Promoting and sustaining a historical and global effort to prevent sepsis: the 2018 World Health Organization SAVE LIVES: Clean Your Hands campaign

Sepsis is estimated to affect more than 30 million patients with potentially five million deaths every year worldwide. Prevention of sepsis, as well as early recognition, diagnosis and treatment, can’t be overlooked to mitigate this global public health threat. World Health Organization (WHO) promotes hand hygiene in health care through its annual global campaign, SAVE LIVES: Clean Your Hands campaign on 5 May every year. The 2018 campaign targets sepsis with the overall theme “It’s in your hands; prevent sepsis in health care”.

[Burden of healthcare-associated infections in outpatient care]

There is little evidence on healthcare-associated infections in outpatient care. The Swiss Federal Office for Public Health commissioned a systematic review to estimate the incidence of healthcare-associated infections in non-institutional settings. A total of 126 papers were eligible for data abstraction. The identified reports and studies were heterogeneous and generally of low quality. The main outcomes were surgical site infections, central venous catheter-related bloodstream infections, and urinary tract infections. While no comparison to inpatients was possible for surgical site infection, the incidence of urinary tract infection and central venous catheter-related bloodstream infection in haemodialysis and home intravenous therapy was similar to the incidence of these infections observed in acute care settings.

[Prevention of influenza in acute care settings : a multimodal intervention]

Preventing an influenza outbreak in an acute care requires a multimodal intervention, taking into account the actors involved (influenza virus, staff, patients, visitors), and the stage of the epidemic. Different means are used for this purpose : immunization, use of alcohol-based hand rub, identification of influenza cases, wearing of medical masks, social distance, and antiviral treatment. In addition, an epidemiological surveillance of influenza cases, in the general population and within the health facilities, must be associated.

Correction to: Management and investigation of a Serratia marcescens outbreak in a neonatal unit in Switzerland - the role of hand hygiene and whole genome sequencing

[This corrects the article DOI: 10.1186/s13756-017-0285-x.].

Determinants of success and sustainability of the WHO multimodal hand hygiene promotion campaign, Italy, 2007-2008 and 2014

A national hand hygiene promotion campaign based on the World Health Organization (WHO) multimodal, Clean Care is Safer Care campaign was launched in Italy in 2007. One hundred seventy-five hospitals from 14 of 20 Italian regions participated. Data were collected using methods and tools provided by the WHO campaign, translated into Italian. Hand hygiene compliance, ward infrastructure, and healthcare workers’ knowledge and perception of healthcare-associated infections and hand hygiene were evaluated before and after campaign implementation. Compliance data from the 65 hospitals returning complete data for all implementation tools were analysed using a multilevel approach. Overall, hand hygiene compliance increased in the 65 hospitals from 40% to 63% (absolute increase: 23%, 95% confidence interval: 22–24%). A wide variation in hand hygiene compliance among wards was observed; inter-ward variability significantly decreased after campaign implementation and the level of perception was the only item associated with this. Long-term sustainability in 48 of these 65 hospitals was assessed in 2014 using the WHO Hand Hygiene Self-Assessment Framework tool. Of the 48 hospitals, 44 scored in the advanced/intermediate categories of hand hygiene implementation progress. The median hand hygiene compliance achieved at the end of the 2007–2008 campaign appeared to be sustained in 2014.

Management and investigation of a Serratia marcescens outbreak in a neonatal unit in Switzerland - the role of hand hygiene and whole genome sequencing

Background

Many outbreaks due to Serratia marcescens among neonates have been described in the literature but little is known about the role of whole genome sequencing in outbreak analysis and management.

Methods

Between February and March 2013, 2 neonates and 2 infants previously hospitalised in the neonatal unit of a tertiary care centre in Switzerland, were found to be colonised with S. marcescens. An investigation was launched with extensive environmental sampling and neonatal screening in four consecutive point prevalence surveys between April and May 2013. All identified isolates were first investigated by fingerprinting and later by whole genome sequencing. Audits of best practices were performed and a hand hygiene promotion programme was implemented.

Results

Twenty neonates were colonised with S. marcescens. No invasive infection due to S. marcescens occurred. All 231 environmental samples were negative. Hand hygiene compliance improved from 51% in April 2013 to 79% in May 2013 and remained high thereafter. No S. marcescens was identified in point prevalence surveys in June and October 2013. All strains were identical in the fingerprinting analysis and closely related according to whole genome sequencing.

Conclusions

Improving best practices and particularly hand hygiene proved effective in terminating the outbreak. Whole genome sequencing is a helpful tool for genotyping because it allows both sufficient discrimination of strains and comparison to other outbreaks through the use of an emerging international database.

