Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study

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.

Patient-derived pathogenic microbe deposition enhances exposure risk in pediatric clinics

Healthcare-associated infections (HAIs) pose significant risks to pediatric patients in outpatient settings. To prevent HAIs, understanding the sources and transmission routes of pathogenic microorganisms is crucial. This study aimed to identify the sources of opportunistic bacterial pathogens (OBPs) in pediatric outpatient settings and determine their transmission routes. Furthermore, assessing the public health risks associated with the core OBPs is important. We collected 310 samples from various sites in pediatric outpatient areas and quantified the bacteria using qPCR and CFU counting. We also performed 16S rRNA gene and single-bacterial whole-genome sequencing to profile the transmission routes and antibiotic resistance characteristics of OBPs. We observed significant variations in microbial diversity and composition among sampling sites in pediatric outpatient settings, with active communication of the microbiota between linked areas. We found that the primary source of OBPs in multi-person contact areas was the hand surface, particularly in pediatric patients. Five core OBPs, Staphylococcus epidermidis, Acinetobacter baumannii, Pseudomonas aeruginosa, Streptococcus mitis, and Streptococcus oralis, were mainly derived from pediatric patients and spread into the environment. These OBPs accumulated at multi-person contact sites, resulting in high microbial diversity in these areas. Transmission tests confirmed the challenging spread of these pathogens, with S. epidermidis transferring from the patient's hand to the environment, leading to an increased abundance and emergence of related strains. More importantly, S. epidermidis isolated from pediatric patients carried more antibiotic-resistance genes. In addition, two strains of multidrug-resistant A. baumannii were isolated from both a child and a parent, confirming the transmission of the five core OBPs centered around pediatric patients and multi-person contact areas. Our results demonstrate that pediatric patients serve as a significant source of OBPs in pediatric outpatient settings. OBPs carried by pediatric patients pose a high public health risk. To effectively control HAIs, increasing hand hygiene measures in pediatric patients and enhancing the frequency of disinfection in multi-person contact areas remains crucial. By targeting these preventive measures, the spread of OBPs can be reduced, thereby mitigating the risk of HAIs in pediatric outpatient settings.

Ten years of hand hygiene excellence: a summary of outcomes, and a comparison of indicators, from award-winning hospitals worldwide

BACKGROUND

Hand hygiene is a crucial measure for the prevention of healthcare-associated infections (HAIs). The Hand Hygiene Excellence Award (HHEA) is an international programme acknowledging healthcare facilities for their leadership in implementing hand hygiene improvement programmes, including the World Health Organisation's Multimodal Improvement Strategy. This study aimed at summarising the results of the HHEA campaign between 2010 and 2021 and investigating the relationship between different hand hygiene parameters based on data from participating healthcare facilities.

METHODS

A retrospective analysis was performed on datasets from HHEA forms, including data on hand hygiene compliance, alcohol-based handrub (ABHR) consumption, and Hand Hygiene Self-Assessment Framework (HHSAF) scores. Descriptive statistics were reported for each variable. The correlation between variables was inspected through Kendall's test, while possible non-linear relationships between hand hygiene compliance, ABHR consumption and HHSAF scores were sought through the Locally Estimated Scatterplot Smoothing or logistic regression models. A tree-structured partitioning model was developed to further confirm the obtained findings.

RESULTS

Ninety-seven healthcare facilities from 28 countries in three world regions (Asia-Pacific, Europe, Latin America) were awarded the HHEA and thus included in the analysis. HHSAF scores indicated an advanced hand hygiene promotion level (median 445 points, IQR 395-480). System change (100 [95-100] points) and institutional safety climate (85 [70-95] points) showed the highest and lowest score, respectively. In most cases, hand hygiene compliance was above 70%, with heterogeneity between countries. ABHR consumption above 20 millilitres per patient-day (ml/PD) was widely reported, with overall increasing trends. HHSAF scores were positively correlated with hand hygiene compliance (τ = 0.211, p = 0.007). We observed a positive correlation between compliance rates and ABHR consumption (τ = 0.193, p < 0.001), although the average predicted consumption was stable around 55-60 ml/PD for compliance rates above 80-85%. Logistic regression and partitioning tree analyses revealed that higher HHSAF scores were more likely in the high-ABHR consumption group at cut-offs around 57-59 ml/PD.

CONCLUSION

Ten years after its inception, the HHEA proves to be a valuable hand hygiene improvement programme in healthcare facilities worldwide. Consistent results were provided by the different hand hygiene indicators and the HHSAF score represents a valuable proxy measure of hand hygiene compliance.

Bloodstream infections in neutropenic and non-neutropenic patients with haematological malignancies: epidemiological trends and clinical outcomes in Queensland, Australia over the last 20 years

Knowledge of the epidemiology of bloodstream infection (BSI) in haematology patients is essential to guide patient management. We investigated the epidemiology of BSI in patients with haematological malignancies in Queensland over the last 20 years (2000-2019), including all episodes diagnosed by the state-wide microbiology service. We identified 7749 BSI in 5159 patients, 58% associated with neutropenia. Gram-negatives were the main causative pathogens (58.3%), more frequent in neutropenic than non-neutropenic patients (3308/5309, 62.3% vs 1932/3678, 52.5%, p < 0.001). Amongst 8987 isolates the most common were E. coli (15.4%) and Pseudomonas spp. (14.2%). Pseudomonas spp. (16.6% vs 10.7%, p < 0.001), Klebsiella spp. (11.6% vs 6.8%, p < 0.001), viridans-group streptococci (4.4% vs 1.2%, p < 0.001) and E. faecium (2.4% vs 0.9%, p < 0.001) were more common in neutropenic than non-neutropenic patients, while S. aureus was less common (5.9% vs 15.6%, p < 0.001). Several antimicrobial resistance rates increased over time and had higher prevalence in neutropenic than non-neutropenic patients, including ciprofloxacin-resistant E. coli (94/758, 12.4% vs 42/506, 8.3%, p = 0.021), trimethoprim-sulfamethoxazole-resistant E. coli (366/764, 47.9% vs 191/517, 36.9%, p < 0.001), penicillin-resistant streptococci (51/236, 21.6% vs 28/260, 10.8%, p < 0.001) and vancomycin-resistant enterococci (46/250, 18.4% vs 9/144, 6.3%, p < 0.001). Carbapenem-resistant Pseudomonas spp. (OR 7.32, 95%CI 2.78-19.32) and fungi, including yeasts and moulds (OR 3.33, 95%CI 2.02-5.48) were associated to the highest odds of 30-day case-fatality at a multivariable logistic regression analysis. Neutropenia was associated with survival (OR 0.66, 95%CI 0.55-0.78). Differences were observed in the BSI epidemiology according to neutropenic status, with an overall increase of resistance over time associated to adverse outcome.

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.

Incremental costs of hospital-acquired infections in COVID-19 patients in an adult intensive care unit of a tertiary hospital from a low-resource setting

BACKGROUND

Hospital-acquired infections (HAIs) are a global public health problem and put patients at risk of complications, including death. HAIs increase treatment costs, but their financial impact on Serbia's healthcare system is unknown. Our goal was to assess incremental costs of HAIs in a tertiary care adult intensive care unit (ICU) that managed COVID-19 patients.

METHODS

A retrospective study from March 6th to December 31st, 2020 included patients with microbiologically confirmed COVID-19 (positive rapid antigen test or real-time polymerase chain reaction) treated in the ICU of the Teaching Hospital for Infectious and Tropical Diseases, University Clinical Centre of Serbia. Demographic and HAI-specific data acquired in our ICU were collected, including total and stratified medical costs (services, materials, laboratory testing, medicines, occupancy costs). Median total and stratified costs were compared in relation to HAI acquisition. Linear regression modelling was used to assess incremental costs of HAIs, adjusted for age, biological sex, prior hospitalisation, Charlson Comorbidity Index (CCI), and Glasgow Coma Scale (GCS) on admission. Outcome variables were length of stay (LOS) in days and mortality.

RESULTS

During the study period, 299 patients were treated for COVID-19, of which 214 were included. HAIs were diagnosed in 56 (26.2%) patients. Acinetobacter spp. was the main pathogen in respiratory (38, 45.8%) and bloodstream infections (35, 42.2%), the two main HAI types. Median total costs were significantly greater in patients with HAIs (€1650.4 vs. €4203.2, p < 0.001). Longer LOS (10.0 vs. 18.5 days, p < 0.001) and higher ICU mortality (51.3% vs. 89.3%, p < 0.001) were seen if HAIs were acquired. Patients with ≥ 2 HAIs had the highest median total costs compared to those without HAIs or with a single HAI (€1650.4 vs. €3343.4 vs. €7336.9, p < 0.001). Incremental costs in patients with 1 and ≥ 2 HAIs were €1837.8 (95% CI 1257.8-2417.7, p < 0.001) and €5142.5 (95% CI 4262.3-6022.7, p < 0.001), respectively.

