Effect of proactive infection control measures on benchmarked rate of hospital outbreaks: An analysis of public hospitals in Hong Kong over 5 years

The Emergence of Candida auris is Not Associated with Changes in Antifungal Prescription at Hospitals

Purpose

This study describes the emergence of Candida auris in Hong Kong, focusing on the incidence and trends of different Candida species over time. Additionally, the study analyzes the relationship between C. auris and antifungal prescription, as well as the impact of outbreaks caused by C. auris.

Patients and Methods

Data were collected from 43 public hospitals across seven healthcare networks (A to G) in Hong Kong, including Candida species culture and antifungal prescription information. Among 150,267 patients with 206,405 hospitalization episodes, 371,653 specimens tested positive for Candida species. Trends in Candida species and antifungal prescription were analyzed before (period 1: 2015 1Q to 2019 1Q) and after (period 2: 2019 2Q to 2023 2Q) the emergence of C. auris in Hong Kong.

Results

Candida albicans was the most prevalent species, accounting for 57.1% (212,163/371,653) of isolations, followed by Candida glabrata (13.1%, 48,666), Candida tropicalis (9.2%, 34,261), and Candida parapsilosis (5.3%, 19,688). C. auris represented 2.0% of all Candida species isolations. Comparing period 2 to period 1, the trend of C. albicans remained stable, while C. glabrata, C. tropicalis, and C. parapsilosis demonstrated a slower increasing trend in period 2 than in period 1. Other species, including C. auris, exhibited a 1.1% faster increase in trend during period 2 compared to period 1. Network A, with the highest antifungal prescription, did not experience any outbreaks, while networks F and G had 40 hospital outbreaks due to C. auris in period 2. Throughout the study period, healthcare networks B to G had significantly lower antifungal prescription compared to network A, ranging from 54% to 78% less than that of network A.

Conclusion

There is no evidence showing correlation between the emergence of C. auris and antifungal prescription in Hong Kong. Proactive infection control measures should be implemented to prevent nosocomial transmission and outbreak of C. auris.

Epidemiology of multidrug-resistant organisms before and during COVID-19 in Hong Kong

Background

The coronavirus disease 2019 (COVID-19) has influenced antimicrobial consumption and incidence of multidrug-resistant organisms (MDROs). We aimed to study the epidemiology of MDROs before and during the COVID-19 pandemic in Hong Kong.

Methods

With the maintenance of infection control measures, we described the trend of MDRO infections, including methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Acinetobacter species (CRA), and extended-spectrum-beta-lactamase-(ESBL)-producing Enterobacterales, in a healthcare region with 3100-bed before (1 January 2016 to 31 December 2019, period 1) and during COVID-19 (1 January 2020 to 30 September 2022, period 2), together with the antimicrobial consumption using piecewise Poisson regression. The epidemiological characteristics of newly diagnosed COVID-19 patients with or without MDRO infections were analyzed.

Results

Between period 1 and 2, we observed a significant increase in the trend of CRA infections (P<0.001), while there was no significant increase in the trend of MRSA (P=0.742) and ESBL-producing Enterobacterales (P=0.061) infections. Meanwhile, a significant increase in the trend of carbapenems (P<0.001), extended-spectrum beta-lactam-beta-lactamase inhibitor combinations (BLBI) (P=0.045), and fluoroquinolones (P=0.009) consumption was observed. The observed opportunity (23,540 ± 3703 vs 26,145 ± 2838, p=0.359) and compliance (81.6% ± 0.5% vs 80.1% ± 0.8%, P=0.209) of hand hygiene per year was maintained. In a multivariable model, older age, male sex, referral from residential care home for the elderly, presence of indwelling device, presence of endotracheal tube, and use of carbapenems, use of BLBI, use of proton pump inhibitors and history of hospitalization in the past 3 months were associated with higher risks of infections by MDROs among COVID-19 patients.

Conclusion

Infection control measures may control the surge of MDROs despite an increasing trend of antimicrobial consumption.

