IJADS 2016 / 1 by KAREPUBLISHING

INTERNATIONAL JOURNAL OF ANTISEPSIS DISINFECTION STERILIZATION

OWNER

On behalf of Society of Disinfection Antisepsis and Sterilization (DAS)

Prof. Murat GÜNAYDIN, MD President of DAS Society

EDITOR-IN-CHIEF

Murat GÜNAYDIN (Istanbul, Turkey) DEPUTY EDITORS

Şaban ESEN (Samsun, Turkey) Duygu PERÇİN (Kayseri, Turkey) Yavuz UYAR (Istanbul, Turkey) EDITORIAL BOARD

Erdal AKALIN (Ankara,Turkey) Ramin BAYRAMLI (Baku, Azerbaijan) Christine DENIS DELEBECQUE (Lille, France) Bülent GÜRLER (Istanbul, Turkey) Oğuz KARABAY (Sakarya,Turkey) Ayşegül KARAHASAN (Istanbul, Turkey) Hiroyoshi KOBAYASHI (Tokyo, Japan) Hakan LEBLEBİCİOĞLU (Samsun, Turkey) Recep ÖZTÜRK (Istanbul, Turkey) Meral SAĞIROĞLU (Ankara, Turkey) Edmond PUCA (Tirana, Albania) Salvatore RUBINO (Sassari, Italy) Francesco TESSAROLO (Trento, Italy) TECHNICAL BOARD

Ali CANGÜL (Kare Publishing Ltd, Istanbul) Z. Metin ATEŞ (LookUs Ltd, Istanbul) Susan ATWOOD (English Editing, İstanbul) Salih ERGÖÇEN (Statistical Analysis, Ankara) Dilek ZENCİROĞLU (DAS Society, İstanbul, Turkey)

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INTERNATIONAL JOURNAL OF ANTISEPSIS DISINFECTION STERILIZATION

ADVISORY BOARD Hakan ABACIOĞLU (Turkey)

Nezahat GÜRLER (Turkey)

Nefise ÖZTOPRAK (Turkey)

Çagatay ACUNER (Turkey)

Inge GYSSENS (Nederlands)

Mustafa ÖZYURT (Turkey)

Sead AHMETAGIC (BIH)

Salih HOŞOĞLU (Turkey)

David PERRETT (United Kingdom)

Alper AKÇALI (Turkey)

Murat HÖKELEK (Turkey)

Eskild PETERSEN (Denmark)

Yurdanur AKGÜN (Turkey)

Elif DOYUK KARTAL (Turkey)

Nicola PETROSILLO (Italy)

Sebahat AKSARAY (Turkey)

Esma KAYA (Turkey)

Wim RENDERS (Belgium)

Dilek ARMAN (Turkey)

Çigdem KAYACAN (Turkey)

Mustafa SAMASTI (Turkey)

Turan ASLAN (Turkey)

Ejaz KHAN (Pakistan)

Yesim ÇETİNKAYA ŞARDAN (Turkey)

Lela BAKANIDZE (Georgia)

Nuri KİRAZ (Turkey)

İrfan ŞENCAN (Turkey)

Nick BEECHING (United Kingdom)

Esra KOÇOĞLU (Turkey)

Aneta SIMONOSKA (Macedonia)

Christina BRADLEY (United Kingdom)

Safiye KOÇULU (Turkey)

Robert SKOV (Denmark)

Demet CANYILMAZ (Turkey)

Peter KOZIN (Slovenia)

Jasenka SKRLIN (Croatia)

Freddy CAVIN (Switzerland)

İftihar KÖKSAL (Turkey)

Nedim SULTAN (Turkey)

Masuet Aumatell CRISTINA (Spain)

Behice KURTARAN (Turkey)

Mustafa SÜNBÜL (Turkey)

Ahmet ÇARHAN (Turkey)

Tatjana LEJKO-ZUPANC (Slovenia)

Süheyla SÜRÜCÜOĞLU (Turkey)

Güven ÇELEBİ (Turkey)

Mark LOBE (Canada)

Yeşim TAŞOVA (Turkey)

Rıza DURMAZ (Turkey)

Ziad MEMISH (Saudi Arabia)

Nijaz TIHIC (BIH)

Cafer EROĞLU (Turkey)

Aziz ÖĞÜTLÜ (Turkey)

Viktorija TOMIC (Slovenia)

Mustafa ERTEK (Turkey)

Mehmet Ali ÖKTEM (Turkey)

Zeliha TUFAN KOÇAK (Turkey)

Yasemin ERSOY (Turkey)

Yekta ÖZER (Turkey)

Sercan ULUSOY (Turkey)

Gülden ERSÖZ (Turkey)

Mehmet Ali ÖZİNEL (Turkey)

Gaye USLUER (Turkey)

Şaban ESEN (Turkey)