CONCLUSIONS

This is the first economic evaluation of HAIs in Serbia, showing significant additional costs to our healthcare system. HAIs prolong LOS and influence ICU mortality rates. Larger economic assessments are needed to enhance infection control practices.

Interactive Interventions Can Improve Hand Hygiene and Aseptic Techniques During Perioperative Care-Experience From the "Safe Hands" Project

PURPOSE

This paper evaluates a theory-driven, interactive hand hygiene (HH) intervention, the Safe Hands project, based on theories of organizational learning and culture including leadership support, dialogue and co-creation.

DESIGN

This prospective quasi-experimental study used unobtrusive overt observations to evaluate adherence to HH recommendations after implementing an infection-prevention intervention.

METHODS

The primary outcome was differences in HH practices "Before aseptic/clean procedure" (WHO moment 2), "After body fluid exposure risk" (WHO moment 3) and performance of aseptic techniques. One operating room (OR) department served as the study hospital and the other as the control hospital, both at Swedish university hospitals. Adherence to HH guidelines was measured 4 times during 2015 to 2017.

FINDINGS

The intervention site displayed a significant improvement in adherence to HH guidelines and aseptic techniques. WHO 2; from 23.8% to 36.2%, (P = .014), WHO 3; from 22.2% to 42.3%, (P = .002), and aseptic techniques; from 17.5% to 31.6%, (P = .003). No changes in adherence were identified at the control site. The use of contaminated gloves decreased post intervention at the study operating department.

CONCLUSIONS

This study shows that implementing tailored interventions that are underpinned by theories from organizational learning and culture can improve adherence to hand hygiene in a complex setting as the OR up to 6 months post-intervention. The interprofessional co-creation of standards operating procedures addressing specific care procedures and emphasizing the importance of aseptic techniques can be an acceptable and feasible way to reduce the risks of contaminating medical devices and patients during perioperative care.

Development and evaluation of an ultra-wide bandwidth based electronic hand hygiene monitoring system

BACKGROUND

A large variety of electronic hand hygiene monitoring systems (EHHMS) are being developed and applied in health care settings. Monitoring hand hygiene (HH) opportunity at bed-level has been the key technical challenge. Accuracy evaluation needs more attention as the prerequisite upon widespread acceptance and adoption.

METHODS

For the first time, we explored, debugged and upgraded an EHHMS based on ultra-wide bandwidth (UWB) which can obtain HH opportunities at bed-level. The real-time positioning and electronic fence of UWB technology was applied for EHHMS. The accuracy of EHHMS was compared with the simultaneous manual direct observations in real-world clinical setting. Sensitivity and specificity were calculated for EHHMS capturing HH action and opportunity.

RESULTS

Two generations of EHHMS were constructed. For the first generation, the system properly recorded 84% and 78% of the pre-identified HH actions and opportunities performed by experimenters. For the second generation, sensitivity and specificity of the system capturing HH action were 89% (84.83-92.36) and 100% (98.26-100.00), respectively. For capturing HH opportunity, the system showed the sensitivity and specificity of 86.52% (82.52-89.89) and 88.10% (84.14-91.36)), respectively.

CONCLUSION

The EHHMS based on UWB could accurately identify HH action and opportunity with equivalent accuracy compared with simultaneous direct observation.

A randomised controlled trial investigating the effect of improving the cleaning and disinfection of shared medical equipment on healthcare-associated infections: the CLEaning and Enhanced disiNfection (CLEEN) study

BACKGROUND

Healthcare-associated infections (HAIs) are a common, costly, yet largely preventable complication impacting patients in healthcare settings globally. Improving routine cleaning and disinfection of the hospital environment has been shown to reduce the risk of HAI. Contaminated shared medical equipment presents a primary transmission route for infectious pathogens, yet is rarely studied. The CLEEN study will assess how enhanced cleaning and disinfection of shared medical equipment affects the rate of HAIs in a tertiary hospital setting. The initiative is an evidence-based approach combining staff training, auditing and feedback to environmental services staff to enhance cleaning and disinfection practices.

METHODS

The CLEEN study will use a stepped wedge randomised controlled design in 10 wards of one large Australian hospital over 36 weeks. The intervention will consist of 3 additional hours per weekday for the dedicated cleaning and disinfection of shared medical equipment on each ward. The primary outcome is to demonstrate the effectiveness of improving the quality and frequency of cleaning shared medical equipment in reducing HAIs, as measured by a HAI point prevalence study (PPS). The secondary outcomes include the thoroughness of equipment cleaning assessed using fluorescent marker technology and the cost-effectiveness of the intervention.

DISCUSSION

Evidence from the CLEEN study will contribute to future policy and practice guidelines about the cleaning and disinfection of shared medical equipment. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in healthcare facilities.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ACTRN12622001143718.

Paradoxes of pandemic infection control: Proximity, pace and care within and beyond SARS-CoV-2

From the adoption of mask-wearing in public settings to the omnipresence of hand-sanitising, the SARS-CoV-2 pandemic has brought unprecedented cultural attention to infection prevention and control (IPC) in everyday life. At the same time, the pandemic threat has enlivened and unsettled hospital IPC processes, fracturing confidence, demanding new forms of evidence, and ultimately involving a rapid reassembling of what constitutes safe care. Here, drawing on semi-structured interviews with 63 frontline healthcare workers from two states in Australia, interviewed between September 2020 and March 2021, we illuminate some of the affective dimensions of IPC at a time of rapid change and evolving uncertainty. We track how a collective sense of risk and safety is relationally produced, redefining attitudes and practices around infective risk, and transforming accepted paradigms of care and self-protection. Drawing on Puig de la Bellacasa's formulation, we propose the notion of IPC as a multidimensional matter of care. Highlighting the complex negotiation of space and time in relation to infection control and care illustrates a series of paradoxes, the understanding of which helps illuminate not only how IPC works, in practice, but also what it means to those working on the frontline of the pandemic.

Limited evidence of patient-to-patient transmission of Staphylococcus aureus strains between children with cystic fibrosis, Queensland, Australia

OBJECTIVES

Here we used whole genome sequencing (WGS) to understand strain diversity and potential for patient-to-patient transmission of Staphylococcus aureus among children with cystic fibrosis (CF) in Queensland, Australia.

METHODS

S. aureus isolates (n = 401) collected between January 2018 and April 2019 from 184 patients with CF (n = 318 isolates) and 76 patients without CF (n = 83 isolates) were subjected to WGS and subsequent multilocus sequence typing (MLST), and a phylogeny was constructed from core genome single nucleotide polymorphism (SNP) analysis. The subsequent data was compared with available patient information.

RESULTS

WGS revealed that patients with CF were essentially colonised by the same genotypes as those seen in patients without CF. Sequence types (ST) for our patients with CF were predominantly ST5 (20.1%), ST30 (7.3%), ST15 (6.3%) and ST8 (5.3%). Two Australian clones, ST93 and ST239, typically seen in skin infections and health-care settings, respectively, were notably absent from our patients with CF. Based on a SNP distance threshold of 14 SNPs, 20 cluster types involving 50/260 patients were evident; of these, 6 clusters contained only patients found to be siblings or otherwise living in the same household. Epidemiological relationships could not be determined for a remaining 14 cluster types involving 38 patients, comprising 2-7 (median 2) patients each. Multiple S. aureus genotypes were observed in 19/73 CF patients who provided more than one sample.

CONCLUSION

These results show that WGS is a useful tool for surveillance of S. aureus strains in children with CF and that the strains in our CF cohort were largely consistent with those circulating in patients without CF. Overall, this confirms previous findings and indicates that S. aureus acquisition in children with CF is similar to that of other patient groups, with limited evidence of potential patient-to-patient transmission within this patient group.

Hand Hygiene Compliance Rates in 9 Pediatric Intensive Care Units Across Europe: Results from the Reducing Antimicrobial use and Nosocomial Infections in Kids Network

A unified surveillance mechanism for hand hygiene and hospital-acquired infections for pediatric wards is lacking in Europe. We managed to setup such a mechanism in 9 pediatric intensive care units in 7 European countries, using World Health Organization's definitions and common methodology which allows for benchmarking among units and countries. Median hand hygiene compliance was found high 82.3% (interquartile range 71.6-94.5%), but gaps in practices were identified.

