Hand hygiene in hospitals: anatomy of a revolution

Quick and dirty: improper glove use increases infection risk and has global consequences

The development of disposable gloves and the discovery that good hand hygiene are essential for protecting patients are among the most important developments in the history of infection prevention and control, and are both essential for protecting patients and healthcare workers. Although there are international-level guidelines for glove use and hand hygiene during patient care, there are major issues concerning compliance. The overuse of gloving does not only contribute to reduced patient safety and increased healthcare-associated infections, but leads directly to environmental degradation and labor rights abuses.

Kotter's 8-step change model to improve hand hygiene compliance in intensive care unit: A 41-month prospective longitudinal quality improvement study

BACKGROUND

Despite numerous studies assessing bundled interventions to enhance hand hygiene compliance (HHC), compliance rates persist at suboptimal levels. Our objective was to employ Kotter's Change Model (KCM) to enhance HHC and conduct a comprehensive process evaluation among medical staff within the intensive care unit (ICU).

METHODS

KCM was implemented at the ICU of Zhongnan Hospital of Wuhan University from March 2018 to August 2021, with a 41-month longitudinal monitoring of HHC. The primary outcome focused on the absolute monthly change in HHC. Secondary outcomes encompassed the HHC characteristics across different phases, varying trends in HHC concerning different hand hygiene opportunities and occupations, quarterly incidences of central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI).

RESULTS

This study included 20,222 hand hygiene actions and 24,195 opportunities. The overall HHC was 83.58 % (95 %CI, 83.11 %-84.04 %). Following the KCM implementation, HHC surged from 35.71 % (95 % CI, 22.99 %-50.83 %) to 87.75 % (95 % CI, 85.53 %-89.67 %), reflecting a notable increase of 145.73 %. The most rapid growth in HHC occurred post-patient contact, elevating from 35.29 % to 89.8 %. Despite escalating patient numbers and treatment complexities annually, the quarterly rates of CLABSI (0 ‰-3.53 ‰) and CAUTI (0.96 ‰-4.26 ‰) remained consistently low.

CONCLUSION

Utilizing KCM systematically alters healthcare providers' perception of hand hygiene, fostering an environment that advocates for and sustains improved HHC among ICU personnel.

IMPLICATIONS FOR CLINICAL PRACTICE

The Kotter's change model can be an effective framework for healthcare organizations to systematically improve and maintain hand hygiene compliance among healthcare providers, which can in turn help reduce healthcare-associated infections.

Drivers of extended-spectrum β-lactamase (ESBL)- producing Enterobacterales colonization among residents of long-term care facilities: a European multicentre prospective cohort study

BACKGROUND

Extended-spectrum β-lactamase (ESBL)-producing Enterobacterales (ESBL-PE) are highly prevalent in long-term care (LTCF) settings. In order to estimate the acquisition rate of ESBL-producing Escherichia coli and Klebsiella pneumoniae in LTCF settings, and identify clinical and environmental risk factors, a multi-centre, prospective cohort study was conducted in six LTCFs in Germany, France, Spain and the Netherlands.

METHODS

Longitudinal screening of residents was performed over 32 weeks, collecting epidemiological and clinical data and environmental samples. The primary outcome was the rate of new acquisition of ESBL-PE among LTCF residents. Molecular epidemiology was studied using whole genome sequencing, and risk factor analysis was undertaken using logistic and Poisson regression models.

RESULTS

In total, 299 residents provided 1958 samples during follow-up. The prevalence of ESBL-PE colonization at baseline was 16.4%, and the incidence of acquisition was 0.79 per 1000 resident-days, both with high variability between LTCFs. Age ≥80 years, vascular disease and antibiotic consumption within the preceding year were risk factors for baseline colonization. Lack of hand sanitizers and a low nurse:resident ratio were associated with colonization. The presence of medical devices was associated with risk of acquisition. Vascular disease, hemiplegia, antibiotic consumption, and non-availability of private bathrooms were associated with carriage of multiple sequence types (STs). The prevalence of ESBL-PE among environmental samples was 2%, exclusively in LTCFs with high prevalence among residents. Genetic analysis showed a high prevalence of ST10 E. coli and ST405 K. pneumoniae at two study sites.

CONCLUSION

Infection prevention interventions, including availability of hand sanitizers, the number of nurses per resident, and antimicrobial stewardship, constitute important measures to control ESBL-PE in LTCFs. Genome-based surveillance could guide targeted interventions.

Ultraviolet-C-based sanitization is a cost-effective option for hospitals to manage health care-associated infection risks from high touch mobile phones

Mobile phones have become essential tools for health care workers around the world, but as high touch surfaces, they can harbor microorganisms that pose infection risks to patients and staff. As their use in hospitals increases, hospital managers must introduce measures to sanitize mobile phones and reduce risks of health care-associated infections. But such measures can involve substantial costs. Our objective in this paper was to consider two mobile phone risk mitigation strategies that managers of a hypothetical hospital could implement and determine which involves the lowest cost. The first strategy required all staff to sanitize their hands after every contact with a mobile phone. The second involved the hospital investing in ultraviolet-C-based mobile phone sanitization devices that allowed staff to decontaminate their mobile phones after every use. We assessed each intervention on material and opportunity costs assuming both achieved an equivalent reduction in microbe transmission within the hospital. We found that ultraviolet-C devices were the most cost-effective intervention, with median costs of approximately AUD360 per bed per year compared to AUD965 using hand hygiene protocols. Our results imply that a 200-bed hospital could potentially save AUD1-1.4 million over 10 years by investing in germicidal ultraviolet-C phone sanitizers rather than relying solely on hand hygiene protocols.

Consensus-Based Guidelines for Best Practices in the Selection and Use of Examination Gloves in Healthcare Settings

BACKGROUND/OBJECTIVES

Healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) present significant challenges in modern healthcare, leading to increased morbidity, mortality, and healthcare costs. Examination gloves play a critical role in infection prevention by serving as a barrier to reduce the risk of cross-contamination between healthcare workers and patients. This manuscript aims to provide consensus-based guidelines for the optimal selection, use, and disposal of examination gloves in healthcare settings, addressing both infection prevention and environmental sustainability.

METHODS

The guidelines were developed using a multi-stage Delphi process involving healthcare experts from various disciplines. Recommendations were structured to ensure compliance with international regulations and sustainability frameworks aligned with the One Health approach and Sustainable Development Goals (SDGs).

RESULTS

Key recommendations emphasize selecting gloves based on clinical needs and compliance with EN 455 standards. Sterile gloves are recommended for surgical and invasive procedures, while non-sterile gloves are suitable for routine care involving contact with blood and other body fluids or contaminated surfaces. Proper practices include performing hand hygiene before and after glove use, avoiding glove reuse, and training healthcare providers on donning and removal techniques to minimize cross-contamination. Disposal protocols should follow local clinical waste management regulations, promoting sustainability through recyclable or biodegradable materials whenever feasible.

CONCLUSIONS

These consensus-based guidelines aim to enhance infection control, improve the safety of patients and healthcare workers, and minimize environmental impact. By adhering to these evidence-based practices, grounded in European regulations, healthcare settings can establish safe and sustainable glove management systems that serve as a model for global practices.

