Bacterial carriage by artificial versus natural nails

The glitz and glamour randomized trial: the effect of fingernail polish on post-caesarean surgical site infection

Current surgical scrub guidelines suggest that fingernail polish should not be worn by healthcare providers despite collective evidence not demonstrating a relationship between fingernail polish and surgical-site infection (SSI). The purpose of this study was to determine the effect of surgical staff wearing nail polish on the incidence of SSI after caesarean delivery. In this calendar block-randomised clinical trial, surgical staff were assigned to wear nail polish or to have unpainted nails for alternating two-week periods. The primary outcome was surgical site infection within 6 weeks of caesarean delivery. There were 372 patients in the nail polish arm and 465 in the polish-free arm. The rate of SSIs was not significantly different between the nail polish arm and the polish-free arm (1.3% vs 2.8% p = .155). We found the rate of SSI following caesarean delivery is not significantly affected by surgical staff wearing fingernail polish.Impact StatementWhat is already known on this subject? Current surgical scrub guidelines state that fingernail polish should not be worn by healthcare providers even though the collective evidence has not been able to show the relationship between fingernail polish and surgical site infection. Previous studies have only used bacterial colony count after handwashing as a primary endpoint. The evidence they provide for developing scrub guidelines have been contradictory and inconclusive.What do the results of this study add? To better inform surgical scrub guidelines, evidence is needed that evaluates the effect of fingernail polish on clinically significant endpoints. Our study, Glitz & Glamour, examined 885 non-emergent Caesarian sections using a calendar-block schedule to determine if wearing nail polish had an impact on rates of surgical site infection.What are the implications of these findings for clinical practice and/or further research? Results suggested that fingernail polish had no difference on frequency of surgical site infections, and neither condition of the polish (chipped vs. freshly applied) nor the type of polish (gel vs. regular) had any impact either.

Microbial Growth on the Nails of Direct Patient Care Nurses Wearing Nail Polish

OBJECTIVES

To determine whether nurses wearing nail polish pose a greater infection risk to patients than nurses who are not wearing nail polish.

SAMPLE & SETTING

89 direct patient care oncology nurses at a large midwestern National Cancer Institute-designated comprehensive cancer center.

METHODS & VARIABLES

The investigators assigned participants' three middle fingers of their dominant hand to three groups.

RESULTS

Comparison of colony-forming units revealed that one-day-old polish exhibited fewer gram-positive microorganisms than the unpolished nail (p = 0.04). The four-day-old polish showed significantly more microorganisms than the one-day-old polish (p = 0.03). The same trend was demonstrated for gram-negative microorganisms, but the difference was not statistically significant (p = 0.3 and p = 0.17, respectively).

IMPLICATIONS FOR NURSING

The results should be interpreted and applied to expert nursing practice in the care of vulnerable patient populations. Each institution and practitioner should make their own decisions and interpretation of evidence into practice.

Evaluation of the bacterial burden of gel nails, standard nail polish, and natural nails on the hands of health care workers

BACKGROUND

Acrylic nails harbor more bacteria than natural nails, and wear is not recommended for health care workers (HCWs). Little is known about the new and popular gel nail products. This study sought to evaluate the bacterial burden of gel nails, standard nail polish, and natural nails on the hands of HCWs.

METHODS

The study was conducted at 3 health centers. Nails on the dominant hand of 88 HCWs were painted with gel polish and standard polish. Cultures were obtained on days 1, 7, and 14 of wear and before and after hand hygiene with alcohol hand gel.

RESULTS

A total of 741 cultures were obtained. Bacterial burden increased over time for all nail types (P ≤ .0001). Reductions in the bacterial burden of natural nails and standard polish, but not gel polish, (P = .001, P = .0028, and P = .98, respectively) were seen after hand hygiene. All 3 nail types become more contaminated with bacteria over time. Standard polish and natural nails may be more amenable to hand hygiene than gel polish.

CONCLUSIONS

This study did not show an increased number of microorganisms on nails with gel polish; however, gel nails may be more difficult to clean using alcohol hand gel.

