Hand disinfection: a comparison of various agents in laboratory and ward studies

Biomonitoring of volatile organic compounds and organophosphorus flame retardands in commercial aircrews after "fume and smell events"

Health risks to humans after "fume and smell events", short-term incidents on aircrafts that are accompanied by unpleasant odour or visible smoke, remain a subject of controversy. We assessed exposure to volatile organic compounds (VOC) and organophosphorus compounds (OPC) by biomonitoring in 375 aircrew members after self-reported "fume and smell events" and in 88 persons of the general population. A total of 20 parameters were analysed in blood and urine by gas chromatography and mass spectrometry. Median levels of acetone in blood and urine and 2-propanol in blood were elevated in aircrews compared to controls (p < 0.0001). Additionally, elevated peak exposures, best estimated by the 95th percentiles, were observed in aircrews for n-heptane and n-octane in blood, and acetone, 2,5-hexanedione and o-cresol in urine. Only the maximum observed levels of 2,5-hexandione in urine (768 μg/L) and toluene in blood (77 μg/L) in aircrew members were higher than the current biological exposure indices (BEI® levels) (500 and 20 μg/L, respectively) of the American Conference of Governmental Industrial Hygienists (US-ACGIH) for workers occupationally exposed to n-hexane and toluene, two well-accepted human neurotoxicants. Low-level exposures to n-hexane and toluene could be also observed in controls. The majority of OPC parameters in urine, including those of neurotoxic ortho-isomers of tricresylphosphate, were below the limit of quantitation in both aircrews and controls. Our comparative VOC and OPC analyses in biological samples of a large number of aircrew members and controls suggest that exposures are similar in both groups and generally low.

Ventriculoperitoneal Shunt Surgery in Pediatrics: Does Preoperative Skin Antisepsis with Chlorhexidine/Alcohol Reduce Postoperative Shunt Infection Rate?

BACKGROUND

 In pediatrics, shunt infection is considered the most common complication of ventriculoperitoneal (VP) shunt insertion and the main cause of shunt failure. Careful surgical technique and hygienic skin preparations are highly important for prevention of shunt infections. Our objective was to assess the significance of using preoperative chlorhexidine/alcohol as a skin antiseptic in reducing the infection rate in pediatric VP shunts surgery.

METHODS

 We conducted a retrospective, case control study of 80 pediatric patients with active hydrocephalus. The control group (a single step of preoperative skin antisepsis using povidone-iodine and isopropyl alcohol) comprised 40 patients who underwent a shunt surgery between January 2019 and June 2020 and the study group (two steps of preoperative skin antisepsis using 2% chlorhexidine gluconate in 70% isopropyl alcohol as a first step followed by povidone-iodine as a second step) comprised 40 patients who underwent a shunt surgery between July 2020 and January 2022.

RESULTS

 Shunt infection was encountered in 11 (13.7%) patients. It was significantly higher in preterm babies (p = 0.010), patients with a previous shunt revision (p < 0.001), and those with a previous shunt infection (p < 0.001). The incidence of infection was 22.5% in the control group and 5% in study group, with a statistically significant difference (p = 0.023).

CONCLUSIONS

 Two steps of preoperative skin antisepsis, first using chlorhexidine/alcohol and then povidone-iodine scrub solution, may significantly reduce the infection rate in pediatric VP shunt surgeries.

Prospective evaluation of the prevalence of conjunctival and intraocular bacteria in dogs undergoing phacoemulsification following a standardized aseptic preparation with 0.5% povidone iodine

PURPOSE

To evaluate bacterial contamination of conjunctiva and aqueous humor in dogs undergoing phacoemulsification following asepsis with 0.5% povidone iodine and determine the influence of intravenous antibiotics on outcome of contamination.

METHODS

Client-owned dogs were prospectively enrolled and randomly assigned to a control group, receiving 22 mg/kg intravenous cefazolin at induction prior to sampling, or experimental group receiving no antibiotic prior to sampling, masked to the surgeon. Dogs receiving antimicrobials in the pre-operative period were excluded. Asepsis was performed on all operated eyes using 0.5% iodine with minimum 3 min contact time at induction of anesthesia and repeated before surgery. A conjunctival swab and aqueous humor sample were collected prior to incision and following incision closure, respectively. Samples were submitted for aerobic and anaerobic bacterial culture and susceptibility.

RESULTS

Seventy-one eyes of 42 dogs were included. Median age was 9 years. Thirty-nine and 32/71 eyes received intravenous cefazolin and no antibiotic, respectively. Median procedure time was 40 min per eye. Conjunctival cultures were positive in 6 eyes (8.5%): Serratia marcescens (5 eyes) and Cutibacterium acnes (1 eye). Aqueous humor cultures were positive in 5 eyes (7.0%): S. marcescens (2 eyes), Pseudomonas aeruginosa (2 eyes), Staphylococcus pseudointermedius (1 eye). Prevalence of positive culture did not differ between groups (p = .74), order of eyes for bilateral procedures (p = .74) and diabetic status (p = 1).

CONCLUSIONS

Bacterial contamination of the conjunctiva and aqueous humor was present in 8.5% and 7.0% of dogs undergoing phacoemulsification after asepsis. Lack of IV cefazolin was not significantly associated with positive culture.

Hand Hygiene in the Intensive Care Unit: Knowledge, Compliance and Factors Influencing Nursing Adherence, a Descriptive Study

Background:

Nosocomial infections are particularly common among hospitalized patients who undergo resuscitation compared with other types of care. Hand hygiene remains the simplest and most effective measure to prevent and control the risk of infection.

Objective:

The main objectives are to evaluate hand hygiene compliance among nursing staff in the different intensive care units and to identify the factors influencing the adherence of nursing staff to the practice.

Methods:

It was a quantitative descriptive study using a questionnaire and an observation grid with all the nursing staff working in all the intensive care units of our university hospital.

Results:

The study showed a hand contamination rate of (80%), a hand hygiene compliance rate of (21.3%), it also showed the different factors explaining non-adherence, these are not necessarily related to training, nor to the availability of material resources but related to hidden reasons, non-apparent factors, which are often more important. (Workload and work environment)

Conclusion:

This study examined hand hygiene in the ICU setting, obtained data on overall compliance, which remains poor, and the various factors influencing nurses' adherence to the practice.

