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Society for Healthcare Epidemiology of America
Handwashing with soap and water alone no longer recommended
Hand hygiene has been elegantly and extensively researched and there is conclusive evidence that finding ways to improve hand hygiene is the biggest problem facing epidemiologists and control of infection practitioners throughout the world.
Poor hand hygiene contributes to the spread of multiresistant organisms and nosocomial infections, a major cause of morbidity, mortality and increased length of stay in hospitals. Astoundingly, despite the evidence and the apparent simplicity of this message, it became abundantly clear during the conference that most health care organisations worldwide can still only achieve compliance with good hand hygiene practice in 30?50 per cent of cases.
The current hand hygiene champions have reached a consensus that washing with soap and water will never be practical as the sole method of decontaminating hands, and no longer advocate this alone. All recent guidelines instead promote the use of alcoholic hand rubs or gels. To improve compliance rates substantially these products need to be widely and continually available at the point of patient care. As a minimum, an individual container should be available at each bedside; leading practitioners recommend that pocket sized containers are given to all health care workers.
Pharmacists must ensure that they are familiar with their local recommended practices and may be well positioned to support the improvement of hand hygiene in a number of ways: personal good practice contributes to clinical leadership, and expertise in supply and distribution can help ensure the availability of suitable products.
Some of the best hand hygiene practice in the world has been demonstrated by infection control practitioners in Geneva, who reported a compliance rate of 80 per cent, which is still rising after seven years of campaigns. They have also demonstrated a clinical impact with reduced rates of important hospital-acquired infections.
Cycling and antibiotic resistance
In contrast to the evidence for good hand hygiene, what was surprising was the weakness of the evidence associated with methods of reducing antibiotic resistance. This was demonstrated by Dr Neil Fishman, University of Pennsylvania, during a session on antibiotic cycling. An extensive literature search had yielded only six peer-reviewed papers and one abstract on true antibiotic cycling (defined as rotating antibiotics across an organisation in a cyclical fashion, including a return to the first agent). Of the six antibiotic cycling papers identified, four were published between 1973 and 1985 and described aminoglycoside cycling only. In three of these studies, rotation was between gentamicin and amikacin.
The most impressive results were presented in an abstract that described a substantial and sustained decrease in resistance, but showed that it took five years for the plasmid for gentamicin resistance to be lost in the bacterial population. Over the five years, amikacin was used for two two-year periods interspersed with one year of gentamicin.
A second seemingly impressive study, on further examination, had failed adequately to control for other changes in practice, most notably a dramatic change in case mix and improved hand hygiene practices. Hence the impact of antibiotic cycling on the reduction in resistance patterns was unproven.
In concluding, Dr Fishman felt that in the absence of evidence, institutional cycling should not be advocated until more robust and generalisable data are available. Unfortunately, the sample size required to provide more conclusive evidence was likely to be 30 to 40 hospitals. Since financial constraints mean this is unlikely to be achieved, Dr Fishman had developed a series of mathematical models. These suggest that a 50-50 mix of two different antibiotic regimens within any clinical area may be more effective than cycling in reducing resistance.
This raises the important concern of whether working to restrictive protocols will give rise to increased resistance as a result of increased homogeneity of antibiotic use. Dr Fishman believed that this could be avoided if, within protocols, different classes of antibiotic agents were used for different infections or sites of infection within individual clinical areas, preserving heterogeneity of antibiotic use across the organisation.
Citation: The Pharmaceutical Journal URI: 20006538
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