Microbial counts in hands with and without nail varnish after surgical skin preparation: a randomized control trial

Nail varnish is commonly removed from fingernails prior to surgical procedures. We report the results of a randomized controlled trial comparing the microbial counts in hands with and without nail varnish applied, following surgical skin preparation. Forty-three patients were randomized; three patients were lost to follow-up. Each patient had one hand painted with nail varnish and had both hands tested 1 week later. There was no significant difference in terms of positive microbial growth between the nail plates or hyponichia with or without nail varnish applied. Our results demonstrate that the presence of nail varnish does not have an effect on the microbial counts of hands following surgical skin preparation.

LEVEL OF EVIDENCE

I.

Safety and Efficacy of Nail Products

Over the past several decades, the commercialization of nail cosmetics has increased. From nail polishes to artificial nails, different methods of nail beautification have become popularized. However, the impact of these products remains largely unknown. Governments have passed legislation in attempts to regulate nail cosmetics, but these regulations may not be adequate and are difficult to enforce. Knowledge of the safety and efficacy of nail products remains limited due to the relative dearth of literature published on the topic. This review serves to summarize and interpret the data available regarding common nail products and their safety and efficacy. Nail products such as nail polish, nail polish removers, and artificial nails have shown to have some adverse effects through case reports and studies. Harmful substances such as toluenesulfonamide-formaldehyde resin and methacrylates have been identified in commercial nail products, leading to several adverse effects, but in particular, allergic contact dermatitis. Exposure to substances such as acetonitrile found in removers may have more toxic and caustic effects, especially if ingested. In addition, for nail technicians there are negative effects linked with occupational exposure. Compounds used in nail products may become aerosolized and lead to asthma, eye and throat irritation, and even neurocognitive changes.

The Neurostimulation Appropriateness Consensus Committee (NACC) Recommendations for Infection Prevention and Management

INTRODUCTION

The use of neurostimulation for pain has been an established therapy for many decades and is a major tool in the arsenal to treat neuropathic pain syndromes. Level I evidence has recently been presented to substantiate the therapy, but this is balanced against the risk of complications of an interventional technique.

METHODS

The Neurostimulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society convened an international panel of well published and diverse physicians to examine the best practices for infection mitigation and management in patients undergoing neurostimulation. The NACC recommendations are based on evidence scoring and peer-reviewed literature. Where evidence is lacking the panel added expert opinion to establish recommendations.

RESULTS

The NACC has made recommendations to improve care by reducing infection and managing this complication when it occurs. These evidence-based recommendations should be considered best practices in the clinical implantation of neurostimulation devices.

CONCLUSION

Adhering to established standards can improve patient care and reduce the morbidity and mortality of infectious complications in patients receiving neurostimulation.

Artificial Nails: Are They Putting Patients at Risk? A Review of the Research

The use of artificial nails has become a popular fashion trend, and many health care workers are following this trend. There is debate whether artificial nails are putting patients at risk of nosocomial infections. Researchers have shown that the colony counts on artificial nails are greater than the colony counts on native nails. Artificial nails have also been linked to poor hand washing practices and more tears in gloves. These factors lead to an increased risk of transmitting bacteria to patients. This transmission could greatly affect patients because the hospitalized patient's risk of nosocomial infection is high. The purpose of this article is to review the data related to the bacterial and fungal contamination of artificial nails and their implications for health care workers. Most of the review describes findings of studies of surgical patients and health care workers who work in surgery departments, but the research applies to any area where there is a risk of transferring potential pathogens to immunocompromised patients.

Infection Prevention and Control Guideline for Cystic Fibrosis: 2013 Update

The 2013 Infection Prevention and Control (IP&C) Guideline for Cystic Fibrosis (CF) was commissioned by the CF Foundation as an update of the 2003 Infection Control Guideline for CF. During the past decade, new knowledge and new challenges provided the following rationale to develop updated IP&C strategies for this unique population:

1.The need to integrate relevant recommendations from evidence-based guidelines published since 2003 into IP&C practices for CF. These included guidelines from the Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC), the World Health Organization (WHO), and key professional societies, including the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). During the past decade, new evidence has led to a renewed emphasis on source containment of potential pathogens and the role played by the contaminated healthcare environment in the transmission of infectious agents. Furthermore, an increased understanding of the importance of the application of implementation science, monitoring adherence, and feedback principles has been shown to increase the effectiveness of IP&C guideline recommendations.

