Reduction in Nosocomial Transmission of Drug-Resistant Bacteria After Introduction of an Alcohol-Based Handrub

Impact of a multi-hospital intervention utilising screening, hand hygiene education and pulsed xenon ultraviolet (PX-UV) on the rate of hospital associated meticillin resistant Staphylococcus aureus infection

Standard approaches to meticillin resistant Staphylococcus aureus (MRSA) prevention have included hand hygiene and active surveillance. These approaches have shown mixed results. The addition of pulsed xenon ultraviolet (PX-UV) room disinfection for MRSA prevention is a novel approach. This new MRSA prevention method was implemented at an acute care hospital system in Greensboro, NC, USA. An MRSA screening programme was implemented over a six-month period from July 2011 to January 2012 to include all high-risk patients and the majority of surgical patients. A two-week hand hygiene education initiative was implemented in February 2011. The use of PX-UV for terminal cleaning of MRSA patient rooms was also implemented in February 2011. The rates of hospital associated MRSA (HA-MRSA) infections were monitored before and after implementation of all prevention efforts. The HA-MRSA rate decreased at the largest facility in the system by 57%, and for the entire healthcare system by 56% ( p=0.001). The two smaller hospitals saw reductions of 51% and 66%, but the results were not statistically significant ( p=0.1047 and p=0.2263). Implementing a PX-UV device in conjunction with active screening and hand hygiene was associated with a decrease in HA-MRSA rates. Studies on the individual effect of PX-UV on HA-MRSA rates are warranted.

Role of the environment in the transmission of Clostridium difficile in health care facilities

Recent data demonstrate that the contaminated hospital surface environment plays a key role in the transmission of Clostridium difficile. Enhanced environmental cleaning of rooms housing Clostridium difficile-infected patients is warranted, and, if additional studies demonstrate a benefit of "no-touch" methods (eg, ultraviolet irradiation, hydrogen peroxide systems), their routine use should be considered.

Modern trends in infection control practices in intensive care units

Hospital-acquired infections (HAIs) are common in intensive care unit (ICU) patients and are associated with increased morbidity and mortality. There has been an increasing effort to prevent HAIs, and infection control practices are paramount in avoiding these complications. In the last several years, numerous developments have been seen in the infection prevention strategies in various health care settings. This article reviews the modern trends in infection control practices to prevent HAIs in ICUs with a focus on methods for monitoring hand hygiene, updates in isolation precautions, new methods for environmental cleaning, antimicrobial bathing, prevention of ventilator-associated pneumonia, central line-associated bloodstream infections, catheter-associated urinary tract infections, and Clostridium difficile infection.

New Drugs and Strategies for Management of Clostridium difficile Colitis

Approaches for management of Clostridium difficile infection continually evolve as research reveals shifts in epidemiology, microbial pathogenesis, disease severity states, and response to therapy. These new discoveries significantly impact diagnostic and therapeutic strategies, given the high morbidity associated with this common nosocomial infectious diarrhea. Critically ill patients are at an increased risk of developing diarrheal illness like C. difficile and succumbing to potentially fatal complications of this infection. Early diagnosis of severe disease state may improve patient outcomes. In this article, we review treatment strategies and new approaches for the management of C. difficile in critically ill patients.

Clostridium difficile colitis: a review

Clostridium difficile has become an increasingly important nosocomial pathogen and is one of the most common causes of hospital-acquired diarrhea. The incidence of C difficile infection (CDI) is increasing worldwide. Overuse of antibiotics is felt to be a major contributing factor leading to the increased incidence of CDI. The clinical manifestations of CDI vary from a mild form of the disease to fulminant diarrhea, leading to significant patient morbidity and mortality. The increasing incidence of CDI has a major impact on increasing health care costs. This article will summarize the epidemiology, pathogenesis, clinical manifestations, laboratory diagnosis, and treatment options for CDI, as well as infection-control measures for the prevention of CDI.

[Study on the effect of Feiji Decoction for soothing the liver combined with psychotherapy on the quality of life for primary lung cancer patients]

BACKGROUND AND OBJECTIVE

Lung cancer is the most common type among all malignant tumors, bringing huge pain and mood disorders to patients suffering from it. This study aims to evaluate the effect of the Feiji Decoction for soothing the liver combined with psychotherapy for depression and anxiety on patients with primary lung cancer. It also aims to further explore the relationship between depression and anxiety.

