{"id":2744,"date":"2015-04-28T07:55:18","date_gmt":"2015-04-28T07:55:18","guid":{"rendered":"http:\/\/biomedpharmajournal.org\/?p=2744"},"modified":"2016-10-26T06:54:23","modified_gmt":"2016-10-26T06:54:23","slug":"role-of-hand-washing-antiseptics-in-open-containers-as-source-of-pathogens-in-nosocomial-infections","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol6no2\/role-of-hand-washing-antiseptics-in-open-containers-as-source-of-pathogens-in-nosocomial-infections\/","title":{"rendered":"Role of Hand Washing Antiseptics in Open Containers as Source of Pathogens in Nosocomial Infections"},"content":{"rendered":"

Introduction <\/strong><\/p>\n

Seminal studies of Ignaz Semmelweis[1846] and Oliver Wendell Holmes[1843] have proved the role of hand washing with soap and water in between examination of two patients and disproved the role of just rinsing hands in antiseptics in preventing transmission of nosocomial infections in health care setting.[1,2]<\/sup>However, entry of hand washing antiseptics in open containers [HWAOC] for hand washing in health care setting,\u00a0 not recommended by Ignaz Semmelweis,Oliver Wendell Holmes, World Health Organization(WHO) or Centre for Disease Control(CDC),\u00a0 remains largely unknown. [IMAGE]\n

Outbreaks of nosocomial infections have most frequently incriminated the environmental sources like, ventilators circuits, suction apparatus, nebulizers and other patient care equipments especially contaminated antiseptic solutions, which form a\u00a0 suitable\u00a0 environmental niche for P. aeruginosa<\/em> and other gram negative pathogens which have tendency\u00a0 to remain viable on both animate and inanimate objects around the patient, including antiseptic solutions.[3,4]<\/sup>Contaminated antiseptics acting as a source of pathogens in nosocomial infections has been proved by several studies.[5,6]<\/sup><\/p>\n

Stringent hand washing with soap and water \u00a0is followed by HCWs\u00a0 at our hospital in between two\u00a0 patients during\u00a0 examination,with the exception of some\u00a0 areas where\u00a0\u00a0 antiseptic solutions \u00a0in open containers \u00a0are used. It was hypothesized that contaminated HWAOCmay act as \u00a0source of nosocomial pathogens, spreading through hands of HCWs after washing\/rinsing their hands in such solutions.<\/p>\n

Although, commonly used for hand washing both in resource poor government hospital and corporate hospitals, role of HWAOC in nosocomial infections has not been investigated by systematic studies. Hence the present study was conducted to determine rate of contaminated Hand Washing Antiseptics In Open Containers(cHWAOC)by In-use test \u00a0\u00a0and their role as\u00a0 source of\u00a0 pathogens in nosocomial infections.<\/p>\n

Materials And Methods<\/strong><\/p>\n

Study design<\/strong><\/p>\n

A hospital based cross sectional\u00a0\u00a0 observational study of two months duration was conducted in a tertiary care hospital with prior approval from Institutional Ethical Committee.A total of 65 HWAOC from Intensive care units(ICUs),Out patient departments (OPDs), Emergency ward, General wards and labor room were included in the present study.<\/p>\n

Specimen collection<\/strong><\/p>\n

One ml of\u00a0\u00a0 In-use antiseptic solution from open container was drawn into sterile 2ml disposable syringe and immediately added to 9 ml of nutrient broth in a sterile universal container with aseptic precautions.<\/p>\n

In-Use Test<\/strong><\/p>\n

0.02 ml of diluted antiseptic in nutrient broth from sterile universal container was spot inoculated onto ten different areas on two well dried nutrient agar plates. One plate was incubated at 370<\/sup>C\u00a0 for three days and the other for 7 days at room temperature.<\/p>\n

Antiseptic solution from a open container was considered as contaminated if there was growth in more than five spot inoculations on either plate.<\/p>\n

Bacterial strains and susceptibility testing<\/strong><\/p>\n

Bacterialisolates from cHWAOC on nutrient agar plates were sub-cultured on \u00a0Mac-Conkey agar and Blood agar (Hi media, Mumbai, India) and identified by standard laboratory procedures.[8] <\/sup>Antimicrobial susceptibility testing\u00a0 was\u00a0 performed on Muller Hinton agar (Hi media, Mumbai, India) by Kirby Bauer\u2019s disc diffusion method as per guidelines of\u00a0 Clinical Laboratory Standards Institute(CLSI).[9]<\/sup><\/p>\n

