Objective: To assess the effect of a multifaceted hand hygiene culture-change program on health care worker behaviour, and to reduce the burden of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infections.
Design and setting: Timetabled introduction of interventions (alcohol/chlorhexidine hand hygiene solution [ACHRS], improved cleaning of shared ward equipment, targeted patient decolonisation, comprehensive “culture change” package) to five clinical areas of a large university teaching hospital that had high levels of MRSA.
Main outcome measures: Health care worker hand hygiene compliance; volume of ACHRS used; prevalence of patient and health care worker MRSA colonisation; environmental MRSA contamination; rates of clinical MRSA infection; and rates of laboratory detection of ESBL-producing Escherichia coli and Klebsiella spp.
Results: In study wards, health care worker hand hygiene compliance improved from a pre-intervention mean of 21% (95% CI, 20.3%–22.9%) to 42% (95% CI, 40.2%–43.8%) 12 months post-intervention (P < 0.001). ACHRS use increased from 5.7 to 28.6 L/1000 bed-days. No change was observed in patient MRSA colonisation or environmental colonisation/contamination, and, except in the intensive care unit, colonisation of health care workers was unchanged. Thirty-six months post-intervention, there had been significant reductions in hospital-wide rates of total clinical MRSA isolates (40% reduction; P < 0.001), patient-episodes of MRSA bacteraemia (57% reduction; P = 0.01), and clinical isolates of ESBL-producing E. coli and Klebsiella spp (90% reduction; P < 0.001).
Conclusions: Introduction of ACHRS and a detailed culture-change program was effective in improving hand hygiene compliance and reducing nosocomial MRSA infections, despite high-level MRSA endemicity.
- 1. Kopp BJ, Nix DE, Armstrong EP. Clinical and economic analysis of methicillin-susceptible and -resistant Staphlococcus aureus infections. Ann Pharmacother 2004; 38: 1377-1382.
- 2. McHugh CG, Riley LW. Risk factors and costs associated with methicillin-resistant Staphylococcus aureus bloodstream infections. Infect Control Hosp Epidemiol 2004; 25: 425-430.
- 3. Engemann JJ, Carmeli Y, Cosgrove SE, et al. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003; 36: 592-598.
- 4. Selvey LA, Whitby M, Johnson B. Nosocomial methicillin-resistant Staphylococcus aureus bacteremia: is it any worse than nosocomial methicillin-sensitive Staphylococcus aureus bacteremia? Infect Control Hosp Epidemiol 2000; 21: 645-648.
- 5. Abramson MA, Sexton DJ. Nosocomial methicillin-resistant and methicillin-susceptible Staphylococcus aureus primary bacteremia: at what costs? Infect Control Hosp Epidemiol 1999; 20: 408-411.
- 6. Whitby M, McLaws ML, Berry G. Risk of death from methicillin-resistant Staphylococcus aureus bacteraemia: a meta-analysis. Med J Aust 2001; 175: 264-267.
- 7. Boyce JM. MRSA patients: proven methods to treat colonization and infection. J Hosp Infect 2001; 48: S9-S14.
- 8. Farr BM. Methicillin-resistant Staphylococcus aureus infections. Curr Infect Dis Rep 1999; 1: 328-333.
- 9. Boyce JM, Potter-Bynoe G, Chenevert C, King T. Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications. Infect Control Hosp Epidemiol 1997; 18: 622-627.
- 10. Oie S, Hosokawa I, Kamiya A. Contamination of room door handles by methicillin-sensitive/methicillin-resistant Staphylococcus aureus. J Hosp Infect 2002; 51: 140-143.
- 11. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000; 356: 1307-1312.
- 12. Boyce JM, Pittet D. 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. Society for Healthcare Epidemiology of America/Association for Professionals in Infection. Control/Infectious Diseases Society of America. MMWR Morb Mortal Wkly Rep 2002; 51: 1-45.
- 13. Turnidge JD, Nimmo GR, Francis G. Evolution of resistance in Staphylococcus aureus in Australian teaching hospitals. Australian Group on Antimicrobial Resistance (AGAR). Med J Aust 1996; 164: 68-71.
