Strategic measures for the control of surging antimicrobial resistance in Hong Kong and mainland of China

Cheng, Vincent CC; Wong, Sally CY; Ho, Pak-Leung; Yuen, Kwok-Yung

act, vigorous screening and isolation of MRSA was performed by the Scandinavians and the Dutch in the late 1980s, 99, 100 and their prevalence of MRSA remain less than 1% in admission screening, while the prevalence in the US and other parts of Europe is much higher. 101 Their experience strongly supports the concept of proactive screening, isolation and decolonization, also called a 'search and kill' strategy. Mandatory surveillance is also useful even in an endemic setting where MRSA bacteremia in England was reduced from over 7000 to less than 2000 cases per year. 102 In addition, active surveillance played an important role in the control of a hospital-wide outbreak of carbapenem-resistant K. pneumoniae infection Israel. Of 12 391 days of contact precautions, 4713 (38%) were added as a result of active surveillance. 103 However, infection control measures should not be limited to an institution. A nationwide intervention has to be launched to contain MDROs, as illustrated in the containment of a country-wide outbreak of carbapenem-resistant K. pneumoniae in Israeli hospitals via a nationally implemented intervention where the monthly incidence of nosocomial carbapenem-resistant K. pneumoniae was significantly reduced from 55.5 cases per 100 000 patientdays in March 2007 to 11.7 cases per 100 000 patient-days in May 2008 (P,0.001). 104 Hand hygiene is always considered a critical component of infection control practices. Promotion in the 'Five Moments' in the WHO recommendation-namely, before patient contact, before an aseptic task, after body fluid exposure risks, after patient contact and after contact with patient surroundings-is a key measure to reduce the risk of nosocomial transmission of MDROs, but compliance is often limited to the first four moments and not the 5th moment. Therefore, MDROs can be easily transmitted via contact with mutually touched items by healthcare workers, conscious patients, and visitors in institutional environments ( Figure 6 ). Although hand hygiene monitoring demonstrated compliance of over 70% in our center, manual observation of hand hygiene practice may be overestimated due to the Hawthorne effect. When hand hygiene compliance was continuously and unobtrusively monitored by an electronic monitoring system, the overall compliance was found to be less than 40%, 105 which was consistent with previous findings. 106 The concept of infection control is simple, but compliance is difficult. Introduction of directly observed Control of antibiotic resistance in China VCC Cheng et al 8 hand hygiene in clinical settings may be a better option, where a designated healthcare assistant or nurse delivers alcohol-based hand rub to all conscious patients and healthcare workers once every 2-3 h. This practice appeared to be useful in the prevention of nosocomial outbreaks due to epidemiologically important viruses or MDROs in our setting. 90, 91, 97, [107] [108] [109] [110] [111] [112] Because there are many more patients than healthcare workers in clinical areas, hand hygiene practice in conscious patients is equally important. Directly observed hand hygiene in patients was promoted as a new core infection control component, and alcohol-based hand rub was delivered to all conscious patients before meals and medications. In addition, alcohol foam and hand rub was also made available in patients' bathrooms. Patients were encouraged to disinfect toilet seats prior to use and to clean their hands after using the toile