Effectiveness and Safety of Measures to Prevent Infections and Other Complications Associated With Peripheral Intravenous Catheters: A Systematic Review and Meta-analysis.

BACKGROUND: Peripheral intravenous catheters (PIVCs) contribute substantially to the global burden of infections. This systematic review assessed 24 infection prevention and control (IPC) interventions to prevent PIVC-associated infections and other complications. METHODS: We searched Ovid MEDLINE, Embase, Cochrane Library, WHO Global Index Medicus, CINAHL, and reference lists for controlled studies from 1 January 1980-16 March 2023. We dually selected studies, assessed risk of bias, extracted data, and rated the certainty of evidence (COE). For outcomes with 3 or more trials, we conducted Bayesian random-effects meta-analyses. RESULTS: 105 studies met our prespecified eligibility criteria, addressing 16 of the 24 research questions; no studies were identified for 8 research questions. Based on findings of low to high COE, wearing gloves reduced the risk of overall adverse events related to insertion compared with no gloves (1 non-randomized controlled trial [non-RCT]; adjusted risk ratio [RR], .52; 95% CI, .33-.85), and catheter removal based on defined schedules potentially resulted in a lower phlebitis/thrombophlebitis incidence (10 RCTs; RR, 0.74, 95% credible interval, .49-1.01) compared with clinically indicated removal in adults. In neonates, chlorhexidine reduced the phlebitis score compared with non-chlorhexidine-containing disinfection (1 RCT; 0.14 vs 0.68; P = .003). No statistically significant differences were found for other measures. CONCLUSIONS: Despite their frequent use and concern about PIVC-associated complications, this review underscores the urgent need for more high-quality studies on effective IPC methods regarding safe PIVC management. In the absence of valid evidence, adherence to standard precaution measures and documentation remain the most important principles to curb PIVC complications. CLINICAL TRIALS REGISTRATION: The protocol was registered in the Open Science Framework (https://osf.io/exdb4).

Control of Carbapenem-resistant Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa in Healthcare Facilities: A Systematic Review and Reanalysis of Quasi-experimental Studies.

Carbapenem-resistant Enterobacteriaceae (CRE), Acinetobacter baumannii (CRAB), and Pseudomonas aeruginosa (CRPsA) are a serious cause of healthcare-associated infections, although the evidence for their control remains uncertain. We conducted a systematic review and reanalysis to assess infection prevention and control (IPC) interventions on CRE-CRAB-CRPsA in inpatient healthcare facilities to inform World Health Organization guidelines. Six major databases and conference abstracts were searched. Before-and-after studies were reanalyzed as interrupted time series if possible. Effective practice and organization of care (EPOC) quality criteria were used. Seventy-six studies were identified, of which 17 (22%) were EPOC-compatible and interrupted time series analyses, assessing CRE (n = 11; 65%), CRAB (n = 5; 29%) and CRPsA (n = 3; 18%). IPC measures were often implemented using a multimodal approach (CRE: 10/11; CRAB: 4/5; CRPsA: 3/3). Among all CRE-CRAB-CRPsA EPOC studies, the most frequent intervention components included contact precautions (90%), active surveillance cultures (80%), monitoring, audit and feedback of measures (80%), patient isolation or cohorting (70%), hand hygiene (50%), and environmental cleaning (40%); nearly all studies with these interventions reported a significant reduction in slope and/or level. The quality of EPOC studies was very low to low.

Effectiveness of 80% vs 30-35% fraction of inspired oxygen in patients undergoing surgery: an updated systematic review and meta-analysis.

