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Hand hygiene in the intensive care unit
Abstract
Healthcare-associated infections affect 1.4 million patients at any time worldwide, as estimated by the World Health Organization. In intensive care units, the burden of healthcare-associated infections is greatly increased, causing additional morbidity and mortality. Multidrug-resistant pathogens are commonly involved in such infections and render effective treatment challenging. Proper hand hygiene is the single most important, simplest, and least expensive means of preventing healthcare-associated infections. In addition, it is equally important to stop transmission of multidrug-resistant pathogens. According to the Centers for Disease Control and Prevention and World Health Organization guidelines on hand hygiene in health care, alcohol-based handrub should be used as the preferred means for routine hand antisepsis. Alcohols have excellent in vitro activity against Gram-positive and Gram-negative bacteria, including multidrug-resistant pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, Mycobacterium tuberculosis, a variety of fungi, and most viruses. Some pathogens, however, such as Clostridium difficile, Bacillus anthracis, and noroviruses, may require special hand hygiene measures. Failure to provide user friendliness of hand hygiene equipment and shortage of staff are predictors for noncompliance, especially in the intensive care unit setting. Therefore, practical approaches to promote hand hygiene in the intensive care unit include provision of a minimal number of handrub dispensers per bed, monitoring of compliance, and choice of the most attractive product. Lack of knowledge of guidelines for hand hygiene, lack of recognition of hand hygiene opportunities during patient care, and lack of awareness of the risk of cross-transmission of pathogens are barriers to good hand hygiene practices. Multidisciplinary programs to promote increased use of alcoholic handrub lead to an increased compliance of healthcare workers with the recommended hand hygiene practices and a reduced prevalence of nosocomial infections.
... Among the participants, 135 (53.2%) observed the sterilization process in the hospital and 103 (40.6%) had received educational sessions on the use of autoclaves for linen and instruments as per protocol(Sukhlecha et al., 2015). Lack of knowledge of guidelines for hand hygiene, lack of recognition of hand hygiene opportunities during patient care, and lack of awareness of the risk of cross-transmission of pathogens are barriers to good hand hygiene practices(Tschudin-Sutter, Pargger, & Widmer, 2010). ...
Introduction: Patients being admitted to the intensive care unit (ICU) pose a risk of developing common healthcare-acquired infections. Healthcare workers (HCWs) must be well-equipped and knowledgeable to deliver effective cleaning and disinfection protocols to reduce the chances of hospital-acquired infections. Objective: This study aimed to assess the knowledge and practice of cleaning and disinfection after the discharge/death of patients among the HCWs in selected ICUs.
Methods: A cross-sectional descriptive survey was conducted in selected ICUs of a tertiary care hospital. A purposive sampling technique was used to select the participants which included 106 staff nurses and 47 housekeeping staff and 110 events of cleaning and disinfection were observed. A structured knowledge questionnaire was used to collect the knowledge among the participants and a practice checklist was used to collect the practice regarding cleaning and disinfection separately from both staff nurses and housekeeping staff. The study was analyzed using descriptive and inferential statistics.
Results: Good knowledge was reported among 75 (70.8%) nursing staff and 28 (59.6%) housekeeping staff on cleaning and disinfection. It was found that in all the observed events, 110 (100%) of the HCWs had worn gloves and discarded the single-used items and linens of the patients.
Conclusions: Most of the HCWs used good barrier techniques while at work and cleaning and disinfection practices were found to be appropriate in maintaining the ideal infection control practices in ICUs with compliance with the hospital policies.
... The UNDP ranks Malawi 171 out of 184 on the human development index making it one of the poorest countries in the world 14 . Access to second and third-line antibiotic therapies is often limited; reducing transmission of drug-resistant infections is vital 15,16 . ...
Background: Neonatal sepsis is responsible for a considerable burden of morbidity and mortality in sub-Saharan African countries. Outcomes from neonatal sepsis are worsening due to increasing rates of antimicrobial resistance. Sub-optimal Infection Prevention and Control (IPC) practices of health care workers and caregivers are important drivers of infection transmission. The Chatinkha Neonatal Unit at Queen Elizabeth Central Hospital, Blantyre, Malawi has experienced multiple outbreaks of neonatal sepsis, associated with drug resistant Klebsiella pneumoniae. We aimed to understand the barriers to implementation of optimal IPC focusing on hand hygiene practice.
