Efficacy of Hand rubbing
with alcohol based solution versus standard hand washing with soap and water in
a Tertiary care Hospital in The North Iran
Aydin Pourkazemi1, Ali
Mojtahedi2*,
Samaneh Kazemi3, Masoud Asgari4
1Razi
Clinical Research Development Unit, Guilan University of Medical Sciences,
Rasht, Iran
2Department
of Microbiology, School of Medicine, Guilan University of Medical Sciences,
Rasht, Iran
3Deputy
of Research and Technology, Guilan University of Medical Sciences, Rasht, Iran
4School
of Medicine, Guilan University of Medical Sciences, Rasht, Iran
*Corresponding Author E-mail: alimojtahedi@yahoo.com
ABSTRACT:
Nosocomial infections have a growing trend and are a
serious threat to the health system. The aim of this work was to compare the
effectiveness of hand rubbing with alcohol-based solution and standard hand
washing with soap and water on transient flora of hands in intensive care unit
(ICU) staff. This cross-sectional study was done at Razi Hospital, Rasht, Iran
between March to August 2016. Nurses who were willing to participate were
included. In each group (alcohol group, typical soap group), 50 health cares
were considered randomly (a total of 100 health cares in two groups). Since 4
samples were taken from each care (two samples before work and two samples
after work, both of which were taken before and after washing), a total of 400
samples were analyzed for microbial status. A total of 15 nurses (all were
female) with 100 samples were included. The most rate of colony count before
hands washing and operation was 45.8±39.99 CFU/ml, and the least rate after
hand washing with alcohol after the operation was 15.07±31.87CFU/ml. There was
a significant relationship between colony count and the measured time. There
was also a significant relationship between alcohol and soap groups,as the
reduction in the alcohol group was 20.58±54.4 and in soap group was 2.66 ±
48.17 (p=0.001).Our study showed that alcohol significantly decreased
colony counts of staffs’ hands after operation in intensive care unit, whereas
no significant differences were seen with soap solution.
KEYWORDS:
Nosocomial infections, Hand disinfection, Intensive care units, Alcohol-based
solution.
INTRODUCTION:
Nosocomial infections are a major threat in
most hospitals and have a high prevalence in the developing countries,
especially in the intensive care units (ICU), where direct contacts between
hands of health care workers (HCWs) and the patients occurs, which mandates the
strict adherence to infection control policies and standards [1-3]. In the ICU, patients are often exposed to multiple
procedures, invasive devices etc., which increases the acquiring such potential
pathogens [1]. The growing use of antibiotics is resulting in
increase in trend of resistant strains; unfortunately, these pathogens
sometimes exhibit multiple drug resistance (MDR) [4]. MDR bacteria show resistance to at least one agent
in more than three classes of antibiotics [5].
Hand washing is emphasized as the most important
measure to prevent cross transmission of microorganisms and thus nosocomial infections
[2]. However, compliance with this measure under routine
hospital practice is still unacceptably low, less than 50% in most published
studies in the past 20years. This constant finding is worrying because recent studies
have shown that this level of compliance will not reduce the risk of MDR
transmission in hospital [6].
There are two types of colonizing flora in hands: the
resident flora, which consists of microorganisms residing under the superficial
cells of the stratum corneum and the transient flora, which colonizes in the
superficial layers of the skin, and is more amenable to remove by routine hand
hygiene [2]. Transient microorganisms survive, but do not usually
multiply on the skin. They are often acquired by HCWs during direct contact
with patients or their nearby contaminated environmental surfaces and are the
organisms most frequently associated with health care associated infections
(HCAIs) [2].
Hand rubbing with an alcohol based hand antiseptic
seems to be the best method for increasing compliance with hand hygiene. Recent
studies have shown a significant improvement in compliance after introducing of
hand rubbing as a substitute for handwashing with plain soap and water [7,8].
This study was undertaken to assess the efficiency of
hand rubbing with alcohol based solution compared with standard hand washing
with antiseptic soap in reducing transient flora of ICU workers hand.
MATERIALS AND METHODS:
Study design and Participants:
This present randomized, single blind, clinical trial
was conducted at Razi educational and remedial Hospital in the north of Iran
during March to August 2016. The study was carried out in the ICU of
hospital. Fifteen female
nurses in the ICU were included in the study. The mean age of the subjects was
28.4±4.8 years; the younge stand oldest were 22 and 38 years old respectively.
The hands were checked for the presence of transient flora. Samples of staffs'
hands in different work shifts were cultured once per day. In each group (soap and alcohol), 50 health
care was taken randomly (100 health care in two groups), and since four samples
are provided from each case of care (two samples before work and two samples
after work, both of which were taken before and after wash) so, a total of 400
samples were examined for microbial status. The exclusions criteria were
including; clearly contamination to patients' body fluids, the presence of
infectious wounds in the hands of a nurse, dissatisfaction to participate in
the study. Type of detergent, transient flora count and sampling time were the
investigated variables. The alcoholic hand rub was used containing 18 gr
Propanol in 100 ml/Ethanol 100% which were obtained from (B. Braun Co.
