"Hand Hygiene week- 2013"

(Contributed by Dr. Megha Sharma, R.D. Gardi Medical College, Ujjain, M.P. India)

WHO has recommended '5^th May' as 'Hand hygiene day' which is celebrated in many countries. The week before or after the Hand hygiene day is celebrated as 'Hand hygiene week'. The purpose is to remind the health care workers (HCWs) about the importance of possessing clean hands during patient care. This directly relates to the decrease in the health care associated infections (HAIs). HAIs are the infections that result in long term disability and longer duration of hospitalization and treatment with antibiotics. The hands of the HCWs are the major cause of spread of HAIs in any medical facility.

Acknowledging the importance of hand hygiene- "Hand Hygiene week- 2013" was celebrated in a tertiary care hospital in Central India from 29^th April 2013 to 05^th May 2013 under the collaborative research project (APRIAM). The institute, R.D. Gardi Medical College, Ujjain is hosting the research project (APRIAM) in collaboration with Karolinska Institutet, Stockholm, Sweden, since 2007. Dr. Cecilia Stalsby Lundborg (Prof, Global Health-IHCAR, Karolinska Institutet, Sweden), Dr. A.J. Tamhankar (National Coordinator, IIMAR, Prof, RD Gardi Medical College), Dr. Ragini Macaden (Prof, St. John's Research Institute, Bangalore) and Dr. V.K. Mahadik (Medical Director, RD Gardi Medical College) are the esteemed pioneers and mentors of the project APRIAM.

The project aims at improving antibiotic prescribing and maintaining hygiene in the study settings. The project coordinator and team leader (Hygiene team) Dr. Megha Sharma along with her team associates; Dr. Vishal Diwan, Dr. Anshu Jain, Amit Pawar, Dr. Love mehra, Dr. Devendra Parmar, Himanshu, Jeetendra Jat and Jaipal, developed and conducted the  "Hand Hygiene week- 2013" activities in the facility.

The objectives to conduct the activity were to sensitize the HCWs regarding importance of maintaining hand hygiene and to encourage the HCWs to maintain hand hygiene during patient care. All the activities were designed locally and were conducted in a joyful and interesting yet informative and purposeful manner.  

The celebration was inaugurated on 29^th April 2013 by Honorable Medical Director, Dr. V. K. Mahadik in presence of Dean Dr. J.K. Sharma, Medical Superintendent Dr. S. Sharma and other staff members.

For the active participation of the HCWs; competitions such as Poster competition: with theme "Use of alcohol based hand rub in prevention of healthcare associated infections", Slogan writing: with topic “Use of gloves in patient care” were planned. Crossword puzzles related to hand hygiene, use of antibiotics and importance of alcohol based hand rub were provided to assess the knowledge of the HCWs. Answers to the puzzle were displayed on the following day.

One of the most popular activities was- “Add colours to life: Keep your hands clean”. Colour full hand prints of all HCWs were printed on the white sheet. Soap and water was provided to wash hands. Single use paper napkins was provided to dry hands thus to convey the message of “Use single use napkin/ towel to dry up your hands”.

Live videos and slideshows were displayed, both in Hindi and English, on computer screen at the site. This activity was mainly to target the persons accompanying the patients and visitors. The videos mainly demonstrated “How to wash hands?” and the importance of hand washing and maintaining hygiene.

Demonstration and training sessions for the community- This activity was conducted for the persons accompanying the patients such as attainders and visitors present in the hospital. The team demonstrated the 6 steps of hand washing and the participants followed it. Soap, water and single use paper napkins were provided to the participants.

During the week, the team also visited district government hospital to conduct the activities. This was in relation to make the HCWs of the hospital, a part of the hand hygiene activities.

Feedback for the concept of the hand hygiene week was taken from the HCWs with the help of a locally developed feedback form.

Prize distribution-Prizes were distributed for various competitions. The WHO Surveillance officer, Indore region, Dr. Sudhir Soni was invited as chief guest for the occasion. Dean, Dr. J.K. Sharma and many respected senior staff of the institute were present for the occasion.

Overall more than 500 HCWs participated in various activities during the "Hand Hygiene Week 2013". The whole event was appreciated by the HCWs and the print media as well.

