3.

WHO‐based multimodal interventions compared with some or no interventions for promotion of hand hygiene or reduction of infection or colonisation rates
Patient or population: Healthcare workers Settings: Acute care hospitals Intervention: Multimodal with all five strategies recommended by WHO: ABHR at point of care, education, performance feedback, reminders, and administrative support. Comparison: Varied by study
Outcomes	Impact	Studies	Certainty of the evidence (GRADE)
Hand hygiene compliance	The absolute difference in hand hygiene compliance between intervention and control group was 6.3 percentage points in the RCT. One ITS reported a difference of 17 percentage points in hand hygiene compliance compared to baseline, while another ITS reported no change on medicine units and a RR of 1.56, 95% CI 1.29 to 1.89 in IDUs favouring intervention. One ITS in a multistate system reported an increase of 27.45 ounces of ABHR per adjusted bed‐day. One ITS did not report estimates of change	1 RCT, 4 ITS 1 multistate system with 166 hospitals, 5 hospitals and 13 ICUs	⊕⊝⊝⊝ very low1
Infection rates	1 ITS reported a decrease in blood stream infections of 0.191 cases per 1000 line‐days and a decrease in ventilator‐associated pneumonia of 0.538 cases per 1000 ventilator days. 1 ITS reported that MRSA decreased by 0.03 clinical isolates for each litre of ABHR per 100 patient‐days but there was no change in C. difficile	2 ITS 3 hospitals and 13 ICUs	⊕⊝⊝⊝ very low2
Colonisation rates	1 RCT reported no difference in MRSA colonisation. 1 ITS reported a slight decrease in MRSA acquisition (IRR 0.976 favouring intervention) but no change in VRE or HRE acquisition.	1 RCT, 1 ITS 1 multistate system with 166 hospitals, 1 hospital	⊕⊕⊝⊝ low3
GRADE Working Group grades of evidence High certainty: Further research is very unlikely to change our confidence in the estimate of effect. Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very certainty: We are very uncertain about the estimate. Abbreviations: ABHR: alcohol‐based hand rub; C. difficile: Clostridium difficile; CI: confidence interval; HRE: highly‐resistant Enterobacteriaceae; ICU: intensive care unit; IDU: immunisation and diagnosis unit; ; ITS: interrupted time series; MRSA: methicillin‐resistant Staphylococcus aureus; RCT: randomised (controlled) trial; RR: risk ratio; VRE: vancomycin‐resistant enterococci; WHO: World Health Organization

¹Evidence downgraded from high to very low due to non‐randomised evidence (four of five studies); high risk of bias (four of five studies have two or more sources of high risk of bias), and inconsistency in effect sizes between studies and within multi‐unit studies.
 ²Evidence downgraded from high to very low due to non‐randomised evidence (two studies), high risk of bias (studies have two or more sources of high risk of bias), and inconsistency in effect sizes between studies and within multi‐unit studies.
 ³Evidence downgraded from high to low due to non‐randomised evidence (one of two studies), high risk of bias (both studies have two or more sources of high risk of bias), and inconsistency in results with one study reporting changes for some microorganisms but not others and the other reporting no change.