Effectiveness of Hand Hygiene Intervention.

A Review of the Effectiveness of Hand Hygiene Intervention to Reduce the Spread of Extended-Spectrum β-Lactamase- Producing Enterobacteriaceae (ESBL-PE) among ICU Patients

ORDER CUSTOM, PLAGIARISM-FREE PAPER

Background: Historically, Multidrug resistant organisms including the Extended-Spectrum β-Lactamases (ESBLs) are a major public health predicament not only in the United States but also globally as infections caused by those organisms are linked to severe health complications and great financial liability to the healthcare system. There are many interventions strategies have been put in place to eliminate or to reduce the risk of the ESBL infections, yet the search for an effective prevention control strategy will always stay a challenge to the public health. Objective: The purpose of this review is to measure the effectiveness of the hand hygiene as an intervention to reduce the spread of the ESBLs among severely ill patients in the ICU. Methods: An article search was performed in PubMed, EMBASE and CINAHL databases to identify publications on the effectiveness of hand hygiene intervention to reduce the spread of the ESBLs among ICU’s patients. The search was limited to English language, human subjects, and date range of 2002-current. A total of 10 articles were eligible for this review. Results: Strategic and organizational efforts were made to improve hand hygiene compliances. Among the observed opportunities for hand hygiene, increased staff compliances were noted. 8 out of 10 of those studies showed that increase rate of hand hygiene compliance was correlated with a significant reduction in the prevalence of ESBLs infections among hospital patients, however 2 of the studies did not show any correlation. Conclusions: The results of this review suggest that a systemic approach is needed to improve compliances with the hand hygiene intervention among hospital staff to be an effective strategy to eliminate or to reduce the transmission of ESBLs among ICU’s patients.

Key words ; ESBL, Extended-Spectrum β-Lactamases, Intervention, Effectiveness, Hand Hygiene, ICU, Intensive Care Unit, Prevalence.

Introduction

Infections that are caused by Extended Spectrum Beta Lactamases-Producing

Enterobacteriaceae (ESBL-PE) has a significant impact on clinical outcomes, including

delays in infusing the appropriate antibiotic treatment and increased the chance of

medical complications which might lead to fatality.

In particular, hospital’s ill patients who are admitted to the ICU units are the most vulnerable to many hospitals acquired infections especially to the Multi drug resistant pathogens such as the ESBL-PE (Cantey, Joseph B., et al 2013). The genomic structure of those pathogens makes it more challenging for the laboratory personnel to identify those organisms by the standard assays, which might lead to delay or inappropriate treatment of antimicrobial therapy. Gram-negative bacteria such as ESBL-PE cause 20-40% of sepsis in the neonatal intensive care units (NICUs) usually was due to delayed antibiotic treatment (L. P G Derde et al. 2014). Some of the sepsis cases lead to serious systemic complications and have led to fatalities (Cantey, Joseph B., et al 2013). Many studies were conducted to measure the effectiveness of different interventions strategies to eliminate or to reduce the spread of the super bug among ICU’s patients, however, due to the un-controllable human and or environmental variables achieving the optimal goal of those interventions will always be challenging and very hard to sustain (E. Alp et al. 2014). In this review we will evaluate the effectiveness of the hand hygiene intervention strategies to reduce the spread of the ESBL-PE among ICU patients. Some of these studies used actual ICU patient’s population for their data to measure the outcome of the hand hygiene intervention, yet others such as (Pelat, C., et al 2016) used a simulation model to measure the effectiveness of the hand hygiene intervention to reduce the spread of the ICU super bug. Changing human behavior such as complying with the hand hygiene practice among the hospital is very challenging and have led to many interventions failures, however in many cases the changes were successful due to support of all the stakeholders and the consistency of the enforcing the hand hygiene policies. The purpose of this review to evaluate the effectiveness of the hand hygiene interventions to reduce the spread of the ESBL- PE among ICU patients. The effectiveness will be evaluated by measuring the improvement rate of the hospital staff hand hygiene compliances and the reduction rate of the spread of the ESBL-PE in those targeted populations (Pelat, C., et al 2016).

