Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units

Topical applications of chlorhexidine to the umbilical cord for prevention of omphalitis and neonatal mortality in southern Nepal: a community-based, cluster-randomised trial

BACKGROUND

Omphalitis contributes to neonatal morbidity and mortality in developing countries. Umbilical cord cleansing with antiseptics might reduce infection and mortality risk, but has not been rigorously investigated.

METHODS

In our community-based, cluster-randomised trial, 413 communities in Sarlahi, Nepal, were randomly assigned to one of three cord-care regimens. 4934 infants were assigned to 4.0% chlorhexidine, 5107 to cleansing with soap and water, and 5082 to dry cord care. In intervention clusters, the newborn cord was cleansed in the home on days 1-4, 6, 8, and 10. In all clusters, the cord was examined for signs of infection (pus, redness, or swelling) on these visits and in follow-up visits on days 12, 14, 21, and 28. Incidence of omphalitis was defined under three sign-based algorithms, with increasing severity. Infant vital status was recorded for 28 completed days. The primary outcomes were incidence of neonatal omphalitis and neonatal mortality. Analysis was by intention-to-treat. This trial is registered with , number NCT00109616.

FINDINGS

Frequency of omphalitis by all three definitions was reduced significantly in the chlorhexidine group. Severe omphalitis in chlorhexidine clusters was reduced by 75% (incidence rate ratio 0.25, 95% CI 0.12-0.53; 13 infections/4839 neonatal periods) compared with dry cord-care clusters (52/4930). Neonatal mortality was 24% lower in the chlorhexidine group (relative risk 0.76 [95% CI 0.55-1.04]) than in the dry cord care group. In infants enrolled within the first 24 h, mortality was significantly reduced by 34% in the chlorhexidine group (0.66 [0.46-0.95]). Soap and water did not reduce infection or mortality risk.

INTERPRETATION

Recommendations for dry cord care should be reconsidered on the basis of these findings that early antisepsis with chlorhexidine of the umbilical cord reduces local cord infections and overall neonatal mortality.

Nosocomial pneumonia: state of the science

Nosocomial pneumonia is the leading cause of mortality due to hospital-acquired infections. A thorough understanding of the most recent developments in evaluating and managing nosocomial pneumonia is critical for infection control professionals and hospital epidemiologists, given the incidence and cost of this important patient safety problem. We review the evidence on pathogenesis, diagnosis, treatment, and prevention of both ventilator-associated and nonventilator-associated pneumonia. Key recommendations are then provided for diagnostic testing strategies, antibiotic selection, and treatment duration. We also summarize the most recent data on how to prevent hospital-acquired infection, in general, and nosocomial pneumonia, in particular.

Impact of an infection control program on rates of ventilator-associated pneumonia in intensive care units in 2 Argentinean hospitals

BACKGROUND

Hospitalized, critically ill patients have a significant risk of developing nosocomial infection. Most episodes of nosocomial pneumonia occur in patients undergoing mechanical ventilation (MV).

OBJECTIVE

To ascertain the effect of an infection control program on rates of ventilator-associated pneumonia (VAP) in intensive care units (ICUs) in Argentina.

METHODS

All adult patients who received MV for at least 24 hours in 4, level III adult ICUs in 2 Argentinean hospitals were included in the study. A before-after study in which rates of VAP were determined during a period of active surveillance without an infection control program (phase 1) were compared with rates of VAP after implementation of an infection control program that included educational and surveillance feedback components (phase 2).

RESULTS

One thousand six hundred thirty-eight MV-days were accumulated in phase 1, and 1520 MV-days were accumulated during phase 2. Rates of VAP were significantly lower in phase 2 than in phase 1 (51.28 vs 35.50 episodes of VAP per 1000 MV-days, respectively, RR = 0.69, 95% CI: 0.49-0.98, P <or= .003).

CONCLUSION

Implementation of a multicomponent infection control program in Argentinean ICUs was associated with significant reductions in rates of VAP.

The Impact of Gown-Use Requirement on Hand Hygiene Compliance

BACKGROUND

Hand hygiene compliance remains low, despite its effectiveness in preventing infections. Gowns are routinely used to reduce dissemination of organisms within hospitals. Use of gowns is time consuming and costly, and their effectiveness, compared with that of hand hygiene alone, is debated. Among the arguments supporting a gown-use requirement is the potential to boost awareness of infection control, leading to improved hand hygiene compliance.

METHODS

Hand hygiene compliance was recorded in a 14-month crossover trial comparing compliance at 2 intensive care units during periods with and without a gown-use requirement.

RESULTS

During 170 h of observation, 1619 hand hygiene opportunities were recorded. Compliance was 10% before care was given and 36% after care was given. Compliance with glove and gown use was 62% and 63%, respectively. After-care hand hygiene compliance for nurses, physicians, and therapists was 40%, 38%, and 22%, respectively. Compliance after patient contact, body fluid contact, and other in-room activity was 42%, 48%, and 22%, respectively. For periods with and without a gown-use requirement, overall after-care compliance (37% vs. 34%) and rates by personnel and activity type were similar. In the subgroup of patients on contact precautions, hand hygiene compliance during the period with a gown-use requirement versus the period without a gown-use requirement was 11% versus 10% (P=.85) before care was given and 45% versus 39% (P=.09) after care was given. In this subgroup, after adjustment for type of in-room activity, medical personnel, intensive care unit, and observer, the predicted after-care hand hygiene compliance during periods with and without a gown-use requirement was 48% versus 41% (P=.02).

CONCLUSIONS

The hypothesis that a gown-use requirement might improve hand hygiene compliance in the intensive care unit could not be confirmed. In the subgroup of patients on contact precautions, improvement in hand hygiene compliance associated with the gown-use requirement was small and did not affect precare rates.

Guidelines for the control of glycopeptide-resistant enterococci in hospitals

The increase since the mid 1980s in glycopeptide resistant enterococci (GRE) raised concerns about the limited options for antimicrobial therapy, the implications for ever-increasing numbers of immunocompromised hospitalised patients, and fuelled fears, now realised, for the transfer of glycopeptide resistance to more pathogenic bacteria, such as Staphylococcus aureus. These issues underlined the need for guidelines for the emergence and control of GRE in the hospital setting. This Hospital Infection Society (HIS) and Infection Control Nurses Association (ICNA) working party report reviews the literature relating to GRE prevention and control. It provides guidance on microbiological investigation, treatment and management, including antimicrobial prescribing and infection control measures. Evidence identified to support recommendations has been categorized. A risk assessment approach is recommended and areas for research and development identified.