2.Experience with emerging pathogens in the non-CF population has expanded our understanding of droplet transmission of respiratory pathogens and can inform IP&C strategies for CF. These pathogens include severe acute respiratory syndrome coronavirus and the 2009 influenza A H1N1. Lessons learned about preventing transmission of methicillin-resistantStaphylococcus aureus(MRSA) and multidrug-resistant gram-negative pathogens in non-CF patient populations also can inform IP&C strategies for CF.

Infection Risk Reduction in the Intensive Care Nursery: A Review of Patient Care Practices That Impact the Infection Risk in Global Care of the Hospitalized Neonates

Neonates are at high risk for developing an infection during their hospital stay in the neonatal intensive care unit. Increased risk occurs because of immaturity of the neonate's immune system, lower gestational age, severity of illness, surgical procedures, and instrumentation with life support devices such as vascular catheters. Neonates become colonized with bacteria prior to or at delivery and also during their hospital stay. They can then become infected with those bacteria if there is a breakdown in the primary defenses such as tissue injury due to skin breakdown, nasal erosion, or trauma to the respiratory tract. Neonates are also at high risk for bacterial translocation due to the altered permeability of the intestinal mucosa, loss of commensal flora, and bacterial overgrowth. The unit-based neonatal care team must implement global care delivery and safety practices, utilize published care guidelines, know and apply evidence-based practices from collaborative quality improvement efforts and other sources, and use auditing and monitoring practices that can identify risks and lead to better practice options to prevent infections. This article presents several aspects of global neonatal care delivery, including vascular access, which may reduce the risk of systemic infection during the hospitalization.

Principles of infection prevention and reprocessing in ENT endoscopy

This article gives an overview on the principles of reprocessing of rigid and flexible endoscopes used in ENT units including structural and spatial requirements based on general and ENT-specific risks of infection associated with diagnostic and therapeutic endoscopy. The underlying legal principles as well as recommendations from scientific societies will be exemplified in order to give a practical guidance to the otorhinolaryngologist. Preliminary results of a small nation-wide survey on infection control standards based on data of 29 ENT practices in Germany reveal current deficits of varying degree concerning infection control management including reprocessing of endoscopes. The presented review aims to give support to the establishment of a structured infection control management program including the evaluation of results by means of a prospective surveillance.

Comprehensive review of methicillin-resistant Staphylococcus aureus: screening and preventive recommendations for plastic surgeons and other surgical health care providers

BACKGROUND

Up to 2.3 million people are colonized with methicillin-resistant Staphylococcus aureus in the United States, causing well-documented morbidity and mortality. Although the association of clinical outcomes with community and hospital carriage rates is increasingly defined, less is reported about asymptomatic colonization prevalence among physicians, and specifically plastic surgeons and the subsequent association with the incidence of patient surgical-site infection.

METHODS

A review of the literature using the PubMed and Cochrane databases analyzing provider screening, transmission, and prevalence was undertaken. In addition, a search was completed for current screening and decontamination guidelines and outcomes.

RESULTS

The methicillin-resistant S. aureus carriage prevalence of surgical staff is 4.5 percent. No prospective data exist regarding transmission and interventions for plastic surgeons. No studies were found specifically looking at prevalence or treatment of plastic surgeons. Current recommendations by national organizations focus on patient-oriented point-of-care testing and intervention, largely ignoring the role of the health care provider. Excellent guidelines exist regarding screening, transmission prevention, and treatment both in the workplace and in the community. No current such guidelines exist for plastic surgeons.

CONCLUSIONS

No Level I or II evidence was found regarding physician screening, treatment, or transmission. Current expert opinion, however, indicates that plastic surgeons and their staff should be vigilant for methicillin-resistant S. aureus transmission, and once a sentinel cluster of skin and soft-tissue infections is identified, systematic screening and decontamination should be considered. If positive, topical decolonization therapy should be offered. In refractory cases, oral antibiotic therapy may be required, but this should not be used as a first-line strategy.

