Bland Soap Handwash - Research Paper Example

On better hand washing techniques Good practices of asepsis, sterilization and disinfection are of utmost importance in treatment and care of the sick and immunosuppressed people. According to health care professionals, MRSA (Methicillin resistant Staphylococcus aureus) is a serious concern in hospitals and is identified as one of the biggest killers in NHS. Hand washing is the single most effective technique which can help prevent a large number of nosocomial (hospital acquired) infections. Normal hand washing procedure was compared to the NHS standard methods in this study. Assessment was based on the E. coli K 12 colony count before and after the hand washing, E.coli K12 strain being the indicator organism used in the study. In normal hand wash, the reduction factor was found to vary from 2.4 - 4.18 where as in case of NHS hand wash the value ranges from 0.86 – 2.91. The average reduction factor was found to be higher in case of the NHS hand wash. NHS protocol of hand rubbing for 30 seconds was found very effective in bringing down the microbial load of the hands. Aim of the study: The major objective of the study was to compare the normal hand washing techniques with that of NHS standard techniques (in accordance with BS EN 1500). Assessment was based on the E.coli count before and after the hand washing. E.coli normal inhabitants of the normal intestine and they are excreted out in large numbers to the outside through human faeces. Presence of E.coli is thus an indication of feacal contamination of the concerned food item or object by means of insects or human hands. Adequate hand hygiene is the most effective method of preventing infection in hospitals, homes and workplaces. Introduction: Health care related problems has been in the air for the past two decades with an alarming rate of nosocomial infections. The public concern on hand hygiene has stimulated a review of the scientific data regarding the same and the development of new guidelines designed to improve hand-hygiene practices in health-care facilities. Proper hand washing using detergents like soap was considered as a criteria of personal hygiene since olden days. In 1843, Oliver Wendwell Holmes brought to light the reason for perpural fever found in parturient women as improper hand hygiene of health professionals. The Healthcare Infection Control Practices Advisory Committee (HICPAC) in the year 1995 recommended that either antimicrobial soap or a waterless antiseptic agent should be used for cleaning hands upon leaving the rooms of patients with multidrug-resistant pathogens like vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). Scores of hospitalized people get infected due to lack of hand hygiene of the health care professionals. European norms set down for the testing of anti microbials and handrubs -EN1500 form the basis of this analysis. Conventionally hand washing is performed using soft soaps, antiseptic soaps, alcoholic solutions, Iodine or iodophore solutions or other organic compounds. Most of the traditional aseptic hand washing methods have its on pros and cones and none has proved 100% bactericidal, most of them are only bacteriostatic. In this study an attempt was made for comparing the normal handwashing techniques with the NHS standard hand washing technique towards electing the better hand washing procedure. A harmless E.coli, E.coli K12 was used as an indicator of the contamination in this study. Review of literature: Microbial flora of the skin: Bacteria recovered from the hands mainly fall into two categories: transient and resident flora. Transient flora colonizes the superficial layers of the skin and are mostly removed by routine handwashing. They are often acquired by Health care workers (HCW)s during direct contact with patients or contact with contaminated environmental surfaces within close proximity of the patient. Transient flora are the organisms most frequently associated with health-care--associated infections. Resident flora, which are attached to deeper layers of the skin, are more resistant to removal. Resident flora like coagulase-negative staphylococci and diphtheroids are less likely to be associated with such infections. The hands of HCWs may become persistently colonized with pathogenic flora (e.g., S. aureus), gram-negative bacilli, or yeast. Modes of transmission: HCWs can contaminate their hands with gram-negative bacilli, S. aureus, enterococci, or Clostridium difficile by performing "cleaning procedures" (Ehrenkranz NJ,1991; McFarland LV,1989; Samore MH; 1996; Ojajärvi J,1980). Personnel caring for infants with respiratory syncytial virus (RSV) infections have acquired RSV (e.g., feeding infants, changing diapers) (Hall C.B,1981). RSV may be transmitted by contaminating their hands with RSV and inoculating their oral or conjunctival mucosa. Contamination of HCWs hands also occurred during direct wound care, intravascular catheter care, respiratory-tract care, and the handling of patient secretions (Pittet D,1999). Detecting contamination: Agar fingertip impression plates were used to culture and identify contaminant bacteria; the number of bacteria recovered from fingertips ranged from 0 to 300 CFUs. Data from this experiment indicated that direct patient contact and respiratory-tract care were most likely to contaminate the fingers of caregivers. Among the isolates from