Nosocomial infections in a Dutch neonatal intensive care unit: surveillance study with definitions for infection specifically adapted for neonates

The incidence of nosocomial infection in neonatal intensive care units (NICUs) is high compared with other wards. However, no definitions for hospital-acquired infection are available for NICUs. The aim of this study was to measure the incidence of such infections and to identify risk factors in the NICU of the VU University Medical Center, which serves as a level III regional NICU. For this purpose, a prospective surveillance was performed in 1998-2000. We designed definitions by adjusting the current definitions of the Centers for Disease Control and Prevention (CDC) for children <1 year of age. Birth weight was stratified into four categories and other baseline risk factors were dichotomized. Analysis of risk factors was performed by Cox regression with time-dependent variables. The relationship between the Clinical Risk Index for Babies (CRIB) and nosocomial infection was investigated. Furthermore, for a random sample of cases, we determined whether bloodstream infection and pneumonia would also have been identified with the CDC definitions. Seven hundred and forty-two neonates were included in the study. One hundred and ninety-one neonates developed 264 infections. Bloodstream infection (N=138, 14.9/1000 patient-days) and pneumonia (N=69, 7.5/1000 patient-days) were the most common infections. Of bloodstream infections, 59% were caused by coagulase-negative staphylococci; in 21% of neonates, blood cultures remained negative. In 25% of pneumonias, Enterobacteriaceae were the causative micro-organisms; 26% of cultures remained negative. Compared with the Nosocomial Infections Surveillance System (NNIS) of the CDC, our device utilization ratios and device-associated nosocomial infection rates were high. The main risk factors for bloodstream infection were birth weight [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.45-2.17] and parenteral feeding with hospital-pharmacy-produced, all-in-one mixture 'Minimix' (HR 3.69, 95%CI 2.03-6.69); administration of intravenous antibiotics (HR 0.39, 95%CI 0.26-0.56) was a protective risk factor. The main risk factors for pneumonia were low birth weight (HR 1.37, 95%CI 1.01-1.85) and mechanical ventilation (HR 9.69, 95%CI 4.60-20.4); intravenous antibiotics were protective (HR 0.37, 95%CI 0.21-0.64). In a subcohort of 232 very-low-birthweight neonates, the CRIB was not predictive for infection. With the CDC criteria, only 75% (21/28) of bloodstream infections and 87.5% of pneumonias (21/24) would have been identified. In conclusion, our local nosocomial infection rates are high compared with those of NICUs participating in the NNIS. This can be partially explained by: (1) the use of our definitions for nosocomial infection, which are more suitable for this patient category; and (2) the high device utilization ratios.

Handwashing practice and the use of personal protective equipment among medical students after the SARS epidemic in Hong Kong

BACKGROUND

Hand hygiene is an important element of infection control. We conducted 2 surveys on hand hygiene practices and use of personal protective equipment among medical students during and after the outbreak of severe acute respiratory syndrome (SARS) to study its impact on their personal hygiene practice when they contacted patients.

METHODS

Two cross-sectional surveys were conducted among medical students in their clinical training years (years 3-5) in a teaching hospital (at which the first and major SARS outbreak occurred) in March 2003 and August 2004, respectively.

RESULTS

Prior to the recognition of the SARS outbreak in March 2003, 35.2% of the students washed their hands before and 72.5% after they physically examined patients in the wards. None of the students wore masks during history taking and physical examination. In the 2004 survey, the corresponding proportions were 60.3% and 100%, respectively, and 86.1% and 93.8% of students wore masks during history taking and physical examination, respectively. Attitudes to handwashing and perception of infection risk were not significantly associated with handwashing practice, whereas peer behavior might be a significant influencing factor.

CONCLUSION

A significant improvement in compliance with hand hygiene practice was found after the SARS outbreak.

Use of stochastic epidemic modeling to quantify transmission rates of colonization with methicillin-resistant Staphylococcus aureus in an intensive care unit

OBJECTIVE

To consider statistical methods for estimating transmission rates for colonization of patients with methicillin-resistant Staphylococcus aureus (MRSA) in an intensive care unit (ICU) from three different sources: background contamination, non-isolated patients, and isolated patients.

METHODS

We developed statistical methods that allowed for the analysis of interval-censored, routine surveillance data and extended the general epidemic model for the flow of patients through the ICU.

RESULTS

Within this ICU, the rate of transmission to susceptible patients from a background source of MRSA (0.0092 case per day; 95% confidence interval [CI95], 0.0062-0.0126) is approximately double the rate of transmission from a non-isolated patient (0.0052 case per day; CI95, 0.0013-0.0096) and six times the rate of transmission from an isolated patient (0.0015 case per day; CI95, 0.0001-0.0043). We used the methodology to investigate whether transmission rates vary with workload.

CONCLUSION

Our methodology has general application to infection by and transmission of pathogens in a hospital setting and is appropriate for quantifying the effect of infection control interventions.

The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care

OBJECTIVE

Critically ill patients require high-intensity care and may be at especially high risk of iatrogenic injury because they are severely ill. We sought to study the incidence and nature of adverse events and serious errors in the critical care setting.

DESIGN

We conducted a prospective 1-year observational study. Incidents were collected with use of a multifaceted approach including direct continuous observation. Two physicians independently assessed incident type, severity, and preventability as well as systems-related and individual performance failures.

SETTING

Academic, tertiary-care urban hospital.

PATIENTS

Medical intensive care unit and coronary care unit patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes of interest were the incidence and rates of adverse events and serious errors per 1000 patient-days. A total of 391 patients with 420 unit admissions were studied during 1490 patient-days. We found 120 adverse events in 79 patients (20.2%), including 66 (55%) nonpreventable and 54 (45%) preventable adverse events as well as 223 serious errors. The rates per 1000 patient-days for all adverse events, preventable adverse events, and serious errors were 80.5, 36.2, and 149.7, respectively. Among adverse events, 13% (16/120) were life-threatening or fatal; and among serious errors, 11% (24/223) were potentially life-threatening. Most serious medical errors occurred during the ordering or execution of treatments, especially medications (61%; 170/277). Performance level failures were most commonly slips and lapses (53%; 148/277), rather than rule-based or knowledge-based mistakes.

CONCLUSIONS

Adverse events and serious errors involving critically ill patients were common and often potentially life-threatening. Although many types of errors were identified, failure to carry out intended treatment correctly was the leading category.

Strategies to prevent antimicrobial resistance in the intensive care unit

OBJECTIVE

To assemble the available clinical data for the prevention of antimicrobial resistance into practical recommendations for clinicians.

DATA SOURCE

A Medline database and references from identified articles were employed to perform a literature search relating to the prevention of antimicrobial resistance.