- 14. McLaws ML, Murphy C, Whitby M. Standardising surveillance of nosocomial infections: the HISS program. Hospital Infection Standardised Surveillance. J Qual Clin Pract 2000; 20: 6-11.
- 15. Pittet D, Boyce JM. Revolutionising hand hygiene in health-care settings: guidelines revisited. Lancet Infect Dis 2003; 3: 269-270.
- 16. Graham M, Nixon R, Burrell LJ, et al. Low rates of cutaneous adverse reactions to alcohol-based hand hygiene solution during prolonged use in a large teaching hospital. Antimicrob Agents Chemother 2005; 49: 4404-4405.
- 17. Brown TL, Burrell LJ, Edmonds D, et al. Hand-hygiene: a standardised tool for assessing compliance. Aust Infect Control 2005; 10: 51-58.
- 18. Murray PR, Baron EJ, Jorgensen JH, et al, editors. Manual of clinical microbiology. 8th ed. Herndon, VA: American Society for Microbiology, 2003.
- 19. Performance standards for antimicrobial susceptibility testing: fourteenth informational supplement document. NCCLS document MS100-S14. Wayne, PA: Clinical and Laboratory Standards Institute, 2004.
- 20. Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 2002; 27: 299-309.
- 21. Tomic V, Svetina Sorli P, Trinkaus D, et al. Comprehensive strategy to prevent nosocomial spread of methicillin-resistant Staphylococcus aureus in a highly endemic setting. Arch Intern Med 2004; 164: 2038-2043.
- 22. Silvestri L, Petros AJ, Sarginson RE, et al. Handwashing in the intensive care unit: a big measure with modest effects. J Hosp Infect 2005; 59: 172-179.
- 23. Tvedt C, Bukholm G. Alcohol-based hand disinfection: a more robust hand-hygiene method in an intensive care unit. J Hosp Infect 2005; 59: 229-234.
- 24. Verhoef J, Beaujean D, Blok H, et al. A Dutch approach to methicillin-resistant Staphylococcus aureus. Eur J Clin Microbiol Infect Dis 1999; 18: 461-466.
- 25. British Society for Antimicrobial Chemotherapy, Hospital Infection Society, Infection Control Nurses Association. Revised guidelines for the control of methicillin-resistant Staphylococcus aureus infection in hospitals. J Hosp Infect 1998; 39: 253-290.
- 26. Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals, part II: recommendations for isolation precautions in hospitals. Am J Infect Control 1996; 24: 32-52.
- 27. Cepeda JA, Whitehouse T, Cooper B, et al. Isolation of patients in single rooms or cohorts to reduce spread of MRSA in intensive-care units: prospective two-centre study. Lancet 2005; 365: 295-304.
- 28. Huskins WC, Goldmann DA. Controlling methicillin-resistant Staphylococcus aureus, aka “Superbug”. Lancet 2005; 365: 273-275.
- 29. Harbarth S, Martin Y, Rohner P, et al. Effect of delayed infection control measures on a hospital outbreak of methicillin-resistant Staphylococcus aureus. J Hosp Infect 2000; 46: 43-49.
- 30. Collignon P, Nimmo GR, Gottlieb T, Gosbell IB, Australian Group on Antimicrobial Resistance. Staphylococcus aureus bacteremia, Australia. Emerg Infect Dis 2005; 11: 554-561.
- 31. Abramson MA, Sexton DJ. Nosocomial methicillin-resistant and methicillin-susceptible Staphylococcus aureus primary bacteremia: at what costs? Infect Control Hosp Epidemiol 1999; 20: 408-411.
- 32. Semmelweis IF, Carter KC. The etiology, concept, and prophylaxis of childbed fever. Madison, WI: University of Wisconsin Press, 1983.
- 33. Wimer AF. Replace hand washing with use of a waterless alcohol hand rub? Clin Infect Dis 2000; 31: 136-143.
- 34. Zaragoza M, Salles M, Gomez J, et al. Handwashing with soap or alcoholic solutions? A randomized clinical trial of its effectiveness. Am J Infect Control 1999; 27: 258-261.
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