BACKGROUND:Disinfection, sterilization, and antisepsis play a critical role in protecting patients from healthcare-associated infections. Numerous studies have emphasized the significant role of environmental surfaces, reusable medical and surgical devices, and hands in the transmission of healthcare pathogens. METHODS:We searched published literature for articles that will appreciably improve disinfection and sterilization practices and antiseptic use in health care. RESULTS:This paper describes the appropriate use of disinfectants, sterilization technologies, and antiseptics to reduce infection risk from environmental surfaces, reusable medical and surgical devices, and antiseptic usage in health care. CONCLUSIONS:Faithful and appropriate use of disinfectants, decontamination, and sterilization technologies can now prevent virtually all infections associated with the environmental surfaces and reusable medical and surgical devices. Antiseptics are crucial in health care for preventing infections by reducing healthcare pathogens on hands before and after patient contact and skin preparation before invasive procedures.

BACKGROUND:Achieving optimum levels of hand hygiene adherence among health care personnel (HCP) remains a challenge in many health care facilities. The purpose of this article is to review recent guidelines and new findings of potential importance, and suggest strategies for continued improvement of hand hygiene practices among HCP. METHODS:A search included articles that addressed important issues related to HCP hand hygiene. RESULTS:The 2022 SHEA/IDSA/APIC Practice Recommendations on hand hygiene provide an extensive list of evidence-based recommendations for improving hand hygiene practices among HCP. The accuracy of direct covert observations can be improved by having "secret shoppers" limit observation sessions to 15-20 minutes and by randomly selecting units to observe. A standard method is needed for determining an adequate sample size of direct covert observations in facilities with varying levels of baseline adherence. Combining direct covert observations with automated hand hygiene monitoring will likely provide the most robust data on hand hygiene practices of HCP. Greater attention should be devoted to improving hand hygiene technique. CONCLUSIONS:Continuing efforts are needed to maximize hand hygiene practices among HCP.

BACKGROUND:Automated hand hygiene monitoring systems (AHHMSs) can monitor a large number of hand hygiene opportunities, and some provide real-time feedback; however, the impact of these systems is unclear. We sought to better understand how one of these systems improves hand hygiene adherence. METHODS:The AHHMS was installed in seven units of an urban teaching hospital, and healthcare workers, primarily nurses and nurse technicians, were enrolled. We used a prospective observational cohort design with multiple interventions, including providing individual adherence rates and real-time voice reminders, to understand how these interventions improve hand hygiene adherence. RESULTS:Over the 40-week study period, 744,769 hand hygiene observations were observed among the 346 participants. The overall hand hygiene adherence rate increased from 37.0% (95% CI: 34.3% to 39.9%) at the start of the study to 55.5% (95% CI: 51.6% to 59.6%). This increase of 18.5% was statistically significant. However, adherence varied widely among different units and between individual participants. Voice reminders (58.7% (95% CI: 55.9% to 61.6%)) led to a significantly higher hand hygiene adherence rate than weekly individual feedback (46.4% (95%: 42.2% to 51.0%)) after adjusting for work shift and the seven individual participating clinical units. With the combination of interventions, improved adjusted adherence rates were sustained until the end of the study period. CONCLUSIONS:After the introduction of the AHHMS, real-time voice reminders improved short-term hand hygiene adherence more than feedback of individual adherence rates. Multiple interventions and cultural changes are required to sustain improved adherence.

BACKGROUND:Health care-associated infections (HAIs) remain a major concern in US hospitals, contributing to significant patient mortality and medical costs. Studies indicate that up to 70% of HAIs are preventable, with proper hand hygiene the most effective method of preventing transmission. Despite this, adherence to hand hygiene in hospitals remains low. METHODS:This article describes the process of developing, testing, and refining a standard to improve hand hygiene adherence in US hospitals. Building on the published literature and guidance from a national expert panel, Leapfrog developed a standard with 5 key domains. RESULTS:In 2019, 1,698 hospitals pilot tested an initial set of survey questions intended to measure hospital performance against the hand hygiene standard. Responses were not scored, but reviewed to make refinements. The scoring of hospital responses to the survey questions and the public reporting of hospitals' performance on meeting the hand hygiene standard began in 2020. From 2020 to 2023, the percentage of reporting hospitals that have met each domain of the hand hygiene standard and fully achieved Leapfrog's hand hygiene standard continued to grow. CONCLUSIONS:Leapfrog's hand hygiene standard provides hospitals with a "how-to guide" for best practices to promote hand hygiene and prevent HAIs.

Healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) pose threats to global health. Effective hand hygiene is essential for preventing HAIs and the spread of AMR in healthcare. We aimed to highlight the recent progress and future directions in hand hygiene and alcohol-based handrub (ABHR) use in the healthcare setting. In September 2023, 42 experts in infection prevention and control (IPC) convened at the 3rd International Conference on Prevention and Infection Control (ICPIC) ABHR Taskforce in Geneva, Switzerland. The purpose of this meeting was to provide a synthesis of recent evidence and formulate a research agenda on four critical areas for the implementation of effective hand hygiene practices: (1) ABHR formulations and hand rubbing techniques, (2) low-resource settings and local production of ABHR, (3) hand hygiene monitoring and technological innovations, and (4) hand hygiene standards and guidelines.

Healthcare-associated infections (HAIs) caused by multidrug-resistant organisms (MDROs) represent a global threat to human health and well-being. Because transmission of MDROs to patients often occurs via transiently contaminated hands of healthcare personnel (HCP), hand hygiene is considered the most important measure for preventing HAIs. Environmental surfaces contaminated with MDROs from colonized or infected patients represent an important source of HCP hand contamination and contribute to transmission of pathogens. Accordingly, facilities are encouraged to adopt and implement recommendations included in the World Health Organization hand hygiene guidelines and those from the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America/Association for Professionals in Infection Control and Epidemiology. Alcohol-based hand rubs are efficacious against MDROs with the exception of Clostridiodes difficile, for which soap and water handwashing is indicated. Monitoring hand hygiene adherence and providing HCP with feedback are of paramount importance. Environmental hygiene measures to curtail MDROs include disinfecting high-touch surfaces in rooms of patients with C. difficile infection daily with a sporicidal agent such as sodium hypochlorite. Some experts recommend also using a sporicidal agent in rooms of patients colonized with C. difficile, and for patients with multidrug-resistant Gram-negative bacteria. Sodium hypochlorite, hydrogen peroxide, or peracetic acid solutions are often used for daily and/or terminal disinfection of rooms housing patients with Candida auris or other MDROs. Products containing only a quaternary ammonium agent are not as effective as other agents against C. auris. Portable medical equipment should be cleaned and disinfected between use on different patients. Detergents are not recommended for cleaning high-touch surfaces in MDRO patient rooms, unless their use is followed by using a disinfectant. Facilities should consider using a disinfectant instead of detergents for terminal cleaning of floors in MDRO patient rooms. Education and training of environmental services employees is essential in assuring effective disinfection practices. Monitoring disinfection practices and providing personnel with performance feedback using fluorescent markers, adenosine triphosphate assays, or less commonly cultures of surfaces, can help reduce MDRO transmission. No-touch disinfection methods such as electrostatic spraying, hydrogen peroxide vapor, or ultraviolet light devices should be considered for terminal disinfection of MDRO patient rooms. Bundles with additional measures are usually necessary to reduce MDRO transmission.

BACKGROUND:The importance of ethanol-based hand rubs (EBHRs) to prevent health care-associated infections is undisputed. However, there is a lack of meaningful data regarding the influence of EBHRs on skin microbiome. METHODS:Four nurses in a neonatal intensive care unit were included. After a leave of 14 days, samples were taken before the first hand rubbing action and at the end of shift, with continued sampling on days 1, 7, and 28. To analyze the hand microbiome, microbial cells were collected using the glove-juice technique. Pro- and eukaryotic community profiles were created using amplicon sequencing of 16S and 18S ribosomal RNA (rRNA) gene markers. RESULTS:On average, hand antisepsis was performed 108 times per 8-hour work shift. Microbial communities were dominated by typical taxa found on human skin. In addition, a clear nurse-specific (ie, individual) microbiome signature could be observed. For Prokaryota, daily exposure led to the end-of-the-day microbiomes being more similar to each other across nurses. In contrast, longitudinal effect of 28-day application revealed more similarity of the Eukaryotic community. CONCLUSIONS:Frequent occupational use of EBHR did not adversely affect the composition of the human hand microbiome. Thus, daily hand antisepsis retains its significance as the most important procedure for infection control.