Ayşegül TAYLAN ÖZKAN (Turkey)

Serhat ÜNAL (Turkey)

Mustafa GÜL (Turkey)

Cumhur ÖZKUYUMCU (Turkey)

John WAIN (United Kingdom)

Meral GÜLTEKİN (Turkey)

Aydan ÖZKÜTÜK (Turkey)

Zerrin YULUĞKURAL (Turkey)

Rahmet GÜNER (Turkey)

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CORRESPONDENCE

INTERNATIONAL JOURNAL OF ANTISEPSIS DISINFECTION STERILIZATION Address: International Journal of Antisepsis Disinfection Sterilization (IJADS) İstanbul University Cerrahpaşa School of Medicine Medical Microbiology Laboratory 34098 Fatih, Istanbul, Turkey Phone: +90 212 414 30 00 (Internal: 23085) E-mail: ijads-editor@das.org.tr, ijads@ijads.org

DAS

DISINFECTION ANTISEPSIS AND STERILIZATION ASSOCIATION President: Vice President: Secretary General: Treasurer: Members:

PUBLISHER

KARE P U B L I S H I N G

ONLINE SYSTEMS

Murat GÜNAYDIN Duygu PERÇİN Dilek ZENCİROĞLU Şaban ESEN Bülent GÜRLER Recep ÖZTÜRK Hakan LEBLEBİCİOĞLU

KARE PUBLISHING Address: Altayçeşme Mah., Samanyolu Sok., Mecit Varlı Apt. No: 19/6, 34843 Maltepe, İstanbul, Turkey Phone: +90 216 550 61 11 Fax: +90 216 550 61 12 Web: http://www.kareyayincilik.com e-mail: kareyayincilik@gmail.com

LOOKUS Address: Halk Sk. 29, Golden Plaza C Blok, 34734 Sahrayicedid, İstanbul, Turkey Phone: +90 216 372 66 44 Fax: +90 216 372 66 48 Web: http://www.lookus.net e-mail: lookus@lookus.net

International Journal of Antisepsis Disinfection Sterilization (IJADS) is a peer-reviewed journal published three times a year. Materials published in the Journal is covered by copyright ©2016 All rights reserved.

INSTRUCTIONS FOR THE AUTHORS PUBLISHING POLICY International Journal of Antisepsis Disinfection Sterilization (IJADS) is a publication of the “Society of Disinfection Antisepsis Sterilization (DAS)” in Turkey. The Journal is published every four months and one volume consists of three issues. The journal publishes disinfection, antisepsis, sterilization, hospital infection, antimicrobial resistance and related subjects in the field of original research, case report, reviews and letters to the editor are published in English. Articles which are not previously published in another journal or not currently under evaluation elsewhere can be accepted for the journal. Articles approved by the Scientific Committee and Editorial Board are eligible to be released after receiving at least two positive opinions from the Scientific Committee members of the IJADS. Those committees have the authority to make all corrections and abbreviations but not to change the content of the article. The authors have the all the scientific and legal responsibilities of the manuscripts. The authors must fully obey the ethics of research and publication. The editorial and publication processes of the journal are shaped in accordance with the guidelines of the International Council of Medical Journal Editors (ICMJE), the World Association of Medical Editors (WAME), the Council of Science Editors (CSE), the Committee on Publication Ethics (COPE), and the European Association of Science Editors (EASE). The journal conforms to the Principles of Transparency and Best Practice in Scholarly Publishing (doaj.org/bestpractice). COPYRIGHT NOTICE All published material will become the sole property and will be copyrighted by the Journal. No part of the publication may be used without prior written permission of the publisher. ONLINE SUBMISSIONS Registration and login are required to submit items online and to check the status of current submissions. Users should visit journal’s web site (www.ijads.org) and create an account before submitting their manuscripts. PRIVACY STATEMENT The names and email addresses entered in this journal site will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose or to any other party. AUTHOR GUIDELINES International Journal of Antisepsis Disinfection Sterilization (IJADS) publishes disinfection, antisepsis, sterilization, hospital infection, antimicrobial resistance in the field of original research, case report, reviews and letters to the editor are published in English. Contributions may be in the form of clinical and basic research articles, case reports, personal clinical and technical notes, and letters to the Editor. The Journal also publishes brief reports on original studies or evaluations, book reviews, and proceedings of scientific meetings. Opinions presented in published articles by no means represent the official endorsement of the Society of Disinfection Antisepsis Sterilization (DAS). Articles and illustrations become the property of the Journal after publication. The Editor-inChief may request from the authors additional data, information, or complementary material concerning the manuscripts and the authors must comply with such requests. ETHICAL ISSUES IJADS expects the authors to comply with the ethics of research and publication. In human research, a statement of the informed consent of those who participated in the study is needed in the section of the “Materials and Methods”. All studies should be carried out in accordance with the World Medical Association Declaration of Helsinki (http://www.wma.net/ en/30publications/10policies/b3/), covering the latest revision date. Patient confidentiality must be protected according to the universally accepted guidelines and rules. In case of procedures that will apply to volunteers or patients, it should be stated that the study objects have been informed and given their approval before the study started. In case the authors do not have a local ethics committee, the principles outlined in the “Declaration of Helsinki” should have been followed. Authors

