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

Effects of oral amino acid supplementation on long-term-care-acquired infections in elderly patients

The very high general infection rate (IRI) observed in our Geriatric Intensive Rehabilitation Center (GIRC) led us to investigate whether patient supplementation with essential amino acids (EAAs), modulators of immuno-competence, could reduce IRI. Eighty elderly patients admitted to our GIRC (n=40; age 79.5 ± 7.71; male/female 14/26) or placebo (n=40; age 82.13 ± 6.15; male/female 13/27) were allocated to an 8 g/day oral EAAs group and were surveyed for infections (>48 h from admission) over the first month of their hospital stay. The IRI was 67% for the entire population of patients, 82.5% (33/40 patients) in the placebo group and 52% (21/40 patients) in the EAA group (p<0.02). When patients were divided into infection group (IG) and without-infection group (WIG), independently of post randomization allocation, the WIG had higher levels of serum albumin (p<0.001), blood hemoglobin (Hb) concentration (p=0.01), dietary protein (p=0.008) calorie intakes (p=0.05) but lower serum C-reactive protein (CRP) (p<0.001). The factor of CRP>0.8 mg/dl and Hb ≤ 12 in females, ≤13 in males was associated 4 times and 3.6 times risk of infection, respectively, by sex. EAAs supplementation may lower the risk of infection by 30% in the rehabilitative elderly population. CRP and blood hemoglobin levels can be considered risk markers of future infection.

Evaluation of handwashing behaviors and analysis of hand flora of intensive care unit nurses

PURPOSE

The aim of this study was to evaluate the handwashing behaviors of intensive care nurses based on personal statements, and to identify the microorganisms represented in the hand flora preshift and postshift.

METHODS

This prospective study was performed with 60 intensive care nurses between January and December 2008, at a training and research hospital at a university in Turkey. Samples were taken from the hands of the nurses for bacteriological culture, using the bag-broth method, at the beginning and end of the shift. The samples were cultured aerobically and the colonies that grew were counted and identified. The nurses completed a self-report questionnaire, and their answers were evaluated.

RESULTS

The frequency of handwashing by participants during each shift was 32.8±13.9. Overall, 65% of the nurses preferred alcohol-based antiseptic solutions for handwashing, 95% used paper towels to dry their hands, and 98.3-100% of the nurses washed their hands after performing care procedures. The Escherichia coli and coagulase negative Staphylococcus species were found to be at significantly higher levels in the postshift hand culture samples when compared to the preshift hand culture sample values. Enterobacter cloacae was the only species found in the postshift hand culture samples of the nurses.

CONCLUSIONS

The number of colonies of the microorganisms in the hand flora of the nurses increased postshift. The handwashing behavior of intensive care nurses must be improved as they nurse critical patients.

A review of health system infection control measures in developing countries: what can be learned to reduce maternal mortality

A functional health system is a necessary part of efforts to achieve maternal mortality reduction in developing countries. Puerperal sepsis is an infection contracted during childbirth and one of the commonest causes of maternal mortality in developing countries, despite the discovery of antibiotics over eighty years ago. Infections can be contracted during childbirth either in the community or in health facilities. Some developing countries have recently experienced increased use of health facilities for labour and delivery care and there is a possibility that this trend could lead to rising rates of puerperal sepsis. Drug and technological developments need to be combined with effective health system interventions to reduce infections, including puerperal sepsis. This article reviews health system infection control measures pertinent to labour and delivery units in developing country health facilities. Organisational improvements, training, surveillance and continuous quality improvement initiatives, used alone or in combination have been shown to decrease infection rates in some clinical settings. There is limited evidence available on effective infection control measures during labour and delivery and from low resource settings. A health systems approach is necessary to reduce maternal mortality and the occurrence of infections resulting from childbirth. Organisational and behavioural change underpins the success of infection control interventions. A global, targeted initiative could raise awareness of the need for improved infection control measures during childbirth.

Multiresistant Gram-negative infections: a global perspective

PURPOSE OF REVIEW

Multiresistant Gram-negative infections are an increasing problem in hospitals and healthcare facilities worldwide. While much attention has been paid to Gram-positive pathogens such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus lately, the importance of Gram-negative nosocomial infections has also been recognized globally.

RECENT FINDINGS

Recent reports have described the spread of carbapenemase-producing Klebsiella pneumoniae across North America. In addition, many strains of Pseudomonas and Acinetobacter in Asia are resistant to all known antibiotics. The global epidemiology of multiresistant Gram-negative pathogens seems to vary by continent. There are very few existing agents which can be used for these pathogens and there are limited options on the horizon. This limited therapeutic armamentarium has been an impetus for novel approaches including combination therapies and increased attention to infection control and prevention efforts.

SUMMARY

Clinicians need to be aware of the rising problem of resistance in nosocomial and community-acquired Gram-negative pathogens. Novel agents are urgently needed to combat these infections and innovative infection control strategies need to be devised to protect our vulnerable patients.

