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

Do isolation rooms reduce the rate of nosocomial infections in the pediatric intensive care unit?

PURPOSE

To determine the effect of isolation rooms on the direct spread of nosocomial infections (NIs) owing to cross-colonization in a pediatric intensive care unit (PICU).

MATERIALS AND METHODS

This 6-month comparative clinical study used retrospective data from 1992 (an open single-space unit) and prospective surveillance from 1995 (individual rooms) to assess the effectiveness of the latter design on the control of NIs in critically ill pediatric patients. Patients admitted to the PICU for at least 48 hours underwent a microbiologic survey.

RESULTS

The average number of NIs per patient was higher in 1992 (3.62 +/- 0.7, 78 patients) compared with 1995 (1.87 +/- 0.2, 115 patients). Bacterial NIs were caused by gram-positive cocci (33.3%) and aerobic gram-negative bacilli (66.6%). Fungemia in all cases was caused by Candida albicans. Similarly, length of stay was significantly higher in 1992 compared with 1995 (25 +/- 6 and 11 +/- 6 days, respectively; P <.05). There was a significant reduction of respiratory and urinary tract episodes of NI as well as catheter-related infections in the separate room arrangement.

CONCLUSIONS

Our preliminary analysis suggests a possible beneficial effect of single isolation rooms in reducing NI rate in the PICU. Hence, the influence of room isolation on NIs in pediatric intensive care warrants further investigation.

Action of chlorhexidine digluconate against yeast and filamentous forms in an early-stage Candida albicans biofilm

An in situ method for sensitive detection of differences in the action of chlorhexidine against subpopulations of cells in Candida albicans biofilms is described. Detection relies on monitoring the kinetics of propidium iodide (PI) penetration into the cytoplasm of individual cells during dosing with chlorhexidine. Accurate estimation of the time for delivery of the dosing concentration to the substratum was facilitated by using a flow cell system for which transport to the interfacial region was previously characterized. A model was developed to quantify rates of PI penetration based on the shape of the kinetic data curves. Yeast were seeded onto the substratum, and biofilm formation was monitored microscopically for 3 h. During this period a portion of the yeast germinated, producing filamentous forms (both hyphae and pseudohyphae). When the population was subdivided on the basis of cell morphology, rates of PI penetration into filamentous forms appeared to be substantially higher than for yeast forms. Based on the model, rates of penetration were assigned to individual cells. These data indicated that the difference in rates between the two subpopulations was statistically significant (unpaired t test, P < 0.0001). A histogram of rates and analysis of variance indicated that rates were approximately equally distributed among different filamentous forms and between apical and subapical segments of filamentous forms.

Assessment of handwashing practices with chemical and microbiologic methods: preliminary results from a prospective crossover study

BACKGROUND

Handwashing (HW) by clinical staff is the single most important measure for preventing transmission of nosocomial infection (NI). The primary objectives of this study were to improve the motivation and awareness of the importance of HW practices among health care workers (HCWs) and to assess the effectiveness of a new chemical system in checking HW compliance. In addition, we evaluated the efficacy and tolerability of 2 soap solutions used during regular working hours by HCWs at our institution.

METHOD

A preliminary short training course was performed to promote HW compliance and awareness. We chose 2 surgical wards at our 1200-bed teaching hospital. Sampling of hands was conducted weekly during routine activities of HCWs without advance warning. We used the staff list as a sampling frame to select subjects. Data were collected anonymously. On the basis of a crossover study design, a plain soap and one containing 4% chlorhexidine gluconate (CHG) were used alternatively in each ward for 4 consecutive months. Hand samples were evaluated with microbiologic cultures and with a commercially available kit that measures adenosine triphosphate (ATP) bioluminescence. As additional process indicators, we examined the amount of hand soap and CHG solution distributed and rate of NIs.

RESULTS

A total of 74 HCWs were evaluated for hand contamination. During the 4-month study, we found a significant reduction in colony-forming unit counts (P <.008) and ATP levels (P <.002) compared with baseline values. The results showed a positive correlation (r = 0.68, P <.0001) between the microbial counts detected by standard culture and ATP levels measured with the commercial kit. Plain soap (P <.003) was more effective than CHG in reducing colony-forming unit counts among HCWs in the vascular surgery ward. We documented a reduction in the NI rate and an increase in the consumption of soap and paper towels.

CONCLUSION

HW compliance improved during the study period among HCWs. The method to measure ATP bioluminescence is simple and easy to perform and provides reliable results within a few minutes of sampling hands. It can be used extensively to test HW compliance among HCWs.

Sustained ex vivo skin antiseptic activity of chlorhexidine in poly(epsilon-caprolactone) nanocapsule encapsulated form and as a digluconate