should declare that they have followed the internationally accepted latest guidelines, legislation and other related regulations and should sent “Approval of the Ethics Committee”. In case animal studies, approval also is needed; it should be stated clearly that the subjects will be prevented as much as possible from pain, suffering and inconvenience. SUBMISSION AND PEER-REVIEWING The official language of the Journal is English. Any type of submission and letters in during the review process has to be strictly in English. EDITORIAL EVALUATION WORKFLOW All submitted materials undergo a technical check following initial submission. Technical check evaluates existence of required documents, structural consistency of manuscript and supplementary files. In case there’s a discordance, manuscript is returned to the corresponding Author for correction. Following technical check, Editorial Office of IJADS assign a manuscript number and officially start peer-review process. Assigned Vice/or Section Editors execute process on behalf of Editor of IJADS and manuscripts are subject to blind peer review by at least two reviewers. Reviewers are assigned considering the field of the study. The Editor, who judges and analyzes the entire review process, reaches a final decision to accept or reject a manuscript, or to recommend a revision. The Editor has the right to reject a revised manuscript. COPYRIGHT - AUTHORS’ APPROVAL - CONFLICT OF INTEREST The authors should disclose all issues concerning financial relationship, conflict of interest, and competing interest that may potentially influence the results of the research or scientific judgment. All financial contributions or sponsorship, financial relations, and areas of conflict of interest should be clearly explained in a separate letter to the editor at the time of submission, with full assurance that any related document will be submitted to the Journal when requested. Manuscripts should be sent with the Copyright-Authors’ Approval-Conflict of Interest Letter signed by the author(s). A copy of this letter can be found at www.ijads.org. Manuscripts will not be accepted for evaluation until the receipt of this document by the Journal. SUBMITTING A MANUSCRIPT Submission and tracking of a manuscript can only be made online through the http://www.ijads.org web site at http://www.journalagent. com/ijads. Corresponding author should register to http://www.journalagent.com/ijads web site and login to start a submission process. PREPRATION OF MANUSCRIPT 1. The “Copyright Transfer Form” after being signed by all authors should be uploaded using the article accepting system of the IJADS. 2. The title of article, short title, author name(s), names of institutions and the departments of the authors, full address, telephone numbers (landline and mobile) and e-mail address should be given. The title should be short and written in lower case. In addition, the running title should be written and it should not exceed 40 characters. 3. The microorganism’s Latin names of used for the first time in the text have to be written in full. If these names are used later, they should be abbreviated in accordance to international scientific rules. The original Latin names of microorganisms should be written in Italic style: for example, Staphyloccoccus aureus, S. aureus. The antibiotics’ names should be abbreviated in accordance with international standards and they should be used with generic names. 4. Symbols of the international units mentioned in the text should be according to “The SystÃ¨me International (SI). 5. Manuscripts should be written in one of the “past perfect, present perfect and past tenses” and in the passive mode. 6. A4 paper should be used and should have a 2.5 cm margin on each side. Times New Roman font, 12 pt, and double lines space should be used. 7. International Journal of Antisepsis Disinfection Sterilization (IJADS) expects the authors to comply with the ethics of research and publication. In human research, a statement of the informed consent of those who participated in the study is needed in the section of the