Typing of bacterial isolates<\/strong><\/p>\n

Isolates were typed by ANTIBIOGRAM TYPING.\u00a0 Association of isolates from cHWAOC with nosocomial infections was\u00a0 done by circumstantial evidence(Tempororspatial association) and\u00a0 bacterial\u00a0 isolates with identical antibiogram type from cHWAOC and cases. Results were quantitated by analyzing\u00a0\u00a0 microbiology culture reports during past six months.<\/p>\n

Exclusion Criteria \u00a0 \u00a0<\/strong><\/p>\n

Samples from freshly prepared \u00a0HWAOC were not\u00a0 collected.<\/p>\n

Samples from HWAOC not being used for hand washing were not\u00a0 collected.<\/p>\n

Questionnaire survey<\/strong><\/p>\n

Hand washing practices in HWAOC was studied to determine<\/strong><\/p>\n

Concentration of antiseptic used in HWAOC<\/p>\n

Frequency of changing antiseptics in HWAOC<\/p>\n

Method of washing containers of antiseptics<\/p>\n

Number of health care workers washing hands in HWAOC\/day<\/p>\n

Statistical Analysis<\/strong><\/p>\n

Distribution of cHWAOC was analyzed by Chi-square test.<\/p>\n

Results <\/strong><\/p>\n

HWAOC were used in 26\/54 wards, 4\/7 ICUs , all\u00a0 three areas of casualty and all OPDs for hand washing in between examination of two patients. A total of 46\u00a0 HWAOC, after excluding 14 were included in the present study.<\/p>\n

The present study revealed a\u00a0\u00a0 high rate of contamination, 28.26% (13\/46), with Savlon as the only antiseptic used in all HWAOC. Rate of contamination was highest in casualty 66.67%(2\/3) and lowest in OPDs 15.38(2\/13). Distribution of cHWAOC in different areas of hospital was statistically not significant. (P<\/em> \u22650.05)<\/p>\n

Table 1: Distirbution of Contaminated Hand Washing Antiseptics\u00a0 in Open Containers in Different Areas of the Hospital<\/strong><\/p>\n\n\n\n\n\n\n\n\n
AREAS OF THE HOSPITAL <\/strong><\/td>\nNUMBER OF SAMPLES TESTED <\/strong><\/td>\nNUMBER OF CONTAMINATED SAMPLES <\/strong><\/td>\nPERCENTAGE OF CONTAMINATED SAMPLES <\/strong><\/td>\n<\/tr>\n
WARDS<\/strong><\/td>\n26<\/td>\n7<\/td>\n26.92<\/td>\n<\/tr>\n
ICUs<\/strong><\/td>\n4<\/td>\n2<\/td>\n50<\/td>\n<\/tr>\n
CASUALTY<\/strong><\/td>\n3<\/td>\n2<\/td>\n66.67<\/td>\n<\/tr>\n
OUT PATIENT DEPARTMENTS <\/strong><\/td>\n13<\/td>\n2<\/td>\n15.38<\/td>\n<\/tr>\n
TOTAL <\/strong><\/td>\n46<\/td>\n13<\/td>\n28.26<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Note:\u00a0 ICU= Intensive care Units<\/p>\n

Pseudomonas aeruginosa<\/em> was the most common bacterial isolate from cHWAOC,29.41%(5\/17) followed by Acinetobacterbaumannii<\/em> 17.64%( 3\/17).\u00a0 Rhizopus spp, Aspergillus spp,<\/em> and many Mycelia sterilia <\/em>were also isolated. Aerobic spore bearers isolated were ignored.<\/p>\n

