Didier Pittet

Effectiveness of a hospital-wide programme to improve compliance with hand hygiene

BACKGROUND Hand hygiene prevents cross infection in hospitals, but compliance with recommended instructions is commonly poor. We attempted to promote hand hygiene by implementing a hospital-wide programme, with special emphasis on bedside, alcohol-based hand disinfection. We measured nosocomial infections in parallel. METHODS We monitored the overall compliance with hand hygiene during routine patient care in a teaching hospital in Geneva, Switzerland, before and during implementation of a hand-hygiene campaign. Seven hospital-wide observational surveys were done twice yearly from December, 1994, to December, 1997. Secondary outcome measures were nosocomial infection rates, attack rates of methicillin-resistant Staphylococcus aureus (MRSA), and consumption of handrub disinfectant. FINDINGS We observed more than 20,000 opportunities for hand hygiene. Compliance improved progressively from 48% in 1994, to 66% in 1997 (p<0.001). Although recourse to handwashing with soap and water remained stable, frequency of hand disinfection substantially increased during the study period (p<0.001). This result was unchanged after adjustment for known risk factors of poor adherence. Hand hygiene improved significantly among nurses and nursing assistants, but remained poor among doctors. During the same period, overall nosocomial infection decreased (prevalence of 16.9% in 1994 to 9.9% in 1998; p=0.04), MRSA transmission rates decreased (2.16 to 0.93 episodes per 10,000 patient-days; p<0.001), and the consumption of alcohol-based handrub solution increased from 3.5 to 15.4 L per 1000 patient-days between 1993 and 1998 (p<0.001). INTERPRETATION The campaign produced a sustained improvement in compliance with hand hygiene, coinciding with a reduction of nosocomial infections and MRSA transmission. The promotion of bedside, antiseptic handrubs largely contributed to the increase in compliance.

Compliance with handwashing in a teaching hospital. Infection Control Program.