INSTRUCTIONS FOR THE AUTHORS “Materials and Methods”. In case animal studies, approval also is needed. Please, see at: Ethical issue. 8. In Original Articles; Research/Original manuscripts should consist of English abstract. Introduction, Materials and Methods, Results, Discussion, Acknowledgements (if any), and References sections. These sections should be written in bold capital letters and aligned left. English manuscripts should have a Turkish abstract and title in Turkish (If all authors are from Turkey). If the all of the authors from abroad the manuscript can be write only English language. a. Turkish Abstract should consist of the subheadings of Objective (Amaç), Methods (Yöntem), Results (Sonuçlar) and Conclusion (Tartışma) (Structured Abstract). It should be between 300 and 400 words. b. English Abstract: The abstract should be structured like the Turkish abstract (Objective, Methods, Results, and Conclusion). It should be between 300 and 400 words. c. Key words: The number of keywords should be between 3-6 and the terminology of the Medical Subjects Headings (Index Medicus Medical Subject Headings - MeSH) should be used. Please check at: https://www.nlm.nih.gov/mesh/MBrowser.html d. Introduction: The aim of the study, and references given to similar studies should be presented briefly and should not exceed more than two pages. e. Materials and Methods: The date of the study, institution that performed the study, and materials and methods should be clearly presented. Statistical methods should be clearly stated. All research manuscripts will send to professional statistician for their statistical evaluation by the Editor.Â f. Results: The results should be stated clearly and only include the current research. g. Conclusions: In this section, the study findings should be compared with the findings of other researchers. Authors should mention their comments in this section. h. Acknowledgements: Acknowledgements should be placed at the end of the main text and before the references. In this section, the institutions/departments and person which supported the research should be stated. I) The study supported by a fund or scientific organization must be mentioned in the acknowledgements. II) The study presented in a conference/symposium must be mentioned with the type of presentation in the acknowledgements. i. References: Authors are responsible for supply complete and correct references. References should be numbered according to the order used in the text. Numbers should be given in brackets and placed at the end of the sentence. Examples are given below on the use of references. Detailed information can be found in “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” and see at www.nejm.org/general/text/requirements/1.htm. (J Am Med Assoc 1997 277: 927-934) Periodicals: Author(s) Last Name initial(s) name of author(s) (if there are six or fewer authors, all authors should be written; if the number of authors are seven or more, only the first six of the authors should be written and the rest as “et al”). The title of the article, the abbreviated name of the journal according to the Index Medicus, Year; Volume (Issue): The first and last page numbers. Pleskova SN, Golubeva IS, Verevkin YK. Bactericidal activity of titanium dioxide ultraviolet-induced films. Mater Sci Eng C Mater Biol Appl 2016;1:807-17. Books: Surname of the author(s) initial name(s) of author(s). The name of the book. The edition number. Place of publication: Publisher, Publication year. Example: Murray PR, Baron EJ, Jorgensen JH, Landry ML, Pfaller MA. Manual of clinical microbiology. 9th ed. Washington DC: ASM Pres, 2007. Book chapters: The author (s) surname of the chapter initial (s) letter of the name. Section title. In: Surname of editor (s) initial (s) letter of first name (s) ed / eds. The name of the book. Edition number. Place of publication: Publisher, year of publication: The first and last page numbers of the chapter. Example: Major EO, Ryschkewitsch C, Valsamakis A, Hou J. Human

polyomaviruses. In: Murray PR, Baron EJ, Jorgensen JH, Landry ML, Pfaller MA, eds. Manual of clinical microbiology. 9th ed. Washington DC: ASM Pres, 2007: 1612 - 1621. Web address: If a “web” address is used as the reference address, the web address date should be given in brackets with the address. The DOI (Digital Object Identifier) number must be provided, when a web access article used in the text as a reference. Example: AB Author, CD Author. Title of document. Retrieved from http://Web address (Accession date: aa/bb/2016). Congress papers: Holman KY, Gural ST. Specific Detection of Human BK Polyomavirus in Urine Samples. International Congress of Virology, September, 21-25, Istanbul - Turkey, 2005. Poster Number, Pages. Thesis: Maden KL. Experimental investigation of the â€¦â€¦â€¦â€¦â€¦.. Master Thesis, Health Science Institute of Ankara University, Ankara, 2005. GenBank / DNA sequence analysis: DNA sequences of genes and heredity numbers should be given as references in the article. For more information, check “National Library of Medicine” and “National Center for Biotechnical Information (NCBI)”. Figure and Tables: Each table or figure should be printed on a separate sheet, the top and bottom lines and if necessary column lines must be included. Tables should be numbered like “Table 1.” and the table title should be written above the top line of the table. Explanatory information should be given in footnotes, not in the title and appropriate icons (*,+,++, etc.) should be used. Photos should be in “JPEG” format. In case the quality of the photos is not good for publication, the originals can be requested. 9. Research articles should have up to 40 references. 10. Reviews: Â Author(s) must have done research and published articles previously on this subject; they should discuss their experience and use as reference in the review. Reviews should have English titles (and Turkish), and abstracts (it should contain minimum 300, maximum 400 words) and key words. Reference numbers for the review should be maximum 60. 11. Case reports should have a maximum of seven pages of text. Case report should have a English title ( and Turkish), abstract, keyword(s) and also introduction, case description and discussion sections should be given. Number of references should be maximum 15. 12. Letters to Editor: Written to make criticisms, additions to previously published articles or scientific updates are published after review and assessment of the Editorial Board. Letters should not exceed one page of text and must be supported with up to 10 references. 13. The articles which do not comply with the journal rules are not accepted 14. Authors should keep a copy of the article that they submit. SUBMISSION PREPARATION CHECKLIST As part of the submission process, authors are required to check off their submission’s compliance with all of the following items, and submissions may be returned to authors that do not adhere to these guidelines. Abstract, 300 words or shorter Manuscript without abstract, structured correctly References at the end of the manuscript, listed in order of citation All figures sent separately and not embedded in the manuscript Figure legends included at the end of the manuscript All figures and tables are cited in the manuscript A letter of copyright transfer, signed by all authors ADDRESS OF CORRESPONDENCE Murat GÜNAYDIN, M.D., Prof. Editor, International Journal of Antisepsis Disinfection Sterilization Istanbul University Cerrahpasa School of Medicine Medical Microbiology Laboratory 34098 Fatih, Istanbul, Turkey Phone: +90 212 414 30 00 (Internal: 23085) e-mail: ijads-editor@das.org.tr, ijads@ijads.org