Strategies in the prevention of ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) remains a significant problem in the hospital setting, with very high morbidity, mortality, and cost. We performed an evidence-based review of the literature focusing on clinically relevant pharmacological and nonpharmacological interventions to prevent VAP. Owing to the importance of this condition the implementation of preventive measures is paramount in the care of mechanically ventilated patients. There is evidence that these measures decrease the incidence of VAP and improve outcomes in the intensive care unit. A multidisciplinary approach, continued education, and ventilator protocols ensure the implementation of these measures. Future research will continue to investigate cost/benefit relationships, antibiotic resistance, as well as newer technologies to prevent contamination and aspiration in mechanically ventilated patients.

Response to the challenges of pandemic H1N1 in a small island state: the Barbadian experience

Background

Having been overwhelmed by the complexity of the response needed for the severe acute respiratory syndrome (SARS) epidemic, public health professionals in the small island state of Barbados put various measures in place to improve its response in the event of a pandemic

Methods

Data for this study was collected using Barbados’ National Influenza Surveillance System, which was revitalized in 2007. It is comprised of ten sentinel sites which send weekly notifications of acute respiratory illness (ARI) and severe acute respiratory illness (SARI) to the Office of the National Epidemiologist. During the 2009 H1N1 pandemic, meetings of the National Pandemic Planning Committee and the Technical Command Committee were convened. The pharmaceutical and non-pharmaceutical interventions (NPIs) implemented as a result of these meetings form the basis of the results presented in this paper.

Results

On June 3, 2009, Barbados reported its first case of 2009 H1N1. From June until October 2009, there were 155 laboratory confirmed cases of 2009 H1N1, with one additional case occurring in January 2010. For the outbreak period (June-October 2009), the surveillance team received reports of 2,483 ARI cases, compared to 412 cases for the same period in 2008. The total hospitalization rate due to SARIs for the year 2009 was 90.1 per 100,000 people, as compared to 7.3 per 100,000 people for 2008. Barbados’ pandemic response was characterized by a strong surveillance system combining active and passive surveillance, good risk communication strategy, a strengthened public and private sector partnership, and effective regional and international collaborations. Community restriction strategies such as school and workplace closures and cancellation of group events were not utilized as public health measures to delay the spread of the virus. Some health care facilities struggled with providing adequate isolation facilities.

Conclusions

The number of confirmed cases was small but the significant surge in ARI and SARI cases indicate that the impact of the virus on the island was moderate. As a result of 2009 H1N1, virological surveillance has improved significantly and local, regional and international partnerships have been strengthened.

Method for automated monitoring of hand hygiene adherence without radio-frequency identification

Many efforts to automatically measure hand hygiene activity depend on radio-frequency identification equipment or similar technology that can be expensive to install. We have developed a method for automatically tracking the use of hand hygiene dispensers before healthcare workers enter (or after they exit) patient rooms that is easily and quickly deployed without permanent hardware.

Influence of tumour necrosis factor-α polymorphism-308 and atopy on irritant contact dermatitis in healthcare workers

BACKGROUND

Chronic irritant hand dermatitis is an issue for healthcare workers and may negatively impact infection control.

OBJECTIVES

We examined the effects of a G to A transition at position -308 on the tumour necrosis factor-α (TNF-α) gene on chronically damaged skin of healthcare workers during exposure and recovery from repetitive hand hygiene, after intensive treatment, and on the irritant response in normal skin.

PATIENTS/MATERIALS/METHODS

In 68 healthcare workers with irritant hand dermatitis, we genotyped TNF-α-308 and measured the epidermal response via quantitative digital imaging, erythema, dryness, and barrier integrity.

RESULTS

Excess hand erythema decreased with hand hygiene exposure and increased during time off for AA/GA genotypes, but had opposite effects for GG. AA/GA had smaller reductions in dryness with lotion treatment and larger reductions in excess erythema than GG. The atopic diathesis and heightened neurosensory irritation resulting from water and lactic acid significantly influenced the responses. Repeated exposure to water and sodium lauryl sulfate (0.05, 0.1%) produced higher erythema in normal skin for AA/GA than for GG.

CONCLUSIONS

This study provides evidence that the TNF-α polymorphism at -308 and an atopic history impact the severity of irritation and recovery from exposure and response to treatment for common hand skin products in both chronic irritant hand dermatitis and normal skin.

Stratum corneum cytokines, structural proteins, and transepidermal water loss: effect of hand hygiene

BACKGROUND/AIMS

There are few reports on the cytokine response to high frequency hand hygiene among health care workers (HCWs) in an occupational setting. We have observed significant skin barrier compromise consistent with chronic irritant contact dermatitis in HCWs. We hypothesized that repetitive hand hygiene would activate the epidermal inflammatory cascade and lead to changes in structural proteins and cytokines.

METHODS

Keratin 6, keratin 1, 10, 11, involucrin, IL1alpha, TNFalpha, IL8, IL1RA, and IL10 were analyzed from the SC using bead-based arrays. Knuckle and dorsum samples were evaluated for HCWs (n=23) before and after repetitive hand hygiene and compared with those of age-matched non-wet workers (n=23) without hand skin irritation. Erythema, dryness, and barrier integrity were measured.

RESULTS

Transepidermal water loss (TEWL) was higher for HCWs but unchanged with exposure. IL1alpha and TNFalpha were highest in control volar forearm. IL1alpha, TNFalpha, and IL8 were significantly lower in HCWs than controls despite higher erythema, dryness, and TEWL. Decreases in keratin 1, 10, 11, increases in keratin 6, and reduction in IL1alpha, TNFalpha, and IL8 were seen after hand hygiene.