In this work, the sustained bactericidal activity of chlorhexidine base loaded poly(epsilon-caprolactone), PCL, nanocapsules against Staphylococcus epidermidis inoculated onto porcine ear skin was investigated. Drug loaded nanocapsules were prepared by the interfacial polymer deposition following solvent displacement method, then characterized by photon correlation spectroscopy, electrophoretic measurements, transmission and scanning electron microscopy. Antimicrobial activity of these colloidal carriers was evaluated (i) in vitro against eight strains of bacteria, and (ii) ex vivo against Staphylococcus epidermidis inoculated for 12 h onto porcine ear skin surface treated for 3 min either with 0.6% chlorhexidine base loaded or unloaded nanocapsules suspended in hydrogel, or 1% chlorhexidine digluconate aqueous solution. Chlorhexidine absorption into the stratum corneum (SC) was evaluated by the tape-stripping method. The results showed that chlorhexidine nanocapsules in aqueous suspension having a 200-300 nm size and a positive charge exhibited similar minimum inhibitory concentrations against several bacteria with chlorhexidine digluconate aqueous solution. Ex vivo, there was a significant reduction in the number of colony forming units (CFUs) from 3-min treated skin with chlorhexidine nanocapsule suspension (5 to <1 log(10)) compared to chlorhexidine digluconate solution (5 to 2.02 log(10)) after a 8-h artificial contamination. After a 12-h artificial contamination, both formulations failed to achieve a 5 log(10) reduction. Furthermore, from a 3-min treatment with an identical applied dose and a subsequent 12-h artificial contamination, a residual chlorhexidine concentration in the SC was found to be three-fold higher with chlorhexidine nanocapsule suspension than with chlorhexidine digluconate solution. Interestingly, nanocapsules were shown in porcine skin follicles. Consequently, a topical application of chlorhexidine base-loaded positively charged nanocapsules in an aqueous gel achieved a sustained release of bactericide against Staphylococcus epidermidis for at least 8 h. Enhancement of drug delivery by mediating a more direct and prolonged contact between the carrier and (i) bacteria, (ii) skin surface, and (iii) skin follicles was assumed.

Influence of the hospital environment on yeast colonization in nursing students

Fungemias have increased in recent decades, with high indices of morbidity and mortality. The agents of fungal infection isolated most often are yeasts, which can be acquired by direct contact with already colonized individuals. The present study aimed to detect yeast colonization in nursing students, and to study the possible influence of the hospital environment on colonization. The nasal cavities and hands of 22 students were sampled before and after a 62-day hospital training period. The yeast colonies that developed were identified using standard techniques. In total, 47 yeast samples were isolated, which were part of the normal flora of 15 (68%) students. Candida albicans was the species isolated most often (P < 0.05), comprising 59.6% of all isolates. The hospital environment affected colonization, as following the training period there was a significant increase in the number of microorganisms isolated, and also replacement of less virulent species by C. albicans. Our results are important because hospital infections of fungal origin are emerging today, and cross-transmission appears to be an important factor. In this situation, prophylactic measures are necessary to control the nosocomial microbial flora and thus reduce the incidence of hospital infections.

The impact of alcohol hand sanitizer use on infection rates in an extended care facility

BACKGROUND

Nosocomial infections are a major problem in health care facilities, resulting in extended durations of care and substantial morbidity. 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 alcohol gel hand sanitizer by caregivers on infection types and rates in an extended care facility.

METHOD

Infection rate and type data were collected in a 275-bed extended care facility for 34 months (July 1997 to May 2000), during which an alcohol gel hand sanitizer was used by the caregivers in 2 units of the facility.

RESULTS

The primary infection types found were urinary tract with Foley catheter, respiratory tract, and wound infections. Comparison of the infection types and rates for the units where hand sanitizer was used with those for the control units where the hand sanitizer was not used showed a 30.4% decrease in infection rates for the 34-month period in the units where 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.

Impact of teaching interventions on nurse compliance with hand disinfection

The impact of teaching interventions and the availability of additional dispensers for alcoholic hand disinfection was measured during three study periods. A nursing care system of relevant nursing interventions was found to be a useful tool for the assessment of compliance with hand hygiene requirements if combined with an analysis of hand disinfectant use. This study shows that compliance with hand disinfection can be improved through targeted teaching and supportive structural improvements, and that this positive impact may persist even after targeted teaching activities have ended.

Nonantibibiotic measures for the prevention of Gram-positive infections

While Gram-negative bacteria remain a leading cause of nosocomial infections such as ventilator-associated pneumonia and catheter-associated urinary tract infections, Gram-positive cocci are now responsible for a large majority of surgical site and bloodstream infections. A shift has occurred during the last decade and multidrug-resistant micro-organisms have become predominant in most referral centers. Severe infections with Gram-positive micro-organisms such as methicillin-resistant Staphylococcus aureus, coagulase-negative staphylococci, vancomycin-resistant enterococci, penicillin-resistant Streptococcus pneumoniae and, more recently, glycopeptide intermediate S. aureus are now regularly reported to be associated with increased morbidity and represent a true health problem in many institutions. The importance of nonantimicrobial measures to prevent infections and further spread is reviewed in this paper. New evidence of the effectiveness of basic infection control measures that have been regarded of little importance during the last two decades by the exponential progress of technologically sophisticated medicine, is discussed.

An estimate of the current risk of transmitting blood-borne infections through blood transfusion in Italy

We conducted a retrospective cohort study to estimate the incidence of major blood-borne agents among Italian blood donors and calculated the risk of infection among blood recipients using the 'incidence/window period model'. The study was conducted among 46 180 blood donors enrolled in six blood centres between 1994 and 1999. During follow-up, seven new infections were confirmed: three donors seroconverted for anti-human immunodeficiency virus (HIV); two for anti-hepatitis C virus (HCV); and two showed hepatitis B surface antigen (HBsAg) reactivity; no cases of syphilis were observed. The incidence rates per 100 000 person/years were: 4.06 (95% CI: 0.82-11.85) for HIV; 2.41 (95% CI: 0.29-8.70) for HCV; and 2.70 (95% CI: 0.32-9.77) for HBsAg; the incidence for total hepatitis B virus (HBV) infection was 9.77 per 100 000 person/years (95% CI: 1.16-35.36). The estimated risk of an infectious blood unit not being detected was: 2.45 (95% CI: 0.13-12.33) per 1 million units for HIV; 4.35 (95% CI: 0.30-22.39) for HCV; and 15.78 (95% CI: 1.16-84.23) for HBV. Overall, an estimated 22.58 per 1 million units are infected. In Italy, the risk of transfusion-transmitted infections is low and is similar to that in other western countries. The introduction of new more sensitive screening tests could reduce the residual risk of transfusion-transmitted infection by 40-80%.