INTERNATIONAL JOURNAL OF ANTISEPSIS DISINFECTION STERILIZATION

Contents Volume 1 Issue 1 Year 2016

vii

EDITORIAL Günaydın M

RESEARCH ARTICLES Attitudes of operating theater workers toward patient safety Susan Özsayın F, Özbayır T

Biofilm production and biocidal efficacy in multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii isolates Sebit B, Aksu B, Karahasan Yağcı A

REVIEWS Dare to change Renders W

Sterilization practices and hospital infections: Is there a relationship? Perçin D

Surgical hand washing: A systematic review Gök F, Kabu Hergül F, Özbayır T

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INTERNATIONAL JOURNAL OF ANTISEPSIS DISINFECTION STERILIZATION

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EDITORIAL Int J Antisep Disinfect Steril 2016;1(1):vii–viii doi: 10.14744/ijads.2016.54264

Dear Readers, Nowadays, low healthcare-associated infections (HAI) rates are accepted as an indicator of quality. With the achievement of the target of zero or nearly zero HAI, unless proven otherwise, every nosocomial infection is accepted as a medical error that could have been prevented. In health establishments, improper disinfection or sterilization of reusable medical materials constitutes a risk of infection for the host. Nosocomial infections caused by resistant microorganisms increase mortality and morbidity, and also the prolong hospital stay of the patient, impair his/her quality of life, enhance treatment costs, and result in labor loss and medicolegal problems for health institutions and healthcare professionals. Improvement of disinfection and sterilization procedures obviously will make an important contribution to the decrease in infections related to the use of contaminated material. Economic conditions that would allow resources to be allocated for sterilization and disinfection procedures are not the same throughout the world; however, knowledge and training are key points for good medical practices. With this awareness, our efforts that began as a local symposium called “Sterilization and Disinfection” evolved into national congresses during the 2000s and attracted immense attention. This great interest has also brought about the establishment of “Disinfection, Antisepsis and Sterilization (DAS) Association” in Turkey in 2004. In 2013, 14th WFHSS World Sterilization Congress was held in Antalya, which is one of the major congress centers of Turkey. The congress rich in scientific content was conducted with broad participation of the sponsors. The DAS Association has conducted more than 20 DAS seminars in different provinces of the country. In collaboration with the Ministry of Health of Turkey, DAS Association has been is organizing annual certification program, since 2008, under the name of “DAS School”. The training programs have created significant awareness and DAS School awarded certificate to Medical Doctors, Dentists, and Nurses. After tens of DAS activities conducted since 2004, DAS Association has finally realized the necessity of a qualified and international scientific journal in which verbal and poster presentations conducted in the congress and symposiums, case reports, and conference presentations which could be published in the form of review article could be published. The publication language of the journal is English. This will thereby allow transfer of the fund of knowledge and scientific studies through these published manuscripts to the scholars dealing with DAS, researchers and service providers. In this regard, our journal will close an important gap in the field of sterilization and disinfection. This is because progress only relies on scientific research and evidence-based practices. As the Editor, I experience the pride, and excitement and happiness of pioneering a large group of volunteers who make this journal begin and continue its publication life. Valuable associate editors who are to make significant contribution to our journal, technical editors, and most importantly our readers, authors and certainly our advisors shoulder great responsibility. Success of our journal is only possible with your help. I would have to say that our journal will serve in accordance with the standards of international journals, and ethical and scientific principles, and that infrastructure and organization of the journal has been designed accordingly. You will be able to submit your papers online over the web page at www.ijads.org. The manuscripts approved by the editorial board will be forwarded to at least two reviewers for peer-reviewing. Statistical analysis will be carried out by technical editors specialized in their fields. The manuscripts accepted for publication will be edited to correct English language errors and then sent for typesetting. The manuscripts accepted for publication will be provided a unique “doi” number after which the manuscript will be made “open access” article. I would also have to say that we aim the have our journal indexed by international databases. I thank you in advance, on my behalf and on behalf of the readers, to our colleagues who agrees to take charge in the editorial board and spend valuable working hours for the journal. Prof. Murat Günaydın, M.D. Editor-in-Chief