Disease burden, associated mortality and economic impact of antimicrobial resistant infections in Australia

BACKGROUND

The growing spread of antimicrobial resistance (AMR) is accepted as a threat to humans, animals and the environment. This threat is considered to be both country specific and global, with bacteria resistant to antibiotic treatment geographically dispersed. Despite this, we have very few Australian estimates available that use national surveillance data supplemented with measures of risk, to generate reliable and actionable measures of AMR impact. These data are essential to direct policies and programs and support equitable healthcare resource utilisation. Importantly, such data can lead to implementation of programs to improved morbidity and mortality of patients with a resistant infection.

METHODS

Using data from a previous case-cohort study, we estimated the AMR-associated health and economic impact caused by five hospital-associated AMR pathogens (Enterococcus spp., E. coli, K. pneumoniae, P. aeruginosa and S. aureus) in patients with a bloodstream, urinary tract, or respiratory tract infection in Australia in 2020. We estimated disease burden based on the counterfactual scenario in which all AMR infections were replaced by no infection.We used a population-level simulation model to compute AMR-associated mortality, loss of quality-adjusted life years and costs.

FINDINGS

In 2020, there were 1,031 AMR-associated deaths (95% uncertainty interval [UI] 294, 2,615) from the five resistant hospital-associated infections in Australia. The greatest odds of dying were from respiratory infections (ceftazidime-resistant P. aeruginosa) and bloodstream infections, both resulting in high hospital and premature death costs. MRSA bacteraemia contributed the most to hospital costs (measured as bed-days) as patients with this infection resulted in additional 12,818 (95% UI 7246, 19966) hospital bed-days and cost the hospitals an extra $24,366,741 (95%UI $13,774,548, $37,954,686) per year. However, the cost of premature death from five resistant pathogens was $438,543,052, which was by far greater than the total hospital cost ($71,988,858). We estimate a loss of 27,705 quality-adjusted life years due to the five AMR pathogens.

INTERPRETATION

These are the first Australian estimates of AMR-associated health and economic impact. Country-level estimates of AMR impact are needed to provide local evidence to better inform programs and health policies to reduce morbidity and mortality associated with infection. The burden in hospital is likely an underestimate of the impact of AMR due to community-associated infections where data are limited, and the AMR burden is high. This should now be the focus of future study in this area.

FUNDING

TMW was supported by the Australian Partnership for Preparedness Research on Infectious Disease Emergencies (APPRISE) (grant number GNT1116530) Fellowship.

Hand hygiene compliance by direct observation in physicians and nurses: a systematic review and meta-analysis

BACKGROUND

Direct observation of hand hygiene compliance is the "gold standard" despite limitations and potential for bias. Previous literature highlights poorer hand hygiene compliance amongst physicians than nurses and suggests that covert monitoring may give better compliance estimates than overt monitoring.

AIM

This review aimed to explore differences in compliance between physicians and nurses further, and to analyse if compliance estimates differed when observations were covert rather than overt.

METHODS

A systematic search of databases PubMed, EMBASE, CENTRAL and CINAHL was performed. Experimental or observational studies in hospital settings in high-income countries published in English from 2010 onwards were included if estimates for both physicians and nurses using direct observation were reported. The search yielded 4814 studies, of which 105 were included.

FINDINGS

The weighted pooled compliance rate for nurses was 52% (95% CI 47% to 57%) and for doctors was 45% (95% CI 40% to 49%). Heterogeneity was considerable (I²=99%). The majority of studies were at moderate or high risk of bias. Random-effects meta-analysis of low risk of bias studies suggests higher compliance for nurses than physicians for both overt (difference of 7%, 95% CI for the difference 0.8% to 13.5%, p=0.027) and covert (difference of 7%, 95% CI 3% to 11%, p=0.0002) observation. Considerable heterogeneity was found in all analyses.

CONCLUSION

Wide variability in compliance estimates and differences in the methodological quality of hand hygiene studies were identified. Further research with meta-regression should explore sources of heterogeneity and improve the conduct and reporting of hand hygiene studies.

The effect of compliance to Hand hygiene during COVID-19 on intestinal parasitic infection and intensity of soil transmitted helminthes, among patients attending general hospital, southern Ethiopia: Observational study

BACKGROUND

Intestinal parasitic infection (IPIs) is one of the major health problems in Sub -Saharan Africa where water, sanitation and hygiene practices are inadequate. Taking into account the national level implementation of intensive hand hygiene against COVID-19 pandemic and general protective effect this study assessed its effect on intestinal parasite.

OBJECTIVE

This study aim to investigate the effect of compliance to hand hygiene practice on the prevalence of intestinal parasitic infection (IPIs) and intensity of Soil transmitted helminthes (STH) among patients attending tertiary care hospital in southern Ethiopia.

METHODS

Observational study was conducted from June to September 2021. Data on socio demographic, hand hygiene practice and intestinal parasite (prevalence and intensity of helminthic infection) was collected from randomly selected and consented patients. Compliance to hand hygiene practice was assessed using pre-tested questionnaire. Fresh stool sample from each participant was examined by direct wet mount, concentration and Ziehl-Neelson (ZN) staining technique to detect intestinal parasite. Intensity of STH measurements was done through direct egg-count per gram using Kato Katz methods. Data analysis was done using SPSS version 25. Odds ratio with 95% confidence interval was used to measure association and p-value <0.05 was considered as statistically significant.

RESULTS

The study population (N = 264) consisted of 139(52.65%) male and 125 (47.34%) female with the mean ages of 36 ±16.12(±SD). The proportion of good compliance to hand hygiene during COVID-19 to was 43.93% (95%CI: 37% to 47) and prevalence of intestinal parasite was 26.14% (95%CI:21.2% to 31.75) comprising 23.48% intestinal protozoa and 6.43% of soil transmitted helminthic infection. Gardia lamblia, Entamoeba histolytica/dispar, Ascaris lumbricoides were the common parasite in the study area with prevalence of 15.53%, 6.44%, and 1.52% respectively. Prevalence of intestinal parasite among participants with good compliance to hand hygiene group and poor compliance to hand hygiene were (14.65% vs. 35.13%)(AOR: 0.48,95%CI:0.13 to 0.68) (p = 0.002) implying that good compliance to hand hygiene can reduce the risk of IPIs by 52%. Moreover significantly lower odds of intestinal protozoa among good compliance to hand hygiene group than the control (OR:0.38; (95%CI: 0.20 to 0.71);P = 0.001. However, no significant difference in the odds of intensity of STH infection in good compliance hand hygiene and poor compliance group. The result of this study also confirmed the association between intestinal parasitic infections and younger /adolescent age, education status, habit of eating raw vegetable and figure nail status.

CONCLUSION

Good hand hygiene compliance during COVID-19 significantly associated with reduction of intestinal parasitic infection. This finding highlights the secondary protective effect of improved hand hygiene against IPIs and suggest it can used in augmenting the existing parasitic control strategies in the study setting.

Direct hand hygiene observations and feedback increased hand hygiene compliance among nurses and doctors in medical and surgical wards - an eight-year observational study

BACKGROUND

The improvement of hand hygiene compliance (HHC) is critical to preventing healthcare-associated infections (HCAIs). The present study explored how direct observation and feedback influences HHC among nurses and doctors in surgical and medical wards, and whether these actions impact HCAI incidence.

METHODS

In this longitudinal observational study, HHC and the incidence of HCAIs were observed in six medical and seven surgical wards in a tertiary hospital in Finland from May 2013 to Dec 2020. Data of the observations of five hand hygiene (HH) moments were collected from the hospital HH and the HCAI monitoring registries. For statistical analyses a multivariable logistic regression analysis and a Poisson regression model were used.

FINDINGS

HH monitoring included 24 614 observations among nurses and 6 396 observations among doctors. In medical wards, HHC rates increased 10.8% - from 86.2% to 95.5%, and HCAI incidence decreased from 15.9 to 13.5 per 1000 patient days (p<0.0001). In surgical wards, HHC increased 32.7% - from 67.6% to 89.7%, and HCAI incidence decreased from 13.7 to 12.0 per 1000 patient days (p< 0.0001). The overall HHC increased significantly among nurses (17.8%) and doctors (65.8%). The HHC was better among nurses than doctors (in medical wards; OR 3.36; 95% CI 2.90-3.90, p<0.001 and in surgical wards; OR 9.85; 95% CI 8.97-10.8, p<0.001).

CONCLUSION

Direct observations and feedback of HH increased significantly HHC among nurses and doctors over an eight-year period. During the same period, the incidence of HCAIs significantly decreased in both medical and surgical wards.

Neonatal Staphylococcus Aureus Sepsis: a 20-year Western Australian experience

OBJECTIVES

The purpose of this study was to characterise neonatal Staphylococcus aureus (SA) sepsis in Western Australia (WA) between 2001 and 2020 at the sole tertiary neonatal intensive care unit (NICU), examine risk factors for sepsis in the cohort, and compare short- and long-term outcomes to control infants without any sepsis.