METHODS

A total of 118 patients with primary non-small cell lung cancer were randomly divided into two groups. The combined therapy group consisted of 57 patients who were treated with Feiji Decoction for soothing the liver and psychotherapy combined with chemotherapy. The control group consisted of 61 patients who were treated with chemotherapy only. Both groups were observed for two treatment courses. The Zung Self-reported Depression Scales (SDS) and Zung Self-reported Anxiety Scales (SAS) were used to assess the patients' psychology status in both groups before and after treatment scales.

RESULTS

After treatment, the depression and anxiety scores of the therapy group remarkably decreased compared with scores before treatment, indicating a statistical significance (P<0.01). In comparison, after treatment, the depression and anxiety scores of the control group significanfly increased compared with scores before treatment, indicating a statistical significance (P<0.01) as well. The depression and anxiety scores of the therapy group significanfly decreased compared with scores of the control group, showing statistical significance (P<0.01). Thus, depression and anxiety score has a close co-relationship, showing significant positive correlation (P<0.01).

CONCLUSIONS

Feiji Decoction for soothing the liver combined with psychotherapy can alleviate depression and anxiety in patients with primary lung cancer. This therapy has good clinical therapeutic effect.

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

Hand hygiene is the single most important intervention for reducing healthcare associated infections and preventing the spread of antimicrobial resistance. This sentence begins most publications regarding hand hygiene in the medical literature. But why - as we mark 150 years since the publication of Ignaz Semmelweis' landmark monograph on the subject - do we continue to repeat it? One might be tempted to regard it as a truism. However, while tremendous progress has certainly been made in this field, a significant amount of work is yet to be done in both strengthening the evidence regarding the impact of hand hygiene and maximizing its implementation. Hand hygiene cannot yet be taken for granted. This article summarizes historical perspectives, dynamics of microbial colonization and efficacy of hand cleansing methods and agents, elements and impacts of successful hand hygiene promotion, as well as scale-up and sustainability. We also explore hand hygiene myths and current challenges such as monitoring, behavior change, patient participation and research priorities.

Effectiveness of a hand hygiene promotion strategy using alcohol-based handrub in 6 intensive care units in Colombia

BACKGROUND

Hand hygiene is an effective strategy for the prevention of health care-associated infection (HAI). We investigated the effect of a hand hygiene promotion strategy introducing alcohol-based handrub (AHBR) on the incidence of HAI in a university hospital in Colombia.

METHODS

A Prospective cohort study was performed in 6 intensive care units from January 2001 to December 2005. HAI were identified using standard US Centers for Disease Control and Prevention definitions. Alcohol-based handrub dispensers were installed between February and June 2002.

RESULTS

Total ABHR consumption was 5,794 L (mean, 28.9 L per 1,000 patient-days) and significantly increased over time (+9.2% per year; P < .001). Of 14,516 patients cumulating 166,498 patient-days, 2,398 (16.5%) acquired a total of 3,490 HAI episodes (20.9 per 1,000 patient-days). Incidence densities for central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia, and urinary tract infections were 7.7, 10.6, and 3.6 episodes per 1,000 device-days, respectively. A significant decrease was observed for CLABSI (-12.7% per year; P < .001) with low nurse-to-patient ratio independently associated with infection (odds ratio, 1.11; 95% confidence interval: 1.07-1.16; P < .001).

CONCLUSION

Improved hand hygiene measured by increased ABHR consumption resulted in CLABSI reduction. Low nurse-to-patient ratio is independently associated with HAI in an upper-middle income country.

[Epidemiology of healthcare-associated infections due to MRSA in Brest University Hospital from 2004 to 2007. Impact of hydroalcoholic gel and antibiotics consumptions]

The fight against healthcare-associated infections is based on preventive measures of multidrug resistant bacteria diffusion. Hand hygiene is the simplest and the most effective preventive measure to reduce cross-transmission of infectious agents. Hydroalcoholic solutions for hand hygiene was recently introduced in the University Hospital of Brest (France). The aims of the study were: to describe the epidemiology of healthcare-associated infections due to methicillin-resistant Staphylococcus aureus (MRSA); to determine the annual consumptions of antistaphylococcal antibiotics; and to discuss the relation between consumption of antiseptic products or antibiotics and the epidemiology of MRSA.

METHODS

A retrospective epidemiological and pharmaco-epidemiological study was realized from January 2004 to December 2007 in the University Hospital of Brest (France). It allowed to bring to light the cases of healthcare-associated infections due to MRSA and to quantify the consumptions of hang hygiene products and antistaphylococcal antibiotics.