CONCLUSIONS

Antimicrobial resistance has emerged as an important determinant of mortality for patients in the intensive care unit. This is largely due to the increasing presence of pathogenic microorganisms with resistance to existing antimicrobial agents, resulting in the administration of inappropriate treatment. Effective strategies for the prevention of antimicrobial resistance within intensive care units are available and should be aggressively implemented. These strategies can be divided into nonpharmacologic infection control strategies (e.g., routine hand hygiene, implementation of infection-specific prevention protocols) and antibiotic management strategies (e.g., shorter courses of appropriate antibiotic treatment, narrowing of antimicrobial spectrum based on culture results). Increasing current efforts aimed at the prevention of antimicrobial resistance is especially important given the limited availability of new antimicrobial drug classes for the foreseeable future.

Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina

BACKGROUND

Hand hygiene is a fundamental measure for the control of nosocomial infection. However, sustained compliance with hand hygiene in health care workers is poor. We attempted to enhance compliance with hand hygiene by implementing education, training, and performance feedback. We measured nosocomial infections in parallel.

METHODS

We monitored the overall compliance with hand hygiene during routine patient care in intensive care units (ICUs); 1 medical surgical ICU and 1 coronary ICU, of 1 hospital in Buenos Aires, Argentina, before and during implementation of a hand hygiene education, training, and performance feedback program. Observational surveys were done twice a week from September 2000 to May 2002. Nosocomial infections in the ICUs were identified using the National Nosocomial Infections Surveillance (NNIS) criteria, with prospective surveillance.

RESULTS

We observed 4347 opportunities for hand hygiene in both ICUs. Compliance improved progressively (handwashing adherence, 23.1% (268/1160) to 64.5% (2056/3187) (RR, 2.79; 95% CI: 2.46-3.17; P < .0001). During the same period, overall nosocomial infection in both ICUs decreased from 47.55 per 1000 patient-days (104/2187) to 27.93 per 1000 patient days (207/7409) RR, 0.59; 95% CI: 0.46-0.74, P < .0001).

CONCLUSION

A program consisting of focused education and frequent performance feedback produced a sustained improvement in compliance with hand hygiene, coinciding with a reduction in nosocomial infection rates in the ICUs.

Hand hygiene: an evidence-based review for surgeons

This review of the literature discusses the scientific evidence behind using different hand hygiene agents on the surgical ward, and in theatre for preoperative disinfection. It considers the mechanism of action of the agents and their effectiveness against different pathogens, as well as possible future agents, and how they are tested. It addresses problems such as the poor compliance with hand hygiene guidelines by healthcare workers (especially doctors) and investigates what can be done to improve compliance. Finally, it demonstrates the reduction in hospital acquired infection (HAI) rate that can be achieved by improving hand hygiene compliance, and shows that the savings associated with this easily outweigh the cost.

Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia

PURPOSE

Several modalities have been shown to be individually effective in reducing the incidence (and hence associated morbidity, mortality, and costs) of ventilator-associated pneumonia, but their implementation into clinical practice is inconsistent. We introduced an intensive care unit protocol and measured its effect on ventilator-associated pneumonia.

METHODS

A multidisciplinary team constructed a multifaceted protocol incorporating low risk and low cost strategies, many of which had independent advantages of their own. Some components were already in use, and their importance was emphasized to improve compliance. New strategies included elevation of the head of the bed, transpyloric enteral feeding, and antiseptic mouthwash. The approach to implementation and maintenance included education, monitoring, audits and feedback to encourage compliance with the protocol.

RESULTS

The implementation of this prevention protocol reduced the incidence of ventilator-associated pneumonia from a baseline of 94 cases per year or 26.7 per 1,000 ventilator days to 51.3 per year or 12.5 per 1,000 ventilator days, i.e., about 50% of the pre-protocol rate (P < 0.0001).

CONCLUSION

Adherence to simple and effective measures can reduce the incidence of ventilator-associated pneumonia. The protocol described was inexpensive and effective, and estimated savings are large. Implementation and maintenance of gains require a multidisciplinary approach, with buy-in from all team members, and ongoing monitoring, education, and feedback to the participants.

An alcohol hand rub containing a synergistic combination of an emollient and preservatives: prolonged activity against transient pathogens

A new alcohol-based hand antiseptic (Octoxy hand rub) containing a synergistic combination of an emollient (Octoxyglycerine) and preservatives was developed and evaluated for immediate and prolonged activity against transient bacteria. The in vitro and in vivo antimicrobial efficacy was compared with other alcohol hand rubs containing preservative/antimicrobial (Prevacare and Avagard). In vitro evaluation was carried out using a tube-dilution method and a pig-skin model. Rapid and prolonged efficacy in vivo was evaluated against Staphylococcus epidermidis on the hands of volunteers. Octoxy hand rub was 100% effective in rapidly killing pathogens including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecium in vitro. In volunteers, all three hand rubs gave a significant reduction in microbial count within 15s. Octoxy hand rub showed significantly higher efficacy against S. aureus and Escherichia coli than Avagard and Prevacare 15 min after application to the pig-skin model, and against S. epidermidis in both the pig-skin model and in volunteers. Use of Octoxy hand rub with broad-spectrum immediate and prolonged antimicrobial activity may be a very effective way of improving hand hygiene without exposing the hands to higher concentrations of antimicrobials.

Infection control policies and hospital-associated infections among surgical patients: variability and associations in a multicenter pediatric setting

BACKGROUND

Hospital-associated infections are an important cause of patient morbidity and death. Little is known about the variability of infection rates and infection control practices among pediatric hospitals.

METHODS

This cross-sectional study was performed with the Pediatric Health Information System database, which includes demographic and diagnostic data for 35 freestanding, noncompeting, children's hospitals, and with data from a survey of the hospitals, which yielded additional information on infection control policies and practices. Patients undergoing elective surgical procedures were included in this study.

RESULTS

Of the 35 eligible hospitals, 31 (89%) chose to participate in the survey component of this study. A total of 48278 patients met the inclusion criteria for the study; 2.3% of these patients had respiratory infections and 0.8% had gastrointestinal infections. The frequency of patients diagnosed with respiratory or gastrointestinal infections varied considerably among the hospitals and ranged from <1% to 6%. Certain infection control processes also varied among the hospitals during the study period. For instance, of the 31 hospitals, 12 monitored hand hygiene, 19 had administrative support of hand hygiene, and 16 had alcohol hand gel present for the entire study period. The presence of alcohol hand gel for the entire study was strongly and independently associated with lower odds of gastrointestinal infections (adjusted odds ratio: 0.64; 95% confidence interval: 0.49-0.85).

CONCLUSIONS

Hospitals should support the use of alcohol hand gel, with the aim of decreasing hospital-associated infection rates.

