Improving adherence to hand hygiene practice: a multidisciplinary approach.

Hand hygiene prevents cross-infection in hospitals, but health-care workers' adherence to guidelines is poor. Easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol- based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating, and contribute to sustained improvement in compliance associated with decreased infection rates. This article reviews barriers to appropriate hand hygiene and risk factors for noncompliance and proposes strategies for promoting hand hygiene

Increasing Bacteremia Due to Coagulase-Negative Staphylococci: Fiction or Reality?

Abstract BACKGROUND: The role of coagulase-negative staphylococci (CNS) in bacteremias continues to be controversial. Until the 1970s, CNS were mostly recognized as contaminants, being part of the cutaneous flora. Since then, several studies have reported increasing incidence and severity of infections due to CNS. PURPOSE: To review the literature concerning the epidemiology of CNS bacteremia in the United States and Europe with reference to the multiple definitions of infection versus contamination, considering the effect of potential biases influencing the validity of the reported results. METHODS: Literature search of the MEDLINE database from January 1980 to February 1998. Studies with fewer than 500 episodes of bloodstream infections or fewer than 100 episodes of CNS bacteremia were not included in the pooled analysis. RESULTS: (1) CNS remain the most frequent contaminants (58%-83% of positive blood cultures); (2) the proportion of all bloodstream infections caused by CNS is increasing (R=.51); (3) the overall incidence of true CNS bacteremia is increasing (R=.54, P=.0014); (4) comparing the United States to Europe, there is an increasing trend in the incidence of nosocomial bacteremia due to CNS in the United States (R=.82, P=.0006), but no trend is seen in European studies; (5) the mortality associated with true CNS bacteremia varies between 4.9% and 28%. DISCUSSION: This review confirms the increasing importance of CNS bacteremias, measured both as a proportion and as an incidence of bloodstream infections. The contributions of several possible explanations for the incidence increase and the difference between the United States and Europe need further evaluation: (1) increased recognition and awareness of CNS infections among clinicians; (2) a gradual change in the definition of true bacteremia from an obligatory two positive blood cultures to one positive blood culture associated with a clinical picture compatible with infection; (3) a change in blood culture practices and techniques; (4) an increase in the numbers of blood cultures performed, which is reported both in the United States and in Europe; (5) a shift toward more elderly patients with increasingly severe underlying illnesses; and (6) increasing use of intravascular devices. CONCLUSIONS: The apparent trend of increasing CNS bacteremia seems to be valid. Whether there is a real difference between the United States and Europe concerning the increase of CNS bacteremia is difficult to establish due to the large number of confounding factors. Few studies take into account the number of blood cultures performed or the use of intravascular devices to adjust for the observed trends. Further on-site surveillance studies are needed to investigate the phenomenon more extensivel

Increasing the frequency of hand washing by healthcare workers does not lead to commensurate reductions in staphylococcal infection in a hospital ward

Hand hygiene is generally considered to be the most important measure that can be applied to prevent the spread of healthcare-associated infection (HAI). Continuous emphasis on this intervention has lead to the widespread opinion that HAI rates can be greatly reduced by increased hand hygiene compliance alone. However, this assumes that the effectiveness of hand hygiene is not constrained by other factors and that improved compliance in excess of a given level, in itself, will result in a commensurate reduction in the incidence of HAI. However, several researchers have found the law of diminishing returns to apply to hand hygiene, with the greatest benefits occurring in the first 20% or so of compliance, and others have demonstrated that poor cohorting of nursing staff profoundly influences the effectiveness of hand hygiene measures. Collectively, these findings raise intriguing questions about the extent to which increasing compliance alone can further reduce rates of HAI. In order to investigate these issues further, we constructed a deterministic Ross-Macdonald model and applied it to a hypothetical general medical ward. In this model the transmission of staphylococcal infection was assumed to occur after contact with the transiently colonized hands of HCWs, who, in turn, acquire contamination only by touching colonized patients. The aim of the study was to evaluate the impact of imperfect hand cleansing on the transmission of staphylococcal infection and to identify, whether there is a limit, above which further hand hygiene compliance is unlikely to be of benefit. The model demonstrated that if transmission is solely via the hands of HCWs, it should, under most circumstances, be possible to prevent outbreaks of staphylococcal infection from occurring at a hand cleansing frequencies <50%, even with imperfect hand hygiene. The analysis also indicated that the relationship between hand cleansing efficacy and frequency is not linear - as efficacy decreases, so the hand cleansing frequency required to ensure R0<1 increases disproportionately. Although our study confirmed hand hygiene to be an effective control measure, it demonstrated that the law of diminishing returns applies, with the greatest benefit derived from the first 20% or so of compliance. Indeed, our analysis suggests that there is little benefit to be accrued from very high levels of hand cleansing and that in most situations compliance >40% should be enough to prevent outbreaks of staphylococcal infection occurring, if transmission is solely via the hands of HCWs. Furthermore we identified a non-linear relationship between hand cleansing efficacy and frequency, suggesting that it is important to maximise the efficacy of the hand cleansing process

The effect of surveillance and appreciative inquiry on puerperal infections : a longitudinal cohort study in India

Peer reviewedPublisher PD

Azathioprine and 6-Mercaptopurine use in the Swiss IBD cohort : adverse effects, causes of discontinuation and risk of "flares" according to 6-TG levels

Background: To characterize and analyze in the Swiss IBD Cohort: a) reported Azathioprine (AZA) and 6-Mercaptopurine (6-MP) adverse effects (AE), b) causes of discontinuation and c) response to therapy according to gastroenterologists' clinical judgment, d) whether level of 6-TGN &lt; 235pmol/8 x108 red blood cells (RBC) is associated with a higher risk of "flare" occurrence. Methods: Retrospective statistical description, Cox model and Kaplan-Meier survival estimation. Results: 1499 patients with Crohn's Disease (CD) and 1066 with Ulcerative colitis (UC)