A helping hand: Applying behavioural science and co-design methodology to improve hand hygiene compliance in the hospital setting

Compliance with hand hygiene is an effective way of reducing the incidence of healthcare acquired infections (HCAI). At one London National Health Service (NHS) Trust, improving hand hygiene compliance (HHC) was a patient safety priority in response to non-compliance and ongoing occurrences of HCAI. The objective of this study was to co-design a behavioural science informed intervention to improve HHC. To obtain a baseline level of HHC and understand associated behaviours, 18 hours of observation were undertaken on three inpatient wards. These focused upon Moment 1 and 5 of the World Health Organisation's moments for hand hygiene. The intervention was co-designed with clinical staff and took the form of "visual primes". Three different stickers designed to create a motivational "nudge" were placed at key points where HHC had been observed to fail. Following implementation, a further 18 hours of observation took place. A Chi-squared statistical analysis compared proportions of HHC pre- and post-intervention. Our intervention led to an 11% increase in HHC across the three study wards for both Moments (X2 (1, N = 1,285) = 13.711, p = <0.001) in the six weeks following the intervention. The intervention had a more marked effect on Moment 1, (with an increase of 15%, X2 (1, N = 667) = 17.091, p = <0.001 when compared to the change in compliance with Moment 5 (11%, X2 (1, N = 652) = 7.449, p = 0.06). This study demonstrated that utilising behavioural science in the co-design and placement of visual motivational nudges can significantly improve compliance with hand hygiene practices. We highlight the benefit of co-design when designing interventions-both in terms of engagement with and efficacy of the intervention.

The '5 Moments for Hand Hygiene': casting a critical eye on the implications for practice

The '5 Moments' approach is a time-space framework that delineates when hand hygiene should be performed and provides a resource for educators and auditors. It has become the dominant paradigm for organisations, practice, policy, and research in relation to hand hygiene. It is a concept that adopts the 'precautionary principle' that if the relative risk of a specific care task is unknown, a safe system must be to treat them on an equal level. However, a literal interpretation will frequently result in an extraordinary, implausible number of hand-hygiene opportunities and if this then becomes the standard to audit practice, within a policy document that espouses zero tolerance, it is likely to generate inauthentic data. If used effectively the 5 Moments concept provides an opportunity to enhance practice and reduce healthcare-associated infections but the healthcare provider organisation must embody a 'just culture' and collect the data in a climate of openness, transparency, and learning.

Immersive technology and hand hygiene: scoping review

BACKGROUND

The use of immersive technology in healthcare education is on the rise, yet its impact on learner engagement, knowledge retention, and specifically in areas like hand hygiene training, remains underexplored. The aim of this scoping review was to summarize the existing studies of immersive technology in hand hygiene training of healthcare providers and health professions students.

METHODS

A scoping review following the Levac et al. framework was conducted. The literature search was performed in databases PubMed, CINAHL Ultimate, ScienceDirect (Elsevier), Web of Science in addition to Google Scholar and ProQuest Dissertation & Theses. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Reviews (PRIMSA-ScR) guideline was used to report the results. We analysed data using tabular and descriptive summary.

RESULTS

In the final analysis 11 studies from seven countries were included. Most of the studies (n = 10, 90,91%) used virtual reality in hand hygiene training of healthcare providers and health professions students. Most studies have found that immersive technology is useful in teaching hand hygiene (n = 6, 54,55%). There are some theories and concepts that support the teaching of hand hygiene with immersive technology, but most of the research is not supported by them. Theories or concepts were included in two studies (18,18%).

CONCLUSION

Immersive technology, especially virtual reality, enhances hand hygiene learning and engagement compared to traditional methods. However, most studies lack theoretical support. To advance this field, exploring immersive technology for further research and incorporating relevant theories is encouraged. Additionally, conducting a thorough cost-effectiveness analysis and establishing a robust evaluation framework, encompassing both short-term and long-term outcomes, will be beneficial for a comprehensive understanding of the impact of immersive technology in hand hygiene education.

Clinical Effectiveness of a 3-Step Versus a 6-Step Hand Hygiene Technique: A Randomized Controlled Cross-over Study

BACKGROUND

The aim of this study is to assess the clinical effectiveness of the 3-step hand hygiene (HH) technique (3-HT) compared with the 6-step HH technique (6-HT; World Health Organization 6-step technique) using an alcohol-based hand rub.

METHODS

A randomized controlled crossover trial was conducted from November to December 2023 in 10 wards of a tertiary A-level hospital according to CONSORT guidelines. The 240 healthcare workers (HCWs) were randomly divided into the 3-HT intervention group or the 6-HT control group. The trial was conducted in 2 stages, and the effectiveness of each indicator in the 2 groups was compared after a washout period of 2 weeks.

RESULTS

Compared with the 6-HT, the 3-HT has demonstrated significant superiority in all indicators of HH compliance as well as the accuracy rate of HH practices. The total HH median times for the 3-HT and 6-HT were 16.00 (interquartile range, 15.00-20.00) and 32.50 (30.00-40.00) seconds, respectively (P < .05). The reduction factors for bacterial colony-forming unit counts did not differ and the colony-forming unit counts were not significantly different. Bacillus, Staphylococcus, and Micrococcus were detected before and after the use of hand rubs. HCWs preferred the 3-HT over the 6-HT. There were no significant difference in healthcare-associated infections rate between the 2 techniques.

CONCLUSIONS

The 3-HT was significantly superior to the 6-HT in terms of the HH eligibility rate, compliance, and HH time. The safety and feasibility of the 3-HT were verified by assessing microorganism count.

Tunable Assembly of Photocatalytic Colloidal Coatings for Antibacterial Applications

In this study, evaporation-induced size segregation and interparticle interactions are harnessed to tune the microstructure of photocatalytic colloidal coatings containing TiO2 nanoparticles and polymer particles. This enabled the fabrication of a library of five distinct microstructures: TiO2-on-top stratification, a thin top layer of polymer or TiO2, homogeneous films of raspberry particles, and a sandwich structure. The photocatalytic and antibacterial activities of the coatings were evaluated by testing the viability of Methicillin-resistant Staphylococcus aureus (MRSA) bacteria using the ISO-27447 protocol, showing a strong correlation with the microstructure. UVA irradiation for 4 h induces a reduction in MRSA viability in all coating systems, ranging from 0.6 to 1.1 log. Films with TiO2-enriched top surfaces exhibit better resistance to prolonged exposure to disinfection and bacterial testing. The remaining systems, nonetheless, present higher antibacterial activity because of a larger number of pores and coating defects that enhance light and water accessibility for the generation and transport of reactive oxygen species. This work establishes design rules for photocatalytic coatings based on the interplay between performance and film architecture, offering valuable insights for several applications, including antibacterial surfaces, self-cleaning/antifogging applications, and water purification.

Digital Maturity as a Predictor of Quality and Safety Outcomes in US Hospitals: Cross-Sectional Observational Study

BACKGROUND

This study demonstrates that digital maturity contributes to strengthened quality and safety performance outcomes in US hospitals. Advanced digital maturity is associated with more digitally enabled work environments with automated flow of data across information systems to enable clinicians and leaders to track quality and safety outcomes. This research illustrates that an advanced digitally enabled workforce is associated with strong safety leadership and culture and better patient health and safety outcomes.

OBJECTIVE

This study aimed to examine the relationship between digital maturity and quality and safety outcomes in US hospitals.

METHODS

The data sources were hospital safety letter grades as well as quality and safety scores on a continuous scale published by The Leapfrog Group. We used the digital maturity level (measured using the Electronic Medical Record Assessment Model [EMRAM]) of 1026 US hospitals. This was a cross-sectional, observational study. Logistic, linear, and Tweedie regression analyses were used to explore the relationships among The Leapfrog Group's Hospital Safety Grades, individual Leapfrog safety scores, and digital maturity levels classified as advanced or fully developed digital maturity (EMRAM levels 6 and 7) or underdeveloped maturity (EMRAM level 0). Digital maturity was a predictor while controlling for hospital characteristics including teaching status, urban or rural location, hospital size measured by number of beds, whether the hospital was a referral center, and type of hospital ownership as confounding variables. Hospitals were divided into the following 2 groups to compare safety and quality outcomes: hospitals that were digitally advanced and hospitals with underdeveloped digital maturity. Data from The Leapfrog Group's Hospital Safety Grades report published in spring 2019 were matched to the hospitals with completed EMRAM assessments in 2019. Hospital characteristics such as number of hospital beds were obtained from the CMS database.