Handwashing in the intensive care unit: a big measure with modest effects

Handwashing is widely accepted as the cornerstone of infection control in the intensive care unit. Nosocomial infections are frequently viewed as an indicator of poor compliance of handwashing. The aim of this review is to evaluate the effectiveness of handwashing on infection rates in the intensive care unit, and to analyse the failure of handwashing. A literature search identified nine studies that evaluated the impact of handwashing or hand hygiene on infection rates, and demonstrated a low level of evidence for the efforts to control infection with handwashing. Poor compliance cannot be blamed as the only reason for the failure of handwashing to control infection. Handwashing on its own does not abolish, but only reduces transmission, as it is dependent on the bacterial load on the hand of healthcare workers. Finally, recent studies, using surveillance cultures of throat and rectum, have shown that, under ideal circumstances, handwashing can only influence 40% of all intensive care unit infections. A randomised clinical trial with the intensive care as randomisation unit is required to support handwashing as the cornerstone of infection control.

Alcohol-based hand disinfection: a more robust hand-hygiene method in an intensive care unit

This study involved observation of hand-hygiene behaviour and evaluation of the effect of alcohol-based hand disinfection and handwashing with plain liquid soap on microbial flora. The study was performed in a combined medical and surgical intensive care unit. We demonstrated a crude compliance of hand hygiene of 50.4%, which was only performed adequately in 20.8% of cases. Of this group, handwashing and hand-disinfection procedures were performed properly 34.0% and 71.6% of the time, respectively. Hand samples for bacteriological examinations with the glove juice method demonstrated that whilst handwashing was sensitive to the way in which hand hygiene was performed, alcohol-based hand disinfection was less sensitive to such performance. Our study demonstrated that alcohol-based hand disinfection is a robust hand-hygiene method with many advantages in a practical setting. It is very feasible for use in hospital wards.

A multicentric survey of the practice of hand hygiene in haemodialysis units: factors affecting compliance

BACKGROUND

This study intended to investigate the degree of compliance with hand hygiene and use of gloves by health workers in haemodialysis (HD) units, and the factors that influenced adherence to hand hygiene protocols.

METHODS

During the month of November 2003, one person observed the health care staff in each of nine different dialysis units, during 495 randomly distributed 30 min observation periods that covered all steps of a haemodialysis session (connection, dialysis and disconnection). The observers noted the number of potential opportunities to implement standard precautions and the number of occasions on which the precautions were actually taken. Adherence to standard precautions was evaluated, analysing the influence of the following variables: the patient-to-nurse ratio, the number of HD shifts scheduled per day, acute HD units vs chronic, whether or not infectious patients were isolated and in-house vs contract cleaning personnel.

RESULTS

There were a total of 977 opportunities to wear gloves for, and to wash the hands following, a patient-oriented activity, and 1902 opportunities to wash hands before such an activity. Gloves were actually used on 92.9% of these occasions. Hands were washed only 35.6% of the time after patient contact, and only 13.8% of the time before patient contact. Poor adherence to hand washing was associated with the number of shifts per HD unit per day and with higher patient-to-nurse ratios. In the acute HD units, there was greater adherence to standard precautions than in the chronic units, although there too it was substandard. The personnel's knowledge of patients' infectious status did not modify their adherence to hand hygiene practices. A higher patient-to-nurse ratio independently influenced hand washing both before and after patient contact.

CONCLUSIONS

The overall adherence of health care workers to recommended hand washing practices is low. Whether or not programmes promoting higher hand hygiene standards and the potential use of alcohol-based hand cleansers will improve hand hygiene practices in HD units requires further investigation.

Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses

Background

Health care-associated infections most commonly result from person-to-person transmission via the hands of health care workers.

Methods

We studied the efficacy of hand hygiene agents (n = 14) following 10-second applications to reduce the level of challenge organisms (Serratia marcescens and MS2 bacteriophage) from the hands of healthy volunteers using the ASTM-E-1174-94 test method.

Results

The highest log₁₀ reductions of S marcescens were achieved with agents containing chlorhexidine gluconate (CHG), triclosan, benzethonium chloride, and the controls, tap water alone and nonantimicrobial soap and water (episode 1 of hand hygiene, 1.60-2.01; episode 10, 1.60-3.63). Handwipes but not alcohol-based handrubs were significantly inferior from these agents after a single episode of hand hygiene, but both groups were significantly inferior after 10 episodes. After a single episode of hand hygiene, alcohol/silver iodide, CHG, triclosan, and benzethonium chloride were similar to the controls in reduction of MS2, but, in general, handwipes and alcohol-based handrubs showed significantly lower efficacy. After 10 episodes, only benzethonium chloride (1.33) performed as well as the controls (1.59-1.89) in the reduction of MS2.

Conclusions

Antimicrobial handwashing agents were the most efficacious in bacterial removal, whereas waterless agents showed variable efficacy. Alcohol-based handrubs compared with other products demonstrated better efficacy after a single episode of hand hygiene than after 10 episodes. Effective hand hygiene for high levels of viral contamination with a nonenveloped virus was best achieved by physical removal with a nonantimicrobial soap or tap water alone.

Prevention of acquired infections in intubated patients with the combination of two decontamination regimens

OBJECTIVE

The use of topical polymyxin and tobramycin to prevent intensive care infections is controversial. Moreover, these antibiotics are ineffective against methicillin-resistant Staphylococcus aureus. A decontamination regimen using mupirocin and chlorhexidine could prevent acquired infections, including those involving S. aureus. Because these two regimens could have a complementary role, we evaluated their effects when given both alone and combined.

DESIGN

The authors conducted a multiple-center, placebo-controlled, randomized, double-blind study performed according to a 2 x 2 factorial design.

SETTING

The study was conducted at three polyvalent medical intensive care units at university-affiliated hospitals in France.

PATIENTS

Adult patients (age, > or =18 yrs) intubated for <48 hrs who were likely to be ventilated for >48 hrs.

INTERVENTION

Two regimens were used: topical administration of polymyxin/tobramycin (or placebo) and nasal mupirocin with chlorhexidine body washing (or nasal placebo with liquid soap). The patients (n = 515) received polymyxin/tobramycin alone (n = 130), mupirocin/chlorhexidine alone (n = 130), both regimens (n = 129), or all placebos (n = 126) for the period of mechanical ventilation plus 24 hrs.