Manual emptying of ventilated improved pit latrines and hygiene challenges - a baseline survey in a peri-urban community in KwaZulu-Natal, South Africa

The presence of Escherichia coli and Staphylococcus spp. was determined on the skin, personal protective equipment, the municipal vehicle, and various surfaces at ten households in a peri-urban community (KwaZulu-Natal, South Africa) before and after manual emptying of ventilated improved pit latrines. Surface samples (n = 14) were collected using sterile wet wipes, and target bacteria were detected using standard procedures. Additionally, E. coli was enumerated in soil samples from an area of open defecation (log₁₀ 3.7 MPN/g) and areas where geophagia occurred (log₁₀ 2.7 - log₁₀ 3.3 MPN/g), using a most probable number (MPN) method. The detection frequency for the target bacteria on household surfaces (e.g., the walkway between the pit latrine and the municipal vehicle) and on municipal workers' hands (which were frequently contaminated before pit emptying), occasionally increased after the pits were emptied, indicating that manual pit emptying might pose a potential health risk to workers and community members.

Comparative Assessment of the Efficacy of Commercial Hand Sanitizers Against Human Norovirus Evaluated by an in vivo Fingerpad Method

Human noroviruses (hNoV) are the leading cause of acute non-bacterial gastroenteritis worldwide and contaminated hands play a significant role in the spread of disease. Some hand sanitizers claim to interrupt hNoV transmission, but their antiviral efficacy on human hands is poorly characterized. The purpose of this work was to characterize the efficacy of representative commercial hand sanitizers against hNoV using an in vivo fingerpad method (ASTM E1838-17). Eight products [seven ethanol-based and one benzalkonium chloride (BAK)-based], and a benchmark 60% ethanol solution, were each evaluated on 10 human volunteers using the epidemic GII.4 hNoV strain. Virus titers before and after treatment were evaluated by RT-qPCR preceded by RNase treatment; product efficacy was characterized by log₁₀ reduction (LR) in hNoV genome equivalent copies after treatment. The benchmark treatment produced a 1.7 ± 0.5 LR, compared with Product A (containing 85% ethanol) which produced a 3.3 ± 0.3 LR and was the most efficacious (p < 0.05). Product B (containing 70% ethanol), while less efficacious than Product A (p < 0.05), performed better than the benchmark with a LR of 2.4 ± 0.4. Five of the other ethanol-based products (labeled ethanol concentration ranges of 62–80%) showed similar efficacy to the 60% ethanol benchmark with LR ranging from 1.3 to 2.0 (p > 0.05). Product H (0.1% BAK) was less effective than the benchmark with a LR of 0.3 ± 0.2 (p < 0.05). None of the products screened were able to completely eliminate hNoV (maximum assay resolution 5.0 LR). Product performance was variable and appears driven by overall formulation. There remains a need for more hand sanitizer formulations having greater activity against hNoV, a virus that is comparatively recalcitrant relative to other pathogens of concern in community, healthcare, and food preparation environments.

Molecular iodine is not responsible for cytotoxicity in iodophors

Background

Ten percent povidone-iodine (PVP-I) was initially promoted as ‘tamed iodine’ as the chemical activity of the active biocide, uncomplexed or free molecular iodine (I₂), is reduced 30- to 50-fold compared with Lugol's solution. The idea that I₂ is responsible for topical iodine staining and irritation remains widely held. However, there are no controlled studies that characterize the cytotoxicity and staining of the hydrophobic I₂ species compared with the other hydrophilic iodine species that comprise over 99.9% of the total iodine in topical iodine disinfectants.

Aims

To compare the staining properties of the I₂ species with other topical iodine disinfectants; to evaluate if the concentrations of I₂ in diluted PVP-I used to reduce severe acute respiratory syndrome coronavirus-2 in the nasal cavity are potentially cytotoxic; and to determine if high concentrations of I₂ can be delivered beyond the stratum corneum into the hypodermis, which could provide a mechanistic rationale for I₂ out-gassing.

Methods

Five liquid compositions that contained complexed and uncomplexed (free) I₂ in aqueous and non-aqueous carriers were used to evaluate the interaction of I₂ with mammalian cells in culture as well as human and pig skin.

Findings

Concentrations of I₂ (7800 ppm) that are 1500 times higher than that found in PVP-I can be applied to skin without irritation and staining. I₂ is not cytotoxic at concentrations >100 times higher than that found in PVP-I, and does not contribute materially to staining of skin at concentrations found in Lugol's solution (approximately 170 ppm). I₂ can partition into hypodermis tissue, remain there for hours and out-gas from skin. PVP-I and Lugol's solution are highly effective topical disinfectants, but do not facilitate diffusion of I₂ through the stratum corneum.

Conclusion

The maximum concentration of I₂ found in diluted PVP, approximately 25 ppm, is not cytotoxic or irritating. The potential clinical utility of I₂ has been limited by incorporating this broad-spectrum biocide into acidic aqueous formulations that contain numerous chemical species that contribute toxicity but not biocidal activity. I₂ can be delivered topically into hypodermis tissue without irritation.

Scientific Evidence Supports the Use of Alcohol-Based Hand Sanitizers as an Effective Alternative to Hand Washing in Retail Food and Food Service Settings When Heavy Soiling Is Not Present on Hands

ABSTRACT

Suboptimal food worker health and hygiene has been a common contributing factor in foodborne disease outbreaks for many years. Despite clear U.S. Food and Drug Administration (FDA) Model Food Code recommendations for hand washing and glove use, food worker compliance with hand washing recommendations has remained poor for >20 years. Food workers' compliance with recommended hand washing guidelines is adversely impacted by a number of barriers, including complaints of time pressure, inadequate number and/or location of hand washing sinks and hand washing supplies, lack of food knowledge and training regarding hand washing, the belief that wearing gloves obviates the need for hand washing, insufficient management commitment, and adverse skin effects caused by frequent hand washing. Although many of the issues related to poor hand washing practices in food service facilities are the same as those in health care settings, a new approach to health care hand hygiene was deemed necessary >15 years ago due to persistently low compliance rates among health care personnel. Evidence-based hand hygiene guidelines for health care settings were published by both the Centers for Disease Control and Prevention in 2002 and by the World Health Organization in 2009. Despite similar low hand washing compliance rates among retail food establishment workers, no changes in the Food Code guidelines for hand washing have been made since 2001. In direct contrast to health care settings, where frequent use of alcohol-based hand sanitizers (ABHSs) in lieu of hand washing has improved hand hygiene compliance rates and reduced infections, the Food Code continues to permit the use of ABHSs only after hands have been washed with soap and water. This article provides clear evidence to support modifying the FDA Model Food Code to allow the use of ABHSs as an acceptable alternative to hand washing in situations where heavy soiling is not present. Emphasis on the importance of hand washing when hands are heavily soiled and appropriate use of gloves is still indicated.

