INTRODUCTION:

Hand hygiene is the single most important factor in preventing nosocomial infections. It prevents transmission of pathogens by contact and the fecal- oral route [1], and its effectiveness has recently been reviewed by Larson [2]. The principles of hand washing are based on the work of Semmelweis, a pioneer in this field. [3]. Infection is a globally recognized problem that results in significant morbidity.[4] Joseph Lister was among the first to demonstrate the effect of skin disinfection on reducing infections.[5]

Thus, washing hands with antimicrobial soaps, warm water, and frequently with a brush became the primary protocol for hand preparation. Antiseptic soaps should rapidly eliminate transient skin flora and reduce resident flora on the hands to a minimum during a procedure, and thus lower the risk of contamination.[6]

Conventional surgical hand antisepsis consists of an aqueous scrub with a brush by using povidone iodine (PVP-I) or chlorhexidine-based detergents. However, scrubbing with these detergents strips skin oils, compromises skin integrity, and (if a brush is used) often causes micro abrasions, thereby increasing the risk of subsequent colonization by pathogens.[7] As a result, conventional surgical scrub has the disadvantages of skin damage and allergic skin reaction. It is also time consuming to use them. In the laboratory setting, an alcohol-based hand rub is as effective as conventional surgical scrub in its antimicrobial ability.[8,9] In addition, skin irritation or dermatitis happened less frequently with an alcohol-based hand rub in a small series of case studies. This can also help increase the compliance of hand washing by healthcare providers in hospitals. [10,11,12]

The density of bacteria on normal human skin ranges from 102 to 103 cfu/cm². These bacteria may limit colonization with more pathogenic microorganisms, just as fatty acids have antimicrobial efficacy [13]. Doctors can acquire pathogens from patients during their daily work and transmit them to susceptible patients. Multiple epidemics have been traced to contaminated hands of practioners [13-16]. Most of the transient flora is found on the uppermost level of the stratum corneum. The doctors’ hands are frequently contaminated by direct contact while caring for a patient or while touching a contaminated surface or device. Several studies have indicated that their hands may be colonized or contaminated with pathogens, such as Staphylococcus aureus [17,18], Klebsiellapneumoniae, Acinetobacter species, Enterobacter species, or Candida species.

In addition, Pittet et al. [19] demonstrated that microorganisms accumulate on their hands over time during patient care. Therefore, they can transmit pathogens even without previous contact with other patients. Even using gloves does not completely protect against contamination of the hands. Doebbeling et al. [20] put different microorganisms on gloved hands; they were able to isolate the same microorganisms on the skin after removal of the gloves that were placed on the gloved hands. Therefore, hand hygiene is still necessary along with the use of gloves.

Several alcohol-based hand rubs have been licensed for the commercial market, although there are few clinical studies to compare the antisepsis efficacy against conventional surgical scrub in a routine hospital environment. [19,21] Ours is an observational study in our hospital with the aim of comparing a conventional medicated and non-medicated soaps, chlorhexidine hand wash, ethanol based hand rub and medicated and non - medicated hand washes to evaluate their antisepsis efficacy before and after hand disinfection.

MATERIALS AND METHODS:

The participants were selected at random from a dental college in Chennai, Tamil Nadu, India. The samples were collected from dental graduates who were working in the clinic at that time. There were a total of 50 participants (n=50), 10 participants for each method of disinfection. This study tested 5 different disinfectants- a non medicated soap, a medicated soap, a non medicated hand wash, a medicated surgical standard handwash (with 4% chlorhexidinegluconate), and ethanol based hand rub. Every participant was sampled before the hand disinfection. They then performed the hand disinfection following the handwashing protocol using 2 ml of handwash. In case of hand rubs, 5ml was used. The hand washes and sops followed the standard handwashing protocol and for the alcohol based hand rub, the standard hand rub protocol was as followed. Another sample was obtained after disinfection. We used normal saline-moistened sterile cotton swabs to obtain specimens for cultures by wiping through every part of the hand (including the ventral and dorsal side of the hands), the fingertips, and the lateral sides of the fingers and the wrists. The samples were immediately inoculated onto brain heart infusion agar plates. We incubated plates at 37°C under aerobic conditions. We recorded the total bacterial contamination of hands as the number of colony forming units (CFU) recovered from both the fingertips and palm after 24 hours of incubation. The nutrient agar plates were checked 24 hours after incubation at 37c. The plate was counted for the number of colonies formed. The values obtained were neatly tabulated. The average number of bacterial colonies present after hand disinfection was calculated for each method of disinfection and the values are given in table 1. Our primary objective was the reduction of total bacterial hand contamination. we obtained the average percentage reduction for each participant by calculating the mean value of the total CFU.

RESULTS:

TABLE 1- PRECENTAGEOF BACTERIAL COLONIES AFTER DISINFECTION

METHOD OF DISINFECTION	BEFORE (CFU)	AFTER (CFU)	EFFICACY (%)
MEDICATED HANDWASH - 4% CHLORHEXIDINE GLUTAMATE	102	10.4	89.06%
ETHANOL BASED HAND SANITISER	85.6	14.5	83.06%
MEDICATED SOAP	100.6	16.2	84.04%
NON-MEDICATED HANDWASH	99.8	45.6	54.06%
NON-MEDICATED SOAP	101.2	52.8	48.06%

From table 1, it Is seen that the number of bacterial colonies before disinfection was 102CFU and after disinfection was 10.4CFU with medicated hand wash containing 4% chlorhexidine glutamate. The number of colonies present before and after disinfection with ethanol based hand sanitisers is 85.6CFU and 14.5CFU. The number of colonies present before and after disinfection with medicated soap is 100.6CFU and 16.2CFU. With non medicated ha swashbuckling it is 99.8 and 45.6CFU. Non medicated soap results are 101.2 CFUand 52.8CFU From the various methods of disinfection,it is evident that the number of bacterial colonies is minimum with medicated hand wash containing 4% chlorhexidine glutamate (10.04%). This is followed by the use of ethanol based hand sanitiser (17.04%) for 2 mins. Next is the use of medicated soap (16.02%), followed by non-medicated handwash (46.50%) and finally the maximum number of bacterial colonies present after hand disinfection is with the use of non-medicated soaps (52.06%).