HCWs, Gram-negative bacilli accounted for 15% of isolates and S. aureus for 11%. Duration of patient-care activity was strongly associated with the load of bacterial contamination on care givers hands. Aseptic techniques: Hand disinfection procedures reduces the incidence of health-care--associated infections (Larson E,1988; 1989). Antiseptic hand washing was found to reduce hospital acquired infections very much (Maki DG,1989). Infection rates were lower after antiseptic handwashing using a chlorhexidine-containing detergent compared with handwashing with plain soap or use of an alcohol-based hand rinse (Doebbeling BN, 1992). Methods of evaluation of the hand hygiene products: Studies on product evaluation can be placed into two major categories: studies focusing on products to remove transient flora and studies involving products that are used to remove resident flora from the hands. The studies of products for removing transient flora from the hands of HCWs involve artificial contamination of the volunteers skin with a defined inoculum of a test organism before the volunteer uses a plain soap, an antimicrobial soap, or a waterless antiseptic agent. On the other hand, products used for the preoperative cleansing of surgeons hands are tested for their ability to remove resident flora without artificially contaminating the volunteers hands. EN 1500: The widely used method in Europe for evaluation of the efficacy of hand-hygiene agents is European Standard 1500--1997 (EN 1500---Chemical disinfectants and antiseptics. Hygienic hand-rub test method and requirements). This method requires 12 to 15 test volunteers and an 18- to 24-hour growth of broth culture of E. coli K12. Hands are washed with a soft soap, dried, and then immersed halfway to the metacarpals in the broth culture for 5 seconds. Hands are removed from the broth culture, excess fluid is drained off, and hands are air dried for 3 minutes. Bacterial recovery for the initial value is obtained by immersing the fingertips of each hand separately for 60 seconds in 10 mL of tryptic soy broth (TSB) without neutralizers. The hands are removed from the broth and disinfected with 3 mL of the hand-rub agent for 30 seconds . The same procedure is repeated with total disinfection time not exceeding 60 seconds. Both hands are rinsed in running water for 5 seconds and water is drained off. Fingertips of each hand are immersed separately in 10 mL of TSB with added neutralizers. These broths are used to obtain the final value. Log10 dilutions of recovery medium are prepared and plated . Within 3 hours, the same volunteers are tested with the reference disinfectant (60% isopropanol) and the test product. Colony counts are performed after 24 and 48 hours of incubation at 36ºC. The average colony count of both left and right hand is found out. The log-reduction factor is calculated and compared with the initial and final values. The reduction factor of the test product should be superior or the same as the reference alcohol-based rub for acceptance. Hand hygiene products in use: Plain, non-antimicrobial soap: Soaps contain esterified fatty acids and sodium or potassium hydroxide. Plain soaps have detergent properties which makes them organic dirt particles from a surface. They have only a minimal antimicrobial activity. Use of plain soap can only remove only loosely adhering transient microflora. Alcohol: Alcohol-based hand antiseptics contain either isopropanol, ethanol, n-propanol, or a combination of two of these products. Anti microbial effect of alcohol is by protein denaturing (Larson EL,1991). Alcohol solutions containing 60%--95% alcohol are found to be most effective antimicrobials. Alcohols are found to be effective against multidrug-resistant pathogens (e.g., MRSA and VRE), Mycobacterium tuberculosis, and various fungi (Price PB,1939; Harrington C,1903; Coulthard CE, 1936; Pohle WD,1940; Gardner AD,1948; Sakuragi T, 1995; Kampf G, 1998; Kampf G,1999). Certain enveloped (lipophilic) viruses (e.g., herpes simplex virus, human immunodeficiency virus (HIV), influenza virus, respiratory syncytial virus, and vaccinia virus) are susceptible to alcohols when tested in vitro (Larson EL,1991; Platt J,1985; Krilov LR,1993). Other anti microbial agents: Chlorhexidines which are effective against gram positive bacteria, Chloroxylenol, also known as parachlorometaxylenol (PCMX) an active agent in antimicrobial soaps. Hexachlorophene is bacteriostatic, with good activity against S. aureus and relatively weak activity against gram-negative bacteria, fungi, and mycobacteria (Larson E,1988). Iodophors are active ingredients in antiseptics. Iodophor preparations used for hand hygiene contain 7.5%--10% povidone-iodine. Formulations with lower concentrations also have good antimicrobial activity because dilution can increase free iodine concentrations (Berkelman RL ,1982)Quaternary ammonium compounds are used as bacteriostatic and fungistatic agents. Triclosan is yet another antimicrobial agent in use. Materials and Methods: Bacterial strain: Non pathogenic E.coli K12 strain was used as the indicator organism for evaluation of the bacterial load of the hands. Hand washing procedure: Pre wash and post wash values are detected from E.coli culture of the samples on specific media plates. Two different washing methods were compared to spot out the better one. Hands were washed clean with soft soap for 1 minute, dry