HIGHLIGHTS

Health care worker sensitivity to chlorhexidine-based hand hygiene solutions: A cross-sectional survey

BACKGROUND

Health service hand hygiene programs have seen widespread use of chlorhexidine solutions. Reports of both immediate and delayed hypersensitivity to chlorhexidine are increasing among health care workers. This study examined the prevalence of self-reported symptoms of sensitivity to chlorhexidine solutions among health care workers.

METHODS

This study was a cross-sectional online anonymous survey of all workers at a single health service.

RESULTS

Of the 1,050 completed responses, 76.3% were female, 35.3% were nurses and midwives, 28% were medical staff, and 8.7% were working in nonclinical areas. Over 95% used chlorhexidine-based hand hygiene products in their workplace. Nurses and midwives most frequently reported asthma (13.7%), contact dermatitis (27.8%), and previous testing for allergy to chlorhexidine (4.9%). There was a correlation between both the presence of atopy, eczema, or dermatitis and the self-reporting of dry skin, eczema, or dermatitis attributed to chlorhexidine use.

DISCUSSION

Occupational chlorhexidine allergy is an important risk to health care workers. Self-reported symptoms of sensitivity to chlorhexidine solutions revealed high reported use and presence of skin symptoms among health care workers.

CONCLUSIONS

Screening programs need to identify nurses who develop chlorhexidine sensitivity due to occupational exposure. Strategies to mitigate risk should provide alternatives for those with sensitization.

Hand Washing Before and After Applying Different Hand Hygiene Techniques in Places of Public Concern in Tripoli-Libya

Background:

Hand hygiene has being considered as one of the primary measures to improve standards and practice for hospital care and to minimize the transmission of nosocomial pathogens. There is substantial evidence that incidence of hospital acquired infections is reduced by applying hand antisepsis. Regarding hand hygiene and public concern, hand washing has revealed that 85% of the observed adults wash their hands after using public toilets.

Objective:

To compare the efficacy of hand rubbing with an alcohol based solution versus conventional hand washing with antiseptic and non-antiseptic soaps in reducing bacterial counts using different hand hygiene techniques.

Methods:

Ninety-three volunteers took part in this study; 57 from Tripoli Medical Center (TMC); 16 from school; 11 from bank; and 9 from office. All volunteers performed six hand hygiene techniques, immediately before and after a volunteer practice activity: hand washing with non-antiseptic soap for 10 and 30 second (s); hand washing with antiseptic soap for 10, 30 or 60 s; and alcohol-based hand rub. A total of 864 specimens were taken: 432 before and 432 after volunteer's hand hygiene. The fingertips of the dominant hand for each volunteer were pressed on to agar for culture before and after each hand hygiene technique. Plates were incubated at 37oC, and colony-forming units were counted after 48 hours and pathogenic bacteria were identified.

Results:

Results showed that 617 specimens (71.41%) were positive for bacterial growth. 301 (48.78%) were from TMC, 118 (19.12%) were from office; 107 (14.34%) were from school and 91 (14.75%) were from bank.

Conclusion:

Both antiseptic and non–antiseptic soaps did not work properly in reducing bacterial counts of worker’s hands at all places of study, but significantly improved by an application of alcohol based gel.

Bactericidal and Virucidal Activity of Povidone-Iodine and Chlorhexidine Gluconate Cleansers in an In Vivo Hand Hygiene Clinical Simulation Study

Introduction

Standard in vitro and in vivo tests help demonstrate efficacy of hand hygiene products; however, there is no standard in vivo test method for viruses. We investigated the bactericidal and virucidal efficacy of povidone-iodine (PVP-I) 7.5% scalp and skin cleanser, chlorhexidine gluconate (CHG) 4% hand cleanser and the reference hand wash (soft soap) in 15 healthy volunteers following European Standard EN1499 (hygienic hand wash test method for bacteria), which was adapted for virucidal testing.

Methods

Separate test series were performed for bactericidal (Escherichia coli) and virucidal [murine norovirus (MNV)] testing. After pre-washing and artificial contamination of hands with test organisms, volunteers underwent testing with 3 and 5 mL of each product for contact times of 15, 30 and 60 s according to a Latin-square randomization. The number of test organisms released from fingertips into sampling fluids was assessed before and after hand washing and mean log₁₀ reduction factor (RF) was calculated. RFs (test-reference) were compared using a Wilcoxon–Wilcox multiple comparisons test per EN1499; efficacy was concluded if p ≤ 0.01.

Results

PVP-I 7.5% and CHG 4% cleansers both passed EN1499 requirements against E. coli, with statistically significantly greater (p ≤ 0.01) mean log₁₀ RFs compared with reference soft soap across all tests (PVP-I: 4.09–5.27; CHG: 4.12–5.22; soap: 2.75–3.11). The experimental design using EN1499 was applicable to testing with MNV as discriminatory and reproducible results were generated. Mean log₁₀ RFs of MNV were statistically significantly greater for PVP-I (1.57–2.57) compared with soft soap (1.24–1.62), while mean log₁₀ RFs with CHG (0.90–1.34) were lower than for soft soap across all tests.

Conclusion

PVP-I 7.5% cleanser showed superior efficacy against MNV compared to soft soap and CHG 4% cleanser, while both PVP-I and CHG were superior to soft soap against E. coli. The experimental set-up may be applicable to future testing for antiviral hand washes.

Funding

Mundipharma Manufacturing Pte Ltd.

Plain Language Summary

Plain language summary available for this article.

Preoperative Hand Decontamination in Ophthalmic Surgery: A Comparison of the Removal of Bacteria from Surgeons' Hands by Routine Antimicrobial Scrub versus an Alcoholic Hand Rub

PURPOSE

The goal of this experiment was to evaluate and compare the antimicrobial efficacy of routine preoperative hand washing using commercial medicated sponge brushes versus an alcoholic hand rub, by comparing bacterial growth on ophthalmic surgeons' hands after application of each of these methods.