CONCLUSION

This preliminary study showed significantly lower SC biomarker levels in HCW compared with controls and regional differences between the hand and forearm. Exposure to repetitive hand hygiene results in substantial chronic skin irritation without time for barrier recovery between work periods. The impact on SC structural proteins and cytokines has many commonalities with chronic inflammation, although mechanistic questions remain.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Can intensive use of alcohol-based hand rubs lead to passive alcoholization?

Hand disinfection with alcohols-based hand rubs (ABHRs) are known to be the most effective measure to prevent nosocomial infections in healthcare. ABHRs contain on average 70% by weight of one or more alcohols. During the hand rubbing procedure, users are exposed to these alcohols not only through dermal contact, but also via inhalation, due to the physical and chemical properties of alcohols volatilizing from alcoholic solutions or gels into the air. Ethanol ingestion is well known to increase risks of several diseases (affecting the pancreas, liver, cardiovascular system…), but there is a lack of knowledge about the effects of exposure to other alcohols (including n- or isopropanol) via inhalation and dermal contact, despite the worldwide use of ABHRs. This work aims at discussing possible health effects related to unintentional alcoholization (via inhalation and dermal contact) from professional ABHR usage to suggest the need for more research in this area (but not to question the value of ABHRs). Based upon an average of 30 hand rubbings per healthcare professional per day, it can be assumed that a healthcare worker may be exposed to a maximum 5,500 mg/m(3) per work shift, five times above the recommended occupational time weighted average limit. Thus, in order to answer the question posed in the title, studies on spatial and temporal variability of alcohol emission from ABHRs in real world situations and studies on certain high risk individuals are needed.

[Investigation of in vitro and in vivo efficacy of a novel alcohol based hand rub, MR06B7]

Alcohol based hand rubs have been used for hand hygiene in health-care settings. Compared with hand scrubbing, using suitable alcohol based hand rub provides several advantages like usability in a ward with no tap, requiring less time and mildly-irritating. Alcohol provides immediate activity, but poor virucidal activity against certain viruses including norovirus. It is important to develop further improved alcohol based hand rubs which have characteristics of sufficient effectiveness, skin-safe and extended spectrum to non-enveloped viruses for infection control. In the study, in vitro microbicidal evaluations and in vivo efficacy evaluation study were investigated to clarify the characteristics of a novel hand antiseptic MR06B7 composed of additives with synergetic activities. MR06B7 showed bactericidal activity of more than 5 Log(10) reduction within 15 sec against 20 challenged strains. MR06B7 also demonstrated potent fungicidal activities at exposure time of 30 sec (more than 4 Log(10) reduction). Against all test viruses including non-enveloped viruses (adenovirus, feline calicivirus, murine norovirus and poliovirus), MR06B7 had excellent virucidal activity to reduce the titer of viability to the limit of detection within 30 sec exposure (more than 4 Log(10) reduction), whereas 83%(v/v) ethanol indicated the inadequate effectiveness. On the clinical study conducted in accordance with standard method for Healthcare Personnel Handwash of American Society for Testing and Materials, MR06B7 showed excellent immediate antimicrobial activity. The result surpassed the critical indices set forth in the FDA's Tentative Final Monograph. These findings suggest MR06B7 which satisfies most requirements of efficacy qualifications including potent virucidal activity against non-enveloped viruses may contribute to accomplish advanced infection control in clinical practice.

The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban neonatal intensive care unit: an intervention study with before and after comparison

BACKGROUND

Nosocomial bloodstream infections are a major cause of morbidity and mortality in neonatal intensive care units. Appropriate hand hygiene is singled out as the most important measure in preventing these infections. However, hand hygiene compliance among healthcare professionals remains low despite the well-known effect on infection reduction.

OBJECTIVES

We studied the effectiveness of a hand hygiene education program on the incidence of nosocomial bloodstream infections.

DESIGN

Observational study with two pretests and two posttest measurements and interrupted time series analysis.

SETTING

A 27 bed level IIID neonatal intensive care unit in a teaching hospital in the Netherlands.

PARTICIPANTS

Healthcare professionals who had physical contact with very low birth weight (VLBW) infants.

METHODS

The study was conducted during a period of 4 years. Medical and nursing staff followed a problem-based education program on hand hygiene. Hand hygiene practices before and after the education program were compared by guided observations. The incidence of nosocomial infections in VLBW infants was compared. In addition, numbers of nosocomial bloodstream infections per day-at-risk in very low birth weight infants were analyzed by a segmented loglinear regression analysis.

RESULTS

During 1201 observations hand hygiene compliance before patient contact increased from 65% to 88% (p<0.001). Median (interquartile range) drying time increased from 4s (4-10) to 10s (7-14) (p<0.001). The proportion of very low birth weight infants with one or more bloodstream infections and the infection rate per 1000 patient days (relative risk reduction) before and after the education program on hand hygiene intervention decreased from 44.5% to 36.1% (18.9%, p=0.03) and from 17.3% to 13.5% (22.0%, p=0.03), respectively. At the baseline the nosocomial bloodstream infections per day-at-risk decreased by +0.07% (95% CI -1.41 to +1.60) per month and decreased with -1.25% (95% CI -4.67 to +2.44) after the intervention (p=0.51). The level of instant change was -14.8% (p=0.48).

