Current guidelines recommend the use of ABHR when hands are not visibly soiled, but recommendations vary in terms of the concentration of required alcohol (60–95%), the type of alcohol and the formulation (solution or rinse vs. gel vs. foam) [3,52]. The WHO has created simple formulations for ABHR solutions for use in settings in which commercial products may not be readily available .
Factors that can affect results include in-vitro vs. in-vivo testing methodology (e.g., European Norm 1500 vs. ASTM E1174 vs. glove juice techniques), the species and inoculum of pathogens tested, the volume of ABHR utilized and the time between ABHR application and assessment of pathogen kill. Overall, the optimum ABHR formulation has not been clearly established [53–58]. Edmonds et al. evaluated 12 different ABHR formulations and did not find that alcohol content (within the WHO recommended range) influenced efficacy. Contrary to previous reports, gel or foam ABHR preparations were not shown to be inferior to solutions or rinses, although design flaws have subsequently been highlighted with this study . A key issue with all these studies is that they utilize in-vivo models to extrapolate to clinical effectiveness, whereas multiple other factors, including healthcare worker product preference, ease or accuracy of various dispensers and hand hygiene compliance, are also critical factors in this equation. Gels and foams appeared to be equally acceptable to healthcare workers in one study , whereas solutions were preferred in others [13,14,16,17].
A number of ABHR preparations have demonstrated virucidal and bactericidal activity [63,64]. The effectiveness of ABHR against norovirus remains controversial . Although the WHO favours the use of ABHR during norovirus outbreaks , the Centre for Disease Control (CDC) continues to recommend handwashing with soap and water . Paulmann et al. recently demonstrated that two WHO ABHR solutions were effective against murine norovirus (a surrogate for human norovirus) both in vitro and in vivo, although the efficacy of other formulations remains unclear. Further research is required in this area. A variety of ABHR formulations appeared to have equivalent efficacy to soap and water handwashing in reducing hand contamination with H1N1 influenza . A study from Taiwan [69▪] demonstrated poor activity of existing ABHR formulations against human enterovirus 71, a nonenveloped virus of public health significance in the Asia-Pacific region.
Despite these in-vivo studies, the clinical utility of ABHR for preventing respiratory virus infections in the community remains less certain. Turner et al. conducted a randomized trial in young adult volunteers on the ability of ABHR to prevent rhinovirus infection or rhinovirus-associated illness. Despite the earlier promise in experimental models , they were not able to demonstrate a benefit. Wong et al.[72▪▪] performed a meta-analysis on the efficacy of hand hygiene interventions in preventing influenza virus transmission in the community. Although subgroup analysis from developed countries suggested that a combined intervention of hand hygiene with facemasks is a beneficial strategy, the efficacy of hand hygiene alone was not demonstrated.
It has previously been demonstrated that washing with soap and water is more effective than ABHR in removing C. difficile spores from the hands of healthcare workers . Edmonds et al. evaluated 10 different test products in their ability to remove C. difficile spores from the hands of test subjects. The only substances that were able to achieve significantly higher log10 reductions than tap water were not suitable for routine use in healthcare environments. This reinforces the current recommendation of handwashing with soap and water and contact precautions for care of patients with C. difficile.
One formulation of ABHR (70% isopropanol and 0.5% chlorhexidine) effectively reduced the density of vancomycin-resistant enterococci (VRE) contamination by approximately 104 in a detailed assessment of 20 healthcare workers who had their hands heavily contaminated (108 cfu/ml) with two strains of VRE .
Finally, the worldwide dissemination of carbapenem-resistant enterobacteriaceae (CRE) has provided some insights into effective infection control strategies. These strategies, usually instituted as bundles, include patient isolation, active surveillance, geographic cohorting, standards for detection and reporting, monitoring of adherence and environmental control initiatives. These bundles have proven to be successful in multiple settings worldwide [83▪,84▪,85,86], with early identification and isolation of asymptomatic carriers appearing to be a key component of successful interventions [85,87].