Survey of Knowledge, Beliefs, and Practices of Neonatal Intensive Care Unit Healthcare Workers Regarding Nosocomial Infections, Central Venous Catheter Care, and Hand Hygiene

Objective:

To assess the knowledge, beliefs, and practices of neonatal intensive care unit (NICU) healthcare workers (HCWs).

Design:

Self-administered survey.

Setting:

A 55-bed NICU.

Participants:

NICU HCWs (N = 215).

Results:

The response rate was 68%. Ninety-two percent knew central venous catheters (CVCs) should be capped, clamped, or connected to running fluids at all times. Ninety-five percent knew when to change gloves. Thirty-one percent knew the recommended duration for handwashing. Most HCWs believed sterile technique in CVC care (96%), gloves (91%), and handwashing (99%) prevent nosocomial infection (NI). Sixty-seven percent used sterile barriers to insert CVCs, 76% reported wearing gloves, 81% reported routine handwashing, 35% knew that bacterial hand counts are higher with rings, 30% knew that long fingernails are associated with higher gram-negative bacterial hand contamination, and 35% knew that artificial fingernails are associated with higher gram-negative bacterial hand contamination. Most (93%) believed HCWs can affect outcomes of patients with NIs. Fewer believed rings (40%), artificial fingernails (61%), and long fingernails (48%) play a role in NIs, or that policies concerning number of rings (50%), cutting fingernails (35%), or prohibiting artificial fingernails (47%) would prevent NIs. Sixty-one percent of HCWs regularly wore at least one ring to work, 56% wore their fingernails shorter than the fingertip, and 8% wore artificial fingernails.

Conclusions:

A disconnect existed between CVC knowledge and beliefs and practice. HCWs did not know the relationship between bacterial hand counts and rings and fingernails, and did not believe rings or long or artificial fingernails increased the risk of NIs.

[Infections of finger and toe nails due to fungi and bacteria]

Infections of the finger and the toe nails are most frequently caused by fungi, primarily dermatophytes. Causative agents of tinea unguium are mostly anthropophilic dermatophytes. Both in Germany, and worldwide, Trichophyton rubrum represents the main important causative agent of onychomycoses. Yeasts are isolated from fungal nail infections, both paronychia and onychomycosis far more often than generally expected. This can represent either saprophytic colonization as well as acute or chronic infection of the nail organ. The main yeasts causing nail infections are Candida parapsilosis, and Candida guilliermondii; Candida albicans is only in third place. Onychomycosis due to molds, or so called non-dermatophyte molds (NDM), are being increasingly detected. Molds as cause of an onychomycosis are considered as emerging pathogens. Fusarium species are the most common cause of NDM onychomycosis; however, rare molds like Onychocola canadensis may be found. Bacterial infections of the nails are caused by gram negative bacteria, usually Pseudomonas aeruginosa (recognizable because of green or black coloration of the nails) but also Klebsiella spp. and gram positive bacteria like Staphylococcus aureus. Treatment of onychomycosis includes application of topical antifungal agents (amorolfine, ciclopirox). If more than 50 % of the nail plate is affected or if more than three out of ten nails are affected by the fungal infection, oral treatment using terbinafine (in case of dermatophyte infection), fluconazole (for yeast infections), or alternatively itraconazole are recommended. Bacterial infections are treated topically with antiseptic agents (octenidine), and in some cases with topical antibiotics (nadifloxacin, gentamicin). Pseudomonas infections of the nail organ are treated by ciprofloxacin; other bacteria are treated according to the results of culture and sensitivity testing.

[Assessing the wearing of jewellery by French healthcare professionals]

OBJECTIVE

A prospective observation study was undertaken in seven medical centers, in the French region Alpes-Maritime, to assess nail hygiene of healthcare professionals and how often they wear hand jewellery.

METHOD

Seven hundred and six healthcare workers in seven medical centers were interviewed from March to April 2008.