Methods: We used a qualitative research methodology to meet the study aim. Combining participant observation (PO) over a seven-month period with semi structured interviews (SSI) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward.
Results: While most staff and some caregivers, had a good understanding of ideal IPC and understood the importance of good handwashing practices, they faced substantial structural limitations, and scarce resources (both material and human) which made implementation challenging. For staff, the overwhelming numbers of patients meant the workload was often unmanageable and practicing optimal IPC was challenging. Caregivers lacked access to basic amenities, including linen and chairs, meaning that it was almost impossible for them to maintain good hand hygiene. Limited access to soap and the erratic water supply for both caregivers and healthcare workers further worsened the situation. Communication challenges between different cadres of staff and with patient caregivers meant that those handling neonates and cleaning the wards were often unaware of outbreaks of drug resistant infection.
Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.
... Hand hygiene is the most important measure in inhibiting the transmission of MDROs. Healthcare workers' compliance with hand hygiene protocols is paramount [86,87]; a 100% compliance would prevent MDRO transmission through touch. Therefore, the level of compliance is important; in particular, scores of studies have shown that the observance of hand hygiene by healthcare workers remains insufficient. ...
The spread of multidrug-resistant organisms (MDRO) is associated with additional costs as well as higher morbidity and mortality rates. Risk factors related to the spread of MDRO can be classified into four categories: bacterial, host-related, organizational, and epidemiological. Faced with the severity of the MDRO predicament and its individual and collective consequences, many scientific societies have developed recommendations to help healthcare teams control the spread of MDROs. These international recommendations include a series of control measures based on surveillance cultures and the application of barrier measures, ranging from patients’ being isolated in single rooms, to the reinforcement of hand hygiene and implementation of additional contact precautions, to the cohorting of colonized patients in a dedicated unit with or without a dedicated staff. In addition, most policies include the application of an antimicrobial stewardship program. Applying international policies to control the spread of MDROs presents several challenges, particularly in low-to-middle-income countries (LMICs). Through a review of the literature, this work evaluates the real risks of dissemination linked to MDROs and proposes an alternative policy that caters to the means of LMICs. Indeed, sufficient evidence exists to support the theory that high compliance with hand hygiene and antimicrobial stewardship reduces the risk of MDRO transmission. LMICs would therefore be better off adopting such low-cost policies without necessarily having to implement costly isolation protocols or impose additional contact precautions.
... Healthcare-associated infections (HCAIs) occur while patients receive medical care (Haque et al., 2018;Organization, 2011). It is estimated that more than 1.4 million patients worldwide are infected with HCAIs at any given time, posing a significant healthcare challenge (Haque et al., 2020;Tschudin-Sutter et al., 2010). HCAIs are mainly bacterial infections, such as Staphylococcus aureus and Escherichia coli (Stewart et al., 2021;Wilcox and Dryden, 2021), and catheters and ventilators are thought to be the main routes of infection (Khan et al., 2017;Smyth et al., 2008). ...
Vancomycin (VCM) causes poisoning symptoms at high concentrations; thus, therapeutic drug monitoring is recommended to measure and control blood levels regularly. However, blood analysis at regular intervals does not allow knowing the detailed temporal change in concentration. To address this challenge, we developed a long-range surface plasmon (LRSP) aptasensor for measuring VCM label-free and real-time by combining a sensitive LRSP sensor and a peptide aptamer with a VCM recognition site. First, three different biosensors for VCM were compared. One was prepared by immobilizing the peptide aptamer directly on (Direct-Apt) or via a self-assembled monolayer (SAM) on a gold surface (SAM-Apt). The other used anti-VCM antibodies immobilized on a gold surface via the SAM (SAM-Ab). The Direct-Apt showed larger sensor output to VCM than the other biosensors. The dynamic range for VCM was 0.78–100 μM, including the therapeutic range (6.9–13.8 μM). The Direct-Apt also showed the sensor output only from VCM among four different antibiotics, demonstrating the high selectivity for VCM. The VCM captured by the aptamer could be removed by rinsing with phosphate-buffered saline. The measurement was rapid, with 72- and 77-sec response and recovery times, allowing not only repeated but also real-time measurements. Finally, the Direct-Apt in 20% serum solutions showed comparable sensitivity to VCM in the buffer solution, indicating high capability for real-sample.