INTERNATIONAL JOURNAL OF ANTISEPSIS DISINFECTION STERILIZATION

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EDİTÖRYAL

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INTERNATIONAL JOURNAL OF ANTISEPSIS DISINFECTION STERILIZATION

RESEARCH ARTICLE Int J Antisep Disinfect Steril 2016;1(1):1–6 doi: 10.14744/ijads.2016.98608

Attitudes of operating theater workers toward patient safety Fatma SUSAM ÖZSAYIN1, Türkan ÖZBAYIR2 İzmir Katip Çelebi University, Atatürk Training and Research Hospital, Management of Health Care Services, İzmir-Turkey 2 Ege University Faculty of Nursing, Department of Surgical Nursing, İzmir-Turkey

SUMMARY

Objective: This research was performed to evaluate the attitudes of operating theater staff members toward patient safety. Methods: A survey was conducted of 200 operating theater members of staff (surgeons, surgical assistants, anesthetists, assistant anesthetists, anesthesia technicians, anesthesia nurses, and operating theater nurses) at Izmir Katip Çelebi University Atatürk Training and Research Hospital. An employee information form and the version of the Safety Attitudes Questionnaire (SAQ) designed for operating theater employees were used to collect data in six areas: team cooperation, job satisfaction, thoughts on management, safety environment, working conditions and stress level. Average, standard deviation, frequency, and percentage were used to provide descriptive data. One-way analysis of variance (ANOVA), t-test, Kruskall-Wallis H test, and Mann-Whitney U test were used to evaluate the data. Results: Data indicated that 42.5% of operating theater employees surveyed were between the ages of 30-39. It was determined that 33.5% of the group were surgeons, 14.5% were anesthetists, and 41% were operating theater nurses; 37% had 11 or more years of experience in their field of specialization. According to the research, 46.5% of the employees had participated in an orientation program when they first started to work at the hospital. The SAQ mean score for job satisfaction it was 63.13±20.27, the mean for stress levels was 28.55±14.67, and the total mean score for patient safety attitude was 52.51 ±11.78. When mean scores for patient safety were compared according to participants’ area of expertise using Kruskall-Wallis analysis, it was found that there was a statistically significant difference. It was also determined that employees who have specialized experience of 6-10 years and 11 years or more, had been participants in job training or had attended an orientation program had higher safety attitude point average. Conclusion: A plan was proposed to reduce employee stress levels, regulate work hours, have operating theater employees attend an orientation program, improve communication and collaboration between and among teams, and to support operation theater employees and directors joining educational programs related to patient safety. Keywords: Attitudes toward patient safety; culture of patient safety; patient safety.

How to cite: Özsayın FS, Özbayır T. Attitudes of operating theater workers toward patient safety. Int J Antisep Disinfect Steril 2016;1(1):1-6.

Correspondence: Fatma Susam Özsayın. İzmir Katip Çelebi Üniversitesi, Atatürk Eğitim ve Araştırma Hastanesi Sağlık Bakım Hizmetleri Müdürlüğü, Süpervizör Hemşirelik Birimi, Yeşilyurt, Karabağlar İzmir. Tel: +90 232 – 243 43 43 e-mail: ftmsusam@gmail.com Submitted: March 11, 2016 Accepted: May 11, 2016 Available online date: May 10, 2016 Society of Disinfection Antisepsis Sterilization ©2016 Production by Kare Publishing on behalf of the Owner. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

ne of the most important topics for quality programs in health service is patient safety.[1] In the United States, the most influential organization guiding medical practice, the Institute of Medicine (IOM), defines patient safety as “the prevention of harm which could come to a patient.”[2] It states that this can be achieved with a care system founded on a culture of safety that includes health care workers, institutions, and patients, and in which mistakes are prevented, and lessons are learned from mistakes that are made.[3] An increase in the intricacy as well as the number of health services now provided has led to greater awareness of the importance of the concept of patient safety in all hospital services. Providing patient safety at every stage and preventing medical errors is an institutional priority. The purpose of health services is to provide patients with care and treatment, protection from disease, and rehabilitation. Complex treatment and care procedures, rapid changes in the health field and a reduction in the number of qualified health workers threaten patient safety.[4] Though they may mean additional expense for the hospital, actions taken related to patient safety prevent harmful effects.[5] In a retrospective study of 1014 patients, 10.8% had experienced adverse effects from services received. Approximately half of the mistakes were avoidable. Different types of failures were observed, from a simple mistake to one resulting in death.[6] It has been stated that in industrialized countries, about half of harmful effects to patients are related to surgery and 5% of them can be avoided.[7] In the United States, surgical complications arise in 40% of surgeries performed each year. The most common surgical complications are surgical site infections, cardiovascular complications, postoperative venous thromboembolism and ventilator-associated pneumonia.[8] The reporting of errors related to patient safety in Turkey has been analyzed and it was found that a significant portion of health professionals surveyed (71.3%) was unable to report any incident that may have endangered patient safety.[9] In another study carried out in Turkey, it was found that prophylactic antibiotic is administered to 59% of patients undergoing surgical operation. Medical errors have been the cause of numerous post-operative and peri-operative complications.[10] The present study evaluates attitudes of operating theater workers toward patient safety, factors affecting those attitudes, and differences between them.