Melsungen, Germany). The
Ethics Committee of Guilan University of Medical Sciences approved the study
protocol. All study participants provided informed consent.
Sample collection:
The process of hand rubbing with alcohol based
solution and standard hand washing with soap and water were taught to nurses by
a person according to WHO guideline. Nurses were randomly divided into two
groups of soap and alcohol (by selecting a paper from inside a black bag by nurses).
Hands sampling was done before starting working time (sample 1). Then the
nurses wash their hands with soap or alcohol and the next sample was taken
(sample 2). Next sample was taken after working time (sample 3). Nurses washed
their hands twice and after that the final sample was taken (sample 4). It
should be noted that all sampling was done by a person and the first care of
each shift to reduce the error rate.
Microbiological samples and processing:
The hands sampling were taken from the subjects using
a sterile swab moistened with sterile physiologic saline and immediately were
embedded into glass test tubes with caps containing transport medium. The
collected samples were transported to microbiological laboratory in the
shortest possible time for further processes. The samples were inoculated onto
Blood agar and Mac Conkey agar plates and the plates were incubated aerobically
at 37 °C for 24 hours. Those plates which showed growth were further processed
to identify the organisms by performing standard microbiological methods
including Gram staining, growth the colonies on differential media, and
appropriate biochemical reactions.
Statistical analysis
Data was analyzed by Diagrammatic representation
utility in SPSS software version 21. The statistical analysis was done using
Chi-Square, Repeated measure and Man Whitney U methods, and a significant
relevance was considered at p-value less than 0.05
RESULTS:
Among 526 cultures, 443 cultures were positive for Coagulase
negative Staphylococcci, Bacillus spp, Enterobacter spp, Klebsiella
spp, fungi, Acinetobacter spp, Escherichia coli, Staphylococcus
aureus and yeast. Eighty three negative cultures were reported (Table 1).
Table 1: The frequency of transient flora types on the HCWs
hands
|
Microorganism
|
No. (%)
|
|
Coagulase negative Staphylococci
|
260(49.4)
|
|
Bacillus spp.
|
111(41.1)
|
|
Enterobacter spp.
|
40(7.6)
|
|
Klebsiella spp.
|
20(3.8)
|
|
Fungi
|
6(1.1)
|
|
Acinetobacter spp.
|
3 (0.6)
|
|
Escherichia coli
|
1 (0.2)
|
|
Staphylococcus aureus
|
1 (0.2)
|
|
Yeast
|
1 (0.2)
|
|
Negative culture
|
83 (15.8)
|
|
Total
|
526 (100)
|
The repeated Measurement revealed a significantly
correlation between colony and sampling time in each group. As it shown in
table 2, there was significant difference between colony count of staffs’ hands
after washing with soap and alcohol based solution in different times (P value
˂ 0.005). The frequency of the types of transient flora of the HCWs hands
according to sampling time were shown in table 3. Chi-square test showed that the
two groups differed significantly in terms of the frequency of obtained samples
depending on the time of measurement in both groups (p<0.001).
Table 2: The colony count of transient flora on the HC Wash hands
according to sampling time
|
Group
|
Colony count
CFU/ml(±SD)
|
p-value
|
p-value
|
|
Before wash/ before working time
|
After wash/ before working time
|
Before wash/ after working time
|
After wash/ after working time
|
|
Alcohol
|
53.11±41.89
|
18.33±33.91
|
25.44±31.04
|
15.07±31.57
|
0.0001
|
0.0001
|
|
Soap
|
42.88±39.84
|
54.27±43.17
|
33.67±38.27
|
40.22±43.67
|
0.008
|
Table 3: The frequency of the types of transient flora of the
HCWs hands according to sampling time
|
 Sampling time
Microorganism
|
Colony count CFU/ml
|
Total
|
|
Alcohol group
|
Soap group
|
|
Before wash/ before care
|
After wash/ before care
|
Before wash/ after care
|
After wash/ after care
|
Before wash/ before care
|
After wash/ before care
|
Before wash/ after care
|
After wash/ after care
|
|
Coagulase negative Staphylococci
|
47
|
19
|
28
|
18
|
42
|
36
|
36
|
34
|
260
|
|
Bacillus
|
12
|
13
|
14
|
12
|
19
|
13
|
16
|
12
|
111
|
|
Enterobacter
|
3
|
3
|
4
|
2
|
7
|
8
|
4
|
9
|
40
|
|
Klebsiella
|
0
|
0
|
2
|
0
|
5
|
5
|
2
|
6
|
20
|
|
Fungus
|
1
|
0
|
0
|
2
|
1
|
0
|
2
|
0
|
6
|
|
Escherichia coli
|
0
|
0
|
0
|
0
|
0
|
1
|
0
|
0
|
1
|
|
Acinetobacter
|
0
|
0
|
0
|
0
|
1
|
0
|
1
|
1
|
3
|
|
Staphylococcus aureus
|
0
|
0
|
0
|
1
|
0
|
0
|
0
|
0
|
1
|
|
Yeast
|
0
|
0
|
0
|
0
|
1
|
0
|
0
|
0
|
1
|
|
Negative culture
|
2
|
22
|
14
|
25
|
2
|
6
|
7
|
5
|
83
|
|
Total
|
65
|
57
|
62
|
60
|
78
|
69
|
68
|
68
|
526
|
According to Man Whitney U test, there was also a
significant relationship between alcohol and soap groups in the reduction of
colony count. So that, in the alcohol group was 20.58±54.4 and in soap group
was 2.66±48.17 (p<0.001).