BACKGROUND: In 2016, the World Health Organization (WHO) strongly recommended the use of a high fraction of inspired oxygen (FiO2) in adult patients undergoing general anaesthesia to reduce the risk of surgical site infection (SSI). Since then, further trials have been published, trials included previously have come under scrutiny, and one article was retracted. We updated the systematic review on which the recommendation was based. METHODS: We performed a systematic literature search from January 1990 to April 2018 for RCTs comparing the effect of high (80%) vs standard (30-35%) FiO2 on the incidence of SSI. Studies retracted or under investigation were excluded. A random effects model was used for meta-analyses; the sources of heterogeneity were explored using meta-regression. RESULTS: Of 21 RCTs included, six were newly identified since the publication of the WHO guideline review; 17 could be included in the final analyses. Overall, no evidence for a reduction of SSI after the use of high FiO2 was found [relative risk (RR): 0.89; 95% confidence interval (CI): 0.73-1.07]. There was evidence that high FiO2 was beneficial in intubated patients [RR: 0.80 (95% CI: 0.64-0.99)], but not in non-intubated patients [RR: 1.20 (95% CI: 0.91-1.58); test of interaction; P=0.048]. CONCLUSIONS: The WHO updated analyses did not show definite beneficial effect of the use of high perioperative FiO2, overall, but there was evidence of effect of reducing the SSI risk in surgical patients under general anaesthesia with tracheal intubation. However, the evidence for this beneficial effect has become weaker and the strength of the recommendation needs to be reconsidered.

Safety of 80% vs 30-35% fraction of inspired oxygen in patients undergoing surgery: a systematic review and meta-analysis.

BACKGROUND: Evidence-based guidelines from the World Health Organization (WHO) have recommended a high (80%) fraction of inspired oxygen (FiO2) to reduce surgical site infection in adult surgical patients undergoing general anaesthesia with tracheal intubation. However, there is ongoing debate over the safety of high FiO2. We performed a systematic review to define the relative risk of clinically relevant adverse events (AE) associated with high FiO2. METHODS: We reviewed potentially relevant articles from the WHO review supporting the recommendation, including an updated (July 2018) search of EMBASE and PubMed for randomised and non-randomised controlled studies reporting AE in surgical patients receiving 80% FiO2 compared with 30-35% FiO2. We assessed study quality and performed meta-analyses of risk ratios (RR) comparing 80% FiO2 against 30-35% for major complications, mortality, and intensive care admission. RESULTS: We included 17 moderate-good quality trials and two non-randomised studies with serious-critical risk of bias. No evidence of harm with high FiO2 was found for major AE in the meta-analysis of randomised trials: atelectasis RR 0.91 [95% confidence interval (CI) 0.59-1.42); cardiovascular events RR 0.90 (95% CI 0.32-2.54); intensive care admission RR 0.93 (95% CI 0.7-1.12); and death during the trial RR 0.49 (95% CI 0.17-1.37). One non-randomised study reported that high FiO2 was associated with major respiratory AE [RR 1.99 (95% CI 1.72-2.31)]. CONCLUSIONS: No definite signal of harm with 80% FiO2 in adult surgical patients undergoing general anaesthesia was demonstrated and there is little evidence on safety-related issues to discourage its use in this population.

Injection practices in 2011-2015: a review using data from the demographic and health surveys (DHS).

BACKGROUND: Reuse of injection devices to give healthcare injections decreased from 39.8 to 5.5% between 2000 and 2010, but trends since 2011 have not been described. We reviewed results of Demographic and Health Surveys (DHS) to describe injection practices worldwide from 2011 to 2015. METHODS: We searched the DHS Internet site for data published on injection practices conducted in countries from 2011 to 2015, extracted information on frequency (number of healthcare injections per person in the last 12 months) and safety (proportion of syringes and needles taken from a new, unopened package). We compared gender groups and WHO regions in terms of frequency and safety. For countries with data available, we compared injection practices 2004-2010 and 2011-2015. RESULTS: Since 2011, 40 of 92 countries (43%) that conducted DHS surveys reported on injection practices. On average, the frequency of injection was 1.64 per person per year (from 3.84 in WHO Eastern Mediterranean region to 1.18 in WHO African region). Among those, 96.1% of injections reportedly used new injection devices (from 90.2% in the WHO Eastern Mediterranean region to 98.8% in the WHO Western Pacific region). On average, women received more injections per year (1.85) than men (1.41). Among 16 (40%) countries with data in 2004-2010 and 2011-2015, 69% improved in terms of safety. The annual number of unsafe injections reduced in 81% of countries. In Pakistan, the number of unsafe injections was the highest and did not decrease between 2006 and 2012. CONCLUSIONS: Injection practices have continued to improve in most countries worldwide, although the Eastern Mediterranean region in particular still faces unsafe practices that are not improving. Further efforts are needed to eliminate unsafe injection practices in health care settings, including through the use of reuse-prevention devices. Despite some limitations, DHS is an easily available method to measure progress over time.