METHODS

Retrospective cohort study at the Neonatal Directorate at King Edward Memorial Hospital (KEMH) and Perth Children's Hospital, using electronic databases and patient medical records.

RESULTS

The overall incidence of SA sepsis was 0.10 per 1000 live births (62/614207). From 2001 to 2010 the incidence was 0.13/1000 live births, reducing to 0.07/1000 live births from 2011 to 2020. SA was most frequently isolated from endotracheal aspirates, and infants with SA sepsis had longer median duration of ventilatory support than those without any sepsis (31 days vs 18 days respectively, p < 0.001). In our cohort, SA sepsis was associated with worse neurodevelopmental outcomes compared to infants without any sepsis.

CONCLUSIONS

The incidence of neonatal SA sepsis has reduced over the last 20 years, suggesting potential effectiveness of the preventative interventions implemented. Endotracheal tube (ETT) colonisation and prolonged ventilation may be under-recognised as potential sources of SA infection. Our study suggests SA sepsis may negatively impact neurodevelopmental outcomes.

Implementation of a structured practical activity to analyse student healthcare worker perceptions and compliance with prescribed infection control procedures

BACKGROUND

Non-compliance with infection control guidelines has been reported within healthcare settings. Infection control education in undergraduate healthcare education programs forms a critical component in preparing student healthcare workers for vocational roles.

METHODS

Clinical sciences students (nutrition science, paramedicine, pharmacy, podiatry, optometry studying for qualifications recognised by the Australian Health Practitioner Regulation Agency) self-reported hygiene perceptions and practices and collected microbiological swabs from personal or medical equipment items before and after recommended disinfection procedures.

RESULTS

Cultivable microorganisms were isolated from 95% of student medical equipment items. Disinfection significantly reduced microbial growth on student medical equipment items (P < 0.05).

CONCLUSIONS

Student perceptions of infection control procedures do not always correlate with infection control practice. Infection control education of undergraduate healthcare students requires ongoing assessment to ensure successful translation into clinical practice.

Evaluation of the Residual Disinfection Effects of Commonly Used Skin Disinfectants against Viruses: An Innovative Contact Transmission Control Method

Lasting disinfection effects, that is, the residual disinfection effects (RDEs), of skin-coated disinfectants have rarely been considered for infection control owing to the challenges involved in the accurate evaluation of RDEs. In this study, we constructed a new skin evaluation model and determined the RDEs of existing disinfectants against viruses. Our results showed that ethanol and isopropanol had no RDE, whereas povidone-iodine, chlorhexidine gluconate, and benzalkonium chloride (BAC) exhibited RDEs, with 10% povidone-iodine and 0.2% BAC showing particularly strong RDEs. The RDE of 0.2% BAC was strong enough to reduce the median survival times of severe acute respiratory syndrome coronavirus-2, human coronavirus-OC43, and influenza virus from 670 to 5.2, 1300 to 12, and 120 to 4.2 min, respectively. Additionally, this strong RDE was maintained even 4 h after coating the skin. Clinical data also showed that the strong RDE of 0.2% BAC was maintained for more than 2 h. Thus, applying disinfectants with strong RDEs on the skin correlates with a reduction in virus survival time and appears to create a skin surface environment that is not conducive to virus survival. A prolonged reduction in virus survival decreases the contact transmission risk, thereby enabling stronger infection control.

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.

Level of Knowledge of Medical Staff on the Basis of the Survey in Terms of Risk Management, Associated with Clostridioides difficile Infections

Infections caused by the toxigenic strains of Clostridioides difficile in the hospital environment pose a serious public health problem. The progressive increase in hospital infections in Poland indicates that risk management is a tool that is not used in an effective way and significantly differs from the goals set by the Leading Authorities, the Ministry of Health and its subordinate units. Systematic education of medical personnel constitutes the basic element of rational risk management aimed at reducing the number of infections as it allows for the transfer of knowledge, development of appropriate organizational procedures, and improves internal communication. This paper presents the results of a survey conducted in hospital facilities throughout Poland. The study dealt with what medical personnel know about channels of transmission and prevention of Clostridioides difficile infections in the hospital setting, professional training and risk management in terms of reducing the number of infections. The survey reveals that Clostridioides difficile continues to be a serious problem in the inpatient care system. Procedures and management strategies implemented by hospitals in order to limit the spread of the pathogen are predominantly focused on short-term action, which does not lead to a real improvement in terms of hospitalized patients' safety. The infection risk management system was assessed at a fairly low level. The obtained research results confirmed the research hypotheses that had been formulated.

The impact of a 'milking the COW' campaign in a regional hospital in Singapore

Background

Computerisation of various processes in hospitals and reliance on electronic devices raises the concern of contamination of these devices from the patient environment. We undertook this study to determine if an attached hand hygiene device that unlocks the screen of a computer on wheels (COW) on usage can be effective in decreasing the microbiological burden on computer keyboards.

Methods

An electronic hand sanitizer was integrated onto the COW. A prospective cohort study with a crossover design involving 2 control and 2 intervention wards was used. The study end point was the number of colony forming units found on the keyboards. Bacteria were classified into 4 main groups; pathogenic, skin flora, from the environment or those thought to be commensals in healthy individuals. We then used a mixed effects model for the statistical analysis to determine if there were any differences before and after the intervention.

Results

Thirty-nine keyboards were swabbed at baseline, day 7 and 14, with 234 keyboards cultured, colony forming units (CFUs) counted and organisms isolated. By mixed model analysis, the difference of mean bacteria count between intervention and control for week 1 was 32.74 (− 32.74, CI − 94.29 to 28.75, p = 0.29), for week 2 by 155.86 (− 155.86, CI − 227.45 to − 83.53, p < 0.0001), and after the 2-week period by 157.04 (− 157.04, CI − 231.53 to − 82.67, p < 0.0001). In the sub-analysis, there were significant differences of pathogenic bacteria counts for the Intervention as compared to the Control in contrast with commensal counts.

Conclusion

A hand hygiene device attached to a COW may be effective in decreasing the microbiological burden on computer keyboards.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00948-1.

Molecular Epidemiology of Third-Generation-Cephalosporin-Resistant Enterobacteriaceae in Southeast Queensland, Australia

Third-generation cephalosporin-resistant (3GC-R) Enterobacteriaceae represent a major threat to human health. Here, we captured 288 3GC-R Enterobacteriaceae clinical isolates from 264 patients presenting at a regional Australian hospital over a 14-month period. In addition to routine mass spectrometry and antibiotic sensitivity testing, isolates were examined using rapid (∼40-min) real-time PCR assays targeting the most common extended-spectrum β-lactamases (ESBLs; bla _CTX-M-1 and bla _CTX-M-9 groups, plus bla _TEM, bla _SHV, and an internal 16S rRNA gene control). AmpC CMY β-lactamase (bla _CMY) prevalence was also examined. Escherichia coli (80.2%) and Klebsiella pneumoniae (17.0%) were dominant, with Klebsiella oxytoca, Klebsiella aerogenes, and Enterobacter cloacae infrequently identified. Ceftriaxone and cefoxitin resistance were identified in 97.0% and 24.5% of E. coli and K. pneumoniae isolates, respectively. Consistent with global findings in Enterobacteriaceae, most (98.3%) isolates harbored at least one β-lactamase gene, with 144 (50%) harboring bla _CTX-M-1 group, 92 (31.9%) harboring bla _CTX-M-9 group, 48 (16.7%) harboring bla _SHV, 133 (46.2%) harboring bla _TEM, and 34 (11.8%) harboring bla _CMY genes. A subset of isolates (n = 98) were subjected to whole-genome sequencing (WGS) to identify the presence of cryptic resistance determinants and to verify genotyping accuracy. WGS of β-lactamase-negative or carbapenem-resistant isolates identified uncommon ESBL and carbapenemase genes, including bla _NDM and bla _IMP, and confirmed all PCR-positive genotypes. We demonstrate that our PCR assays enable the rapid and cost-effective identification of ESBLs in the hospital setting, which has important infection control and therapeutic implications.

Effects of a 4-year intervention on hand hygiene compliance and incidence of healthcare associated infections: a longitudinal study

Purpose

Studies have demonstrated improvements in hand hygiene (HH) compliance through interventions, noting the negative association of HH and healthcare associated infections (HAIs), but how to sustain long-term improvement is still unknown in the Chinese population. This study sought to determine the extent of change in HH compliance after multimodal HH interventions, and to evaluate the relationship between that change and HAI incidence.