RESULTS

The results revealed that the odds of achieving a higher Leapfrog Group Hospital Safety Grade was statistically significantly higher, by 3.25 times, for hospitals with advanced digital maturity (EMRAM maturity of 6 or 7; odds ratio 3.25, 95% CI 2.33-4.55).

CONCLUSIONS

Hospitals with advanced digital maturity had statistically significantly reduced infection rates, reduced adverse events, and improved surgical safety outcomes. The study findings suggest a significant difference in quality and safety outcomes among hospitals with advanced digital maturity compared with hospitals with underdeveloped digital maturity.

Mobile Applications for Learning Hand Hygiene: A Comparative Analysis

Infection control is crucial for high-quality patient care. One of the most effective and commonly used infection control procedures is hand hygiene which, it is known, requires repeated refresher training. There are many ways to educate healthcare professionals about hand hygiene, including the use of mobile applications (apps). Our aim is to review such hand hygiene apps, and to identify which have been available since 2021 and to assess their quality. We conducted a review using the PRISMA diagram to document our app selection process in the Google Play Store and Apple store in March 2024. For the evaluation of apps, we used the user version of the Mobile Application Rating Scale questionnaire (uMARS). Of 16 apps only five adhere to WHO hand hygiene guidelines. Timers were included in 12 of the 16 apps and reminders were included in 10 of 16 apps. The highest overall uMARS scoring app was Give Me 5-Hand Hygiene (4.31 ± 0.28), while Wash your hands! (1.17 ± 0.14) had the lowest score. We found that more than half of the apps were unavailable from the 2021 review. We believe that app-based education could effectively sustain hand hygiene knowledge in healthcare settings.

Italian National Surveillance of Alcohol-Based Hand Rub Consumption in a Healthcare Setting-A Three-Year Analysis: 2020-2022

Background/Objectives: Hand hygiene (HH) is pivotal in mitigating infectious disease transmission and enhancing public health outcomes. This study focuses on detailing the national surveillance system for alcohol-based hand rub (ABHR) consumption in healthcare facilities across Italy, presenting results from a comprehensive three-year evaluation period, from 2020 to 2022. It aims to delineate this surveillance system and report on ABHR consumption trends in various Regions/Autonomous Provinces (Rs/APs). Methods: ABHR consumption data, collected through the ABHR Italian national surveillance system, coordinated by the Istituto Superiore di Sanità (ISS), were analyzed. Statistical methods, e.g., the Mann-Whitney test, were used to assess trends in ABHR consumption, expressed in liters per 1000 patient days (L/1000PD). Results: The results show significant variation in ABHR consumption across Rs/APs and over the years studied. National median ABHR consumption decreased from 2020 to 2022, with a significant reduction from a median of 24.5 L/1000PD in 2020 to 20.4 L/1000PD in 2021 and 15.6 L/1000PD in 2022. Conclusions: The decline in ABHR consumption raises concerns about the ongoing adherence to HH practices in Italian healthcare settings. This underscores the essential role that systematic ABHR monitoring and improved surveillance play in enhancing HH compliance, suggesting that sustained and strategic efforts are fundamental to uphold high standards of hygiene and to effectively respond to fluctuating ABHR usage trends over time. Further research is needed to explore barriers to effective ABHR use and to develop targeted strategies to improve HH practices.

An intervention study investigating the effectiveness of contextualizing multimodal strategy on improving hand hygiene at a tertiary hospital in Nigeria

BACKGROUND

Hand hygiene (HH) is a proven low-cost means to curtail the problem of hospital-acquired infection (HAI). However, a low HH compliance rate of 17.1% was found among surgical health workers at Ahmadu Bello University Teaching Hospital (ABUTH) in Zaria, Nigeria.

METHODS

This was an intervention study conducted utilizing mixed methods to investigate the effectiveness of the World Health Organization (WHO) multimodal strategy to improve the HH compliance rate of doctors at ABUTH Zaria. The study was conducted between June and August 2022 and included delivering a behavioural change HH workshop to doctors followed by data collection in the surgical wards that had received environmental modification through the provision of an alcohol-based hand rub (ABHR), HH posters and nurses for visual and/or verbal reminders.

RESULTS

The cumulative HH compliance rate was 69% (n=1774) and was significantly different from the baseline HH compliance rate of 17.1% (confidence interval 45.5 to 57.7, p<0.001). Observed HH was highest in the ward with both visual and verbal reminders (78%) and lowest (59%) where neither visual nor verbal reminders were provided (n=444 per ward). All respondents reported motivation to perform HH with the presence of ABHR.

CONCLUSIONS

The WHO multimodal strategy is good for enhancing HH among health workers in the context of low- and middle-income countries. More research is needed to understand how much of a reduction in HAI is directly associated with efficient HH by health workers.

Updates and future directions regarding hand hygiene in the healthcare setting: insights from the 3rd ICPIC alcohol-based handrub (ABHR) task force

Healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) pose threats to global health. Effective hand hygiene is essential for preventing HAIs and the spread of AMR in healthcare. We aimed to highlight the recent progress and future directions in hand hygiene and alcohol-based handrub (ABHR) use in the healthcare setting. In September 2023, 42 experts in infection prevention and control (IPC) convened at the 3rd International Conference on Prevention and Infection Control (ICPIC) ABHR Taskforce in Geneva, Switzerland. The purpose of this meeting was to provide a synthesis of recent evidence and formulate a research agenda on four critical areas for the implementation of effective hand hygiene practices: (1) ABHR formulations and hand rubbing techniques, (2) low-resource settings and local production of ABHR, (3) hand hygiene monitoring and technological innovations, and (4) hand hygiene standards and guidelines.

The Effect of Video-Assisted Training and Visual Feedback With UV Germ Technology on Nursing Students' Hand Hygiene Beliefs, Practices, and Compliance: A Randomized Controlled Study

BACKGROUND

Hand hygiene (HH) is the most effective way to prevent health care-associated infections; however, HH compliance rates continue to be suboptimal.

PURPOSE

To determine the effectiveness of video-assisted training and visual feedback with ultraviolet (UV) germ technology on nursing students' HH beliefs, practices, and compliance.

METHODS

This study used a double-blind, posttest randomized controlled design. The experimental group received training, visual feedback with UV germ technology, and instructional videos.

RESULTS

A total of 46 students were included in the study (experimental 21 and control 25). The mean score of the HH skills checklist of the experimental group was significantly higher than that of the control group ( P = .0001). The HH compliance rate was also higher in the experimental group (52.62%) compared with the control group (39.1%).

CONCLUSIONS

The training, visual feedback with UV germ technology, and instructional videos increased HH compliance rates in nursing students.

Health Science Students' Perceptions of Hand Hygiene Education and Practice in a South African University: Introducing the University Hand Hygiene Improvement Model

Hand hygiene serves as a critical preventative measure against the spread of acquired infections in healthcare facilities and is an integral component of patient safety programs. While healthcare students in training are typically introduced to the principles underlying hand hygiene, the translation of this understanding into practice is often lacking, and compliance has remained low. This study aimed to evaluate health science students' in biomedical sciences, chiropractic and emergency medical care, environmental health, complementary medicine, medical imaging and radiation sciences, nursing, optometry, podiatry, and sports and movement studies perceptions regarding hand hygiene education (knowledge and attitude) and practice at a university in South Africa. Consenting students were asked to complete an online questionnaire that tested their knowledge, practices, and skills in handwashing. The ANOVA analysis results suggested significant differences in hand hygiene scores across departments and years of study. The multiple regression analyses confirmed these findings, suggesting that the department of study significantly influenced all aspects of hand hygiene, while the year of study affected hand hygiene skills, and age group influenced hand hygiene practices. Based on these findings, a conceptual model, the University Hand Hygiene Improvement Model (UHHIM), was proposed to enhance the teaching and learning of hand hygiene at the university level. The model underscores the necessity of targeted education, continuous monitoring, and feedback, and the pivotal roles of hand hygiene facilitators and student participation in enhancing hand hygiene behaviors.