CONCLUSIONS

The results are consistent with relevant improvement of hand hygiene practices among healthcare professionals due to an education program. Improved hand hygiene resulted in a reduction in nosocomial bloodstream infections.

Impact of the bag exchange procedure on risk of peritonitis

OBJECTIVE

We studied whether improper bag exchange predicts the first peritonitis episode in continuous ambulatory peritoneal dialysis (CAPD) patients.

PATIENTS AND METHODS

Our single-center prospective observational study of 130 incident urban CAPD patients who started peritoneal dialysis (PD) between March 2005 and August 2008 aimed to determine the relationship between bag exchange procedures examined at the 6th month of PD and risk for a first peritonitis episode. All patients were followed until a first peritonitis episode, censoring, or the end of the study.

RESULTS

These 130 patients experienced 22 first peritonitis episodes during the 14-month follow-up. During bag exchange evaluation, 51.5% of patients washed their hands improperly, 46.2% failed to check expiration date or bag leakage, and 11.5% forgot to wear a face mask and cap. Patients experiencing peritonitis were more likely to forget to wear a face mask and cap. In multivariate Cox regression model, not wearing a face mask and cap [hazard ratio (HR): 7.26; 95% confidence interval (CI): 2.6 to 20.1; p < 0.001] and having anemia (HR: 0.96; 95% CI: 0.94 to 0.99; p = 0.005) were independent risk factors for a first episode of peritonitis.

CONCLUSIONS

Not wearing a face mask and cap and having anemia were independent risk factors for peritonitis. A further randomized control study needs to verify the correlation between improper bag exchange technique and peritonitis in PD patients.

Bare below the elbows policies: unnecessary bureaucracy

A knee-jerk reaction is defined in non-medical terms as ‘an automatic readily predictable response’, while the classical medical definition emphasizes that the outgoing message bypasses the core of the central nervous system. The current bare below the elbows policy, as advocated by the Health Secretary Alan Johnson in September 2007, seems to fit these definitions. It is an ill thought-out and evidence-deficient policy that was more of a response to the popular press than a true solution to the problem of hospital-acquired infections. This editorial looks at some of the key elements in that policy as well as some of the others that should have been included in the original package to tackle hospital-acquired infection.

Effectiveness of a training programme to improve hand hygiene compliance in primary healthcare

BACKGROUND

Hand hygiene is the most effective measure for preventing infections related to healthcare, and its impact on the reduction of these infections is estimated at 50%. Non-compliance has been highlighted in several studies in hospitals, although none have been carried out in primary healthcare.

MAIN OBJECTIVE

To evaluated the effect of a "Hand Hygiene for the reduction of healthcare-associated infections" training program for primary healthcare workers, measured by variation from correct hand hygiene compliance, according to regulatory and specific criteria, 6 months after the baseline, in the intervention group (group receiving a training program) and in the control group (a usual clinical practice).

SECONDARY OBJECTIVES

-To describe knowledges, attitudes and behaviors as regards hand hygiene among the professionals, and their possible association with "professional burnout", stratifying the results by type of group (intervention and usual clinical practice).-To estimate the logistic regression model that best explains hand hygiene compliance.

METHODS/DESIGN

Experimental study of parallel groups, with a control group, and random assignment by Health Center.Area of study.- Health centers in north-eastern Madrid (Spain).Sample studied.- Healthcare workers (physicians, odontostomatologists, pediatricians, nurses, dental hygienists, midwife and nursing auxiliaries).Intervention.- A hand hygiene training program, including a theoretical-practical workshop, provision of alcohol-based solutions and a reminder strategy in the workplace.Other variables: sociodemographic and professional knowledges, attitudes, and behaviors with regard to hand hygiene.

STATISTICAL ANALYSIS

descriptive and inferential, using multivariate methods (covariance analysis and logistic regression).

DISCUSSION

This study will provide valuable information on the prevalence of hand hygiene non-compliance, and improve healthcare.

Effect of topical treatments on irritant hand dermatitis in health care workers

BACKGROUND

Irritant contact dermatitis (ICD) from repetitive hand hygiene is the primary reason for compliance failure among health care workers (HCWs). Chronic ICD has implications for infection control because higher bacterial counts are associated with increased skin compromise. Guidelines recommend lotions/creams to lessen irritation. We evaluated the effects of 5 to 10 daily applications of a test cream (A, glove and chlorhexidine gluconate compatible) and current lotions/creams (B) compared with a control of normal skin care.

METHODS

Outcomes were visual skin erythema and dryness, excess erythema (quantitative image analysis), and hydration among 80 HCWs in an intensive care unit.

RESULTS

Knuckle dryness was lower for both treatments than the no treatment control (P < .02) after 2 weeks. Skin treated with A had lower knuckle erythema (P=.03) than B and control. HCWs using A had lower excess erythema (right) than B and control (P < .04). Excess erythema was lower for A and B versus control (P=.003).

CONCLUSION

Reduction in erythema suggests that frequent use of cream A may mitigate the damaging effects of repetitive hand hygiene and allow the skin to recover. Intensive treatment of HCW ICD may be required to counteract the skin compromise and minimize the negative impact on infection control.