Methods

We conducted a longitudinal study in a general teaching hospital in China from 2017 to 2020. Trained investigators observed HH practices based on the World Health Organization’s 5 moments for HH. We identified the incidence of HAIs using semi-automated constant surveillance software. We used the Cochran–Mantel–Haenszel test to assess the secular trend of HH compliance and HAIs. The Spearman correlation coefficient (r_s) was used to evaluate the relationship between the incidence of HAIs and compliance with HH.

Results

The study made 480,943 observations, where HH was occurring between 2017 and 2020. HH compliance increased from 68.90 to 91.76% during that period (P_trend < 0.01), while the incidence of HAIs decreased from 1.10 to 0.91%. Compliance also increased for each moment type and for each healthcare worker (P_trend < 0.01). Lower HH compliance was observed in before-patient contact and after contact with patient surroundings, and among interns and cleaners. We also observed a weak but statistically significant negative correlation between the monthly HH compliance and incidence of HAIs (r_s =  − 0.27; P = 0.037).

Conclusions

The multimodal HH implementation delivered sustained improvement in HH compliance, and this change was associated with a decline in the incidence of HAIs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-021-01626-5.

What is new with hand hygiene?

PURPOSE OF REVIEW

Healthcare-associated infections (HAIs) challenge healthcare systems worldwide. As healthcare workers' hands are considered the main vector for transmission of pathogens, effective hand hygiene is the single most important action to prevent HAIs. We sought to highlight new developments and advances in hand hygiene.

RECENT FINDINGS

Hand hygiene compliance averages at 38%. A sustained increase of compliance with a subsequent decrease of HAIs may be achieved by national, systematic and rigorous education, and auditing programs. Periodically deployed self-operating hand hygiene surveillance systems coupled with personalized reminders could facilitate such efforts. Alcohol-based hand-rub (ABHR) solutions remain the hand hygiene gold standard, but are modified in texture and composition to better meet healthcare workers' preferences. Modifications of the hand hygiene procedure have been proposed targeting both time and technique of hand rub application. Reducing rub-time from 30 to 15 s and simplifying the technique to consist of three rather than six steps yielded encouraging results in terms of microbiological efficacy and higher compliance.

SUMMARY

Implementation and promotion of compliance are the major concerns of today's research on hand hygiene. Developments towards better surveillance and systematic education, improved ABHR formulation and streamlining of hand hygiene actions are paving the way ahead.

Education and training in infection prevention and control: Exploring support for national standards

BACKGROUND

Effective infection prevention and control (IPC) programmes comprise a hierarchy of preventive measures, one of which is appropriate use of personal protective equipment (PPE). A poor understanding of the role of PPE and sub-optimal use may fail to prevent or even increase pathogen transmission during routine care or an infectious disease outbreak. Variability in delivery and content of IPC and PPE education and training across organisations can lead to confusion, unsafe practice, and lack of confidence among clinicians. In a national survey we explored the perspectives of Australian and New Zealand IPC professionals on the value and feasibility of a national IPC training and monitoring programme to improve and standardise PPE practice and raise the profile of IPC.

METHODS

A population-based online survey that examined hospital PPE training programmes was distributed to members of three major Australasian organisations representing IPC professionals. Quantitative results of the survey have been reported previously. This paper is a qualitative analysis of responses to two open-ended questions about a national approach to training in IPC and the use of PPE.

RESULTS

Most respondents agreed that standardising IPC and PPE training could achieve more consistent practice nationally, supported through the provision of educational resources. Including competency in the use of PPE in mandatory IPC standards would assist in improving the practice and raising the profile of IPC more generally.

CONCLUSION

The results of this study suggest that that there is support for national programmes and standards for use of PPE in Australia and New Zealand.

Exploring the Cost of eLearning in Health Professions Education: Scoping Review

BACKGROUND

Existing research on the costs associated with the design and deployment of eLearning in health professions education is limited. The relative costs of these learning platforms to those of face-to-face learning are also not well understood. The lack of predefined costing models used for eLearning cost data capture has made it difficult to complete cost evaluation.

OBJECTIVE

The key aim of this scoping review was to explore the state of evidence concerning cost capture within eLearning in health professions education. The review explores the available data to define cost calculations related to eLearning.

METHODS

The scoping review was performed using a search strategy with Medical Subject Heading terms and related keywords centered on eLearning and cost calculation with a population scope of health professionals in all countries. The search was limited to articles published in English. No restriction was placed on literature publication date.

RESULTS

In total, 7344 articles were returned from the original search of the literature. Of these, 232 were relevant to associated keywords or abstract references following screening. Full-text review resulted in 168 studies being excluded. Of these, 61 studies were excluded because they were unrelated to eLearning and focused on general education. In addition, 103 studies were excluded because of lack of detailed information regarding costs; these studies referred to cost in ways either indicating cost favorability or unfavorability, but without data to support findings. Finally, 4 studies were excluded because of limited cost data that were insufficient for analysis. In total, 42 studies provided data and analysis of the impact of cost and value in health professions education. The most common data source was total cost of training (n=29). Other sources included cost per learner, referring to the cost for individual students (n=13). The population most frequently cited was medical students (n=15), although 12 articles focused on multiple populations. A further 22 studies provide details of costing approaches for the production and delivery of eLearning. These studies offer insight into the ways eLearning has been budgeted and project-managed through implementation.

CONCLUSIONS

Although cost is a recognized factor in studies detailing eLearning design and implementation, the way cost is captured is inconsistent. Despite a perception that eLearning is more cost-effective than face-to-face instruction, there is not yet sufficient evidence to assert this conclusively. A rigorous, repeatable data capture method is needed, in addition to a means to leverage existing economic evaluation methods that can then test eLearning cost-effectiveness and how to implement eLearning with cost benefits and advantages over traditional instruction.

Comparison of two electronic hand hygiene monitoring systems in promoting hand hygiene of healthcare workers in the intensive care unit

Background

Hand hygiene (HH) is the cornerstone of infection control, and the promotion of HH is the focus of the world. The study aims to compare the role of two different types of electronic hand hygiene monitoring systems (EHHMSs) in promoting HH of healthcare workers (HCWs) in the intensive care unit (ICU).

Methods

In a 16-bed ICU of a general tertiary hospital in Shenzhen, the research was divided into three stages with interrupted time series (ITS) design. In the first stage, the direct observation method was used to monitor and feed back the HH compliance rate of HCWs monthly. In the second stage, the type1 EHHMS was applied to monitor and feed back the individual number of HH events monthly. In the third stage, the type2 EHHMS with a function of instant reminder and feedback was employed, and the personal HH compliance rates were fed back monthly. Meanwhile, direct observation continued in the last two stages.

Results

In the second stage, The HH compliance rate increased. However, there was no significant difference in the trajectory of the rate compared with the first stage. In the first month of the third stage, the HH compliance rate increased by 12.324% immediately and then ascended by 1.242% over time. The number of HH events per bed day and HH products’ consumption per bed day were consistent with the change of HH compliance rate observed.

Conclusion

Monitoring and feedback can improve the HH of HCWs. The EHHMS, with the function of real-time reminders and feedback, has a more noticeable effect on promoting HH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05748-3.

Risk factors for candidaemia: A prospective multi-centre case-control study

OBJECTIVES

Candidaemia carries a mortality of up to 40% and may be related to increasing complexity of medical care. Here, we determined risk factors for the development of candidaemia.

METHODS

We conducted a prospective, multi-centre, case-control study over 12 months. Cases were aged ≥18 years with at least one blood culture positive for Candida spp. Each case was matched with two controls, by age within 10 years, admission within 6 months, admitting unit, and admission duration at least as long as the time between admission and onset of candidaemia.

RESULTS

A total of 118 incident cases and 236 matched controls were compared. By multivariate analysis, risk factors for candidaemia included neutropenia, solid organ transplant, significant liver, respiratory or cardiovascular disease, recent gastrointestinal, biliary or urological surgery, central venous access device, intravenous drug use, urinary catheter and carbapenem receipt.

CONCLUSIONS

Risk factors for candidaemia derive from the infection source, carbapenem use, host immune function and organ-based co-morbidities. Preventive strategies should target iatrogenic disruption of mucocutaneous barriers and intravenous drug use.

Implementation of the infection prevention and control core components at the national level: a global situational analysis

Background

Strengthening infection prevention and control (IPC) is essential to combat healthcare-associated infections, antimicrobial resistance, and to prevent and respond to outbreaks.

Aim

To assess national IPC programmes worldwide according to the World Health Organization (WHO) IPC core components.

Methods

Between June 1^st, 2017 and November 30^th, 2018, a multi-country, cross-sectional study was conducted, based on semi-structured interviews with national IPC focal points of countries that pledged to the WHO ‘Clean Care is Safer Care’ challenge. Results and differences between regions and national income levels were summarized using descriptive statistics.