Limited impact of sustained simple feedback based on soap and paper towel consumption on the frequency of hand washing in an adult intensive care unit

OBJECTIVE

To determine whether hand washing would increase with sustained feedback based on measurements of soap and paper towel consumption.

DESIGN

Prospective trial with a nonequivalent control group.

SETTING

Open multibed rooms in the Omaha Veterans Affairs Medical Center's Surgical Intensive Care Unit (SICU) and Medical Intensive Care Unit (MICU).

SUBJECTS

Unit staff.

INTERVENTION

Every weekday from May 26 through December 8, 1998, we recorded daytime soap and paper towel consumption, nurse staffing, and occupied beds in the SICU (intervention unit) and the MICU (control unit) and used these data to calculate estimated hand washing episodes (EHWEs), EHWEs per occupied bed per hour, and patient-to-nurse ratios. In addition, from May 26 through June 26 (baseline period) and from November 2 through December 8 (follow-up period), live observers stationed daily for random 4-hour intervals in the MICU and the SICU counted actual hand washing episodes (CHWEs). The intervention consisted of posting in the SICU, but not in the MICU, a graph showing the weekly EHWEs per occupied bed per hour for the preceding 5 weeks.

RESULTS

Directly counted hand washing fell in the SICU from a baseline of 2.68+/-0.72 (mean +/- standard deviation) episodes per occupied bed per hour to 1.92+/-1.35 in the follow-up period. In the MICU, episodes fell from 2.58+/-0.95 (baseline) to 1.74+/-0.69. In the MICU, the withdrawal of live observers was associated with a decrease in estimated episodes from 1.36+/-0.49 at baseline to 1.01+/-0.36, with a return to 1.16+/-0.50 when the observers returned. In the SICU, a similar decrease did not persist throughout a period of feedback. Estimated hand washing correlated negatively with the patient-to-nurse ratio (r = -0.35 for the MICU, r = -0.46 for the SICU).

CONCLUSIONS

Sustained feedback on hand washing failed to produce a sustained improvement. Live observers were associated with increased hand washing, even when they did not offer feedback. Hand washing decreased when the patient-to-nurse ratio increased.

Clinical review: non-antibiotic strategies for preventing ventilator-associated pneumonia

Prevention of nosocomial pneumonia (NP) is the most important step towards reducing hospitalisation costs. The non-antibiotic prevention strategies include measures related to the correct care of the artificial airway, strategies related directly to the maintenance of the mechanical ventilator and the equipment, strategies focused in the gastrointestinal tract, and strategies related to the position of the intubated patients. While simple methods should be part of routine practice, the use of more invasive and expensive preventive measures should be used only in patients who are at high risk of NP. The appropriate use of these techniques can reduce the incidence of NP in intensive care unit patients.

Hand washing and physicians: how to get them together

OBJECTIVE

To determine the motivating and behavioral factors responsible for improving compliance with hand washing among physicians.

DESIGN

Five unobtrusive, observational studies recording hand washing after direct patient contact, with study results reported to physicians.

SETTING

A 450-bed hospital in a health maintenance organization with an 18-bed medical-surgical intensive care unit (ICU) and a 12-bed cardiac care unit.

METHODS

An infectious disease physician met individually with participants to report study results and obtain a commitment to hand washing guidelines. Follow-up interviews were conducted to evaluate behavioral factors and educational programs. Hand washing study results were presented to all staff physicians by live and videotaped inservice presentations and electronic mail (e-mail) newsletters. The importance of influencing factors and the educational effectiveness of the hand washing program were evaluated.

RESULTS

Five observational hand washing studies were conducted in the ICU between April 1999 and September 2000. Rates of physician compliance with hand washing were 19%, 85%, 76%, 74%, and 68%, respectively. There were 71 initial encounters and 55 follow-up interviews with the same physicians. Physician interviews revealed that 73% remembered the initial encounter, 70% remembered the hand washing inservice presentations, and 18% remembered the e-mail newsletters. Personal commitment and meeting with an infectious disease physician had the most influence on hand washing behavior. Direct inservice presentations (either live or videotaped) had more influence than did e-mail information. Rates of ventilator-associated pneumonia did not significantly change before and during the study periods. A decrease in the rate of central-line-related bloodstream infections from 3.2 to 1.4 per 1,000 central-line days was found, but could not be solely attributed to improved physician compliance with hand washing.

CONCLUSIONS

Physician compliance with hand washing can improve. Personal encounters, direct meetings with an infectious disease physician, and videotaped presentations had the greatest impact on physician compliance with hand washing at our medical center, compared with newsletters sent via e-mail. Local data on compliance with hand washing and physician involvement are factors to be considered for physician hand washing compliance programs in other medical centers.