Int J Antisep Disinfect Steril

Materials and methods The study was conducted between December 2014 and January 2015 at İzmir Katip Çelebi University Atatürk Research and Education Hospital. The population group consisted of the 354 people working in the central operating theater of the hospital (surgeons and surgical assistants, anesthetists, assistant anesthetists, anesthesia technicians, anesthesia nurses, and operating theater nurses). Criterion sampling method was used to form a study sample of 200 people who had at least 1 year of experience working in the operating theater. Prior to beginning the research, written permission was obtained from the Scientific Ethics Committee of Ege University Nursing Faculty and the Southern Secretariat of the Public Health Association, and oral permission was obtained from the employees. An employee information form and the Safety Attitudes Questionnaire (SAQ) version for operating theater were used to collect data. There were 21 questions that included age, gender, marital status, education level, position at work, year of graduation, average working hours, years of experience in their professional specialty, whether they knew of in-service training opportunities at the hospital and if they had participated, and whether they had had training in patient safety. The operating room version of SAQ was developed by Sexton et al. at the University of Texas to measure attitudes of operating theater employees toward patient safety. Validity and reliability studies were carried out in 2006.[11] Data are collected in six areas relating to team cooperation, job satisfaction, thoughts on method, safety environment, working conditions and stress levels. A 5-point Likert-type scale is used for responses (1=I completely disagree, 2=I disagree, 3=I am undecided, 4=I agree, 5=I completely agree). Items containing negative statements (1, 12, 16, 24, 25, 27, 31, 32, 33, 36, 39, 44, 47, 49, 52, 53, 56, 58) are scored in reverse: a higher score denotes a more positive attitude. Scores are converted to percentages thus: 1=0, 2=25, 3=50, 4=75, 5=100.[12–14] SPSS software (version 17.0; SPSS Inc., Chicago, IL, USA) was used to analyze the data. Frequencies, percentages, means and standard deviations were used to present the data. One-way variance analysis (ANOVA), t-test, Kruskall-Wallis H test and Mann-Whitney U test were used to determine correlations between the data. Results The study sample consisted of 200 individuals working in the central operating theater of Izmir Katip Çelebi

Susam Özsayın F et al. Attitudes toward patient safety

Table 1. Distribution of workers by age, gender and marital status. Variables Gender Female Male Age 18-29 30-39 40-49 ≥50 Marital status Married Single

Table 2. Distribution of participants by specialty. Characteristic

No. %

112 88

Position Surgeon 67 33.5 Anesthetist 29 14.5

56.0 44.0

32 16.0 85 42.5 60 30.0 23 11.5 151 49

No. %

Anesthesia Nurse Anesthesia Technician Operating Theater Nurse

11 11 82

Table 3. Distribution of participants by years of experience in specialty.

75.5 24.5

Characteristic

University Atatürk Teaching and Research Hospital. It was determined that 16% of participants were between the ages of 18 and 29, 42.5% were between 30 and 39 years of age, 30% were between 40 and 49, and 11.5% were aged 50 or over. Of the total, 56% were female, and 75.5% were married (Table 1). It was found that 33.5% of the work group were surgeons, 14.5% were anesthetists, 5.5% were anesthesia nurses, 5.55% were anesthesia technicians, and 41% were operating theater nurses (Table 2). The data indicated that 36.5% of the work group had 1-5 years of experience in their field of specialization, 26.5% had 6-10 years of experience, and 37% had 11 or more years of experience (Table 3). When joining the staff at İzmir Katip Çelebi University Atatürk Research and Education Hospital, 46.5% of the study group participated in an orientation program (Table 4). The mean SAQ scores were as follows: team cooperation was 62.60±13.82, job satisfaction was 63.13±20.27, thoughts on method was 52.79 ±19.09, safe environment was 56.89 ±15.10, working conditions was 58.04 ±26.00, and stress level was 28.55±14.67;

No. %

Years of experience in specialty 1-5 years 73 6-10 years 53 11 years or more 74

Team cooperation Job satisfaction Thoughts on method Safety environment Working conditions Stress level Total patient safety attitude

36.5 26.5 37.0

Table 4. Distribution by participation in orientation program upon employment at hospital. Characteristic

No. %

Participation in orientation program Yes 93 No 107

46.5 53.5

the total mean score for patient safety attitude was 52.51 ±11.78 (Table 5). Kruskall-Wallis analysis of mean patient safety attitude results compared according to specialty revealed a statistically significant difference between the groups (p<0.05). It was established by Mann-Whitney U test post-hoc analysis that there was a significant difference between surgeons and anesthesia nurses, anesthesia technicians and operation theater nurses, and between anesthetists and anesthesia nurses, anesthesia technicians and operating theater nurses (Table 6).