Government of India to crack whip on India`s pharma-doctor nexus

 The government of India is all set to crack the whip on India's shameful pharma-doctor nexus. The National Development Council (NDC), led by Prime Minister Manmohan Singh, will meet on December 27 to discuss bringing a legislation requiring drug companies to mandatorily disclose payments made to doctors for research, consulting, lectures, travel and entertainment. Doctors involved in ghost writing to promote pharma products will also be disqualified.

The official NDC document says, "Mandated disclosure by pharmaceutical companies of the expenditure incurred on drug promotion, and penalty on the company and vetting of drug related material in continuing medical education would be considered."

The Planning Commission says pharmaceutical marketing and aggressive promotion contributes to irrational use of drugs and therefore there is a need for a mandatory code to identify and penalize unethical promotion by pharma companies. The government will also make compulsory the use of generic names or the International Non-proprietary Name (INN), instead of brand names, at all stages of government procurement, distribution, prescription and use.

"Brand manufacturers will be encouraged to bid for government procurement, but should provide medicines in generic names," the document says.

Health minister Ghulam Nabi Azad recently said the ministry had received several complaints on this unholy pharma-doctor nexus.

According to the Medical Council of India (MCI), it received 702 such complaints in 2011-12 of which 343 were referred to state medical councils. In 2010-11, MCI received 824 such complaints following which it cancelled the registration of 10 doctors and warned four others.

Drug companies were recently caught red-handed writing scientific recommendations of their own products and submitting them to the Drug Controller General of India (DCGI) after getting them endorsed by top doctors for quicker marketing approval.

Usually, scientific recommendations are submitted by experts after they have studied a drug's content. The endorsement is considered a crucial testimony that convinces the DCGI to trust the drug's effectiveness, in turn, allowing it to be launched in the market.

Some of India's top medical experts — even heads of departments — from the country's most prestigious medical institutes such as PGI Chandigarh, CMC Vellore, AIIMS Delhi and St John's Medical College, Bangalore had signed recommendations for drug companies which may have been written by the companies themselves.

A recent study by the Planning Commission's high-level expert group (HLEG) said the pharmaceutical industry spent more than 25% of its annual turnover on sales promotion alone as compared to a paltry 7% on research and development in 2008-09.

India plans to soon introduce the 'Uniform Code of Pharmaceutical Marketing Practices' after which the word "safe" cannot be used on a drug without qualification and it must be stated categorically that a medicine has no side-effects, toxic hazards or risk of addiction.

The code says, "No gifts, pecuniary advantages or benefits in kind may be supplied, offered or promised to persons qualified to prescribe or supply by a pharmaceutical company. Gifts for the personal benefit of healthcare professionals (such as tickets to entertainment events) also are not be offered or provided. Companies must not organize meetings to coincide with sporting, entertainment or other leisure events. Venues that are renowned for their entertainment must not be used."

It adds, "Any hospitality offered to healthcare professionals must not be extended to spouses. Funding of healthcare professionals to compensate them for the time spent in attending the event is not permitted."

Planning Commission member Syeda Hameed recently took the example of the Food and Drugs Administration (FDA) of the US and how it has mandated strict regulations to curb unethical promotions.

These include mandated disclosure by pharmaceutical companies of the expenditure incurred on drug promotion, ghost writing in promotion of pharma products to attract disqualification of the author and penalty on the company and vetting by FDA of drug related material in CME.

Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines by the Infectious Diseases Society of America

These guidelines are intended for use by infectious disease specialists, orthopedists, and other healthcare professionals who care for patients with prosthetic joint infection (PJI). They include evidence-based and opinion-based recommendations for the diagnosis and management of patients with PJI treated with debridement and retention of the prosthesis, resection arthroplasty with or without subsequent staged reimplantation, 1-stage reimplantation, and amputation. (FullText)                    

Antimicrobial Stewardship

The issue of continuously increasing antimicrobial resistance has necessitated actions on the part of the society in general and stakeholders in antibiotic use in particular, to create pathways to minimise antimicrobial resistance. A particular programme which has attracted worldwide attention currently is the ‘Antimicrobial Stewardship programme’.

