Back to the future: rising to the Semmelweis challenge in hand hygiene

Perspectives on research needs in healthcare epidemiology and antimicrobial stewardship: what's on the horizon - Part I

In this overview, we articulate research needs and opportunities in the field of infection prevention that have been identified from insights gained during operative infection prevention work, our own research in healthcare epidemiology, and from reviewing the literature. The 10 areas of research need are: 1) transmissions and interruptions, 2) personal protective equipment and other safety issues in occupational health, 3) climate change and other crises, 4) device, diagnostic, and antimicrobial stewardship, 5) implementation and de-implementation, 6) health care outside the acute care hospital, 7) low- and middle-income countries, 8) networking with the "neighbors", 9) novel research methodologies, and 10) the future state of surveillance. An introduction and chapters 1-5 are presented in part I of the article, and chapters 6-10 and the discussion in part II. There are many barriers to advancing the field, such as finding and motivating the future IP workforce including professionals interested in conducting research, a constant confrontation with challenges and crises, the difficulty of performing studies in a complex environment, the relative lack of adequate incentives and funding streams, and how to disseminate and validate the often very local quality improvement projects. Addressing research gaps now (i.e., in the postpandemic phase) will make healthcare systems more resilient when facing future crises.

A large-scale investigation of alcohol-based handrub (ABHR) volume: hand coverage correlations utilizing an innovative quantitative evaluation system

Background

Current hand hygiene guidelines do not provide recommendations on a specific volume for the clinical hand rubbing procedure. According to recent studies volume should be adjusted in order to achieve complete coverage. However, hand size is a parameter that highly influences the hand coverage quality when using alcohol-based handrubs (ABHR). The purpose of this study was to establish a quantitative correlation between applied ABHR volume and achieved hand coverage.

Method

ABHR based hand hygiene events were evaluated utilizing a digital health device, the Semmelweis hand hygiene system with respect to coverage achieved on the skin surface. Medical students and surgical residents (N = 356) were randomly selected and given predetermined ABHR volumes. Additionally, hand sizes were calculated using specialized software developed for this purpose. Drying time, ABHR volume awareness, as well spillage awareness were documented for each hand hygiene event.

Results

Hand coverage achieved during a hand hygiene event strongly depends on the applied ABHR volume. At a 1 ml dose, the uncovered hand area was approximately 7.10%, at 2 ml it decreased to 1.68%, and at 3 ml it further decreased to 1.02%. The achieved coverage is strongly correlated to hand size, nevertheless, a 3 ml applied volume proved sufficient for most hand hygiene events (84%). When applying a lower amount of ABHR (1.5 ml), even people with smaller hands failed to cover their entire hand surface. Furthermore, a 3 ml volume requires more than the guideline prescribed 20–30 s to dry. In addition, results suggest that drying time is not only affected by hand size, but perhaps other factors may be involved as well (e.g., skin temperature and degree of hydration). ABHR volumes of 3.5 ml or more were inefficient, as the disinfectant spilled while the additional rubbing time did not improve hand coverage.

Conclusions

Hand sizes differ a lot among HCWs. After objectively measuring participants, the surface of the smallest hand was just over half compared to the largest hand (259 cm² and 498 cm², respectively). While a 3 ml ABHR volume is reasonable for medium-size hands, the need for an optimized volume of handrub for each individual is critical, as it offers several advantages. Not only it can ensure adequate hand hygiene quality, but also prevent unnecessary costs. Bluntly increasing the volume also increases spillage and therefore waste of disinfectant in the case of smaller hands. In addition, adherence could potentially decrease due to the required longer drying time, therefore, adjusting the dosage according to hand size may also increase the overall hand hygiene compliance.

Critical Reliability Issues of Common Type Alcohol-Based Handrub Dispensers

BACKGROUND

Hand hygiene can only be efficient if the whole hand surface is treated with sufficient alcohol-based handrub (ABHR); therefore, the volume of handrub applied is a critical factor in patient safety. The proper amount of ABHR should be provided by handrub dispensers. The aim of this study was to investigate the dispensing performance of wall-mounted ABHR dispensers commonly employed in hospital settings.

METHOD

In a multicenter study, we tested 46 dispensers (22 in laboratory and 24 in clinical environments), measuring dispensed ABHR volume during continuous use and after a period of non-use. The influence of the pumping mechanism, liquid level, ABHR formats, handrub composition, temperature, and atmospheric pressure was investigated.

