MJA
MJA

Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection

Med J Aust 2005; 183 (10): 509-514.

Summary

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.

Please login with your free MJA account to view this article in full

  • Paul D R Johnson1
  • Rhea Martin2
  • Laurelle J Burrell3
  • Elizabeth A Grabsch4
  • Susan W Kirsa5
  • Jason O’Keeffe6
  • Barrie C Mayall7
  • Deidre Edmonds8
  • Wendy Barr9
  • Christopher Bolger10
  • Humsha Naidoo11
  • M Lindsay Grayson12

  • Austin Health, Heidelberg, VIC.

Correspondence: 

Acknowledgements: 

We thank Sara Elkerton from pharmacy for assistance with product useage data and Courtney Thornely, Natalie Plumbley and Shirley Xie from Microbiology for assistance with MRSA screening.

Competing interests:

DeBug™ (a trademark for the hand hygiene product referred to in this article) was developed by the authors (employees of Austin Health) with funding in part from the Victorian Department of Human Services. The intellectual property for this development is held by Austin Health, which handles all patent, trademark and licensing issues. Austin Health, but no individual author, receives a small income stream from the sale of DeBug™.

  • 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.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article