RESULTS

this retrospective study showed a decrease of healthcare-associated infections due to MRSA and an increase of the consumption of hydroalcoholic solutions. Antistaphylococcal resistance rates also decreased in a context of fall of the global antibiotics consumption in the hospital.

Hospital epidemiology and infection control in acute-care settings

Health care-associated infections (HAIs) have become more common as medical care has grown more complex and patients have become more complicated. HAIs are associated with significant morbidity, mortality, and cost. Growing rates of HAIs alongside evidence suggesting that active surveillance and infection control practices can prevent HAIs led to the development of hospital epidemiology and infection control programs. The role for infection control programs has grown and continues to grow as rates of antimicrobial resistance rise and HAIs lead to increasing risks to patients and expanding health care costs. In this review, we summarize the history of the development of hospital epidemiology and infection control, common HAIs and the pathogens causing them, and the structure and role of a hospital epidemiology and infection control program.

Prevention of endemic healthcare-associated Clostridium difficile infection: reviewing the evidence

OBJECTIVES

Clostridium difficile is the most common infectious cause of healthcare-associated diarrhea. Because of the increasing incidence and severity of endemic C. difficile infection (CDI), interventions to prevent healthcare-associated CDI are essential. We undertook a systematic review of interventions to reduce healthcare-associated CDI.

METHODS

We searched multiple computerized databases, and manually searched for relevant articles to determine which interventions are useful in preventing CDI. Studies were required to be controlled in design and to report the incidence of endemic CDI as an outcome. Data on the patient population, intervention, study design, and outcomes were abstracted and reviewed using established criteria.

RESULTS

Few randomized controlled trials exist in the area of CDI prevention. The interventions with the greatest evidence for the prevention of CDI include antimicrobial stewardship, glove use, and disposable thermometers. Environmental decontamination also may decrease CDI rates, although the level of evidence is not as strong as for the other proven interventions. Treatment of asymptomatic carriage of C. difficile is not recommended. There is insufficient evidence to make a recommendation for or against the use of probiotics. In cases of known or suspected CDI, hand hygiene with soap and water is preferred over use of waterless alcohol hand rub. Many nonrandomized trials included in our analysis used multiple interventions concurrently, making the independent role of each preventive strategy difficult to determine. We chose to include only studies that focused on endemic CDI because studies of outbreaks have used multiple strategies, making it difficult to measure the relative efficacy of each strategy. Environmental disinfection and probiotics need to be studied further to evaluate their roles in the prevention of CDI. Although there have been no studies assessing the utility of isolation and cohorting for the prevention of endemic CDI specifically, it is a widely used intervention for containment of this and other similar multidrug-resistant pathogens.

CONCLUSIONS

Antimicrobial stewardship, glove use, hand hygiene, and disposable thermometers should be routinely used for the prevention of CDI. Environmental disinfection and probiotics should be studied further for their role in reducing CDI.

Recognition and prevention of hospital-associated enteric infections in the intensive care unit

The objectives of this article were to review the causes and extent of hospital-associated infectious diarrhea and associated risks in the general hospital ward and intensive care unit (ICU), to compare microorganisms with similar symptoms to aid in recognition that will lead to timely and appropriate treatment and control measures, and to propose infection prevention protocols that could decrease human process errors in the ICU. This literature review describes epidemiology, comparison of microbial characteristics for potential hospital-associated enteric pathogens, diagnosis, and prevention, especially if important in the ICU, and particularly in regard to Clostridium difficile. Enteric organisms that most commonly cause hospital-associated infectious diarrhea in acute care settings and the ICU are C. difficile, rotavirus, and norovirus, although others may also be important, particularly in developing countries. To recognize and control infectious diarrhea successfully in the ICU, intensivists should be aware that epidemiology, risks, and prevention measures may differ between these microorganisms. In addition, intensivists should be ready to implement systems changes related to notification, isolation precautions and prevention, and environmental cleaning in the ICU.

Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands

BACKGROUND

Alcohol-based hand rubs (ABHRs) are an effective means of decreasing the transmission of bacterial pathogens. Alcohol is not effective against Clostridium difficile spores. We examined the retention of C. difficile spores on the hands of volunteers after ABHR use and the subsequent transfer of these spores through physical contact.