The term ‘antimicrobial stewardship’ is defined as the optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance. With the emerging knowledge of antimicrobial residues in the environment and the non-human use of antimicrobials contributing to antimicrobial resistance, an all round multidisciplinary approach involving also the veterinarians and environmentalist would in effect result in a really reduced existence of resistant bacteria. Such an `Augmented Antibiotic Stewardship Programme’ (AASP) is thus a need of the hour.

Studies have established a strong relationship between antimicrobial use and resistance. Therefore prescribing antimicrobial therapy when and only when it is beneficial to the patient, targeting therapy to the desired pathogens, and using the appropriate drug, dose, and duration are important contributions towards reducing resistance. Overuse and misuse must be decreased to reduce the selective pressure that results in the spread of resistance.

Current ‘Antimicrobial stewardship programmes’ have evolved as a means for clinicians to optimize antimicrobial use in hospitals in accordance with consensus recommendations. The literature describes a multitude of strategies ranging from many individual interventions (e.g., formulary manipulations, dosing recommendations, and academic detailing) to less common but more broad and programmatic approaches (e.g., prior-approval programs, concurrent review and feedback).All of these strategies seem to impact on appropriate antimicrobial use, clinical outcomes, antimicrobial resistance and costs.

Antimicrobial stewardship programs, whose goal is to improve the use of antimicrobials at the institutional level, have been successful. Two dominant strategies exist for these programs -- prior approval, and concurrent review and feedback. Many issues, including measurable outcomes, barriers, funding, and personnel, must be identified before a program is implemented. studies indicate that oversight of antimicrobial use (whether restrictive or more subtle through concurrent review and feedback) has had a measurable impact on appropriateness of antimicrobial use, antimicrobial consumption, and/or expenditures, resistance rates, infection rates, and clinical outcomes.

Antimicrobial stewardship programs should have definite goals ensuring that performance outcomes are easily measured and relevant. Financial issues will automatically resolve themselves as ‘money saved is money gained’.

Measured outcomes and performance indicators include recommendation acceptance rates, adherence rates with antibiotic use guidelines, microbiologic and clinical response rates, frequency of antibiotic re-administration within 7 days, adverse drug events, time to approve antimicrobials and time to their administration to the patient, hospital readmission rates related to infectious diagnoses, length of hospital stay, mortality rates, antimicrobial resistance rates, infection rates, antibiotic expenditures and use rates measured in terms of defined daily dose, associations between antimicrobial use and resistance or infection rates, overall hospital costs, and costs directly attributable to the infectious process. Outcome measurements should be institution specific and discussed and agreed on before the program is implemented. Surveys may be used before the introduction of an antimicrobial stewardship program and should be used as a continuing tool. Depending on the programme, population-based antimicrobial use and resistance correlation can also be studied.  Interrupted time series with segmented regression analysis can result in a sophisticated means of measuring the true impact of interventions on antimicrobial use.

When considering the `Augmented Antibiotic Stewardship Programme’ (AASP), involvement of appropriate management of bio-medical waste and hospital waste water which create environmental residues that generate resistant bacteria is a must and proper guidelines for this must be created.   Veterinarians should be considered a must as their prescriptions also constitute a risk to development of antimicrobial resistance and actually several Antibiotic Stewardship Programme guidelines could be common to them.

 Barriers/ Impediments

The perception of threatened autonomy can be a significant impediment to the effort.  This can be resolved by creating Multidisciplinary Committees. Being proactive and not reactive is also very helpful, e.g. provide program's antibiotic guidelines to all faculty members and important administrative personalities for review to gain consensus before they are circulated for implementation. Monitoring of ‘pseudo-outbreaks’ (i.e. increased rate of infections represented by clinicians attempting to justify the use of a particular restricted antimicrobial by documenting in the medical record that infection existed) is also crucial to the success of the programme.

Environment and the antibiotic resistance

Environment is all around us and is influencing antibiotic use by us as well as the development of antibiotic resistance. We are dumping antibiotics in our environment, which in turn is not only helping resistance development in bacteria but is also toxic to us.

We may not be able to control the environment fully

But

We may become wise

And

Manage antibiotic resistance better

If we know

What`s the relationship between

The environment and the antibiotic resistance

Ashok J. Tamhankar