Discussion

The results of our study demonstrate that a small portion of patients’ hands in medical ICUs harbor pathogenic bacteria, including MDROs. These results appear to be consistent with prior studies that investigated the burden of pathogenic organisms on patients’ hands, though the prevalence of contamination with MDROs appears to be lower in our study. In a 100-patient study on non-ICU medical and surgical unit floors, 39% of patients’ hands were contaminated with at least 1 pathogenic organism 48 hours after admission. Similarly, when 357 newly admitted patients in postacute-care facilities hands were swabbed, 24% of patients had at least 1 MDRO, and another 10% had acquired an MDRO during their stay.^{Reference Kundrapu, Sunkesula, Jury, Deshpande and Donskey5, Reference Deshpande, Fox and Wong9} The difference in prevalence of MDROs between our study and prior studies may be because of our focus on ICU patients, who underwent daily chlorhexidine bathing per protocol. Previous studies have also demonstrated a potential relationship between patient hand contamination and contamination of high-touch room surfaces. In a study of ∼400 non-ICU general medicine floor patients, 10% of patients’ hands were contaminated with MDROs, and there was a correlation between the MDROs on patient hands and the contaminated room surfaces.^{Reference Cao, Min, Lansing, Foxman and Mody7}

Despite the emerging evidence potentially highlighting the role of patient hand hygiene in the transmission of HAIs, current best-practice recommendations do not provide a strong guidance regarding patient hand hygiene. One previous study has demonstrated that bundling of infection prevention strategies including patient hand hygiene can potentially reduce the rate of hospital-acquired infections, including Clostridioides difficile.^{Reference Pokrywka, Feigel and Douglas10} Therefore, building and implementing effective patient hand hygiene protocols and/or bundles has the opportunity to reduce the risk of life-threatening HAIs.

The strengths of this study include its relatively novel focus on the burden on MDROs on patients’ hands in an ICU setting and the study’s contribution to ongoing discussions surrounding infection prevention strategies targeting patient hand hygiene. On the other hand, our study was performed at a single tertiary-care center, and our results may not be applicable to other hospital settings. Furthermore, this study reports patient microbial colonization of hands, which does not necessarily indicate clinical infection. In addition, agar hand plates were used to assess bacterial contamination instead of the glove juice technique. The handprint method can be less effective because it solely provides information about the microbial burden from the anterior surface of the hand, whereas the glove-juice technique recovers microbes from the entire hand. Thus, the hand plate technique may yield comparatively less microbe recovery.

In conclusion, our study demonstrates that ICU patients’ hands may harbor pathogenic bacteria, providing further evidence that poor patient hand hygiene may contribute to transmission of resistant HAIs. Further studies are necessary to understand barriers to adequate patient hand hygiene and to identify best practice strategies.