Authors: Elizabeth A. Scott PhD, MPhil. College of Natural, Behavioral and Health Sciences, Simmons University, MA, USA.
Exploring the evidence to support the role of home and community hygiene in preventing the spread of infection and reducing antibiotic resistance.
Recent global efforts to limit the spread of COVID-19 have put the spotlight on the importance of home hygiene practices as the first line of defense to prevent the spread of common infections. Optimal hygiene practices are vital to not only reduce the risk of both viral and bacterial infections and the need for antibiotics, but also to help mitigate the risk of antibiotic resistance by preventing the escalating spread of resistant bacteria in everyday life settings.
Antimicrobial resistance is one of the biggest global public health threats, with 2000 people worldwide currently dying as a result of an infection with resistant bacteria every day. Without prompt action, it is estimated that by 2050, around 10 million people could die each year as a result of bacterial resistance to antibiotics and other antimicrobial agents .
The latest analysis by the World Health Organization’s (WHO) Global Antimicrobial Resistance Surveillance (GLASS) program, which included data from 49 countries, found high levels of AMR in Escherichia coli, Klebsiella pneumoniae, Salmonella spp., Acinetobacter spp., Staphylococcus aureus and Streptococcus pneumoniae in every WHO region .
The spread of resistant bacteria in homes and communities
Home and everyday life settings provide multiple opportunities for spread of infection and now, increasingly multidrug-resistant bacteria have been found circulating in communities as well as hospital settings. These everyday settings include locations where normally there is no mandated hygiene policy as is typically found in clinical and educational settings; for example: workplaces, public transport, gyms, child day-care facilities and shopping centers.
Although multidrug-resistant (MDR) bacteria (i.e. bacteria that have acquired resistance to at least one agent in three or more antimicrobial classes) are typically hospital-acquired , studies conducted primarily in high-income countries show that some have become quite prevalent in the community .
Infected or colonized patients discharged from healthcare settings can remain persistent skin carriers of methicillin-resistant Staphylococcus aureus (MRSA), or fecal carriers of enterobacteria strains, which carry MDR factors (e.g. New Delhi metallo-beta-lactamase 1 [NDM-1] or extended spectrum beta-lactamase [ESBL] enzymes). Many community-onset infections are associated with recently discharged patients from a healthcare setting [5–9]. MDR strains can then be passed to other family members who become infected or colonized  although, carrier status is often not apparent as colonization does not necessarily result in clinical disease.
Factors affecting the spread of MDR bacteria into home and everyday life settings are complex. MRSA is probably the most important MDR bacterium to transition from healthcare settings to the community. The ease of transfer of MRSA from hospitals to the home via healthcare workers and others in contact with hospitals has been demonstrated in multiple studies [5–9]. This is further illustrated by a study  where significant levels of community and hospital strains of MRSA were recovered from high-frequency touch surfaces (door handles, toilet seats, reception areas, public washrooms, corridors and lifts) in public areas in the community and in London (UK) hospitals, suggesting cross-contamination between the two settings. Once in the home, MRSA can colonize and/or cause infection among family members [11–13]. Resistance to first-line drugs to treat infections caused by S. aureus – a common cause of severe infections in health facilities and the community – is widespread. People with MRSA are estimated to be 64% more likely to die than people with a non-resistant form of the infection .
Recent community acquired resistant strains
Since 2000, we have seen the emergence of new “community acquired” strains of MRSA (CA-MRSA). While healthcare-associated strains are mainly a risk to vulnerable people, for CA-MRSA, any family member is at risk and it is more prevalent among children and young adults where they cause infections of cuts, wounds and abrasions. Studies suggest the risk is greatest among those engaging in skin-to-skin contact activities and contact with contaminated objects such as towels, sheets and sports equipment. Transmission is common in settings such as prisons, schools and sports teams .
A study assessing the transmission of CA-MRSA in a university in the USA, found multidrug-resistant USA300 – responsible for diseases including necrotizing pneumonia, severe sepsis and necrotizing fasciitis – on common touch surfaces at the university, student homes and local community settings. This suggests transfer between different locations within the community .
