Handrubbing with sprayed alcohol-based hand rub: an alternative method for effective hand hygiene.

BACKGROUND: Hand hygiene is crucial in infection prevention and control. It is unclear whether sprayed alcohol-based hand rub (ABHR) is non-inferior to the World Health Organization (WHO)-recommended method of handrubbing with poured ABHR. AIM: To test whether sprayed ABHR can be an alternative (non-inferior) method for effective hand hygiene with/without handrubbing. METHODS: A laboratory experiment was conducted with ABHR (isopropanol 60% v/v) according to European Norm 1500. Hand hygiene was performed by: (1) handrubbing with ABHR poured on to the palm of the hand; (2) handrubbing with sprayed ABHR; and (3) applying sprayed ABHR to hands without handrubbing. Hands were contaminated with Escherichia coli ATCC 10536, followed by hand hygiene and microbiological sampling. A generalized linear mixed model with a random intercept per subject was used to analyse the reduction in bacterial count following hand hygiene. FINDINGS: In total, 19 healthcare workers participated in the study. Handrubbing with sprayed ABHR was non-inferior [margin log10 0.6 colony-forming units (cfu)/mL] to the WHO-recommended method of handrubbing with poured ABHR; bacterial count reductions were log10 3.66 cfu/mL [95% confidence interval (CI) 1.68-5.64] and log10 3.46 cfu/mL (95% CI 1.27-5.65), respectively. Conversely, non-inferiority was not found for sprayed ABHR without handrubbing [bacterial count reduction log10 2.76 cfu/mL (95% CI 1.65-3.87)]. CONCLUSION: Handrubbing with sprayed ABHR was non-inferior to handrubbing with ABHR poured on to the palm of the hand to reduce bacterial counts on hands under experimental conditions. Handrubbing with sprayed ABHR may be an acceptable alternative hand hygiene method pending assessment in other settings and for other pathogens.

Association between treatment duration and mortality or relapse in adult patients with Staphylococcus aureus bacteraemia: a retrospective cohort study.

OBJECTIVES: The aim was to evaluate the effect of duration of therapy (DOT) on mortality and relapse for patients with Staphylococcus aureus bacteraemia (SAB). METHODS: We performed a retrospective single-centre cohort study including adult patients with SAB. We determined the association between DOT (≤14 days versus >14 days) and mortality by adjusted hazard ratios (aHR) and 95% confidence intervals through Cox regression adjusted for immortal-time bias and confounding by indication, stratified by presence of complicated SAB (any of: endocarditis, implant, duration of SAB >2 days, fever >3 days). The primary outcome was 90-day all-cause mortality, and the secondary outcome was 90-day relapse. RESULTS: Between January 2010 and December 2015, we included 530 patients, of whom 94 out of 530 (17.7%) had methicillin-resistant SAB and 305 out of 530 (57.6%) had complicated SAB. Ninety-day mortality was 27.0% (143/530), with no significant trend across the study period; median time to death was 17 days (interquartile range (IQR) 8-30) after onset of SAB. Median DOT was 20 days (IQR 13-39). Patients with complicated SAB had significantly reduced mortality with DOT >14 days (aHR 0.32, 95% CI 0.16-0.64). DOT was not associated with mortality in patients with uncomplicated SAB (aHR 0.85; 0.41-1.78). Eighteen (18/530) patients (3.4%) relapsed; on univariate analysis, DOT was not associated with relapse (HR 1.01; 0.97-1.06). CONCLUSIONS: DOT >14 days is associated with higher survival in patients with complicated SAB, but not for patients with uncomplicated SAB. No association was found for relapse, but 90-day relapse was very low in this cohort. Importantly, 90-day mortality remained high across the study period.

Antibacterial efficacy of handrubbing for 15 versus 30 seconds: EN 1500-based randomized experimental study with different loads of Staphylococcus aureus and Escherichia coli.