RESULTS

Among the 706 professionals, 306 (43%) were wearing one or several pieces of jewellery. The nails of 81 (11.5%) were non-standard according to guidelines. Three hundred and forty-four health care professionals (49%) were wearing one or several pieces of jewellery and/or presented with non-standard nails. In univariate analysis, the wearing of jewellery was linked to the medical centre (P<0.001), to the professional category (p<0.001), to the number of times people washed their hands or used hand gel per day (ABHR) by categories (<10 times per day or ≥10 times per day) (P<0.017). In the multivariate analysis, the risk factors linked to the wearing of jewellery were the medical centers, the professional category, and the age.

CONCLUSION

There are still too many healthcare professionals who do not comply to French recommendations on hand hygiene concerning the wearing of jewellery and nail hygiene standards.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 8. Gloves as barriers to prevent contamination of food by workers

The role played by food workers and other individuals in the contamination of food has been identified as an important contributing factor leading to foodborne outbreaks. To prevent direct bare hand contact with food and food surfaces, many jurisdictions have made glove use compulsory for food production and preparation. When properly used, gloves can substantially reduce opportunities for food contamination. However, gloves have limitations and may become a source of contamination if they are punctured or improperly used. Experiments conducted in clinical and dental settings have revealed pinhole leaks in gloves. Although such loss of glove integrity can lead to contamination of foods and surfaces, in the food industry improper use of gloves is more likely than leakage to lead to food contamination and outbreaks. Wearing jewelry (e.g., rings) and artificial nails is discouraged because these items can puncture gloves and allow accumulation of microbial populations under them. Occlusion of the skin during long-term glove use in food operations creates the warm, moist conditions necessary for microbial proliferation and can increase pathogen transfer onto foods through leaks or exposed skin or during glove removal. The most important issue is that glove use can create a false sense of security, resulting in more high-risk behaviors that can lead to cross-contamination when employees are not adequately trained.

Simple strategies to reduce healthcare associated infections in the neonatal intensive care unit: line, tube, and hand hygiene

This article describes strategies to prevent 2 important healthcare associated infections in the neonatal intensive care unit: central line-associated bloodstream infections and catheter-associated urinary tract infections. Hand hygiene is discussed as the cornerstone for prevention of all healthcare associated infections. Specific recommendations for education and training of health care personnel who insert and maintain central venous catheters and urinary tract catheters are made and best practices for insertion and maintenance of these catheters are discussed. Throughout this article, the emphasis is on prevention of these high morbidity and mortality healthcare associated infections.

Controlling antimicrobial resistance in the hospital

Most evidence-based methods to control the spread of antimicrobial resistance have been developed and applied to the hospital setting. Strategies to control the emergence and spread of antimicrobial resistance in hospitals can be categorized as either infection control or antibiotic stewardship strategies. Infection control is the discipline focused on preventing the spread of infections within the health care setting; antibiotic stewardship can help minimize the emergence of multidrug-resistant organisms by promoting prudent use of antibiotics. This article describes different infection control and antibiotic management strategies that can be used to control antimicrobial resistance in hospital settings.

The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations

The World Health Organization's Guidelines on Hand Hygiene in Health Care have been issued by WHO Patient Safety on 5 May 2009 on the occasion of the launch of the Save Lives: Clean Your Hands initiative. The Guidelines represent the contribution of more than 100 international experts and provide a comprehensive overview of essential aspects of hand hygiene in health care, evidence- and consensus-based recommendations, and lessons learned from testing their Advanced Draft and related implementation tools.

Hand adornment and infection control

Studies have shown that despite infection control guidelines recommending that false fingernails, nail varnish, stoned rings and wrist watches not be worn by clinical staff, a large proportion of them continue to do so. The recently updated epic guidelines (Pratt et al, 2007) state that hand jewellery and false finger nails should be kept short, clean and free from nail polish. This article discusses the bacterial carriage, contributions to outbreaks of infection and interference with proper hand hygiene practices, thereby explaining why these recommendations are made in infection control policies and guidelines.