Findings

Eighty-eight of 103 (85.4%) eligible countries participated; 22.7% were low-income, 19.3% lower-middle-income, 23.9% upper-middle-income, and 34.1% high-income economies. A national IPC programme existed in 62.5%, but only 26.1% had a dedicated budget. National guidelines were available in 67.0%, but only 36.4% and 21.6% of countries had an implementation strategy and evaluated compliance with guidelines, respectively. Undergraduate IPC curriculum and in-service and postgraduate IPC training were reported by 35.2%, 54.5%, and 42% of countries, respectively. Healthcare-associated infection surveillance was reported by 46.6% of countries, with significant differences ranging from 83.3% (high-income) to zero (low-income) (P < 0.001); monitoring and feedback of IPC indicators was reported by 65.9%. Only 12.5% of countries had all core components in place.

Conclusion

Most countries have IPC programme and guidelines, but many less have invested adequate resources and translated them in implementation and monitoring, particularly in low-income countries. Leadership support at the national and global level is needed to achieve implementation of the core components in all countries.

Pilot study of a combined genomic and epidemiologic surveillance program for hospital-acquired multidrug-resistant pathogens across multiple hospital networks in Australia

OBJECTIVES

To conduct a pilot study implementing combined genomic and epidemiologic surveillance for hospital-acquired multidrug-resistant organisms (MDROs) to predict transmission between patients and to estimate the local burden of MDRO transmission.

DESIGN

Pilot prospective multicenter surveillance study.

SETTING

The study was conducted in 8 university hospitals (2,800 beds total) in Melbourne, Australia (population 4.8 million), including 4 acute-care, 1 specialist cancer care, and 3 subacute-care hospitals.

METHODS

All clinical and screening isolates from hospital inpatients (April 24 to June 18, 2017) were collected for 6 MDROs: vanA VRE, MRSA, ESBL Escherichia coli (ESBL-Ec) and Klebsiella pneumoniae (ESBL-Kp), and carbapenem-resistant Pseudomonas aeruginosa (CRPa) and Acinetobacter baumannii (CRAb). Isolates were analyzed and reported as routine by hospital laboratories, underwent whole-genome sequencing at the central laboratory, and were analyzed using open-source bioinformatic tools. MDRO burden and transmission were assessed using combined genomic and epidemiologic data.

RESULTS

In total, 408 isolates were collected from 358 patients; 47.5% were screening isolates. ESBL-Ec was most common (52.5%), then MRSA (21.6%), vanA VRE (15.7%), and ESBL-Kp (7.6%). Most MDROs (88.3%) were isolated from patients with recent healthcare exposure.Combining genomics and epidemiology identified that at least 27.1% of MDROs were likely acquired in a hospital; most of these transmission events would not have been detected without genomics. The highest proportion of transmission occurred with vanA VRE (88.4% of patients).

CONCLUSIONS

Genomic and epidemiologic data from multiple institutions can feasibly be combined prospectively, providing substantial insights into the burden and distribution of MDROs, including in-hospital transmission. This analysis enables infection control teams to target interventions more effectively.

Hospital infection control: old problem - evolving challenges

Hospital infection prevention and control (IPC) is often regarded by doctors as mundane and unnecessarily rigid, but the continued occurrence of preventable healthcare-associated infections, increasing antimicrobial resistance (to which hospitals are major contributors) and rare, but potentially devastating hospital outbreaks of emerging infectious diseases, suggest that IPC must be taken seriously. Healthcare professionals often fail to comply with effective, evidence-based IPC practices and there is ample evidence that doctors, generally, do so less consistently than nurses. However, doctors' practices are highly variable, apparently because of a perceived entitlement to clinical autonomy. In practice, most doctors observe safe IPC practices, most of the time. However, some are ignorant or dismissive of IPC policies and some respond angrily, when reminded. Among a small proportion of senior consultants, negative attitudes to IPC are perceived by their peers to correlate with a more general failure to meet their public hospital commitments, apparently because of conflicting demands, including private practice. The fact that breaches of IPC practice have significant, although often hidden, consequences indicates a need for continued improvement based on new strategies that might include: better surveillance, to identify and inform doctors of the true burdens of healthcare-associated infections; professional self-reflection on falsely dichotomous claims of medical professionalism namely: clinical autonomy versus regard for patient welfare by complying with 'rules' designed to protect them; and review of the consequences of recent changes in healthcare delivery, including proliferation of multiple, part-time consultant contracts at the expense of public hospital culture and status.

Increased hand hygiene compliance in nursing homes after a multimodal intervention: A cluster randomized controlled trial (HANDSOME)

OBJECTIVE

To assess the effect of a multimodal intervention on hand hygiene compliance (HHC) in nursing homes.

DESIGN, SETTING, AND PARTICIPANTS

HHC was evaluated using direct, unobtrusive observation in a cluster randomized controlled trial at publicly funded nursing homes in the Netherlands. In total, 103 nursing home organizations were invited to participate; 18 organizations comprising 33 nursing homes (n = 66 nursing home units) participated in the study. Nursing homes were randomized into a control group (no intervention, n = 30) or an intervention group (multimodal intervention, n = 36). The primary outcome measure was HHC of nurses. HHC was appraised at baseline and at 4, 7, and 12 months after baseline. Observers and nurses were blinded.

INTERVENTION

Audits regarding hand hygiene (HH) materials and personal hygiene rules, 3 live lessons, an e-learning program, posters, and a photo contest. We used a new method to teach the nurses the WHO-defined 5 moments of HH: Room In, Room Out, Before Clean, and After Dirty.

RESULTS

HHC increased in both arms. The increase after 12 months was larger for units in the intervention arm (from 12% to 36%) than for control units (from 13% to 21%) (odds ratio [OR], 2.10; confidence interval [CI], 1.35-3.28). The intervention arm exhibited a statistically significant increase in HHC at 4 of the 5 WHO-defined HH moments. At follow-up, HHC in the intervention arm remained statistically significantly higher (OR, 1.93; 95% CI, 1.59-2.34) for indications after an activity (from 37% to 39%) than for indications before an activity (from 14% to 27%).

CONCLUSIONS

The HANDSOME intervention is successful in improving HHC in nursing homes.

A multimodal intervention to improve hand hygiene compliance in peripheral wards of a tertiary care university centre: a cluster randomised controlled trial

Background

Interventions to improve hand hygiene (HH) compliance are a key element in the practice infection prevention and control. It was our objective to assess the effect of a multimodal intervention on HH compliance at a tertiary care university hospital. As a secondary objective, we investigated the effect of the intervention on the occurrence of device-associated bloodstream infections.

Methods

We performed a single centre cluster randomised controlled trial at a university hospital in Germany. Twenty peripheral wards were invited to participate and randomly assigned to either the intervention (n = 10) or control group (n = 10). Quarterly, specifically trained student employees conducted direct compliance observations in all twenty wards. The intervention entailed dissemination of teaching materials on aseptic procedures, equipment with flexibly mountable alcoholic hand rub dispensers, and quarterly feedback on HH compliance.

Results

In total, 21,424 HH opportunities were observed. Overall, compliance did not change significantly in either group (intervention group: 59% vs. 61% (1482 HH actions for 2494 HH opportunities vs. 5033 HH actions for 8215 HH opportunities), odds ratio (OR) 1.08 (95% confidence interval (CI95) 0.88, 1.33)); control group: 59% vs. 60% (1457 HH actions for 2484 HH opportunities vs. 4948 HH actions for 8231 HH opportunities), OR 1.06 (CI95 0.84, 1.35)). Compliance prior to aseptic procedures improved significantly in the intervention group from 44% (168 HH actions for 380 HH opportunities) to 53% (764 HH actions for 1452 HH opportunities) (OR 1.40 (CI95 1.04, 1.89), p = 0.03), while no significant increase was noted in the control group. In the intervention group, significantly fewer device-associated bloodstream infections per 1000 patient-days occurred than in the control group (84 vs. 123, incidence rate ratio 0.61 (CI95 0.46, 0.81), p < 0.01).

Conclusions

The lack of a significant overall improvement of HH compliance demonstrated that comprehensive implementation of HH interventions in multiple wards simultaneously is difficult. However, through targeted intervention measures, we were able to significantly increase HH compliance before aseptic procedures.

No increase in compliance before aseptic procedures in German hospitals. A longitudinal study with data from the national surveillance system over four years

BACKGROUND

Hand hygiene plays a crucial role in the prevention of healthcare-associated infections and transmission of pathogens. In 2008 the national campaign 'Aktion Saubere Hände' was launched in Germany. It is based on the World Health Organization (WHO) 'Clean Care is Safer Care' initiative. Direct observation and feedback of the results are key components in the improvement of hand hygiene compliance. In 2014 a voluntary national surveillance electronic tool for the documentation of directly observed compliance to hand hygiene was introduced.