RESULTS

A total of 7 out of the 22 investigated dispensers (32%) lost a significant amount of handrub; greater than 30% of the nominal volume after 8 h of non-use, thus frequently dispensing suboptimal volume, as measured in laboratory settings. Key influencing factors were found to be handrub format (gel or liquid), handrub level in the container and type of dispenser. When gel ABHR was used, after 4 h of non-use of the dispensers, the volume of the dispensed amount of ABHR insignificantly changed (97% of the original amount), while it technically decreased to zero in the case of liquid ABHR (1% of the original amount). The liquid level had a medium effect on the dispensed volume in each investigated case; the magnitude of this effect varied widely depending on the dispensing mechanism. When dispensers were in continuous use, they dispensed a cumulated 3 mL of ABHR from two consecutive pushes, while when they were not in use for 1 h, up to 4 consecutive pushes were necessary to provide a total of 3 mL ABHR. Design and production quality were also identified as important contributing factors with respect to the volume dispensed. Data collected in clinical settings confirmed these findings, for multiple types of dispensers.

CONCLUSION

All ABHR dispensers should be regularly audited to control the reference volume distributed, with particular attention paid to regular mechanical pump units filled with liquid handrub.

Semmelweis Reflex: An Age-Old Prejudice

BACKGROUND

Semmelweis reflex is a human behavioral tendency to stick to preexisting beliefs and to reject fresh ideas that contradict them (despite adequate evidence). We aim to familiarize the readers with the term that not only has a significant historical background but also grave clinical implications.

METHODS

A keyword search for "Semmelweis reflex," "Belief perseverance," "handwashing," and "Idea rejection" was conducted using PubMed Central, MEDLINE, and Google SCHOLAR. Literature published in paper-based journals and books was also searched. All manuscripts pertaining to these keywords were thoroughly analyzed for this review.

RESULTS

The first section of our paper briefs the story of Ignaz Semmelweis and brushes on the contributions of other intellectual researchers that were rebuffed initially. The discussion further explains the root cause of this dismissal, an inherent bias against uncertainty that may be at the core of our fear for new ideas. Finally, this review explores the means by which we can prevent ourselves from being a victim of rejection.

CONCLUSIONS

The age-old prejudice that is Semmelweis reflex is explored in this review. With careful and thorough study design, scientific rigor, and critical self-analysis of the manuscript, one can avoid being victimized by this reflex. The dual edged nature of this reflex lays unveiled when its importance is highlighted in the prematurely accepted medical failures. Understanding that any new idea goes through the grill of being critically analyzed and perceived encourages the scientist to hold on to the original thought as it may rather be practice changing.

Hand hygiene in low- and middle-income countries

A panel of experts was convened by the International Society for Infectious Diseases (ISID) to overview evidence based strategies to reduce the transmission of pathogens via the hands of healthcare workers and the subsequent incidence of hospital acquired infections with a focus on implementing these strategies in low- and middle-income countries. Existing data suggests that hospital patients in low- and middle-income countries are exposed to rates of healthcare associated infections at least 2-fold higher than in high income countries. In addition to the universal challenges to the implementation of effective hand hygiene strategies, hospitals in low- and middle-income countries face a range of unique barriers, including overcrowding and securing a reliable and sustainable supply of alcohol-based handrub. The WHO Multimodal Hand Hygiene Improvement Strategy and its associated resources represent an evidence-based framework for developing a locally-adapted implementation plan for hand hygiene promotion.

Biology of Hand-to-Hand Bacterial Transmission

Numerous studies have demonstrated that adequate hand hygiene among hospital staff is the best measure to prevent hand-to-hand bacterial transmission. The skin microbiome is conditioned by the individual physiological characteristics and anatomical microenvironments. Furthermore, it is important to separate the autochthonous resident microbiota from the transitory microbiota that we can acquire after interactions with contaminated surfaces. Two players participate in the hand-to-hand bacterial transmission process: the bacteria and the person. The particularities of the bacteria have been extensively studied, identifying some genera or species with higher transmission efficiency, particularly those linked to nosocomial infections and outbreaks. However, the human factor remains unstudied, and intrapersonal particularities in bacterial transmission have not been yet explored. Herein we summarize the current knowledge on hand-to-hand bacterial transmission, as well as unpublished results regarding interindividual and interindividual transmission efficiency differences. We designed a simple in vivo test based on four sequential steps of finger-to-finger contact in the same person artificially inoculated with a precise bacterial inoculum. Individuals can be grouped into one of three observed transmission categories: high, medium, and poor finger-to-finger transmitters. Categorization is relevant to predicting the ultimate success of a human transmission chain, particularly for the poor transmitters, who have the ability to cut the transmission chain. Our model allowed us to analyze transmission rate differences among five bacterial species and clones that cause nosocomial infections, from which we detected that Gram-positive microorganisms were more successfully transmitted than Gram-negative.