METHODS

Nontoxigenic C. difficile spores were spread on the bare palms of 10 volunteers. Use of 3 ABHRs and chlorhexidine soap-and-water washing were compared with plain water rubbing alone for removal of C. difficile spores. Palmar cultures were performed before and after hand decontamination by means of a plate stamping method. Transferability of C. difficile after application of ABHR was tested by having each volunteer shake hands with an uninoculated volunteer.

RESULTS

Plain water rubbing reduced palmar culture counts by a mean (+/- standard deviation [SD]) of 1.57 +/- 0.11 log10 colony-forming units (CFU) per cm2, and this value was set as the zero point for the other products. Compared with water washing, chlorhexidine soap washing reduced spore counts by a mean (+/- SD) of 0.89 +/- 0.34 log10 CFU per cm2; among the ABHRs, Isagel accounted for a reduction of 0.11 +/- 0.20 log10 CFU per cm2 (P = .005), Endure for a reduction of 0.37 +/- 0.42 log10 CFU per cm2 (P = .010), and Purell for a reduction of 0.14 +/- 0.33 log10 CFU per cm2 (P = .005). There were no statistically significant differences between the reductions achieved by the ABHRs; only Endure had a reduction statistically different from that for water control rubbing (P = .040). After ABHR use, handshaking transferred a mean of 30% of the residual C. difficile spores to the hands of recipients.

CONCLUSIONS

Hand washing with soap and water is significantly more effective at removing C. difficile spores from the hands of volunteers than are ABHRs. Residual spores are readily transferred by a handshake after use of ABHR.

Effectiveness of a catheter-associated bloodstream infection bundle in a Thai tertiary care center: a 3-year study

BACKGROUND

We sought to determine the long-term impact of "bundled" infection control interventions on the rates of catheter-associated bloodstream infection (CA-BSI) in a middle-income country.

SETTING

A 500-bed tertiary care center in Thailand.

METHODS

A 3-year, hospital-wide, prospective quasi-experimental study was conducted for 1 year before the intervention (period 1), 1 year after implementation of the CA-BSI bundle (period 2), and at a 1-year follow-up after the intervention with intensified hand hygiene promotion (period 3).

RESULTS

In period 1, 88 episodes of CA-BSI (14 cases per 1000 catheter-days) were recorded. During period 2, the CA-BSI rate decreased by 54.1 % (6.4 cases per 1000 catheter-days; P <.001). Compared with period 1 (8% adherence), hand hygiene adherence was improved in period 2 (24%; P <.001) and period 3 (54%; P <.001). The CA-BSI rate was further decreased by 78% (1.4 cases per 1000 catheter-days; P <.001) during period 3. Notably, no CA-BSIs were seen in 6 of the 12 months (50%) of period 3. Compared with period 1, the mean number of catheter-days was significantly reduced in period 2 (4.9 +/- 1.5 days; P <.001) and period 3 (4.1 +/- 1.1 days; P <.001).

CONCLUSION

Bundled infection control practices are feasible and effective in sustaining reduced incidence of CA-BSI in patients with central venous catheters in a resource-limited setting.

Stool studies: tried, true, and new

Much information can be obtained about a patient's gastrointestinal and overall nutritional status through stool samples. Important infectious processes and neoplastic processes are initially identified through diagnostic tests and screening of stool samples. Although in some arenas they are a source of embarrassment and distaste, the value of correctly obtained samples is unquestionable. Patient collaboration with a critical care nurse is integral to obtaining stool samples.

Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile

OBJECTIVE

To evaluate common hand hygiene methods for efficacy in removing Clostridium difficile.

DESIGN

Randomized crossover comparison among 10 volunteers with hands experimentally contaminated by nontoxigenic C. difficile.

METHODS

Interventions included warm water with plain soap, cold water with plain soap, warm water with antibacterial soap, antiseptic hand wipes, alcohol-based handrub, and a control involving no intervention. All interventions were evaluated for mean reduction in colony-forming units (CFUs) under 2 contamination protocols: "whole hand" and "palmar surface." Results were analyzed according to a Bayesian approach, by using hierarchical models adjusted for multiple observations.