METHODS

Twenty ophthalmic surgeons were recruited at the Hadassah-Hebrew University Medical Center in Jerusalem, Israel. Samples were collected twice from the hands of each surgeon after hand decontamination using two different protocols during routine surgical practice. The routine preparation consisted of a 3-minute surgical scrub using commercial brush-sponges incorporating either 4% chlorhexidine gluconate (CHG) or 1% povidone-iodine (PVP-I) formulations with detergent, followed by drying the hands with a sterile towel, while the 70% ethanol solution was applied for 60-seconds and allowed to air dry. Half of the group was randomly assigned to provide samples first after the routine method and the alcoholic solution a week later, and the other half of the group was sampled in the reverse order. Viable counts of bacteria were evaluated using a modified glove juice method. Bacterial colonies were enumerated after incubation for 24 hours and expressed as colony forming units (CFU)/mL for each pair of hands.

RESULTS

Geometric mean counts were 1310 and 39 CFU/mL, in the routine and alcohol rub groups, respectively, representing a mean log₁₀ reduction in 1.53. The difference between the paired bacterial counts for the routine versus the alcohol rub was statistically significant (p < 0.0001). There was no statistically significant difference between log₁₀ reductions for CHG and PVP-I (p = 0.97).

CONCLUSIONS

This study provides evidence that an alcohol rub protocol is more effective in reducing bacterial counts on hands than routine surgical hand preparation with PVP-I and CHG in a population of practicing ophthalmic surgeons in the operative clinical setting. Thus, it provides a safe alternative as a preoperative hand disinfection method.

Anti-bacterial efficacy of alcoholic hand rubs in the Kenyan market, 2015

Background

Hand hygiene is known to be effective in preventing hospital and community-acquired infections. The increasing number of hand sanitizer brands in Kenyan hospitals and consumer outlets is of concern. Thus the main aim of this study was to evaluate the anti-bacterial efficacy and organoleptic properties of these hand sanitizers in Kenya.

Methods

This was an experimental, laboratory-based study of 14 different brands of hand sanitizers (coded HS1-14) available in various retail outlets and hospitals in Kenya. Efficacy was evaluated using standard non-pathogenic Escherichia coli (ATCC 25922), Staphylococcus aureus (ATCC 25923) and Pseudomonas aeruginosa (ATCC 27853) as per the European Standard (EN). The logarithmic reduction factors (RF) were assessed at baseline and after treatment, and log reduction then calculated. Ten and 25 healthy volunteers participated in the efficacy and organoleptic studies respectively.

Results

Four (28.6%) hand sanitizers (HS12, HS9, HS13 and HS14) showed a 5.9 reduction factor on all the three bacteria strains. Seven (50%) hand sanitizers had efficacies of <3 against all the three bacteria strains used. Efficacy on E. Coli was higher compared to the other pathogens. Three hand sanitizers were efficacious on one of the pathogens and not the other. In terms of organoleptic properties, gel-based formulations were rated far higher than the liquid based formulations brands.

Conclusion

Fifty percent (50%) of the selected hand sanitizers in the Kenyan market have efficacy that falls below the World Health Organization (WHO) and DIN EN 1500:2013. Of the 14 hand sanitizers found in the Kenyan market, only four showed efficacies that were comparable to the WHO-formulation. There is a need to evaluate how many of these products with <3 efficacy that have been incorporated into the health system for hand hygiene and the country’s policy on regulations on their usage.

Evidence-based Practices in Infection Control

Abstract Evidence can be obtained from clinical trials and bacteriological studies. The latter consist mainly of measuring reductions in colonization, or reductions in bacterial counts on naturally or artificially contaminated surfaces, following the introduction of the measure to be tested. Controlled clinical trials usually provide the best evidence, but are infrequently carried out due to the large number of subjects required, low initial infection rates and a multiplicity of associated factors. Bacteriological studies can be carried out more easily and can often provide statistically significant results not readily available in clinical studies, but they require care in interpretation. Studies involving bacterial counts in the inanimate environment are particularly likely to give misleading results, but have often provided useful confirmatory evidence in eliminating rituals.

The Inanimate Environment of an Intensive Care Unit as a Potential Source of Nosocomial Bacteria: Evidence for Long Survival of Acinetobacter calcoaceticus

Environmental surface and personnel hand impression cultures were obtained during 13 sampling periods in the University of Virginia Pediatric Intensive Care Unit to document potential reservoirs of nosocomial pathogens. In 78 environmental cultures Staphylococcus aureus was found eight times and gram-negative bacilli ten times. The patient chart cover was the most commonly contaminated surface. Acinetobacter calcoaceticus was found in five of ten cultures positive for gram-negative bacilli. Thirty of 59 hand cultures were positive for S aureus and gram-negative bacilli; nurses and residents had both, respiratory therapists only gram-negative bacilli, and A calcoaceticus was the most commonly isolated bacterium of potentially nosocomial significance (14/30). Laboratory investigation of bacterial survival revealed that gramnegative bacilli survived on a dry formica surface from a few hours up to three days but Acinetobacter survived up to 13 days. Since A calcoaceticus has been implicated in many nosocomial infections, its long survival on a dry surface may be an additional factor in its transmission in hospitals and suggests that more attention be paid to environmental surfaces as a source of significant nosocomial pathogens.

Surgical hand antisepsis to reduce surgical site infection

BACKGROUND

Medical professionals routinely carry out surgical hand antisepsis before undertaking invasive procedures to destroy transient micro-organisms and inhibit the growth of resident micro-organisms. Antisepsis may reduce the risk of surgical site infections (SSIs) in patients.

OBJECTIVES

To assess the effects of surgical hand antisepsis on preventing surgical site infections (SSIs) in patients treated in any setting. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony-forming units (CFUs) of bacteria on the hands of the surgical team.

SEARCH METHODS

In June 2015 for this update, we searched: The Cochrane Wounds Group Specialized Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations) and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed studies for inclusion and trial quality and extracted data.