Nosocomial infections constitute a major challenge of modern medicine. On average, infections complicate 7% to 10% of hospital admissions (1). Transmission of microorganisms from the hands of health care workers is the main cause of nosocomial infections, and handwashing remains the most important preventive measure (2). Unfortunately, compliance with handwashing is unacceptably low in most institutions (3-7). Determinants of adequate handwashing in hospitals are largely unknown. We investigated factors associated with poor compliance with handwashing in a teaching hospital. Methods Study Design We conducted an observational study at the University of Geneva Hospital, Geneva, Switzerland. Handwashing facilities are conveniently located throughout the institution. One to three sinks are located inside every patient room, along with paper towels and unmedicated soap. Dispensers of hand antiseptic solutions are available in high-risk areas. Individual bottles containing an alcohol-based preparation of 0.5% chlorhexidine gluconate are available in every ward. The study took place in a sample of 48 wards (964 of 1382 beds [70%]) in December 1994. Five trained infection-control nurses recorded potential opportunities for and actual performance of handwashing during 20-minute observation periods distributed randomly during day and night over 14 days. Observations could be prolonged until completion of a patient care episode. Usually, health care workers providing patient care in a randomly selected room were observed; in intensive care units, health care workers providing care to two patients in randomly selected beds were observed. Data were recorded on a specially designed report form that had been pretested and adjusted in a pilot study. Interobserver variability was evaluated during 110 monitoring sessions (48 before and 62 during the study) in which 2 to 3 observers worked simultaneously. At the time of the study, interrater reliability was high for all variables (=0.92 [range, 0.81 to 1.0]). We informed department chairs about the upcoming study in November 1994. Personnel were not informed of which aspects of handwashing would be studied, and performance feedback was not reported during the study. In accordance with the requirements of the institutional review board, we did not identify staff members by unique identifier. Study Variables Opportunities for handwashing were all situations in which handwashing is indicated according to published guidelines (2, 8) (Appendix). Compliance with handwashing was defined as either washing the hands with water or plain soap or rubbing the hands with an antiseptic solution. Departure from the room after patient care without handwashing was regarded as noncompliance. Handwashing was required regardless of whether gloves were used or changed. Failure to remove gloves after patient contact or contact between a dirty and a clean body site on the same patient was considered noncompliance. Predictors were hospital ward; patient-to-staff ratio; time of day; day of week; professional category of health care worker; type of patient care; level of risk for cross-contamination (high-risk, before patient contact or care or between a dirty and a clean site on the patient; medium-risk, after contact with patient or body fluid or after patient care; low-risk, activity involving indirect patient contact or hospital maintenance); and intensity of patient care, estimated by the number of observed opportunities for handwashing per hour for each observation period (activity index). Statistical Analysis We used univariate analysis to examine the associations between predictors and compliance. Proportions were compared by using chi-square tests and odds ratios with 95% CIs. Logistic regression models were used for multivariate analysis. To account for interdependence of observations performed in the same unit, we used robust estimates of variance (generalized estimating equations [9]) by including each period of observation as a cluster. The association between the activity index and average compliance was examined across observation periods by using nonparametric regression (10). We used Stata version 5 (Stata Corp., College Station, Texas) for all analyses. All tests were two-tailed, and a P value less than 0.05 was considered statistically significant. Results In 307 sessions totalling 105 hours of observation, observers recorded 2834 opportunities for handwashing among 1043 health care workers (520 nurses, 158 physicians, 166 nursing assistants, and 199 other types of health care workers). We observed no opportunity for handwashing during 14 sessions. The average compliance with handwashing was 48% (Table): Handwashing was done with soap in 34% of instances and hand antisepsis was performed in 14%. Compliance with handwashing differed significantly among professional health care workers and was lower in surgical and intensive care wards than in other locations. Compliance was lowest during morning shifts and on weekdays. Table. Factors Associated with Noncompliance with Handwashing at the University of Geneva Hospitals Handwashing compliance also varied with type of patient care. The four moments (after patient care, during drug preparation, during housekeeping, and after intravenous care) that generated most opportunities for handwashing (78%) were associated with compliance rates of 48% to 52%. Compliance was lower for procedures associated with a high risk for transmission (before intravenous care, 39%; before respiratory care, 18%; and care between a dirty and a clean body site, 11%) and was higher for low-risk activities (after contact with body fluid, 63%; after wound care, 58%) (Table). Compliance with handwashing was worse when the activity index was high (Table). Compliance decreased on average (SD) by 5% 2% every 10 opportunities per hour when the intensity of patient care exceeded 10 opportunities per hour (linear trend, P<0.001) (Figure). The lowest compliance rate (36%) was found in intensive care units, where indications for handwashing were typically more frequent (average, 43.4 opportunities per hour). The highest compliance rate (59%) was observed in pediatric units, where the average activity index was lower than it was elsewhere (average, 24.4 opportunities per hour). Figure. Opportunities to wash hands and compliance with handwashing. In multivariate analysis (Table), care provided in intensive care units, higher-risk procedures, and a high activity index were associated with low compliance. Nurses had better compliance than any other type of health care worker. Compliance was also higher on weekends. Adding the patient-to-staff ratio to the model did not improve the results. Discussion Our study confirms that the primary problem with handwashing is laxity of practice (3-7). During routine patient care, health care workers disinfected or washed their hands in approximately half of the indicated instances. Like other investigators (3, 4), we observed better compliance in pediatric wards and found that nurses washed their hands more often than did other health care workers. This is fortunate, because nurses had the most opportunities (66%) to wash their hands. A disturbing finding was that activities that carried higher risk for transmission were associated with low compliance. In particular, compliance was very low (11%) for care between a dirty and a clean body site. Health care workers are most likely to wash hands after patient care (6, 7); for instance, Thompson and colleagues (7) reported an average compliance rate of 0% during staff-patient interaction that increased to 63% after interaction. Handwashing-education programs that give specific consideration to the sequence of steps in patient care may help address this problem. There has been some concern that using gloves may be considered an alternative to handwashing (11, 12), but failure to change contaminated gloves is at least as common as failure to wash hands (2, 7). Glove use was observed in fewer than 12% of handwashing opportunities in our study and thus was not a major determinant of noncompliance. Of note, we found that high demand for hand cleansing, which reflects high workload (13), was associated with low compliance. Opportunities for handwashing were much more frequent during busier times of the day and during care of critically ill patients. These results confirm reports by health care workers that perceived busyness substantially reduces handwashing (6, 11). Furthermore, understaffing of hospital wards decreases compliance with isolation precautions (14) and increases risk for nosocomial infections (15, 16). Although causality was not established in these reports, the investigators mentioned possible lack of compliance with infection-control measures, particularly handwashing, as a potential explanatory factor (15, 16). To our knowledge, our study is the first to assess the relation between increased need for handwashing and reduced compliance. A disturbing implication of our findings is that full compliance with handwashing guidelines may be unrealistic. Actual wash time in routine hospital practice averages 8 to 20 seconds, which may be too short to be fully effective (2, 8). In intensive care units, health care workers need about 1 minute to walk to the sink, wash their hands, and return to the patient (17). If 40 opportunities to wash the hands occur per hour of care, the total amount of time spent washing hands becomes prohibitive. One possible solution is to replace time-consuming handwashing with bedside hand antisepsis. Whether switching from traditional handwashing to hand antisepsis improves compliance deserves testing in clinical trials. Our study has several limitations. First, although our observations were as unobtrusive as possible, health care workers may have changed their behavior because they were being observed. Such a bias would probably inflate compliance estimates, and the