MEASUREMENTS AND MAIN RESULTS

The incidence of total infections acquired from the date of randomization until the termination date of study treatments plus 48 hrs was assessed. There were fewer acquired infections with both regimens than with polymyxin/tobramycin alone (odds ratio, 0.44; 95% confidence interval, 0.26-0.75; p = .003), mupirocin/chlorhexidine alone (0.43; 0.25-0.73; p = .002), or all placebos (0.42; 0.25-0.72; p = .001). There were no differences between polymyxin/tobramycin alone (0.95; 0.59-1.54; p = .84) and mupirocin/chlorhexidine alone (0.98; 0.60-1.58; p = .92) vs. all placebos. The probability of freedom from infection was higher with both regimens than with polymyxin/tobramycin alone (p = .002), mupirocin/chlorhexidine alone (p < .001), or all placebos (p < .001). Infection rates were also significantly lower with both regimens than with polymyxin/tobramycin alone (p = .017), mupirocin/chlorhexidine alone (p < .001), or all placebos (p < .001).

CONCLUSION

Acquired infections were substantially reduced by mupirocin/chlorhexidine plus polymyxin/tobramycin, whereas each regimen given alone was ineffective. Whether both regimens could increase Candida infections deserves further investigation.

Managing infection in the critical care unit: how can infection control make the ICU safe?

The goal of this article is to use ventilator-associated pneumonia (VAP) as a prototype for nosocomial infections to explore the issues of patient safety and infection control. To do this, we review disease-specific aspects of VAP, develop a brief working definition of patient safety, and then determine how the concepts of infection control fit into the broader context of patient safety.

Hand washing and hand disinfection: more than your mother taught you

Hand washing is considered the single most important intervention for prevention of nosocomial infections in patients and health care workers. Unfortunately, compliance with standard protocols for hand hygiene in the health care environment, and especially within intensive care areas such as operating rooms and post-anesthesia care units, has been generally poor. In this article, we consider the current standards for hand hygiene as they pertain to the practice of anesthesiology. We discuss the consequences of poor compliance with hand washing practices for patient and health care provider safety. And we describe modern innovations in hand washing procedures and products that improve the opportunities for anesthesiologists to employ safe hand hygiene.

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

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

High-risk populations for nasal carriage of methicillin-resistant Staphylococcus aureus

To determine the population at high risk of nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) on hospital patients admission, a nasal swab was taken from the following patients: (1) those aged 70 years or over (age >or= 70), (2) non ambulatory receiving regular home visits by nurses and physicians (visiting), (3) residents of nursing homes (nursing home), (4) patients from other hospitals (another Hp), and (5) those scheduled for surgery (presurgery). Between March and July 2000, a total of 412 patients were admitted and 136 were enrolled. MRSA was isolated from 12 (8.8%) patients. The number of patients positive for MRSA in the five groups, age >or=70, visiting, nursing home, another Hp, and presurgery, were 3 of 68, 3 of 21, 2 of 3, 3 of 9, and 1 of 35, respectively. Multivariate analysis revealed that living in a nursing home [odds ratio (OR) = 32.82, P = 0.010] or coming from another hospital (OR = 14.55, P = 0.0043) were high risk factors with for nasal carriage of MRSA. Furthermore, patients' ages were further divided into three categories, <or=79, 80-89, >or=90, and regarded as independent high risk factors (OR = 3.08, P = 0.043). The results were that advanced living in a age (>or=80, >or=90), living in a nursing home or coming from another hospital are high risk factors of nasal carriage of MRSA on hospital admission.

Prevention and treatment of nosocomial sepsis in the NICU

Nosocomial sepsis is a serious problem for neonates who are admitted for intensive care. It is associated with an increase in mortality, morbidity, and prolonged length of hospital stay. Thus, both the human and fiscal costs of these infections are high. Although the rate of nosocomial sepsis increases with the degree of both prematurity and low birth weight, no specific lab test has been shown to be very useful in improving our ability to predict who has a "real" blood-stream infection and, therefore, who needs to be treated with a full course of antibiotics. As a result, antibiotic use is double the rate of "proven" sepsis and we are facilitating the growth of resistant organisms in the neonatal intensive care unit. The purpose of this article is to describe simple changes in process, which when implemented, can reduce nosocomial infection rates in neonates and improve outcomes.

Comparative in vitro and in vivo study of nine alcohol-based handrubs

BACKGROUND

Hygienic hand disinfection using alcohol-based handrubs (AHRs) is an alternative method to conventional handwashing in hospital wards. Because a documented choice of such products would consider data from in-care evaluation, we designed a comparative study of 9 AHRs both in vitro and in vivo in actual care conditions.

METHODS

The bactericidal activity of AHRs was first measured in vitro against 4 hospital strains exhibiting multiple antibiotic resistance: Acinetobacter baumannii, Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacter aerogenes. In a second time, AHRs were tested in an intensive care unit for antibacterial activity against the cutaneous flora of personnel hands and for acceptance by the care personnel.

RESULTS

The 9 AHRs could be classified in 3 groups on the basis of their in vitro activity: products of the first group showed a bactericidal activity higher than 4 log(10) against the 4 strains. Only 1 of these products presented simultaneously an effective antibacterial activity against the cutaneous flora of care personnel hands and a good acceptance by the care personnel.

CONCLUSION

The in vitro study allowed the differentiation of the AHRs tested on the basis of bactericidal activity, but evaluation in an in-care situation allowed further discrimination through both antibacterial activity and acceptance. Thus, the combination of in vitro and in vivo evaluations should provide helpful arguments in the choice of AHRs.

Dynamics of bacterial hand contamination during routine neonatal care

OBJECTIVE

To evaluate the dynamics of bacterial contamination of healthcare workers' (HCWs) hands during neonatal care.

SETTING

The 20-bed neonatal unit of a large acute care teaching hospital in Geneva, Switzerland.

METHODS

Structured observation sessions were conducted. A sequence of care began when the HCW performed hand hygiene and ended when the activity changed or hand hygiene was performed again. Alcohol-based handrub was the standard procedure for hand hygiene. An imprint of the five fingertips of the dominant hand was obtained before and after hand hygiene and at the end of a sequence of care. Regression methods were used to model the final bacterial count according to the type and duration of care and the use of gloves.

RESULTS

One hundred forty-nine sequences of care were observed. Commensal skin flora comprised 72.4% of all culture-positive specimens (n = 360). Other microorganisms identified were Enterobacteriaceae (n = 55, 13.8%); Staphylococcus aureus (n = 10, 2.5%); and fungi (n = 7, 1.8%). Skin contact, respiratory care, and diaper change were independently associated with an increased bacterial count; the use of gloves did not fully protect HCWs' hands from bacterial contamination.

CONCLUSIONS

These data confirm that hands become progressively contaminated with commensal flora and potential pathogens during neonatal care, and identify activities at higher risk for hand contamination. They also reinforce the need for hand hygiene after a sequence of care, before starting a different task, and after glove removal.

