# Impact of a multimodal hand hygiene intervention on methicillin-resistant Staphylococcus aureus carriage among healthcare workers in Libya: a quasi-experimental pre–post study

## TL;DR

A hand hygiene program in a Libyan hospital reduced MRSA carriage among healthcare workers and lowered multidrug resistance, offering a low-cost solution for infection control in low-resource settings.

## Contribution

Demonstrates the effectiveness of a multimodal hand hygiene intervention in reducing MRSA carriage and multidrug resistance in a low-resource setting.

## Key findings

- MRSA carriage decreased from 31.1% to 19.5% after the intervention.
- Hand hygiene compliance improved from 42.7% to 71.3%.
- The median MAR index decreased, indicating reduced multidrug resistance burden.

## Abstract

Healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) remains a major threat in low-resource settings, where interventional evidence linking improvements in hand hygiene (HH) to changes in MRSA carriage among healthcare workers (HCWs) is limited. We evaluated the association between implementation of a multimodal HH program and MRSA carriage in a tertiary-care hospital in Libya.

We conducted a quasi-experimental pre–post study (January–December 2024) across four hospital units (intensive care unit, neonatal intensive care unit, surgical ward, and radiology department). Paired anterior nares swabs were collected from HCWs at baseline and one year after intervention implementation. MRSA was identified using cefoxitin disk diffusion according to CLSI 2024 guidelines. Antimicrobial susceptibility testing was performed by the Kirby–Bauer method, and vancomycin minimum inhibitory concentrations were determined using E-test. HH compliance was assessed using WHO observational methods. The primary analysis used McNemar’s test and generalized estimating equation (GEE) logistic regression, while multidrug resistance was summarized using the multiple antibiotic resistance (MAR) index.

Among 318 paired HCWs, MRSA carriage decreased from 31.1 (99/318) at baseline to 19.5% (62/318) post-intervention (absolute reduction of 11.6 percentage points; p < 0.001). The adjusted odds of MRSA carriage post-intervention were 0.52 (95% CI 0.36–0.75; p < 0.001). HH compliance improved from 42.7% (486/1139 observed opportunities) to 71.3% (801/1123; p < 0.001). Although individual antimicrobial resistance proportions remained largely unchanged, the median MAR index decreased from 0.42 (IQR 0.33–0.50) to 0.33 (IQR 0.25–0.42) (p < 0.001), indicating a reduction in the overall multidrug resistance burden among circulating MRSA isolates. No vancomycin resistance was detected.

Implementation of a multimodal WHO-aligned HH intervention was associated with a significant reduction in MRSA carriage among HCWs and a lower overall multidrug resistance burden, as reflected by the MAR index. These findings provide pragmatic, low-cost evidence to support strengthening infection prevention and control programs in Libya and comparable low- and middle-income country settings.

The online version contains supplementary material available at 10.1186/s13756-026-01721-y.