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The Influence of Role Models and Hand Hygiene.  Feb 2007   We assessed the effect of medical staff role models and the number of health-care worker sinks on hand-hygiene compliance before and after construction of a new hospital designed for increased access to handwashing sinks. We observed health-care worker hand hygiene in four nursing units that provided similar patient care in both the old and new hospitals: medical and surgical intensive care, hematology/oncology, and solid organ transplant units. Of 721 hand-hygiene opportunities, 304 (42%) were observed in the old hospital and 417 (58%) in the new hospital. Hand-hygiene compliance was significantly better in the old hospital (161/304; 53%) compared to the new hospital (97/417; 23.3%) (p<0.001). Health-care workers in a room with a senior (e.g., higher ranking) medical staff person or peer who did not wash hands were significantly less likely to wash their own hands (odds ratio 0.2; confidence interval 0.1 to 0.5); p<0.001). Our results suggest that health-care worker hand-hygiene compliance is influenced significantly by the behavior of other health-care workers. An increased number of hand-washing sinks, as a sole measure, did not increase hand-hygiene compliance. b77

Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach Feb 2007.  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.  b80

Improving Adherence to Hand Hygiene Practice, a MultiDis

Would Active Surveillance Cultures Heop Control Healthcare-related Methicillin Resistant Staphylococcus aureus Infections?  Barry M. Farr, MD, Msc University of Virginia Health System; William R. Jarvis, MD Centers for Disease Control and Prevention, Atlanta Ga b84

The CDC Healthcare Infection Control Practices Advisory Committee has issued a guidance to help state legislators implement public reporting bills. The Committee report states these minimal recommendations should be viewed as the first steps to giving consumers information about hospital-acquired infections.  [Doc54]

Why Don't I Wash My Hands Between Patient Contacts:  The editorial on hand washing calls for all hospital staff to start regularly washing their hands between each patient contact.1 If, as the authors claim, there is such compelling evidence for the need to wash hands between each patient contact then why do I and the vast majority of my colleagues not do it?  Firstly, I have never seen any convincing evidence that hand washing between each patient contact reduces infection rates. ... b81

Healthcare workers washed their hands on only a third of occasions:  We agree with the Handwashing Liaison Group that an explicit standard for hand washing needs to be set and that hand washing should be regarded as part of the normal duty of care.1 The group states that "it has even been suggested that patients should be encouraged to ask carers to wash their hands." We carried out a handwashing study on a busy general surgical ward in which patients were specifically requested to do this.

After studying an information sheet and giving written consent each patient was given a yellow card; they were asked to show this to healthcare workers if they had not seen them wash their hands before approaching them. The card read: "Please wash or disinfect your hands before and after contact with me or my environment." Read this letter b82

Hand Washing Laison Group- This is a must read editorial for everyone interested in Hand Hygiene. and the health care setting.  Great discussion of behavorial studies of why doctors do not wash their hands.b83


Fast Facts about Hospital-Acquired Infections [Doc58]  

Myth:  Hospitals keep you safe from Germs.  Hospital Infections are the fourth leading cause of death b78

The Impact of Hospital-Acquired Bloodstream Infections a CDC Special Report; Wenzel; Emerging Infectious Diseases; Vol 7 #2 March-April 2001.  Nosocomial bloodstream infections are a leading cause of death in the United States. If we assume a nosocomial infection rate of 5%, of which 10% are bloodstream infections, and an attributable mortality rate of 15%, bloodstream infections would represent the eighth leading cause of death in the United States.  Because most risk factors for dying after bacteremia or fungemia may not be changeable, prevention efforts must focus on new infection-control technology and techniques. b79

CDC Oct 25, 2002. Hand Hygiene in Healthcare Settings. CDC Media Relations.  "CDC releases new hand-hygiene guidelines"  b41

Hygiene of the Skin: When Is Clean Too Clean?  b73 We have found claims on the internet that whole body cleansing before surgery will reduce the risk of surgical site infections SSI.  We looked at many studies and found little evidence that whole body cleansing is beneficial.  This article does a good job of summarizing the evidence.  Of particular interest to us is the reference to immuno suppressed patients and the benefit of whole body cleansing and reduction of the Staphylococcus aureus acquisition rates.

