It’s common for infection preventionists to talk hand hygiene, which is very important, but how is stethoscope hygiene at your hospital? Chances are not very good.

The American Journal of Infection Control recently reported zero incidences of stethoscope hygiene out of 169 observations among medical students on rotation. The researchers expected the rate to be low, but there are several reasons that zero incidences is surprising. First, stethoscope hygiene is on the checklist for second year medical students. Second, and more disappointing, stethoscope hygiene rates did not improve after an education initiative.

After zero incidences of stethoscope hygiene out of 128 observations, the researchers intervened. They showed the students a stethoscope hygiene powerpoint with their attending physicians present and stated the students would be observed for compliance. The presentation seemed to be enthusiastically received. They also placed posters at the entrance to every nursing unit, and made boxes of alcohol swabs abundantly available for sanitizing stethoscopes.

In 41 post-intervention observations they still found zero occurrences.

The study highlights the fact that education and availability of supplies alone are not sufficient to encourage proper hygiene.

In my experience the involvement of medical leadership is required for significant change. It has to be a part of the culture, and culture change starts at the top.

But how do you get medical administration involved in promoting hygiene accountability in sustainable ways?

One way is demonstrated by a program at Vanderbilt University in Nashville Tennessee which was able to increase average adherence from 55% to over 85% for hand hygiene and sustain the improvement across the organization since 2011.

How do they accomplish this? In addition to marketing efforts they provide financial incentives to departments for increasing adherence. Departments can be refunded up to 2.5% of premiums paid into the hospital’s malpractice self-insurance and use the funds however they see fit.

Leadership across the institution stayed involved with hand hygiene accountability and gave observers the ability to intervene when hospital hygiene policies were not being implemented. Intervention started with a non-judgemental talk they termed a “cup of coffee” conversation. Intervention severity could increase from awareness to authority and finally disciplinary actions if patterns of non-compliance were not addressed.

The Vanderbilt example is helpful in demonstrating one of the ways medical leadership can affect sustained change. The particular circumstances may be different in your hospital (for example, the physicians may not be employees) but the essential point is that sustained improvement of hand and stethoscope hygiene will not occur without a complete culture change.

To see dismal stethoscope hygiene rates improve, more than observations and education are required. Culture change requires sustained involvement from medical administration. At Infection Prevention Services we’re always thinking about ways leadership and infection preventionists can collaborate more effectively for best outcomes.

The prevalence of antibiotic resistant pathological bacteria highlights the need for antibiotic stewardship.

In June of 2017 the Society for Healthcare Epidemiology of America reported that an alarming 5.2% of inpatients across healthcare facilities in the Washington D.C. area tested positive for Carbapenem-resistant Enterobacteriaceae or CRE. CRE are “a family of germs that are difficult to treat because they have high levels of resistance to antibiotics.” For example, E. coli is a member of this family of bacteria. According to the press release, one facility reported a prevalence of 29.4%, “indicating the potential for hyperendemicity.”

This report highlights the increasing need for antibiotic stewardship. Misuse and overuse of antimicrobials is one of the world’s most pressing public health problems.

Nowhere is this more urgent right now than in nursing homes, according to the Association of Practitioners in Infection Control and Epidemiology (APIC), where patients are especially vulnerable to infections due to multiple comorbidities, advanced age, and immune dysfunction. In May the American Journal of Infection Control reported MDR-GNB colonization prevalence ranged from 11.2%-59.1%, with a pooled average of 27 percent. The prevalence is such that living in a nursing home is itself considered a risk factor, and frequent transfers aid the spread of infection and introduction of pathogens into acute care settings. Bacterial strains are becoming resistant to nearly all drugs that would be considered for treatment while few new antibacterial treatments are being developed.

So what can be done? Thankfully, there are examples where antimicrobial stewardship has led to a reduction in the prevalence of drug resistant bacteria.

From 2008 - 2012 Wilhelminenspital – a hospital in Vienna Austria – recorded a steady increase of mortality rates due to Clostridium difficile infections. They knew something had to be done. In 2013 they conducted a study that demonstrated significant and measurable decrease in Clostridium difficile infections (CDI) by reducing their use of Moxifloxacin in treatment for community acquired pneumonia (CAP).

Their success in reducing the infections came from a combination of reduced Moxifloxacin, distribution of information on CDI, and continuation of concrete hygiene behaviors which had been implemented years earlier. According to the study, routine hygiene measures included a visit from an infection control specialist in every case of CDI to augment hand hygiene, i.e., hand-washing and disinfection in the appropriate indications, protective clothing, change to a sporicidal surface disinfectant, and strict isolation of the patient whenever possible.

The biggest difficulty posed in the study was finding alternatives to the highly promoted Moxifloxacin, which proved effective for multiple respiratory infections, patients with insufficient kidney function, and patients allergic to penicillin.

The challenge of finding alternative antibiotic treatments when implementing antimicrobial stewardship programs will likely only become more difficult as more bacteria becomes resistant. This fact only serves to highlight the urgent need for such programs while a range of optimal clinical responses exist.

A key goal of improving antibiotic prescription behavior is to only prescribe antibiotics when they are needed according to current guidelines. As we at Infection Prevention Services seek to help healthcare facilities decrease the transmission of disease, it is our view that evidence-based antimicrobial stewardship should be a key priority.