Acute necrotising gingivitis in young children from villages with and without noma in Niger and its association with sociodemographic factors, nutritional status and oral hygiene practices: results of a population-based survey

Background

Previous studies have suggested that acute necrotising gingivitis precedes noma disease and that noma clusters in some villages in certain regions of low- and middle-income countries. We sought to assess the prevalence of gingivitis with bleeding in young children from villages with or without a history of noma and to analyse epidemiological differences related to sociodemographic characteristics, nutritional status and oral hygiene practices.

Methods

We conducted a cross-sectional study in 440 children aged between 2 and 6 years from four villages in the Zinder region of southeast Niger in Africa. In two villages, cases of noma have repeatedly been detected; in the other two, noma has never been identified. We randomly selected 110 participants from each village.

Results

The prevalence of acute necrotising gingivitis was significantly higher in the noma villages compared with the non-noma villages (6.8% vs 0.9%; p=0.001). We found differences between the four villages regarding socioeconomic factors, stunting, undernourishment and oral hygiene practices. The type of oral hygiene procedures influenced the amount of dental plaque and gingival inflammation. Children using sand, coal or other abrasive products instead of a toothbrush had a significantly increased likelihood to be diagnosed with acute necrotising gingivitis (p=0.041).

Conclusions

Our data suggest that efforts to prevent noma should focus on populations with a high prevalence of acute necrotising gingivitis and include nutritional support and attempts to introduce safe and efficient oral hygiene practices to improve gingival health.

Efficacy of the World Health Organization-recommended handwashing technique and a modified washing technique to remove Clostridium difficile from hands

BACKGROUND

The efficacy of the World Health Organization (WHO)-recommended handwashing technique against Clostridium difficile is uncertain, and whether it could be improved remains unknown. Also, the benefit of using a structured technique instead of an unstructured technique remains unclear.

METHODS

This study was a prospective comparison of 3 techniques (unstructured, WHO, and a novel technique dubbed WHO shortened repeated [WHO-SR] technique) to remove C difficile. Ten participants were enrolled and performed each technique. Hands were contaminated with 3 × 10⁶ colony forming units (CFU) of a nontoxigenic strain containing 90% spores. Efficacy was assessed using the whole-hand method. The relative efficacy of each technique and of a structured (either WHO or WHO-SR) vs an unstructured technique were assessed by Mann-Whitney U test and Wilcoxon signed-rank test.

RESULTS

The median effectiveness of the unstructured, WHO, and WHO-SR techniques in log₁₀ CFU reduction was 1.30 (interquartile range [IQR], 1.27-1.43), 1.71 (IQR, 1.34-1.91), and 1.70 (IQR, 1.54-2.42), respectively. The WHO-SR technique was significantly more efficacious than the unstructured technique (P = .01). Washing hands with a structured technique was more effective than washing with an unstructured technique (median, 1.70 vs 1.30 log₁₀ CFU reduction, respectively; P = .007).

CONCLUSIONS

A structured washing technique is more effective than an unstructured technique against C difficile.

Antimicrobial resistance: The complex challenge of measurement to inform policy and the public

Didier Wernli and colleagues discuss the role of monitoring in countering antimicrobial resistance.

Mapping global policy discourse on antimicrobial resistance

The rising importance of antimicrobial resistance (AMR) to the global health agenda is associated with a growing number of parties voicing their concern about the issue. With more recommendations and policies appearing, understanding the policy process requires making sense of the views, values, interests and goals of each participant. Policy frame analysis provides a method to understand both the scientific view and the actions advocated by global health actors to tackle AMR. Here we review and refine policy frame analyses of AMR using a deductive approach. Among several policy frames previously defined in the field of global health, we identify 'AMR as healthcare', 'AMR as development', 'AMR as innovation' and 'AMR as security' as frequent frames used in dealing with AMR. In addition, we found that 'AMR as One Health' constitutes a recent framing of the topic that seeks to provide an integrated understanding between human and animal health. Each frame originates in distinct scientific fields, conceptualises the main causes of AMR and prioritises different interventions and measurements. Better understanding and integration of these frames into an overarching social and ecological framework will support policy progress in tackling AMR.

One- vs 2-Stage Bursectomy for Septic Olecranon and Prepatellar Bursitis: A Prospective Randomized Trial

OBJECTIVE

To assess the optimal surgical approach and costs for patients hospitalized with septic bursitis.

PATIENTS AND METHODS

From May 1, 2011, through December 24, 2014, hospitalized patients with septic bursitis at University of Geneva Hospitals were randomized (1:1) to receive 1- vs 2-stage bursectomy. All the patients received postsurgical oral antibiotic drug therapy for 7 days.