Decreased Antibiotic Consumption Coincided with Reduction in Bacteremia Caused by Bacterial Species with Respiratory Transmission Potential during the COVID-19 Pandemic

Nonpharmaceutical interventions implemented during the COVID-19 pandemic (2020−2021) have provided a unique opportunity to understand their impact on the wholesale supply of antibiotics and incidences of infections represented by bacteremia due to common bacterial species in Hong Kong. The wholesale antibiotic supply data (surrogate indicator of antibiotic consumption) and notifications of scarlet fever, chickenpox, and tuberculosis collected by the Centre for Health Protection, and the data of blood cultures of patients admitted to public hospitals in Hong Kong collected by the Hospital Authority for the last 10 years, were tabulated and analyzed. A reduction in the wholesale supply of antibiotics was observed. This decrease coincided with a significant reduction in the incidence of community-onset bacteremia due to Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, which are encapsulated bacteria with respiratory transmission potential. This reduction was sustained during two pandemic years (period 2: 2020−2021), compared with eight pre-pandemic years (period 1: 2012−2019). Although the mean number of patient admissions per year (1,704,079 vs. 1,702,484, p = 0.985) and blood culture requests per 1000 patient admissions (149.0 vs. 158.3, p = 0.132) were not significantly different between periods 1 and 2, a significant reduction in community-onset bacteremia due to encapsulated bacteria was observed in terms of the mean number of episodes per year (257 vs. 58, p < 0.001), episodes per 100,000 admissions (15.1 vs. 3.4, p < 0.001), and per 10,000 blood culture requests (10.1 vs. 2.1, p < 0.001), out of 17,037,598 episodes of patient admissions with 2,570,164 blood culture requests. Consistent with the findings of bacteremia, a reduction in case notification of scarlet fever and airborne infections, including tuberculosis and chickenpox, was also observed; however, there was no reduction in the incidence of hospital-onset bacteremia due to Staphylococcus aureus or Escherichia coli. Sustained implementation of non-pharmaceutical interventions against respiratory microbes may reduce the overall consumption of antibiotics, which may have a consequential impact on antimicrobial resistance. Rebound of conventional respiratory microbial infections is likely with the relaxation of these interventions.

Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

Investigation of Acinetobacter baumannii Activity in Vascular Surgery Units through Epidemiological Management Based on the Analysis of Antimicrobial Resistance, Biofilm Formation and Genotyping

Background/Objectives: The genus Acinetobacter demonstrates resistance to antibiotics and has been shown to spread in the hospital environment causing epidemic outbreaks among hospitalized patients. The objectives of the present study was to investigate the antibiotic resistance, biofilm formation, and clonality among Acinetobacter baumannii strains. Materials and Methods: The study involved 6 (I Outbreak) and 3 (II Outbreak) A. baumannii strains isolated from patients hospitalized in vascular surgery unit. Results: All tested A. baumannii strains were extensively drug resistant (XDR) and all the isolates were carbapenem-resistant and among them, all carried the bla_OXA-51 gene, the bla_OXA-24 gene, as well as the bla_OXA-23 gene. All of the investigated strains had the ability to form a biofilm, but all of them produced less biofilm than the reference strain. Multi-locus sequence typing (MLST) showed that all strains belonged to the ST2 clone. Pulsed-field gel electrophoresis (PFGE) divided the tested outbreak strains into two clones (A and B). Conclusion: This study shows a nosocomial spread of XDR A. baumannii ST2 having the bla_OXA-51 gene, the bla_OXA-24 gene, as well as the bla_OXA-23 gene, low biofilm formers, that was prevalent in the vascular surgery unit. To identify the current situation of vascular surgery departments targeted epidemiological investigation was needed. Effective implementation of infection control prevented the spread of the epidemic outbreaks.

Use of "Social Media"-an Option for Spreading Awareness in Infection Prevention

Purpose of review

There is a need for enhanced adoption of infection prevention and control (IPC) practices in both healthcare settings and the entire community, more so during pandemics. The exponential increase in the use of social media (SM) has made it a powerful tool for creating awareness, education, training and community engagement on IPC. Here, we review how social media can be used effectively to implement strategies to combat public health issues especially vis-à-vis infection prevention and control.