Effect of Drinking Water Salt Content on the Interaction between Surfactants and Bacteria

Sodium dodecyl sulfate (SDS) is a common surfactant used in various hygienic products. Its interactions with bacteria were studied previously, but the three-way interaction between surfactants, bacteria, and dissolved salts in the context of bacterial adhesion has not been studied. Here, we examined the combined effects of SDS (at concentrations typical of everyday hygienic activities) and salts, sodium chloride, and calcium chloride (at concentrations typically found in tap water) on the adhesion behavior of the common opportunistic pathogen Pseudomonas aeruginosa. We found that bacterial adhesion in the absence of SDS was dependent on the cation concentration rather than the total ionic strength and that combined treatment with several millimolar NaCl and SDS can increase bacterial adhesion. The addition of low concentrations of SDS (2 mM) to tens to hundreds millimolar concentrations of NaCl, typical of systems that suffer seawater incursion, reduced bacterial adhesion dramatically. Combined treatment with Ca+2 (in concentrations typical of those found in hard water) and SDS produced a small increase in total adhesion but a dramatic increase in the strength of adhesion. We conclude that the type and concentration of salts in water can have a considerable effect on the efficacy of soap in reducing bacterial adhesion and should be taken under consideration in critical applications. IMPORTANCE Surface-adhering bacteria are a reoccurring problem in many settings, including households, municipal water systems, food production facilities, and hospitals. Surfactants, and specifically sodium dodecyl sulfate (also known as SDS/SLS), are commonly used to remove bacterial contamination, but data regarding the interaction of SDS with bacteria and especially the effects of water-dissolved salts on this interaction are lacking. Here, we show that calcium and sodium ions can dramatically affect the efficacy of SDS on bacterial adhesion behavior and conclude that salt concentrations and ion species in the water supply should be considered in SDS applications.

Hand Sanitizer Gels: Classification, Challenges, and the Future of Multipurpose Hand Hygiene Products

Hand hygiene is a crucial measure in the prevention and control of infections, and there is a growing awareness among individuals who are making a conscious effort to maintain hand cleanliness. With the advent of the SARS-CoV-2 outbreak, the demand for hand hygiene products has also gradually shifted towards those with antimicrobial properties. Among these products, hand sanitizer gels (HSGs) have gained considerable popularity as an efficient method of hand cleaning, due to their rapid drying and sustained antimicrobial efficacy. Concurrently, there has been a growing interest in novel HSGs that offer additional functions such as skin whitening, moisturizing, and anti-inflammatory effects. These novel HSGs effectively address concerns associated with the ingestion of antimicrobial ingredients and demonstrate reduced skin irritation, thereby alleviating hand dermatological issues. This review provides an extensive overview of the application scenarios, classification, and challenges associated with HSGs while emphasizing the emergence of novel components with biological functions, aiming to contribute to the advancement of hand hygiene practices and offer novel insights for the development of novel HSGs with outstanding antimicrobial properties with other multiple biological functions and desirable biosafety profiles.

Microbiological Analysis of Surgeons' Hands in a Public Hospital in São Luis, Maranhão State, Brazil: A Cross-Sectional Study

Antisepsis of the hands of medical personnel is one of the most important steps in the process of patient care, since direct contact can cause the cross-transfer of potentially pathogenic microorganisms at surgical sites. This study aimed to analyze the prevalence of microorganisms on the hands of 131 surgeons in a university hospital before the surgical procedure. Swabs were collected from each clinician's hands before and after handwashing. The samples were placed in a transport medium and immediately delivered to a private clinical analysis laboratory from São Luis-Maranhão. The microorganisms were identified by ionization source mass spectrometry and matrix-assisted laser desorption (MALDI-TOF), and antibiotic susceptibility tests (AST) were performed using the Vitek2 and Phoenix-BD automated system. The results showed a high frequency (100%) of microorganisms before handwashing, but after surgical antisepsis, the rate dropped significantly (p < 0.05) to 27.5%. The gram-positive species most detected were Staphylococcus spp. and Micrococcus luteus, representing 83.9%, followed by gram-negative species, Stenotrophomonas maltophilia, Acinetobacter baumanii, Pseudomonas aeruginosa, Pseudomonas gessardi, Pantoea septica, Serratia marcescens, and Burkholderia lata. The effectiveness of hand antisepsis was 72.5%, demonstrating that surgeons' hands are an important source of microorganisms that can cause infections in hospitalized patients in different care settings.

A Multifaceted Approach to the "Bare below the Elbow" Concept and Hand Hygiene Compliance among Healthcare Professionals-Multicenter Population-Based Study

Nosocomial infections remain an important issue for patient safety concerns. Since hospital infections are mainly connected with healthcare professionals' routines, an increase in hand hygiene effectiveness through compliance with the "bare below the elbow" (BBE) concept could reduce the number of nosocomial infections. Therefore, this study aims to evaluate hand hygiene and to investigate healthcare professionals' compliance with the BBE concept. We performed our study on a group of 7544 hospital professionals involved in patient care. During the national preventive action, questionnaires, demographic data, and hand hygiene preparations were recorded. Hand disinfection was verified by COUCOU BOX, containing a UV camera. We noted that 3932 (52.1%) persons complied with the BBE rules. Nurses and non-medical personnel were significantly more often classified as BBE rather than non-BBE (2025; 53.3% vs. 1776; 46.7%, respectively, p = 0.001 and 1220; 53.7% vs. 1057; 46.3%, p = 0.006). Different proportions were demonstrated for the groups of physicians-non-BBE (783; 53.3%) compared to BBE (687; 46.7%) (p = 0.041). Healthcare workers from the BBE group statistically more often disinfected their hands correctly (2875/3932; 73.1%) compared to the non-BBE group (2004/3612; 55.5%) (p < 0.0001). This study demonstrates the positive impact of compliance with the BBE concept on effective hand disinfection and patient safety. Therefore, education and infection-prevention actions should be popularized to improve the BBE policy's effectiveness as well.

Nosocomial bacterial infections in Victoria decreased during the COVID-19 pandemic

Background

A number of infection control interventions were implemented during the COVID-19 pandemic in order to reduce the spread of this virus.

Objective

The purpose of this study was to determine if these interventions were associated with reduced nosocomial bacterial infections in Victoria, Australia.

Methods

Observational data were obtained from the Victorian Healthcare Associated Infection Surveillance System (VICNISS) based on admitted hospital patients in two 6-month timeframes representing pandemic and pre-pandemic hospital practices. Data were collected for surgical site infections, Staphylococcus aureus bacteraemia, Clostridioides difficile infection, and central line-associated bloodstream infections.

Results

There was a significant reduction in the rates of S. aureus bacteraemia (0.74 infections/10, 000 bed days pre-pandemic vs. 0.53/10,000 bed days in the pandemic period [rate ratio 0.72, 95% CI 0.57–0.90]; p = .003) and in C. difficile infections (2.2 infections/10,000 bed days pre-pandemic vs. 0.86/10 000 bed days in the pandemic era [rate ratio 0.76, 95% C.I. 0.67–0.86]; p <.001). There was no change in the overall rate of surgical site infections or central line-associated infections however.

