The World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) have been advocating for hand hygiene as an important tool in infection control within healthcare facilities.^1,2 Campaigns such as “Clean Care is Safer Care” and “Clean Hands Count for Safe Healthcare” were launched to improve healthcare providers’ adherence to hand hygiene practices in reducing healthcare associated infections (HAIs). However, a recent study suggests that the focus of these efforts should be expanded to include patients.

Mody et al.³ reported that 14% of hospitalised patients (n=399) had tested positive for at least one multidrug-resistant organism (MDRO) on their hands or in their nares within 24 hours of their admission.³ Among these patients, 57% harboured methicillin-resistant Staphylococcus aureus (MRSA), 36% resistant gram-negative bacilli (RGNB), and 14% vancomycin-resistant enterococci (VRE). The presence of these MDROs correlates with the contamination of high-touch surfaces in patient rooms such as bed controls, call buttons, and bedside tray tables – with 29% (n=115) of the sampled surfaces being contaminated with an MDRO at the beginning of the study.

The superbug colonisation of patients’ hands appears to be common. A previous US study reported that 39% (n=100) of patients’ hands were contaminated at ≥48 hours after admission;⁴ whereas another study conducted in post-acute care facilities reported one in four recently hospitalised patients had at least one MDRO on their hands.⁵

MDROs are frequently shed by both healthcare providers and patients, thereby contaminating surfaces in patient rooms.³ As compared to other anatomic sites, patients’ hands are more likely to come into contact with these contaminated surfaces, thus increasing the risk of pathogen transmission. This was shown in the current study, in which the colonisation of superbugs on patients’ hands was associated with the same MDROs.

Previously, infection prevention in healthcare facilities has focused primarily on improving hand hygiene among healthcare providers. Such efforts include the use of more effective cleansing products, innovative education and training models, and strict audit strategies.³ Evidence has emerged showing that patient hand hygiene is as equally important in infection reduction as it is in prevention. In fact, the current study demonstrated that hand contamination in patients occur within eight hours of room occupancy, with a rapid change in the microbial milieu in patients’ rooms.³ This phenomenon underlines the importance of patient hand hygiene programs – particularly targeting superbug-infected patients – as an additional infection control strategy.

While patient hand hygiene programmes are still lacking, several programmes involving patients as monitors, or observers of hand hygiene have been created. For instance, the US Joint Commission’s “Five Things You Can Do to Prevent Infections” and the WHO’s “My 5 Moments for Hand Hygiene” encourage patients to ask healthcare providers to wash their hands before any treatments.⁶

The researchers of the current study concluded that patient hands are an important reservoir of MDROs and the burden of infection prevention should also be borne by patients.³ Therefore, patient hand hygiene protocols and patient engagement represent the next crucial step in infection prevention.

References

1. World Health Organization. Clean Care is Safer Care. Available at: https://www.who.int/gpsc/background/en/. Accessed 4 June 2019.
2. Centers for Disease Control and Prevention. Clean Hands Count for Safe Healthcare. Available at: https://www.cdc.gov/features/handhygiene/index.html. Accessed 4 June 2019.
3. Mody L, et al. Clin Infect Dis 2019 Apr 13. doi: 10.1093/cid/ciz092. [Epub ahead of print]
4. Istenes N, et al. Am J Infect Control 2013;41:793-798.
5. Cao J, et al. JAMA Intern Med 2016;176:705-706.
6. Landers T, et al. Am J Infect Control 2012;40(4 Suppl 1):S11-S17.