Recent findings

According to the World Health Organization, 10% of patients get an infection whilst receiving care in healthcare institutions. Effective infection prevention and control measures can reduce healthcare-associated infections by at least 30%. Education and awareness play a vital role in implementation of infection prevention and control (IPC) strategies. Various studies show how social media has been used successfully in education and training activities, for awareness campaigns, community engagement, risk communications during outbreaks, disease surveillance and pharmacovigilance.

Summary

Infection prevention and control (IPC) is the need of the hour to mitigate transmission of disease in healthcare settings as well as in the community. SM is the fastest and most efficient way of communicating with the general population as well as health professionals. SM can help people take the right decisions and enable change in their behaviour patterns to introduce infection control practices.

Model of Healthcare-Associated Infection Control in Primary Health Care Institutions: A Structural Equation Modeling

The purpose of this study was to construct the model of organization system, management, training and surveillance in healthcare-associated infection prevention and control (IC) of primary health care institutions and identify its effect on patient safety and decreasing economic burden by standardizing IC. A cross-sectional survey was conducted with questionnaires. Data were collected from 268 primary health care institutions in Hubei province, China. Hypotheses on the model of IC were analyzed by means of confirmatory factor analysis and structural equation modeling. The results showed that the fit indices of the hypothesized model of IC satisfied recommended levels: root mean square error of approximation (RMSEA)=0.071; comparative fit index (CFI)=0.965; tucker-lewis index (TLI)=0.956; weighted root mean square residual (WRMR)=1.014. The model showed that organization system had a direct effect on management (β=0.311, P<0.01), and training (β=0.365, P<0.01). Management and training played an intermediary role that partially promoted organization system impact on surveillance. Results also showed that institutional factors such as the number of physicians, the number of nurses, the designated capacity of beds, the actual number of open beds and surgery trips had positive impacts on management (β=0.050, P<0.01; β=0.181, P<0.01; β=0.111, P<0.01; β=0.064, P<0.01; β=0.084, P=0.04) and training (β=0.21, P=0.03; β=0.050, P=0.02; β=0.586, P=0.01; β=-0.995, P=0.02; β=-0.223, P=0.03). In conclusion, the model of organization system, management, training and surveillance in IC of primary health care institutions is valuable for guiding IC practice.

Serratia marcescens outbreak in a neonatology unit of a Spanish tertiary hospital: Risk factors and control measures

BACKGROUND

We describe the investigation undertaken and the measures adopted to control a Serratia marcescens outbreak in the neonatology unit of La Paz University Hospital in Madrid, Spain.

METHODS

Weekly rectal and pharyngeal screenings for S marcescens were performed in the neonates starting after detection of the outbreak. Environmental samples and samples from health care workers (HCWs) were obtained for microbiological analysis. An unmatched case-control study was carried out to investigate risk factors for infection/colonization.

RESULTS

The outbreak began in June 2016 and ended in March 2017, affecting a total of 59 neonates. Twenty-five (42.37%) neonates sustained an infection, most frequently conjunctivitis and sepsis. Multivariate logistic regression identified the following risk factors: parenteral nutrition (odds ratio [OR], 103.4; 95% confidence interval [CI], 11.9-894.8), history of previous radiography (OR, 15.3; 95% CI, 2.4-95.6), and prematurity (OR, 5.65; 95% CI, 1.5-21.8). Various measures were adopted to control the outbreak, such as strict contact precautions, daily multidisciplinary team meetings, cohorting, allocation of dedicated staff, unit disinfection, and partial closure. Hands of HCWs were the main suspected mechanism of transmission, based on the inconclusive results of the environmental investigation and the high number of HCWs and procedures performed in the unit.

CONCLUSIONS

S marcescens spreads easily in neonatology units, mainly in neonatal intensive care units, and is often difficult to control, requiring a multidisciplinary approach. Strict measures, including cohorting and medical attention by exclusive staff, are often needed to get these outbreaks under control.