Ineffectiveness of handwashing with lotion soap to remove nosocomial bacterial pathogens persisting on fingertips: a major link in their intrahospital spread

The effectiveness of five 30-second handwashes with a non-antiseptic lotion soap to remove nosocomial pathogens (10(8) CFU) applied to fingertips was studied. CFU for all species dropped rapidly after the first handwash; persistence (10 to 15 CFU) was maintained thereafter. Wiping hands with an antiseptic (70% isopropyl or 10% povidone-iodine) sponge removed persisters.

A systematic review on the effectiveness of alcohol-based solutions for hand hygiene

The use of alcohol has been proposed as an option for hand hygiene. A systematic review was conducted to evaluate the clinical evidence supporting the use of alcohol-based solutions in hospitals as an option for hand hygiene. Studies published between January 1992 and April 2002 in English and Thai, related to the effectiveness of alcohol-based solutions, were reviewed. The databases searched included Medline, DARE, CINAHL and Dissertation Abstracts International. All studies were assessed as having adequate methodological quality. Results of this systematic review supported that alcohol-based hand rubbing removes microorganisms effectively, requires less time and irritates hands less often than does handwashing with soap or other antiseptic agents and water. Furthermore, the availability of bedside alcohol-based solutions increases compliance with hand hygiene among health care workers.

Pneumonia in the intensive care unit

OBJECTIVE

To update the state-of-the-art on pneumonia in adult patients in the intensive care unit (ICU), with special emphasis on new developments in management.

METHODS

We searched MEDLINE, using the following keywords: hospital-acquired pneumonia, ventilator-associated pneumonia and healthcare-associated pneumonia, diagnosis, therapy, prevention.

RESULTS

Interventions to prevent pneumonia in the ICU should combine multiple measures targeting the invasive devices, microorganisms, and protection of the patient. Once pneumonia develops, the appropriateness of the initial antibiotic regimen is a vital determinant of outcome. Three questions should be formulated: a) Is the patient at risk of methicillin-resistant Staphylococcus aureus?; b) Is Acinetobacter baumannii a problem in the institution?; and c) is the patient at risk of Pseudomonas aeruginosa? Antibiotic therapy should be started immediately and must circumvent pathogen-resistance mechanisms developed after previous antibiotic exposure. Therefore, antibiotic choice should be institution specific and patient oriented. Microbiologic investigation is useful on evaluating the quality of the respiratory sample and permits early modification of the regimen in light of the microbiologic findings.

CONCLUSION

A decision tree outlining an approach to the evaluation and management of ventilator-associated pneumonia is provided.

Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia*

OBJECTIVE

To review barriers to nursing adherence to nonpharmacologic evidence-based guidelines for preventing ventilator-associated pneumonia.

DESIGN

Descriptive study.

SETTING

Intensive care units.

SUBJECTS

Subjects were 110 nurses approached at two critical care nursing meetings.

INTERVENTIONS

A questionnaire was administered to nurses to assess their adherence to 19 nonpharmacologic prevention strategies and to identify barriers to adherence to evidence-based guidelines.

MEASUREMENTS AND MAIN RESULTS

Fifty-one nurses responded, and overall nonadherence was 22.3%. Significant differences of adherence were identified when compared with the rates previously reported by physicians in nine of the 19 strategies investigated. The most important reasons for nonadherence were unavailability of resources (37.0%), patient discomfort (8.2%), disagreement with reported trial results (7.8%), fear of potential adverse effects (5.8%), and costs (3.4%). Nurses were more likely (p <.05) to identify patient discomfort (odds ratio, 4.8) and fear of adverse events (odds ratio, 3.3), whereas physicians were more likely to report costs (odds ratio, 5.4) and disagreement with interpretation of trials (odds ratio, 3.7) as reasons for nonadherence.

CONCLUSIONS

Nurses had different levels of adherence than physicians for many nonpharmacologic strategies. The most important barriers to implementation were environment-related. Other reasons for nonadherence show significant variability between nurse and physician opinion leaders, patient-related barriers being significantly more important for nurses. Our findings suggest the need for development of multinational guidelines to reduce variability and the need to include the nursing point of view in these guidelines.

Umbilical cord care in premature infants: the effect of two different cord-care regimens (salicylic sugar powder vs chlorhexidine) on cord separation time and other outcomes

OBJECTIVES

To evaluate the effect of 2 cord-care regimens (salicylic sugar powder vs chlorhexidine as a 4% detergent water solution) on cord separation time and other outcomes in preterm infants.

METHODS

A prospective, randomized, controlled trial was conducted on 244 preterm newborns with a gestational age of <34 weeks and a birth weight of <2500 g. All preterm newborns were enrolled, regardless of their health condition. We excluded from the study infants whose conditions during the first hours of life required the catheterization of umbilical vessels. We also excluded from the general statistical analysis all newborns who had their programmed cord-care regimen changed because of the presence or the suspicion of omphalitis. On arrival at our neonatal intensive care unit or neonatal special care unit, infants were bathed thoroughly with a soap solution (Saugella, Guieu, Italy), and the umbilical cord (UC) was treated with 1 of the 2 antiseptic products chosen for the study. The stump was then folded and covered with common sterile, dry gauze and kept in place by an elastic net. Until cord detachment and at every diaper change, the cord stump was cleaned with sterile water and treated with the same product initially used for first-time cord care. On the third day of life, we obtained an umbilical swab either from the base of the cord or from the umbilicus if the cord was already sloughed. Six weeks after birth, during hospitalization or during a follow-up visit if already discharged, all infants had a medical examination to check the umbilicus area. Cord separation time, changing of the programmed cord-care regimen, death, omphalitis, sepsis, cord bleeding, nurses' opinion on treatments efficacy, and UC colonization were measured.

RESULTS

The cord separation time was significantly lower in infants who were treated with salicylic sugar powder (6 +/- 2 days) than in infants who were treated with chlorhexidine (9 +/- 2 days). The programmed cord-care regimen was changed in a significantly higher number of newborns in the chlorhexidine group (17) than in the salicylic sugar group (3). None of the newborns died, and we found only sporadic cases of sepsis (1 patient in each group) and omphalitis (1 patient in the chlorhexidine group). A significantly higher percentage of nurses were satisfied with the salicylic sugar powder treatment (98%) than with the chlorhexidine treatment (67%), notwithstanding a more frequent occurrence of slight cord scar bleeding in the salicylic sugar group (7.8%) than in the chlorhexidine group (4%). The rate of negative umbilical swabs was significantly higher in infants treated with salicylic sugar powder (73.1%) than with chlorhexidine (53%).