MAIN RESULTS

Fourteen trials were included in the updated review. Four trials reported the primary outcome, rates of SSIs, while 10 trials reported number of CFUs but not SSI rates. In general studies were small, and some did not present data or analyses that could be easily interpreted or related to clinical outcomes. These factors reduced the quality of the evidence. SSIsOne study randomised 3317 participants to basic hand hygiene (soap and water) versus an alcohol rub plus additional hydrogen peroxide. There was no clear evidence of a difference in the risk of SSI (risk ratio (RR) 0.97, 95% CI 0.77 to 1.23, moderate quality evidence downgraded for imprecision).One study (500 participants) compared alcohol-only rub versus an aqueous scrub and found no clear evidence of a difference in the risk of SSI (RR 0.56, 95% CI 0.23 to 1.34, very low quality evidence downgraded for imprecision and risk of bias).One study (4387 participants) compared alcohol rubs with additional active ingredients versus aqueous scrubs and found no clear evidence of a difference in SSI (RR 1.02, 95% CI 0.70 to 1.48, low quality evidence downgraded for imprecision and risk of bias).One study (100 participants) compared an alcohol rub with an additional ingredient versus an aqueous scrub with a brush and found no evidence of a difference in SSI (RR 0.50, 95% CI 0.05 to 5.34, low quality evidence downgraded for imprecision). CFUsThe review presents results for a number of comparisons; key findings include the following.Four studies compared different aqueous scrubs in reducing CFUs on hands.Three studies found chlorhexidine gluconate scrubs resulted in fewer CFUs than povidone iodine scrubs immediately after scrubbing, 2 hours after the initial scrub and 2 hours after subsequent scrubbing. All evidence was low or very low quality, with downgrading typically for imprecision and indirectness of outcome. One trial comparing a chlorhexidine gluconate scrub versus a povidone iodine plus triclosan scrub found no clear evidence of a difference-this was very low quality evidence (downgraded for risk of bias, imprecision and indirectness of outcome).Four studies compared aqueous scrubs versus alcohol rubs containing additional active ingredients and reported CFUs. In three comparisons there was evidence of fewer CFUs after using alcohol rubs with additional active ingredients (moderate or very low quality evidence downgraded for imprecision and indirectness of outcome). Evidence from one study suggested that an aqueous scrub was more effective in reducing CFUs than an alcohol rub containing additional ingredients, but this was very low quality evidence downgraded for imprecision and indirectness of outcome.Evidence for the effectiveness of different scrub durations varied. Four studies compared the effect of different durations of scrubs and rubs on the number of CFUs on hands. There was evidence that a 3 minute scrub reduced the number of CFUs compared with a 2 minute scrub (very low quality evidence downgraded for imprecision and indirectness of outcome). Data on other comparisons were not consistent, and interpretation was difficult. All further evidence was low or very low quality (typically downgraded for imprecision and indirectness).One study compared the effectiveness of using nail brushes and nail picks under running water prior to a chlorhexidine scrub on the number of CFUs on hands. It was unclear whether there was a difference in the effectiveness of these different techniques in terms of the number of CFUs remaining on hands (very low quality evidence downgraded due to imprecision and indirectness).

AUTHORS' CONCLUSIONS

There is no firm evidence that one type of hand antisepsis is better than another in reducing SSIs. Chlorhexidine gluconate scrubs may reduce the number of CFUs on hands compared with povidone iodine scrubs; however, the clinical relevance of this surrogate outcome is unclear. Alcohol rubs with additional antiseptic ingredients may reduce CFUs compared with aqueous scrubs. With regard to duration of hand antisepsis, a 3 minute initial scrub reduced CFUs on the hand compared with a 2 minute scrub, but this was very low quality evidence, and findings about a longer initial scrub and subsequent scrub durations are not consistent. It is unclear whether nail picks and brushes have a differential impact on the number of CFUs remaining on the hand. Generally, almost all evidence available to inform decisions about hand antisepsis approaches that were explored here were informed by low or very low quality evidence.

Triclosan Induces Thymic Stromal Lymphopoietin in Skin Promoting Th2 Allergic Responses

Triclosan is an antimicrobial chemical incorporated into many personal, medical and household products. Approximately, 75% of the U.S. population has detectable levels of triclosan in their urine, and although it is not typically considered a contact sensitizer, recent studies have begun to link triclosan exposure with augmented allergic disease. We examined the effects of dermal triclosan exposure on the skin and lymph nodes of mice and in a human skin model to identify mechanisms for augmenting allergic responses. Triclosan (0%-3%) was applied topically at 24-h intervals to the ear pinnae of OVA-sensitized BALB/c mice. Skin and draining lymph nodes were evaluated for cellular responses and cytokine expression over time. The effects of triclosan (0%-0.75%) on cytokine expression in a human skin tissue model were also examined. Exposure to triclosan increased the expression of TSLP, IL-1β, and TNF-α in the skin with concomitant decreases in IL-25, IL-33, and IL-1α. Similar changes in TSLP, IL1B, and IL33 expression occurred in human skin. Topical application of triclosan also increased draining lymph node cellularity consisting of activated CD86(+)GL-7(+) B cells, CD80(+)CD86(+) dendritic cells, GATA-3(+)OX-40(+)IL-4(+)IL-13(+) Th2 cells and IL-17 A(+) CD4 T cells. In vivo antibody blockade of TSLP reduced skin irritation, IL-1β expression, lymph node cellularity, and Th2 responses augmented by triclosan. Repeated dermal exposure to triclosan induces TSLP expression in skin tissue as a potential mechanism for augmenting allergic responses.

Role of healthcare apparel and other healthcare textiles in the transmission of pathogens: a review of the literature

Healthcare workers (HCWs) wear uniforms, such as scrubs and lab coats, for several reasons: (1) to identify themselves as hospital personnel to their patients and employers; (2) to display professionalism; and (3) to provide barrier protection for street clothes from unexpected exposures during the work shift. A growing body of evidence suggests that HCWs' apparel is often contaminated with micro-organisms or pathogens that can cause infections or illnesses. While the majority of scrubs and lab coats are still made of the same traditional textiles used to make street clothes, new evidence suggests that current innovative textiles function as an engineering control, minimizing the acquisition, retention and transmission of infectious pathogens by reducing the levels of bioburden and microbial sustainability. This paper summarizes recent literature on the role of apparel worn in healthcare settings in the acquisition and transmission of healthcare-associated pathogens. It proposes solutions or technological interventions that can reduce the risk of transmission of micro-organisms that are associated with the healthcare environment. Healthcare apparel is the emerging frontier in epidemiologically important environmental surfaces.