Hand hygiene: simple and complex

This review gives an overview of hand hygiene in healthcare and in the community, including some aspects which have attracted little attention, such as hand drying and cultural issues determining hand hygiene behaviour. Hand hygiene is the most effective measure for interrupting the transmission of microorganisms which cause infection both in the community and in the healthcare setting. Using hand hygiene as a sole measure to reduce infection is unlikely to be successful when other factors in infection control, such as environmental hygiene, crowding, staffing levels and education are inadequate. Hand hygiene must be part of an integrated approach to infection control. Compliance with hand hygiene recommendations is poor worldwide. While the techniques involved in hand hygiene are simple, the complex interdependence of factors which determine hand hygiene behaviour makes the study of hand hygiene complex. It is now recognised that improving compliance with hand hygiene recommendations depends on altering human behaviour. Input from behavioural and social sciences is essential when designing studies to investigate compliance. Interventions to increase compliance with hand hygiene practices must be appropriate for different cultural and social needs. New strategies to promote hand hygiene worldwide include the formation of public-private partnerships.

Use of Macrolides and Tetracyclines for Chronic Inflammatory Diseases

OBJECTIVE:

To review the efficacy of macrolides and tetracyclines in several chronic inflammatory conditions.

DATA SOURCES:

Searches of MEDLINE (1966–March 2004) and an extensive bibliography search were undertaken. Key terms included acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis.

STUDY SELECTION AND DATA EXTRACTION:

Data were obtained primarily from randomized placebo-controlled trials upon which key recommendations are based.

DATA SYNTHESIS:

Antibiotics are often prescribed for months or even years for treatment of chronic inflammatory conditions such as acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis. Randomized controlled trials have shown that azithromycin is useful in the management of cystic fibrosis and the tetracyclines are beneficial in the management of rheumatoid arthritis, acne, blepharitis, and periodontitis. Several large, randomized controlled trials have failed to show any benefit of macrolides in the secondary prevention of cardiovascular disease. No randomized placebo-controlled clinical trials have been performed to assess the efficacy of macrolides or tetracyclines in patients with rosacea.

CONCLUSIONS:

The use of tetracyclines and macrolides for rosacea is based primarily on anecdotal reports or open-label trials. Limited clinical trials support the use of tetracyclines or macrolides in acne, blepharitis, periodontitis, rheumatoid arthritis, and cystic fibrosis. Trials to date do not support the use of antibiotics for secondary prevention of cardiovascular disease.

Barrier precautions, isolation protocols, and personal hygiene in veterinary hospitals

Because nosocomial and zoonotic diseases are inherent and ever-present risks in veterinary hospitals, proactive policies should be in place to reduce the risk of sporadic cases and outbreaks. Policies should ideally be put in place before disease issues arise, and policies should be effectively conveyed to all relevant personnel. Written policies are required for practical and liability reasons and should be reviewed regularly. Although no infection control program can eliminate disease concerns, proper implementation of barrier precautions and isolation can reduce the exposure of hospitalized animals and hospital personnel to infectious agents. Appropriate personal hygiene, particularly hand hygiene, can assist in the prevention of disease transmission when pathogens bypass barriers and are able to contact personnel. Veterinary hospitals have moral, professional, and legal requirements to provide a safe workplace and to reduce the risks to hospitalized patients. Based on experience in the human medical field and on the continual emergence of new infectious diseases, infection control challenges can only be expected to increase in the future. Regular reassessment of protocols based on ongoing research and clinical experiences is required.

Prevention and treatment of nosocomial sepsis in the NICU

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

Strategic use of antibiotics in the neonatal intensive care unit

Infection is one of the most common causes of infant morbidity and mortality in the neonatal intensive care unit, despite the availability of various therapeutic medical interventions, such as mechanical ventilation, that allow premature infants a better chance of survival. In fact, many of these therapeutic interventions violate the natural protective barriers for infection. Fortunately, maternal and neonatal risk factors have been identified for early- and late-onset sepsis and the prevalence of highly suspected pathogens for each type of infection influences the empiric selection of antibiotics. In many institutions, the common pathogens have developed resistance to antibiotics. In others, the predominance of pathogens has shifted. Both challenges may warrant modification of traditional antibiotic regimens. Continual monitoring of pathogen shifts within an individual neonatal intensive care unit and application of various antibiotic characteristics are key elements of strategic, safe, and effective use of antibiotics in this patient population. Development of a protocol incorporating infection control measures and guidelines for judicious use of antibiotics can minimize the threat of antibiotic resistance.

Outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in a neonatal intensive care unit linked to artificial nails

BACKGROUND

From April to June 2001, an outbreak of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae infections was investigated in our neonatal intensive care unit.

METHODS

Cultures of the gastrointestinal tracts of patients, the hands of healthcare workers (HCWs), and the environment were performed to detect potential reservoirs for ESBL-producing K. pneumoniae. Strains of K. pneumoniae were typed by pulsed-field gel electrophoresis using XbaI. A case-control study was performed to determine risk factors for acquisition of the outbreak clone (clone A); cases were infants infected or colonized with clone A and controls (3 per case) were infants with negative surveillance cultures.

RESULTS

During the study period, 19 case-infants, of whom 13 were detected by surveillance cultures, harbored clone A. The overall attack rate for the outbreak strain was 45%; 9 of 19 infants presented with invasive disease (n = 6) or developed invasive disease (n = 3) after colonization was detected. Clone A was found on the hands of 2 HCWs, 1 of whom wore artificial nails, and on the designated stethoscope of a case-infant. Multiple logistic regression analysis revealed that length of stay per day (odds ratio [OR], 1.05; 95% confidence interval [CI95], 1.02 to 1.09) and exposure to the HCW wearing artificial fingernails (OR, 7.87; CI95, 1.75 to 35.36) were associated with infection or colonization with clone A.

CONCLUSION

Short, well-groomed, natural nails should be mandatory for HCWs with direct patient contact

A comparison of hand washing techniques to remove Escherichia coli and caliciviruses under natural or artificial fingernails

Compared with other parts of the hand, the area beneath fingernails harbors the most microorganisms and is most difficult to clean. Artificial fingernails, which are usually long and polished, reportedly harbor higher microbial populations than natural nails. Hence, the efficacy of different hand washing methods for removing microbes from natural and artificial fingernails was evaluated. Strains of nonpathogenic Escherichia coli JM109 and feline calicivirus (FCV) strain F9 were used as bacterial and viral indicators, respectively. Volunteers with artificial or natural nails were artificially contaminated with ground beef containing E. coli JM109 or artificial feces containing FCV. Volunteers washed their hands with tap water, regular liquid soap, antibacterial liquid soap, alcohol-based hand sanitizer gel, regular liquid soap followed by alcohol gel, or regular liquid soap plus a nailbrush. The greatest reduction of inoculated microbial populations was obtained by washing with liquid soap plus a nailbrush, and the least reduction was obtained by rubbing hands with alcohol gel. Lower but not significantly different (P > 0.05) reductions of E. coli and FCV counts were obtained from beneath artificial than from natural fingernails. However, significantly (P < or = 0.05) higher E. coli and FCV counts were recovered from hands with artificial nails than from natural nails before and after hand washing. In addition, microbial cell numbers were correlated with fingernail length, with greater numbers beneath fingernails with longer nails. These results indicate that best practices for fingernail sanitation of food handlers are to maintain short fingernails and scrub fingernails with soap and a nailbrush when washing hands.

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

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

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

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

Risk factors for hospital-acquired infections in the neonatal intensive care unit

Infants in the neonatal intensive care unit (NICU) have many risk factors for infection. Compared with older children and adults, infants, particularly premature infants, are relatively immunocompromised. Patients in the NICU have intrinsic risk factors for infections due to immunological "deficiencies" or inadequate development of mechanical barriers such as skin and gastrointestinal tract mucosa. Like other ICU populations, NICU patients have extrinsic risk factors for infection such as prolonged hospitalization, invasive procedures, instrumentation, medical treatments and concomitant medical conditions. Compared with healthy full-term infants, patients in the NICU develop abnormal flora, which is generally acquired in the NICU from patient-to-patient transmission via hand carriage of healthcare workers. This flora is frequently multidrug-resistant as it has developed under the selective pressure of antibiotics and can cause invasive disease. An understanding of the risk factors that are associated with hospital-acquired infections is essential to design preventive strategies.

