Antimicrobial resistance – new tools for a growing scourge

In June 2017, the European Commission adopted an Action Plan to tackle Antimicrobial Resistance (AMR) which is responsible for an estimated 25,000 deaths in the EU every year.  Worldwide, the death toll from AMR is reported to be as high as 700,000. The World Bank warns that by 2050, the economic impact of drug-resistant infections due to AMR would be on par with the financial crisis in 2008.

Contamination and resistance
Overall, healthcare-associated infections (HAIs) affect up to 15% of hospitalized patients. The main causes are persistent microbial contamination of hospital surfaces, along with a growth of drug-resistant pathogens. Although antimicrobial misuse is believed to be largely responsible for AMR, hospital hygiene has come sharply into focus as traditional cleaning methods begin to encounter limits in their capacity to control infection.

WHO guidelines on hand hygiene
According to the World Health Organization (WHO), good hand hygiene practices could halve the infection level in hospitals.  The WHO guidelines are also known as the ‘Five Moments for Hand Hygiene.’ They involve the occasion before a patient is touched, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching the patient’s surroundings. However, much more needs to be done to validate training or control the implementation of the WHO guidelines.

Challenges of compliance
One of the biggest challenges is the time required for the most effective form of hand hygiene, namely alcohol-based hand rubs (ABHR). WHO recommends applying ABHRs for 20 to 30 seconds, while the US Centers for Disease Control and Prevention (CDC) recommends doing so until the hands feel dry, which it states ought to take about 20 seconds. Such time-spans are considered far too long for busy, practising clinicians.
However, it seems that such requirements may be unnecessarily arduous. In Dec 2017 / Jan 2018, a clinical observational study in Germany found that reducing the recommended application time for hand rubs improved compliance rates with no significant difference in efficacy. The researchers at the Institute for Hygiene and Environmental Medicine of the University Hospital of Greifswald focused on nurses who applied ABHRs for either 15 or 30 seconds. The study found ABHRs were “equal or even more effective” within 15 seconds versus 30 seconds for a variety of micro-organisms. The only caveat was that the ABHR needed to have a proven efficacy after 15 seconds. This did not extend to all ABHRs available on the market, and particularly not to gel formulations.

Other researchers are approaching the problem differently. In October 2013, an article in the journal ‘Clinical Infectious Diseases’ published results of a meta-study on hand hygiene, which it called “the critical intervention underlying modern infection prevention efforts.” The authors concluded that, in spite of limited research and evidence, “bundles including education, feedback, reminders, access to ABHR and administrative support” would be the most effective at improving hand hygiene compliance.

Three years before this, the ‘American Journal of Infection Control’ reported results from a project at one hospital, where compliance with hand hygiene was improved and sustained through use of a multi-faceted bundle approach. One aspect of the latter was a violation notice letter sent to non-compliant staff and enforced by managers. This appears to have been the key factor in dramatically raising hand hygiene compliance from a rate of 34% to more than 90% in the space of just two years.

Recent developments in hand hygiene

Recent developments related to hand hygiene include new test methods for evaluating hand hygiene products, improvements in ABHR, novel antisepsis techniques and new strategies for monitoring hand hygiene practices among healthcare personnel.  A host of new methodologies is also being explored to implement hand hygiene at hospitals. These range from new digital tools to robotics, artificial intelligence and genetics.

Gesture recognition algorithms

In late 2017, global hand hygiene company GOJO reported results from a ‘smart hospital’ project with two medical technology companies from Ireland, SureWash and MEG Support Tools. The three joined forces with an infection control team at Manchester’s Christie Hospital, to create a live data dashboard using an interactive training kiosk from SureWash, an audit app from MEG and GOJO’s Smartlink dispenser. Analytics were run in real time on the data to provide actionable feedback when hand hygiene standards slipped.

Patients and infection control

During the study, hand hygiene education and compliance were also targeted at patients by means of gesture recognition and camera-based algorithm technology.
Indeed, patients have recently begun to be harnessed as key actors in infection prevention. So far, there were few resources available for such a task, in spite of a growing body of evidence to suggest that patients’ flora too were a primary source of several infections, and that these could be prevented by correct hand hygiene. Most previous work involving patients had simply included them as monitors of hand hygiene practices by healthcare workers.