AIM

Description and evaluation of compliance with the WHO model 'my 5 moments' in German hospitals after implementation.

METHODS

Direct observation was performed in the participating hospitals by trained local staff according to the WHO recommendations. We evaluated wards that reported annually at least 150 hand hygiene opportunities (HHOs) of hand hygiene per observation period from January 1^st, 2015 until December 31^st, 2018.

FINDINGS

In all, 1,485,622 HHOs observed on 3337 wards in 525 hospitals were included into analysis. Overall compliance increased from 72% (interquartile range: 61-82) to 76% (66-84). Compliance significantly increased for all individual moments of the WHO model except moment 2. In the multivariate logistic regression analysis the following parameters were independently associated with a high compliance in hand hygiene: intensive care unit, nurse, opportunity observed in 2017 or 2018, as well as all moments except moment 2.

CONCLUSION

Overall compliance in German hospitals increased over time. To improve HH compliance 'before aseptic procedures' appears to be difficult and should be addressed explicitly. Underlying reasons need to be the focus of future investigations.

Characteristics of personal protective equipment training programs in Australia and New Zealand hospitals: A survey

Background

Using personal protective equipment (PPE) is one of several fundamental measures to prevent the transmission of infection and infectious diseases and is particularly pertinent in the current COVID-19 pandemic. Appropriate use of PPE by healthcare workers is, however, often suboptimal. Training and monitoring of PPE competency are essential components of an infection prevention and control program but there is a paucity of research and data on the content of such training programs across Australasia. This paper reports the results of a survey that characterised the nature of PPE training in Australian and New Zealand hospitals.

Methods

A population-based online survey was distributed to members of three major Australasian colleges representing infection prevention and control.

Results

Results indicate that, although training is frequently provided at orientation, many healthcare workers do not receive regular updates. Training programmes combine online and classroom sessions, but over a third do not include a practical component. The frequency of monitoring PPE competency is variable with one third of respondents indicating that no auditing occurs. PPE items used for high-level training are variable, with use of powered air purifying respirators (PAPRs) uncommon.

Conclusion

The results of this study suggest that HCWs’ confidence, competence and familiarity with PPE are a concern, which in the context of the current global COVID-19 pandemic is problematic. More research is needed into how PPE training programs could be better designed, to prepare HCWs for practice using PPE safely and confidently.

•

Most HCW orientation programmes include PPE training but fewer than half are updated annually.

•

One third of PPE programmes do not include a practical component.

•

Only two thirds of PPE training programmes monitor PPE compliance.

•

Future research should consider the design of PPE training programs to optimise HCW PPE practice.

Impact of an automated hand hygiene monitoring system combined with a performance improvement intervention on hospital-acquired infections

OBJECTIVE

Hand hygiene adherence has been associated with reductions in nosocomial infection. We assessed the effect of improvements in electronically measured hand hygiene adherence on the incidence of hospital-acquired infections.

METHODS

This quasi-experimental study was conducted in a 555-bed urban safety-net level I trauma center. The preintervention period was January 2015 through June 2016. Baseline electronic hand hygiene data collection took place from April through June 2016. The intervention period was July 2016 through December 2017. An electronic hand hygiene system was installed in 4 locations in our hospital. Performance improvement strategies were implemented that included education, troubleshooting, data dissemination, and feedback. Adherence rates were tracked over time. Rates of hospital-acquired infections were evaluated in the intervention units and in control units selected for comparison. The intervention period was subdivided into the initial and subsequent 9-month periods and were compared to the baseline period.

RESULTS

Electronically measured hand hygiene rates improved significantly from baseline to intervention, from 47% 77% adherence. Rates >70% continued to be measured 18 months after the intervention. Interrupted time series analysis indicated a significant effect of hand hygiene on healthcare facility-onset Clostridioides difficile infection rates during the first 9 months of the intervention. This trend continued during the final 9 months of the intervention but was nonsignificant. No effects were observed for other hospital-acquired infection rates.

CONCLUSIONS

Implementation of electronic hand hygiene monitoring and performance improvement interventions resulted in reductions in hospital-onset Clostridioides difficile infection rates.

The effect of a 5-year hand hygiene initiative based on the WHO multimodal hand hygiene improvement strategy: an interrupted time-series study

Background

A World Health Organization (WHO) guideline-based multimodal hand hygiene (HH) initiative was introduced hospital-wide to a nonteaching Japanese hospital for 5 years. The objective of this study was to assess the effect of this initiative in terms of changes in alcohol-based hand rub (ABHR) consumption and the Hand Hygiene Self-Assessment Framework (HHSAF) score.

Methods

The consumption of monthly hospital-wide ABHR was calculated in L per 1000 patient days (PDs). The change in ABHR consumption was analysed by an interrupted time series analysis with a pre-implementation period of 36 months and an implementation period of 60 months. The correlation between annual ABHR consumption and the HHSAF score was estimated using Pearson’s correlation coefficients.

Results

The annual ABHR consumption was 4.0 (L/1000 PDs) to 4.4 in the pre-implementation period and 10.4 to 34.4 in the implementation period. The HHSAF score was 117.5 (out of 500) in the pre-implementation period and 267.5 to 445 in the implementation period. A statistically significant increase in the monthly ABHR consumption (change in slope: + 0.479 L/1000 PDs, p <  0.01) was observed with the implementation of the initiative. Annual ABHR consumption was strongly correlated with the annual HHSAF score (r = 0.971, p <  0.01).

Conclusions

A 5-year WHO-based HH initiative significantly increased ABHR consumption. Our study suggested that the HHSAF assessment can be a good process measure to improve HH in a single facility, as ABHR consumption increased with the HHSAF score.

Hand-hygiene compliance by hospital staff and incidence of health-care-associated infections, Finland

Objective

To determine changes in hand-hygiene compliance after the introduction of direct observation of hand-hygiene practice for doctors and nurses, and evaluate the relationship between the changes and the incidence of health-care-associated infections.

Methods

We conducted an internal audit survey in a tertiary-care hospital in Finland from 2013 to 2018. Infection-control link nurses observed hand-hygiene practices based on the World Health Organization's strategy for hand hygiene. We calculated hand-hygiene compliance as the number of observations where necessary hand-hygiene was practised divided by the total number of observations where hand hygiene was needed. We determined the incidence of health-care-associated infections using a semi-automated electronic incidence surveillance programme. We calculated the Pearson correlation coefficient (r) to evaluate the relationship between the incidence of health-care-associated infections and compliance with hand hygiene.

Findings

The link nurses made 52 115 hand-hygiene observations between 2013 and 2018. Annual hand-hygiene compliance increased significantly from 76.4% (2762/3617) in 2013 to 88.5% (9034/10 211) in 2018 (P < 0.0001). Over the same time, the number of health-care-associated infections decreased from 2012 to 1831, and their incidence per 1000 patient-days fell from 14.0 to 11.7 (P < 0.0001). We found a weak but statistically significant negative correlation between the monthly incidence of health-care-associated infections and hand-hygiene compliance (r = -0.48; P < 0.001).

Conclusion

The compliance of doctors and nurses with hand-hygiene practices improved with direct observation and feedback, and this change was associated with a decrease in the incidence of health-care-associated infections. Further studies are needed to evaluate the contribution of hand hygiene to reducing health-care-associated infections.

Hand hygiene compliance monitoring: Do video-based technologies offer opportunities for the future?

Hand hygiene is universally recognised as the primary measure to reduce healthcare-associated infections. Studies have convincingly demonstrated a link between increased hand hygiene compliance and reductions in rates of healthcare-associated infections. Direct observation is considered the gold standard method for monitoring hand hygiene compliance. Despite the acknowledged benefits of this approach, recent literature has highlighted a range of issues impacting on the reliability and validity of this data collection technique. The rise of technology in healthcare provides opportunity for alternative methods that promise advantages over direct human observation. There have been no published examples of systems that are able to capture data consistent with all the WHO '5 Moments for Hand Hygiene'. In this paper we explore current human-based auditing practises for monitoring hand hygiene compliance and raise for discussion and debate video-based technologies to monitor hand hygiene compliance. We raise questions regarding hybrid approaches that incorporate both direct human observation and indirect video-based surveillance, and the possible advantages and disadvantages therein for monitoring hand hygiene compliance. We suggest that such methods have the potential to ameliorate, or minimise, the inherent biases associated with direct observation, notably the Hawthorne Effect. Future research into the utility of a hybrid approach to auditing, including the technical specifications, efficacy, cost effectiveness and acceptability of such a model is warranted.