Table 2: Bacterial Isolates from Contaminated Hand Washing Antiseptics in Open Containers <\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n
NAME OF THE BACTERIAL ISOLATE<\/strong><\/td>\nNUMBER OF BACTERIAL ISOLATES <\/strong><\/td>\nPERCENTAGE <\/strong><\/td>\n<\/tr>\n
Pseudomonas aeruginosa<\/em><\/td>\n5<\/td>\n29.41<\/td>\n<\/tr>\n
Pseudomonas stutzeri<\/em><\/td>\n1<\/td>\n5.88<\/td>\n<\/tr>\n
Acinetobacterbaumanii<\/em><\/td>\n3<\/td>\n17.64<\/td>\n<\/tr>\n
Acinetobacterlwoffii<\/em><\/td>\n1<\/td>\n5.88<\/td>\n<\/tr>\n
Klebsiellapneumoniae<\/em><\/td>\n2<\/td>\n11.76<\/td>\n<\/tr>\n
Escherichia coli <\/em><\/td>\n2<\/td>\n11.76<\/td>\n<\/tr>\n
Staphylococcus aureus<\/em><\/td>\n1<\/td>\n5.88<\/td>\n<\/tr>\n
Coagulase negative staphylococci <\/em><\/td>\n1<\/td>\n5.88<\/td>\n<\/tr>\n
Nocardia species <\/em><\/td>\n1<\/td>\n5.88<\/td>\n<\/tr>\n
TOTAL<\/td>\n17<\/td>\n100<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Multiple antibiogram types of Pseudomonas aeruginosa<\/em>[PA-1 to PA-5] and Acinetobacter baumannii<\/em>[AB-1 to AB-3], Klebsiella pneumoniae<\/em>[KP-1 and KP-2] and Escherichia coli<\/em>[EC-1 and EC-2] and several other bacterial isolates\u00a0 which could not be typed, were observed. Multi drug resistant strains PA-3\u00a0 and AB-1\u00a0 were isolated from Surgical Intensive care unit and Intensive Cardiac care units respectively. PA-4, PA-5 and KP-2\u00a0 were isolated from orthopedics OPDs.<\/p>\n

Bacterial isolates from cHWAOC could be associated with 11 clinical cases[5\u00a0 in ICUs]\u00a0 by criteria used in the study.<\/p>\n

Table 3: Antibiogram Types of Pseudomonas Aeruginosa<\/em> Isolates <\/strong><\/p>\n\n\n\n\n\n\n\n\n
STRAINS <\/strong><\/td>\nANTIBIOGRAM TYPE <\/strong><\/td>\nAREA OF THE HOSPITAL <\/strong><\/td>\nNUMBER OF INFECTIONS CAUSED <\/strong><\/td>\n<\/tr>\n
PA-1<\/strong><\/p>\n

\u00a0<\/strong><\/td>\n

R to: Cpt,Pit,Spx,I, Tob, Pc, Net, Gat,Le,Ak, Nx, Ctx<\/p>\n

 <\/p>\n

S to:\u00a0 Others<\/td>\n

FEMALE SURGERY WARD [215]<\/td>\n2<\/td>\n<\/tr>\n
\u00a0<\/strong><\/p>\n

PA-2 <\/strong><\/td>\n

R to: Nil<\/p>\n

S to :\u00a0 All<\/td>\n

MALE SURGERY WARD [223]<\/td>\n1<\/td>\n<\/tr>\n
\u00a0<\/strong><\/p>\n

PA-3 <\/strong><\/td>\n

R to : Cz, Ax, Azm<\/p>\n

S to : Others<\/p>\n

 <\/p>\n

 <\/td>\n

SICU<\/td>\n–<\/td>\n<\/tr>\n
\u00a0<\/strong><\/p>\n

PA-4 <\/strong><\/td>\n

R to: Azm, As, Ax,, Cis, Cpt, Spx, Le, Ctx, Amc, Nx, Tob<\/p>\n

S to : Gat, Net, Ctr, Pit, Ic, Pc, Ak<\/td>\n

ORTHOPEDICS OPD [CCU]<\/td>\n2<\/td>\n<\/tr>\n
\u00a0<\/strong><\/p>\n

PA-5 <\/strong><\/p>\n

\u00a0<\/strong><\/td>\n

R to :\u00a0 Ctr.Azm, As, Ax, Cis, Cpt, Spx, Le, Amc, Nx, Tob<\/p>\n

S to : Pit, Ak, Ic, Net, Ctx, Gat<\/td>\n

ORTHOPEDICS OPD<\/td>\n–<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Note: SICU=Surgical Intensive Care Unit, CCU=Critical Care Unit, OPD= Out Patient Departments, PA-1to PA-5= Pseudomonas aeruginosa strains [1-5],R=Resistant , S=Sensitive,<\/p>\n

 <\/p>\n

Table 4: \u00a0Antibiogram Types of Acinetobacter Baumannii<\/em> Ioslates <\/strong><\/p>\n\n\n\n\n\n\n
STRAINS <\/strong><\/td>\nANTIBIOGRAM TYPE <\/strong><\/td>\nAREA OF THE HOSPITAL <\/strong><\/td>\nNUMBER OF INFECTIONS CAUSED <\/strong><\/td>\n<\/tr>\n
\u00a0<\/strong><\/p>\n