Discussion

The increased emphasis on infection control and prevention strategies during the pandemic period was associated with reduced transmission of S. aureus and C. difficile infections within hospitals.

Effect of Hand Hygiene Intervention in Community Kindergartens: A Quasi-Experimental Study

This study aimed to evaluate the effect of hand hygiene interventions on the overall hand hygiene (HH) status of teaching instruction of hand hygiene in kindergartens, given the vulnerability of kindergarten children and their high risk due to infectious diseases and the current COVID-19 epidemic. We investigated the HH status of teachers from two kindergartens in the same community. The participants were recruited from 28 classes in both kindergartens. After completing the baseline survey, the intervention program consisted of three components: lectures on infectious diseases, lectures on HH, and seven-step hand washing techniques conducted in two kindergartens. The intervention program effectively increased teachers' perceived disease susceptibility (p < 0.05), reduced the total bacterial colonization of children's hands (p < 0.001), and improved the HH environment (p < 0.01). We recommend that health authorities or kindergartens adopt this HH intervention program to effectively improve the HH status in kindergartens and allow for preventive responses to the COVID-19 epidemic or other emerging infectious diseases.

Are emojis ready to promote the WHO 5 moments for hand hygiene in healthcare?

Background

Hand hygiene is universally recognized as a cornerstone measure for the prevention of healthcare-associated infections. Although the WHO “My five Moments for hand hygiene” poster has been used for more than a decade to delineate hand hygiene indications and promote action, adherence levels among healthcare workers are still notoriously low and disquieting. To compensate for the lack of effective hand hygiene communication, we aimed to evaluate emojis as possible surrogates for the non-verbal aspects of hand hygiene behaviour.

Methods

Following a thorough review of the Unicode version 12.0, the most applicable emojis to the terms used in the WHO 5 Moments poster were extracted. We developed a self-administered questionnaire to assess the view of infection prevention and control (IPC) practitioners regarding the use of emojis to show the WHO 5 Moments. Completed questionnaires were collected and analysed to determine the suitability of the existing emojis to illustrate a unified emoji poster. Data were analysed using R (version 3.6.3).

Results

A total of 95 IPC practitioners completed the questionnaire from May to October 2019 from different countries. Of these, 69 (74%) were female, and the mean age of the participants was 44.6 ± 10.87 years. We found appropriate emojis for six of the words used in the poster, including for touching (72%), for patient (63%), for clean (53%), for procedure (56%), for body fluid (58%), and for exposure risk (71%). The existing emojis proposed for the words “hygiene”, “aseptic”, and “surrounding” seemed to be less satisfactory.

Conclusions

In summary, the findings of this study indicate that the existing emojis may not be able to substitute the words used in the WHO 5 Moments poster. Emojis might be helpful to address hand hygiene indications in healthcare that may eventually play a role in promoting this measure. However, emojis should be further studied to choose the most appropriate ones and avoid ambiguity and misinterpretation. More emojis to convey health related messages are needed. We recommend further research in this area to evaluate the effect of using emojis in healthcare-related behaviours.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01164-1.

Comparing the effectiveness of hand hygiene techniques in reducing the microbial load and covering hand surfaces in healthcare workers: Updated systematic review

BACKGROUND

This review, commissioned by the World Health Organization (WHO), examined the effectiveness of the WHO 6-step hand hygiene (HH) technique in reducing microbial load on hands and covering hand surfaces, and compared its effectiveness to other techniques.

METHODS

Medline, CINAHL, ProQuest, Web of Science, Mednar, and Google Scholar were searched for primary studies, published in English (1978-February 2021), evaluating the microbiological effectiveness or hand surface coverage of HH techniques in healthcare workers. Reviewers independently performed quality assessment using Cochrane tools. The protocol for the narrative review was registered (PROSPERO 2021: CRD42021236138).

RESULTS

Nine studies were included. Evidence demonstrated that the WHO technique reduced microbial load on hands. One study found the WHO technique more effective than the 3-step technique (P = .02), while another found no difference between these 2 techniques (P = .08). An adapted 3-step technique was more effective than the WHO technique in laboratory settings (P = .021), but not in clinical practice (P = .629). One study demonstrated that an adapted 6-step technique was more effective than the WHO technique (P = .001). Evidence was heterogeneous in application time, product, and volume. All studies were high risk of bias.

CONCLUSIONS

Eight studies found that the WHO 6-step technique reduced microbial load on healthcare workers' hands; but the studies were heterogeneous and further research is required to identify the most effective, yet feasible technique.

An outbreak of extensively drug-resistant and hypervirulent Klebsiella pneumoniae in an intensive care unit of a teaching hospital in Southwest China

Extensively drug-resistant and hypervirulent Klebsiella pneumoniae (XDR-hvKp) is a new problem for patients in Intensive Care Unit (ICU) and can become an even more severe threat if resistant to tigecycline, considered one of the ‘last lines of defense’ drugs. This study collected seven non-replicated tigecycline-resistant XDR-hvKp from seven patients and performed genome analysis and epidemiological investigation using whole genome equencing (WGS) and other methods. All strains in this study were identified as ST11-KL64 and showed high resistance to antibiotics such as β-lactams, aminoglycosides, quinolones, and tigecycline, and one strain was also resistant to colistin. All strains were determined to be hvKp by the results of serum resistance assay and Galleria mellonella infection models. All strains had resistance genes bla_CTX-M-65,bla_KPC-2,bla_LAP-2,bla_TEM-1B, rmtB, and qnrS1 and virulence factors such as rmpA, rmpA2, and aerobactin (iucABCD, iutA). The expression of the AcrAB-TolC efflux pump was upregulated in all strains, and the expression levels of the gene pmrK was significantly upregulated in colistin-resistant strain DP compared to colistin-sensitive strain WT in this study. In conclusion, we described an outbreak caused by tigecycline-resistant XDR-hvKp in the ICU of a teaching hospital in southwest China. The spread of these superbugs poses a great threat to patients and therefore requires us to closely monitor these XDR-hvKp and develop relevant strategies to combat them.

Behavioural intention of hand hygiene compliance in an average Ecuadorian hospital

OBJECTIVE

This study aimed to characterize hand hygiene behavioural intention by hospital services clusters in a medium-sized hospital in an Ecuadorian city.

METHODS

This is a cross-sectional study based on the World Health Organization Hand Hygiene Knowledge Questionnaire for Health-Care Workers. The responses on hand hygiene behavioural intention for the Five Moments for hand hygiene according to the World Health Organization were recorded in three categories: before patient contact, before and after sterile technique and management of body fluids, and after contact with the environment of the patient. The variables were the knowledge regarding the source of germs causing nosocomial infections, the optimal time to achieve disinfection with alcohol, hospital services clusters (clinical medicine, surgery, and therapeutic services), and history of previous formal hand hygiene training. The variables in each moment were analysed using a saturated log-linear model.

RESULTS

The average age of participants was 34 years (Q1 32.1-Q3 36.4). Of them, 62% belonged to the clinic cluster and 87.6% had previous formal hand hygiene training. The incorrect response rates for before and after sterile technique and management of body fluids, before patient contact, and after contact with the environment of the patient were 30.2, 88.4, and 99.2%, respectively. In before patient contact, the incorrect responses for optimal time depended on the department (worse surgery cluster situation), and in before and after sterile technique and management of body fluids and after contact with the environment of the patient, the incorrect responses for source of germs depended on the previous formal hand hygiene training and the department (worse surgery and clinic clusters).

CONCLUSION

The incorrect answer related to hand hygiene behavioural intention was high compared to other reports, and the worse situation was found in after contact with the environment of the patient and before patient contact. These data suggest the need of strengthening permanently the hand hygiene programme.