RESULTS

Under the whole-hand protocol, the greatest adjusted mean reductions were achieved by warm water with plain soap (2.14 log(10) CFU/mL [95% credible interval (CrI), 1.74-2.54 log(10) CFU/mL]), cold water with plain soap (1.88 log(10) CFU/mL [95% CrI, 1.48-2.28 log(10) CFU/mL), and warm water with antibacterial soap (1.51 log(10) CFU/mL [95% CrI, 1.12-1.91 log(10) CFU/mL]), followed by antiseptic hand wipes (0.57 log(10) CFU/mL [95% CrI, 0.17-0.96 log(10) CFU/mL]). Alcohol-based handrub (0.06 log(10) CFU/mL [95% CrI, -0.34 to 0.45 log(10) CFU/mL]) was equivalent to no intervention. Under the palmar surface protocol, warm water with plain soap, cold water with plain soap, and warm water with antibacterial soap again yielded the greatest mean reductions, followed by antiseptic hand wipes (26.6, 26.6, 26.6, and 21.9 CFUs per plate, respectively), when compared with alcohol-based handrub. Hypothenar (odds ratio, 10.98 [95% CrI, 1.96-37.65]) and thenar (odds ratio, 6.99 [95% CrI, 1.25-23.41]) surfaces were more likely than fingertips to remain heavily contaminated after handwashing.

CONCLUSIONS

Handwashing with soap and water showed the greatest efficacy in removing C. difficile and should be performed preferentially over the use of alcohol-based handrubs when contact with C. difficile is suspected or likely.

Association between use of hand hygiene products and rates of health care-associated infections in a large university hospital in Norway

BACKGROUND

An association between use of hand hygiene products and health care-associated infection rates was investigated in a large Norwegian university hospital.

METHODS

We conducted an ecologic study by combining data from purchasing and admission systems with data from 32 point prevalence surveys (27,248 patients) in 1998-2005. Data on purchase of hand disinfectants and soap, and patient-days, were collected for 20 bed wards similar to those of the prevalence surveys.

RESULTS

The prevalence of infections was 7.1%. We found no significant decline in overall infections (P = .19), but use of hand hygiene products significantly increased from 28.5 L per 1000 patients-days in 1998 to 43.3 L per 1000 patient-days in 2005 (P < .001). After examining a linear dose-response relation between use and infection rates, we observed a borderline significant decline in infections from 8% to 6% with increased use of hand hygiene products (P = .05). This association appeared stronger for wards that were registered with infections >9% at study start in 1998 (P < .001).

CONCLUSION

These data suggests that infection rates may be reflected by amount of hand hygiene products used. Quantification of such products over time may serve as an indicator for hand hygiene performance in hospitals.

Clostridium difficile associated infection, diarrhea and colitis

A new, hypervirulent strain of Clostridium difficile, called NAP1/BI/027, has been implicated in C. difficile outbreaks associated with increased morbidity and mortality since the early 2000s. The epidemic strain is resistant to fluoroquinolones in vitro, which was infrequent prior to 2001. The name of this strain reflects its characteristics, demonstrated by different typing methods: pulsed-field gel electrophoresis (NAP1), restriction endonuclease analysis (BI) and polymerase chain reaction (027). In 2004 and 2005, the US Centers for Disease Control and Prevention (CDC) emphasized that the risk of C. difficile-associated diarrhea (CDAD) is increased, not only by the usual factors, including antibiotic exposure, but also gastrointestinal surgery/manipulation, prolonged length of stay in a healthcare setting, serious underlying illness, immune-compromising conditions, and aging. Patients on proton pump inhibitors (PPIs) have an elevated risk, as do peripartum women and heart transplant recipients. Before 2002, toxic megacolon in C. difficile-associated colitis (CDAC), was rare, but its incidence has increased dramatically. Up to two-thirds of hospitalized patients may be infected with C. difficile. Asymptomatic carriers admitted to healthcare facilities can transmit the organism to other susceptible patients, thereby becoming vectors. Fulminant colitis is reported more frequently during outbreaks of C. difficile infection in patients with inflammatory bowel disease (IBD). C. difficile infection with IBD carries a higher mortality than without underlying IBD. This article reviews the latest information on C. difficile infection, including presentation, vulnerable hosts and choice of antibiotics, alternative therapies, and probiotics and immunotherapy. We review contact precautions for patients with known or suspected C. difficile-associated disease. Healthcare institutions require accurate and rapid diagnosis for early detection of possible outbreaks, to initiate specific therapy and implement effective control measures. A comprehensive C. difficile infection control management rapid response team (RRT) is recommended for each health care facility. A communication network between RRTs is recommended, in coordination with each country’s department of health. Our aim is to convey a comprehensive source of information and to guide healthcare professionals in the difficult decisions that they face when caring for these oftentimes very ill patients.