Background Following publication of the 2009 World Health Organizations Guidelines for Hand Hygiene in Health Care, a debate has emerged regarding the relative antimicrobial efficacy of the different formats (rinse, gel, foam) of ABHRs and their ability to contribute to reduction of healthcare-associated infections (HAIs).Methods Data regarding the in-vivo antimicrobial efficacy of ABHRs and other factors that likely affect their effectiveness in reducing HAIs were reviewed, and a comprehensive review of studies that reported the effectiveness of each of the three ABHR formats to improve hand hygiene compliance and reduce HAIs was conducted.Results The amount of rubbing time it takes for hands to feel dry (dry time) is the major driver of ABHR antimicrobial efficacy. ABHR format is not a major factor, and several studies found that rinse, gel, and foam ABHRs have comparable in-vivo antimicrobial efficacy. Other factors that likely impact the ability of ABHRs to reduce transmission of healthcare-associated pathogens and HAIs include ABHR formulation, the volume applied to hands, aesthetic characteristics, skin tolerance, acceptance by healthcare personnel, and hand hygiene compliance rates. When accompanied by complementary strategies, promoting the use of each of the three ABHR formats has been associated with improvements in hand hygiene compliance rates. A review of 67 studies failed to identify an ABHR format that was significantly more effective in yielding statistically significant reductions in transmission of healthcare-associated pathogens or HAIs.Conclusions Current evidence is insufficient to definitively determine if one ABHR format is more effective in reducing transmission of healthcare-associated pathogens and HAIs. More rigorous studies such as multicenter randomized controlled trials comparing the different formats are needed to establish if one format is significantly more effective in reducing HAIs.

Abstract Background There is emerging evidence that implementation of an automated hand hygiene monitoring system (AHHMS) must be part of a multimodal hand hygiene (HH) program that includes complementary strategies. There are few published studies describing in detail the intervention strategies used with an AHHMS. Methods An AHHMS that provides group HH performance rates (100 x HH product dispenses divided by the number of room entries plus exits) was implemented on two Acute Care (AC) units and six long-term care (LTC) units at a Veterans Affairs Medical Center from March 2021 through April 2022. After a 4-week baseline period and 2.5-week washout period, the 52-week intervention period included many components, such as weekly huddles, unit nurse manager engagement, vendor provided clinician-based training and feedback, leadership support, unit recognition, signage and development of a new slogan to remind colleagues to perform HH. Statistical analysis was performed with a Poisson general additive mixed model. Results During the 4-week baseline period, the median HH performance rate was 18.6 (95% CI: [16.5, 21.0]) for all 8 units. During the intervention period, the median HH rate increased to 21.6 [19.1, 24.4], and during the last 4 weeks of the intervention period (exactly 1 year after baseline), the 8 units exhibited a median HH rate of 25.1 [22.2, 28.4], (p < 0.0001) [Figure 1]. The median HH rate increased from 17.5 to 20.0 (p < 0.0001) in LTC units and from 22.9 to 27.2 (p < 0.0001) in AC units. The intervention increased the use of hand sanitizer from 57.5% during baseline to 65.1% (p < 0.0001). The increase in HH rates was due to HH events increasing from 88,758 dispenses during the baseline to 123,722 dispenses during the last 4 weeks of the intervention. Direct observation results during the same periods showed HH compliance ranging from 61-86%. Figure 1- Monthly Hand Hygiene Performance Rates for all Units The green curve shows the change in the median HH rate during the intervention period compared to the baseline and washout periods, with vertical bars showing 95% confidence intervals for the monthly HH rate. Conclusion The intervention increased hand sanitizer usage and HH performance rates for all units. AC units were consistently better than LTC units, which have more visitors and more mobile veterans. Further HH improvement will rely on continued implementation of complementary strategies and long-term monitoring. Disclosures James W. Arbogast, PhD, GOJO Industries, Inc.: employee Pamela Wagner, RN MSN CPPS, GOJO Industries, Inc: Employee of GOJO Gregory A. Robbins, BS, GOJO Industries, Inc.: Current employee of GOJO Industries, Inc. Albert E. Parker, PhD, GOJO Industries: Advisor/Consultant John M. Boyce, MD, Diversey: Advisor/Consultant|Diversey: Expert Testimony|Diversey: Travel support|GOJO Industries: Advisor/Consultant|GOJO Industries: Expert Testimony|GOJO Industries: Travel support|Sodexo Healthcare: Advisor/Consultant.