Clean bots
Germ-killing robots provide a new weapon in the arsenal against health care-associated infections.
One study funded by the CDC in the US showed that germ-killing robots (also being described as Clean Bots) could reduce common healthcare-associated infections by 30 percent.
At the end of 2017, Vanderbilt University Medical Center in Nashville, Tennessee, began deploying robots to protect hospitalized patients from two of the toughest strains of resistant bacteria: methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). The first area of application is the burns ward, which hosts some of the most vulnerable patient groups. Rooms are cleaned with traditional liquid disinfectants. After this, hallway doors and curtains are closed, while  cabinets and drawers are left open. This is followed by the despatch of a remote-controlled robot, which floods the room with ultraviolet radiation to kill any residual germs. The robot shuts itself down after its sensors detect adequate reflected UV from the room surfaces, which typically takes about 25 minutes. However, longer settings can be used in rooms likely to host hospital-acquired infections.
Nevertheless, authorities at the Vanderbilt Medical Center reiterate that Clean Bots are not a replacement for good hand hygiene.
Vanderbilt now plans to monitor the effects of the robots on infection rates and on workflow, and is developing protocols to optimize use of the robots without delaying patients arriving from the emergency department or the recovery room.

Artificial intelligence
Artificial intelligence (AI) is also being utilized to enhance hygiene. The magazine ‘New Scientist’ recently reported efforts by a Stanford University research team, which sought to harness AI to spot behaviour that might contribute to the spread of infection. Towards this, the researchers used video cameras at a hospital in a range of hotspots such as patient rooms, hallways and adjacent to hand sanitizing dispensers. The cameras made recordings over the course of one high activity hour. 80 percent of the video was used to train tracking algorithms, while the rest was used to test the algorithms.
During the hour when the recording was made, 170 people entered patient rooms. However, only 30 followed appropriate protocols for hand hygiene. The researchers found that computer vision algorithms were more accurate in making such a judgement than people in the hospital covertly recording hand sanitation practices.
The researchers are now planning to outfit three hospitals for a year to see how the technology and the observations it reports impact infection rates. One of the researchers, Alexandre Alahi, told ‘New Scientist’ that though it may not be affordable to have a doctor in a room round-the-clock, an AI doctor could well be economically viable, freeing up humans to do other jobs.

Video analytics
Video analytics has also been used for a study by the Division of Infectious Diseases and Hospital Epidemiology at University Hospital Zurich to make in-depth follow-up of hand hygiene practices, in order to systematically document hand-to-surface exposures (HSE) and delineate true hand transmission pathways. The authors of the study, published in the October 30, 2017 issue of ‘Antimicrobial Resistance & Infection Control’ concluded that the “abundance of HSE underscores the central role of hands in the spread of potential pathogens while hand hygiene occurred rarely at potential colonization and infection events.” They aim to propagate their hand trajectory monitoring approach to design more efficient prevention schemes.

The trajectories of infection
One of the newest tools in the fight against infection seeks to provide a first-person view of pathogen transmission. It involves the documentation of hand-to-surface exposures (HSE) by healthcare workers and tracking their trajectories.
The process, which was developed by researchers at Zurich University Hospital in Switzerland, uses a head-mounted camera and commercial coding software to code HSE type and duration based on a hierarchical scheme. It identifies HSE sequences with particular relevance to infectious risks, based on the WHO’s ‘Five Moments for Hand Hygiene.’
The Swiss researchers recorded and studied hand movements of 8 nurses and two physicians and confirmed the central role of hands in the spread of potential pathogens. During the study period of almost five hours, a total of 4,222 HSEs were identified, corresponding to one HSE every 4.2 seconds. Of this, 291 HSE transitions were ‘colonization events’, occurring from outside to inside the patient zone. Hand hygiene occurred rarely at potential colonization and infection events.
According to the researchers, an in-depth analysis of hand trajectories during active patient care may help to design more efficient prevention schemes.

Colour coding bedsheets

While tools such as video analytics and robotics offers new approaches to the challenge of hygiene, others are turning to imaginative, lower tech solutions. In India, health officials in West Bengal’s Raiganj district hospital recently announced that bedsheets of varying colours would be used on different days a week to check cross infection and ensure that the beds and the wards were cleaned every day.
There authorities were responding to complaints that bedsheets were not regularly changed, in some cases even after a patient had been discharged. Using bedsheets of different colours gives an immediate solution to such a problem. The hospital has put up a chart mentioning days of the week and the corresponding colour of the bedsheets, allowing family members of patients to confirm that their beds had been cleaned.