Whole-genome sequencing data-based modeling for the investigation of an outbreak of community-associated methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit in Hong Kong

We describe a nosocomial outbreak of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) ST59-SCCmec type V in a neonatal intensive care unit (NICU) in Hong Kong. In-depth epidemiological analysis was performed by whole-genome sequencing (WGS) of the CA-MRSA isolates collected from patients and environment during weekly surveillance and healthcare workers from the later phase of the outbreak. Case-control analysis was performed to analyze potential risk factors for the outbreak. The outbreak occurred from September 2017 to February 2018 involving 15 neonates and one healthcare worker. WGS analysis revealed complicated transmission dynamics between patients, healthcare worker, and environment, from an unrecognized source introduced into the NICU within 6 months before the outbreak. In addition to enforcement of directly observed hand hygiene, environmental disinfection, cohort nursing of colonized and infected patients, together with contact tracing for secondary patients, medical, nursing, and supporting staff were segregated where one team would care for CA-MRSA-confirmed/CA-MRSA-exposed patients and the other for newly admitted patients in the NICU only. Case-control analysis revealed use of cephalosporins [odds ratio 49.84 (3.10-801.46), p = 0.006] and length of hospitalization [odds ratio 1.02 (1.00-1.04), p = 0.013] as significant risk factors for nosocomial acquisition of CA-MRSA in NICU using multivariate analysis. WGS facilitates the understanding of transmission dynamics of an outbreak, providing insights for outbreak prevention.

Knowledge and practices of isolation precautions among nurses in Jordan

Background

Implementation of isolation precautions from the Centers for Disease Control and Prevention (CDC) has been justified through research and clinical evidence. However, nurses' understanding and compliance with these precautions is still unknown. The aim of this study was to assess nurses' knowledge and practices in relation to isolation precautions in Jordan.

Methods

A cross-sectional, descriptive design was used. The study took place in 8 hospitals in Jordan. A self-reported questionnaire and an observational checklist were developed based on the CDC (2007) isolation precautions guidelines.

Results

A total of 247 questionnaires were returned out of 400, for a response rate of 61.7%. The results show that most nurses (90%) have good knowledge of isolation precautions. However, only 65% of nurses reported good compliance with isolation precautions. The results of a t test revealed that nurses with Bachelor's degrees perform better in knowledge examinations than nurses with 2-year diplomas (P < .001). However, there was no significant difference in knowledge and self-report practices scores based on nurses' previous training and existence of isolation guidelines in their units or wards (P > .05). The results of the checklists confirm that there is a low compliance with standard isolation practice. In addition, the checklist shows that a high percentage of units and wards do not use isolation signs (46.4%) and posters (34.5%).

Conclusions

This study revealed that educating nurses about isolation is not enough strategy to improve their compliance. It is important to adapt other strategies, such as supporting nurses by giving them a manageable workload, and providing more supplies and reminders of isolation precautions in the hospitals.

Role of Hand Hygiene Ambassador and Implementation of Directly Observed Hand Hygiene Among Residents in Residential Care Homes for the Elderly in Hong Kong

OBJECTIVEMultidrug-resistant organisms (MDROs) are increasingly reported in residential care homes for the elderly (RCHEs). We assessed whether implementation of directly observed hand hygiene (DOHH) by hand hygiene ambassadors can reduce environmental contamination with MDROs.METHODSFrom July to August 2017, a cluster-randomized controlled study was conducted at 10 RCHEs (5 intervention versus 5 nonintervention controls), where DOHH was performed at two-hourly intervals during daytime, before meals and medication rounds by a one trained nurse in each intervention RCHE. Environmental contamination by MRDOs, such as methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Acinetobacter species (CRA), and extended-spectrum β-lactamse (ESBL)-producing Enterobacteriaceae, was evaluated using specimens collected from communal areas at baseline, then twice weekly. The volume of alcohol-based hand rub (ABHR) consumed per resident per week was measured.RESULTSThe overall environmental contamination of communal areas was culture-positive for MRSA in 33 of 100 specimens (33%), CRA in 26 of 100 specimens (26%), and ESBL-producing Enterobacteriaceae in 3 of 100 specimens (3%) in intervention and nonintervention RCHEs at baseline. Serial monitoring of environmental specimens revealed a significant reduction in MRSA (79 of 600 [13.2%] vs 197 of 600 [32.8%]; P<.001) and CRA (56 of 600 [9.3%] vs 94 of 600 [15.7%]; P=.001) contamination in the intervention arm compared with the nonintervention arm during the study period. The volume of ABHR consumed per resident per week was 3 times higher in the intervention arm compared with the baseline (59.3±12.9 mL vs 19.7±12.6 mL; P<.001) and was significantly higher than the nonintervention arm (59.3±12.9 mL vs 23.3±17.2 mL; P=.006).CONCLUSIONSThe direct observation of hand hygiene of residents could reduce environmental contamination by MDROs in RCHEs.Infect Control Hosp Epidemiol 2018;39:571-577.