Infection control in the ICU

Nosocomial infections (NIs) now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to ICUs. The most common causes are pneumonia related to mechanical ventilation, intra-abdominal infections following trauma or surgery, and bacteremia derived from intravascular devices. This overview is targeted at ICU physicians to convince them that the principles of infection control in the ICU are based on simple concepts and that the application of preventive strategies should not be viewed as an administrative or constraining control of their activity but, rather, as basic measures that are easy to implement at the bedside. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. The principles of general preventive measures such as the implementation of standard and isolation precautions, and the control of antibiotic use are reviewed. Specific practical measures, targeted at the practical prevention and control of ventilator-associated pneumonia, sinusitis, and bloodstream, urinary tract, and surgical site infections are detailed. Recent data strongly confirm that these strategies may only be effective over prolonged periods if they can be integrated into the behavior of all staff members who are involved in patient care. Accordingly, infection control measures are to be viewed as a priority and have to be integrated fully into the continuous process of improvement of the quality of care.

Consequences of inaction: importance of infection control practices

The increasing prevalence of antimicrobial-resistant pathogens in health care facilities is due in large part to overuse of antibiotics and poor compliance with recommended infection control practices. To control the spread of such pathogens, health care facilities must reduce overuse and abuse of antibiotics, and they must implement new multidisciplinary programs to improve hand hygiene practices among health care workers and improve compliance with recommended barrier precautions.

Nosocomial transmission of antibiotic-resistant microorganisms

The spread of nosocomially acquired, antibiotic-resistant microorganisms has grown dramatically over the past 20 years and has increasingly attracted the attention of academic inquiry. This article reviews recent epidemiological data about the trends and patterns of nosocomial transmission, presents clinical studies investigating mechanisms of cross-transmission, and discusses recent literature on preventive strategies aimed at reducing hand-carriage of antibiotic-resistant pathogens.

Compliance with hand disinfection and its impact on hospital-acquired infections

Hand hygiene prevents cross-infection in hospitals, but adherence to guidelines is poor among healthcare workers. Although some interventions to improve compliance have been successful, none had achieved lasting improvement until very recently. Reasons for non-compliance with recommendations occur at individual, group and institutional levels. The complexity of the process of behavioural change would suggest that the application of multimodal, multidisciplinary strategies are necessary. Both easy access to hand hygiene in a timely fashion and skin protection appear necessary prerequisites for satisfactory hand hygiene behaviour. Alcohol-based hand-rub may be superior to traditional handwashing as it requires less time, acts faster, irritates hands less often, and recently proved significantly to contribute to sustained improvement in compliance associated with decreased infection rates. This paper reviews barriers to appropriate hand hygiene and describes the results of the first successful experience of sustained hand hygiene promotion and its effectiveness on hospital-acquired infection.

Assessment of two hand hygiene regimens for intensive care unit personnel

OBJECTIVE

To compare skin condition and skin microbiology among intensive care unit personnel using one of two randomly assigned hand hygiene regimens: a 2% chlorhexidine gluconate (CHG)-containing traditional antiseptic wash and a waterless handrub containing 61% ethanol with emollients (ALC).

DESIGN

Prospective, randomized clinical trial.

SETTING

Two critical care units (medical and surgical) in a large, metropolitan academic health center in Manhattan.

SUBJECTS

Fifty staff members (physicians, nurses, housekeepers, respiratory therapists) working full time in the intensive care unit.

INTERVENTIONS

One of two hand hygiene regimens randomly assigned for four consecutive weeks.

MEASUREMENTS AND MAIN RESULTS

The two outcomes were skin condition (measured by two tools: Hand Skin Assessment form and Visual Skin Scaling form) and skin microbiology. Samples were obtained at baseline, on day 1, and at the end of wks 2 and 4. Participants in the ALC group had significant improvements in the Hand Skin Assessment scores at wk 4 (p = 0.04) and in Visual Skin Scaling scores at wks 3 (p = 0.01) and 4 (p = 0.0005). There were no significant differences in numbers of colony-forming units between participants in the CHG or ALC group at any time period. The ALC regimen required significantly less time than the CHG regimen (mean: 12.7 secs and 21.1 secs, respectively; p = 0.000) and resulted in a 50% reduction in material costs.

CONCLUSIONS

Changes in hand hygiene practices in acute care settings from the traditional antiseptic wash to use of plain, mild soap and an alcohol-based product should be considered. Further research is needed to examine the association between use of antiseptic products for hand hygiene of staff and reductions in nosocomial infection rates among patients.

Nosocomial coagulase negative staphylococcal (CoNS) catheter-related sepsis in preterm infants: definition, diagnosis, prophylaxis, and prevention

Nosocomial infections with coagulase negative staphylococcus (CoNS) are a frequent and significant cause of morbidity in the preterm infant. Infections diagnosed after the first 72 hours of life are arbitrarily deemed to be "nosocomial." There are many difficulties encountered in efforts to evaluate and compare nosocomial sepsis in the NICU. An issue of primary concern is the lack of uniformity in the definition of sepsis in the NICU. Based on the frequency of positive blood cultures in infants less than 1000 g, it appears reasonable to evaluate methods for the prevention of nosocomial sepsis. These include prophylactic antibiotic administration, antiseptic impregnated catheters, and the use of an antibiotic lock technique.