Enterobacterales are a common cause of community-associated infections, including urinary tract infections and bacteremia as well as gastrointestinal infections . Resistance in community-associated enterobacterales mediated by extended spectrum β-lactamases is now common in Asia, the Middle East, South America and some parts of Europe. A 2012 study in Birmingham (UK) indicated that the proportion of E. coli carrying CTX-M ESBL genotypes in a community population was 11.3% , while a 2006–2011 study  reported a 10-fold increase (from 0.6% and 6% respectively) in ESBL-producing E. coli fecal carriage in healthy subjects in a Parisian community.
Overall, the evidence suggests that MDR strains of bacteria, like any other strains of bacteria, can enter the home or other settings via people who are infected or colonized or via contaminated food and can be spread to other members of the family via hands and contaminated surfaces.
Poor hygiene and vulnerable family members increase spread of infections
Poor hygiene is considered a major factor in the transmission of community-based infections, including gastrointestinal (GI) and respiratory tract (RT) infections such as colds and influenza, and skin infections caused by S. aureus . For the elderly, communal living environments, combined with problems of fecal incontinence, create an environment in which enteric and foodborne pathogens are easily spread. As a result, the incidence of salmonellosis and campylobacteriosis appears to be higher among the elderly in these situations.
More vulnerable ‘at risk’ members of society are now being looked after outside hospital settings. For example, in Germany, it is estimated that approximately three-quarters of all people in need of care are currently being cared for at home. In the community the immunocompromised are also at risk from opportunistic pathogens such as E. coli, Klebsiella spp., and Pseudomonas aeruginosa, which are considered hospital related .
How hygiene interventions prevent infections and the spread of AMR
Good hygiene contributes to the fight against AMR by preventing infection, therefore reducing the need for antibiotic prescriptions and preventing person-to-person spread of antibiotic resistant bacterial pathogens. If implemented effectively, home and everyday life hygiene has the potential to reduce rates of infection and the need for antibiotic prescriptions, thereby reducing the selective pressure for the development and subsequent dissemination of resistance [20, 21]. As witnessed in the recent global efforts to contain the SARS-CoV-2 virus and delay the spread of COVID-19, hygiene practices including handwashing are the first line of defense to reduce the transmission of infection. Targeted hygiene also helps to reduce spread of bacterial species with a low degree of pathogenicity (opportunistic pathogens) such as, enterococci, that are known to contain MDR determinants. These can form reservoirs of resistance determinants, which can be disseminated by horizontal transfer to other pathogenic species .
What is targeted hygiene?
Targeted hygiene means focusing hygiene practices in places and at times (referred to as “risk moments”) when harmful microbes are most likely to be spread, in order to break the chain of infection transmission.
Microbiological data [19,20] suggest that the surfaces that are most often responsible for spread of harmful microbes at key moments include the hands themselves, hand contact surfaces, food contact surfaces, cleaning cloths and other cleaning items. These surfaces are referred to as critical surfaces or critical control points. Clothing, household linen, toilets, sinks and bath surfaces may also contribute to establishing a chain of infection, however, the risks associated with these surfaces are typically lower as they rely on the hands and other “chain links” to disseminate infectious microbes to cause human exposure.
In the past, recommendations on selection of hygiene procedures for home and everyday life were based on the health status of family members, and it is still argued by some that disinfectants should only be used in situations where people are infected or at increased risk of infection. However, if home and everyday life hygiene is to be effective, it is important to take into account the established evidence from models simulating use conditions, showing that, in some risk situations, hygiene procedures that involve just wiping or detergent-based cleaning are insufficient .
These studies have been highlighted in a recent paper  developed by the Global Hygiene Council experts, published in the American Journal of Infection Control, which suggests that targeted hygiene in the home and other community settings can prevent infections, reduce rates of illness, and, importantly, reduce the use of antibiotics. Moreover, if combined with the provision of clean water and sanitation, targeted hygiene can reduce the circulation of resistant bacteria in homes and communities in all regions, helping to manage the escalating threat of AMR.
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