BACKGROUND:Multiple aspects of hand hygiene have changed in recent years. METHODS:A PubMed search was conducted to identify recent articles about hand hygiene. RESULTS:The COVID-19 pandemic caused temporary changes in hand hygiene compliance rates and shortages of alcohol-based hand sanitizers (ABHSs), and in marketing of some products that were ineffective or unsafe. Fortunately, ABHSs are effective against SARS-CoV-2 and other emerging pathogens including Candida auris and mpox. Proper placement, maintenance, and design of ABHS dispensers have gained additional attention. Current evidence suggests that if an adequate volume of ABHS has been applied to hands, personnel must rub their hands together for at least 15 seconds before hands feel dry (dry time), which is the primary driver of antimicrobial efficacy. Accordingly, practical methods of monitoring hand hygiene technique are needed. Direct observation of hand hygiene compliance remains a challenge in many healthcare facilities, generating increased interest in automated hand hygiene monitoring systems (AHHMSs). However, several barriers have hindered widespread adoption of AHHMSs. AHHMSs must be implemented as part of a multimodal improvement program to successfully improve hand hygiene performance rates. CONCLUSIONS:Remaining gaps in our understanding of hand hygiene warrant continued research into factors impacting hand hygiene practices.

A 70-year-old woman presented with a 2-week history of left hemiparesis. She had no history of fever or of risk factors for opportunistic infections. Physical examination revealed subcutaneous nodules on her fifth digit, left hemiparesis, and dysarthria. Neuroimaging revealed ring-enhancing masses

Background: Maintenance hemodialysis (HD) patients are at increased risk of bloodstream infections (BSI). We investigated a cluster of Delftia acidovorans infections among patients undergoing HD at an outpatient unit (Facility A).Methods: A case was defined as a Facility A HD patient with >= 1 culture positive for D acidovorans between February 1 and April 30, 2018. An investigation included review of patient records, facility policies, practice observations, and environmental cultures.Results: The cluster included 2 patients with confirmed D acidovorans BSI. Both patients had recently been dialyzed at Station #2, where a wall box culture yielded D acidovorans. One patient also had a BSI due to Enterobacter asburiae, which was recovered from several other wall boxes and saline prime buckets (SPB). Observations revealed leakage of wastewater from wall boxes onto the floor, and that SPBs were not always disinfected and dried appropriately before reuse. Multiple deficiencies in hand hygiene and station disinfection were observed. No deficiencies in water treatment practices were identified, and water cultures were negative for the observed pathogens.Conclusions: The cluster of D acidovorans infections was most likely due to indirect exposures to contaminated wall boxes and possibly SPBs due to poor hand hygiene and station disinfection.(c) 2022 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Background Due to the substantial increase in the use of disinfectants containing quaternary ammonion compounds (QACs) in healthcare and community settings during the COVID-19 pandemic, there is increased concern that heavy use might cause bacteria to develop resistance to QACs or contribute to antibiotic resistance. The purpose of this review is to briefly discuss the mechanisms of QAC tolerance and resistance, laboratory-based evidence of tolerance and resistance, their occurrence in healthcare and other real-world settings, and the possible impact of QAC use on antibiotic resistance. Methods A literature search was conducted using the PubMed database. The search was limited to English language articles dealing with tolerance or resistance to QACs present in disinfectants or antiseptics, and potential impact on antibiotic resistance. The review covered the period from 2000 to mid-Jan 2023. Results Mechanisms of QAC tolerance or resistance include innate bacterial cell wall structure, changes in cell membrane structure and function, efflux pumps, biofilm formation, and QAC degradation. In vitro studies have helped elucidate how bacteria can develop tolerance or resistance to QACs and antibiotics. While relatively uncommon, multiple episodes of contaminated in-use disinfectants and antiseptics, which are often due to inappropriate use of products, have caused outbreaks of healthcare-associated infections. Several studies have identified a correlation between benzalkonium chloride (BAC) tolerance and clinically-defined antibiotic resistance. The occurrence of mobile genetic determinants carrying multiple genes that encode for QAC or antibiotic tolerance raises the concern that widespread QAC use might facilitate the emergence of antibiotic resistance. Despite some evidence from laboratory-based studies, there is insufficient evidence in real-world settings to conclude that frequent use of QAC disinfectants and antiseptics has promoted widespread emergence of antibiotic resistance. Conclusions Laboratory studies have identified multiple mechanisms by which bacteria can develop tolerance or resistance to QACs and antibiotics. De novo development of tolerance or resistance in real-world settings is uncommon. Increased attention to proper use of disinfectants is needed to prevent contamination of QAC disinfectants. Additional research is needed to answer many questions and concerns related to use of QAC disinfectants and their potential impact on antibiotic resistance.