OBJECTIVES: Compliance with the World Health Organization 'how to handrub' action is suboptimal. Simplifying the hand-hygiene action may improve practice. However, it is crucial to preserve antibacterial efficacy. We tested the non-inferiority of 15 versus 30 seconds handrubbing for Staphylococcus aureus and Escherichia coli contamination at different loads, using hand-size customized alcohol-based handrub (ABHR) volumes. METHODS: In an EN1500-based study, 18 health-care workers (HCWs) with extensive experience in hand hygiene rubbed hands with a hand-size customized volume of isopropanol 60% v/v. They repeated the following sequence: hand contamination (E. coli or S. aureus; broth containing 108 or 106 CFU/mL); baseline fingertips sampling; handrubbing (15 or 30 seconds); re-sampling. The main outcome was log10 CFU corrected reduction factor (cRF) on HCWs' hands, applying a generalized linear mixed model with a random intercept for subject. RESULTS: The median cRF was 2.1 log10 (interquartile range 1.50-3.10). After fitting the model, cRF was significantly higher for S. aureus compared with E. coli but there was no significant effect for duration of handrubbing or contamination fluid concentration. Fifteen seconds of handrubbing was non-inferior to 30 (-0.06 log10, 95% CI -0.34 to 0.22; EN1500 0.60 log10 non-inferiority margin). This was confirmed in all pre-specified subgroups. CONCLUSION: Among experienced HCWs using a hand-size customized volume of ABHR, handrubbing for 15 seconds was non-inferior to 30 seconds in reducing bacterial load, irrespective of type of bacteria or contamination fluid concentration. This provides further support for a shorter, 15-seconds, hand-hygiene action.

Impact of participation in a surgical site infection surveillance network: results from a large international cohort study.

BACKGROUND: Surveillance of surgical site infections (SSIs) is a core component of effective infection control practices, though its impact has not been quantified on a large scale. AIM: To determine the time-trend of SSI rates in surveillance networks. METHODS: SSI surveillance networks provided procedure-specific data on numbers of SSIs and operations, stratified by hospitals' year of participation in the surveillance, to capture length of participation as an exposure. Pooled and procedure-specific random-effects Poisson regression was performed to obtain yearly rate ratios (RRs) with 95% confidence intervals (CIs), and including surveillance network as random intercept. FINDINGS: Of 36 invited networks, 17 networks from 15 high-income countries across Asia, Australia and Europe participated in the study. Aggregated data on 17 surgical procedures (cardiovascular, digestive, gynaecological-obstetrical, neurosurgical, and orthopaedic) were collected, resulting in data concerning 5,831,737 operations and 113,166 SSIs. There was a significant decrease in overall SSI rates over surveillance time, resulting in a 35% reduction at the ninth (final) included year of surveillance (RR: 0.65; 95% CI: 0.63-0.67). There were large variations across procedure-specific trends, but strong consistent decreases were observed for colorectal surgery, herniorrhaphy, caesarean section, hip prosthesis, and knee prosthesis. CONCLUSION: In this large, international cohort study, pooled SSI rates were associated with a stable and sustainable decrease after joining an SSI surveillance network; a causal relationship is possible, although unproven. There was heterogeneity in procedure-specific trends. These findings support the pivotal role of surveillance in reducing infection rates and call for widespread implementation of hospital-based SSI surveillance in high-income countries.

Good epidemiological practice: a narrative review of appropriate scientific methods to evaluate the impact of antimicrobial stewardship interventions.

AIMS: In this narrative review, we provide a framework for assessing the quality of evidence provided by studies investigating antimicrobial stewardship (AMS) interventions, and inform the design and planning stage for future AMS evaluation studies to determine the best strategies to keep antimicrobial resistance at bay. SOURCES: Cochrane/Pubmed. CONTENT: As AMS is mostly applied in a complex, real-world setting, bias and random time effects can jeopardize the validity of causal inference. The most important risks include simultaneously implemented infection prevention strategies and regression to the mean. Inclusion of homogeneous intervention and control arms, through randomization of the intervention, can limit these risks. However, contamination can play an important role for AMS; therefore, randomization at cluster-level, instead of randomization at individual-level, is recommended. It can be challenging to identify enough representative clusters, and implementation of a cluster-RCT (cRCT) can be costly. Controlled interrupted time series (ITS) design has a high validity as well, and is relatively straightforward to implement, although time-varying confounding should be considered. Independent of the study design, it is crucial to include multiple process, clinical outcome, microbiological and financial measures, to be able to detect possible, unintended consequences. IMPLICATIONS: Future studies assessing the impact of new AMS strategies should produce compelling evidence by opting for cRCTs, or ITS including a control arm. Furthermore, a holistic view of intended and unintended consequences should be reported, and a detailed process evaluation should be provided to adequately inform implementation of successful AMS strategies to battle the rising burden of AMR.