CONCLUSIONS

In neonatal intensive care units and neonatal special care units of developed countries, salicylic sugar powder can be used effectively and safely for UC care of preterm infants.

Percutaneous injury, blood exposure, and adherence to standard precautions: are hospital-based health care providers still at risk?

To examine factors associated with blood exposure and percutaneous injury among health care workers, we assessed occupational risk factors, compliance with standard precautions, frequency of exposure, and reporting in a stratified random sample of 5123 physicians, nurses, and medical technologists working in Iowa community hospitals. Of these, 3223 (63%) participated. Mean rates of hand washing (32%-54%), avoiding needle recapping (29%-70%), and underreporting sharps injuries (22%-62%; overall, 32%) varied by occupation (P<.01). Logistic regression was used to estimate the adjusted odds of percutaneous injury (aOR(injury)), which increased 2%-3% for each sharp handled in a typical week. The overall aOR(injury) for never recapping needles was 0.74 (95% CI, 0.60-0.91). Any recent blood contact, a measure of consistent use of barrier precautions, had an overall aOR(injury) of 1.57 (95% CI, 1.32-1.86); among physicians, the aOR(injury) was 2.18 (95% CI, 1.34-3.54). Adherence to standard precautions was found to be suboptimal. Underreporting was found to be common. Percutaneous injury and mucocutaneous blood exposure are related to frequency of sharps handling and inversely related to routine standard-precaution compliance. New strategies for preventing exposures, training, and monitoring adherence are needed.

SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus

BACKGROUND

Infection control programs were created three decades ago to control antibiotic-resistant healthcare-associated infections, but there has been little evidence of control in most facilities. After long, steady increases of MRSA and VRE infections in NNIS System hospitals, the Society for Healthcare Epidemiology of America (SHEA) Board of Directors made reducing antibiotic-resistant infections a strategic SHEA goal in January 2000. After 2 more years without improvement, a SHEA task force was appointed to draft this evidence-based guideline on preventing nosocomial transmission of such pathogens, focusing on the two considered most out of control: MRSA and VRE.

METHODS

Medline searches were conducted spanning 1966 to 2002. Pertinent abstracts of unpublished studies providing sufficient data were included.

RESULTS

Frequent antibiotic therapy in healthcare settings provides a selective advantage for resistant flora, but patients with MRSA or VRE usually acquire it via spread. The CDC has long-recommended contact precautions for patients colonized or infected with such pathogens. Most facilities have required this as policy, but have not actively identified colonized patients with surveillance cultures, leaving most colonized patients undetected and unisolated. Many studies have shown control of endemic and/or epidemic MRSA and VRE infections using surveillance cultures and contact precautions, demonstrating consistency of evidence, high strength of association, reversibility, a dose gradient, and specificity for control with this approach. Adjunctive control measures are also discussed.

CONCLUSION

Active surveillance cultures are essential to identify the reservoir for spread of MRSA and VRE infections and make control possible using the CDC's long-recommended contact precautions.

Antiseptic chamber-containing hub reduces central venous catheter-related infection: a prospective, randomized study

OBJECTIVE

The hub connecting the catheter and the infusion equipment is a common portal of entry for bacteria causing catheter-related sepsis. We assessed the efficacy of a new hub model (Segur-Lock) that incorporates an antiseptic chamber filled with 3% iodinated alcohol in preventing endoluminal catheter contamination and catheter-related bloodstream infection arising at the hub.

DESIGN

Prospective, randomized, multicenter study.

SETTING

Seven medical and surgical adult intensive care units in Spain.

PATIENTS

A total of 230 patients aged 18 yrs or older requiring the insertion of a nontunneled central venous catheter for >or=6 days from January 1, 1998, to April 30, 1999.

INTERVENTIONS

Patients were randomized at the time of catheter insertion to receive catheters with standard Luer-lock connector (control group, n = 114) or catheters with the new hub model (n = 116).

MEASUREMENTS AND MAIN RESULTS

Skin, catheter tip, and hub cultures were performed at the time the catheter was withdrawn because therapy was terminated or due to suspicion of sepsis, in which case peripheral blood and infusate cultures were simultaneously taken. Catheter-related bloodstream infection was diagnosed in 19 (8.3%) patients. Catheters were more often withdrawn because of suspicion of infection in the control group (43.8%) than in the new hub model group (30.1%, p <.035). The prevalence of culture-positive catheter hubs without associated bacteremia (colonization) was higher in the control group (14.4% vs. 4.3%, p <.001). Catheter-related bloodstream infection from the catheter hub also occurred more frequently in controls than in patients assigned to the new hub model (7% vs. 1.7%; p <.049; relative risk, 4.14; 95% confidence interval, 0.8-19).

CONCLUSIONS

This new antiseptic chamber-containing hub has proved to be effective in preventing endoluminal bacterial colonization and catheter-related bloodstream infection from hub contamination in intensive care unit patients with central venous catheters inserted for >or=6 days.

Effect of education and performance feedback on handwashing: the benefit of administrative support in Argentinean hospitals

BACKGROUND

Patients admitted to hospitals are at risk of acquiring nosocomial infections. Many peer-reviewed studies show that handwashing (HW) significantly reduces hospital infections and mortality. Our objective was to evaluate the effects of HW by health care workers (HCW) before contact with patients in 3 Argentinean hospitals. We performed an observational study of HCW to measure the effect of 2 interventions: education alone and education plus performance feedback.

METHODS

A total of 3 hospitals were studied for adherence to a HW protocol. The observed HCW included physicians, nursing personnel, and ancillary staff. After initial observations to establish baseline rates of HW (phase 1), we evaluated the effect of education alone (phase 2), followed by education plus performance feedback (phase 3). We also evaluated the relationship between the administrative support and HW adherence.

RESULTS

We observed 15,531 patient contacts in 3 hospitals. The baseline rate of HW before contact with patients was 17%. With education, HW before contact with the patients increased to 44% (relative risk 2.65; 95% confidence interval 2.33-3.02; P <.001). Using education and performance feedback HW further increased to 58% (relative risk 1.86; 95% confidence interval 1.38-2.51; P <.001). In the private hospitals where administrative support for the HW program was significantly greater, HW compliance was significantly higher (logistic regression analysis: odds ratio 5.57; 95% confidence interval 5.25-6.31; P <.001).

CONCLUSIONS

In this study, HW policies and education of HCW significantly improved HCW adherence to the HW protocol, however, when performance feedback was incorporated, the HW compliance increased to a greater degree. We identified that administrative support provides a positive influence in efforts to improve HW adherence.