AbstractObjective:To determine how engagement of the hospital and/or vendor with performance improvement strategies combined with an automated hand hygiene monitoring system (AHHMS) influence hand hygiene (HH) performance rates.Design:Prospective, before-and-after, controlled observational study.Setting:The study was conducted in 58 adult and pediatric inpatient units located in 10 hospitals.Methods:HH performance rates were estimated using an AHHMS. Rates were expressed as the number of soap and alcohol-based hand rub portions dispensed divided by the number of room entries and exits. Each hospital self-assigned to one of the following intervention groups: AHHMS alone (control group), AHHMS plus clinician-based vendor support (vendor-only group), AHHMS plus hospital-led unit-based initiatives (hospital-only group), or AHHMS plus clinician-based vendor support and hospital-led unit-based initiatives (vendor-plus-hospital group). Each hospital unit produced 1–2 months of baseline HH performance data immediately after AHHMS installation before implementing initiatives.Results:Hospital units in the vendor-plus-hospital group had a statistically significant increase of at least 46% in HH performance compared with units in the other 3 groups (P ≤ .006). Units in the hospital only group achieved a 1.3% increase in HH performance compared with units that had AHHMS alone (P = .950). Units with AHHMS plus other initiatives each had a larger change in HH performance rates over their baseline than those in the AHHMS-alone group (P < 0.001).Conclusions:AHHMS combined with clinician-based vendor support and hospital-led unit-based initiatives resulted in the greatest improvements in HH performance. These results illustrate the value of a collaborative partnership between the hospital and the AHHMS vendor.