The changing epidemiology of bacteraemias in Europe: trends from the European Antimicrobial Resistance Surveillance System.

We investigated bacteraemia trends for five major bacterial pathogens, Staphylococcus aureus, Escherichia coli, Streptococcus pneumoniae, Enterococcus faecalis and Enterococcus faecium, and determined how expanding antimicrobial resistance influenced the total burden of bacteraemias in Europe. Aetiological fractions of species and antibiotic phenotypes were extracted from the European Antimicrobial Resistance Surveillance System (EARSS) database for laboratories, which consistently reported between 2002 and 2008. Trend analyses used generalized linear models. Robustness of results was assessed by iterative analysis for different geographic regions. From 2002 to 2008, the overall number of reports increased annually by 6.4% (95% confidence interval (CI) 6.2-6.5%), from 46 095 to 67 876. In the subset of laboratories providing denominator information, the overall incidence increased from 0.58/1000 patient-days to 0.90/1000 patient-days (7.2% per year; 95% CI 6.9-7.5%). The frequency of reported bacteraemia isolates of S. aureus and Streptococcus pneumoniae increased moderately, while increase in E. coli and Enterococcus faecium was more pronounced. Bacteraemias caused by methicillin-resistant S. aureus increased until 2005 (7.6% per year; 95% CI 6.1-9.1%), and then decreased (-4.8% per year; 95% CI -6.1 to -3.5%), whereas the number attributable to methicillin-sensitive S. aureus increased continuously (3.4% per year; 95% CI 3.0-3.7). Increasing rates of E. coli were mainly caused by antibiotic-resistant phenotypes. Our data suggest that the burden of bacterial bloodstream infection has been increasing for all species during EARSS surveillance. Trends were mainly driven by resistant strains and clearly dissociated between resistant and susceptible isolates. It appears that infections with resistant clones add to rather than replace infections caused by susceptible bacteria. As a consequence, expansion of antibiotic resistance creates an additional strain on healthcare systems.

Burden of antimicrobial resistance in European hospitals: excess mortality and length of hospital stay associated with bloodstream infections due to Escherichia coli resistant to third-generation cephalosporins.

OBJECTIVES: This study determined excess mortality and length of hospital stay (LOS) attributable to bloodstream infection (BSI) caused by third-generation-cephalosporin-resistant Escherichia coli in Europe. METHODS: A prospective parallel matched cohort design was used. Cohort I consisted of patients with third-generation-cephalosporin-resistant E. coli BSI (REC) and cohort II consisted of patients with third-generation-cephalosporin-susceptible E. coli BSI (SEC). Patients in both cohorts were matched for LOS before infection with patients free of the respective BSI. Thirteen European tertiary care centres participated between July 2007 and June 2008. RESULTS: Cohort I consisted of 111 REC patients and 204 controls and cohort II consisted of 1110 SEC patients and 2084 controls. REC patients had a higher mortality at 30 days (adjusted odds ratio = 4.6) and a higher hospital mortality (adjusted hazard ratio = 5.7) than their controls. LOS was increased by 8 days. For SEC patients, these figures were adjusted odds ratio = 1.9, adjusted hazard ratio = 2.0 and excess LOS = 3 days. A 2.5 times [95% confidence interval (95% CI) 0.9-6.8] increase in all-cause mortality at 30 days and a 2.9 times (95% CI 1.2-6.9) increase in mortality during entire hospital stay as well as an excess LOS of 5 days (95% CI 0.4-10.2) could be attributed to resistance to third-generation cephalosporins in E. coli BSI. CONCLUSIONS: Morbidity and mortality attributable to third-generation-cephalosporin-resistant E. coli BSI is significant. If prevailing resistance trends continue, high societal and economic costs can be expected. Better management of infections caused by resistant E. coli is becoming essential.