Method

An article search was performed in PubMed, EMBASE and CINAHL databases to identify publications on the effectiveness of hand hygiene intervention to reduce the spread of the ESBL-PE among ICU’s patients (Fig. 1). The search was limited to English language, human subjects, date range of 2002-current; article type of case report, clinical trial, comparative study, journal article, multicenter study, or randomized controlled trial. The date range of 2002-current was selected to include articles published after the CDC published revised guidelines for hand hygiene to include the recommendation to use alcohol based hand rubs for decontamination of hands between each patient contact (of non-soiling type) and the use of liquid soap and water for cleaning visibly contaminated or soiled hands. Inclusion criteria for the literature review included: adult population, English language, hand hygiene intervention in the ICU’s intervention and primary outcome of reducing the spread of the ESBL-PE .The initial included PubMed, EMBASE and CINAHL databases. The same Keywords used in the three data bases were (ESBL OR Extended-spectrum β-lactamase) AND (Hand hygiene OR hand washing OR Handwashing OR hospital sanitation OR Hand Disinfection OR Hand Hygiene) AND (Intensive Care Units OR ICU OR NICU OR CCU OR neonatal intensive care units OR coronary care units OR Burn Units OR Intensive Care Units, Pediatric OR Pediatric Intensive Care Units OR Intensive Care Units, Neonatal OR Respiratory Care Units). This search yielded 24 articles in PubMed and 14 articles in EMBASE and 6 articles in CINAHL. After removing articles duplicated in the PubMed search and that did not meet inclusion criteria, initially 24 articles were included form PubMed , in 3 articles were included in the review form the EMBASE database and 1 article was included from the CINAHL database. After a review of article abstracts, 10 articles were excluded from PubMed because they were including other interventions were used in the study in parallel with the hand hygiene and the outcome might be as result of the other interventions as monitoring antibiotic usage or patient isolation. A total of 18 articles were identified as eligible for inclusion in the iterature review from PubMed, EMBASE and CINAHL, however only 10 articles were used in this review.

Results:

1- E. Alp et al. (2014); Hand hygiene compliance improved significantly from 2009 to 43.5% by 2010 (IRR, 1.3; P < .0001), and reached 63.8% by 2012 (IRR 1.9; P <. 0001). The rate of ESBL was 14.3/1,000 patient-days in 2004 declined significantly in 2005 (IRR, 0.73; P ¼.012), fluctuated between 2006 and 2010, then declined significantly to 10.44/1,000 patient-days in 2011 (IRR, 0.74; P ¼.007) and to 7.6/1,000 patient-days in 2012 (IRR, 0.53; P < .001).

2- Boyer et al. (2015); The intervention implemented in November 2007 resulted in a significant increase in ABHR see (Table 1). The pooled mean values for ABHR use were 89 _ 21 L/1,000 patient-days before the intervention and 151 _ 54 L/1,000 patient days after the intervention (P < .0001). The pooled mean number of ESBLE acquisitions was 8.9 _ 3.8 before November 2007 versus 4.5 _ 4.3 after November 2007 (P < .001).

3- (L. P G Derde et al. (2014); Of 41 558 hand hygiene opportunities, mean compliance was 52% in phase 1, 69% in phase 2, and 77% in phase 3. We found no evidence of a change of behaviour of health-care workers as a result of observation . 1966 (92%) produced extended-spectrum β lactamases, of which 571 (29%) were also resistant to carbapenems, and 241 (12%) produced AmpC. Trend in acquisition of antimicrobial-resistant bacteria decreased during phase 2 with no evidence of a stepwise change in incidence between phases 1 and 2.

4- (N Sing , et al 2015 ); Prevalence of beta lactams producers gram negative were reduced form 65.49% to 58.06% , compliances with hand hygiene was improved.