World Health Organization - Prevention of hospital-acquired infections, a Practical Guide second edition b69

Pittet D., Mourouga P., Perneger T. V., and members of the Infection Control Program. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126-130.  Largest and most sophisticated observational study of handwashing compliance of healthcare workers, involving more than 2800 observations and multivariate analysis.  Factors associated with poor compliance included being a physician, working weekdays or in an intensive care unit, performing procedures with a high risk of contamination, and when workloads were high (high intensity of care).  In 2834 observed opportunities for handwashing, average compliance was 48%. In multivariate analysis.  These factors need to be considered when designing programs to promote improved hand hygiene.  b34

Pittet D., Hugonnet S., Harbarth S., Mourouga P., Sauvan V., and Touveneau S. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307-1312.  A 4-year study of the impact of implementing a multidisciplinary hand hygiene promotional campaign on hand hygiene compliance.  The campaign included administrative support, use of “talking walls” (posting color cartoons), promoting use of an alcohol hand rinse, surveys of compliance, and feedback of compliance rates to healthcare workers.  Compliance steadily increased (due primarily to increased use of alcohol hand antisepsis), and the prevalence of nosocomial infections decreased, as did the incidence of MRSA colonization/infection.  b36

Berndt U., Wigger-Alberti W., Gabard B., and Elsner P. Efficacy of a barrier cream and its vehicle as protective measures against occupational irritant contact dermatitis. Contact Dermatitis 2000;42:77-80.  A randomized, double-blinded trial demonstrating the benefit of regular and frequent application of skin cream on the condition of nurses’ hands.  B1

Bischoff W. E., Reynolds T. M., Sessler C. N., Edmond M. B., and Wenzel R. P. Handwashing compliance by health care workers. The impact of introducing an accessible, alcohol-based hand antiseptic.  Arch Intern Med 2000;160:1017-1021.  A 6-month prospective observational study of hand hygiene compliance before and after introduction of an alcohol hand rub in two intensive care units. Hand hygiene compliance increased significantly after the alcohol hand rub was made available. 

Bonten M. J. M., Hayden M. K., Nathan C., VanVoorhis J., Matushek M., Slaughter S., Rice T., and Weinstein R. A. Epidemiology of colonisation of patients and environment with vancomycin-resistant enterococci. Lancet 1996;348:1615-1619.  Culture survey revealing that patients with VRE frequently carry the organism on healthy, intact skin above the waist and on their upper extremities – a potential source of contamination of healthcare worker hands.  B3

Boyce J. M., Potter-Bynoe G., Chenevert C., and King T. Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications. Infect Control Hosp Epidemiol 1997;18:622-627.  Culture survey demonstrating that environmental surfaces in the rooms of patients with MRSA are frequently contaminated with the organism, and may represent a source of contamination of healthcare worker hands.  B4

Boyce J. M., Kelliher S., and Vallande N. Skin irritation and dryness associated with two hand hygiene regimens: soap and water handwashing versus hand antisepsis with an alcoholic hand gel. Infect Control Hosp Epidemiol 2000;21:442-448.  Prospective, randomized clinical trial comparing the impact of soap and water handwashing versus hand antisepsis with an alcohol hand gel on condition of nurses’ hands.  Objective measurements and visual assessments of nurses’ hands documented that nurses experienced significantly less skin dryness when using the alcohol hand gel.  B5

Boyce J. M. Antiseptic techology:access, affordability and acceptance. Emerg Infect Diseases 2001;7:231-233.  Review of the importance of easy accessibility and skin compatibility of hand hygiene agents.  Costs of hand hygiene agents are compared to those associated with nosocomial infections. B6

Boyce J. M., Pittet D., and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Hand hygiene guideline for healthcare settings. MMWR 2002;51(RR-16):1-45.  New evidence-based hand hygiene guidelines for healthcare facilities, developed by the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.  Includes extensive literature review and recommendations on new strategies for improving hand hygiene practices among healthcare workers, including greater use of alcohol-based hand rubs.  B7

Casewell M. and Phillips I. Hands as route of transmission for Klebsiella species. Br Med J 1977;2:1315-1317.  Study showing how nurses may contaminate their hands when touching normal, intact areas of patients’ skin.  Nosocomial infection rates decreased with increasing handwashing.  B8

Cohen B., Saiman L., Cimiotti J. and Larson E.  Factors associated with hand hygiene practices in two neonatal intensive care units.  Pediatr Infect Dis 2003;22:494-9.   NEW  Investigators observed over 1400 episodes in which healthcare workers had varying levels of contact with neonates or their immediate environment.  Only 23% of episodes were performed with cleaned and/or newly gloved hands.  Direct touching of neonates or their immediate environment was performed more often in the NICU using an alcohol-based hand rub.  B9 source

Doebbeling B. N., Pfaller M. A., Houston A. K., and Wenzel R. P. Removal of nosocomial pathogens from the contaminated glove. Ann Intern Med 1988;109:394-398.  Study showing the ability of bacteria to penetrate gloves and contaminate hands of volunteers.  Emphasizes the need to clean hands after glove removal  B10 .