Control of multidrug-resistant Acinetobacter baumannii in Hong Kong: Role of environmental surveillance in communal areas after a hospital outbreak

BACKGROUND

Environmental reservoir is an important source of multidrug-resistant Acinetobacter baumannii (MRAB) outbreaks. The role of postoutbreak environmental surveillance for guiding sustained infection control effort has not been examined.

METHODS

Enhanced environmental disinfection and regular environmental surveillance of ward communal areas after an outbreak were performed in a university-affiliated hospital. To assess the usefulness of environmental culture in predicting patients with MRAB, weekly surveillance of communal areas was continued for 3 months after the outbreak in intervention wards. The incidence of MRAB in intervention and nonintervention wards (control) was compared, whereas the other infection control measures remained identical.

RESULTS

Postoutbreak weekly surveillance of communal areas showed that identification of newly diagnosed MRAB patients was significantly correlated with preceding environmental contamination with MRAB (P = .001). The incidence of nosocomial MRAB infection was significantly lower in the intervention compared with nonintervention wards (0.55 vs 2.28 per 1,000 patient days, respectively; P = .04). All MRAB isolated from the environmental and patients' samples belonged to multilocus sequence typing ST457 and were blaOXA23-like positive.

CONCLUSIONS

Environmental surveillance may serve as a surrogate marker for the presence of MRAB carriers. Implementation of timely infection control measures should be guided by environmental culture for MRAB to minimize the risk of MRAB outbreak.

Successful control of emerging vancomycin-resistant enterococci by territory-wide implementation of directly observed hand hygiene in patients in Hong Kong

With the emergence of vancomycin-resistant enterococci (VRE) in our public hospitals, territory-wide implementation of directly observed hand hygiene before meals and medications for all conscious hospitalized patients reverted the rising VRE incidence of 16.5% per month (P < .001) to a reduction of -9.8% per month (P < .001). The outbreak rate reverted from an increasing trend of 10.5% per month (P < .001) to a decreasing trend of -13.3% per month (P < .001) between January 2011 and October 2015.

A Novel Risk Factor Associated With Colonization by Carbapenemase-Producing Enterobacteriaceae: Use of Proton Pump Inhibitors in Addition to Antimicrobial Treatment

OBJECTIVE

To study the association between gastrointestinal colonization of carbapenemase-producing Enterobacteriaceae (CPE) and proton pump inhibitors (PPIs).

METHODS

We analyzed 31,526 patients with prospective collection of fecal specimens for CPE screening: upon admission (targeted screening) and during hospitalization (opportunistic screening, safety net screening, and extensive contact tracing), in our healthcare network with 3,200 beds from July 1, 2011, through December 31, 2015. Specimens were collected at least once weekly during hospitalization for CPE carriers and subjected to broth enrichment culture and multiplex polymerase chain reaction.

RESULTS

Of 66,672 fecal specimens collected, 345 specimens (0.5%) from 100 patients (0.3%) had CPE. The number and prevalence (per 100,000 patient-days) of CPE increased from 2 (0.3) in 2012 to 63 (8.0) in 2015 (P<.001). Male sex (odds ratio, 1.91 [95% CI, 1.15–3.18], P=.013), presence of wound or drain (3.12 [1.70–5.71], P<.001), and use of cephalosporins (3.06 [1.42–6.59], P=.004), carbapenems (2.21 [1.10–4.48], P=.027), and PPIs (2.84 [1.72–4.71], P<.001) in the preceding 6 months were significant risk factors by multivariable analysis. Of 79 patients with serial fecal specimens, spontaneous clearance of CPE was noted in 57 (72.2%), with a median (range) of 30 (3–411) days. Comparing patients without use of antibiotics and PPIs, consumption of both antibiotics and PPIs after CPE identification was associated with later clearance of CPE (hazard ratio, 0.35 [95% CI, 0.17–0.73], P=.005).