Use of alcohol hand sanitizer as an infection control strategy in an acute care facility

BACKGROUND

Nosocomial infections are a major problem in health care facilities, resulting in extended durations of care, substantial morbidity and mortality, and excess costs. Since alcohol gel hand sanitizers combine high immediate antimicrobial efficacy with ease of use, this study was carried out to determine the effect of the use of an alcohol gel hand sanitizer by caregivers on infection types and rates in an acute care facility. Patients were educated about the study through a poster on the unit, and teachable patients were given portable bottles of the alcohol hand gel for bedside use, along with an educational brochure explaining how and why to practice good hand hygiene.

METHODS

Infection rate and type data were collected in 1 unit of a 498-bed acute care facility for 16 months (February 2000 to May 2001). An alcohol gel hand sanitizer was provided and used by caregivers in the orthopedic surgical unit of the facility during this period.

RESULTS

The primary infection types (more than 80%) found were urinary tract (UTI) and surgical site (SSI) infections. Infection types and rates for the unit during the period the alcohol hand sanitizer (intervention) was used were compared with the infection types and rates for the same unit when the alcohol hand sanitizer was not used (baseline); the results demonstrated a 36.1% decrease in infection rates for the 10-month period that the hand sanitizer was used.

CONCLUSION

This study indicates that use of an alcohol gel hand sanitizer can decrease infection rates and provide an additional tool for an effective infection control program in acute care facilities.

Handwashing among female college students

Handwashing has been recognized as a critical factor in infection control policies. Whereas handwashing compliance among health care workers and school-aged students has been previously documented, practices among college students remain relatively unknown. The objective of this study was to determine handwashing compliance of female college students after using the bathroom. A researcher situated in a toilet stall unobtrusively observed handwashing compliance among 100 female students. Most students (63%) washed their hands, 38% used soap, 32% washed with soap for 5 or more seconds, but only 2% washed their hands with soap for 10 or more seconds. Fewer students left without handwashing when someone else was present in the sink area (9%) than when they were alone (45%) (P =.002). Substantial bacterial colony counts were found on a female bathroom sink faucet and toilet seat confirming the need for programs to increase handwashing compliance. Potential strategies to optimize infection control include harnessing the influence of peer pressure on handwashing and the installation of motion-activated faucets, disposable seat covers, and exit doors that can be pushed open. These results should be confirmed in a larger study that includes both male and female college students.

Rates of hand disinfection associated with glove use, patient isolation, and changes between exposure to various body sites

BACKGROUND

Handwashing is the most effective and economic intervention shown to reduce nosocomial infection rates. However, studies have consistently documented low hand disinfection compliance. Literature regarding the roles that concomitant glove use and isolation precautions play in health care worker compliance with hand disinfection is limited. It is unclear whether workers change gloves and disinfect hands adequately between exposures to different body sites/secretions while caring for a patient.

METHODS

This was an observational study in which hand disinfection compliance and glove use among workers was evaluated in 2 intensive care units at a tertiary care hospital.

RESULTS

Five hundred eighty-nine opportunities for hand disinfection were recorded in 40 hours of observation. Overall compliance was 22.1%. We found a statistically significant, positive association between glove use and subsequent hand disinfection (relative risk [RR], 3.9 [95% CI, 2.5-6.0]; P <.0001). Isolation precautions did not significantly increase disinfection compliance. Only 4.8% (3/63) of workers appropriately complied with disinfection when hands were exposed to multiple body sites/secretions while caring for a patient.

CONCLUSIONS

Glove use increases compliance with hand disinfection. Isolation precautions do not increase compliance. Workers do not appropriately comply with disinfection guidelines when attending to multiple body sites/secretions on the same patient. Compliance with hand disinfection remains low.

Hand antisepsis: evaluation of a sprayer system for alcohol distribution

OBJECTIVE

To evaluate the usefulness of a new alcohol sprayer by comparing it with an individual bottle of alcohol. Patterns of use and perceptions among healthcare personnel were compared for the two products.

DESIGN

Observational study recording the volume of alcohol used and the compliance rate (frequency of hand antisepsis per number of opportunities), and a survey of healthcare workers' perceptions of the different hand hygiene strategies.

SETTING

A 20-bed medical unit in a public hospital in Marseille, France.

PARTICIPANTS

Healthcare workers of an infectious disease unit

INTERVENTIONS

Hand hygiene alcohol systems (sprayer vs individual bottle, 70% ethyl alcohol).

RESULTS

The sprayer was used more frequently than the individual bottle (12.6 vs 9.7 hand washes per day). With the sprayer system, compliance was 91% for physicians, 28% for nurses, and 8% for housekeeping personnel. Alcohol hand antisepsis was preferred to washing hands with soap and water in low-risk situations such as simple entrance into a room (91% vs 36%; P < 10(-6)) or simple contact with a patient (69% vs 40; P < .005). The sprayer system was considered easier to use (95%), more hygienic (90%), and faster (92%), with a better tolerance than the individual bottle.

CONCLUSION

The new alcohol sprayer should improve rapid hand antisepsis.

Influence of role models and hospital design on hand hygiene of healthcare workers

We assessed the effect of medical staff role models and the number of health-care worker sinks on hand-hygiene compliance before and after construction of a new hospital designed for increased access to handwashing sinks. We observed health-care worker hand hygiene in four nursing units that provided similar patient care in both the old and new hospitals: medical and surgical intensive care, hematology/oncology, and solid organ transplant units. Of 721 hand-hygiene opportunities, 304 (42%) were observed in the old hospital and 417 (58%) in the new hospital. Hand-hygiene compliance was significantly better in the old hospital (161/304; 53%) compared to the new hospital (97/417; 23.3%) (p<0.001). Health-care workers in a room with a senior (e.g., higher ranking) medical staff person or peer who did not wash hands were significantly less likely to wash their own hands (odds ratio 0.2; confidence interval 0.1 to 0.5); p<0.001). Our results suggest that health-care worker hand-hygiene compliance is influenced significantly by the behavior of other health-care workers. An increased number of hand-washing sinks, as a sole measure, did not increase hand-hygiene compliance.

Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Combating bacterial resistance in otorhinolaryngology

Bacterial resistance appears to be an ever-increasing problem and is threatening to spiral out of control. The scare caused by the rapid spread of methicillin-resistant Staphylococcus aureus among hospitals in the UK is the most recent. Otorhinolaryngology is deeply involved in this problem, as one of the reasons often cited for increasing bacterial resistance is the use of antibiotics in suspected bacterial infections in ear, nose and throat by primary care physicians. This speciality is also involved in the development of guidelines for antimicrobial use by primary and secondary care. This review attempts to discuss the reason for the development of antimicrobial resistance especially in relation to otorhinolaryngology, what can be done to contain this menace and the surveillance system developed to monitor the trend in the development of bacterial resistance.

Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.