Earl M. Improved rates of compliance with hand antisepsis guidelines. Am J Nursing 2001;101:26-33.  Prospective observational study which documented that hand antisepsis rates improved after an easily accessible alcohol hand gel was made available in two intensive care units.  B11 source

Ehrenkranz N. J. and Alfonso B. C. Failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters. Infect Control Hosp Epidemiol 1991;12:654-662.  Innovative clinical study which found that nurses who contaminated their hands by touching patients transferred the patient’s flora to urinary catheter material despite washing their hands with plain soap and water. In contrast, alcohol hand disinfection prevented transfer of organisms in most experiments. b12

Foca M., Jakob K., Whittier S., Della Latta P., Factor S., Rubenstein D., and Saiman L. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med 2000;343:695-700.  Nosocomial infections due to Pseudomonas aeruginosa have been well described, but the environmental reservoir of the organism varies. We conducted an epidemiologic and molecular investigation of endemic P. aeruginosa infection among infants in a neonatal intensive care unit that was associated with carriage of the organisms on the hands of health care workers. B39

Foca M., Jakob K., Whittier S., Della Latta P., Factor S., Rubenstein D., and Saiman L. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med 2000;343:695-700.  An outbreak investigation which implicated healthcare workers who wore artificial fingernails or had onychomycosis as a source of P. aeruginosa acquired by infants in a NICU.  b13

Fox M. K., Langner S. B., and Wells R. W. How good are hand washing practices? Am J Nursing 1974;74:1676-1678.  An observational study of handwashing technique among 90 nursing personnel found that breaks in technique were common, and duration of handwashing was too short.  b14

Garner J. S.  Guideline for isolation in hospitals.  The Hospital Infection Control Practices Advisory Committee.  Infect Control Hosp Epidemiol 1996;17:53-80.  Isolation guidelines, which include a recommendation to either wash hands with an antiseptic soap or use a waterless antiseptic agent (e.g., an alcohol-based hand rub) for cleaning hands after caring for patients with multi-drug resistant pathogensb15

Girou E, Loyeau S, Legrand P, et al.  Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial.  B Med J 2002;325:362-366.  Unlike many laboratory-based studies, this ward-based study involved healthcare workers who were caring for ICU patients.  Their hands were cultured before and after cleaning their’ hands with either antimicrobial soap or an alcohol-based hand rinse.  The authors found that the alcohol hand rinse reduced bacterial counts on the hands of personnel significantly better than handwashing.  b16

Korniewicz D. M., Laughon B. E., and Butz A. Integrity of vinyl and latex procedures gloves. Nurs Res 1989;38:144-146.  Study showing that Serratia marcescens was able to penetrate vinyl gloves more frequently than latex gloves under conditions simulating clinical use.  Emphasizes the need to clean hands after removing gloves.  b17

Kretzer E. K. and Larson E. L. Behavioral interventions to improve infection control practices. Am J Infect Control 1998;26:245-253.  Excellent review article of behavioral theories that should be considered when developing new programs to modify handwashing habits of healthcare personnel.  b18

Lankford M.G, Zembower T.R., Trick W.E., Hacek D.M., Noskin G.A., and Peterson L.R.  Influence of role models and hospital design on hand hygiene of health care workers.  Emerging Infect Dis 2003;9:217-23.   NEW  Adherence of healthcare workers to recommended hand hygiene procedures was observed in an old hospital and subsequently in a new hospital with improved access to sinks. Surprisingly, adherence was lower in the new hospital. Factors associated with greater hand hygiene adherence included glove use, performing an invasive procedure and having patient contact.  Adherence was lower when a high-ranking healthcare worker in the room did not wash his/her hands, suggesting that role models may influence hand hygiene habits among healthcare workers.  b19

Larson E. and Killien M. Factors influencing handwashing behavior of patient care personnel. Am J Infect Control 1982;10:93-99.  One of the early questionnaire studies of healthcare worker attitudes affecting handwashing practices.  Issues raised by the paper are still very pertinent today.  b20

Larson E., Silberger M., Jakob K., Whittier S., Lai L., Della Latta P., and Saiman L. Assessment of alternative hand hygiene regimens to improve skin health among neonatal intensive care unit nurses. Heart Lung 2000;29:136-142.  A prospective, randomized trial which found that using a mild soap for cleaning and an alcohol rinse for degerming hands produced less skin damage than washing hands with chlorhexidine-containing soap.  b21