Increasing prevalence of antimicrobial resistance in intensive care units

The unique nature of the intensive care unit (ICU) environment makes this part of the hospital a focus for the emergence and spread of many antimicrobial-resistant pathogens. There are ample opportunities for the cross-transmission of resistant bacteria from patient to patient, and patients are commonly exposed to broad-spectrum antimicrobial agents. Rates of resistance have increased for most pathogens associated with hospital-acquired infections among ICU patients, and rates are almost universally higher among ICU patients than non-ICU patients. Likewise, ICU patients hospitalized longer (i.e., >7 days) are two- to three-fold more likely to be infected with a pathogen possessing an antimicrobial-resistant phenotype of concern. However, there are many opportunities to prevent the emergence and spread of these resistant pathogens through improved use of established infection control measures (patient isolation, handwashing, glove use, and appropriate gown use) and implementation of a systematic review of antimicrobial use. (Crit Care Med 2001; 29[Suppl.]: N64-N68)

Infection control measures to limit antimicrobial resistance

Increasing antimicrobial resistance has resulted in a rapidly decreasing array of therapeutic options for infections in the critical care setting. Reports of reduced susceptibility to vancomycin in Staphylococcus aureus raise the possibility of patients being infected with a virulent pathogen for which most antibiotics are ineffective. Infection control methods to contain resistance, exclusive of antimicrobial restrictions, focus on surveillance to identify carriers of resistant organisms, prevention of nosocomial infections, adequate hand hygiene, isolation of patients who harbor resistant organisms, and the use of barrier techniques such as gowns and gloves. Surveillance using clinical isolates alone is inadequate for the identification of the majority of patients who carry resistant organisms. However, it is unclear what intensity of surveillance is needed to control the spread of these organisms in the intensive care unit in nonoutbreak situations. Attempts at eradicating carriage are often unsuccessful when there is extranasal colonization with methicillin-resistant S. aureus. Transmission of resistant organisms is primarily the result of transient contamination of healthcare workers' hands. Adequate handwashing, isolation of carriers, and barrier techniques are all necessary for containing resistance within the intensive care unit, however, compliance with these measures can be compromised by high staff turnover and heavy workload.

Lapses in measures recommended for preventing hospital-acquired infection

This study was carried out in a rural tertiary care referral hospital in central India, to ascertain lapses made by people caring for neonates in measures recommended for preventing hospital-acquired infections. Unobtrusive observation of the healthcare personnel (doctors, nurses, mothers and hospital attendants) during care of the newborn was undertaken. Lapse in handwashing by healthcare personnel was observed around 41% of the time, although mothers practiced their instructions meticulously. Lapses in methods of hand drying were seen around 7-8% of the time, in those who did wash their hands. Gloves were not used around 21% of the time, when they should have been; and of those using gloves, they were unsterile in around 22% cases. At delivery babies were received unhygienically on approximately 67% of occasions observed. Lapses during cord care ranged from 14.2% to 28.6% and during resuscitation from 16.6% to 60% of occasions. An uncleaned stethoscope was used 75% of the time. The practice of putting a finger in the baby's mouth was observed on 18 occasions. Considerable lapses by all, in every measure recommended for the prevention of hospital-acquired infections were observed. It is concluded that nothing other than an individual's commitment is likely to be successful in preventing hospital-acquired infections.

A hospital epidemic of vancomycin-resistant Enterococcus: risk factors and control

OBJECTIVE

To determine risk factors for vancomycin-resistant Enterococcus (VRE) colonization during a hospital outbreak and to evaluate Centers for Disease Control and Prevention (CDC)-recommended control measures.

DESIGN

Epidemiological study involving prospective identification of colonization and a case-control study.

SETTING

A university hospital.

PARTICIPANTS

Patients on eight wards involved in outbreak from late 1994 through early 1995.

METHODS

Cases were matched by ward and culture date with up to two controls. Risk factors were evaluated with four multivariate models using conditional logistic regression. The first evaluated proximity to other VRE patients and isolation status. The second evaluated proximity to unisolated VRE cases and three variables independently predictive after adjustment for proximity. The third evaluated seven significant univariate predictors in addition to proximity to unisolated VRE in backward, stepwise logistic regression. The fourth assessed proximity to VRE with all other variables collected, clustered in a principal components analysis. Pulsed-field gel electrophoresis was performed to assess clonality of two outbreak strains.

RESULTS

The incidence of transmission declined significantly after CDC guidelines were implemented. Proximity to unisolated VRE cases during the prior week was a significant predictor of acquisition in each of four multivariate models. Other significant risk factors in multivariate models included a history of major trauma and treatment with metronidazole. Pulsed-field gel electrophoresis confirmed the clonality of two outbreak strains.

CONCLUSIONS

VRE was transmitted between patients during a hospital epidemic, with proximity to previously unisolated VRE patients being an important risk factor. Weekly surveillance cultures and contact isolation of colonized patients significantly reduced spread

An organizational climate intervention associated with increased handwashing and decreased nosocomial infections

Handwashing practices are persistently suboptimal among healthcare professionals and are also stubbornly resistant to change. The purpose of this quasi-experimental intervention trial was to assess the impact of an intervention to change organizational culture on frequency of staff handwashing (as measured by counting devices inserted into soap dispensers on four critical care units) and nosocomial infections associated with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). All staff in one of two hospitals in the mid-Atlantic region received an intervention with multiple components designed to change organizational culture; the second hospital served as a comparison. Over a period of 8 months, 860,567 soap dispensings were recorded, with significant improvements in the study hospital after 6 months of follow-up. Rates of MRSA were not significantly different between the two hospitals, but rates of VRE were significantly reduced in the intervention hospital during implementation.

Monitoring adherence to Standard Precautions

BACKGROUND

Health care workers (HCWs) do not consistently follow Standard Precautions (SP). This is a serious problem because inadequate compliance is associated with increased blood exposure thus predisposing HCWs to bloodborne pathogen transmission.