Epidemiology of Candida species infections in critically ill non-immunosuppressed patients

A substantial proportion of patients become colonised with Candida spp during hospital stay, but only few subsequently develop severe infection. Clinical signs of severe infection manifest early but lack specificity until late in the course of the disease, thus representing a particular challenge for diagnosis. Mostly nosocomial, invasive candidiasis occurs in only 1-8% of patients admitted to hospitals, but in around 10% of patients housed in intensive care units where it can represent up to 15% of all nosocomial infections. We review the epidemiology of invasive candidiasis in non-immunocompromised, critically ill patients with special emphasis on disease trends over time, pathophysiology, diagnostic approach, risk factors, and impact. Recent epidemiological data suggesting that the emergence of non-albicans candida strains with reduced susceptibility to azoles, previously linked to the use of new antifungals for empiric and prophylactic therapy in immunocompromised patients, may not have occurred in the critically ill. Management of invasive candidiasis in these patients will be addressed in the December issue of The Lancet Infectious Diseases.

Candida colonization and subsequent infections in critically III surgical patients

ObjectiveThe authors determined the role of Candida colonization in the development of subsequent infection in critically ill patients.DesignA 6-month prospective cohort study was given to patients admitted to the surgical and neonatal intensive care units in a 1600-bed university medical center. MethodsPatients having predetermined criteria for significant Candida colonization revealed by routine microbiologic surveillance cultures at different body sites were eligible for the study. Risk factors for Candida infection were recorded. A Candida colonization index was determined daily as the ratio of the number of distinct body sites (dbs) colonized with identical strains over the total number of dbs tested; a mean of 5.3 dbs per patient was obtained. All isolates (n = 322) sequentially recovered were characterized by genotyping using contour-clamped homogeneous electrical field gel electrophoresis that allowed strain delineation among Candida species. ResultsTwenty-nine patients met the criteria for inclusion; all were at high risk for Candida infection; 11 patients (38%) developed severe infections (8 candidemia); the remaining 18 patients were heavily colonized, but never required intravenous antifungal therapy. Among the potential risk factors for candidal infection, three discriminated the colonized from the infected patients—i.e., length of previous antibiotic therapy (p < 0.02), severity of illness assessed by APACHE II score (p < 0.01), and the intensity of Candida spp colonization (p < 0.01). By logistic regression analysis, the latter two were the independent factors that predicted subsequent candidal infection. Candida colonization always preceded infection with genotypically identical Candida spp strain. The proposed colonization indexes reached threshold values a mean of 6 days before Candida infection and demonstrated high positive predictive values (66 to 100%). ConclusionsThe intensity of Candida colonization assessed by systematic screening helps predicting subsequent infections with identical strains in critically ill patients. Accurately identifying high-risk patients with Candida colonization offers opportunity for intervention strategies.

Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis

BACKGROUND Health-care-associated infection is the most frequent result of unsafe patient care worldwide, but few data are available from the developing world. We aimed to assess the epidemiology of endemic health-care-associated infection in developing countries. METHODS We searched electronic databases and reference lists of relevant papers for articles published 1995-2008. Studies containing full or partial data from developing countries related to infection prevalence or incidence-including overall health-care-associated infection and major infection sites, and their microbiological cause-were selected. We classified studies as low-quality or high-quality according to predefined criteria. Data were pooled for analysis. FINDINGS Of 271 selected articles, 220 were included in the final analysis. Limited data were retrieved from some regions and many countries were not represented. 118 (54%) studies were low quality. In general, infection frequencies reported in high-quality studies were greater than those from low-quality studies. Prevalence of health-care-associated infection (pooled prevalence in high-quality studies, 15·5 per 100 patients [95% CI 12·6-18·9]) was much higher than proportions reported from Europe and the USA. Pooled overall health-care-associated infection density in adult intensive-care units was 47·9 per 1000 patient-days (95% CI 36·7-59·1), at least three times as high as densities reported from the USA. Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5·6 per 100 surgical procedures), strikingly higher than proportions recorded in developed countries. Gram-negative bacilli represented the most common nosocomial isolates. Apart from meticillin resistance, noted in 158 of 290 (54%) Staphylococcus aureus isolates (in eight studies), very few articles reported antimicrobial resistance. INTERPRETATION The burden of health-care-associated infection in developing countries is high. Our findings indicate a need to improve surveillance and infection-control practices. FUNDING World Health Organization.

Micafungin versus liposomal amphotericin B for candidaemia and invasive candidosis: a phase III randomised double-blind trial

BACKGROUND Invasive candidosis is increasingly prevalent in seriously ill patients. Our aim was to compare micafungin with liposomal amphotericin B for the treatment of adult patients with candidaemia or invasive candidosis. METHODS We did a double-blind, randomised, multinational non-inferiority study to compare micafungin (100 mg/day) with liposomal amphotericin B (3 mg/kg per day) as first-line treatment of candidaemia and invasive candidosis. The primary endpoint was treatment success, defined as both a clinical and a mycological response at the end of treatment. Primary analyses were done on a per-protocol basis. This trial is registered with ClinicalTrials.gov, number NCT00106288. FINDINGS 264 individuals were randomly assigned to treatment with micafungin; 267 were randomly assigned to receive liposomal amphotericin B. 202 individuals in the micafungin group and 190 in the liposomal amphotericin B group were included in the per-protocol analyses. Treatment success was observed for 181 (89.6%) patients treated with micafungin and 170 (89.5%) patients treated with liposomal amphotericin B. The difference in proportions, after stratification by neutropenic status at baseline, was 0.7% (95% CI -5.3 to 6.7). Efficacy was independent of the Candida spp and primary site of infection, as well as neutropenic status, APACHE II score, and whether a catheter was removed or replaced during the study. There were fewer treatment-related adverse events--including those that were serious or led to treatment discontinuation--with micafungin than there were with liposomal amphotericin B. INTERPRETATION Micafungin was as effective as--and caused fewer adverse events than--liposomal amphotericin B as first-line treatment of candidaemia and invasive candidosis.

Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients.