Larson E. L., Eke P. I., and Laughon B. E. Efficacy of alcohol-based hand rinses under frequent-use conditions. Antimicrob Agents Chemother 1986;30:542-544.  Laboratory-based study involving volunteers who cleaned their hands 15 times a day for 5 days with either a non-antimicrobial soap, a 4% CHG-based detergent, or one of 3 alcohol-based hand rinses.  The alcohol-based products were highly efficacious.  b22

Larson E. L., Early E., Cloonan P., Sugrue S., and Parides M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behavioral Medicine 2000;26:14-22.  An intervention trial demonstrating that implementation of a multidisciplinary program (including administrative support, recruitment of role models, and involvement by nursing managers) can improved handwashing frequency and lower nosocomial infections.  Comparable improvements did not occur in the control hospital.  b23

Lucet JC, Rigaud MP, Mentre F, et al.  Hand contamination before and after different hand hygiene techniques: a randomized clinical trial.  J Hosp Infection 2002;50:276-280.  This study involved healthcare workers whose hands became contaminated while performing a variety of common patient care activities.  The authors demonstrated that both handwashing with an antimicrobial soap and hand disinfection with an alcohol-based hand rinse reduced bacterial counts on the hands of personnel significantly better than washing hands with plain soap. The greatest log reductions in bacterial counts occurred with the alcohol-based hand rinse.  b24

Maury E., Alzieu M., Baudel J. L., and Haram N. Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit. Am J Respir Crit Care Med 2000;162:324-327.  A prospective intervention trial of conventional handwashing (period 1) versus alcohol hand rub or conventional handwashing (period 2).  Compliance of healthcare workers with recommended hand hygiene practices improved when the alcohol hand rub was available (period 2).  b25

McFarland L. V., Mulligan M. E., Kwok R. Y. Y., and Stamm W. E. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989;320:204-210.  Elegant epidemiological study of C. difficile transmission, demonstrating the frequency of environmental contamination, contamination of care giver hands during minor patient care activities, the protective effect of gloves, and the value of washing hands with an antiseptic agent.  b26

McGuckin M., Waterman R., Storr J., Bowler I. C. J. W., Ashby M., Topley K., and Porten L. Evaluation of a patient-empowering hand hygiene programme in the U.K. J Hosp Infect 2001;48:222-227.  MUST SEE  Partners in Your Care, a patient education behavioral model for increasing handwashing compliance and empowering the patient with responsibility for their care was evaluated in an acute care hospital in Oxford, UK.  b27

Moolenaar R. L., Crutcher M., San Joaquin V. H., Sewell L. V., Hutwagner L. C., Carson L. A., Robison D. A., Smithee L. M., and Jarvis W. R. A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol 2000;21:80-85.  Outbreak investigation found that neonates who acquired Pseudomonas were significantly more likely to have been exposed to two nurses with Pseudomonas hand colonization.  One nurse had long natural nails and the other had long artificial nails, suggesting a possible role of long or artificial fingernails in colonization of hands with Pseudomonas.  b28 

Mortimer E. A., Lipsitz P.J., Wolinsky E. et al.  Transmission of staphylococci between newborns.  Am J Dis Child 1962;104:289-295.  Prospective, controlled clinical trial comparing the influence of no handwashing versus  washing with hexachlorophene soap on acquisition of S. aureus by infants in a nursery.  Infants cared for by nurses who did not wash their hands between patients acquired S. aureus significantly more often and more rapidly than infants cared for by nurses who washed with an antiseptic soap between patient contacts. Compelling evidence that handwashing with an antiseptic soap reduces transmission of pathogenic microorganisms.  b29

Muto C. A., Sistrom M. G., and Farr B. M. Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic. Am J Infect Control 2000;28:273-276.  Intervention trial showing that a brief educational program and making an alcohol hand gel available on wards does not necessarily lead to sustained improvement in hand hygiene compliance of healthcare workers.  Compliance of physicians was greatly affected by the level of compliance by attending physicians on the ward.  More long-term, multidisciplinary  programs to promote hand hygiene are necessary.  b30

Olsen R. J., Lynch P., Coyle M. B., Cummings J., Bokete T., and Stamm W. E. Examination gloves as barriers to hand contamination in clinical practice. JAMA 1993;270:350-353.  Observational study demonstrating that healthcare workers contaminated their hands with patient skin flora despite wearing gloves during patient contact, presumably via tiny holes in gloves or by contaminating their hands when removing gloves. Emphasizes the need to clean hands after glove removal.  b31