METHODS

The primary goal of this study was to identify institutional factors associated with adequacy of HCW training to monitor coworkers' adherence to SP. Surveys were sent to all community hospital infection control practitioners (ICPs) in Iowa and Virginia. ICPs indicated on a 5-point Likert scale, ranging from strongly disagree to strongly agree, their assessment of HCW training adequacy. Data from another statewide survey of HCWs in Iowa were assessed to validate this outcome measure. Multiple logistic regression models were developed to identify predictors of assessed training adequacy. Independent variables included methods of education, training, approaches to SP compliance assessment, provision of SP reinforcement by clinical leaders, and organizational data.

RESULTS

A total of 149 institutions (62%) participated. Models of training program adequacy varied across occupations. Management commitment to SP training programs, leadership support, frequency of providing bloodborne pathogen information, and safety climate were important institutional predictors of assessed adequacy of training. The outcome was validated by demonstrating an association between the ICPs' assessment of HCW training and workers who reported having sufficient information to comply with SP (P <.05).

CONCLUSIONS

Institutional safety climate, leadership support, and frequency of education play an important role in HCWs' training adequacy to monitor coworkers' adherence to SP. Occupational groups should be considered independently when strategies are developed to increase compliance. Interventions based on modifiable factors identified by this study may reduce bloodborne pathogen exposure among HCWs.

The role of gown and glove isolation and strict handwashing in the reduction of nosocomial infection in children with solid organ transplantation

OBJECTIVE

Nosocomial infection is an important contributor to morbidity and mortality in pediatric solid organ transplantation. The relative effect of protective gown and glove isolation was compared with strict handwashing in pediatric intensive care unit (PICU) patients with solid organ transplantation.

DESIGN/SETTING

A prospective, randomized design was used; children in a 23-bed PICU with solid organ transplantation were enrolled into a gown and glove protective isolation protocol or a strict handwashing protocol.

PATIENTS

All children admitted to the PICU immediately after solid organ transplantation, excluding renal transplantation, and at subsequent readmissions to the PICU were eligible for the study. Children with current infection or known exposure to varicella were excluded from the study initially or at readmission.

INTERVENTIONS

By using a block randomization design based on organ transplanted, age, and initial admission vs. readmission, each patient was randomized to either strict handwashing or protective gown and glove isolation intervention groups.

MEASUREMENTS

We analyzed demographics, infection outcomes (defined according to Centers for Disease Control criteria), and monitoring of patient contacts in compliance with protocols.

RESULTS

The infection rate in the overall PICU population did not change significantly from the year before the study compared with during the study (2.1 per 100 vs. 1.95 per 100 patient days; p =.4) The infection rate in the gown and glove group (2.3 per 100 patient days) was reduced significantly compared with the prestudy infection rate in the transplant population (4.9 per 100 patient days; p =.0008). Strict handwashing also significantly reduced the infection rate in the transplant population (3.0 per 100 patient days; p =.008). Compliance with gowning and gloving was 82% and compliance with handwashing was 76% (compared with 22% before study [p <.0001] and 52% after the study [p <.0001]). Despite an increased mean length of stay in the PICU in the gown and glove group (p =.014), there was a trend toward reduction in the incidence of infection (Fisher's exact test, p =.07; odds ratio,.76) in the gown and glove group.

CONCLUSIONS

Increased compliance with handwashing was associated with a reduction in nosocomial infections, and gown and glove isolation appeared to have an additional protective effect. Some nosocomial infections may be preventable in the pediatric solid organ transplantation population.

Hygiene of the skin: when is clean too clean?

Skin hygiene, particularly of the hands, is a primary mechanism for reducing contact and fecal-oral transmission of infectious agents. Widespread use of antimicrobial products has prompted concern about emergence of resistance to antiseptics and damage to the skin barrier associated with frequent washing. This article reviews evidence for the relationship between skin hygiene and infection, the effects of washing on skin integrity, and recommendations for skin care practices.

Improving adherence to hand hygiene practice: a multidisciplinary approach

Hand hygiene prevents cross-infection in hospitals, but health-care workers' adherence to guidelines is poor. Easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol- based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating, and contribute to sustained improvement in compliance associated with decreased infection rates. This article reviews barriers to appropriate hand hygiene and risk factors for noncompliance and proposes strategies for promoting hand hygiene.

The impact of hospital-acquired bloodstream infections

Nosocomial bloodstream infections are a leading cause of death in the United States. If we assume a nosocomial infection rate of 5%, of which 10% are bloodstream infections, and an attributable mortality rate of 15%, bloodstream infections would represent the eighth leading cause of death in the United States. Because most risk factors for dying after bacteremia or fungemia may not be changeable, prevention efforts must focus on new infection-control technology and techniques.

Hand Hygiene Revisited: Lessons from the Past and Present

Hand hygiene is the most effective measure to prevent cross-transmission of microorganisms. Adequate hand hygiene can be achieved by standard handwashing--with water alone or with soap--or by the use of an alcohol-based hand-rub solution. Despite considerable efforts, compliance with this simple infection-control measure remains low. Factors predicting non-compliance have been extensively studied, and include physician status, procedures associated with a high risk of cross-transmission, and an important workload. Future interventions to improve compliance should consider complex behavioral theories and the use of multimodal and multidisciplinary strategies. We believe that one of the key components of these interventions should be the wide use of alcohol-based hand-rub, which is microbiologically effective and less time-consuming than standard handwashing.

