Hand rub dose needed for a single disinfection varies according to product: a bias in benchmarking using indirect hand hygiene indicator

Rinse, gel, and foam - is there any evidence for a difference in their effectiveness in preventing infections?

BACKGROUND

Following publication of the 2009 World Health Organizations Guidelines for Hand Hygiene in Health Care, a debate has emerged regarding the relative antimicrobial efficacy of the different formats (rinse, gel, foam) of ABHRs and their ability to contribute to reduction of healthcare-associated infections (HAIs).

METHODS

Data regarding the in-vivo antimicrobial efficacy of ABHRs and other factors that likely affect their effectiveness in reducing HAIs were reviewed, and a comprehensive review of studies that reported the effectiveness of each of the three ABHR formats to improve hand hygiene compliance and reduce HAIs was conducted.

RESULTS

The amount of rubbing time it takes for hands to feel dry (dry time) is the major driver of ABHR antimicrobial efficacy. ABHR format is not a major factor, and several studies found that rinse, gel, and foam ABHRs have comparable in-vivo antimicrobial efficacy. Other factors that likely impact the ability of ABHRs to reduce transmission of healthcare-associated pathogens and HAIs include ABHR formulation, the volume applied to hands, aesthetic characteristics, skin tolerance, acceptance by healthcare personnel, and hand hygiene compliance rates. When accompanied by complementary strategies, promoting the use of each of the three ABHR formats has been associated with improvements in hand hygiene compliance rates. A review of 67 studies failed to identify an ABHR format that was significantly more effective in yielding statistically significant reductions in transmission of healthcare-associated pathogens or HAIs.

CONCLUSIONS

Current evidence is insufficient to definitively determine if one ABHR format is more effective in reducing transmission of healthcare-associated pathogens and HAIs. More rigorous studies such as multicenter randomized controlled trials comparing the different formats are needed to establish if one format is significantly more effective in reducing HAIs.

Current issues in hand hygiene

BACKGROUND

Multiple aspects of hand hygiene have changed in recent years.

METHODS

A PubMed search was conducted to identify recent articles about hand hygiene.

RESULTS

The COVID-19 pandemic caused temporary changes in hand hygiene compliance rates and shortages of alcohol-based hand sanitizers (ABHSs), and in marketing of some products that were ineffective or unsafe. Fortunately, ABHSs are effective against SARS-CoV-2 and other emerging pathogens including Candida auris and mpox. Proper placement, maintenance, and design of ABHS dispensers have gained additional attention. Current evidence suggests that if an adequate volume of ABHS has been applied to hands, personnel must rub their hands together for at least 15 seconds before hands feel dry (dry time), which is the primary driver of antimicrobial efficacy. Accordingly, practical methods of monitoring hand hygiene technique are needed. Direct observation of hand hygiene compliance remains a challenge in many healthcare facilities, generating increased interest in automated hand hygiene monitoring systems (AHHMSs). However, several barriers have hindered widespread adoption of AHHMSs. AHHMSs must be implemented as part of a multimodal improvement program to successfully improve hand hygiene performance rates.

CONCLUSIONS

Remaining gaps in our understanding of hand hygiene warrant continued research into factors impacting hand hygiene practices.

Comparison of two alcohol hand rubbing techniques regarding hand surface coverage among hospital workers: a quasi-randomized controlled trial

BACKGROUND

The adapted 6-step without interlock (A6Sw/oI) hand rub technique, commonly practiced in Japan, adds the "wrist" but omits the "interlock" step compared to the WHO 6-step technique (WHO6S). The first objective of this study was to assess the differences of the two techniques regarding surface coverage. The second objective was to analyze the coverage differences between hand sizes.

METHODS

Hospital workers went under stratified quasi-randomization by glove size. The overall mean coverage, and the coverage of the sections of the hands were evaluated by fluorescent dye-based coverage assessment using a digital device with artificial intelligence technology.

RESULTS

Total of 427 workers were randomly allocated to WHO6S (N = 215) or the A6Sw/oI (N = 212). The overall mean dorsum coverage by WHO6S and A6Sw/oI was 90.6% versus 88.4% (p < 0.01), and the percentage of the participants with insufficient coverage of the backs of the four fingers ranged from 0.0-7.4% versus 28.2-51.4% (p < 0.001). Dorsum coverage varied largely between hand size for both techniques, and significant differences were found between small and large hands.

CONCLUSION

The WHO6S was superior to the locally adapted technique regarding hand surface coverage. Hand size should be considered when assessing coverage differences between procedures. No trial registrations or fundings.

Systematic review on factors influencing the effectiveness of alcohol-based hand rubbing in healthcare

BACKGROUND

The effectiveness of hand rubbing with alcohol-based handrub (ABHR) is impacted by several factors. To investigate these, World Health Organization (WHO) commissioned a systematic review.