Passaro D. J., Waring L., Armstrong R., Bolding F., Bouvier B., Rosenberg J., Reingold A. W., McQuitty M., Philpott S. M., Jarvis W. R., Werner S. B., Tompkins L. S., and Vugia D. J. Postoperative Serratia marcescens wound infections traced to an out-of-hospital source. J Infect Dis 1997;175:992-995.  An epidemiologic investigation implicated a  nurse who wore artificial fingernails as the probable source of an outbreak of surgical site infections.  Although cultures of the nurse’s hands were negative, the outbreak strain was recovered from a jar of exfoliant cream in the nurse’s home. Removal of the cream ended the outbreak. b32

Pittet D., Dharan S., Touveneau S., Sauvan V., and Perneger T. V. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med 1999;159:821-826.  A clinical study showing that bacterial contamination of healthcare worker hands increased with the time spent caring for patients with ungloved hands, especially during direct patient contact, respiratory care, handling body secretions, and interruptions in the sequence of patient care.  Wearing gloves reduced hand contamination.  Washing hands with non-medicated soap before patient care resulted in significantly higher bacterial counts on the hands than using an alcohol hand rinse.  b33

Pittet D, Stephan F., Hugonnet S., Akakpo C., Souweine B., and Clergue F.  Hand-cleansing during postanesthesia care.  Anesthesiology 2003;99:530-35.   NEW  A prospective observational studied found that hand hygiene compliance was only 20% among personnel caring for patients admitted to a postanesthesia care unit.  Caring for patients greater than 65 years old, those recovering from clean/clean-contaminated surgery, and a high intensity of care were independent factors associated with non-compliance. b40

Tenorio A. R., Badri S. M., Sahgal N. B., Hota B., Matushek M., Hayden M. K., Trenholme G. M., and Weinstein R. A. Effectiveness of gloves in preventing personnel handcarriage of vancomycin-resistant enterococcus (VRE) after patient care. Clin Infect Dis 2001;32:826-829.  Prospective study of the ability of gloves to prevent healthcare workers from contaminating their hands with VRE during routine patient care.  About 40% of personnel contaminated their gloves with VRE when caring for affected patients, and 29% of those with contaminated gloves had the same strain on their hands after glove removal.  The study illustrates the need to cleanse hands after glove removal.  b42

Trick W.E., Vernon M.O., Hayes R.A., Nathan C., Rice T.W., Peterson B.J., Segreti J., Welbel S.F., Solomon S.L. and Weinstein R.A.  Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital.  Clin Infect Dis 2003;36:1383-90.   NEW  A prospective study found that wearing rings was associated with a 10-fold greater counts of organisms on hands, with pathogens such as S. aureus, gram-negative bacillin and yeast.  Contamination increased with the number of rings worn.  Use of an alcohol-based hand rub reduced hand contamination significantly better than a medicated hand wipe. b43

Voss A. and Widmer A. F. No time for handwashing!?  Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol 1997;18:205-208.  Investigators documented that it took intensive care nurses an average of 62 seconds to walk to a sink, wash hands, and return to patient care.  A model based on varying levels of hand hygiene compliance of nurses revealed that handwashing required four times more nursing time than using an alcohol hand rub available at patient bedsides. The authors suggested that replacing handwashing with alcohol hand disinfection might lead to improved hand hygiene compliance.  b37

Zimakoff J., Kjelsberg A. B., Larsen S. O., and Holstein B. A multicenter questionnaire investigation of attitudes toward hand hygiene, assessed by the staff in fifteen hospitals in Denmark and Norway. Am J Infect Control 1992;20:58-64.  A questionnaire study involving more than 2500 healthcare workers in Scandinavia lists factors that personnel felt promoted hand hygiene and those which interfered with hand hygiene.  Highlights behavioral issues that need to be considered when designing campaigns to improve hand hygiene compliance. b38

Singapore Med J. 1998 Jul;39(7):319-23. Reduction of nosocomial infection in a neonatal intensive care unit (NICU).  The aim of this study was to evaluate the impact of these measures on the incidence of nosocomial infection in our NICU B35

JAMA.   Control of endemic methicillin-resistant Staphylococcus aureus: a cost-benefit analysis in an intensive care unit.  1999 Nov 10;282(18):1745-51.  Despite the success of some countries in controlling endemic methicillin-resistant Staphylococcus aureus (MRSA), such programs have not been implemented for some hospitals with endemic infection because of concerns that these programs would be costly and of limited benefit. B44 

