A multimodal approach to fighting a rising problem
The rise of multi-resistant pathogens poses a massive challenge to modern medicine, but the solutions are already in front of our noses.
Ominous European infection data published in the Lancet at the beginning of 2019, showed that antibiotic-resistant infections more than doubled from 2007 to 2015 in Europe – with 240,000 cases increasing to 600,000 in the span of eight years. The number of deaths resulting from these infections even tripled in that same period.
The major factors for increasing resistance are well known. Probably the most significant contributor is overprescription of antibiotics in animal farming. The largest portion of antibiotics produced worldwide is used in this sector – mainly to prevent infections and promote growth. The second main driver is the overprescription of antibiotics in human medicine, which is often used needlessly to treat viral infections.
An important finding of the Lancet study is that the majority of the infections involving multidrug-resistant organisms (MDRO) occur in healthcare facilities such as hospitals and nursing homes. These areas in particular harbor numerous pathogens that often encounter immunocompromised patients. In these settings, the most important weapon for infection prevention often appears to be neglected – hand hygiene.
Prevention over therapy
It is estimated that more than 80 percent of all infections are transmitted by the hands. This sobering figure underlines the importance of thorough hand hygiene to prevent infections. 
Keeping this in mind, there appears to be significant potential to contain antibiotic-resistant organisms before they infect patients. Better infection prevention efforts would have the added effect of reducing both the number of patients infected, and the number of antibiotic prescriptions required – thereby protecting the efficacy of these drugs.
But how can healthcare hand hygiene compliance be improved in practice?
The World Health Organization (WHO) clearly defines the multimodal approach as the best standard. This approach attempts to solve the issue that positive hand hygiene behaviour, through the use of stand-alone concepts, tends to evaporate after a short period of time.
A holistic approach is therefore needed, with several components of hand hygiene coming together. The first important component for increasing hand hygiene compliance is optimizing the availability of hand sanitizer, which must be located as close to the point of care as possible.
With good hand hygiene, we can not only avoid infections that often lead to septic syndrome and end fatally in hospitals, but also counteract the development of antibiotic resistance and minimize the spread of MDRO.Dr. med. Andreas Glöckner, Medical Director
When workflow is interrupted by a dispenser that is located far from a patient, either the patient care suffers, or hygiene compliance is not adhered to. Therefore the consequence of not optimizing dispenser availability is the increased spread of infectious pathogens, including MDROs.
Another useful tool to promote hand hygiene is the employment of touchless dispenser systems. Automatic dispenser systems have been proven to increase dispenser use by more than 50 percent and can increase hand hygiene compliance rates. As an added benefit, touch free sensor technology reduces the possibility of cross-contamination at the point of the dispenser.
Healthcare facilities also have multiple psychological tools available to them. The WHO sees the use of visual reminders as another useful piece of the puzzle to improve hand hygiene compliance. Bright, high-visibility colours on dispenser systems, for example, have been shown to increase compliance by up to 6%. 
Feedback systems on hand hygiene behaviour for doctors and nursing staff have proven to be particularly effective psychological tools. As a result, feedback systems have been an increasingly prevalent component of the multimodal approach. Technical innovations that support compliance feedback, through dispenser data transmission, already exist.
These systems conveniently report back to healthcare staff via live screens in central locations. Though these feedback systems have been proven to motivate users themselves, detailed data can be analyzed by hygiene departments to carry out targeted compliance training sessions.
Finally, in addition to the psychological and infrastructural factors, there must also be a personnel framework to ensure that hand disinfection is carried out in accordance with the rules. The trend toward increased work loads per healthcare worker has been shown to decrease compliance, and therefore poses a threat to overcoming the problem of antibiotic resistance.
 Cassini, Alessandro, et al. “Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis.” The Lancet Infectious Diseases 19.1 (2019): 56-66.
 4 Scheithauer, S., et al. “Increase of alcoholic hand disinfection usage due to new touchless dispensers.“ Hyg Med 36 (2011): 494-496.
 Scheithauer, Simone, et al. “Influence of signal colored hand disinfectant dispensers on hand hygiene compliance at a medical intensive care unit.” American Journal of Infection Control 42.8 (2014): 926-928.
 Scheithauer, S., et al. “Workload even affects hand hygiene in a highly trained and well-staffed setting: a prospective 365/7/24 observational study.” Journal of Hospital Infection 97.1 (2017): 11-16.