Current knowledge of methicillin-resistant Staphylococcus aureus and community-associated methicillin-resistant Staphylococcus aureus

BACKGROUND

Bacterial strains that are oxacillin and methicillin-resistant, historically termed methicillin-resistant Staphylococcus aureus (MRSA) are resistant to all beta-lactam agents, including cephalosporins and carbapenems. MRSA are pathogenic and have a number of virulence factors that enable them to result in disease. They are transmissible and important causes of nosocomial infections worldwide. An MRSA outbreak can occur when one strain is transmitted to other patients or through close contacts of infected persons in the community. Hospital-associated MRSA (HA-MRSA) isolates are also frequent causes of healthcare-associated bloodstream and catheter-related infections. Community-associated MRSA (CA-MRSA) isolates are often only resistant to beta-lactam agents and erythromycin but they are an emerging cause of community-associated infections, especially skin and soft tissue infections (SSTI) and necrotizing pneumonia.

METHODS

Current possibilities for detecting MRSA strains in the laboratory are reviewed and discussed in the context of the recent literature.

RESULTS AND CONCLUSION

The active surveillance and prevention of MRSA occurrence and spreading in hospitals are discussed in the context of recent literature.

Clostridium difficile infection in solid organ transplant recipients

PURPOSE OF REVIEW

To provide a general understanding of Clostridium difficile infection with a focus on recent publications that evaluate the disease in solid organ transplant recipients.

RECENT FINDINGS

The incidence of C. difficile infection is increasing worldwide. Epidemics due to a hypervirulent C. difficile strain are associated with an escalating severity of disease. New evidence further supports basing initial treatment choice on disease severity.

SUMMARY

C. difficile is a significant pathogen in solid organ transplant recipients. Multiple risk factors are found in this population that may result in more severe disease. A high index of suspicion is necessary for the early diagnosis and treatment of C. difficile infection in transplant recipients. Metronidazole and vancomycin show equivalent efficacy in the treatment for mild-to-moderate disease, but vancomycin has demonstrated superiority in the treatment of severe disease. Surgical intervention is also an important consideration in the treatment of solid organ transplant recipients with severe colitis. Rigorous infection control practices are essential for preventing the spread of C. difficile within the hospital environment.

Adoption of alcohol-based handrub by United States hospitals: a national survey

The extent to which the use of alcohol-based handrub for hand hygiene has been adopted by US hospitals is unknown. A survey of infection control coordinators (response rate, 516 [72%] of 719) revealed that most hospitals (436 [84%] of 516) have adopted alcohol-based handrub. Leadership support and staff receptivity play a significant role in its adoption.

Quantitative detection of Clostridium difficile in hospital environmental samples by real-time polymerase chain reaction

C. difficile-associated diarrhoea occurs commonly in hospitals and is a significant cause of morbidity and mortality. Hospital surfaces are often contaminated with nosocomial pathogens and may be responsible for cross-transmission, especially if hardy Gram-positive and spore-forming organisms are involved. The aim of this study was to quantify C. difficile in the hospital environment near C. difficile-positive and -negative patients using a quantitative real-time polymerase chain reaction. A total of 531 samples was collected from the clinical environment and classified into three groups according to patient and ward status for C. difficile. As expected, there were significantly higher counts of C. difficile on the floor and in the near environment of C. difficile patients. However, a significant correlation was found between C. difficile counts on the floor and on the hands of patients and healthcare workers (HCWs) in wards without evidence of C. difficile. This suggests that asymptomatic carriage among patients and HCWs can also contribute towards C. difficile transmission in hospitals. In conclusion, C. difficile can be transmitted via personal contact or via contaminated areas of the hospital environment.

Infection control measures to limit the spread of Clostridium difficile

Clostridium difficile-associated diarrhoea (CDAD) presents mainly as a nosocomial infection, usually after antimicrobial therapy. Many outbreaks have been attributed to C. difficile, some due to a new hyper-virulent strain that may cause more severe disease and a worse patient outcome. As a result of CDAD, large numbers of C. difficile spores may be excreted by affected patients. Spores then survive for months in the environment; they cannot be destroyed by standard alcohol-based hand disinfection, and persist despite usual environmental cleaning agents. All these factors increase the risk of C. difficile transmission. Once CDAD is diagnosed in a patient, immediate implementation of appropriate infection control measures is mandatory in order to prevent further spread within the hospital. The quality and quantity of antibiotic prescribing should be reviewed to minimise the selective pressure for CDAD. This article provides a review of the literature that can be used for evidence-based guidelines to limit the spread of C. difficile. These include early diagnosis of CDAD, surveillance of CDAD cases, education of staff, appropriate use of isolation precautions, hand hygiene, protective clothing, environmental cleaning and cleaning of medical equipment, good antibiotic stewardship, and specific measures during outbreaks. Existing local protocols and practices for the control of C. difficile should be carefully reviewed and modified if necessary.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Temporal effects of antibiotic use and hand rub consumption on the incidence of MRSA and Clostridium difficile

OBJECTIVES

The aim of this study was to determine the temporal relation between the use of antibiotics and alcohol-based hand rubs (ABHRs) and the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile.