\u00a0<\/strong><\/p>\n

AB-1 <\/strong><\/td>\n

R to : Cz, Ax, Ak,Net, Pi, Tob, Nx,<\/p>\n

S to:\u00a0 Others<\/td>\n

 <\/p>\n

MICU<\/td>\n

 <\/p>\n

3<\/td>\n<\/tr>\n

\u00a0<\/strong><\/p>\n

AB-2 <\/strong><\/p>\n

\u00a0<\/strong><\/td>\n

R to :\u00a0 Cz, Ax, Azm<\/p>\n

S to :\u00a0 Others<\/td>\n

CARDIOLOGY<\/p>\n

WARD<\/td>\n

1<\/td>\n<\/tr>\n
\u00a0<\/strong><\/p>\n

AB-3 <\/strong><\/td>\n

R to :\u00a0 Cz, Ax, Amc, Azm, Cpt,<\/p>\n

S to :\u00a0 Others<\/td>\n

MALE SURGERY WARD [220]<\/td>\n <\/p>\n

–<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Note: MICU= Medical Intensive Care Unit, AB-1 to 3( Acinetobacterbaumannii ),R=Resistant , S=Sensitive<\/p>\n

 <\/p>\n

Table 5: Antibiogram Types of Klebsiella Pneumoniae<\/em>\u00a0 Ioslates<\/strong><\/p>\n\n\n\n\n\n
STRAINS <\/strong><\/td>\nANTIBIOGRAM TYPE <\/strong><\/td>\nAREA OF THE HOSPITAL <\/strong><\/td>\nNUMBER OF INFECTIONS CAUSED <\/strong><\/td>\n<\/tr>\n
KP-1<\/strong><\/p>\n

\u00a0<\/strong><\/td>\n

R to:\u00a0 Ax, Cpt, Net, Cz, Azm<\/p>\n

S to : Others<\/td>\n

FEMALE SURGERY WARD [215]<\/td>\n <\/p>\n

–<\/td>\n<\/tr>\n

KP-2 <\/strong><\/p>\n

\u00a0<\/strong><\/td>\n

R to :\u00a0 Ak, Cz, Tob, Net, Ax,<\/p>\n

S to : Others<\/td>\n

ORTHOPEDICS OPD<\/td>\n <\/p>\n

–<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Note:\u00a0 OPD= Out Patient Departments, R=Resistant , S=Sensitive<\/p>\n

 <\/p>\n

Table 6: Antibiogram Types of Escherichia Coli<\/em>\u00a0\u00a0 Ioslates<\/strong><\/p>\n\n\n\n\n\n
STRAINS <\/strong><\/td>\nANTIBIOGRAM TYPE <\/strong><\/td>\nAREA OF THE HOSPITAL <\/strong><\/td>\nNUMBER OF INFECTIONS CAUSED <\/strong><\/td>\n<\/tr>\n
EC-1 <\/strong><\/p>\n

\u00a0<\/strong><\/td>\n

R to : Ax, Amc, Cz, Azm<\/p>\n

S to : Others<\/td>\n

FEMALE SURGERY WARD [215]<\/td>\n2<\/td>\n<\/tr>\n
\u00a0<\/strong><\/p>\n

EC-2 <\/strong><\/td>\n

S to :\u00a0 All<\/td>\nEMERGENCY TRIAGE ROOM<\/td>\n <\/p>\n

–<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Note:\u00a0 EC= Escherichia coli, R=Resistant , S=Sensitive<\/p>\n

Questionnaire survey revealed\u00a0 variable concentration of Savlon used; 1:6 to 1:250 [2.5% to 17% v\/v] with tap water, not prepared by designated health care worker, variable number of health care workers washing their hands in \u00a0HWAOC[0-25\/day] with most common being 0-5[19%] and 5-10%[20%] excluding medical and nursing students. Different methods of washing containers: water alone 3(6.5%)\/ water and soap\u00a0 41(89.13 %)\/ water and Hypochlorite\u00a0 1(2.174%), Variable frequency of changing disinfectants: Once daily, 80.435 [37\/46] and twice daily, 17.391%[8\/46].<\/p>\n

Discussion <\/strong><\/p>\n

The present study, first of its kind to the best of our knowledge conducted to determine role of cHWAOC in nosocomial infections revealed important and significant findings in a health care setting\u00a0 with a changing scenario in hand washing practices in terms of strict adherence to hand washing in sinks with alcohol based hand washing solutions\/soap and water as per standard guidelines.<\/p>\n

Diluted Savlon in\u00a0 HWAOC for hand washing, the only antiseptic,being used without\u00a0 any\u00a0 guidelines from the local\u00a0 Hospital Infection Control Committee in some areas of our hospital necessitated the\u00a0 present study to determine their role as source of nosocomial pathogens.<\/p>\n