Aust N Z J Surg.   A prospective survey of current methicillin-resistant Staphylococcus aureus control measures. 1999 Oct;69(10):712-6 Methicillin-resistant Staphylococcus aureus (MRSA) is now endemic in tertiary referral hospitals among the developed world. By prospective survey, the effect of two measures aimed to reduce the spread of MRSA was determined. First, a surgical ward with persistently high levels of MRSA detection was cleaned and renovated. Second, the medical records of all MRSA-colonized patients were electronically flagged  B45

Infect Control Hosp Epidemiol. Control of methicillin-resistant Staphylococcus aureus at a university hospital: one decade later.  1995 Dec;16(12):686-96.  To investigate the cause of increasing rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection at a university hospital. DESIGN: Review of data collected by prospective hospital wide surveillance regarding rates of nosocomial MRSA colonization and infection.  B46

Nippon Koshu Eisei Zasshi. A study on the transmission of MRSA among the family members including clients of visiting nurse and related infection control.  2001 Mar;48(3):190-9.  The purpose of the study was to clarify MRSA (methicillin-resistant Staphylococcus aureus) transmission among clients, receiving nursing care from visiting nurse stations, and family members, as well as to determine MRSA positive rates of visiting nurses themselves and their handwashing habits. METHODS: The subjects were 131 clients who had utilized 32 visiting nurse stations, and had tested MRSA positive in our previous study performed 2-5 months earlier. B47

Infez Med. 2001 Evaluation of the efficacy of a program to control nosocomial spread of methicillin-resistant Staphylococcus aureus.  Sep;9(3):163-9.  To evaluate the efficacy of a program to control nosocomial spread of methicillin-resistant Staphylococcus aureus (MRSA). METHODS: Analysis of the incidence of infection and contamination due to MRSA in patients admitted to the hospital of Cremona 6 months before and 3 years after the introduction of the guidelines (July 1997). B48

J Perinatol. Effect of an evidence-based hand washing policy on hand washing rates and false-positive coagulase negative staphylococcus blood and cerebrospinal fluid culture rates in a level III NICU  2002 Mar;22(2):137-43  CONCLUSION: Implementation of an evidence-based hand washing policy resulted in a significant increase in hand washing compliance and a significant decrease in false-positive coagulase negative staphylococcal blood and CSF culture rates. Exploratory data analysis revealed a possible effect on true-positive coagulase negative staphylococcal blood and CSF culture rates, but these results need to be confirmed in future studies.  B49

Gary Null PhD, Carolyn Dean MD ND, Martin Feldman MD, Debora Rasio MD Death by Medicine part 6 Never Enough studies November 2003 The rate of nosocomial infections per 1,000 patient days has increased 36% - from 7.2 in 1975 to 9.8 in 1995. Reports from more than 270 U.S. hospitals showed that the nosocomial infection rate itself had remained stable over the previous 20 years with approximately five to six hospital-acquired infections occurring per 100 admissions, which is a rate of 5-6%. However, because of progressively shorter inpatient stays and the increasing number of admissions, the actual number of infections increased. It is estimated that in 1995, nosocomial infections cost $4.5 billion and contributed to more than 88,000 deaths - one death every 6 minutes.9 The 2003 incidence of nosocomial mortality is quite probably higher than in 1995 because of the tremendous increase in antibiotic-resistant organisms. Morbidity and Mortality Report found that nosocomial infections cost $5 billion annually in 1999.10 This is a $0.5 billion increase in four years. The present cost of nosocomial infections might now be in the order of $5.5 billion.  b50

Reduction of nosocomial infection during pediatric intensive care by protective isolation.  BS Klein, WH Perloff, and DG Maki To determine whether simple protective isolation reduces the incidence of nosocomial bacterial and fungal infection during pediatric intensive care, we randomly assigned 70 children who were not immuno-suppressed and who required mechanical ventilatory support and three or more days of intensive care to receive standard care (n = 38) or protective isolation (n = 32) with use of disposable, non-waven, polypropylene gowns and nonsterile latex gloves. Risk factors predisposing patients to infection were comparable in the two groups. Nosocomial colonization occurred later among isolated patients (median, vs. 7 days; P less than 0.01) and was associated with subsequent infection in 12 patients, as compared with 12 patients given standard care (P = 0.01). Among patients who were isolated, the interval before the first infection was significantly longer than (median, 20 vs. 8 days; P = 0.04), the daily infection rate was 2.2 times lower than (95 percent confidence interval, 1.2 to 4.0; P = 0.007), and there were fewer days with fewer (13 percent vs. 21 percent; P = 0.001). The benefit of isolation was most notable after seven days of intensive care. Isolation was well tolerated by patients and their families. Regular monitoring showed that the children in each group were touched and handled comparably often by hospital personnel and family members. We conclude that the use of disposable, high-barrier gowns and gloves for the care of selected, high-risk children who require prolonged intensive care significantly reduces the incidence of nosocomial infection, is well tolerated, and does not compromise the delivery of care.  Source Department of Medicine, University of Wisconsin Medical School, Madison.  [B51]