... [13] Several studies document that hands of ICU staff accounts for 20-40% infections due to the cross transmission between colonized / infected patients. [14,15] A study conducted by Tajeddin et al. on the hands of ICU staff yielded Acinetobacter baumannii (1.4%), Staphylococcus aureus (5.9%), epidermidis (20.9%) and Enterococcus spp. (1%). ...
ICU-acquired infections are a challenging health problem worldwide as the patient’s immunity is already compromised and these infections are usually caused by MDR pathogens. In ICUs inanimate surfaces and equipment may be contaminated by bacteria. Cross-transmission of microorganisms from inanimate surfaces may have a significant role for ICU-acquired infections. Contamination may result from HCWs hands or by direct patient shedding of bacteria. This study was conducted to determine the rate of bacterial contamination on environmental surfaces and health care workers of ICU our hospital. Swabs from healthcare workers and surrounding environmental surfaces were collected randomly from Adult Intensive care units. Bacterial isolates were identified by standard microbiological techniques. Antibiotic sensitivity testing was performed by Kirby Bauer disc diffusion method and data was analyzed. A total of 35 samples were collected, of which 29 (82.8 %) samples yielded positive bacterial growth. Of these 29-positive growth, 10 (34.1%) were from hand swabs of HCWs, 10(34.1%) were from nasal swabs and 9(31.0%) were from environment. Seven different bacterial isolates were identified. Coagulase Negative Staphylococcus (CONS) 10(28.5%), MRSA 5(14.2%) and Klebsiella spp 5(14.2%) accounted for majority of the isolates followed by MSSA 3(8.5%), Pseudomonas spp 1(2.8%), E.coli 1(2.8%) and ASB 4(11.4%).
... In low-income contexts like Malawi, where access to secondand third-line antibiotic therapies are often limited, reducing transmission of drug resistant infections is vital 12,13 . Most health care associated infections (HAI), are transmitted via the hands of healthcare workers through either direct contact with patients or through wider environmental contamination, making handwashing a vital preventive strategy 14 . ...
Background: Neonatal sepsis is responsible for a considerable burden of morbidity and mortality in sub-Saharan African countries. Outcomes from neonatal sepsis are worsening due to increasing rates of antimicrobial resistance. Sub-optimal Infection Prevention and Control (IPC) practices of health care workers and caregivers are important drivers of infection transmission. The Chatinkha Neonatal Unit at Queen Elizabeth Central Hospital, Blantyre, Malawi has experienced multiple outbreaks of neonatal sepsis, associated with drug resistant Klebsiella pneumoniae. We aimed to understand the barriers to implementation of optimal IPC focusing on hand hygiene practice.
Methods: We used a qualitative research methodology to meet the study aim. Combining participant observation (PO) over a seven-month period with semi structured interviews (SSI) to provide an in-depth understanding of activities relating to hygiene and IPC existing on the ward.
Results: While most staff and some caregivers, had a good understanding of ideal IPC and understood the importance of good handwashing practices, they faced substantial structural limitations, and scarce resources (both material and human) which made implementation challenging. For staff, the overwhelming numbers of patients meant the workload was often unmanageable and practicing optimal IPC was challenging. Caregivers lacked access to basic amenities, including linen and chairs, meaning that it was almost impossible for them to maintain good hand hygiene. Limited access to soap and the erratic water supply for both caregivers and healthcare workers further worsened the situation. Communication challenges between different cadres of staff and with patient caregivers meant that those handling neonates and cleaning the wards were often unaware of outbreaks of drug resistant infection.
Conclusion: For IPC to be improved, interventions need to address the chronic shortages of material resources and create an enabling environment for HCWs and patient caregivers.
... Several studies document that hands of ICU staff accounts for 20-40% infections due to the cross transmission between colonised / infected patients 25,26 15 . In contrast, our study did not show any evidence of bacterial colonization from the HCWs hand swabs collected before performing procedures. ...