Impact of the COVID-19 Pandemic on Levels of Device-Associated Infections and Hand Hygiene Compliance

Background

Healthcare-associated infections (HAIs) have been a major issue in intensive care units (ICUs), contributing to increased morbidity and mortality. They affect patients during the delivery of health care in hospitals where such infections were not present at the time of admission. Meanwhile, the course of coronavirus disease 2019 (COVID-19) may necessitate the transfer of critically ill patients to ICUs. Patients who need ICU services due to COVID-19 share similar underlying comorbidities, making them prone to microbiological infection. We aim to investigate the impact of the COVID-19 emergence period on device-associated infections (DAIs), the compliance of healthcare workers with hand hygiene, and other prevention bundles in ICU.

Materials and methods

This retrospective observational study analyzes secondary data from the infection control department in a single 500-bed hospital, including 80 adult ICU beds. DAI data from 2019, the pre-COVID-19 period, were compared to DAI data during the pandemic in 2020. In addition, prevention bundles and hand hygiene (HH) compliances for the same periods (before and after the COVID-19 pandemic) were compared.

Results

No significant impact was statistically detected in monthly and yearly comparisons of DAIs between 2019 and 2020. Similarly, HH compliance analysis revealed no significant difference between the two periods (p-value > 0.05). However, the data distribution for HH compliance displays a narrower range of measures. Nevertheless, only compliance with ventilator-associated pneumonia (VAP) prevention bundle of 2020 notably improved in comparison to 2019.

Conclusion

The impact of the COVID-19 pandemic was not evident over the DAIs. However, the compliance of healthcare workers to prevention bundles and HH in ICU was improved. Strict following and adherence to infection prevention and control (IPC) measures generally reduce the event of DAIs even on a non-significant scale.

Video engagement to improve handwashing duration: A longitudinal study assessing creative and messaging fatigue

BACKGROUND

Poor hand hygiene can contribute to increased rates of health care and community-acquired infections. Effective hand hygiene involves both a washer's technique and the duration of their wash.

METHODS

The purpose of this longitudinal study was 2-fold: to improve the ability of hand-washers to meet the recommended handwashing duration of ≥20 seconds and to assess the effect of washer fatigue with the intervention. An innovative system of smart connected soap and towel dispensers synchronized to engaging video content was implemented to meet this objective.

RESULTS

The intervention increased mean handwashing duration by 7.5 seconds (95% CI: 6.6, 8.4) and improved handwashing duration ≥20 seconds by 39.3% (P < .001). Using a similar cohort of hand-washers over 26 months, the video content had peak effect in month 1, and declined to a new steady state at month 11.

DISCUSSION

Handwashing for the recommended time can be difficult to achieve. Most hand hygiene studies examine the rate of completion without measuring duration.

CONCLUSIONS

Video engagement can improve and sustain handwashing duration. To mitigate creative and messaging fatigue, video content refresh for this intervention should be considered at 3 months for optimal effect or at 11 months prior to full decline to new steady state.

Impact of environmental hygiene interventions on healthcare-associated infections and patient colonization: a systematic review

BACKGROUND

Healthcare-associated infections (HAI) are one of the gravest threats to patient safety worldwide. The importance of the hospital environment has recently been revalued in infection prevention and control. Though the literature is evolving rapidly, many institutions still do not consider healthcare environmental hygiene (HEH) very important for patient safety. The evidence for interventions in the healthcare environment on patient colonization and HAI with multidrug-resistant microorganisms (MDROs) or other epidemiologically relevant pathogens was reviewed.

METHODS

We performed a systematic review according to the PRISMA guidelines using the PubMed and Web of Science databases. All original studies were eligible if published before December 31, 2019, and if the effect of an HEH intervention on HAI or patient colonization was measured. Studies were not eligible if they were conducted in vitro, did not include patient colonization or HAI as an outcome, were bundled with hand hygiene interventions, included a complete structural rebuild of the healthcare facility or were implemented during an outbreak. The primary outcome was the comparison of the intervention on patient colonization or HAI compared to baseline or control. Interventions were categorized by mechanical, chemical, human factors, or bundles. Study quality was assessed using a specifically-designed tool that considered study design, sample size, control, confounders, and issues with reporting. The effect of HEH interventions on environmental bioburden was studied as a secondary outcome.

FINDINGS

After deduplication, 952 records were scrutinized, of which 44 were included for full text assessment. A total of 26 articles were included in the review and analyzed. Most studies demonstrated a reduction of patient colonization or HAI, and all that analyzed bioburden demonstrated a reduction following the HEH intervention. Studies tested mechanical interventions (n = 8), chemical interventions (n = 7), human factors interventions (n = 3), and bundled interventions (n = 8). The majority of studies (21/26, 81%) analyzed either S. aureus, C. difficile, and/or vancomycin-resistant enterococci. Most studies (23/26, 88%) reported a decrease of MDRO-colonization or HAI for at least one of the tested organisms, while 58% reported a significant decrease of MDRO-colonization or HAI for all tested microorganisms. Forty-two percent were of good quality according to the scoring system. The majority (21/26, 81%) of study interventions were recommended for application by the authors. Studies were often not powered adequately to measure statistically significant reductions.

INTERPRETATION

Improving HEH helps keep patients safe. Most studies demonstrated that interventions in the hospital environment were related with lower HAI and/or patient colonization. Most of the studies were not of high quality; additional adequately-powered, high-quality studies are needed. Systematic registration number: CRD42020204909.

Assessment of Ethanol Exposure from Hand Sanitizer Use and Potential for Developmental Toxicity in Nursing Infants

Ingestion of ethanol during pregnancy is known to have detrimental effects on the fetus. Although the potential developmental effects of maternal ethanol intake during lactation are less well characterized, public health guidelines recommend avoidance of alcohol or, if alcohol is consumed, to allow for 1–2 h to pass before nursing. A proposal to classify ethanol as potentially harmful to breast‐fed children warrants an investigation of the potential adverse neurodevelopmental effects of low‐dose ethanol exposure during lactation. There currently are no studies that have examined neurodevelopmental outcomes from lactational exposure to ethanol from the use of topical products that contain ethanol, such as alcohol‐based hand sanitizers (ABHS). Furthermore, the epidemiological literature of lactational ethanol exposures from maternal alcohol consumption is limited in design, provides equivocal evidence of neurological effects in infants, and is insufficient to characterize a dose–response relationship for developmental effects. Toxicological studies that observed neurodevelopmental effects in pups from ethanol via lactation did so at exceedingly high doses that also caused maternal toxicity. In this investigation, blood ethanol concentrations (BECs) of breastfeeding women following typical‐to‐intense ABHS use were computationally predicted and compared to health benchmarks to quantify the risk for developmental outcomes. Margins of 2.2 to 1000 exist between BECs associated with ABHS use compared to BECs associated with neurotoxicity adverse effect levels in the toxicology literature or oral ethanol intake per public health guidelines. Neurodevelopmental effects are not likely to occur in infants due to ABHS use by breastfeeding women, even when ABHSs are used at intense frequencies.

Adverse neurodevelopmental effects of ethanol exposure are supported by toxicological studies; ethanol as a potential “lactation hazard” needs evaluation. A lactation hazard may not be applicable for all ethanol‐containing products, such as hand sanitizers. Furthermore, internal dose assessments of hand sanitizer use are lacking. Computationally modeled blood ethanol concentrations following hand sanitizer use are lower than concentrations associated with toxicological and guideline benchmarks. Therefore, there is low potential for the use of ethanol‐containing hand sanitizers to be a lactation hazard.

