units. Following an outbreak, hand hygiene adherence among the outbreak units increased above that of the controls.
Greater improvements were noted for outbreaks on surgical units, for outbreaks involving antibiotic-resistant organisms and enteric pathogens, and in those outbreaks where healthcare workers became ill. The researchers summarized that hospital outbreaks tend to occur in units with lower HH adherence and are associated with rapid improvements in hand hygiene performance. Group electronic monitoring of hand hygiene could be used to develop novel, prospective feedback interventions designed to avert hospital outbreaks.
“ This study showed that the wards experiencing an outbreak had a lower hand hygiene compliance rate,” Longtin said.“ It’ s exciting to think that one day you could have an electronic system where it could give a warning that an outbreak might start occurring. That may be science fiction, but this is something we might see at some point in our careers.”
Longtin acknowledged that more research is needed, adding,“ There are many ways to assess hand hygiene compliance, but none of them is perfect. Should we still continue to perform direct monitoring using discreet observers? I think yes, it is still the gold standard, and electronic systems cannot currently replace direct observation, it will most likely be a gradual process, but we’ ll need to find potential uses for new systems that provide us with data that the current gold standard cannot provide, such as individual healthcare worker compliance rates. Eventually, it could replace direct observation, but to me, this would be the Holy Grail study in which we would link compliance collected by an electronic system with the hard outcomes, such as proving that it predicts the risk of nosocomial infection or the risk of mortality. But we’ re not there yet with a single disruptive system.”
HAND HYGIENE The most important measure?
In the presentation,“ Is Hand Hygiene Still the Most Important Measure to Prevent HAI?” Hugo Sax, a medical doctor in infectious diseases and infection prevention in Zurich, Switzerland, proposed the bold claim,“ Healthcare-associated infection is not a transmissible disease. HAIs are endogenous.”
“ That means that infections are created by the microbes that are a part of the patient’ s microbiome, and I’ ve been saying this for 20 years” he emphasized, drawing from concepts embraced by researchers Grundmann, Wenzel, and Gastmier.
Sax continued,“ Grundmann published a
Healthcare-associated infection is not a transmissible disease. HAIs are endogenous. That means that infections are created by the microbes that are a part of the patient’ s microbiome, and I’ ve been saying this for 20 years.”— Dr. Hugo Sax
study in which the team screened all the patients in the ICU and when they got infected, they looked to see if the microbe was already there several days before the infection, and they found that was the case in 86 percent, which they said is endogenous. Wendel examined surgical site infections( SSIs) and concluded up to 95 percent are created by microbes already in the patient. And Gastmeier argued that the endogenous nature of HAI increased over time as hygiene efforts in the hospital increased and that personalized infection prevention approaches are the future of infection prevention and control. Another study found that the preoperative skin microbiome matches the post-surgical site infection pathogens by location.” Let’ s unpack the results of these studies. Grundmann, et al.( 2005) said the proportion of intensive care unit( ICU)-acquired infections that are a consequence of nosocomial cross-transmission between patients in tertiary ICUs is unknown but that such information would be useful for the implementation of appropriate infection control measures. In their prospective cohort study during 18 months in five ICUs from two university hospitals, the researchers looked at all patients admitted for more than 48 hours. ICU-acquired infections were ascertained during daily bedside patient and chart reviews. Episodes of potential cross-transmission were identified by highly discriminating genetic typing of all clinical and surveillance isolates of the ten bacterial species most frequently associated with nosocomial infections in ICUs. Isolation of indistinguishable isolates in two or more patients defined potential transmission episodes. During 28,498 patient days, 431 ICU-acquired infections and 141 episodes of nosocomial transmissions were identified. A total of 278 infections were caused by the 10 species that were genotyped, and 41 of these( 14.5 percent) could be associated with transmissions between patients. The researchers concluded that“ Infections acquired during treatment in modern tertiary ICUs are common, but a causative role of direct patient-to-patient transmission can only be ascertained for a minority of these infections on the basis of routine microbiological investigations.”
Wenzel( 2019) sought to address three questions: What are the origins of bacteria causing surgical site infections( SSIs)? Is there evidence that the offending bacteria are present at the incision site when surgery begins? What are the estimates of the proportion of SSIs that can be prevented with perioperative control of the microbiome? In his review of the literature, examining recognized sources of bacteria causing SSIs, he specifically examined the impact of improved control of the microbiome of the skin and nares on reducing SSIs. As he reported,“ The initial effort was to examine the reduction of SSIs linked solely to preoperative skin preparation regimens and to either topical nasal antibiotics or pre- and postoperative nasal antiseptic regimens. To corroborate the concept of the importance of the microbiome, a review of studies showing the relationship of SSIs and marker organisms( e. g., Propionobacterium acnes) present at the incision sites was performed. The relationships of SSIs to the microbiome of the skin and nares were summarized. Depending on key assumptions, about 70 percent to 95 percent of all SSIs arise from the microbiome of the patients’ skin or nares. Data from the studies of marker organisms suggest that the infecting bacteria are present at the incision site at the time of surgery. Wenzel concluded that,“ The occurrence of SSIs can be viewed as a perioperative failure to control the microbiome.”
As Gastmeier( 2020) noted,“ One hundred years ago, many healthcare-associated infections( HAIs) had an exogenous origin, which means they were caused by micro-organisms from other patients, healthcare workers or the hospital environment. A smaller proportion was due to endogenous micro-organisms from the patients’ own microbial flora. Meanwhile, many improvements have been achieved. Most devices used for diagnosing and treating patients are now single-use items. The disinfection and sterilization measures used for reprocessing the remaining devices are on a very high safety level( at least in high-income countries) and cross- transmission via instruments is a very rare seldom event. Hand hygiene has also improved substantially. We have observed an increase in hand rub consumption of more than 100 percent during the last 12 years in Germany. For these measures the‘ one size fits all approach’ is appropriate because they must be applied for all patients independent of their diseases and pathogens. Today, we
22 • www. healthcarehygienemagazine. com • nov-dec 2025