CONCLUSIONS

Concomitant use of antibiotics and PPIs prolonged duration of gastrointestinal colonization by CPE.

Infect Control Hosp Epidemiol 2016;1418–1425

Implementation of directly observed patient hand hygiene for hospitalized patients by hand hygiene ambassadors in Hong Kong

BACKGROUND

The importance of compliance with hand hygiene by patients is increasingly recognized to prevent health care-associated infections.

METHODS

This descriptive study observed the effects of an education campaign, targeted to increase patients' self-initiated hand hygiene, and a hand hygiene ambassador-initiated directly observed hand hygiene program on patients' hand hygiene compliance in a university-affiliated hospital.

RESULTS

The overall audited compliance of patients' self-initiated hand hygiene was only 37.5%, with a rate of 26.9% (112/416 episodes) before meals and medications, 27.5% (19/69 episodes) after using a urinal or bedpan, and 89.7% (87/97 episodes) after attending toilet facilities. Patients referred from a residential care home for older adults had significantly lower hand hygiene compliance (P = .007). Comparatively, the overall audited compliance of ambassador-initiated directly observed hand hygiene was 97.3% (428/440 episodes), which was significantly higher than patients' self-initiated hand hygiene via a patient education program (37.5%, 218/582 episodes, P < .001).

CONCLUSIONS

Directly observed hand hygiene can play an important role in improving compliance with hand hygiene by hospitalized patients.

Emergence of Carbapenem-Resistant Acinetobacter baumannii in Nursing Homes With High Background Rates of MRSA Colonization

Carbapenem-resistant Acinetobacter baumannii (CRAB) with diverse multilocus sequence typing emerged among our nursing home residents (6.5%) with a high background rate of MRSA (32.2%). Rectal swabs yielded a higher rate of CRAB detection than axillary or nasal swabs. Bed-bound status, use of adult diapers, and nasogastric tube were risk factors for CRAB colonization. Infect Control Hosp Epidemiol 2016;37:983-986.

Use of fluoroquinolones is the single most important risk factor for the high bacterial load in patients with nasal and gastrointestinal colonization by multidrug-resistant Acinetobacter baumannii

Gastrointestinal colonization by carbapenem-resistant Acinetobacter baumannii (CRAB) and multidrug-resistant Acinetobacter baumannii (MRAB) provides an important reservoir for clinical infections and hospital outbreaks. We conducted a 7-month study in a 3200-bed healthcare network to investigate the prevalence of gastrointestinal colonization of CRAB and MRAB in Hong Kong. Between 1 June and 31 December 2014, a total of 17,760 fecal specimens from 9469 patients were screened. Testing showed that 340 (1.9%) specimens from 224 (2.6%) patients were CRAB-positive, which included 70 (0.39%) MRAB-positive specimens from 54 (0.57%) patients. The presence of wound or ulcer, use of broad-spectrum antibiotics in the preceding 6 months, and residence in elderly homes are independent risk factors for gastrointestinal colonization of CRAB. Quantitative bacterial counts in various body sites (rectal, nasal, axilla, wound, catheterized urine, if available) were performed in 33 (61.1%) of 54 MRAB patients. Ten (30.3%) and 8 (24.2%) patients had high bacterial load (defined as over 3 log10) in rectal and nasal swabs, with a median of 5.04 log10 cfu/ml of rectal swab and 4.89 log10 cfu/ml of nasal swab in saline diluent, respectively. Nine (81.8%) of 11 patients with wounds had high bacterial load in wound swabs, with a median of 5.62 log10 cfu/ml. Use of fluoroquinolones 6 months before admission was the only significant factor associated with high bacterial load in nasal and rectal swabs. With the implementation of directly observed hand hygiene before meals and medications to all conscious hospitalized patients, no hospital outbreaks were observed during our study period.