Background: Microbiological monitoring of disinfection of high-touch surfaces identified heavy growth of Serratia marcescens and Achromobacter xylosoxidans not present on surfaces before disinfection, suggesting contamination of the disinfectant used. Methods: An investigation included interview of the housekeeper involved, level of bacterial contamination of the in-use quaternary ammonium (Quat) disinfectant, bactericidal activity of the contaminated disinfec-tant, pulsed field gel electrophoresis of S.marcescens and Achromobacter isolates, survival of S. marcescens on dry surfaces, and genome sequencing to identify possible Quat resistance genes.Results: The housekeeper, who seldom cleaned patient rooms, had used the disinfectant for months without emptying and drying the bucket between uses. The contaminated disinfectant contained 9.3 pound 104 CFU of S. marcescens plus A. xylosoxidans. The log10 reduction of S. marcescens by fresh Quat was 102-fold lower than that achieved against a control strain (S. marcescens ATCC 13380). Genome sequencing of S. marcescens isolates identified the following genes previously shown to encode for efflux pumps associated with Quat resistance: sdeXY, sdeAB, smfY, and a sugE-like gene. Conclusions: Failure to follow existing guidelines and manufacturer's instructions for use resulted in contam-ination by A. xylosoxidans and by S. marcescens that possessed multiple genes associated with Quat resistance.(c) 2022 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Background: Although substantial efforts have been made to improve hand hygiene (HH) compliance among healthcare personnel (HCP), much less attention has been devoted to improving HH technique. To date, no standard method for assessing HH technique has been widely adopted by hospitals. Because applying an alcohol-based hand sanitizer (ABHS) transiently reduces adjacent skin temperature, we explored the feasibility of using thermal imaging to determine whether ABHS has been applied to fingertips and thumbs, areas often missed by HCP. Methods: A convenience sample of 12 Quality and Safety staff volunteered for the study. A FLIR One Pro thermal camera attached to an iPhone was used to obtain thermal images of the palmar aspect of each volunteer’s dominant hand before applying ~1.8 mL ABHS gel, immediately after hands felt dry, and at 1 minute and 2 minutes later. Spot temperature readings of the mid-palm area and middle finger were recorded at each time point. The sex and estimated hand surface area (HSA in cm 2 ) of each volunteer were recorded. Results: In 11 of 12 volunteers, thermal imaging showed a significant decrease in mid-palm and middle finger skin temperatures after performing HH (paired t test P < .01 for both), especially for the fingers and thumb, indicating that ABHS was applied to these areas (Fig. 1). When HH was performed with ABHS and the thumb was purposefully excluded, the lack of colorimetric change in the thumb was visible (Fig. 2). The palmar area showed the least drop in temperature and reverted to normal temperature more quickly. Immediate post-HH mid-palm temperature change ranged from +0.5 to −2.7°C, with a significantly greater mean temperature drop with small or medium hands than with large hands (Mann-Whitney U test P = .048). With some volunteers, the color changes lasted 1 minute or longer. However, for persons with “cold” fingers at baseline, it was more difficult to draw conclusions from the gross assessment for colorimetric change. Conclusions: Thermal imaging of HH performance shows promise as an HH assessment technique and may be useful to determine whether HCP have applied ABHS to their fingertips and thumbs. Additional studies involving a much larger number of HCP under varying conditions are needed to determine whether thermal imaging can be a practical modality for teaching HH technique, for routinely monitoring HH technique, or as a research tool for studying the dynamics of HH using ABHS. Funding: None Disclosures: None

Clostridioides difficile infections (CDIs) cause substantial morbidity and mortality. Patients on maintenance hemodialysis are 2 to 2.5 times more likely to develop CDI, with mortality rates 2-fold higher than the general population. Hospitalizations due to CDI among the maintenance hemodialysis population are high, and the frequency of antibiotic exposures and hospitalizations may contribute to CDI risk. In this report, a panel of experts in clinical nephrology, infectious diseases, and infection prevention provide guidance, based on expert opinion and published literature, aimed at preventing the spread of CDI in outpatient hemodialysis facilities.

Hand hygiene by health care personnel is an important measure for preventing health care-associated infections, but adherence rates and technique remain suboptimal. Alcohol-based hand rubs are the preferred method of hand hygiene in most clinical scenarios, are more effective and better tolerated than handwashing, and their use has facilitated improved adherence rates. Obtaining accurate estimates of hand hygiene adherence rates using direct observations of personnel is challenging. Combining automated hand hygiene monitoring systems with direct observations is a promising strategy, and is likely to yield the best estimates of adherence. Greater attention to hand hygiene technique is needed.

OBJECTIVE: To examine the clinical aspects of idiopathic pulmonary fibrosis (IPF) and the efficacy and safety of interferon gamma-1b (IFN gamma-1b) in its treatment.DATA SOURCES: Epidemiologic, preclinical, and clinical studies published in the English language were identified by a MEDLINE search (1966-January 2005) using the search terms idiopathic pulmonary fibrosis, cryptogenic fibrosing alveolitis, and interferon. Additional citations were identified from the reference lists of related publications.STUDY SELECTION AND DATA EXTRACTION: Selected preclinical studies describing the pathophysiologic basis for IFN gamma-1b therapy and all clinical studies were included. Additional trials describing other treatment modalities and the determinants of response to therapy in patients with IPF were also reviewed.DATA SYNTHESIS: IFN gamma-1b targets the fibrotic rather than inflammatory processes of IPF The efficacy of IFN gamma-1b in patients with IPF is inconsistent with regard to changes in pulmonary function and mortality, although a modest survival benefit was observed in the largest clinical trial. Adverse events related to IFN gamma-1b are frequent although transient. Several cases of respiratory failure occurring subsequent to the administration of IFN gamma-1b are documented.CONCLUSIONS: To date, although trials suggest that earlier-stage IPF may be responsive to IFN gamma-1b, study results overall are inconsistent; further investigation is needed.