Infection Rates and Risk Factors for Infection Among Health Workers During Ebola and Marburg Virus Outbreaks: A Systematic Review.

Background: Infection in health workers (HWs) has characterized outbreaks of Ebola virus disease (EVD) and Marburg virus disease (MVD). We conducted a systematic review to investigate infection and mortality rates and common exposure risks in HWs in EVD and MVD outbreaks. Methods: We searched the EMBASE and PubMed databases to identify articles posted before 27 December 2017, with no language restrictions. Data on the number, frequency, and mortality of HW infection and exposure risks were extracted. Results: Ninety-four articles related to 22 outbreaks were included. HW infections composed 2%-100% of cases in EVD and 5%-50% of cases in MVD outbreaks. Among exposed HWs, 0.6%-92% developed EVD, and 1%-10% developed MVD. HW infection rates were consistent through outbreaks. The most common exposure risk situations were inadequate personal protective equipment and exposure to patients with unrecognized EVD/MVD. Similar risks were reported in past EVD/MVD outbreaks and in the recent outbreak in West Africa. Conclusions: Many outbreaks reported high proportions of infected HWs. Similar HW infection rates and exposure risk factors in both past and recent EVD and MVD outbreaks emphasize the need to improve the implementation of appropriate infection control measures consistently across all healthcare settings.

Determinants of success and sustainability of the WHO multimodal hand hygiene promotion campaign, Italy, 2007-2008 and 2014.

A national hand hygiene promotion campaign based on the World Health Organization (WHO) multimodal, Clean Care is Safer Care campaign was launched in Italy in 2007. One hundred seventy-five hospitals from 14 of 20 Italian regions participated. Data were collected using methods and tools provided by the WHO campaign, translated into Italian. Hand hygiene compliance, ward infrastructure, and healthcare workers' knowledge and perception of healthcare-associated infections and hand hygiene were evaluated before and after campaign implementation. Compliance data from the 65 hospitals returning complete data for all implementation tools were analysed using a multilevel approach. Overall, hand hygiene compliance increased in the 65 hospitals from 40% to 63% (absolute increase: 23%, 95% confidence interval: 22-24%). A wide variation in hand hygiene compliance among wards was observed; inter-ward variability significantly decreased after campaign implementation and the level of perception was the only item associated with this. Long-term sustainability in 48 of these 65 hospitals was assessed in 2014 using the WHO Hand Hygiene Self-Assessment Framework tool. Of the 48 hospitals, 44 scored in the advanced/intermediate categories of hand hygiene implementation progress. The median hand hygiene compliance achieved at the end of the 2007-2008 campaign appeared to be sustained in 2014.

World Health Organization World Hand Hygiene Day, 5 May 2024. SAVE LIVES: Clean Your Hands campaign: Promoting knowledge and capacity building on infection prevention and control, including hand hygiene, among health and care workers.

The World Health Organization's (WHO) World Hand Hygiene Day continues to "bring people together and accelerate hand hygiene action at the point of care in health care to contribute to a reduction in health care-associated infections and the achievement of safer, quality health care for all."

World Health Organization World Hand Hygiene Day, 5 May 2024. SAVE LIVES: clean your hands campaign: promoting knowledge and capacity building on infection prevention and control, including hand hygiene, among health and care workers.

The World Health Organization's (WHO) World Hand Hygiene Day continues to "bring people together and accelerate hand hygiene action at the point of care in health care to contribute to a reduction in health care-associated infections and the achievement of safer, quality health care for all".

Estimating the return on investment of selected infection prevention and control interventions in healthcare settings for preparing against novel respiratory viruses: modelling the experience from SARS-CoV-2 among health workers.