The present cross sectional study revealed a high rate of contamination,28.26%(13\/46) of HWAOC by\u00a0 In-use test, a simple, cheap yet clinically significant test\u00a0 suitable to asses the microbial contamination of in-use disinfectants.Similar studies on HWAOC are not available for comparison after thorough review of literature.However, a\u00a0 large multi centric longitudinal study conducted in Malaysian hospitals by Keahet al.<\/em>\u00a0 reported a lower rate of contamination; 16.4%( 1529\/9265)\u00a0 and 5.3%( 1\/9) for\u00a0 various in-use disinfectants and Cetrimide[one of the ingredients of Savlon] respectively, but not from HWAOC.[10]\u00a0 <\/sup>Gajadharet al.<\/em> have reported a contamination of 15%( 9\/60) for Savlon, both pre-use and in-use,\u00a0 as an highly contaminated antiseptic among the three antiseptics used in the hospital.[11]\u00a0 <\/sup><\/p>\n

Rate of contamination was highest in Casualty and ICUs than in General wards with diverse and often multi-drug resistant bacterial isolates. Distribution of contaminated HWAOC in different areas of the hospital was not statistically significant. Higher incidence of nosocomial infections in areas of the hospital with cHWAOC or vice versa i.e. lower incidence in areas withoutcHWAOC was not observed, indicating several other sources of nosocomial pathogens.<\/p>\n

The most common bacterial isolates from cHWAOC in the present study were P. aeruginosa, Acinetobacter baumannii <\/em>and Klebsiella pneumoniae <\/em>often \u00a0multi-drug resistant with multiple antibiogram types. P. aeruginosa<\/em> was the most common\u00a0 bacterial isolate from cHWAOC since Savlon, a mixture of Chlohexidinegluconate(0.3%v\/v IP) and\u00a0 Strong Cetrimonium bromide(0.6%w\/v BP) was the only antiseptic used in all HWAOC with\u00a0 Cetrimonium bromide acting as\u00a0 selective agent for P. aeruginosa.<\/em>\u00a0 This probably highlight that other isolates from cHWAOC may also be disinfectant resistant rather than representing recent contamination.Gajdharet al.<\/em> have reported that Pseudomonas spp.<\/em> as the only bacterial species isolated from all the contaminated disinfectants. However, Keahet al.<\/em> have reported diverse, Gram negative nonfermenters, predominantly Pseudomonas aeruginosa<\/em> from different disinfectants.[5]<\/sup><\/p>\n

In the present study, role of cHWAOC as source of pathogens by temporospatial association and identical antibiogram type of the isolate from cHWAOC\u00a0 and clinical cases could be established only in 11 nosocomial infections.\u00a0 However, Keahet al.<\/em> and Gajdharet al.<\/em> have not determined the role of contaminated disinfectants\/antiseptics in nosocomial infections by correlating isolates with clinical cases.[10],[11]<\/sup>Large ourbreak of P. maltophila<\/em> was reported by Wishart MM from contaminated Savlon from Australia.[5]<\/sup> Nosocomial infections due to contaminated disinfectants\/antiseptics will have grave consequences.[5],[6]<\/sup><\/p>\n

However, clinical correlation of isolates from cHWAOC with only 11 nosocomial infections appears largely, an underestimation of the role of cHWAOC as source of nosocomial pathogens. This fact is further strengthened by frequent isolation of\u00a0 bacteria with identical antibiogram types as that from cHWAOC\u00a0 from hand of Health Care workers as transient colonizers or carriers [ apart from other antibiogram types] in our hospital. For association of bacterial isolates from cHWAOC with cases, molecular methods of typing like PCR, though costly would be more useful.Antibiogram types, PA-3,PA-5,AB-3,KP-1,KP-2 and EC-2 could not be associated with nosocomial infections with the criteria used in the present study. However, this does not rule out that they have not caused any infection in the past or will not do so if\u00a0 cHWAOC are totally not banned.\u00a0 Contaminated disinfectants exhibit decreased efficacy and effectiveness. Large number of bacterial isolates from disinfectants have also exhibited resistance to commonly used antimicrobial agents thus posing a therapeutic challenge.[12],[13],[14]<\/sup><\/p>\n