5- (M Tanguy, et at (2017), at the end of the study an audit of good practices assessing compliance with hand hygiene was conducted in the ICU. Substantial improvement was noted. This audit coincided with a one-month period when no new case patient had been identified.

Effectiveness of Hand Hygiene Intervention.

6- (J B. Cantey et al. (2013); Compliance with hand hygiene improved from 78%- 88% in February-April 2011 to 91%-100% in May-July 2011, this improved compliances was associated controlling the outbreak and the ESBLs was eradicated from the NICU without the need to resort to extreme measures, such as closing the nursery to new admissions

7- (K. Pelat et al. (2017), HH compliance improvement to 80%/80% ,it was the most effective, resulting in a mean reduction to 2.9 acquired infections per 100 admissions.

8-(O. Cho et al. (2014); ABHG consumption increased gradually from 2007 to 2012, with the following usage reported per 1000 PD: 5.6 L in 2007, 5.5 L in 2008, 9.6 L in 2009, 7.5 L in 2010, 11.2 L in 2011, and 11.9 L in 2012

(P <.001). ABHG consumption was not significantly correlated with the decreased incidence density of ESBL (r._0.310; P..141

9- (J.R. Zahar et al.(2012); Between 2005 and 2008 there was a significant increase in the annual volume of ABHRs of about 8 L per 1000 patient-days per year (P < 0.001). The annual volume of ABHRs was respectively 15.8, 28.1, 33.9 and 40.6 L per 1000 patient-days in 2005, 2006, 2007 and 2008. In the same period the incidence of ESBL-NI increased significantly from 0.21 to 0.40 per 1000 patient-days (P ¼ 0.04

10- (S. Scheithauer,et al.(2010); even with the intervention to educate staff on the important of the hand hygiene on patient safety , yet the outcome was inadequate HH compliances, therefore they were no impact on reducing the ESBL prevalence ; improving HH compliance requires a multimodal strategy implementing sufficient equipment, regular training, positive feedback and motivation, and involvement of opinion leaders.

Discussion and Conclusion:

Healthcare acquired infections always being an important public health problem faced by everyone involve with patient care. Hospital environment get contaminated with the all kind of pathogens as it the place where ill patients go for treatment, those patients are infected or carrier to many pathogens where they make the hospital as the perfect pathogens transmission middleware.

Effectiveness of Hand Hygiene Intervention.

1- (L. Kardas-Sloma et al. (2017), the most effective and cost-effective interventions for controlling MDROs are still debated. Since the spread of ESBL-PE between patients is a dynamic and complex process, modelling can help for understanding the transmission mechanisms and deciding which intervention are to be preferred. This study suggests that a universal approach with improved compliance with HH was the most cost-saving strategy to prevent the transmission of ESBL-PE in an ICU setting. Screening and cohorting of carriers had comparable effectiveness to HH improvement, but was more expensive.

2- (J.R. Zahar et al.(2012); This study was conducted in 17 different wards over a period of three years, and despite a significant improvement in adherence to hand hygiene and a significant increase in ABHR use there was no correlation with the incidence of NI, and specifically with NI due to ESBL-producing Enterobacteriaceae. In conclusion, the data from this intervention show that, despite an improvement in hand hygiene and in adherence rates during the study period, controlling the spread of ESBLs was not achieved. Control of ESBL spread will need more intensive infection control including >70% adherence to hand hygiene, screening patients at admission, and effective antimicrobial stewardship.

3- (L. P G Derde et al. (2014); Improved hand hygiene has no incremental effect on ESBL acquisition,.

4- Boyer et al. (2015); Improved hand hygiene has a direct effect on reducing ESBL acquisition.

5- P. Camill et al. (2016) Improving hand hygiene compliance was the most effective of all individual interventions

6- N Sing , et al 2015 Improving compliances with hand hygiene has was correlated with the a decrease in the prevalence of the gram negative beta lactamase producers .