Vancomycin-resistant enterococci

After they were first identified in the mid-1980s, vancomycin-resistant enterococci (VRE) spread rapidly and became a major problem in many institutions both in Europe and the United States. Since VRE have intrinsic resistance to most of the commonly used antibiotics and the ability to acquire resistance to most of the current available antibiotics, either by mutation or by receipt of foreign genetic material, they have a selective advantage over other microorganisms in the intestinal flora and pose a major therapeutic challenge. The possibility of transfer of vancomycin resistance genes to other gram-positive organisms raises significant concerns about the emergence of vancomycin-resistant Staphylococcus aureus. We review VRE, including their history, mechanisms of resistance, epidemiology, control measures, and treatment.

A comparison of soap, alcohol and glove use during the nappy-changing procedure in a special care baby unit

This study was conducted in a special care baby unit (SCBU) in a district general hospital and concentrated on hand decontamination and glove-wearing during the nappy-changing procedure. The aims were to determine whether or not nurses were adhering to existing infection control policies and guidelines, and to determine the most appropriate product to be used for hand decontamination.

Nurses were observed carrying out nappy changes to determine their existing hand-washing and glove-wearing practices. A microbiological analysis of nurses' hands during the nappy change was performed in order to compare the effectiveness of soap, alcohol, and glove use in eliminating bacteria from the hands.

The observation study demonstrated that not all nurses were adhering to existing infection control policies and guidelines. The microbiological analysis found that on the majority of occasions, alcohol was better than soap at removing bacteria from the hands but that gloves provided the best protection overall for both babies and nurses by preventing the acquisition of bacteria.

Together these findings suggest that nurses' hands may be providing a route for the transmission of hospital-acquired infection in the SCBU. Ideally, nurses should be wearing gloves during the nappy-changing process and using alcohol to decontaminate their hands.

Vancomycin-resistant enterococci

After they were first identified in the mid-1980s, vancomycin-resistant enterococci (VRE) spread rapidly and became a major problem in many institutions both in Europe and the United States. Since VRE have intrinsic resistance to most of the commonly used antibiotics and the ability to acquire resistance to most of the current available antibiotics, either by mutation or by receipt of foreign genetic material, they have a selective advantage over other microorganisms in the intestinal flora and pose a major therapeutic challenge. The possibility of transfer of vancomycin resistance genes to other gram-positive organisms raises significant concerns about the emergence of vancomycin-resistant Staphylococcus aureus. We review VRE, including their history, mechanisms of resistance, epidemiology, control measures, and treatment.

Hand hygiene-beliefs or science?

Over a century has passed since Ignaz P. Semmelweis demonstrated the association between hand hygiene and nosocomial infections, but this simple procedure is still not recognized by many healthcare workers as one of the most important measures to prevent cross-transmission of microorganisms. A relatively large amount of research has been done, in particular to try to understand why compliance remains so low, in order to implement successful promotion campaigns. This research has generated a fair amount of strong scientific data which are sometimes misunderstood and misused because of myths or certain beliefs. Observational or intervention studies have consistently shown a number of risk factors associated with non-compliance, such as high workload, professional category, or type of ward. Others are thought to be barriers to adequate compliance but have not yet been properly assessed. These include skin irritation due to hand hygiene agents, lack of knowledge of hand hygiene recommendations, or lack of institutional policy. Future interventions to promote hand hygiene will need to address these risk factors, and target the individual healthcare worker, as well as the group or institution if a significant degree of success is to be achieved.

Replace hand washing with use of a waterless alcohol hand rub?

Hand hygiene is one of the basic components of any infection control program and is frequently considered synonymous with hand washing. However, health care workers frequently do not wash their hands, and compliance rarely exceeds 40%. Hand rubbing with a waterless, alcohol-based rub-in cleanser is commonly used in many European countries instead of hand washing. Scientific evidence and ease of use support employment of a hand rub for routine hand hygiene. It is microbiologically more effective in vitro and in vivo, it saves time, and preliminary data demonstrate better compliance than with hand washing. Therefore, a task force comprising experts from the Centers for Disease Control and Prevention and from professional societies is designing guidelines for the use of a hand rub in the United States. Today, most countries of Northern Europe recommend a hand rub for hand hygiene unless the hands are visibly soiled. Side effects are rare and are mainly related to dryness of the skin. This review evaluates the scientific and clinical evidence that support the use of alcohol-based hand rubs in health care facilities as a new option for hand hygiene.

Skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing versus hand antisepsis with an alcoholic hand gel

OBJECTIVE

To compare the frequency of skin irritation and dryness associated with using an alcoholic-hand-gel regimen for hand antisepsis versus using soap and water for hand washing.

DESIGN

Prospective randomized trial with crossover design. Irritation and dryness of nurses' hands were evaluated by self-assessment and by visual assessment by a study nurse. Epidermal water content of the dorsal surface of nurses' hands was estimated by measuring electrical capacitance of the skin.

SETTING

Miriam Hospital, a 200-bed university-affiliated teaching hospital.

PARTICIPANTS

Thirty-two nurses working on three hospital wards participated in the trial, which lasted 6 weeks.

RESULTS

Self-assessment scores of skin irritation and dryness decreased slightly during the 2 weeks when nurses used the alcoholic-hand-gel regimen (mean baseline score, 2.72; mean final score, 2.0; P=.08) but increased substantially during the 2 weeks when nurses used soap and water (mean baseline score, 2.0; mean final score, 4.8; P<.0001). Visual assessment scores by the study nurse of skin irritation and dryness did not change significantly when the alcoholic-hand-gel regimen was used (mean baseline and final scores were both 0.55), but scores increased substantially when nurses used soap and water (baseline score, 0.59; mean final score, 1.21; P=.05). Epidermal water content of the dorsal surface of nurses' hands changed little when the alcoholic-hand-gel regimen was used (mean+/-standard deviation baseline electrical capacitance reading, 24.8+/-6.8; mean final reading, 25.7+/-7.3), but decreased significantly (skin became dryer) with soap-and-water hand washing (mean baseline, 25.9+/-7.5; mean final reading, 20.5+/-5.4; P=.0003).

