Hand hygiene In the 2017 clinical practice guidelines for preventing C. difficile, IDSA states that HCWs “must” use gloves while caring for CDI patients, including when entering a room with a CDI patient. 57 In CDI outbreaks or hyperendemic settings (periods of persistently high levels of CDI), the guidelines include performing hand hygiene with soap and water before and after caring for a patient with CDI and after removing gloves. When working with CDI patients in routine or endemic situations, the guidelines recommend washing hands with soap and water or using alcohol-based hand rubs (ABHRs) for hand hygiene after removing gloves. While ABHRs are the preferred means of disinfecting hands for most pathogens, alcohol is not active against C. difficile spores, and it is believed that the most efficacious way to eliminate C. difficile is via the mechanical action of handwashing. Washing hands with soap and water is recommended after any contact with feces. The World Health Organization campaign, “My Five Moments for Hand Hygiene,” promotes hand hygiene at the following times: • Before touching a patient • Before clean/aseptic procedures • After body fluid exposure/risk • After touching a patient • After touching patient surroundings Use of proper handwashing technique is important for C. difficile spore removal. When handwashing is indicated, guidelines recommend vigorous and thorough washing of all surfaces for at least15 seconds. The entire process from start to finish should take between 40 and 60 seconds. This technique has been tested against unstructured and alternative techniques and found to be most effective at removing C. difficile spores. General CDC recommendations (for all HAIs) call for antibacterial soap over plain soap. However, in experimental studies, some researchers have found that plain soap is more effective for removing C. difficile spores. 58 This is one of several unresolved issues in hand hygiene for C. difficile. The CDC defines hand hygiene as a general term that applies to either handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. As such, glove use was not included in most of the reviewed studies. However, C. difficile hand hygiene recommendations strongly recommend the use of gloves. One study found that universal glove use (with emollients for skin care) at 78 percent compliance was more effective than standard contact precautions (use of gowns and gloves; 67% compliance) to avoid C. difficile transmission. 59 Health care workers (HCWs) should conduct hand hygiene before and after wearing gloves. Appropriate technique helps prevent potential hand contamination when removing gloves. Gloves should not be reused on more than one patient. Multiple studies have found C. difficile contamination on healthcare workers’ hands and several studies have linked cases of CDI and
CDI outbreaks to HCW transmission. Similarly, inadequate hand hygiene has been linked to higher incidence of CDI. A study that looked specifically at HCW hand contamination after contact with CDI patients found that 24% of HCW hands were contaminated with CDI (even when gloves were used in 356/386 of patient contacts). 60 In addition, contact without the use of gloves was independently associated with hand contamination (adjusted OR, 6.26; 95% CI, 1.27 to 30.78). Due to concern about HAI rates and poor HCW hand hygiene compliance, hand hygiene (including use of ABHRs) has been heavily promoted over the last two decades. But one systematic review found median hand hygiene compliance across 96 studies in a variety of healthcare settings was only 40%, and hand hygiene rates are potentially even lower at LTCFs. 61 Patient hand hygiene In the past decade, patient hand hygiene has received increasing attention as a potential major source of C. difficile transmission in healthcare settings. Patients colonized with C. difficile often go undetected and may transmit C. difficile to HCWs’ hands directly, or indirectly through contaminated surfaces in the healthcare environment. Patient mobility, dexterity, and cognitive limitations can be barriers to patient hand hygiene. One study found patient hand hygiene compliance rates as low as 10%. 62 Implementation Interventions to increase hand hygiene compliance in healthcare settings fall into five general intervention types: • Education • Facility design (installation of sinks and ABHRs) • Unit-level protocols and procedures It is recommended that hand hygiene education be interactive and engaging and that interventions be tailored to the institution’s unique needs. Researchers have assessed barriers to hand hygiene and report that hand hygiene interventions should be tailored to the particular classification/ role of staff and that context and staff needs should be taken into account when designing hand hygiene interventions. An interactive strategy to assist HCWs in improving glove and gown removal technique includes the use of fluorescent lotion. In the training described by Tomas et al. (2015), fluorescent lotions were used to help HCWs learn proper glove and gown removal to minimize hand contamination. 63 The fluorescent lotion provides immediate visual feedback on contaminated sites. A similar strategy includes the use of nonpathogenic RNA beads that fluoresce under ultraviolet (UV) light to help track contamination during removal of personal protective equipment. This practice can help HCWs see that glove use does not preclude the need for hand hygiene. • Hospital-wide programs • Multimodal interventions
The design of the healthcare environment can affect hand hygiene compliance. Some researchers suggest a human factors engineering approach that calls for abundant, convenient, and available sinks, handwashing products, and ABHRs to improve compliance. Several researchers found that longer distances to sinks, and sink visibility, were related to HCW handwashing compliance. Key findings • Gloves and handwashing with soap and water are the recommended hand hygiene practices for C. difficile prevention. • Multiple experimental studies show ABHRs are not effective in eliminating C. difficile spores. • Studies are needed that measure C. difficile - targeted hand hygiene initiatives, as well as financial outcomes, and hand hygiene programs in nonhospital settings. • Important contextual factors for CDI/hand hygiene include sink location, visibility, and accessibility. • Future directions for hand hygiene programs include patient hand hygiene, studies on glove compliance, electronic monitoring, and sustainable interventions. Infections due to other multidrug-resistant organisms Multidrug-resistant organisms (MDROs) are microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents. These include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci species (VRE), carbapenemase-producing Enterobacteriacea, and Gram-negative bacteria that produce extended spectrum beta-lactamases (ESBLs). These last two types of pathogens produce chemicals that allow them to resist the effect of certain antimicrobials, and this adaptation is easily passed between different species. Other species of note include MDR Escherichia coli and Klebsiella pneumoniae , Acinetobacter baumannii (abbreviated AB; some strains are resistant to all antimicrobial agents), and organisms such as Stenotrophomonas maltophilia that are intrinsically resistant to the broadest-spectrum antimicrobial agents. MDROs’ resistances limit treatment options for patients, making infection critical to preventing further harms. Background The World Health Organization (WHO) now recognizes that MDROs are a growing threat in every geographic region of the world. Drug- resistant bacteria pose a significant public health risk both domestically and abroad due to their ability to colonize individuals without causing symptoms, their endurance in the environment, and the clinical threat they pose. The growing presence of resistant microbes is of particular concern for vulnerable patients, such as those who have received organ transplantation, those with cancer, preterm infants, and immune-suppressed and other medically vulnerable individuals.
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