Guideline for Prevention of Intravascular-Device–Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Effects of food colouring added to 2% chlorhexidine gluconate and 70% alcohol for surgical site antisepsis

Preoperative cleansing of a patient's skin with chlorhexidine gluconate (CHG) in alcohol is superior to cleansing with povidone-iodine for preventing surgical site infection (SSI) after clean-contaminated surgery (Darouilche et al 2010). However, 2% CHG in 70% alcohol, tinted pink, is colourless when applied to limbs for surgery and complete coverage cannot be assured. The purpose of the study was to evaluate the efficacy of food colouring added to CHG in preoperative skin preparation. Two hundred and eight subjects were randomly selected from a population of healthy young adults and were given a questionnaire. They were excluded if they had a known allergy to CHG or food dye, a current infection at the preparation site, or previous preparation with CHG at the site. CHG with food dye additive was applied on the subject's left foot while CHD without the additive was applied on the right. Skin swabs were then taken of both feet and plated on blood agar plates and incubated for 48 hours. Assessment of growth was compared. Patients treated with tinted CHG had around 3.4 times (95% CI: 1.5, 7.8) the risk of a positive bacterial swab compared with those treated with untinted CHG. The efficacy of CHG significantly decreased with food colouring additive. This is consistent with previous studies conducted on similar incompatible substances. In order to have the full efficacy of CHG as a preparation, much thought and care needs to be taken to prevent contamination of the site and substance.

Comparing hand hygiene measures in a neonatal ICU: a randomized crossover trial

OBJECTIVE

To compare plain soap, alcohol hand rub and iodophors as hand hygiene measures in a neonatal intensive care unit (NICU).

DESIGN

Randomized, crossover, three-armed, controlled trial with blinded outcome measurement.

SETTING

Level III NICU.

PARTICIPANTS

35 NICU nurses.

INTERVENTION

Participants were assigned to plain soap hand washing, alcohol hand rub and povidone-iodine hand scrub by a random cross-over design. Interventions were preceded by 14-day neutral periods. Cultures from hands were taken before and after each hand-hygiene use, prior to 5 patient-care activities.

MAIN OUTCOME MEASURE

The primary outcome was mean post-hygiene colony forming unit count (CFU-C).

RESULTS

There were differences between soap, alcohol and povidone groups vis a vis posthygiene CFUC [median: 60, 8 and 10.5, respectively (P<0.001)], absolute reduction in CFU-C [median: 15, 100 and 40, respectively (P<0.001)], percent reduction in CFUC [median: 33.3, 92 and 87, respectively (P<0.001)] and proportion with low CFU-C [47%, 71% and 72%, respectively (P<0.001)]. Alcohol [Adjusted OR 3.2 (95% CI 1.9, 5.3)], povidone-iodine [AOR 3.1 (95% CI 1.8, 5.3)] and high prehygiene CFU-C (>300) [AOR 0.18 (95% CI 0.1, 0.3)] were independently associated with low CFU-C.

CONCLUSION

After a 2 minute hand wash at entry into NICU, alcohol hand rub and povidone-iodine scrub are superior to plain soap hand wash for subsequent decontamination of hands of nurses working in NICU.

Fighting nosocomial infections with biocidal non-intrusive hard and soft surfaces

Approximately 7 million people worldwide acquire a healthcare associated infection each year. Despite aggressive monitoring, hand washing campaigns and other infection control measures, nosocomial infections (NI) rates, especially those caused by antibiotic resistant pathogens, are unacceptably high worldwide. Additional ways to fight these infections need to be developed. A potential overlooked and neglected source of nosocomial pathogens are those found in non-intrusive soft and hard surfaces located in clinical settings. Soft surfaces, such as patient pyjamas and beddings, can be an excellent substrate for bacterial and fungal growth under appropriate temperature and humidity conditions as those present between patients and the bed. Bed making in hospitals releases large quantities of microorganisms into the air, which contaminate the immediate and non-immediate surroundings. Microbes can survive on hard surfaces, such as metal trays, bed rails and door knobs, for very prolonged periods of time. Thus soft and hard surfaces that are in direct or indirect contact with the patients can serve as a source of nosocomial pathogens. Recently it has been demonstrated that copper surfaces and copper oxide containing textiles have potent intrinsic biocidal properties. This manuscript reviews the recent laboratory and clinical studies, which demonstrate that biocidal surfaces made of copper or containing copper can reduce the microbiological burden and the NI rates.

A meta-analysis of the published literature on the effectiveness of antimicrobial soaps

The goal of this research was to conduct a systematic quantitative analysis of the existing data in the literature in order to determine if there is a difference between antimicrobial and nonantimicrobial soaps and to identify the methodological factors that might affect this difference. Data on hand washing efficacy and experimental conditions (sample size, wash duration, soap quantity, challenge organism, inoculum size, and neutralization method) from published studies were compiled and transferred to a relational database. A total of 25 publications, containing 374 observations, met the study selection criteria. The majority of the studies included fewer than 15 observations with each treatment and included a direct comparison between nonantimicrobial soap and antimicrobial soap. Although differences in efficacy between antimicrobial and nonantimicrobial soap were small (∼0.5-log CFU reduction difference), antimicrobial soap produced consistently statistically significantly greater reductions. This difference was true for any of the antimicrobial compounds investigated where n was >20 (chlorhexidine gluconate, iodophor, triclosan, or povidone). Average log reductions were statistically significantly greater (∼2 log CFU) when either gram-positive or gram-negative transient organisms were deliberately added to hands compared with experiments done with resident hand flora (∼0.5 log CFU). Our findings support the importance of using a high initial inoculum on the hands, well above the detection limit. The inherent variability in hand washing seen in the published literature underscores the importance of using a sufficiently large sample size to detect differences when they occur.

Microbial contamination of procedure gloves after opening the container and during exposure in the environment

The objective of this study was to quantify the colony forming units (cfu) on latex procedure gloves in the beginning, middle, and end of the containers in real (professional) and controlled (researcher) gloving situations; evaluate the microbial load of the gloves, considering the time of exposure in the environment. This comparative prospective study was conducted at an intensive care unit of a teaching hospital. The microbiological data was collected from the gloves using digital-pressure. Microbiological evaluations were performed on 186 pairs of gloves: 93 in the control group and 93 in real gloving situations. In the control group, the average cfu was 4.7 against 6.2 in the real gloving situation. Hence, no statistically significant difference was found (p=.601). In addition, the cfu values of gloves in the beginning, middle and end of the containers also did not show any significant differences (p>.05). The most common strain was Staphylococcus spp. The time of exposure in the environment did not increase the cfu value of the latex gloves.