Performance of ultramicrofibre cleaning technology with or without addition of a novel copper-based biocide

This study compared the bacterial removal performance of ultramicrofibre cloths and mops (UMF) moistened with water (UMF+water), with those moistened with a novel copper-based biocide (UMF+CuWB50, 300ppm) in several working hospital environments, specifically accident and emergency (A&E) and three other wards. A total of 13 defined sampling sites (10 sites per ward) were sampled in order to retrieve, culture, and enumerate total viable (bacterial) counts (TVC) for each site. We sampled 1h before, and 1 and 4h after, cleaning three times per week. The trial ran for 7 weeks. Two wards were cleaned with UMF+water for 3 weeks, and UMF+CuWB50 for 4 weeks. The reverse applied to the other two wards in a cross-over design fashion, to eliminate ward- and time-specific bias. Multivariate statistical analyses were used to establish extent and significance of any perceived differences, and to eliminate the effects of potential confounders. Cleaning with UMF+water reduced TVC on the test surfaces by 30%, whereas cleaning with TVC+CuWB50 reduced TVC by 56%. CuWB50 had two separate effects; a direct antibacterial effect (evident shortly after cleaning), and a residual antibacterial effect that lasted approximately 2 weeks. The residual effect requires regular application of CuWB50 if it is to persist. This 'real life' hospital implementation study demonstrates encouraging microbiological cleaning performance for UMF, which is further enhanced with CuWB50.

Clinical features, outcomes, and costs of a conjunctivitis outbreak caused by the ST448 strain of Streptococcus pneumoniae

PURPOSE

An outbreak of pneumococcal conjunctivitis occurred at Dartmouth College in 2002. We describe the clinical features, outcomes, and costs associated with this outbreak.

METHODS

Six hundred ninety-eight students were diagnosed with conjunctivitis; culture of conjunctival discharge was obtained for 254. A screening protocol was used to evaluate 67 patients. A retrospective survey was offered to all 698 cases and follow-up clinical examination to all patients with culture-confirmed infection (n = 110). Local ophthalmology offices were contacted to develop a cost analysis. The college health service provided conjunctivitis data for nonoutbreak years.

RESULTS

Of 67 patients evaluated using the screening protocol, findings associated with culture-confirmed Streptococcus pneumoniae conjunctivitis (P < 0.01) were red eye visible from 2 feet, any type of conjunctival discharge, obscuration of tarsal conjunctival blood vessels, and chemosis. Two hundred thirty-two students responded to our retrospective survey; 89% reported bilateral eye involvement; 96% received topical antibiotics and noted symptom improvement within 3 days of treatment. No ocular sequelae were identified as a result of this infection. No recurrent outbreaks have occurred at Dartmouth since the initial event. The estimated cost of this outbreak including evaluations, cultures, and antibiotics ranged from $66,468 to $120,583.

CONCLUSIONS

The ST448 strain of S. pneumoniae caused a disruptive outbreak of conjunctivitis at Dartmouth College. A screening protocol was effective at identifying culture-positive cases. Although most culture-positive patients experienced bilateral conjunctivitis, the clinical course was mild with quick resolution of symptoms after initiating antibiotics and no ocular sequelae.

Inactivation of chlorhexidine gluconate on skin by incompatible alcohol hand sanitizing gels

Incompatibility of leave-on products with an antimicrobial residual can negate the efficacy benefits of chlorhexidine gluconate (CHG) persistence. Two marketed alcohol products containing Carbomer were tested using a pigskin substrate model against Staphylococcus aureus. The CHG residual achieved a 4.22 log(10) reduction (standard deviation [SD] = 0.32) in this study, which was dramatically reduced to a 0.54 (SD = 0.50) and 0.46 (SD = 0.56) after subsequent treatment with incompatible alcohol gel products. A marketed alcohol product containing a nonionic thickener maintained the efficacy of the CHG chemical reservoir (log(10) reduction = 4.26, SD = 0.00). Similar findings were demonstrated when alcohol solutions containing the individual thickening agents were tested as simple formulations. An in vivo test using human forearms and Serratia marcescens similarly demonstrated that the activity of a CHG reservoir (log(10) reduction = 3.73, SD = 0.86) was not reduced by a nonionic thickened product (log(10) reduction = 3.98, SD = 0.72) but was significantly reduced by treatment with alcohol products containing anionic thickeners carbomer (log(10) reduction = -0.32, SD = 0.34) or acrylates/C10-30 alkyl acrylate crosspolymer (log(10) reduction = -0.20, SD = 0.32). The use of anionic thickeners or emulsifiers in leave-on products, including alcohol hand sanitizers, may inactivate the persistent antibacterial activity of CHG.

The current status of hand washing and glove use among care staff in Japan: its association with the education, knowledge, and attitudes of staff, and infection control by facilities

OBJECTIVE

Hand hygiene is a basic measure to prevent infections. The purpose of this study was to obtain suggestions for the improvement of hand hygiene by evaluating the education, knowledge, and attitudes of care staff at facilities for the elderly in regard to hand washing and glove use, as well as infection control policies by those facilities.