CONTEXT Experts and policy makers have repeatedly called for universal screening at hospital admission to reduce nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. OBJECTIVE To determine the effect of an early MRSA detection strategy on nosocomial MRSA infection rates in surgical patients. DESIGN, SETTING, AND PATIENTS Prospective, interventional cohort study conducted between July 2004 and May 2006 among 21 754 surgical patients at a Swiss teaching hospital using a crossover design to compare 2 MRSA control strategies (rapid screening on admission plus standard infection control measures vs standard infection control alone). Twelve surgical wards including different surgical specialties were enrolled according to a prespecified agenda, assigned to either the control or intervention group for a 9-month period, then switched over to the other group for a further 9 months. INTERVENTIONS During the rapid screening intervention periods, patients admitted to the intervention wards for more than 24 hours were screened before or on admission by rapid, multiplex polymerase chain reaction. For both intervention (n=10 844) and control (n=10 910) periods, standard infection control measures were used for patients with MRSA in all wards and consisted of contact isolation of MRSA carriers, use of dedicated material (eg, gown, gloves, mask if indicated), adjustment of perioperative antibiotic prophylaxis of MRSA carriers, computerized MRSA alert system, and topical decolonization (nasal mupirocin ointment and chlorhexidine body washing) for 5 days. MAIN OUTCOME MEASURES Incidence of nosocomial MRSA infection, MRSA surgical site infection, and rates of nosocomial acquisition of MRSA. RESULTS Overall, 10 193 of 10 844 patients (94%) were screened during the intervention periods. Screening identified 515 MRSA-positive patients (5.1%), including 337 previously unknown MRSA carriers. Median time from screening to notification of test results was 22.5 hours (interquartile range, 12.2-28.2 hours). In the intervention periods, 93 patients (1.11 per 1000 patient-days) developed nosocomial MRSA infection compared with 76 in the control periods (0.91 per 1000 patient-days; adjusted incidence rate ratio, 1.20; 95% confidence interval, 0.85-1.69; P = .29). The rate of MRSA surgical site infection and nosocomial MRSA acquisition did not change significantly. Fifty-three of 93 infected patients (57%) in the intervention wards were MRSA-free on admission and developed MRSA infection during hospitalization. CONCLUSION A universal, rapid MRSA admission screening strategy did not reduce nosocomial MRSA infection in a surgical department with endemic MRSA prevalence but relatively low rates of MRSA infection. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN06603006.

Guideline for hand hygiene in health-care settings : recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Improving Compliance With Hand Hygiene in Hospitals

Hand hygiene prevents cross-infection in hospitals, but compliance with recommended instructions often is poor among healthcare workers. Although some previous interventions to improve compliance have been successful, none has achieved lasting improvement. This article reviews reported barriers to appropriate hand hygiene and factors associated with poor compliance. Easy access to hand hygiene in a timely fashion and the availability of skin-care lotion both appear to be necessary prerequisites for appropriate hand-hygiene behavior. In particular, in high-demand situations, hand rub with an alcohol-based solution appears to be the only alternative that allows a decent compliance. The hand-hygiene compliance level does not rely on individual factors alone, and the same can be said for its promotion. Because of the complexity of the process of change, it is not surprising that solo interventions often fail, and multimodal, multidisciplinary strategies are necessary. A framework that includes parameters to be considered for hand-hygiene promotion is proposed, based on epidemiologically driven evidence and review of the current knowledge. Strategies for promotion in hospitals should include reasons for noncompliance with recommendations at individual, group, and institutional levels. Potential tools for change should address each of these elements and consider their interactivity.

Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care.

BACKGROUND Intravascular devices are a leading cause of nosocomial infection. Specific prevention strategies and improved guidelines for the use of intravascular devices can decrease the rate of infection; however, the impact of a combination of these strategies on rates of vascular-access infection in intensive-care units (ICUs) is not known. We implemented a multiple-approach prevention programme to decrease the occurrence of vascular-access infection in an 18-bed medical ICU at a tertiary centre. METHODS 3154 critically ill patients, admitted between October, 1995, and November, 1997, were included in a cohort study with longitudinal assessment of an overall catheter-care policy targeted at the reduction of vascular-access infections and based on an educational campaign for vascular-access insertion and on device use and care. Incidence of ICU-acquired infections was measured by means of on-site surveillance. FINDINGS 613 infections occurred in 353 patients (19.4 infections per 100 admissions). The incidence density of exit-site catheter infection was 9.2 episodes per 1000 patient-days before the intervention, and 3.3 episodes per 1000 patient-days afterwards (relative risk 0.36 [95% CI 0.20-0.63]). Corresponding rates for bloodstream infection were 11.3 and 3.8 episodes per 1000 patient-days, respectively (0.33 [0.20-0.56]) due to decreased rates of both microbiologically documented infections and clinical sepsis. Rates of respiratory and urinary-tract infections remained unchanged, whereas those of skin or mucous-membrane infections decreased from 11.4 to 7.0 episodes per 1000 patient-days (0.62 [0.41-0.93]). Overall, the incidence of nosocomial infections decreased from 52.4 to 34.0 episodes per 1000 patient-days (0.65 [0.54-0.78]). INTERPRETATION A multiple-approach prevention strategy, targeted at the insertion and maintenance of vascular access, can decrease rates of vascular-access infections and can have a substantial impact on the overall incidence of ICU-acquired infections.