told by seniors, while medical educators relied on their own knowledge and experience. There was a strong belief that evidence for the effectiveness of good hygiene behaviours is lacking. Furthermore, medical educators' behaviour appears to strongly influence others. Finally, hygiene was predominately viewed as an added extra rather than an integral part of the process.

CONCLUSIONS

Awareness of the evidence around good hygiene needs to be improved at all levels. Medical students and junior doctors should be encouraged to consider why they are asked to perform certain hygiene behaviours in order to improve ownership of those behaviours. Medical educators need to recognise their responsibilities as role models for their junior counterparts, thereby understanding their role in developing the culture of hygiene practices within their clinical domains.

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

Control of healthcare- and community-associated MRSA: recent progress and persisting challenges

BACKGROUND

Healthcare adapted meticillin-resistant Staphylococcus aureus (MRSA) has spread to hospitals around the world over 50 years. More recently, other strains of MRSA have emerged with the ability to spread in the community and infect otherwise healthy individuals. Morbidity and mortality associated with MRSA remains high and its control in both the healthcare and community setting has proven challenging.

SOURCES OF DATA

Pubmed (Medline).

AREAS OF AGREEMENT

The use of targeted screening and decolonization, hand hygiene and antimicrobial stewardship is supported by the most robust studies, though many studies have implemented bundles for effective healthcare-associated (HA)-MRSA control.

AREAS OF CONTENTION

Universal screening, universal decolonization and contact precautions for HA-MRSA control are supported by less evidence. Some interventions may not be cost-effective. Contact precautions may be associated with potential for patient harm. Evidence for effective control community acquired (CA)-MRSA is largely lacking.

GROWING POINTS

Programmes that focus on implementing bundles of interventions aimed at targeting HA-MRSA are more likely to be effective, with an emphasis on hand hygiene as a key component. Control of CA-MRSA is likely to be more difficult to achieve and relies on prevalence, risk factors and community healthcare interactions on a broader scale.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further research in the area of CA-MRSA in particular is required. Antimicrobial stewardship for both CA and HA-MRSA is promising, as is the role of whole genome sequencing in characterizing transmission. However, further work is required to assess their long-term roles in controlling MRSA. With many institutions applying widespread use of chlorhexidine washes, monitoring for chlorhexidine resistance is paramount to sustaining efforts at controlling MRSA.

Clostridium Difficile Infection in Acute Care Hospitals: Systematic Review and Best Practices for Prevention

OBJECTIVE Prevention of Clostridium difficile infection (CDI) in acute-care hospitals is a priority for hospitals and clinicians. We performed a qualitative systematic review to update the evidence on interventions to prevent CDI published since 2009. DESIGN We searched Ovid, MEDLINE, EMBASE, The Cochrane Library, CINAHL, the ISI Web of Knowledge, and grey literature databases from January 1, 2009 to August 1, 2015. SETTING We included studies performed in acute-care hospitals. PATIENTS OR PARTICIPANTS We included studies conducted on hospitalized patients that investigated the impact of specific interventions on CDI rates. INTERVENTIONS We used the QI-Minimum Quality Criteria Set (QI-MQCS) to assess the quality of included studies. Interventions were grouped thematically: environmental disinfection, antimicrobial stewardship, hand hygiene, chlorhexidine bathing, probiotics, bundled approaches, and others. A meta-analysis was performed when possible. RESULTS Of 3,236 articles screened, 261 met the criteria for full-text review and 46 studies were ultimately included. The average quality rating was 82% according to the QI-MQCS. The most effective interventions, resulting in a 45% to 85% reduction in CDI, included daily to twice daily disinfection of high-touch surfaces (including bed rails) and terminal cleaning of patient rooms with chlorine-based products. Bundled interventions and antimicrobial stewardship showed promise for reducing CDI rates. Chlorhexidine bathing and intensified hand-hygiene practices were not effective for reducing CDI rates. CONCLUSIONS Daily and terminal cleaning of patient rooms using chlorine-based products were most effective in reducing CDI rates in hospitals. Further studies are needed to identify the components of bundled interventions that reduce CDI rates. Infect Control Hosp Epidemiol 2017;38:476-482.

Changes in antimicrobial susceptibility of commonly clinically significant isolates before and after the interventions on surgical prophylactic antibiotics (SPAs) in Shanghai

Surveillances and interventions on antibiotics use have been suggested to improve serious drug-resistance worldwide. Since 2007, our hospital have proposed many measures for regulating surgical prophylactic antibiotics (carbapenems, third gen. cephalosporins, vancomycin, etc.) prescribing practices, like formulary restriction or replacement for surgical prophylactic antibiotics and timely feedback. To assess the impacts on drug-resistance after interventions, we enrolled infected patients in 2006 (pre-intervention period) and 2014 (post-intervention period) in a tertiary hospital in Shanghai. Proportions of targeted pathogens were analyzed: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), imipenem-resistant Escherichia coli (IREC), imipenem-resistant Klebsiella pneumoniae (IRKP), imipenem-resistant Acinetobacter baumannii (IRAB) and imipenem-resistant Pseudomonas aeruginosa (IRPA) isolates. Rates of them were estimated and compared between Surgical Department, ICU and Internal Department during two periods. The total proportions of targeted isolates in Surgical Department (62.44%, 2006; 64.09%, 2014) were more than those in ICU (46.13%, 2006; 50.99%, 2014) and in Internal Department (44.54%, 2006; 51.20%, 2014). Only MRSA has decreased significantly (80.48%, 2006; 55.97%, 2014) (p < 0.0001). The percentages of VRE and IREC in 3 departments were all <15%, and the slightest change were also both observed in Surgical Department (VRE: 0.76%, 2006; 2.03%, 2014) (IREC: 2.69%, 2006; 2.63%, 2014). The interventions on surgical prophylactic antibiotics can be effective for improving resistance; antimicrobial stewardship must be combined with infection control practices.