A research framework for reducing preventable patient harm

Programs to reduce central line-associated bloodstream infections (CLABSIs) have improved the safety of hospitalized patients. Efforts are underway to disseminate these successes broadly to reduce other types of hospital-acquired infectious and noninfectious preventable harms. Unfortunately, the ability to broadly measure and prevent other types of preventable harms, especially infectious harms, needs enhancement. Moreover, an overarching research framework for creating and integrating evidence will help expedite the development of national prevention programs. This article outlines a 5-phase translational (T) framework to develop robust research programs that reduce preventable harm, as follows: phase T0, discover opportunities and approaches to prevent adverse health care events; phase T1, use T0 discoveries to develop and test interventions on a small scale; phase T2, broaden and strengthen the evidence base for promising interventions to develop evidence-based guidelines; phase T3, translate guidelines into clinical practice; and phase T4, implement and evaluate T3 work on a national and international scale. Policy makers should use this framework to fill in the knowledge gaps, coordinate efforts among federal agencies, and prioritize research funding.

Facile design and nanostructural evaluation of silver-modified titania used as disinfectant

Fundamental research has been carried out to define optimal "green" synthesis conditions for the production of titania (TiO(2)) and silver (Ag) nanocomposites (TANCs) ranging from 12.7-22.8 nm in diameter. A bottom-up colloidal approach was employed to accurately control TANC monodispersity and composition. TANCs were found to be effective at inactivating Escherichia coli (E. coli) in water. The presence of Ag in the nanocomposites induced a decrease in TiO(2) band gap energy, which favoured valence to conduction band electron transfer and allowed for electron excitation using visible light. Aggregation of ultra-fine particles was prevented through the use of a long-chain polymer as evidenced by electrophoretic mobility studies. The TANCs catalyzed oxidation of bacterial membranes and cell death or disinfection. Theoretically, the TANC mode of E. coli disinfection is via water photolysis, which results in production of hydroxyl radicals and hydrogen peroxide. These interact with the outer membrane polysaccharides and lipids, leading to lipid peroxidation, membrane weakening and resulted in cell death. Our overarching goals were to optimize the variables involved in TANC "green" synthesis and to characterize its nanostructure. High resolution (HR) transmission and scanning electron microscopic (TEM and SEM) studies demonstrated that TANCs were highly crystalline and mono-dispersive. Elemental composition of Ag and Ti, as measured by X-ray energy dispersive (EDS) and X-ray photoelectron spectroscopy (XPS) confirmed sample purity. Ultraviolet-visible (UV-VIS) spectroscopy showed that the energy band-gap of Ag modified TiO(2) was in the visible range.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 10. Alcohol-based antiseptics for hand disinfection and a comparison of their effectiveness with soaps

Alcohol compounds are increasingly used as a substitute for hand washing in health care environments and some public places because these compounds are easy to use and do not require water or hand drying materials. However, the effectiveness of these compounds depends on how much soil (bioburden) is present on the hands. Workers in health care environments and other public places must wash their hands before using antiseptics and/or wearing gloves. However, alcohol-based antiseptics, also called rubs and sanitizers, can be very effective for rapidly destroying some pathogens by the action of the aqueous alcohol solution without the need for water or drying with towels. Alcohol-based compounds seem to be the most effective treatment against gram-negative bacteria on lightly soiled hands, but antimicrobial soaps are as good or better when hands are more heavily contaminated. Instant sanitizers have no residual effect, unlike some antimicrobial soaps that retain antimicrobial activity after the hygienic action has been completed, e.g., after hand washing. Many alcohol-based hand rubs have antimicrobial agents added to them, but each formulation must be evaluated against the target pathogens in the environment of concern before being considered for use. Wipes also are widely used for quick cleanups of hands, other body parts, and surfaces. These wipes often contain alcohol and/or antimicrobial compounds and are used for personal hygiene where water is limited. However, antiseptics and wipes are not panaceas for every situation and are less effective in the presence of more than a light soil load and against most enteric viruses.

Occurrence, efficacy, metabolism, and toxicity of triclosan

Triclosan has broad-spectrum anti-microbial activity against most gram-negative and gram-positive bacteria. It is widely used in personal care products, household items, medical devices, and clinical settings. Due to its extensive use, there is potential for humans in all age groups to receive life-time exposures to triclosan, and, indeed, triclosan has been detected in human tissues and the environment. Data gaps exist regarding the chronic dermal toxicity and carcinogenicity of triclosan, which is needed for the risk assessment of triclosan. The US Food and Drug Administration (FDA) nominated triclosan to the National Toxicology Program (NTP) for toxicological evaluations. Currently, the NTP is conducting several dermal toxicological studies to determine the carcinogenic potential of triclosan, evaluate its endocrine and developmental-reproductive effects, and investigate the potential UV-induced dermal formation of chlorinated phenols and dioxins of triclosan. This paper reviews data on the human exposure, environmental fate, efficacy of anti-microbial activity, absorption, distribution, metabolism and elimination, endocrine disrupting effects, and toxicity of triclosan.

Decreasing central line associated bloodstream infection in neonatal intensive care

Central Line Associated Bloodstream Infections (CLABSIs) have come to be recognized as preventable adverse events that result from lapses in technique at multiple levels of care. CLABSIs are associated with increased mortality and adverse outcomes that may have lifelong consequences. This review provides a summary of evidence-based strategies to reduce CLABSI in the newborn intensive care unit that have been described in the literature over the past decades. Implementation of these strategies in "bundles" is also discussed, citing examples of successful quality improvement collaboratives. The methods of implementation require an understanding of the scientific data and technical developments, as well as knowledge of how to influence change within the unique and complicated milieu of the newborn intensive care unit.

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.

Sensing the environment: response of Candida albicans to the X factor

Virulence of the fungal human pathogen Candida albicans is also attributed to its ability to switch reversibly between yeast and hyphal growth forms. Morphogenesis in this yeast is influenced by the composition of the environment, activating sensors, which consequently play an important role in fungal pathogenicity. This review summarizes some of the main environmental sensors, their ligands and downstream signaling pathways in C. albicans. We will focus on proteins localized in the plasma membrane and on the interaction between cells and their environment. This will underline the convergence of several environmental signals onto the mitogen-activated protein kinase and protein kinase A pathways.