RESULTS

Of 164 enrolled patients, 130 had bursitis of the elbow and 34 of the patella. The surgical approach used was 1-stage in 79 patients and 2-stage in 85. Overall, there were 22 treatment failures: 8 of 79 patients (10%) in the 1-stage arm and 14 of 85 (16%) in the 2-stage arm (Pearson χ² test; P=.23). Recurrent infection was caused by the same pathogen in 7 patients (4%) and by a different pathogen in 5 (3%). Outcomes were better in the 1- vs 2-stage arm for wound dehiscence for elbow bursitis (1 of 66 vs 9 of 64; Fisher exact test P=.03), median length of hospital stay (4.5 vs 6.0 days), nurses' workload (605 vs 1055 points), and total costs (Sw₣6881 vs Sw₣11,178; all P<.01).

CONCLUSION

For adults with moderate to severe septic bursitis requiring hospital admission, bursectomy with primary closure, together with antibiotic drug therapy for 7 days, was safe, effective, and resource saving. Using a 2-stage approach may be associated with a higher rate of wound dehiscence for olecranon bursitis than the 1-stage approach.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01406652.

Enterococci in orthopaedic infections: Who is at risk getting infected?

Some orthopaedic patients might be at risk for enterococcal infections and might benefit from adapted perioperative prophylaxis.

METHODS

We performed a single-center cohort of adult patients with orthopaedic infections.

RESULTS

Among 2740 infection episodes, 665 surgeries (24%) involved osteosynthesis material, including total joint arthroplasties. The recommended perioperative prophylaxis was cefuroxime (or vancomycin in case of documented MRSA body carriage). Patients had received antibiotic therapy before surgery in 1167 episodes (43%); among them with potential anti-enterococcal activity (penicillins, glycopeptides, imipenem, linezolid, daptomycin, aminoglycosids, tetracyclins) in 725 (62%) cases. Overall, enterococci were identified in intraoperative samples of 100 different infections (3.6%) (Enterococcus faecalis, 95; Enterococcus faecium, 2; and other enterococci, 3). However, only 15/100 (15%) enterococcal infections were monomicrobial and 19 were nosocomial (19/2740; 0.7%), of which 15 had previous cephalosporin perioperative prophylaxis without other antibiotic exposure. This association to prior cephalosporin use was significant (Pearson-χ²-test; 148/2640 vs. 15/100, p < 0.01). By multivariate analysis, the presence of diabetic foot infection (odds ratio 1.9, 95% confidence interval 1.2-2.9), and polymicrobial infection (OR 6.0, 95%CI 3.9-9.4) were the main predictors of enterococcal infection, while sex, age, and type of material were not.

CONCLUSIONS

Community-acquired or nosocomial enterococcal infections in orthopaedic surgery are mostly polymicrobial, rare and very seldom attributed to a nosocomial origin. Thus, even if they are formally associated with prior cephalosporin use, we do not see a rational for changing our antibiotic prophylaxis.

Why language matters: a tour through hand hygiene literature

Background

Hand hygiene has evolved over the last decades and many terminologies emerged. We aimed to analyse the evolution in the frequency of utilization of key hand hygiene terms in the literature along the years.

Methods

We identified keywords and Medical Subject Headings (MeSH) used in MEDLINE® indexation related to hand hygiene by searching international guidelines and the MeSH database. We performed a MEDLINE® search combining the selected keywords and MeSH and analysed the number of publications retrieved yearly.

Results

The literature search yielded 9019 publications when all hand hygiene related search terms were combined, between 1921 and November 2016. The total number of publications per year increased from a median of 4 (IQR 3, 6) in the 1950’s to 554 (IQR 478, 583) between 2011 and 2015. The most frequently used keywords are hand disinfection, hand hygiene, hand washing, handrub, hand sanitizer and alcohol-based hand rub (ABHR). Until the 1990s, hand disinfection and hand washing were the most frequently used terms. Whilst the last decade has seen a remarkable increase in publications mentioning hand disinfection and hand hygiene and for the first time handrub, hand sanitizers and ABHR were introduced in the literature. Hand disinfection, hand hygiene and hand sanitizers are the main MeSH used by MEDLINE®. Since 2013 hand hygiene is the most frequently used MeSH and keyword.

Conclusions

The change seen in literature in the last two decades, from hand washing and hand disinfection to hand hygiene, most probably reflect the paradigm shift favouring use of ABHR over soap and water promoted by international guidelines in the early 2000s.

Methodology and Background for the World Health Organization Global Guidelines on the Prevention of Surgical Site Infection

Surgical site infections remain an important topic of concern for surgeons in all specialties and are currently the focus of global health agencies for prevention. Because patients have numerous co-morbidities that increase the risks of surgical site infections, and because of the emergence of more resistant pathogens, it is necessary to revise and update guidelines to assist surgeons in the prevention of these infections. This article will summarize the most recent WHO Global Guidelines for the prevention of Surgical Site Infection that will have applicability for surgeons in all countries.