METHODS

Among a total of 147 special nursing homes and health service facilities for the elderly in Yamaguchi Prefecture, Japan, questionnaires were sent from October to November 2007 to 56 facilities which had agreed to participate in this survey. Two types of questionnaire, one for the facility manager and the other for care staff, were sent to each facility.

RESULTS

The questionnaire was responded to by 42 managers (response rate 28.6%) and 1,323 staff members (response rate 26.3%). The rate of compliance with hand hygiene among them was 34.0%. Personal factors promoting hand hygiene were education and attitudes, while facility-related factor was the implementation of hand-washing evaluation.

CONCLUSION

Since the hand hygiene compliance rate is low among care staff at facilities for the elderly, it is necessary to take measures to improve hand hygiene. Educational programs for hand hygiene should be developed in view of the conditions of individual facilities.

Nurses and physicians' perceptions of the importance and impact of healthcare-associated infections and hand hygiene: a multi-center exploratory study in Hong Kong

BACKGROUND

Hand hygiene promotion for patient safety is a challenge worldwide, and local data are critical to tailor strategies to the setting.

METHODS

This is a cross-sectional study of nurses and physicians providing direct patient care in four hospitals in Hong Kong using an anonymous questionnaire survey. Cognitive factors related to hand hygiene and the perception of effective interventions promoting hand hygiene were assessed.

RESULTS

The overall response rate was 59.3%. Among respondents, 70% of the nurses and 49% of the physicians perceived that over 15% of patients would suffer from healthcare-associated infections. A total of 79% of the nurses and 68% of the physicians believed that more than 5% of patients would die as a result of healthcare-associated infection. A total of 60% of the nurses and 46% of the physicians acknowledged that over 75% of healthcare-associated infections could be prevented by optimal hand hygiene practices, although 36% of the nurses and 23% of the physicians claimed that six to ten hand cleansing times per hour would be necessary. Bivariate analysis showed significant differences between professionals in self-reported performance. A multivariate regression model revealed that perceived behavioral control and subjective norms were the most important factors associated with the nurses and physicians' self-reported hand hygiene performance. However when gender was taken into account among professionals, subjective norms was the only consistent one.

CONCLUSION

These results could be used as a tool to create goal-specific strategies for motivating hand hygiene amongst nurses and physicians in Hong Kong, with appropriate promotional interventions delivered to the different professional groups and specialties.

In vitro evaluation of the antimicrobial activity of HM-242, a novel antiseptic compound

The antimicrobial activities of N(4)-octyl-6,6-dimethyl-N(2)-(4-methylbenzyl)-1,6-dihydro-1,3,5-triazine-2,4-diamine (HM-242), a novel synthetic compound, were compared with those of chlorhexidine gluconate (CHG). HM-242 was a more potent microbicide than CHG in vitro; however, its minimal inhibitory concentrations were similar. In particular, HM-242 killed various Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis, both efficiently and rapidly. HM-242 also showed potent virucidal activity against enveloped viruses such as influenza virus and herpes simplex virus. These characteristics suggest that HM-242 may well be useful as an antiseptic.

Lowbury Lecture 2008: infection control and limited resources--searching for the best solutions

Healthcare-associated infections constitute an important public health problem in both developing and transitional countries. Despite considerable progress in the development of infection control programmes in some countries with limited resources, programmes in most developing world settings are non-existent, or are not implemented. Kosova, the poorest country in Europe, illustrates the challenges posed by infection control in the developing world. In many hospitals activities are limited by the lack of financial resources, poor infrastructure, overcrowding, inadequate hygiene, poorly functioning laboratory services, poor management, insufficient technology and a shortage of trained staff. Infection control guidelines from developed countries are often perceived as a standard for the developing world, but have to be modified to take into account differences in local needs. The best solutions entail greater governmental commitment and application of infection control procedures consistent with available resources. The International Nosocomial Infection Control Consortium (INICC) plays an important role in these activities in developing countries.

Hand hygiene compliance by physicians: marked heterogeneity due to local culture?

BACKGROUND

Physician compliance with hand hygiene guidelines often has been reported as insufficient.

METHODS

The study was conducted in 2 hospitals (Hadassah Ein Kerem [EK] and Mt Scopus [MS]) in Jerusalem, Israel. Covert observations were conducted during morning rounds by trained observers. The data were recorded as the percentage of times that hand hygiene was applied out of the total contacts with patients. After the observational step, an intervention-providing an alcohol gel and encouraging its use-was instituted in several wards.

RESULTS

Physicians' compliance with hand hygiene averaged 77% at MS and 33% at EK (P < .001), and was characterized by a marked additional heterogeneity among wards. Rates of adherence ranged from as low as 4% in a gynecology ward to as high as 96% in a neonatal unit. Availability of a handwashing basin in the room and seniority status of the physician were associated with higher compliance rates but explained only a small part of the variation. Compliance improved significantly in 2 wards exposed to the intervention.

CONCLUSION

The remarkable heterogeneity in physicians' hand hygiene compliance among sites within the same institution is consistent with an important role of the local ward culture.