The epidemiology of VRE transmission may not be dissimilar. Using large-scale comparative genomics, Howden et al.[91▪] demonstrated that the epidemiology of hospital vanB VRE was more complex than previously thought. They and others [92,93] have proposed a model in which silent circulation of closely related vancomycin-susceptible Enterococcus faecium isolates acquires the vanB operon via lateral gene transfer from anaerobic bacteria in the gastrointestinal tract. Hence, hospital-acquired vanB VRE may also be driven by de-novo generation rather than solely nosocomial transmission via direct contact. This is in keeping with previous work by Johnson et al., in which it was observed within an institution that each time a new vancomycin-resistant E. faecium (VREfm) sequence type appeared, it was observed first as vancomycin-sensitive E. faecium (VSEfm). This may explain why the incidence of VRE has continued to rise in many countries despite strict patient isolation, effective infection control measures and significant reduction rates of nonenteric pathogens, such as MRSA [94,95].
The potential adverse outcomes of contact precautions have been recently reviewed . In addition, a single-centre retrospective cohort study by Karki et al. compared the incidence rate of documented adverse events in patients before and after initiation of contact precautions for VRE. They found that the overall rate of adverse events was not significantly different, but that there was an increase in medication administration errors and nonpressure-related injuries. The same group also observed that the waiting time for patients to obtain a CT scan, whereas under contact precautions for VRE colonization, was 46% longer than those who were not isolated .
Papers of particular interest, published within the annual period of review, have been highlighted as:
1. Pittet D, Donaldson L. Clean Care is Safer Care: a worldwide priority. Lancet 2005; 366:1246–1247.
2. Pittet D, Allegranzi B, Boyce J. The World Health Organization guidelines on hand hygiene
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4. Pittet D, Allegranzi B, Storr J. The WHO
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improvements. J Infect Public Health 2008; 1:4–10.
5▪▪. Allegranzi B, Gayet-Ageron A, Damani N, et al. Global implementation of WHO
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: a quasi-experimental study. Lancet Infect Dis 2013; 13:843–851.
This quasiexperimental study evaluated the implementation of WHOs multimodal strategy at six pilot sites worlwide. They found the strategy to be feasible, effective and sustainable across a range of diverse settings.
6. Stewardson A, Allegranzi B, Perneger T, et al. Testing the WHO hand hygiene
self-assessment framework for usability and reliability. J Hosp Infect 2013; 83:30–35.
7. Magiorakos AP, Suetens C, Boyd L, et al. National hand hygiene
campaigns in Europe, 2000–2009. Euro Surveill 2009; 14:493–497.
8. Mathai E, Allegranzi B, Kilpatrick C, et al. Promoting hand hygiene
in healthcare through national/subnational campaigns. J Hosp Infect 2011; 77:294–298.
9▪. Allegranzi B, Conway L, Larson E, Pittet D. Status of the implementation of the World Health Organization multimodal hand hygiene
strategy in United States of America healthcare facilities. Am J Infect Control 2014; 42:224–230.
This study reviewed the results of United States healthcare facilities who completed the hand hygeine self-assessment framework from the WHO. Although only 7.5% of invited facilites responded to the survey, the level of progress was promising, although this may reflect reporting bias.
11▪. Latham JR, Magiorakos AP, Monnet DL, et al. The role and utilisation of public health evaluations in Europe: a case study of national hand hygiene
campaigns. BMC Public Health 2014; 14:131.
This study aimed to assess the proportion of European hand hygiene programmes that had undergone evaluation and the characteristics of those evaluations. Among 36 programmes, 50% had undergone evaluation and they utilized a variety of methologies and indicators pre- and postintervention.
This website summarizes the key hand hygiene compliance rates for more than 740 Australian acute-care hospitals (95% of all public hospitals and 50% of private hospitals) following the successful implementation of the hand hygiene Australia programme.
13. Grayson ML, Jarvie LJ, Martin R, et al. Significant reductions in methicillin-resistant Staphylococcus aureus
bacteraemia and clinical isolates associated with a multisite, hand hygiene
culture-change program and subsequent successful statewide roll-out. Med J Aust 2008; 188:633–640.
14. Johnson PD, Martin R, Burrell LJ, et al. Efficacy of an alcohol/chlorhexidine hand hygiene
program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus
(MRSA) infection. Med J Aust 2005; 183:509–514.
15. Allegranzi B, Pittet D. Role of hand hygiene
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16. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene
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17. Grayson ML, Russo PL, Cruickshank M, et al. Outcomes from the first 2 years of the Australian National Hand Hygiene
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18. Stone SP, Fuller C, Savage J, et al. Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus
bacteraemia and Clostridium difficile
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: four year, prospective, ecological, interrupted time series study. BMJ 2012; 344:e3005.