Graph 1 shows the percentage of reduction in the number of bacterial colonies after each method of hand disinfection. The maximum reduction in the number of bacterial colonies is seen with medicated handwash containing 4% chlorhexidine glutamate. The percentage of reduction is 89%. Therefore, medicated hand wash containing 4% chlorhexidine is the best among the five methods of hand disinfection. Ethanol based hand sanitizer is next having an average reduction of 82%. This makes ethanol based hand sanitizers the next best alternative. Medicated soaps have shown an average reduction of 80%. Non-medicated hand washes and non-medicated soaps have a reduction of 53% and 47% respectively.

DISCUSSION:

Universal precautions require that perioperative health care personnel wash their hand before and after all patient contact. Time constraints, however, can make adhering to universal precautions, including proper hand washing, difficult. Some perioperative health care workers, therefore, routinely use rise-free hand sanitizers to supplement normal handwashing [22]. From our study, it is seen that disinfection using non-medicated soaps and hand washes have poor results. This is in accordance with a study by Meerset al., [23] which states ,hand washing with plain soap may fail to remove all transient microorganisms when contamination is heavy.Ojajarvi [24] demonstrated that hand washing did not always remove S. aureus and other patient-borne bacteria from the hands. In a study by Ehrenkranz and Alfonso [25], hand washing with bland soap failed to prevent transmission of gram-negative pathogens, but the alcohol in the same experiment did. Another clinical study indicates that hand washing with a medicated soap was insufficient to completely eradicate methicillin-resistant S. aureus on the hands of all nurses [26].

Water and soap appear to be more effective than waterless products for removal of soil and microorganisms from hands. Alcohol-based products achieve rapid and effective inactivation of various bacteria, but their efficacy is generally lower against non-enveloped viruses. The presence of food debris significantly affects the microbial inactivation rate of hand sanitizers. involves the use of water, soap, and friction to remove dirt and microorganisms. The availability of hand sanitizing products for use when water and soap are unavailable has increased in recent years. [27]

Hand washing is the primary barrier to prevent transmission of enteric pathogens via cross-contamination from infected persons. Our study concludes that handwashing with medicated hand wash containing 4% chlorhexidine has the best reduction in the number of bacterial colonies in terms of hand disinfection.This is in accordance with results from a study done by Smirtiet al., [28] which states that chlorhexidine has good disinfectant properties.However, compliance improved significantly by switchingfrom hand washing to use of a hand rub. Compliancewith hand hygiene procedures improved mainly by introducingthe hand rub into the hospital. [29]. Similar results were observed in Europe [29] and in the United States [18]. Therefore, thehand rub may be crucial to improvement of compliance. Theshorter time required for use of the hand rub may explain theenhanced compliance.

Contaminated hands or inanimate surfaces can act as a source of infection during outbreaks of human norovirus infection and hand sanitizers containing either ethanol and isopropanol concentrations ≥70% reduced the infectivity of human murine Norovirus.[30] According to a study by Dyer et al., the nonflammable, alcohol-free SAB hand sanitizer is the most favourable of the rise-free hand sanitizer formulas for normal hand washing [22]. Alcoholic compounds used as hand rub kill 3.2–5.8 log10 CFU,compared with the 1.8–2.8 log10 cfu in 30 seconds removed withmedicated soap [31]. Hand rubs are also highly effectiveagainst mycobacteria, the bacteria most resistant against anydisinfection process [32]. Multiple in vitro studies and in vivoexperiments indicate significantly better killing with hand disinfectantsthan with hand washing [33]. Hand washing and hand rubbingshow differing activity against viruses, but washing is generallyless effective than the use of a hand rub [34]. Hand rubs withisopropanol are generally more effective against small and/ornon-lipid viruses [35] but have limited efficacy against smallviruses, such as poliovirus or rotavirus. The most effective alcoholagainst viruses is ethanol (195%), which has been demonstratedto kill 3.2 log10 CFU of test organisms (poliovirus) [36]. Hand washing dries out the skin, and lipid replenishmenttakes 13hrs, whereas alcohol compounds only redistributelipids.Some commercial alcoholic rub-ins may change the colour of fingernails, resulting in poor acceptability and compliance. Ethanol is therefore, gentler on the skin in comparison with other alcohols and methods of disinfection. However, either strategy can result in dryness of the skin if no skin-care product is regularly applied [37].

CONCLUSION:

In conclusion, scientific evidence support theuse of a medicated hand wash for routine hand hygiene. It is microbiologicallymore effective in vitro and in vivo, even when hands are visibly soiled, andpreliminary data demonstrate better results than with ethanol based handrubs. However, use of a handrub is the standard for hand hygiene and have minimal side effects preventing dry skin and redistribute surface liquid. Therefore, it is an excellent alternativeto hand washing when antimicrobial efficacy, time for the procedure,and limited access to sinks are of concern.

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Received on 05.04.2018 Modified on 25.05.2018

Research J. Pharm. and Tech 2019; 12(1): 16-20.

DOI: 10.5958/0974-360X.2019.00004.0