Construction of nursing-sensitive quality indicators for cardiac catheterisation: A Delphi study and an analytic hierarchy process

BACKGROUND

Nursing care can profoundly reduce the risk of emergencies related to cardiac catheterisation. Therefore, identifying nursing-sensitive quality indicators (NSQIs) to evaluate nursing quality is critical for optimal cardiac catheterisation. However, studies on NSQIs for cardiac catheterisation are scarce.

OBJECTIVES

This study was conducted to develop a set of NSQIs for cardiac catheterisation.

METHODS

Literature retrieval and expert group discussions were conducted to identify potential NSQIs and compile an inquiry questionnaire. Then, Delphi surveys were used to collect opinions from experts in the field of cardiac catheterisation. The consistency of the consultation results formed the basis on which we conducted the next rounds of consultation. Based on the importance given to each NSQI by the consulted experts in the previous round, we determined the weight coefficient of each indicator with the analytic hierarchy process. This study was performed according to the SRQR guidelines.

RESULTS

We conducted two rounds of expert inquiry. The recovery rates of the first and second questionnaires were 100% and 66.67%, respectively. The average authoritative coefficients were 0.86 and 0.91. The Kendall W values ranged from 0.214~0.361 (p < .001). Consensus was reached on 3 primary indicators, 8 secondary indicators and 20 tertiary indicators.

CONCLUSIONS

A set of NSQIs for cardiac catheterisation was developed. However, the effects of these NSQIs on the evaluation and continuous improvement of nursing quality in cardiac catheterisation need to be verified in clinical practice.

Sensitivity of SARS-CoV-2 towards Alcohols: Potential for Alcohol-Related Toxicity in Humans

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative organism that is highly contagious and has been responsible for more than 240 million cases and 5 million deaths worldwide. Using masks, soap-based hand washing, and maintaining social distancing are some of the common methods to prevent the spread of the virus. In the absence of any preventive medications, from the outset of pandemic, alcohol-based hand sanitizers (ABHS) have been one of the first-line measures to control transmission of Coronavirus Disease 2019 (COVID-19). The purpose of this narrative review is to evaluate the sensitivity of SARS-CoV-2 towards ABHS and understand their potential adverse effects on humans. Ethanol and isopropanol have been the most commonly used alcohols in ABHS (e.g., gel, solution, spray, wipes, or foam) with alcohol in the range of 70–85% v/v in World Health Organization or Food and Drug Administration-approved ABHS. The denaturation of proteins around the envelope of SARS-CoV-2 positive sense single-stranded RNA virus is the major mechanism of action of ABHS. Due to frequent use of high-percentage alcohol-containing ABHS over an extended period of time, the oral, dermal, or pulmonary absorption is a possibility. In addition to the systemic toxicity, topical adverse effects such as contact dermatitis and atopic dermatitis are plausible and have been reported during COVID-19. ABHS appear to be effective in controlling the transmission of SARS-CoV-2 with the concern of oral, dermal, or pulmonary absorption.

Genomic Epidemiology and Characterization of Methicillin-Resistant Staphylococcus aureus from Bloodstream Infections in China

Since 2010, methicillin-resistant Staphylococcus aureus (MRSA) ST59 began to increase in prevalence in China, gradually replacing ST239 and has become the dominant clone in most hospitals in China. Here, we investigated the changing epidemiology, phylogenetic reconstruction, and genomic characterization of MRSA clones in China to identify the genomic driving factors in the prevalence of ST59. Most MRSA isolates were identified as ST59 (36.98%; 277/749), which increased from 25.09% in 2014 to 35.53% in 2019. The phylogenetic analysis of the 749 MRSA isolates showed a high level of diversity and the copresence of hospital-associated, community-associated, livestock-associated, and hypervirulent clones. Furthermore, minimum spanning trees revealed that ST59 MRSA clones from different hospitals and regions were integrated, suggesting that frequent exchanges had occurred between regions and hospitals. ST59 clones displayed higher susceptibility to antimicrobials than did ST239 and ST5 MRSA clones, indicating that resistance to non-β-lactam and fluoroquinolone antibiotics may be not critical for the epidemic success of ST59 clones. Virulence factors detection showed that sak and chp genes enriched in MRSA ST59 may be associated with the enhanced spreading success of ST59, whereas qacA may have contributed to the predominance of ST5 in East China. Our refined analysis of different clones among ST239, ST5, ST59, and ST398 demonstrated the existence of potential driving factors for the evolution of nosocomial MRSA populations and diversity of the evolutionary events surrounding clonal replacement.

IMPORTANCE As a developing country, China has an unbalanced health care system due to regional differences in economic development. However, China is also a country worthy of study with regard to the population dynamics of MRSA within the more resource-rich health care systems. In this study, we carried out genomic analysis to investigate the genomic epidemiology and characterization of MRSA isolated from bloodstream infections over a timespan of 6 years. Our refined analysis of different MRSA clones among ST59, ST5, ST239, and ST398 demonstrated the existence of driving factors for the evolution of nosocomial MRSA populations and diversity of the evolutionary events surrounding clonal replacement.

Utilizing the SEIPS model to guide hand hygiene interventions at a tertiary hospital in Ethiopia

We aimed to apply the Systems Engineering Initiative for Patient Safety (SEIPS) model to increase effectiveness and sustainability of the World Health Organization's (WHOs) hand hygiene (HH) guidelines within healthcare systems. Our cross-sectional, mixed-methods study took place at Jimma University Medical Center (JUMC), a tertiary care hospital in Jimma, Ethiopia, between November 2018 and August 2020 and consisted of three phases: baseline assessment, intervention, and follow-up assessment. We conducted questionnaires addressing HH knowledge and attitudes, interviews to identify HH barriers and facilitators within the SEIPS framework, and observations at the WHO's 5 moments of HH amongst healthcare workers (HCWs) at JUMC. We then implemented HH interventions based on WHO guidelines and results from our baseline assessment. Follow-up HH observations were conducted months later during the Covid-19 pandemic. 250 HCWs completed questionnaires with an average knowledge score of 61.4% and attitude scores indicating agreement that HH promotes patient safety. Interview participants cited multiple barriers to HH including shortages and location of HH materials, inadequate training, minimal Infection Prevention Control team presence, and high workload. We found an overall baseline HH compliance rate of 9.4% and a follow-up compliance rate of 72.1%. Drastically higher follow-up compared to baseline compliance rates were likely impacted by our HH interventions and Covid-19. HCWs showed motivation for patient safety despite low HH knowledge. Utilizing the SEIPS model helped identify institution-specific barriers that informed targeted interventions beyond WHO guidelines aimed at increasing effectiveness and sustainability of HH efforts.

Mathematical modeling applied to epidemics: an overview

This work presents an overview of the evolution of mathematical modeling applied to the context of epidemics and the advances in modeling in epidemiological studies. In fact, mathematical treatments have contributed substantially in the epidemiology area since the formulation of the famous SIR (susceptible-infected-recovered) model, in the beginning of the 20th century. We presented the SIR deterministic model and we also showed a more realistic application of this model applying a stochastic approach in complex networks. Nowadays, computational tools, such as big data and complex networks, in addition to mathematical modeling and statistical analysis, have been shown to be essential to understand the developing of the disease and the scale of the emerging outbreak. These issues are fundamental concerns to guide public health policies. Lately, the current pandemic caused by the new coronavirus further enlightened the importance of mathematical modeling associated with computational and statistical tools. For this reason, we intend to bring basic knowledge of mathematical modeling applied to epidemiology to a broad audience. We show the progress of this field of knowledge over the years, as well as the technical part involving several numerical tools.