METHODS

An interventional time-series analysis was performed to evaluate the impact of two promotion campaigns on the consumption of ABHRs and to assess their effect on the incidence of non-duplicate clinical isolates of MRSA and C. difficile from February 2000 through September 2006. This analysis was combined with a transfer function model of aggregated data on antibiotic use.

RESULTS

Consumption of ABHRs correlated with MRSA, but not with C. difficile. The final model demonstrated the immediate effect of the second hand hygiene promotion campaign and an additional temporal effect of fluoroquinolone (time lag, 1 month; i.e. antibiotic effect delayed for 1 month), macrolide (lag 1 and 4 months), broad-spectrum cephalosporins (lag 3, 4 and 5 months) and piperacillin/tazobactam (lag 3 months) use. The final model explained 57% of the MRSA variance over time. In contrast, the model for C. difficile showed only an effect for broad-spectrum cephalosporins (lag 1 month).

CONCLUSIONS

We observed an aggregate-level relation between the monthly MRSA incidence and the use of different antibiotic classes and increased consumption of ABHR after a successful hand hygiene campaign, while no association with ABHR use was detected for C. difficile.

Modelling the impact of antibiotic use and infection control practices on the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus: a time-series analysis

OBJECTIVES

Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial pathogen worldwide. A wide range of factors have been suggested to influence the spread of MRSA. The objective of this study was to evaluate the effect of antimicrobial drug use and infection control practices on nosocomial MRSA incidence in a 426-bed general teaching hospital in Northern Ireland.

METHODS

The present research involved the retrospective collection of monthly data on the usage of antibiotics and on infection control practices within the hospital over a 5 year period (January 2000-December 2004). A multivariate ARIMA (time-series analysis) model was built to relate MRSA incidence with antibiotic use and infection control practices.

RESULTS

Analysis of the 5 year data set showed that temporal variations in MRSA incidence followed temporal variations in the use of fluoroquinolones, third-generation cephalosporins, macrolides and amoxicillin/clavulanic acid (coefficients = 0.005, 0.03, 0.002 and 0.003, respectively, with various time lags). Temporal relationships were also observed between MRSA incidence and infection control practices, i.e. the number of patients actively screened for MRSA (coefficient = -0.007), the use of alcohol-impregnated wipes (coefficient = -0.0003) and the bulk orders of alcohol-based handrub (coefficients = -0.04 and -0.08), with increased infection control activity being associated with decreased MRSA incidence, and between MRSA incidence and the number of new patients admitted with MRSA (coefficient = 0.22). The model explained 78.4% of the variance in the monthly incidence of MRSA.

CONCLUSIONS

The results of this study confirm the value of infection control policies as well as suggest the usefulness of restricting the use of certain antimicrobial classes to control MRSA.

Use of electronic alerts to enhance hand hygiene compliance and decrease transmission of vancomycin-resistant Enterococcus in a hematology unit

BACKGROUND

Hand hygiene (HH) compliance among health care workers (HCWs) has been historically low and hampered by poor surveillance methods. This study evaluated the use of an electronic device to measure and impact HH compliance.

METHODS

The study is a prospective, interventional study in a 30-bed academic medical center hematology unit. Phase I of the study monitored baseline HH compliance, and phase II monitored HH compliance using automatic alerts. The primary outcome measure was HH compliance, and the secondary end point was nosocomial transmission of vancomycin-resistant Enterococcus (VRE).

RESULTS

Eight thousand two hundred thirty-five HH opportunities were measured during the study, with HH compliance improvement from 36.3% at baseline to 70.1% during phase II. The use of audible alerts improved HH compliance for both the day shift (odds ratio [OR], 3.6) and the night shift (OR, 5.9), as well as across rooms with higher HCW traffic (OR, 1.6) and lower HCW traffic (OR, 3.2).