Hospital-acquired infections in the neonatal intensive care unit--Klebsiella pneumoniae

Klebsiella pneumoniae is medically the most important organism of the Klebsiella species. It is responsible for a significant proportion of hospital-acquired infections including septicemias, urinary tract infections, pneumonia, and soft tissue infections especially in the immunocompromised hosts such as the neonate. The hands of healthcare workers and the gastrointestinal tract of hospitalized infants serve as reservoirs for the transmission of the organism and are responsible for multiple hospital outbreaks. In recent years, there has been an increase in the incidence of outbreaks caused by multidrug resistance K. pneumoniae organisms or the extended spectrum beta-lactamase (ESBL)-producing K. pneumoniae. The problems associated with extended spectrum beta-lactamase-producing organisms include difficulties in accurate antimicrobial susceptibility testing, limited treatment options and increased morbidity and perhaps mortality. Hence, prevention through implementation of strict infection control guidelines, effective hand washing and judicious use of antimicrobials such as third generation cephalosporins is important to effectively reduce the morbidity associated with this infection.

Nail beauty therapy: an attractive enhancement or a potential hazard?

Nail coatings which harden upon evaporation and coatings that polymerize may produce some reactions at the site of application to the nail itself, and distant reactions when small amounts of nail cosmetics are transferred by the hand to other areas of the skin. Nail cosmetic hazards may be occupational, or accidental, especially in children. Individuals wearing artificial nails tend to wear their nails longer, and are more careful about their nails when washing their hands. The sanitary conditions for the application of artificial nails are therefore paramount in preventing nail infections.

Nail art: a review of current infection control issues

Nail art or nail technology is a form of nail decoration which frequently entails applying extensions to the natural nail and then adding decorative effects. There have been a number of outbreaks of infection which have implicated nail art. These infections are likely to be as a result of difficulties in cleaning and maintaining the nail extensions. Nail art appears to be incompatible with clinical care.

Effect of hand cleansing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers

This study was undertaken to determine differences in microflora on the nails of health care workers (HCWs) wearing artificial nails compared with control HCWs with native nails and to assess the effect on these microflora of hand cleansing with antimicrobial soap or alcohol-based gel. Cultures were obtained from 21 HCWs wearing artificial nails and 20 control HCWs before and after using antimicrobial soap or alcohol-based gel. Before cleansing with soap, 86% of HCWs with artificial nails had a pathogen (gram-negative bacilli, Staphylococcus aureus, or yeasts) isolated, compared with 35% of controls (P=.003); a similar difference was noted before hand cleansing with gel (68% vs. 28%; P=.03). Significantly more HCWs with artificial nails than controls had pathogens remaining after hand cleansing with soap or gel. Of HCWs with artificial nails, only 11% cleared pathogens with soap compared with 38% with gel. Of control HCWs, only 14% cleared with soap compared with 80% with gel. Artificial acrylic fingernails could contribute to the transmission of pathogens, and their use by HCWs should be discouraged.

Candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use

Postoperative wound infection after laminectomy is uncommon. In February 1997, 3 patients were confirmed to have postlaminectomy deep wound infections due to Candida albicans. No similar case had been seen during the previous 10 years. The infections were indolent, with a mean time from initial operation to diagnosis of 54 days (range, 26-83 days). All patients were successfully treated. Pulsed-field gel electrophoresis revealed the Candida isolates to be identical. A case-controlled study and medical record review revealed that a single operating room technician scrubbed on all 3 infected case patients but on only 32% of the uninfected controls. The technician had worn artificial nails for a 3-month period that included the dates of laminectomy site infections, and C. albicans was isolated from her throat. She was treated with fluconazole and removed from duty. No subsequent cases have occurred during the ensuing 3 years. Artificial nails are known to promote subungual growth of gram-negative bacilli and yeast. This may be clinically relevant, and hospitals should enforce policies to prevent operating room personnel from wearing artificial nails.