DISCUSSION:
In this study the most common transient
flora was coagulase negative Staphylococci (CoNS) for a total of 4
cultures. Mojtahedi et al. (2014) indicated that out of the 106 ICU staffs in remedial hospitals in Rasht, 91 (85.9%) were positive and 15 (14.1%) were
negative. Pseudomonas was the most common transient flora (73%) on
personnel’s hands. Staphylococcus aureus was the most common infectious
flora isolated [9]. In another study, Khodadad et al. (2004) showed that
the most common isolated organisms from HCWs hand was CoNS in different wards
of children's medical center in Tehran [10]. Shen et al. (2015) compared a conventional surgical
scrub with an alcohol-based hand rub to evaluate antimicrobial efficacy HCWs
hand in Taiwan. The most identified pathogens were Gram-positive with CoNS
being the major pathogen in their study [11]. According to different geographic areas and changes
in bacterial antibiotic resistance isolated from different wards of the
hospitals during years, the results of reported flora from hospital staffs in
various studies were different which confirms the importance of repeating such
cross-sectional studies.
Our results indicated that the colony
reduction rate was significantly higher in the alcohol group which reflects the
effectiveness of alcohol compared to soap. This result is consistent with
results of study by Zaragoza et al. (1999) [12].
Maliekal et al. (2005) compared the
efficacy of conventional hand wash with the hand rub in reducing the transient
bacterial flora on the hands of nurses in ICU. Moderate to heavy bacterial
density was seen in more than 92.2% of the hands before washing or hand rub
application. Conventional hand wash resulted in drastic reduction in the
transient bacterial flora on hands in 50% cases whereas alcoholic hand rub
achieved the effect in 95% of the samples [13].
CONCLUSION:
In conclusion, our study showed that an
alcohol-based hand rub was more efficacious than a soap hand wash. Alcohol
significantly decreased flora colonies of staffs’ hands after the operation in
the intensive care unit, whereas no significant differences were seen with soap
solution compared to pre-wash. Furthermore, its reduced colony compared to
alcohol-based solution was significantly weaker, which can be due to skin
complications or lack of willingness of staff to soap solution.
CONFLICT OF INTEREST:
None declared.
REFERENCES:
1.
Sydnor E. R. and Perl T.
M. Hospital epidemiology and infection control in acute-care settings. Clin
Microbiol Rev. 24 (1); 2011: 141-73.
2.
Mathur P. Hand hygiene:
back to the basics of infection control. Indian J Med Res. 134 (5); 2011:
611-20.
3.
Bibalan M. H., et al.
Accessory Gene Regulator Types of Staphylococcus aureus Isolated in
Gorgan, North of Iran. J Clin Diagn Res. 8 (4); 2014: Dc07-9.
4.
Asadian M., et al.
Antimicrobial resistance pattern and genetic correlation in Enterococcus
faecium isolated from healthy volunteers. Microb Pathog. 92 2016: 54-9.
5.
Visalachy S., et al.
Carriage of Multidrug Resistant Bacteria on Frequently Contacted Surfaces and
Hands of Health Care Workers. J Clin Diagn Res. 10 (5); 2016: Dc18-20.
6.
Girou E., et al.
Efficacy of hand rubbing with alcohol based solution versus standard hand washing
with antiseptic soap: randomised clinical trial. Bmj. 325 (7360); 2002: 362.
7.
Bischoff W. E., et al.
Hand washing compliance by health care workers: The impact of introducing an
accessible, alcohol-based hand antiseptic. Arch Intern Med. 160 (7); 2000:
1017-21.
8.
Maury E., et al.
Availability of an alcohol solution can improve hand disinfection compliance in
an intensive care unit. Am J Respir Crit Care Med. 162 (1); 2000: 324-7.
9.
Mojtahedi A., et al.
Bacterial contamination of health care worker's hands in intensive care units
in Rasht. J Nosocomial Infect. 1 (1); 2014: 36-43.
10. Khodada A., Lameh L. and Shakiba M. The
Prevalence Of Careers And Microbial Spectrum Of Health Care Workers Hand And
Relation Between Detergent Used For Washing. Tehran Univ Med J. 62 (4); 2004:
291-301.
11. Shen N. J., et al. Comparative antimicrobial
efficacy of alcohol-based hand rub and conventional surgical scrub in a medical
center. J Microbiol Immunol Infect. 48 (3); 2015: 322-8.
12. Zaragoza M., et al. Hand washing with soap
or alcoholic solutions? A randomized clinical trial of its effectiveness. Am J
Infect Control. 27 (3); 1999: 258-61.
13. Maliekal M., et al. Comparison of
traditional hand wash with alcoholic hand rub in ICU setup. Indian J Crit Care
Med. 9 (3); 2005: 141-4.