Role of cHWAOCas source of\u00a0 nosocomial pathogens \u00a0in different areas of the hospital was probably not equally significant. Role of\u00a0 cHWAOC in\u00a0 CCU and MICU, 2 of the 4 ICUs with HWAOC, was clinically significant with P. aeruginosa<\/em>(PA-4) associated with 2 infections and Acinetobacterbaumannii<\/em>(AB-1) with 3 infections respectively. Both strains were also isolated from hands of HCWs acting as carriers in respective ICUs. Role of HWAOC as constant source but with different pathogens at different point of time is a strong possibility in our hospital. The finding is \u00a0further strengthened by the fact that P. aeruginosa , A. baumannii and K. pneumoniae<\/em> are most common pathogens at our ICUs, often multi-drug resistant with a complex and highly dynamic transmission and several environmental sources of pathogens.[15]<\/sup><\/p>\n

Although hand washing in sinks with soap and water or alcohol based hand washing solutions is ideal the same is practically impossible in\u00a0 hospital areas like ICUs, with sinks located in remote corners and heavy work load in terms of number of serious patients admitted in ICUs. This has already lead to replacement of HWAOC with alcohol based hand rubs in between two patients with terminal hand washing in sinks in majority of the ICUs.<\/p>\n

Two of the three cHWAOC[66.05%] from casualty were contaminated with P.stutzeri<\/em> and P. aeruginosa<\/em> and E. coli<\/em>[EC-2],from Green area and emergency triage room. This was a worrisome finding since new patients entering into the hospital might get colonized by disinfectant resistant and often multi-drug resistant bacteria. Due to lack of clinical correlation with cases, significance of cHWAOC from casualty could not be determined\/proved from the present cross sectional study.<\/p>\n

High rate of cHWAOC was observed, 26.92%[7\/26]\u00a0 with multi-drug resistant bacterial isolates in wards where strict hand hygiene is being\u00a0 practiced in between two patients, but unfortunately in HWAOC with hand washing in sinks\u00a0 only at the beginning\u00a0 and end of the duty shifts. Six of the seven cHWAOC were observed in surgical wards, the cause of which could not be identified. HWAOC were found to be persistently contaminated in surgical wards but with constantly changing bacterial flora,which was confirmed by sampling\u00a0 three times at different intervals.This\u00a0 confirms\u00a0 the role of cHWAOC as source of diverse bacteria which cannot be identified by a cross sectional\u00a0 study. Diverse, often multi drug resistant\u00a0 bacterial isolates\u00a0 from cHWAOC is not a complete list of nosocomial pathogens in our hospital \u00a0since\u00a0 a cross sectional study like ours, probably underestimates the role of cHWAOC as potential source of nosocomial pathogens.<\/p>\n

Rate of cHWAOC inOPDs was15.38%(2\/13)apparently not a significant risk factor considering the type of health care activities done in OPDs. Both (two) the cHWAOC were observed in OPDs of surgical specialty, the cause and the role of which in nosocomial infections could not be\u00a0 determined with certainty. However, certain procedures done in OPDs like, suture removal, wound dressing and cleaning of external fixators in Orthopedics OPD pose significant\u00a0 risk of acquiring nosocomial infections in patients.<\/p>\n

The In-use test used in the present study will not determine whether the contamination was \u00a0due to an inadequate concentration of disinfectant or whether organisms were surviving or growing at or above the recommended concentration and also inadequate concentrations of disinfectant in the absence of bacterial contamination will not be detected.[16]<\/sup>Majority of the cHWAOC showed confluent growth in all\u00a0 ten spot inoculations indicating a high microbial burden probably indicating disinfectant resistant bacteria rather than heavy contamination.[10]<\/sup> Relatively high microbial burden in cHWAOC is indicative of probability of attaining an infective dose and of establishing a nosocomial infection through hands of HCWs. The risk is further magnified when cHWAOC were found in Surgical wards, Surigical OPDs and ICUs as observed in the present study.<\/p>\n

In 43.48%5(20\/46)\u00a0 of HWAOC growth was observed in 1 to 4 spot inoculations, not declared as contaminated by the In-use test used in the present study. However, changing bacterial flora, often with high degree of microbial burden and variable number of health care workers washing their hands in HWAOC, even these HWAOC can be considered as potential source of nosocomial pathogens which probably could be proved by a longitudinal study.<\/p>\n

To overcome limitations of In-use test and\u00a0 tocomplement methodologyused in the present study to determine \u00a0factors influencing the contamination of HWAOC, a questionnaire method of survey was done. Second author, Phase III MBBS student collected tactfully all the information by inquiry, since the same done by the first author, an Infection Control Officer would have lead to bias in terms of false information[Theoretical] and over consciousness and over\u00a0 glorification of\u00a0 hand washing practices in HWAOC. This revealed several interesting findings, mainly a changing scenario from HWAOC to Alcoholic hand rubs or conventional hand washing in sinks in majority of the areas of the hospital including ICUs.<\/p>\n