Colonization resistance against multi-drug-resistant bacteria: a narrative review

Colonization resistance by gut microbiota is a fundamental phenomenon in infection prevention and control. Hospitalized patients may be exposed to multi-drug-resistant bacteria when hand hygiene compliance among healthcare workers is not adequate. An additional layer of defence is provided by the healthy gut microbiota, which helps clear the exogenous bacteria and acts as a safety net when hand hygiene procedures are not followed. This narrative review focuses on the role of the gut microbiota in colonization resistance against multi-drug-resistant bacteria, and its implications for infection control. The review discusses the underlying mechanisms of colonization resistance (direct or indirect), the concept of resilience of the gut microbiota, the link between the antimicrobial spectrum and gut dysbiosis, and possible therapeutic strategies. Antimicrobial stewardship is crucial to maximize the effects of colonization resistance. Avoiding unnecessary antimicrobial therapy, shortening the antimicrobial duration as much as possible, and favouring antibiotics with low anti-anaerobe activity may decrease the acquisition and expansion of multi-drug-resistant bacteria. Even after antimicrobial therapy, the resilience of the gut microbiota often occurs spontaneously. Spontaneous resilience explains the existence of a window of opportunity for colonization of multi-drug-resistant bacteria during or just after antimicrobial therapy. Strategies favouring resilience of the gut microbiota, such as high-fibre diets or precision probiotics, should be evaluated.

Hand Hygiene, an Update

Hand hygiene by health care personnel is an important measure for preventing health care-associated infections, but adherence rates and technique remain suboptimal. Alcohol-based hand rubs are the preferred method of hand hygiene in most clinical scenarios, are more effective and better tolerated than handwashing, and their use has facilitated improved adherence rates. Obtaining accurate estimates of hand hygiene adherence rates using direct observations of personnel is challenging. Combining automated hand hygiene monitoring systems with direct observations is a promising strategy, and is likely to yield the best estimates of adherence. Greater attention to hand hygiene technique is needed.

Hand hygiene in health care: 20 years of ongoing advances and perspectives

Health-care-associated infections are the most prevalent adverse events of hospital care, posing a substantial threat to patient safety and burden on society. Hand hygiene with alcohol-based hand rub is the most effective preventive strategy to reduce health-care-associated infections. Over the past two decades, various interventions have been introduced and studied to improve hand hygiene compliance among health-care workers. The global implementation of the WHO multimodal hand hygiene improvement strategy and constant efforts to replace the use of soap and water with alcohol-based hand rub have led to a faster and more efficient hand cleaning method. These strategies have strongly contributed to the success of behaviour change and a subsequent decrease in health-care-associated infections and cross-transmission of multidrug-resistant organisms worldwide. The WHO multimodal behaviour change strategy requires a series of elements including system change as a prerequisite for behaviour, change, education, monitoring and performance feedback, reminders in the workplace, and an institutional safety climate. Successful adoption of the promotion strategy requires adaptation to available resources and sociocultural contexts. This Review focuses on the major advances and challenges in hand hygiene research and practices in the past 20 years and sets out various ways forward for improving this lifesaving action.

Utilizing behavioral theories to explain hospital visitors' observed hand hygiene behavior

BACKGROUND

Hand hygiene is essential for infection prevention. This study aimed to find a suitable theoretical model and identify critical facilitators and barriers to explain hospital visitors' hand hygiene practice.

METHODS

Visitors in 4 hospitals were observed and asked to give explanations for using or not using the hand rub dispenser. The written explanations of N = 838 participants were coded according to three theoretical models: Theory of Planned Behavior, Health Action Process Approach (HAPA), and Theoretical Domains Framework (TDF).

RESULTS

Self-reported hand hygiene behavior differed from observed behavior, with 15.75% wrongly claiming to have cleaned their hands. Critical facilitators for hand hygiene were attitude toward the behavior,subjective norm, outcome expectancies, risk perception, planning, action control, knowledge and skills, motivation and goals, and social influences. Key barriers included perceived behavioral control; barriers and resources; memory, attention, and decision processes; and environmental context and resources.

CONCLUSIONS

Visitors' self-reported hand hygiene behavior is over-reported. Both HAPA and TDF were identified as suitable theoretical models for explaining visitor's hand hygiene practice. Future behavior change interventions should focus on (1) visibility and accessibility of cleaning products; (2) informing laypeople about their role regarding infection prevention; and (3) leveraging social influence processes.

Ten Thousand-Fold Higher than Acceptable Bacterial Loads Detected in Kenyan Hospital Environments: Targeted Approaches to Reduce Contamination Levels

Microbial monitoring of hospital surfaces can help identify target areas for improved infection prevention and control (IPCs). This study aimed to determine the levels and variations in the bacterial contamination of high-touch surfaces in five Kenyan hospitals and identify the contributing modifiable risk factors. A total of 559 high-touch surfaces in four departments identified as high risk of hospital-acquired infections were sampled and examined for bacterial levels of contamination using standard bacteriological culture methods. Bacteria were detected in 536/559 (95.9%) surfaces. The median bacterial load on all sampled surfaces was 6.0 × 10⁴ CFU/cm² (interquartile range (IQR); 8.0 × 10³–1.0 × 10⁶). Only 55/559 (9.8%) of the sampled surfaces had acceptable bacterial loads, <5 CFU/cm². Cleaning practices, such as daily washing of patient sheets, incident rate ratio (IRR) = 0.10 [95% CI: 0.04–0.24], providing hand wash stations, IRR = 0.25 [95% CI: 0.02–0.30], having running water, IRR = 0.19 [95% CI: 0.08–0.47] and soap for handwashing IRR = 0.21 [95% CI: 0.12–0.39] each significantly lowered bacterial loads. Transporting dirty linen in a designated container, IRR = 72.11 [95% CI: 20.22–257.14], increased bacterial loads. The study hospitals can best reduce the bacterial loads by improving waste-handling protocols, cleaning high-touch surfaces five times a day and providing soap at the handwash stations.

Nosocomial infection of COVID‑19: A new challenge for healthcare professionals (Review)

Nosocomial infections, also known as hospital-acquired infections, pose a serious challenge to healthcare professionals globally during the Coronavirus disease 2019 (COVID‑19) pandemic. Nosocomial infection of COVID‑19 directly impacts the quality of life of patients, as well as results in extra expenditure to hospitals. It has been shown that COVID‑19 is more likely to transmit via close, unprotected contact with infected patients. Additionally, current preventative and containment measures tend to overlook asymptomatic individuals and superspreading events. Since the mode of transmission and real origin of COVID‑19 in hospitals has not been fully elucidated yet, minimizing nosocomial infection in hospitals remains a difficult but urgent task for healthcare professionals. Healthcare professionals globally should form an alliance against nosocomial COVID‑19 infections. The fight against COVID‑19 may provide valuable lessons for the future prevention and control of nosocomial infections. The present review will discuss some of the key strategies to prevent and control hospital‑based nosocomial COVID‑19 infections.

Reappraising Elements of the Aseptic Technique in Dermatology: A Review

Dermatologic procedures are performed under varying degrees of antisepsis, and no clear guidelines exist regarding the role of the aseptic technique in dermatology. This review aims to clarify the terminology surrounding surgical asepsis and examines the importance of various components of the aseptic technique in cutaneous surgery. Included are studies examining optimal glove type, surgical instruments, skin antisepsis, and cost-reducing protocols. Our review highlights that most dermatology procedures are not performed under completely sterile conditions due to the lack of environmental and foot traffic controls in dermatology offices. In addition, for some outpatient procedures, such as for minor excisions and Mohs surgery before reconstruction, elements of the clean technique can be used without increasing infection rates. However, data on the feasibility of a clean protocol for Mohs reconstruction is conflicting. Future prospective, randomized trials analyzing various components of the aseptic technique in dermatology are greatly needed so that guidelines can be established for practicing dermatologists.