CONCLUSION

Electronic devices can effectively monitor HH compliance among HCWs and facilitate improved adherence to guidelines. Electronic devices improve HH compliance regardless of time of day or room location. The development of innovative devices to improve HH is required to validate the long-term implications of this methodology.

A Review of the Research Literature on Evidence-Based Healthcare Design

Objective:

This report surveys and evaluates the scientific research on evidence-based healthcare design and extracts its implications for designing better and safer hospitals.

Background:

It builds on a literature review conducted by researchers in 2004.

Methods:

Research teams conducted a new and more exhaustive search for rigorous empirical studies that link the design of hospital physical environments with healthcare outcomes. The review followed a two-step process, including an extensive search for existing literature and a screening of each identified study for the relevance and quality of evidence.

Results:

This review found a growing body of rigorous studies to guide healthcare design, especially with respect to reducing the frequency of hospital-acquired infections. Results are organized according to three general types of outcomes: patient safety, other patient outcomes, and staff outcomes. The findings further support the importance of improving outcomes for a range of design characteristics or interventions, including single-bed rooms rather than multibed rooms, effective ventilation systems, a good acoustic environment, nature distractions and daylight, appropriate lighting, better ergonomic design, acuity-adaptable rooms, and improved floor layouts and work settings. Directions for future research are also identified.

Conclusions:

The state of knowledge of evidence-based healthcare design has grown rapidly in recent years. The evidence indicates that well-designed physical settings play an important role in making hospitals safer and more healing for patients, and better places for staff to work.

Comprehensive bactericidal activity of an ethanol-based hand gel in 15 seconds

BACKGROUND

Some studies indicate that the commonly recommended 30 s application time for the post contamination treatment of hands may not be necessary as the same effect may be achieved with some formulations in a shorter application time such as 15 s.

METHOD

We evaluated the bactericidal activity of an ethanol-based hand gel (Sterillium Comfort Gel) within 15 s in a time-kill-test against 11 Gram-positive, 16 Gram-negative bacteria and 11 emerging bacterial pathogens. Each strain was evaluated in quadruplicate.

RESULTS

The hand gel (85% ethanol, w/w) was found to reduce all 11 Gram-positive and all 16 Gram-negative bacteria by more than 5 log10 steps within 15 s, not only against the ATCC test strains but also against corresponding clinical isolates. In addition, a log10 reduction > 5 was observed against all tested emerging bacterial pathogens.

CONCLUSION

The ethanol-based hand gel was found to have a broad spectrum of bactericidal activity in only 15 s which includes the most common species causing nosocomial infections and the relevant emerging pathogens. Future research will hopefully help to find out if a shorter application time for the post contamination treatment of hands provides more benefits or more risks.

Role of acid-suppressing medications during a sustained outbreak of Salmonella enteritidis infection in a long-term care facility

During an insidious outbreak of salmonellosis in a long-term care facility, residents who were treated with acid-suppressing medications were 8 times more likely than other residents to develop Salmonella infection. Among vulnerable populations, the risks and benefits of acid-suppressing medications should be considered carefully before use.

Methicillin-resistant Staphylococcus aureus in critical care areas

In recent years the mainstay of treatment for hospital-associated MRSA infections has been vancomycin, but now vancomycin intermediate S aureus strains are beginning to emerge. Complete vancomycin resistant S aureus can develop, possessing the same vanA gene as vancomycin-resistant enterococcus. Four such isolates have been reported, three of which have been in the United States. There are new antibiotics being developed, but there is always a risk of resistance developing. There are some promising new ideas such as staphylococcal conjugate vaccines that reduce the rates of S aureus bacteremia for up to 10 months postimmunization in patients who have end stage renal disease receiving hemodialysis, but studies are ongoing. With all the uncertainty surrounding treatment, at least one medium has remained consistent and effective if used properly--infection control. But this requires complete support of all healthcare workers and hospital administration from the chief medical officer to doctors and nurses to environmental services personnel to take ownership of an effective infection control program. Who will advocate for more stringent infection control policies and for the equipment to successfully carry them out? Who will take the lead by ensuring implementation of infection control policies on a unit is effective? Who will hold themselves and other health care workers including physicians accountable to comply with these infection control policies every time they enter a patient's room? Nurses are on the front lines in the battle against antibiotic-resistant nosocomial infections such as MRSA, and we should not be apathetic or feel we are helpless. It is our duty as patient advocates not to take a spectator role but to answer these questions: "I will."