Background: Insufficient infection prevention and control (IPC) practices in healthcare settings increase the SARS-CoV-2 infection risk among health workers. This study aimed to examine the level of preparedness for future outbreaks. Methods: We modelled the experience from the COVID-19 pandemic and assessed the return on investment on a global scale of three IPC interventions to prevent SARS-CoV-2 infections among health workers: enhancing hand hygiene; increasing access to personal protective equipment (PPE); and combining PPE, with a scale-up of IPC training and education (PPE+). Our analysis covered seven geographic regions, representing a combination of World Health Organization (WHO) regions and the Organisation for Economic Co-operation and Development (OECD) countries. Across all regions, we focused on the first 180 days of the pandemic in 2020 between January 1st and June 30th. We used an extended version of a susceptible-infectious-recovered compartmental model to measure the level of IPC preparedness. Data were sourced from the WHO COVID-19 Detailed Surveillance Database. Findings: In all regions, the PPE + intervention would have averted the highest number of new SARS-CoV-2 infections compared to the other two interventions, ranging from 6562 (95% CI 4873-8779) to 38,170 (95% CI 33,853-41,901) new infections per 100,000 health workers in OECD countries and in the South-East Asia region, respectively. Countries in the South-East Asia region and non-OECD countries in the Western Pacific region were poised to achieve the highest level of savings by scaling up the PPE + intervention. Interpretation: Our results not only support efforts to make an economic case for continuing investments in IPC interventions to halt the COVID-19 pandemic and protect health workers, but could also contribute to efforts to improve preparedness for future outbreaks. Funding: This work was funded by WHO, with support by the German Federal Ministry of Health for the WHOResearch and Development Blueprint for COVID-19.

WHO research agenda on the role of the institutional safety climate for hand hygiene improvement: a Delphi consensus-building study.

BACKGROUND: Creating and sustaining an institutional climate conducive to patient and health worker safety is a critical element of successful multimodal hand hygiene improvement strategies aimed at achieving best practices. Repeated WHO global surveys indicate that the institutional safety climate consistently ranks the lowest among various interventions. METHODS: To develop an international expert consensus on research agenda priorities related to the role of institutional safety climate within the context of a multimodal hand hygiene improvement strategy, we conducted a structured consensus process involving a purposive sample of international experts. A preliminary list of research priorities was formulated following evidence mapping, and subsequently refined through a modified Delphi consensus process involving two rounds. In round 1, survey respondents were asked to rate the importance of each research priority. In round 2, experts reviewed round 1 ratings to reach a consensus (defined as ≥70% agreement) on the final prioritised items to be included in the research agenda. The research priorities were then reviewed and finalised by members of the WHO Technical Advisory Group on Hand Hygiene Research in Healthcare. RESULTS: Of the 57 invited participants, 50 completed Delphi round 1 (88%), and 48 completed round 2 (96%). Thirty-six research priority statements were included in round 1 across five thematic categories: (1) safety climate; (2) personal accountability for hand hygiene; (3) leadership; (4) patient participation and empowerment and (5) religion and traditions. In round 1, 75% of the items achieved consensus, with 9 statements carried forward to round 2, leading to a final set of 31 prioritised research statements. CONCLUSION: This research agenda can be used by researchers, clinicians, policy-makers and funding bodies to address gaps in hand hygiene improvement within the context of an institutional safety climate, thereby enhancing patient and health worker safety globally.

Infection prevention and control risk factors for SARS-CoV-2 infection in health workers: a global, multicentre case-control study.

BACKGROUND: Health workers were at higher risk for SARS-CoV-2 infection during the COVID-19 pandemic due to occupational risk factors. As part of the WHO Unity Studies initiative, we aimed to characterise these risk factors. METHODS: This global, multicentre, nested, case-control study was conducted in 121 healthcare facilities in 21 countries. Cases were health workers who tested positive for SARS-CoV-2 infection with a documented occupational exposure to COVID-19 patients in the 14 days pre-enrolment. Controls were enrolled from the same facility with a similar exposure but negative serology. Case and control status was confirmed with serological testing at baseline and after 3-4 weeks. Demographic and infection risk factor data were collected using structured questionnaires. FINDINGS: Between June 2020 and December 2021, data were obtained for 1213 cases and 1844 controls. SARS-CoV-2 infection risk was associated with non-adherence to personal protective equipment (PPE) guidelines (aOR 1·67 [95% CI 1·32-2·12]) and not consistently performing hand hygiene after patient contact (aOR 2·52 [1·72-3·68]). Direct close contact with COVID-19 patients was also associated with an increased risk, particularly during prolonged contact (>15 min.). Items associated with a lower risk were respirators during aerosol-generating procedures and gloves, gowns or coveralls during contact with contaminated materials/surfaces. No difference was observed among health workers using respirators versus surgical masks for routine care. CONCLUSION: Appropriate implementation of infection prevention and control measures and PPE use remain a priority to protect health workers from SARS-CoV-2 infection.