Use of digital photography and image analysis techniques to quantify erythema in health care workers

BACKGROUND/AIMS

Nosocomial infections affect up to 26% of ICU patients. Compliance with the required hand hygiene procedures remains low, rarely exceeding 50%, with skin irritation as one of the main reasons for lack of conformity. The aim was to quantify the epidermal barrier effects, particularly erythema, from repetitive exposure to hand hygiene procedures among health care workers (HCWs) using an objective, reliable clinical method that could evaluate the entire hand surface.

METHODS

The hand skin of HCWs was evaluated before the initial scrub and at the end of multiple 2-3 days work cycles during spring (n=54) and winter (n=60) trials. The skin condition was measured with live visual skin evaluation (LSG), digital image analysis (DIA) of high-resolution digital images, and visual perception evaluation (VPS) of image pairs.

RESULTS

The HCWs had significantly higher values of erythema than the non-HCW control group with all methods. Knuckle erythema increased over the cycle in both seasons. It decreased during recovery in spring and continued to increase during recovery in winter. For the DIA area of excess redness, the quantitative measure of erythema, the decrease over the cycle in spring was significantly different than the increase over the cycle in winter. Minimal changes in area of excess redness occurred during recovery in both seasons. With the VPS, both judges found a decrease in erythema during recovery in spring and an increase during recovery in winter, indicating significant differences for spring vs. winter (P<0.05). No differences in VPS erythema were seen for either product set over the work cycle during spring. Correlations were observed for (1) results for the VPS vs. the LSG method and (2) between excess erythema (mu+sigma) from DIA and the VPS erythema scores. Relatively low correlations were found between the DIA and VPS methods, i.e., knuckle mu+sigma and VPS erythema.

CONCLUSIONS

Significant work cycle effects for spring vs. winter were observed with DIA, while significant effects were found during the recovery period with VPS. DIA produced an objective quantitative measure of erythema that was not limited or influenced by other aspects of skin irritation (e.g., dryness, scaling) or texture encountered in the visual methods of LSG and VPS. The DIA method minimizes the difficulty in differentiating erythema severity. Standardization of image capture and processing allows assessment of skin condition across clinical locations. The VPS is a more reliable way to compare skin condition at different times, i.e. beginning vs. the end of a treatment cycle, because images are viewed simultaneously and can be carefully examined for differences.

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

BACKGROUND

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

METHODS

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

RESULTS AND CONCLUSION

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

Evaluation of patient participation in a patient empowerment initiative to improve hand hygiene practices in a Veterans Affairs medical center

BACKGROUND

In patient empowerment initiatives, patients are encouraged to ask caregivers if they have washed their hands. However, relatively little is known about the willingness of patients to participate in such initiatives.

METHODS

Patients were presented with a "Partners in Your Care" script asking them to remind health care workers to wash their hands, and follow-up interviews were conducted. Compliance was reassessed using a modified script in which patients were asked to thank health care workers for washing and/or to display a sign stating "Thanks for Washing."

RESULTS

Of the 193 patients presented with the initial script, 5 (3%) stated that they had reminded health care workers to wash, and 15 (8%) had not commented despite observing health care workers failing to wash in their presence. Of the 38 patients given the modified script instructing them to thank health care workers for washing, 17 (45%) reported mentioning hand hygiene to health care workers (13 of whom thanked the caregivers), and 6 (16%) did not comment despite observing health care workers failing to wash in their presence. Most patients displayed a sign thanking caregivers for washing; however, no patients were observed to comment on hand hygiene during physician work rounds, and only 2 of 30 (7%) nurses on the study wards reported being thanked for washing.

CONCLUSION

In this Veterans Affairs hospital, patients were unlikely to remind health care workers to wash their hands. Patient empowerment initiatives may be more effective if patients are encouraged to provide positive reinforcement and/or display prompting visual reminders.

The influence of sex, handedness, and washing on the diversity of hand surface bacteria

Bacteria thrive on and within the human body. One of the largest human-associated microbial habitats is the skin surface, which harbors large numbers of bacteria that can have important effects on health. We examined the palmar surfaces of the dominant and nondominant hands of 51 healthy young adult volunteers to characterize bacterial diversity on hands and to assess its variability within and between individuals. We used a novel pyrosequencing-based method that allowed us to survey hand surface bacterial communities at an unprecedented level of detail. The diversity of skin-associated bacterial communities was surprisingly high; a typical hand surface harbored >150 unique species-level bacterial phylotypes, and we identified a total of 4,742 unique phylotypes across all of the hands examined. Although there was a core set of bacterial taxa commonly found on the palm surface, we observed pronounced intra- and interpersonal variation in bacterial community composition: hands from the same individual shared only 17% of their phylotypes, with different individuals sharing only 13%. Women had significantly higher diversity than men, and community composition was significantly affected by handedness, time since last hand washing, and an individual's sex. The variation within and between individuals in microbial ecology illustrated by this study emphasizes the challenges inherent in defining what constitutes a "healthy" bacterial community; addressing these challenges will be critical for the International Human Microbiome Project.

Hand hygiene practices: nursing students' perceptions

AIMS AND OBJECTIVES

The present study examines nursing students' perceptions of hand hygiene practices in clinical settings. The objectives were to investigate any factors that affect students' perceptions of their own and healthcare workers' (HCWs) hand hygiene compliance, and to make recommendations for future practice and hand hygiene training in preregistration nursing courses.