CONCLUSIONS

Hand antisepsis with an alcoholic-hand-gel regimen was well tolerated and did not result in skin irritation and dryness of nurses' hands. In contrast, skin irritation and dryness increased significantly when nurses washed their hands with the unmedicated soap product available in the hospital. Newer alcoholic hand gels that are tolerated better than soap may be more acceptable to staff and may lead to improved hand-hygiene practices.

Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit

We investigated whether rubbing with an alcohol solution increases compliance with hand disinfection in a medical intensive care unit (MICU). During a first period (P1), hand disinfection was achieved only through conventional washing, whereas during a second period (P2), hand disinfection could be achieved either through conventional washing or rubbing with an alcohol solution. There were 621 opportunities for hand disinfection during P1 and 905 opportunities during P2. General compliance during P1 was 42.4%, and reached 60.9% during P2 (p < 0.001). This improvement was observed among nurses (45.3% versus 66.9%, p < 0.001), senior physicians (37. 2% versus 55.5%, p < 0.001), and residents (46.9% versus 59.1%, p = 0.03). Acceptability and tolerance were evaluated through the answers to an anonymous questionnaire distributed to all 53 health care workers in the MICU. Rubbing with alcohol solution was an easy procedure (100% of responses) and induced mild side effects in less than 10% of respondents. In a complementary study conducted 3 mo after the first one, compliance remained better than during P1 (51. 3% versus 42.4%, p = 0.007). These findings suggest that rubbing with alcohol solution increases compliance with hand disinfection, and that it could be proposed as an alternative to conventional handwashing in the MICU.

Effects of 4 hand-drying methods for removing bacteria from washed hands: a randomized trial

OBJECTIVE

To evaluate the effects of 4 different drying methods to remove bacteria from washed hands.

SUBJECTS AND METHODS

One hundred adult volunteers participated in this randomized prospective study. All bacterial counts were determined using a modified glove-juice sampling procedure. The difference was determined between the amounts of bacteria on hands artificially contaminated with the bacterium Micrococcus luteus before washing with a nonantibacterial soap and after drying by 4 different methods (cloth towels accessed by a rotary dispenser, paper towels from a stack on the hand-washing sink, warm forced air from a mechanical hand-activated dryer, and spontaneous room air evaporation). The results were analyzed using a nonparametric analysis (the Friedman test). By this method, changes in bacterial colony-forming unit values for each drying method were ranked for each subject.

RESULTS

The results for 99 subjects were evaluable. No statistically significant differences were noted in the numbers of colony-forming units for each drying method (P = .72).

CONCLUSION

These data demonstrate no statistically significant differences in the efficiency of 4 different hand-drying methods for removing bacteria from washed hands.

Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic

OBJECTIVE

The objective of the study was to improve health care workers' compliance with hand hygiene after patient contact by use of an alcohol-based hand antiseptic.

DESIGN AND METHODS

Six commercially available alcohol-based hand antiseptics were evaluated. The one most pleasing to the evaluators' hands was selected for the study. Baseline handwashing rates were assessed on 2 medical wards. Alcohol dispensers were mounted by every door on the 2 wards. An educational campaign was conducted with 4 weekly visits to these floors to remind and reinstruct staff about the use of the alcohol dispensers and to address questions. After 2 months handwashing rates were reassessed.

SETTING

The study was set in a university hospital.

RESULTS

The baseline handwashing rate was 60% (76/126). Physicians were most compliant (83%), followed by nurses (60%), technologists (56%), and housekeepers (36%). Two months later overall hand hygiene rates had decreased to 52% (P = .26). Nurses were most compliant (67%), followed by technologists (57%), physicians (29%), and housekeepers (25%). Physician compliance was associated with compliance by attending physicians whose example was usually followed by all other physicians on rounds.

CONCLUSIONS

A brief educational campaign and installation of dispensers containing a rapidly acting hand hygiene product near hospital rooms did not affect hand hygiene compliance. The behavior of attending physicians was predictive of handwashing rates for all others in the attending's retinue. Compliance with handwashing after half of all patient contacts was a result of perfect compliance by some and total noncompliance by others being observed.

Improving compliance with hand hygiene in hospitals

Hand hygiene prevents cross-infection in hospitals, but compliance with recommended instructions often is poor among healthcare workers. Although some previous interventions to improve compliance have been successful, none has achieved lasting improvement. This article reviews reported barriers to appropriate hand hygiene and factors associated with poor compliance. Easy access to hand hygiene in a timely fashion and the availability of skin-care lotion both appear to be necessary prerequisites for appropriate hand-hygiene behavior. In particular, in high-demand situations, hand rub with an alcohol-based solution appears to be the only alternative that allows a decent compliance. The hand-hygiene compliance level does not rely on individual factors alone, and the same can be said for its promotion. Because of the complexity of the process of change, it is not surprising that solo interventions often fail, and multimodal, multidisciplinary strategies are necessary. A framework that includes parameters to be considered for hand-hygiene promotion is proposed, based on epidemiologically driven evidence and review of the current knowledge. Strategies for promotion in hospitals should include reasons for noncompliance with recommendations at individual, group, and institutional levels. Potential tools for change should address each of these elements and consider their interactivity.