Although findings of the questionnaire were \u00a0analyzed objectively, the inferences drawn appear more or less subjective and to some extent arbitrary. Several studies have reported that unhygienic practices during preparation and distribution of disinfectants\/antiseptics\u00a0\u00a0 contribute significantly to their contamination in a hospital environment. Inappropriate source of water as diluent, failing to maintain adequate cleanliness of the container were found to be important source of contamination by other studies.[5],[6],[10]<\/sup><\/p>\n

Although, findings of questionnaire survey analyzed and interpreted, clearly indicate factors responsible for contamination of HWAOC, this does not necessitate teaching, training or establishing\u00a0 guidelines for hand washing practices in HWAOC since HWAOC should be totally banned in health care setting and should be\u00a0 replaced by conventional hand washing in sinks and limited use of hand washing with alcohol based hand rubs in between two patients in busy hospitals.<\/p>\n

Limitations of the present study<\/strong><\/p>\n

Molecular methods of typing bacterial isolates from cHWAOC were not used.<\/p>\n

Implications of the present study<\/strong><\/p>\n

HWAOC were immediately banned and replaced by conventional hand washing in sinks with soap and water and inICUs by alcohol based hand rubs in between examination of two patients.<\/p>\n

Clear guidelines to ban hand washing in HWAOC were incorporated in the Infection control Manual of our\u00a0 Hospital Infection Control Committee.<\/p>\n

Further In-vitrostudies on disinfectant resistance will be conducted on preserved bacterial isolates from cHWAOC.<\/p>\n

Conclusions of the present study<\/strong><\/p>\n

Higher rate of contamination of HWAOC withPseudomonas aeruginosa<\/em> and Acinetobacterbaumannii<\/em> as most common isolates\u00a0 was\u00a0 observed.<\/strong><\/p>\n

Role of cHWAO as source of nosocomial pathogens though not proved conclusively, could not be ruled out by antibiogram typing and temporospatial association\u00a0 of isolates, necessitating further Phenotypic and Genotypic methods of typing of isolates.<\/p>\n

Variable concentrations of antiseptics and variable number of HCWs using HWAOC and improper washing of containers were found to be risk factors for contamination.<\/p>\n

Clear guidelines to be incorporated in WHO, CDC and other authorities regarding banning HWAOC in health care settings.<\/p>\n

Abbrevations<\/strong><\/p>\n

HWAOC<\/strong><\/p>\n

Hand washing antiseptics in open containers<\/p>\n

CHWAOC<\/strong><\/p>\n

Contaminated Hand washing antiseptics in open containers<\/p>\n

HCW<\/strong><\/p>\n

Health care worker<\/p>\n

WHO<\/strong><\/p>\n

World Health Organization<\/p>\n

CDC<\/strong><\/p>\n

Centre for Disease Control<\/p>\n

Cpt<\/strong><\/p>\n

Cefepime+Tazobactam<\/p>\n

Pit<\/strong><\/p>\n

Piperacillin+Tazobactam<\/p>\n

Spx<\/strong><\/p>\n

Sparfloxacin<\/p>\n

I<\/strong><\/p>\n

Imipenem<\/p>\n

Tob<\/strong><\/p>\n

Tobramycin<\/p>\n

Pc<\/strong>=Piperacillin<\/p>\n

Net<\/strong><\/p>\n

Netilmycin<\/p>\n

Gat<\/strong><\/p>\n

Gatifloxacin<\/p>\n

Le<\/strong><\/p>\n

Levofloxacin<\/p>\n

Ak<\/strong><\/p>\n

Amikacin<\/p>\n

Nx<\/strong><\/p>\n

Norfloxacin<\/p>\n

Ctx<\/strong><\/p>\n

Cefotaxime<\/p>\n

Amc<\/strong><\/p>\n

Amoxycillin+Clavalunic acid<\/p>\n

Ctr<\/strong><\/p>\n

Ceftriaxone<\/p>\n

Azm<\/strong><\/p>\n

Azithromycin<\/p>\n

As<\/strong><\/p>\n

Ampicillin+Sulbactam<\/p>\n

Ic<\/strong><\/p>\n

Imipenem+Cilastatin<\/p>\n

Cz<\/strong><\/p>\n

Cefozoline<\/p>\n

Ax<\/strong><\/p>\n

Ampicilli+Cloxacillin<\/p>\n

Acknowledgement<\/strong><\/p>\n

We duly acknowledge constant support and cooperation of all faculty members and laboratory technicians<\/p>\n