19. Jarlier V, Trystram D, Brun-Buisson C, et al. Curbing methicillin-resistant Staphylococcus aureus
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20. Roberts S, Sieczkowski C, Campbell T, et al. Implementing and sustaining a hand hygiene
culture change programme at Auckland District Health Board. N Z Med J 2012; 125:75–85.
21. McLaws ML, Pantle AC, Fitzpatrick KR, Hughes CF. Improvements in hand hygiene
across New South Wales public hospitals: clean hands save lives, part III. Med J Aust 2009; 191:S18–S24.
22. McLaws ML, Pantle AC, Fitzpatrick KR, Hughes CF. More than hand hygiene
is needed to affect methicillin-resistant Staphylococcus aureus
clinical indicator rates: clean hands save lives, part IV. Med J Aust 2009; 191:S26–S31.
25. Ho ML, Seto WH, Wong LC, Wong TY. Effectiveness of multifaceted hand hygiene
interventions in long-term care facilities in Hong Kong: a cluster-randomized controlled trial. Infect Control Hosp Epidemiol 2012; 33:761–767.
26. Yeung WK, Tam WSW, Wong TW. Clustered randomized controlled trial of a hand hygiene
intervention involving pocket sized containers of alcohol based hand rub for the control of infections in long term care facilities. Infect Control Hosp Epidemiol 2011; 32:67–76.
27. Mertz D, Dafoe N, Walter SD, et al. Effect of a multifaceted intervention on adherence to hand hygiene
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28. Kirkland KB, Homa KA, Lasky RA, et al. Impact of a hospital-wide hand hygiene
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29▪▪. Lee AS, Cooper BS, Malhotra-Kumar S, et al. Comparison of strategies to reduce meticillin-resistant Staphylococcus aureus
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In this prospective, multicentre, interventional cohort study, investigators evaluated the efficacy of enhanced hand hygiene vs screening, contact precautions and decolonization vs. both interventions in their ability to reduce MRSA rates. Baseline MRSA rates were low in the study population, and only the combination of the two interventions resulted in a reduction in MRSA rates.
30▪▪. Schweizer ML, Reisinger HS, Ohl M, et al. Searching for an optimal hand hygiene
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The authors performed a systematic review on all studies on interventions to improve hand hygiene compliance. They included quasiexperimental studies as well as randomized controlled trials. Two bundled interventions were associated with an increase in compliance: the WHO bundle, and a bundle comprised of feedback, education and reminders.
31. Gould DJ, Moralejo D, Drey N, Chudleigh JH. Interventions to improve hand hygiene
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32. Fuller C, Michie S, Savage J, et al. The Feedback Intervention Trial (FIT) – improving hand-hygiene compliance in UK healthcare workers: a stepped wedge cluster randomised controlled trial. PLoS One 2012; 7:e41617.
33. Grayson ML. Keynote: ‘Antibiotics are dead: how will we manage?’ European Congress of Clinical Microbiology and Infectious Diseases. Berlin. Abstract L454. 2013.
34. Haas J, Larson E. Measurement of compliance with hand hygiene
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35. Eckmanns T, Bessert J, Behnke M, et al. Compliance with antiseptic hand rub use in intensive care units: the Hawthorne effect. Infect Control Hosp Epidemiol 2006; 27:931–934.
36. Kohli E, Ptak J, Smith R, et al. Variability in the Hawthorne effect with regard to hand hygiene
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38. Sodré da Costa LS, Neves VM, Marra AR, et al. Measuring hand hygiene
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39. Marra AR, Moura DF Jr, Paes AT, et al. Measuring rates of hand hygiene
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40. Morgan DJ, Pineles L, Shardell M, et al. Automated hand hygiene
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41. McAteer J, Stone S, Fuller C, et al. Development of an observational measure of healthcare worker hand-hygiene behaviour: the hand-hygiene observation tool (HHOT). J Hosp Infect 2008; 68:222–229.
42▪. Reichardt C, Königer D, Bunte-Schönberger K, et al. Three years of national hand hygiene
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This outlines the successful implementation of the WHO hand hygiene multimodal intervention strategy in Germany.