using a paper towel. Immerse fingers till the middle knuckle in E.coli solution for 5 seconds, air dry for 5 minutes holding fingers horizontally and gently turning. Rub fingertips in TSB (Tryptic soy broth) for 1 minute. Add soap and rub as normal or add soap rub using NHS standard process for 30 seconds. This step being the sole difference in procedure between the two methods compared. Rub finger tips in TSB for 1minute. Wash hands with soap, dry using paper towel and repeat. Sampling was done as follows; there were six participants-3 normal and 3 NHS standards. Serial dilution of samples were done. 1 ml was plated from each 10ml dilution. Upto 10-5 to 10-7 dilutions were prepared in case of pre wash and 10-2 to 10-3 dilutions in case of post wash samples. Post wash values were deducted from pre wash values and the reduction factor was found out. Plated samples were incubated for 24 hrs at 360Cto allow bacterial growth and then the colonies were counted. Observation: 1. Normal hand wash: 2. NHS standard technique: Conclusion: The serial dilutions of TSB of pre and post samples were plated on Enrichment media for E.Coli, and the pltes were incubated at 360C for 24 hrs and the colonies of e.coli were counted and expressed as colony forming units (CFU/mL). Pre wash and Post wash values are thus found out. In normal hand wash, the reduction factor was found to vary from 2.2 - 4.6 where as in case of NHS hand wash the value ranges from 0.86 – 2.91. The average reduction factor was found to be higher in case of the NHS hand wash. Microbial load was reduced considerably following the use of the NHS hand washing protocol and hence it is found to be superior to the normal hand wash.. Normal hand washing techniques doesn’t have any antimicrobial effect and hence it helps only in evading the superficial contaminants. Under the normal washing methods, only the superficial bacteria and microorganism are cleaned and the deeply lodged contaminants remain intact. This it could be seen that Ordinary washing is not very beneficial in addressing to bacteria in dermis of hands of HCW. However, as seen from the empirical studies, NHS washing protocol brings down the microbial load considerably as evident from the reduction in factor value. Again the average reduction rate is also significantly lower in the case of NHS washing as compared to normal hand wash. The only differences between the two procedures in the step where the soap rub is applied using NHS standard method for 30 seconds. The method has the advantage of reducing the bacterial load by virtue of the 30 seconds hand rub procedures. The study therefore concludes that the NHS hand wash technique can contribute to improved hand hygiene among health care workers since microbial invasion is lower in the case of NHS as compared to Normal Hand wash and therefore, it may be concluded that the NHS is a far more superior technique as compared to Normal wash method since it is able to reduce the level of contamination significantly and thus add to safety and hygiene of the Health Care Workers. References: 1. Berkelman RL, Holland BW, Anderson RL. Increased bactericidal activity of dilute preparations of povidone-iodine solutions. J Clin Microbiol 1982;15:635-9. 2. Coulthard CE, Sykes G. The germicidal effect of alcohol with special reference to its action on bacterial spores. Pharmaceutical Journal 1936;137:79--81. 3. Doebbeling BN, Stanley GL, Sheetz CT, et al. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med 1992;327:88--93. 4. E. L. Larson ; C. Gomez-Duarte; L. V. Lee; P. Della-Latta; D. J. Kain and B. H. Keswick. Microbial flora of hands of homemakers. American Journal of Infect. Control. 2003 Apr; 31(2): 72-9. 5. E. Larson; A. Aiello; L.V. Lee; P. Della-Latta; C. Gomez-Duarte and S. Lin. Short- and long-term effects of handwashing with antimicrobial or plain soap in the community. Journal of Community Health. 2003 Apr; 28(2): 139-50. 6. Ehrenkranz NJ, Alfonso BC. Failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters. Infect Control Hosp Epidemiol 1991;12:654--62. 7. European Committee for Standardization. Chemical disinfectants and antiseptics---hygienic handrub---test method and requirements (phase2/step2) [European standard EN 1500]. Brussels, Belgium: Central Secretariat: 1997. 8. Gardner AD. Rapid disinfection of clean unwashed skin: further experiments. Lancet 1948:760--3. 9. Hall CB, Douglas RG. Modes of transmission of respiratory syncytial virus. 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Arch Surg 1939;38:528--42. 30. Rotter M. Hand washing and hand disinfection [Chapter 87]. In: Mayhall CG, ed. Hospital epidemiology and infection control. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 1999. 31. Sakuragi T, Yanagisawa K, Dan K. Bactericidal activity of skin disinfectants on methicillin-resistant Staphylococcus aureus. Anesth Analg 1995;81:555--8. 32. Samore MH, Venkataraman L, DeGirolami PC, Levin E, Arbeit RD, Karchmer AW. Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am J Med 1996;100:32--40. 33. Teare EL, Cookson B, French G, Gould D, Jenner E, McCulloch J. Hand washing--A modest measure-with big effects. British Medical Journal. 1999; 318:686. 34. Teare, L;Cookson, B; Stone, S; Stanwell-Smith, R; French, G; Gould, D; Jenner, E.A; et al. Handwashing: answering and pursuing compliance. Journal of Hospital Infection. 2001 Jul; 48(3):244-5. Read More