Literature Update - December 2011
Compiled by Dr Leon Worth, ID Physician
Impact of Gloves upon Hand Hygiene Compliance
Although the wearing of gloves by healthcare workers is recommended when contact with body fluids is anticipated, gloves are not a
substitute for effective hand hygiene. WHO guidelines state that gloves should be changed between patient contacts and that
hands should be cleaned before putting on gloves and immediately after removing gloves. Fuller C. et al.
(Infect Control Hosp Epidemiol 2011; 32:1194-1199) recently reported observations regarding hand hygiene behaviour and glove use in hospitals in England and Wales.
As part of a larger initiative to enhance hand hygiene across England and Wales (the Feedback Intervantion Trial, which commenced in
October 2006), the current study consisted of a series of 1-hour observations of hand hygiene and glove use at 6-week intervals in
a convenience sample of 56 wards within 15 hospitals. Hand hygiene observations were performed in open ward areas using a
standardised tool modified to capture glove use – the HHOT version 1, comparable to WHO '5 moments for hand hygiene'. The HHOT
version 1 enables recording of risk level (e.g. ‘high risk’ corresponding to aseptic task or body fluid contact).
Overall, gloves were used in 1983 of a total of 7578 moments (26.2%). Gloves were used in 551 (16.7%) of 3292 low-risk contacts.
Gloves were not used in 141 (21.1%) of 669 high-risk contacts. When unobserved contacts were removed from analysis, overall hand
hygiene compliance was 47.7%. The rate of compliance was lower when gloves were worn (41.4%), compared to when gloves were not
worn (50.0%). This same trend was observed for high- and low-risk exposures and for moments before and after contact.
Findings of this study suggest that gloves were used when not indicated (low-risk contacts), and not used when indicated (high-risk
contacts). Further, the rate of compliance with hand hygiene was significantly lower when gloves were worn. Although specific
details of behaviour regarding glove use were not evaluated (e.g. whether gloves were changed between patient contacts), these
findings suggest that measures to enhance hand hygiene must also address and refine glove use among healthcare workers.
Standardised tools for measuring hand hygiene compliance should also be refined to allow standardised monitoring of clinical
behaviours surrounding glove use.
Staphylococcus aureus Bloodstream Infections in Haemodialysis Patients
Infections are common in patients on chronic haemodialysis, and Staphylococcus aureus has been reported
as a frequent cause of bloodstream infections (BSIs). FitzGerald S.F. et al (J Hosp infect 2011; 79:218-221)
report findings of a surveillance strategy for S. aureus BSI in the largest renal centre in Ireland
over a 12-year period.
For the period 1998-2009, clinical and microbiologic data for patients receiving haemodialysis at a single centre were summarised for
all S. aureus BSI events, including outcomes at 30 days. Overall and annual rates of
infection were calculated.
The overall number of S. aureus BSI events was 395, corresponding to a rate of 17.9 episodes of
S. aureus BSI per 100-patient years. Annually, rates varied from 9.7 to 36.8 per 100 patient-years.
69% of episodes were due to methicillin-sensitive S. aureus (MSSA), with the remainder (31%) caused
by methicillin-resistant S. aureus (MRSA). An intravascular catheter was deemed to be the source of
infection in 83% (328) of instances. Other sources of infection included: skin and soft tissue (20), lower respiratory tract (6),
abscess (5), vascular graft (5), bone and joint (5), peripheral venous cannula (4), urinary tract (2). Infectious complications
occurred in 11% (43) of episodes, with infectious endocarditis being the most common metastatic complication (7.6% of episodes).
Death occurred within 30days in 9.8% of patients.
These data demonstrate that most episodes of S. aureus BSI were associated with vascular catheters,
and this is consistent with previous reports. Morbidity and mortality were significant, indicating that ongoing monitoring and
prevention strategies are well justified in the haemodialysis patient population. In particular, the high rate of complications
suggests that clinical review and investigation (e.g. routine use of echocardiography) are clearly warranted.