Impact of single room design on the spread of multi-drug resistant bacteria in an intensive care unit

Background

Cross-transmission of nosocomial pathogens occurs frequently in intensive care units (ICU). The aim of this study was to investigate whether the introduction of a single room policy resulted in a decrease in transmission of multidrug-resistant (MDR) bacteria in an ICU.

Methods

We performed a retrospective study covering two periods: between January 2002 and April 2009 (old-ICU) and between May 2009 and March 2013 (new-ICU, single-room). These periods were compared with respect to the occurrence of representative MDR Gram-negative bacteria. Routine microbiological screening, was performed on all patients on admission to the ICU and then twice a week. Multi-drug resistance was defined according to a national guideline. The first isolates per patient that met the MDR-criteria, detected during the ICU admission were included in the analysis. To investigate the clonality, isolates were genotyped by DiversiLab (bioMérieux, France) or Amplified Fragment Length Polymorphism (AFLP). To guarantee the comparability of the two periods, the ‘before’ and ‘after’ periods were chosen such that they were approximately identical with respect to the following factors: number of admissions, number of beds, bed occupancy rate, per year and month.

Results

Despite infection prevention efforts, high prevalence of MRD bacteria continue to occur in the original facility. A marked and sustained decrease in the prevalence of MDR-GN bacteria was observed after the migration to the new ICU, while there appear to be no significant changes in the other variables including bed occupancy and numbers of patient admissions.

Conclusion

Single room ICU design contributes significantly to the reduction of cross transmission of MRD-bacteria.

Bacteriological Aspects of Hand Washing: A Key for Health Promotion and Infections Control

The aim of this review is to show the historical aspects of hands washing for healthy life and explains how can reduce the transmission of community-acquired infectious agents by healthcare workers and patients. This review article is prepared based on available database. The key words used were hands washing, risk assessment, hands hygiene, bacterial flora, contamination, infection, nosocomial, tap water, sanitizer, bacterial resistance, hands bacterial flora, washing methods, antiseptics, healthcare workers, healthcare personnel, from PubMed, ScienceDirect, Embase, Scopus, Web of Sciences, and Google Scholar. Data were descriptively analyzed. The insistence on hand washing has a history of 1400 years. The research results indicate that the bacteria released from the female washed hands in wet and dry condition was lower than from the male's hands with a significance level (3 CFU vs. 8 CFU; confidence interval 95%, P ≤ 0.001). The valuable results of the study indicated that released amount of bacterial flora from wet hands is more than 10 times in compared to dry hands. In addition, established monitoring systems for washing hands before and after patient's manipulation as well as after toilet were dominant indices to prevent the transfer of infectious agents to the patients. Increasing awareness and belief of the healthcare workers have shown an important role by about 30% reduction in the transfection. Hand washing could reduce the episodes of transmission of infectious agents in both community and healthcare settings. However, hand washing is an important key factor to prevent transmission of infectious agents to patients. There is no standard method for measuring compliance. Thus, permanent monitoring of hand washing to reduce the transmission of infections is crucial. Finally, the personnel must believe that hand washing is an inevitable approach to infection control.

Impact of a mandated provincial hand hygiene program: messages from the field

BACKGROUND

The British Columbia Provincial Hand Hygiene Working Group was formed in September 2010 and tasked with the development and implementation of a provincial hand hygiene (HH) program for health care.

METHODS

As part of an evaluation of the provincial HH program, qualitative key informant interviews of program developers, senior administrators, and field workers were performed from December 2011 to March 2012 (phase 1) and again in April to June 2013 (phase 2).

RESULTS

The following 5 broad themes were identified: (1) the provincial HH program became a platform for cooperation; (2) standardization (of HH audits and program components) strengthened and provided credibility to the provincial HH program; (3) quality results and good communication enabled a learning process that resulted in positive change management; (4) with ownership came pride and program success; and (5) management support and infrastructure is needed to sustain a positive culture change.

CONCLUSION

Positive behavior change for HH can be achieved on a provincial scale through a program that is standardized, has mandated components, is well communicated, owned by the frontline workers, and receives sustained support from senior management.

Individual variability in finger-to-finger transmission efficiency of Enterococcus faecium clones

A fingertip-to-fingertip intraindividual transmission experiment was carried out in 30 healthy volunteers, using four MLST-typed Enterococcus faecium clones. Overall results showed an adequate fit goodness to a theoretical exponential model, whereas four volunteers (13%) exhibited a significantly higher finger-to-finger bacterial transmission efficiency. This observation might have deep consequences in nosocomial epidemiology.