Evaluating national infection prevention and control minimum requirements: evidence from global cross-sectional surveys, 2017-22.

BACKGROUND: WHO infection prevention and control (IPC) minimum requirements provide standards to reduce the risk of infection during health-care delivery. We aimed to investigate the global implementation of these requirements at national levels and the progress of doing so across 2021-22 compared with 2017-18 to identify future directions for interventions. METHODS: National IPC focal points were invited to complete an online survey measuring IPC minimum requirements from July 19, 2021, to Jan 31, 2022. The primary outcome was the proportion of countries meeting IPC minimum requirements. Country characteristics associated with this outcome were assessed with beta regression. Subset analyses were conducted to compare the 2021-22 indicators with a WHO IPC survey conducted in 2017-18 and to assess the correlation of the proportion of IPC minimum requirements met with the results of other WHO metrics. FINDINGS: 106 countries (ie, 13 low income, 27 lower-middle income, 33 upper-middle income, and 33 high income) participated in the survey (56% response rate). Four (4%) of 106 met all IPC minimum requirements. The highest scoring IPC core component was multimodal improvement strategies and the lowest was IPC education and training. The odds of meeting IPC minimum requirements was higher among high-income countries compared with low-income countries (adjusted odds ratio 2·7, 95% CI 1·3-5·8; p=0·020). Compared with the 2017-18 survey, there was a significant increase in the proportion of countries reporting an active national IPC programme (65% to 82%, p=0·037) and a dedicated budget (26% to 44%, p=0·037). Evaluation of the IPC minimum requirements compared with other survey instruments revealed a low positive correlation. INTERPRETATION: To build resilient health systems capable of withstanding future health threats, urgently scaling up adherence to WHO IPC minimum requirements is essential. FUNDING: WHO. TRANSLATIONS: For the French and Spanish translations of the abstract see Supplementary Materials section.

Adapting the WHO hand hygiene 'reminders in the workplace' to improve acceptability for healthcare workers in maternity settings worldwide: a mixed methods study.

INTRODUCTION: Hand hygiene is key in preventing healthcare-associated infections, but it is challenging in maternity settings due to high patient turnover, frequent emergencies and volume of aseptic procedures. We sought to investigate if adaptions to the WHO hand hygiene reminders could improve their acceptability in maternity settings globally, and use these findings to develop new reminders specific to maternity settings. METHODS: Informed by Sekhon et al's acceptability framework, we conducted an online survey, semi-structured interviews and a focus group examining the three WHO central hand hygiene reminders ('your five moments of hand hygiene', 'how to hand wash' and 'how to hand rub') and their acceptability in maternity settings. A convergent mixed-methods study design was followed. Findings were examined overall and by country income status. A WHO expert working group tested the integrated findings, further refined results and developed recommendations to improve acceptability for use in the global maternity community. Findings were used to inform the development of two novel and acceptable hand hygiene reminders for use in high-income country (HIC) and low- and middle-income country (LMIC) maternity settings. RESULTS: Participation in the survey (n=342), semi-structured interviews (n=12) and focus group (n=7) spanned 51 countries (14 HICs and 37 LMICs). The highest scoring acceptability constructs were clarity of the intervention (intervention coherence), confidence in performance (self-efficacy), and alignment with personal values (ethicality). The lowest performing were perceived difficulty (burden) and how the intervention made the participant feel (affective attitude). Overfamiliarity reduced acceptability in HICs (perceived effectiveness). In LMICs, resource availability was a barrier to implementation (opportunity cost). Two new reminders were developed based on the findings, using inclusive female images, and clinical examples from maternity settings. CONCLUSION: Following methodologically robust adaptation, two novel and inclusive maternity-specific hand hygiene reminders have been developed for use in both HIC and LMICs.