References

1- Alp, E., Altun, D., Cevahir, F., Ersoy, S., Cakir, O., & McLaws, M. L. (2014). Evaluation of the effectiveness of an infection control program in adult intensive care units: A report from a middle-income country. AMERICAN JOURNAL OF INFECTION CONTROL, (42)10.1056-61

2- Boyer, A., Couallier, V., Clouzeau, B., Lasheras, A., M’zali, F., Kann, M., & … Gruson, D. (2015). Control of extended-spectrum β-lactamase–producing Enterobacteriaceae nosocomial acquisition in an intensive care unit: A time series regression analysis. AMERICAN JOURNAL OF INFECTION CONTROL, (43)2. 1296-1301, http://dx.doi.org/10.1016/j.ajic.2015.07.026

3- Derde, L. G., Cooper, B. S., Goossens, H., Malhotra-Kumar, S., Willems, R. L., Gniadkowski, M., & … Bonten, M. M. (2014). Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial. The Lancet Infectious Diseases, (14)1, 31-39. doi:10.1016/S1473-3099(13)70295-0

4- Singh, N., Singh, K., Kaur, M., Kaur, K., & Aggarwal, A. (2015). Management of [beta]-lactamase producers through infection control measures in burn ICU. Journal Of Evolution Of Medical And Dental Sciences, (99) 4 , 16422-16425 doi:10.14260/jemds/2015/2434

5- Tanguy, M., Kouatchet, A., Tanguy, B., Pichard, A., Fanello, S., & Joly-Guillou, M. (2017). Management of an Acinetobacter baumannii outbreak in an intensive care unit. Medecine Et Maladies Infectieuses, (47) 6, 409-414. doi:10.1016/j.medmal.2017.06.003

6- Cantey, J. B., Sreeramoju, P., Jaleel, M., Treviño, S., Gander, R., Hynan, L. S., & … Sánchez, P. J. (2013). Original Article: Prompt Control of an Outbreak Caused by Extended-Spectrum β-Lactamase–Producing Klebsiella pneumoniae in a Neonatal Intensive Care Unit. The Journal Of Pediatrics, 163672-679.e3. doi:10.1016/j.jpeds.2013.03.001

7- Pelat, C., Kardas-Stoma, L., Birgand, G., Ruppé, E., Schwarzinger, M., Andremont, A., & Yazdanpanah, Y. (2016). Hand Hygiene, Cohorting, or Antibiotic Restriction to Control Outbreaks of Multidrug-Resistant Enterobacteriaceae. Infection control and hospital epidemiology, (37)3. 272-280. DOI: 10.1017/ice.2015.284

8- Cho, O. H., Bak, M. H., Baek, E. H., Park, K. H., Kim, S., & Bae, I. G. (2014). Successful control of carbapene Cho, O. H., Bak, M. H., Baek, E. H., Park, K. H., Kim, S., & Bae, I. G. (2014). Successful control of carbapenem-resistant Acinetobacter baumannii in a Korean university hospital: A 6-year perspective. AMERICAN JOURNAL OF INFECTION CONTROL, (42) 9. 976-979

9- Zahar, J. R., Masse, V., Watier, L., Lanternier, F., Degand, N., Postaire, M., & … Lortholary, O. (2012). Is hand-rub consumption correlated with hand hygiene and rate of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE)-acquired infections?. JOURNAL OF HOSPITAL INFECTION, (80) 4. 348-350. doi:10.1016/j.jhin.2011.10.006

10- Scheithauer, S., Oberröhrmann, A., Haefner, H., Kopp, R., Schürholz, T., Schwanz, T., & … Lemmen, S. (2010). Compliance with hand hygiene in patients with meticillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase-producing enterobacteria. Journal of Hospital Infection, (76) 4, 320-323. doi:10.1016/j.jhin.2010.07.012