Adherence to hand hygiene protocol by clinicians and medical students at Queen Elizabeth Central Hospital, Blantyre-Malawi

BACKGROUND

While communicable diseases are the leading causes of morbidity and mortality in Malawi, the contribution of nosocomial or hospital-acquired infections (HAIs) is unknown but could be substantial. The single most important method of preventing nosocomial infections is hand hygiene. We report a study which was conducted in 2011 to investigate adherence to hand hygiene protocols by clinicians and medical students working at Queen Elizabeth Central Hospital in Blantyre, Malawi.

METHODS

There were two parts to the study: a single blinded arm in which participants were observed without their knowledge by trained nurses; and a second arm which included self-completion of questionnaire after participant consent was obtained. The 2009 World Health Organization hand hygiene technique and recommendations which were adopted by Queen Elizabeth Central Hospital were used to define an opportunity for hand washing and effectiveness of hand washing. Hand hygiene effectiveness was defined as adherence to at least 6 out of 7 steps (80%) of the hand hygiene technique when using alcohol-based formulation or at least 8 out of 10 steps (80%) of the hand hygiene technique when using water and soap formulation before and after having direct contact with patients or their immediate surroundings.

RESULTS

Clinicians were found to have disinfected their hands more than medical students (p<0.05) but effectiveness was similar and very low between the two groups (p=0.2). No association was also found between having a personal hand sanitizer and hand hygiene practice (p=0.3). Adherence to hand hygiene was found to be 23%. Most of the participants mentioned infection transmission prevention as a reason for disinfecting their hands. Other reasons mentioned included: a routine personal hand hygiene behaviour and discomfort if not washing hands. The top three reasons why they did not disinfect hands were forgetfulness, unavailability of sanitizers and negligence.

CONCLUSION

Adherence to hand hygiene practice was found to be low, with forgetfulness and negligence being the major contributing factors. A hospital-wide multifaceted program aiming at clinicians and students education, adoption of alcohol based hand rubs as a primary formulation, production of colored poster reminders and encouraging role modeling of junior practitioners by senior practitioners can help improve compliance to hand hygiene.

Medicine in stamps-Ignaz Semmelweis and Puerperal Fever

Puerperal fever was common in mid-19(th)-century hospitals and often fatal, with mortality at 10%-35%. Ignaz Philipp Semmelweis was a Hungarian gynecologist who is known as a pioneer of antiseptic procedures. Semmelweis discovered that the incidence of puerperal fever could be drastically cut by the use of hand disinfection in obstetrical clinics. He is also described as the "savior of mothers" and "father of infection control". This paper provides an overview on the process of preventing puerperal fever and the life story of the physician behind this attempt, Ignaz Semmelweis, through philately.

The gut is the epicentre of antibiotic resistance

The gut contains very large numbers of bacteria. Changes in the composition of the gut flora, due in particular to antibiotics, can happen silently, leading to the selection of highly resistant bacteria and Candida species. These resistant organisms may remain for months in the gut of the carrier without causing any symptoms or translocate through the gut epithelium, induce healthcare-associated infections, undergo cross-transmission to other individuals, and cause limited outbreaks. Techniques are available to prevent, detect, and treat the carriage of resistant organisms in the gut. However, evidence on these techniques is scant, the only exception being selective digestive decontamination (SDD), which has been extensively studied in neutropenic and ICU patients. After the destruction of resistant colonizing bacteria, which has been successfully obtained in several studies, the gut could be re-colonized with normal faecal flora or probiotics. Studies are warranted to evaluate this concept.

Respiratory viral infections in children with asthma: do they matter and can we prevent them?

BACKGROUND

Asthma is a major public health problem with a huge social and economic burden affecting 300 million people worldwide. Viral respiratory infections are the major cause of acute asthma exacerbations and may contribute to asthma inception in high risk young children with susceptible genetic background. Acute exacerbations are associated with decreased lung growth or accelerated loss of lung function and, as such, add substantially to both the cost and morbidity associated with asthma.

DISCUSSION

While the importance of preventing viral infection is well established, preventive strategies have not been well explored. Good personal hygiene, hand-washing and avoidance of cigarette smoke are likely to reduce respiratory viral infections. Eating a healthy balanced diet, active probiotic supplements and bacterial-derived products, such as OM-85, may reduce recurrent infections in susceptible children. There are no practical anti-viral therapies currently available that are suitable for widespread use.

SUMMARY

Hand hygiene is the best measure to prevent the common cold. A healthy balanced diet, active probiotic supplements and immunostimulant OM-85 may reduce recurrent infections in asthmatic children.