43. Reisinger HS, Yin J, Radonovich L, et al. Comprehensive survey of hand hygiene
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44. Salmon S, Tran HL, Bùi DP, et al. Beginning the journey of hand hygiene
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45. Szilágyi L, Haidegger T, Lehotsky Á, et al. A large-scale assessment of hand hygiene
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6-steps’. BMC Infect Dis 2013; 13:249.
46. Magiorakos AP, Leens E, Drouvot V, et al. Pathways to clean hands: highlights of successful hand hygiene
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47. Boyce JM. Measuring healthcare worker hand hygiene
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48▪▪. Marra AR, Edmond MB. New technologies to monitor healthcare worker hand hygiene
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This article discusses some of the alternatives to direct observation to monitor hand hygiene compliance. They discuss product utilization, automated counters and some of the newer electronic systems.
49. Boudjema S, Dufour J, Aladro AS, et al. MediHandTrace®: a tool for measuring and understanding hand hygiene
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50. Pineles LL, Morgan DJ, Limper HM, et al. Accuracy of a radiofrequency identification (RFID) badge system to monitor hand hygiene
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51. Fisher DA, Seetoh T, May-Lin HO, et al. Automated measures of hand hygiene
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52. Boyce JM, Pittet D. Guideline for hand hygiene
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53. Kramer A, Rudolph P, Kampf G, Pittet D. Limited efficacy of alcohol-based hand gels. Lancet 2002; 359:1489–1490.
54. Kampf G, Marschall S, Eggerstedt S, Ostermeyer C. Efficacy of ethanol-based hand foams using clinically relevant amounts: a cross-over controlled study among healthy volunteers. BMC Infect Dis 2010; 10:78.
55. Edmonds SL, Macinga DR, Mays-Suko P, et al. Comparative efficacy of commercially available alcohol-based hand rubs and World Health Organization-recommended hand rubs: formulation matters. Am J Infect Control 2012; 40:521–525.
56. Eggerstedt S. Comparative efficacy of commercially available alcohol-based hand rubs and World Health Organization-recommended hand rubs. Am J Infect Control 2013; 41:472.
57. Larson EL, Cohen B, Baxter KA. Analysis of alcohol-based hand sanitizer delivery systems: efficacy of foam, gel, and wipes against influenza A (H1N1) virus on hands. Am J Infect Control 2012; 40:806–809.
58. Suchomel M, Kundi M, Pittet D, et al. Testing of the World Health Organization recommended formulations in their application as hygienic hand rubs and proposals for increased efficacy. Am J Infect Control 2012; 40:328–331.
59. Marra AR, Camargo TZS, Cardoso VJ, et al. Hand hygiene
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60. Biagi M, Giachetti D, Miraldi E, Figura N. New nonalcoholic formulation for hand disinfection. J Chemother 2013; 26:86–91.
61. Daeschlein G, Scholz S, Ahmed R, et al. Skin decontamination by low-temperature atmospheric pressure plasma jet and dielectric barrier discharge plasma. J Hosp Infect 2012; 81:177–183.
62. Eichner A, Gonzales FP, Felgenträger A, et al. Dirty hands: photodynamic killing of human pathogens like EHEC, MRSA and Candida within seconds. Photochem Photobiol Sci 2013; 12:135–147.
63. Grayson ML, Melvani S, Druce J, et al. Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers. Clin Infect Dis 2009; 48:285–291.
64. Steinmann J, Paulmann D, Becker B, et al. Comparison of virucidal activity of alcohol-based hand sanitizers versus antimicrobial hand soaps in vitro and in vivo. J Hosp Infect 2012; 82:277–280.
65. Longtin Y, Voss A, Allegranzi B, Pittet D. Norovirus outbreaks and alcohol-based handrub solutions: association does not prove causation. Am J Infect Control 2012; 40:191.
68. Paulmann D, Steinmann J, Becker B, et al. Virucidal activity of different alcohols against murine norovirus, a surrogate of human norovirus. J Hosp Infect 2011; 79:378–379.
69▪. Chang SC, Li WC, Huang KY, et al. Efficacy of alcohols and alcohol-based hand disinfectants against human enterovirus 71. J Hosp Infect 2013; 83:288–293.
Alcohol-based hand disinfectants had poor efficacy against human enterovirus 71 and should not be relied on alone for preventing the spread of this infection.