AIM

To evaluate the impact of ABHR volume, application time, rubbing friction and hand size on microbiological load reduction, hand surface coverage or drying time.

METHODS

Medline, CINAHL, Web of Science and ScienceDirect databases were searched for healthcare or laboratory-based primary studies, published in English, (1980- February 2021), investigating the impact of ABHR volume, application time, rubbing friction or hand size on bacterial load reduction, hand coverage or drying time. Two reviewers independently performed data extraction and quality assessment. The results are presented narratively.

FINDINGS

Twenty studies were included in the review. Categories included: ABHR volume, application time and rubbing friction. Sub-categories: bacterial load reduction, hand size, drying time or hand surface coverage. All used experimental or quasi-experimental designs. Findings showed as ABHR volume increased, bacterial load reduced, and drying times increased. Furthermore, one study showed that the application of sprayed ABHR without hand rubbing resulted in significantly lower bacterial load reduction than poured or sprayed ABHR with hand rubbing (- 0.70; 95%CI: - 1.13 to - 0.28). Evidence was heterogeneous in application time, volume, technique, and product. All studies were assessed as high risk of bias.

CONCLUSIONS

There is insufficient evidence to change WHO recommendation of a palmful of ABHR in a cupped hand applied for 20-30 s or manufacturer-recommended volume applied for about 20 s (Centers for Disease Control and Prevention). Future hand hygiene research should standardise volume, application time, and consider hand size.

Healthcare workers' perceptions and acceptance of an electronic reminder system for hand hygiene

BACKGROUND

Healthcare-associated infections (HCAIs) have a large negative impact on morbidity, mortality, and quality of life. Approximately 9% of all patients hospitalized in Sweden suffer from HCAI. Hand hygiene plays a key role and is considered the single most important measure to reduce HCAI. The hospital organization works actively to reduce HCAI. Implementing electronic systems to remind and/or notify healthcare workers raises awareness of and adherence to hand hygiene. However, there is a paucity of studies addressing individuals' perceptions of having such a system and how the organization works.

AIM

To investigate healthcare workers' perceptions of infection prevention in the healthcare organization and perceptions and acceptance of an electronic reminder system that encourages good hand hygiene.

METHODS

Qualitative descriptive design with data collected in eight focus group interviews including assistant nurses, nurses, and physicians (N = 38). Content analysis was applied and data were related to the Theory of Planned Behaviour.

FINDINGS

Healthcare workers perceive lack of feedback from the hospital organization and are positive towards an electronic reminder system to increase adherence to hand hygiene. The electronic reminder system should not register data at an individual level since it could be used as an instrument for control by the management that could be stressful for staff.

CONCLUSION

In general, there is positive acceptance of the electronic reminder system, and the respondents perceived it as having the ability to change behaviour. However, the concept has to be further developed to protect the individual's integrity and needs to be used with feedback on a group level.

Development of amoxicillin resistance in Escherichia coli after exposure to remnants of a non-related phagemid-containing E. coli: an exploratory study

Objective

To determine the effect of exposure to remnants of a phagemid-containing E. coli, killed by treatment with a propanol-based hand rub, on antimicrobial resistance in E. coli isolates.

Methods

An in vitro model was developed in which a clinical E. coli isolate (EUR1) was exposed to remnants of an E. coli K-12 strain containing a phagemid (pBS-E12) strain treated with Sterillium®. A series of 200 experiments was performed using this in vitro model. As a control, a series of 400 experiments was performed where the EUR1 was exposed either to the remnants of an E. coli K-12 strain (not containing a phagemid) (E12) treated with Sterillium® (n = 200) or to dried Sterillium® only (n = 200). The number of experiments that showed growth of an amoxicillin-resistant EUR1 isolate was evaluated in all three groups. An additional 48 experiments were performed in which a different clinical E. coli isolate (EUR2) was exposed to remnants of the pBS-E12 treated with Sterillium®. Whole-genome sequencing and phenotypic testing for AmpC beta-lactamase production was performed to investigate the mechanism behind this resistance development.

Results

In 22 (11.0%) of 200 experiments in which the EUR1 isolate was exposed to remnants of a pBS-E12 an amoxicillin-resistant mutant isolate was obtained, as opposed to only 2 (1.0%) of 200 experiments involving the exposure of the EUR1 to Sterillium® only (risk difference: 10.0%; 95% CI 5.4–14.6%)) and 1 (0.5%) of 200 experiments involving the exposure of the EUR1 isolate to the remnants of the phagemid-free E12 (risk difference: 10.5%; 95% CI 6.1–14.9%). In 1 (2.1%) of the 48 experiments in which the EUR2 isolate was exposed to remnants of a pBS-E12 an amoxicillin-resistant mutant isolate was obtained. The development of resistance in all experiments was due to mutations in the promoter/attenuator region of the chromosomal AmpC beta-lactamase (cAmpC) gene leading to cAmpC hyperproduction.