Assessing sustainability of hand hygiene adherence 5 years after a contest-based intervention in 3 Japanese hospitals

BACKGROUND

Our goal was to evaluate the 5-year sustainability of a multimodal intervention that included a prize to the hospital with the highest overall hand hygiene adherence rates among health care workers.

METHODS

We conducted an observational study in 3 Japanese tertiary care hospitals using unobtrusive direct observation of physician and nurse hand hygiene adherence. Observations were performed by a trained observer on inpatient medical, surgical, intensive care, and emergency units. The primary outcome was hand hygiene adherence rates before patient contact. Secondary outcomes were health care worker survey responses to a World Health Organization (WHO) questionnaire on hand hygiene practices.

RESULTS

Hand hygiene adherence rates had improved significantly after the introduction of a multimodal intervention (based on principles recommend by the WHO) in 2012 and 2013 (from 18.0% pre-intervention to 32.7% 6 months post-intervention; P < .001). No significant changes were found in hand hygiene adherence in these hospitals 5 years after the original intervention (31.9% 5 years after intervention; P = .53); however, substantial variability in hand hygiene adherence by unit and health care worker type was noted.

CONCLUSIONS

A multimodal hand hygiene initiative achieved sustained improvement in hand hygiene adherence in 3 Japanese hospitals 5 years after the original intervention.

Train-the-Trainers in hand hygiene: a standardized approach to guide education in infection prevention and control

Background

Harmonization in hand hygiene training for infection prevention and control (IPC) professionals is lacking. We describe a standardized approach to training, using a “Train-the-Trainers” (TTT) concept for IPC professionals and assess its impact on hand hygiene knowledge in six countries.

Methods

We developed a three-day simulation-based TTT course based on the World Health Organization (WHO) Multimodal Hand Hygiene Improvement Strategy. To evaluate its impact, we have performed a pre-and post-course knowledge questionnaire. The Wilcoxon signed-rank test was used to compare the results before and after training.

Results

Between June 2016 and January 2018 we conducted seven TTT courses in six countries: Iran, Malaysia, Mexico, South Africa, Spain and Thailand. A total of 305 IPC professionals completed the programme. Participants included nurses (n = 196; 64.2%), physicians (n = 53; 17.3%) and other health professionals (n = 56; 18.3%). In total, participants from more than 20 countries were trained. A significant (p < 0.05) improvement in knowledge between the pre- and post-TTT training phases was observed in all countries. Puebla (Mexico) had the highest improvement (22.3%; p < 0.001), followed by Malaysia (21.2%; p < 0.001), Jalisco (Mexico; 20.2%; p < 0.001), Thailand (18.8%; p < 0.001), South Africa (18.3%; p < 0.001), Iran (17.5%; p < 0.001) and Spain (9.7%; p = 0.047). Spain had the highest overall test scores, while Thailand had the lowest pre- and post-scores. Positive aspects reported included: unique learning environment, sharing experiences, hands-on practices on a secure environment and networking among IPC professionals. Sustainability was assessed through follow-up evaluations conducted in three original TTT course sites in Mexico (Jalisco and Puebla) and in Spain: improvement was sustained in the last follow-up phase when assessed 5 months, 1 year and 2 years after the first TTT course, respectively.

Conclusions

The TTT in hand hygiene model proved to be effective in enhancing participant’s knowledge, sharing experiences and networking. IPC professionals can use this reference training method worldwide to further disseminate knowledge to other health care workers.

Candidaemia and a risk predictive model for overall mortality: a prospective multicentre study

Background

Candidaemia is associated with high mortality. Variables associated with mortality have been published previously, but not developed into a risk predictive model for mortality. We sought to describe the current epidemiology of candidaemia in Australia, analyse predictors of 30-day all-cause mortality, and develop and validate a mortality risk predictive model.

Methods

Adults with candidaemia were studied prospectively over 12 months at eight institutions. Clinical and laboratory variables at time of blood culture-positivity were subject to multivariate analysis for association with 30-day all-cause mortality. A predictive score for mortality was examined by area under receiver operator characteristic curves and a historical data set was used for validation.

Results

The median age of 133 patients with candidaemia was 62 years; 76 (57%) were male and 57 (43%) were female. Co-morbidities included underlying haematologic malignancy (n = 20; 15%), and solid organ malignancy in (n = 25; 19%); 55 (41%) were in an intensive care unit (ICU). Non-albicans Candida spp. accounted for 61% of cases (81/133). All-cause 30-day mortality was 31%. A gastrointestinal or unknown source was associated with higher overall mortality than an intravascular or urologic source (p < 0.01). A risk predictive score based on age > 65 years, ICU admission, chronic organ dysfunction, preceding surgery within 30 days, haematological malignancy, source of candidaemia and antibiotic therapy for ≥10 days stratified patients into < 20% or ≥ 20% predicted mortality. The model retained accuracy when validated against a historical dataset (n = 741).

Conclusions

Mortality in patients with candidaemia remains high. A simple mortality risk predictive score stratifying patients with candidaemia into < 20% and ≥ 20% 30-day mortality is presented. This model uses information available at time of candidaemia diagnosis is easy to incorporate into decision support systems. Further validation of this model is warranted.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4065-5) contains supplementary material, which is available to authorized users.

Cleaning Staff's Attitudes about Hand Hygiene in a Metropolitan Hospital in Australia: A Qualitative Study

Background: In 2009, the National Hand Hygiene Initiative (NHHI) was implemented in hospitals across Australia with the aim of improving hand hygiene practices and reducing healthcare-associated infections. Audits conducted post-implementation showed the lowest rates of compliance with hand hygiene practices are among operational staff including hospital cleaners. There is limited information about hand hygiene issues in hospital cleaners to inform development of evidence-based interventions to improve hand hygiene compliance in this group. Aim: This qualitative study was undertaken to explore the attitudes of hospital cleaning staff regarding hand hygiene and the National Hand Hygiene Initiative. Methodology: Focus groups were conducted with 12 cleaning staff at a large Australian hospital implementing the National Hand Hygiene Initiative. Findings: Hospital cleaners recognise the importance of hand hygiene in preventing healthcare-associated infections. Cleaners cite peer support, leadership, and the recognition and reward of those excelling in hand hygiene as strong motivators. Barriers to optimal hand hygiene practice include the presence of multiple conflicting guidelines, hand hygiene “overload” and a lack of contextualised education programs. This exploratory qualitative study reveals three themes about attitudes of hospital cleaning staff towards hand hygiene. These themes are: (1) “The culture of hand hygiene: It’s drummed into us”; (2) “Reminders and promotion for hand hygiene: We just need a big ‘Please wash your hands’ sign”; and (3) “The personal value of hand hygiene: Like he said, it’s second nature to us”. Conclusion: Hand-hygiene messages and training need to be more consistent and contextualised to achieve improvements in hand hygiene practices in hospital cleaning staff in Australia.

Keeping hospitals clean and safe without breaking the bank; summary of the Healthcare Cleaning Forum 2018

Keeping hospitals clean is a crucial patient safety issue. The importance of the hospital environment in patient care has only recently been recognized widely in infection prevention and control (IPC). In order to create a movement for change, a group of international infection control experts teamed up with Interclean, the largest cleaning trade-show in the world to create the Healthcare Cleaning Forum. This paper is the result of this conference, which featured leaders in healthcare environmental science from across Europe.

Although the available literature is limited, there is now enough evidence to demonstrate that maintaining the hygiene of the hospital environment helps prevent infections. Still, good interventional studies are rare, the quality of products and methods available is heterogeneous, and environmental hygiene personnel is often relatively untrained, unmotivated, under-paid, and under-appreciated by other actors in the hospital. Coupled with understaffed environmental hygiene service departments, this creates lasting issues in regards to patient and healthcare worker safety.

The Healthcare Cleaning Forum was designed as a platform for healthcare experts, cleaning experts, hospital managers and industry to meet productively. The conference aimed to summarize the state-of-the-art knowledge in the field, create awareness and dialogue, challenge dogma and begin to shape a research agenda for developing the field of hospital hygiene and environmental control. Hospital environmental hygiene is far more complex than other types of cleaning; further evidence-based research in the field is needed. It involves the integration of current and new technologies with human elements that must work together synergistically to achieve optimal results. The education, training and career development, behavior, and work organization of environmental hygiene personnel are at the core of the proposals for the creation of a global initiative. Ultimately, what is needed is a reevaluation of how hospitals view environmental hygiene: not just as an area from which to cut costs, but one that can add value. Hospitals and key stakeholders must work together to change how we maintain the hospital environment in order to better protect patients.