Direct shedding of microbes by patients and health care workers results in contamination of Intensive care unit environment. Intensive care unit acquired infections due to microbial contamination is a major concern because the patient’s immunity is already compromised. To determine the rate of bacterial contamination on environmental surfaces of Intensive care unit and health care workers and to determine the antibiogram of the isolates. Air samples and swabs from healthcare workers, their accessories, surrounding environmental surfaces were collected randomly over a period of 2 months in Adult Intensive care units. Bacterial isolates were identified by standard microbiological techniques. Antibiotic sensitivity testing was performed by Kirby Bauer disc diffusion method and data analyzed by Statistical Product and Service Solutions 22 version software. A total of 208 samples were randomly collected over 2 months, of which 56 samples yielded positive bacterial growth. Of 56 growth, 12 isolates were detected from air sampling method and 44 isolates from swabs. Among 44 isolates identified from swabs, 10 were isolated from healthcare workers, 4 from health care worker’s accessories and 30 from environmental surfaces. Six different bacterial isolates were identified, Coagulase Negative Staphylococcus (24) and Micrococcus (15) were the major isolates followed by Non fermenters (6), Staphylococcus aureus(4), Bacillus species(4) and diphtheroids (3) The antimicrobial sensitivity pattern of these bacterial isolates were sensitive to commonly used antibacterial agents. Study results showed Intensive care unit staff and environmental surfaces as probable sources of bacterial contamination. Study highlights the importance of cleaning and disinfection process and educate the health care workers about the possible sources of infections within Intensive care unit.
... Therefore, we believe that education and supervision are important tools to improve HH practice, with the adequate supplementation of human resources. 33 It is worth mentioning that education does not always translate into behavioral change. Clinical administrators should apply appropriate approaches to make education effective, such as education materials and behavioral change strategies. ...
Background
Higher requirement is put forward in the measurement of hand hygiene (HH) during a pandemic. This study aimed to describe HH compliance measurement and explore observed influencing factors with respect to coronavirus disease 2019 (COVID-19) guidelines in China.
Methods
Compliance was measured as the percentage of compliant opportunities based on criteria for 17 moments. The criteria for compliance included HH behavior, procedure, duration, hand drying method and the overall that counts them all. The observed influencing factors included different departments and areas and protection motivation. Descriptive analysis and logistic regression were performed.
Results
The compliance of overall criteria, HH behavior, procedure, duration and hand drying method were 79.44%, 96.71%, 95.74%, 88.93%, 88.42%, respectively, which were significantly different from each other (p<0.001). Meanwhile, the overall and hand drying method compliance in semi-contaminated areas (OR=1.829, p<0.001; OR=2.149, p=0.001) and hygienic areas (OR=1.689, p=0.004; OR=1.959, p=0.015) were significantly higher than those in contaminated area. The compliance with HH behavior for the motivation of patient-protection (OR=0.362, p<0.001) was lower than that for the motivation of self-protection.
Conclusion
HH compliance was firstly measured using different criteria for 17 moments according to COVID-19 guidelines in China. The measurement of HH compliance needs clearer definition and comprehensive practice. Contaminated areas and motivation of patient-protection contribute to lower compliance, which may be addressed by allocating more human resources and increasing supervision and education.
The previous four chapters have laid the foundations needed to design an infection prevention strategy. First, 15 PPMs are responsible for approximately 90% of all ICU infections. Secondly, critical illness and its treatment affect the three defence lines that protect us from bacterial invasion. Thirdly, the carrier state allows you to distinct three types of ICU infections: primary endogenous, secondary endogenous and exogenous infection. Based on these insights, an effective infection control policy has been developed.