Conclusion

Exposure of an E. coli isolate to another phagemid-containing E. coli that was treated with propanol-based hand rub increased the development of amoxicillin resistance. Although phagemids are cloning vectors that are not present in clinical isolates, this finding may have implications for hand disinfection practices in healthcare facilities.

Current issues in hand hygiene

Although substantial improvements in hand hygiene practices have occurred in recent years, many health care facilities continue to encounter challenges in achieving and maintaining high levels of hand hygiene compliance. Issues of current interest include the optimum dose of alcohol-based handrub (ABHR) that should be applied, the impact of hand size and alcohol-based handrub dry times have on efficacy, and ideal hand hygiene technique. There is a need to determine which additional promotional activities can augment improvements in hand hygiene that are achieved by implementing the multimodal improvement strategy recommended by the World Health Organization. Monitoring hand hygiene performance and providing personnel with feedback on their performance are essential elements of successful improvement programs. Further research is needed to establish the most effective methods of providing feedback. Additional studies are needed to optimize strategies for performing direct observation of hand hygiene compliance, and to determine the role of supplementing direct observations using automated monitoring systems.

How long is enough? Identification of product dry-time as a primary driver of alcohol-based hand rub efficacy

Background

The World Health Organization has called for the development of improved methodologies to evaluate alcohol-based handrub (ABHR) efficacy, including evaluation at “short application times and volumes that reflect actual use in healthcare facilities”. The objective of this study was to investigate variables influencing ABHR efficacy, under test conditions reflective of clinical use.

Methods

The test product (60% V/V 2-propanol) was evaluated according to a modified EN 1500 methodology, where application volumes of 1 mL, 2 mL, and 3 mL were rubbed until dry. Statistical analyses were performed to investigate the relative influences of product volume, hand size, and product dry-time on efficacy, and hand size and hand contamination on product dry-time.

Results

Mean log₁₀ reduction factors (SD) were 1.99 (0.66), 2.96 (0.84) and 3.28 (0.96); and mean dry-times (SD) were 24 s (7 s), 50 s (14 s), and 67 s (20 s) at application volumes of 1 mL, 2 mL, and 3 mL, respectively (p ≤ 0.030). When data were examined at the individual volunteer level, there was a statistically significant correlation between dry-time and log reduction factor (p < 0.0001), independent of application volume. There was also a statistically significant correlation between hand surface area and dry-times (p = 0.047), but no correlation between hand surface area and efficacy (p = 0.698).

Conclusions

When keeping other variables such as alcohol type and concentration constant, product dry-time appears to be the primary driver of ABHR efficacy suggesting that dosing should be customized to each individual and focus on achieving a product dry-time delivering adequate efficacy.

Universal or targeted approach to prevent the transmission of extended-spectrum beta-lactamase-producing Enterobacteriaceae in intensive care units: a cost-effectiveness analysis

OBJECTIVE

Several control strategies have been used to limit the transmission of multidrug-resistant organisms in hospitals. However, their implementation is expensive and effectiveness of interventions for the control of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) spread is controversial. Here, we aim to assess the cost-effectiveness of hospital-based strategies to prevent ESBL-PE transmission and infections.

DESIGN

Cost-effectiveness analysis based on dynamic, stochastic transmission model over a 1-year time horizon.

PATIENTS AND SETTING

Patients hospitalised in a hypothetical 10-bed intensive care unit (ICU) in a high-income country.

INTERVENTIONS

Base case scenario compared with (1) universal strategies (eg, improvement of hand hygiene (HH) among healthcare workers, antibiotic stewardship), (2) targeted strategies (eg, screening of patient for ESBL-PE at ICU admission and contact precautions or cohorting of carriers) and (3) mixed strategies (eg, targeted approaches combined with antibiotic stewardship).

MAIN OUTCOMES AND MEASURES

Cases of ESBL-PE transmission, infections, cost of intervention, cost of infections, incremental cost per infection avoided.

RESULTS

In the base case scenario, 15 transmissions and five infections due to ESBL-PE occurred per 100 ICU admissions, representing a mean cost of €94 792. All control strategies improved health outcomes and reduced costs associated with ESBL-PE infections. The overall costs (cost of intervention and infections) were the lowest for HH compliance improvement from 55%/60% before/after contact with a patient to 80%/80%.

CONCLUSIONS

Improved compliance with HH was the most cost-saving strategy to prevent the transmission of ESBL-PE. Antibiotic stewardship was not cost-effective. However, adding antibiotic restriction strategy to HH or screening and cohorting strategies slightly improved their effectiveness and may be worthy of consideration by decision-makers.