Hospital-Acquired Public Infection Rate reporting under consideration in 2005, by states.  Last updated July 7, 2005 [Doc52]

Prevention Experts Stress Importance of Hand Hygiene Compliance PDF [Doc53]

Implementing a Program to Improve Hand Hygiene:  The Hospital of Saint Raphael Experience [Doc57]

UNMH Nurses Fight Staph Testing in Newborn ICU. [Doc55]

New England Journal of Medicine July 13, 2006 - System Failure versus Personal Accountability - The Case for Clean Hands.  Doc 59

Forty-two percent of personnel who had no direct contact with such patients, but had touched contaminated surfaces, contaminated their gloves with MRSA.  JM Boyce, G Potter-Bynoe, C Chenevert, T King - Infect Control Hosp Epidemiol, 1997 -  Environmental contamination due to methicillin-resistant Staphylococcus.  aureus: possible infection control implications. Boyce JM ... b70

A Comparison of the Effect of Universal Use of Gloves and Gowns with That of Glove Use Alone on Acquisition of Vancomycin-Resistant Enterococci in a Medical Intensive Care Unit. Objective: To determine the efficacy of the use of gloves and gowns compared with that of the use of gloves alone for the prevention of nosocomial transmission of vancomycin-resistant enterococci. This study suggested that ;there was no significant difference between the use of gloves and gounds and the use of gloves only in ICU. b71

Stethoscopes:  The authors have provided objective evidence of a high (67%) rate of contamination of gloves, gowns and stethoscopes during routine examination of patients colonised or infected with VRE. The methodology was scientifically sound and it is noteworthy that enrichment culture was not used, thus accurately mimicking the in vivo contact of a hand or glove with contaminated skin. Importantly, the effectiveness of decontaminating the head of a stethoscope with an alcohol wipe has been confirmed.  b72 from 'Clinical Opinions in General Medicine' series.


Impact of Hospital Acquired Bloodstream Infections.  b74 Nosocomial bloodstream infections are a leading cause of death in the United States. If we assume a nosocomial infection rate of 5%, of which 10% are bloodstream infections, and an attributable mortality rate of 15%, bloodstream infections would represent the eighth leading cause of death in the United States.  Because most risk factors for dying after bacteremia or fungemia may not be changeable, prevention efforts must focus on new infection-control technology and techniques.

Mortality Data from the National Vital Statistics System. b75  Great source of health statistics.  This source shows the 15 leading causes of death by year.  Septicemia as the 10th leading cause of death.

National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004 b76

Surgical Infections

Guideline for the Prevention of Surgical Site Infection, 1999 The Guideline for Prevention of Surgical Site Infection, 1999 presents the Centers for Disease Control and Prevention (CDC) recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.

What you can do to protect your self before surgery:

Tips for Surgery Patients  

Tips for Dialysis Patients  

Tips for Adults  

MRSA - Reading List

  • MRSA In US Hospitals 1995-2004
  • MRSA in US Hospitals 1975-1991
  • National Nosocomial Infections Surveillance System (NNIS)  The National Nosocomial Infections Surveillance (NNIS) system was developed in the early 1970s to monitor the incidence of healthcare-associated (nosocomial) infections (HAIs) and their associated risk factors and pathogens. NNIS is the only national system for tracking HAIs. The NNIS system is a cooperative, non-financial relationship between hospitals and CDC. This voluntary reporting system has grown from about 60 hospitals at inception to approximately 300 today. The NNIS system currently is undergoing a major redesign as a web-based knowledge management and adverse events reporting system that is scheduled to be available to participating NNIS hospitals in early 2005; all other U.S. hospitals, long-term-care facilities, and other healthcare organizations will be able to use the system by 2006. Once implemented, the redesigned system (to be called the National Healthcare Safety Network [NHSN]) will cover new areas of patient safety monitoring and evaluation.
  • Buckingham S, McDougal L, Cathey L;et al. Emergence of Community-Associated Methicillin-Resistant Staphylococcus aureusat a Memphis, Tennessee Children's Hospital. Ped InfDis J. 23(7):619-624, 2004
  • Centers for Disease Control and Prevention. Community-acquired methicillin-resistant Staphylococcus aureus infections—Michigan. MMWR. 1981;30:185-7.
  • Centers for Disease Control and Prevention. Methicillin-resistant Staphylococcus aureus skin or soft tissue infections in a state prison—Mississippi, 2000. MMWR 2001;50(42):919-22.
  • Centers for Disease Control and Prevention. Four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus —Minnesota and North Dakota, 1997-1999. JAMA 1999;282:1123-5.
  • Collignon P, Gosbell I, Vickery A, et al. Community-acquired methicillin-resistant Staphylococcus aureus in Australia. Australian Group on Antimicrobial Resistance. Lancet 1998;352:145-6.
  • Embil J, Ramotar K, Romance L, et al. Methicillin-resistant Staphylococcus aureus in tertiary care institutions on the Canadian prairies 1990-1992. Infect Control Hosp Epidemiology 1994;15:646-51.
  • Feder HM, Jr. Methicillin-resistant Staphylococcus aureus infections in 2 pediatric outpatients. Arch Fam Med 2000;1163-6.
  • Frank AL, Marcinak JK, Mangat PD, Schreckenberger PC. Community-acquired and clindamycin-susceptible methicillin-resistant Staphylococcus aureus in children. Ped Inf Dis J 1999;18:993-1000.
  • Goetz A, Posey K, Fleming J, et al. Methicillin-resistant Staphylococcus aureus in the community: a hospital-based study. Infect Control Hosp Epidemiol 1999;20:689-91.
  • Groom AV, Wolsey DH, Naimi TS, Smith K, et al. Community-Acquired Methicillin-Resistant Staphylococcus aureus in a Rural American Indian Community JAMA 2001;286(10),1201-1205
  • Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA 1998;279:593-8.
  • Hussain FM, Boyle-Vavra S, Bethel CD, Daum RS. Current trends in community-acquired methicillin-resistant Staphylococcus aureus at a tertiary care pediatric facility. Ped Inf Dis J 2000;19:1163-6.
  • Kallen AJ, Driscoll TJ, Thornton S, Olson PE, Wallace MR. Increase in community-acquired methicillin-resistant Staphylococcus aureus at a Naval Medical Center. Inf Cont Hosp Epi 2000;21:223-6.
  • Kazakova SV.,Hageman JC, Matava M, et al. A Clone of Methicillin-Resistant Staphylococus aureus among Professional Football Player N Engl J Med 2005;352.
  • Lindenmayer JM, Schoenfeld S, O’Grady R, Carney JK. Methicillin-resistant Staphylococcus aureus in a high school wrestling team and the surrounding community. Arch Int Med 1998;158:895-9.
  • Maguire GP, Arthur AD, Boustead PJ, Dwyer B, Currie BJ. Emerging epidemic of community-acquired methicillin-resistant Staphylococcus aureus infection in the Northern Territory. Med J of Australia 1996;164:721-3.
  • Martinez-Aguilar G, Avalos-Mishaan A, Hulten K, Hammerman W, Mason EO Jr, Kaplan SL. Community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus musculoskeletal infections in children Ped Inf Dis J. 2004;23(8):701-6.
  • Naimi, TS, LeDell, KH, Como-Sabetti, K, et al. Comparison of Community- and Health Care-Associated Methicillin-Resistant Staphylococcus aureus Infection. JAMA 2003 290(22):2976-2984.
  • Price MF, McBride ME, Wolf JE, Jr., Prevalence of methicillin-resistant Staphylococcus aureus in a dermatology outpatient population. South Med J 1998:91:369-71.
  • Rings T, Findlay R, Lang S. Ethnicity and methicillin-resistant S. aureus in South Auckland. N Zeal Med J 1998;111:151.
  • Saravolatz LD, Markowitz N, Arking L, Pohloh D, Fisher E. Methicillin-resistant Staphylococcus aureus . Epidemiologic observations during a community-acquired outbreak. Ann Intern Med. 1982;96:11-16.
  • Stacey AR, Endersby KE, Chan PC, Marples RR. An outbreak of methicillin- resistant Staphylococcus aureus infection in a rugby football team. Br J Sports Med 1998;332: 53-4.


Revised: July 21, 2006 .