Development of a method to measure bacterial transfer from hands

A method was developed to investigate the transfer of bacteria from the hands of healthcare workers (HCWs). The method involved standardised hand contact between the HCW and a recipient wearing sterile gloves, followed by sampling of the bare hands of the HCW and the gloved hands of the recipient by the glove juice method. The duration of contact, degree of friction and dryness of the hands could be varied. We investigated the applicability of the method for measuring transfer from hands artificially contaminated with Escherichia coli as well as from naturally contaminated hands following a 30s contact time with moderate friction and dry hands. Only a small proportion of bacteria on donor hands was recovered from the recipient: 0.15% for E. coli and 0.07% for natural hand flora. A smaller proportion of E. coli was recovered from bare skin compared with gloves, suggesting reduced survival of bacteria as a result of contact with natural skin. We suggest that these data are clinically relevant, and may indicate low transfer of bacteria during short contact with dry hands. This method is suitable to investigate the effect of potential risk factors for ineffective hand hygiene and the effect of hand hygiene procedures on contact transmission in clinical studies with large numbers of HCWs.

Povidone-iodine: use in hand disinfection, skin preparation and antiseptic irrigation

Iodine and its antibacterial properties have been used for the prevention or management of wound infections for over 150 years. However, the use of solutions (tincture) of iodine has been replaced by the widespread use of povidone-iodine, a water-soluble compound, which is a combination of molecular iodine and polyvinylpyrrolidone. The resultant broad spectrum of antimicrobial activity is well documented and its efficacy, particularly in relation to resistant micro-organisms such as methicillin-resistant Staphylococcus aureus, has been shown. In the clinical environment, there is no general agreement regarding the 'best' antiseptic and the practice varies widely. This article reviews the studies that have assessed the efficacy of povidone-iodine in hand disinfection and skin preparation and its use as an antiseptic irrigant. Although there is a distinct lack of well-designed, randomised controlled trials evaluating antiseptic efficacy, selection should be based on the next best available evidence. This evidence suggests that the use of povidone-iodine as an agent of choice is dependent on the clinical need but is also likely to be influenced by personal preference.

Increasing the frequency of hand washing by healthcare workers does not lead to commensurate reductions in staphylococcal infection in a hospital ward

Background

Hand hygiene is generally considered to be the most important measure that can be applied to prevent the spread of healthcare-associated infection (HAI). Continuous emphasis on this intervention has lead to the widespread opinion that HAI rates can be greatly reduced by increased hand hygiene compliance alone. However, this assumes that the effectiveness of hand hygiene is not constrained by other factors and that improved compliance in excess of a given level, in itself, will result in a commensurate reduction in the incidence of HAI. However, several researchers have found the law of diminishing returns to apply to hand hygiene, with the greatest benefits occurring in the first 20% or so of compliance, and others have demonstrated that poor cohorting of nursing staff profoundly influences the effectiveness of hand hygiene measures. Collectively, these findings raise intriguing questions about the extent to which increasing compliance alone can further reduce rates of HAI.

Methods

In order to investigate these issues further, we constructed a deterministic Ross-Macdonald model and applied it to a hypothetical general medical ward. In this model the transmission of staphylococcal infection was assumed to occur after contact with the transiently colonized hands of HCWs, who, in turn, acquire contamination only by touching colonized patients. The aim of the study was to evaluate the impact of imperfect hand cleansing on the transmission of staphylococcal infection and to identify, whether there is a limit, above which further hand hygiene compliance is unlikely to be of benefit.

Results

The model demonstrated that if transmission is solely via the hands of HCWs, it should, under most circumstances, be possible to prevent outbreaks of staphylococcal infection from occurring at a hand cleansing frequencies < 50%, even with imperfect hand hygiene. The analysis also indicated that the relationship between hand cleansing efficacy and frequency is not linear – as efficacy decreases, so the hand cleansing frequency required to ensure R0 < 1 increases disproportionately.

Conclusion

Although our study confirmed hand hygiene to be an effective control measure, it demonstrated that the law of diminishing returns applies, with the greatest benefit derived from the first 20% or so of compliance. Indeed, our analysis suggests that there is little benefit to be accrued from very high levels of hand cleansing and that in most situations compliance > 40% should be enough to prevent outbreaks of staphylococcal infection occurring, if transmission is solely via the hands of HCWs. Furthermore we identified a non-linear relationship between hand cleansing efficacy and frequency, suggesting that it is important to maximise the efficacy of the hand cleansing process.

Impact of a standardized hand hygiene program on the incidence of nosocomial infection in very low birth weight infants

BACKGROUND

This study examined the effects of a standardized hand hygiene program on the rate of nosocomial infection (NI) in very low birth weight (VLBW) infants (birth weight < 1500 g) admitted to our neonatal intensive care unit (NICU).

METHODS

We compared the rate of NI in VLBW infants in 2 separate periods. In the first period, staff were encouraged to perform handwashing using a plain fluid detergent (0.5% triclosan). In the second period, a standardized hand hygiene program was implemented using antimicrobial soap (4% chlorhexidine gluconate) and alcohol-based hand rubs.

RESULTS

NI after 72 hours of life was detected in 16 of the 85 VLBW infants in the first period and in 5 of the 80 VLBW infants in the second period. The rate of central venous catheter colonization was significantly lower in the second period (5.8%) than in the first period (16.6%).

CONCLUSION

In our NICU, the incidence of NI in VLBW infants was significantly reduced after the introduction of a standardized handwashing protocol. In our experience, a proper hand hygiene program can save approximately 10 NI episodes/year, at a cost of $10,000 per episode. Therefore, improving hand hygiene practice is a cost-effective program in the NICU.

Neurological infections after neuraxial anesthesia

Infection is the commonest cause of serious neurologic sequelae of neuraxial anesthesia. The incidence depends on operator skill and patient population. Meningitis, a complication of dural puncture, is usually caused by viridans streptococci. The risk factors are dural puncture during labor, no mask and poor aseptic technique, vaginal infection and bacteremia. Epidural abscess is a complication of epidural catheterization, route of entry the catheter track and the organism usually the staphylococcus. Principal risk factors are prolonged catheterization, poor aseptic technique and traumatic insertion. Prevention includes wearing a mask, using a full sterile technique, avoiding prolonged catheterization and prescribing antibiotics in a high-risk situation.