BACKGROUND

Effective hand hygiene decontamination can lower the prevalence of healthcare-associated infections (HCAIs); unfortunately, the prevalence of HCAIs continues to rise and so poses challenges to healthcare providers to reduce such infections. Previous studies have shown that hand hygiene compliance in HCWs is generally low and that any increase in compliance is difficult to sustain. Several barriers to hand hygiene compliance have been identified in the literature.

DESIGN

A qualitative interpretive design was used to examine nursing students' perceptions of hand hygiene practices.

METHODS

Ten preregistration students participated in semi-structured qualitative interviews, which were analysed thematically.

RESULTS

Hand hygiene compliance was perceived to be effected by specific barriers which included: time and busyness; clinical procedure; skin condition; lack of knowledge and glove use. Importantly, students perceived other HCWs as being the influencing factor for hand hygiene compliance resulting from the perception that they should 'fit in' with those working in the clinical area.

CONCLUSIONS

The findings support previous literature and found that respondents emphasised the importance of fitting into the clinical area and role models in shaping hand hygiene compliance.

RELEVANCE TO CLINICAL PRACTICE

For nursing students, the influence of other HCWs as role models should not be underestimated.

The role of nurses working in emergency and critical care environments in the prevention of intravascular catheter-related bloodstream infections

Intravascular catheter-related infections are a major problem in healthcare. This review provides up-to-date guidance of evidence-based recommendations for the prevention of intravascular catheter-related infections with special focus on strategies relevant for nurses working in emergency and critical care environments or practitioners responsible for surveillance and control of infections. The review concludes by providing a range of approaches advocated for: (i) translating guidelines to the needs and expectations of emergency and critical care nurses, and (ii) increasing the chance of successful implementation and compliance with these recommendations.

Barriers to adherence to cystic fibrosis infection control guidelines

BACKGROUND

In 2003, the American Cystic Fibrosis (CF) Foundation published revised, evidence-based guidelines for infection control. We sought to assess potential barriers to adherence to these guidelines experienced by health care professionals (HCPs) caring for CF patients.

METHODS

From April 2004 to December 2005, a knowledge, attitude, and practice survey was administered to HCPs at randomly selected CF centers in the United States to explore potential barriers to adherence to selected guidelines: (1) obtaining quarterly cultures from CF patients, (2) discouraging socialization among CF patients during hospitalization, (3) educating patients and families about hand hygiene, (4) educating patients and families to clean and disinfect home nebulizers, and (5) cleaning the clinic exam rooms between CF patients.

RESULTS

The survey was completed by 528 HCPs from 25 sites (5-50 respondents per site). Only 60% of respondents were aware of the guidelines, but despite awareness, 31-47% were unfamiliar with the specific guidelines. Self-reported adherence was low; only 23-63% of respondents reported practicing the selected guidelines >75% of the time/opportunities. Lack of self-efficacy, that is, confidence in adequately performing the guidelines, was commonly experienced by respondents. Access to a copy of the guidelines was associated with increased agreement with the recommendations and increased self-efficacy.

CONCLUSIONS

Strategies to reduce barriers to adherence to CF infection control guidelines are needed. Strategies could include quality improvement initiatives with enhanced education and skills workshops, sharing successful interventions among CF centers, and linking adherence to improved patient outcomes.

Chlorhexidine - Pharmacology and Clinical Applications

chlorhexidine is a widely used skin antisepsis preparation and is an ingredient in toothpaste and mouthwash. It is an especially effective antiseptic when combined with alcohol. Its antimicrobial effects persist because it is binds strongly to proteins in the skin and mucosa, making it an effective antiseptic ingredient for handwashing, skin preparation for surgery and the placement of intravascular access. Catheters impregnated with chlorhexidine and antimicrobial agents can reduce the incidence of catheter-related bloodstream infections. Contact dermatitis related to chlorhexidine is not common in health care workers. The incidence of contact dermatitis to chlorhexidine in atopic patients is approximately 2.5 to 5.4%. Acute hypersensitivity reactions to chlorhexidine are often not recognised and therefore may be underreported. This review discusses the pharmacology, microbiology, clinical applications and adverse effects of chlorhexidine.

Prevention of hospital-acquired infections: review of non-pharmacological interventions

Hospital-acquired (nosocomial) infections (HAIs) increase morbidity, mortality and medical costs. In the USA alone, nosocomial infections cause about 1.7 million infections and 99 000 deaths per year. HAIs are spread by numerous routes including surfaces (especially hands), air, water, intravenous routes, oral routes and through surgery. Interventions such as proper hand and surface cleaning, better nutrition, sufficient numbers of nurses, better ventilator management, use of coated urinary and central venous catheters and use of high-efficiency particulate air (HEPA) filters have all been associated with significantly lower nosocomial infection rates. Multiple infection control techniques and strategies simultaneously ('bundling') may offer the best opportunity to reduce the morbidity and mortality toll of HAIs. Most of these infection control strategies will more than pay for themselves by saving the medical costs associated with nosocomial infections. Many non-pharmacological interventions to prevent many HAIs will also reduce the need for long or multiple-drug antibiotic courses for patients. Lower antibiotic drug usage will reduce risk of antibiotic-resistant organisms and should improve efficacy of antibiotics given to patients who do acquire infections.