A rapid increase in the incidence of infection and colonization with vancomycin-resistant enterococci (VRE) has been reported from U.S. hospitals in the last 5 years. This increase poses several problems, including: a) the lack of available antimicrobials for therapy of infections due to VRE, since most VRE are also resistant to multiple other drugs, e.g., aminoglycosides and ampicillin, previously used for the treatment of infections due to these organisms, and b) the possibility that the vancomycin resistance genes present in VRE may be transferred to other gram-positive microorganisms such as Staphylococcus aureus. An increased risk of VRE infection and colonization has been associated with previous vancomycin and/or multi-antimicrobial therapy, severe underlying disease or immunosuppression, and intra-abdominal surgery. Because enterococci can be found in the normal gastrointestinal or female genital tract, most enterococcal infections have been attributed to endogenous sources within the individual patient. However, recent reports of outbreaks and endemic infections due to enterococci, including VRE, have shown that patient-to-patient transmission of the microorganisms can occur either via direct contact or indirectly via hands of personnel or contaminated patient-care equipment or environmental surfaces. Prevention and control of the spread of vancomycin resistance will require coordinated, concerted effort from various departments of the hospital, and can only be achieved if each of the following elements is addressed: 1) prudent vancomycin use by clinicians, 2) education of hospital staff regarding the problem of vancomycin resistance, 3) early detection and prompt reporting of vancomycin resistance in enterococci and other gram-positive microorganisms by the hospital microbiology laboratory, and 4) immediate implementation of appropriate infection-control measures to prevent person-to-person transmission of VRE
Alcohol is probably the most popular of all cutaneous disinfectants. It is generally used in every country, not only in dressing wounds and in preoperative preparation of the surgeon's hands and the field of operation, but for a multitude of minor procedures, such as vaccinations, hypodermic injections and punctures of the skin for blood counts. Reasons for its popularity are obvious: It is relatively cheap and easy to obtain, it is pleasant to use and it "wets" the skin efficiently. An alcohol-soaked pledget can wipe away a certain amount of grease and dirt, and in universal experience its application seems capable of preventing infections from needle punctures and the like.
Laboratory tests, however, as reported in the literature, have on the whole shown alcohol to be but weakly bactericidal, and the prevailing conclusion of present day writers is that whatever efficiency it may have as a cutaneous disinfectant is due
Objective: To study the possible role of contaminated environmental surfaces as a reservoir of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals. Design: A prospective culture survey of inanimate objects in the rooms of patients with MRSA. Setting: A 200-bed university-affiliated teaching hospital. Patients: Thirty-eight consecutive patients colonized or infected with MRSA. Patients represented endemic MRSA cases. Results: Ninety-six (27%) of 350 surfaces sampled in the rooms of affected patients were contaminated with MRSA When patients had MRSA in a wound or urine, 36% of surfaces were contaminated. In contrast, when MRSA was isolated from other body sites, only 6% of surfaces were contaminated (odds ratio, 8.8; 95% confidence interval, 3.7-25.5; P
A rapid increase in the incidence of infection and colonization with vancomycin-resistant enterococci (VRE) has been reported from U.S. hospitals in the last 5 years. This increase poses several problems, including a) the lack of available antimicrobials for therapy of infections due to VRE, since most VRE are also resistant to multiple other drugs, e.g., aminoglycosides and ampicillin, previously used for the treatment of infections due to these organisms, and b) the possibility that the vancomycin resistance genes present in VRE may be transferred to other gram-positive microorganisms such as Staphylococcus aureus.
An increased risk of VRE infection and colonization has been associated with previous vancomycin and/or multi-antimicrobial therapy, severe underlying disease or immunosuppression, and intra-abdominal surgery. Because enterococci can be found in the normal gastrointestinal or female genital tract, most enterococcal infections have been attributed to endogenous sources within the individual patient. However, recent reports of outbreaks and endemic infections due to enterococci, including VRE, have shown that patient-to-patient transmission of the microorganisms can occur either via direct contact or indirectly via hands of personnel or contaminated patient-care equipment or environmental surfaces.
Prevention and control of the spread of vancomycin resistance will require coordinated, concerted effort from various departments of the hospital, and can only be achieved if each of the following elements is addressed: 1) prudent vancomycin use by clinicians, 2) education of hospital staff regarding the problem of vancomycin resistance, 3) early detection and prompt reporting of vancomycin resistance in enterococci and other grampositive microorganisms by the hospital microbiology laboratory, and 4) immediate implementation of appropriate infection-control measures to prevent person-to-person transmission of VRE.