70. Turner RB, Fuls JL, Rodgers ND, et al. A randomized trial of the efficacy of hand disinfection for prevention of rhinovirus infection. Clin Infect Dis 2012; 54:1–5.
71. Turner RB, Fuls JL, Rodgers ND. Effectiveness of hand sanitizers with and without organic acids for removal of rhinovirus from hands. Antimicrob Agents Chemother 2010; 54:1363–1364.
72▪▪. Wong VW, Cowling BJ, Aiello AE. Hand hygiene
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This meta-analysis evaluated studies comparing the effect of hand hygiene interventions in reducing influenza virus transmission in the community. Ten randomized controlled trials met inclusion criteria. The combination of hand hygiene and facemasks was found to be effective whilst hand hygiene alone was not. This is consistent with the known modes of transmission of influenza which includes aerosol transmission which would not be addressed by hand hygiene alone.
73. Jabbar U, Leischner J, Kasper D, et al. Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile
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74. Edmonds SL, Zapka C, Kasper D, et al. Effectiveness of hand hygiene
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75. Grayson ML, Ballard SA, Gao W, et al. Quantitative efficacy of alcohol-based handrub against vancomycin-resistant enterococci on the hands of human volunteers. Infect Control Hosp Epidemiol 2012; 33:98–100.
76. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for isolation
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77▪▪. Tacconelli E, Cataldo M, Dancer S, et al. ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug resistant Gram-negative bacteria in hospitalized patients. Clin Microbiol Infect 2014; 20:1–55.
The recent ESCMID guidelines make a strong recommendation that in the epidemic setting, contact precautions should be initiated for all patients colonized or infected with extended spectrum B-lactamase producing enterobacteriaceae, multidrug resistant (MDR) Kelbsiella pneumoniae, MDR Acinetobacter baumannii (moderate evidence), and Pseudomonas aeruginosa (low level evidence).
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82. Lee VJ, Yap J, Cook AR, et al. Effectiveness of public health measures in mitigating pandemic influenza spread: a prospective sero-epidemiological cohort study. J Infect Dis 2010; 202:1319–1326.
83▪. Schwaber MJ, Carmeli Y. An ongoing national intervention to contain the spread of carbapenem-resistant enterobacteriaceae. Clin Infect Dis 2014; 58:697–703.
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84▪. Palmore TN, Henderson DK. Managing transmission of carbapenem-resistant enterobacteriaceae in healthcare settings: a view from the trenches. Clin Infect Dis 2013; 57:1593–1599.
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86. Apisarnthanarak A, Pinitchai U, Warachan B, et al. Effectiveness of infection prevention measures featuring advanced source control and environmental cleaning to limit transmission of extremely-drug resistant Acinetobacter baumannii
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88▪▪. Eyre DW, Cule ML, Wilson DJ, et al. Diverse sources of C. difficile
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89. Eyre DW, Griffiths D, Vaughan A, et al. Asymptomatic Clostridium difficile
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96. Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: a review of the literature. Am J Infect Control 2009; 37:85–93.
97. Karki S, Leder K, Cheng AC. Patients under contact precautions have an increased risk of injuries and medication errors: a retrospective cohort study. Infect Control Hosp Epidemiol 2013; 34:1118–1120.
98. Karki S, Leder K, Cheng AC. Delays in accessing radiology in patients under contact precautions because of colonization with vancomycin-resistant enterococci. Am J Infect Control 2013; 41:1141–1142.
99. Mehrotra P, Croft L, Day HR, et al. Effects of contact precautions on patient perception of care and satisfaction: a prospective cohort study. Infect Control Hosp Epidemiol 2013; 34:1087–1093.
100▪▪. Dhar S, Marchaim D, Tansek R, et al. Contact precautions: more is not necessarily better. Infect Control Hosp Epidemiol 2014; 35:213–221.
In this prospective cohort study conducted across 11 sites, investigators found that the proportion of patients in contact isolation increases within an individual unit, compliance with isolation precautions decreased. This was particularly with regards to hand hygiene prior to gloving and gowning.
101. Huskins WC, Huckabee CM, O’Grady NP, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med 2011; 364:1407–1418.
102▪. Zahar J, Garrouste-Orgeas M, Vesin A, et al. Impact of contact isolation
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