References<\/strong><\/p>\n

    \n
  1. Rotter M, Hand washing and hand disinfection. In: Mayhall, editor. Hospital Epidemiology and Infection Control. 2nd<\/sup> ed. Philadelphia: Lippincott Williams and Wilkins;1999.<\/li>\n
  2. Semmelweis I, Etiology, concept and prophylaxis of childbed fever. In: Carter KC, editors. 1st<\/sup> ed. Maidson, WI: The University of\u00a0 Wisconsin Press;1983.<\/li>\n
  3. Lowe C, Willey B, Shaugnessy AO, Lee W, Lum M, Pike K, et al. Outbreak of extended spectrum \u03b2-lactamase producing Klebsiellaoxytoca infections associated contaminated hand washing sinks. Emerging Infectious Diseases. 2012;8:1242-7.<\/li>\n
  4. Laupland KB, Parkins MD, Church DL. Population-based epidemiological study of infections caused by carbapenem-resistant Pseudomonas aeruginosa in the Calgary health region: Importance of metallo-beta-lactamase (MBL) producing strains. J Infect Dis 2005;192:1606-12.<\/li>\n
  5. Wishart MM, Riley TV. Infection with Pseudomonas maltophilia hospital outbreak due to contaminated disinfectant. Med J Austr 1976;2:710-12.<\/li>\n
  6. Zembrzuska, Sadkowska E. The danger of infections of the hospitalized patients with the microorganisms present in the prepartations and in the hospital environment. Acta Pol Pharm 1995;52:173-8.<\/li>\n
  7. White AB. Sterilization and disinfection in laboratory. In: Collee G, Barrie PM, Andrew PF, Anthony S, editors. Mackie and McCartney practical Medical Microbiology. 14th ed. New York: Churchill Livingstone;2006. p. 813-33.<\/li>\n
  8. Govan JR. Pseudomonas aeruginosa. In: Collee G, Barrie PM, Andrew PF, Anthony S, editors. Mackie and McCartney practical Medical Microbiology. 14th ed. New York: Churchill Livingstone;2006. p. 413-24.<\/li>\n
  9. Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing, Wayne,\u00a0 PA: Clinical Laboratory Standards 2007;27 (17,Suppl.).<\/li>\n
  10. Keah SC, Jegathesan M, Tan SC, Chan SH, Chee OM, Cheong YM et al.<\/em> Bacterial Contamination of Hospital Disinfectants. Med J Malaysia 1995;50:291-7.<\/li>\n
  11. Gajadhar T, Lara A, Sealy P, Adesiyun AA. Microbial contamination of disinfectants and antiseptics in four major hospitals in Trinidad. Rev PanamSalud \/ Pan Am J Public Health 2003;14:193-9.<\/li>\n
  12. Newmann KA, Tenney JH, Oken HA,\u00a0 Moody MR, Wharton R, Schimpff\u00a0 SC. Persistent isolation of an unusual\u00a0 Pseudomonas species from a phenolic disinfectant system. Infect Control 1984;5:219-22.<\/li>\n
  13. Whitemore E, Mcbee ML, Miner NA, Klasky S. Susceptibility of\u00a0 Pseudomonas to disinfectant. Respir Care 1975;20:745-9.<\/li>\n
  14. Winnefield M, Richard MA, Drancourt M, Grob JJ. Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use. Br J Dermatol 2000;143:546-50.<\/li>\n
  15. Yogeesha\u00a0 KVB, Jayasimha VL, Basavarajappa KG, Arun K, Raghu\u00a0 KKG, Niranjan HP. A comparative study of ventilator associated pneumonia and ventilator associated tracheobronchitis:\u00a0 Incidence, outcome and risk factors. Biosci Biotech Res Asia 2011;8(1):195-203.<\/li>\n
  16. Kelsey JC, Maurer IM, An in-use test for hospital disinfectants. Mon Bull Ministry Health Lab Services.1966;25:180.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    Introduction Seminal studies of Ignaz Semmelweis[1846] and Oliver Wendell Holmes[1843] […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[17],"tags":[],"class_list":["post-2744","post","type-post","status-publish","format-standard","hentry","category-vol6no2"],"_links":{"self":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/2744","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/comments?post=2744"}],"version-history":[{"count":6,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/2744\/revisions"}],"predecessor-version":[{"id":9324,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/2744\/revisions\/9324"}],"wp:attachment":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/media?parent=2744"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/categories?post=2744"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/tags?post=2744"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}