Table 5. Mean score for patient safety and subdimensions.

5.5 5.5 41

Minimum 19.64 .00 .00 7.35 -8.33 -2.08 10.78

Maximum 89.29 100.00 100.00 85.29 100.00 91.67 76.72

Mean±SD 62.60±13.82 63.13±20.27 52.79±19.09 56.89±15.10 58.04±26.00 28.55±14.67 52.51±11.78

Int J Antisep Disinfect Steril

Table 6. Comparison of Safety Attitudes Questionnaire mean score and participant specialization. No

Mean H p order

Surgeon (1) 67 79.79 Anesthetist (2) 29 63.88 Anesthesia Nurse (3) 12 139.80 39.926 0.000 Anesthesia Technician (4) 11 135.41 Operating Theater Nurse (5) 81 119.85

Significant difference 1-3 1-4 1-5 2-3 2-4 2-5

Table 7. Comparison of mean Safety Attitudes Questionnaire score according to specialty experience. No Mean±SD F p 1-5 years 6-10 years ≥11 years

73 53 74

49.19±12.44 54.39±9.48 54.43±12.02

4.721

0.010

Significant difference 1-2 1-3

Table 8. Comparison of mean Safety Attitudes Questionnaire score according to specialty experience. No Mean±SD t p Yes No

93 55.75±10.69 107 49.69±12.01

When the number of years of specialized experience was compared with mean patient safety attitude scores by one-way variance analysis (ANOVA), a statistically significant difference was found between experience and average attitude scores (p<0.05). It was established by post-hoc analysis that there was a significant difference between those with 1-5 years of experience and those with 6-10 years of experience, as well as those with 11 or more years of experience (Table 7). When a comparison was made by t-test of the mean patient safety attitude scores and participation in an orientation program when the participants started to work at the hospital, a significant difference was found (p<0.05, Table 8). Discussion In a study by Sexton et al., it was found that the mean score on the sub-dimension of stress levels on the SAQ was 54.7±26.6.[11] According to a study conducted in Turkey, it was found that the mean score on the SAQ sub-dimension of stress levels was 67±17.59.[15] In a survey of operating room staff - both surgeons and op-

3.743 0.000

erating room nurses - at 17 hospitals in Scotland participants stated that stress had not affected their performances.[16] However, Flinn et al. stated in a study of 222 anesthesiologists that 83% of participants reported that stress and fatigue had an adverse affect on their performance.[17] When mean SAQ scores of operating theater employees were examined in this study, it was established that total mean score for patient safety attitude was 52.51±11.78. Mean scores on the subscale of job satisfaction were the highest, 63.13±20.27, and those on the subscale of stress level were lowest, 28.55±14.67. In a study by Sexton et al., it was found that SAQ mean scores on the subdimension of stress level were 54.7±26.6.[3] Pressure and the delicate nature of operating theater work in addition to high turnover of patients as well as employees increase workers’ stress levels. Research conducted by Önler and Akyolcu revealed no statistically significant difference in mean safety attitude scores of doctors, nurses and anesthetists in the sampling group of the study.[15] In a study conducted by Prati and Pietrantoni on the safety attitudes of operating theater nurses and surgeons in Italy, a statistically signifi-

Susam Özsayın F et al. Attitudes toward patient safety

cant difference was found between professional groups. [18] The present study also a found statistically significant difference (p<0.05); the mean SAQ scores of anesthesia nurses, anesthesia technicians and operating theater nurses were significantly higher than those of surgeons and anesthetists. It is thought that this difference may be an effect of the fact that at the institution where the study took place, anesthesia technicians, anesthesia nurses and operating theater nurses take part more regularly in in-service training programs on patient safety than do surgeons and anesthetists. Önler and Akyolcu, determined that the mean safety attitude scores of those who had been working in their field of specialization for 6-11 years were lower than those of individuals with more than 11 years of experience.[15] In the present study, a statistically significant difference was found between experience in the field of specialty and mean attitude scores (p<0.05). It is an expected result that as professional experience increases, patient safety attitudes would increase. In a study by Beuzekum et al., it was stated that lack of education and experience was the source of most medical errors.[19] Önler and Akyolcu reported that whether or not operating theater workers had taken part in an orientation program when they started to work at the hospital did not yield a significant difference in mean patient safety attitude scores.[15] In the present study, a significant difference was found between mean patient safety attitude scores based on whether the participant had taken part in an orientation program when they started to work at the hospital (p<0.05). The patient safety attitude scores of those who had participated in an orientation program were found to be significantly higher than those of individuals who had not. These results are in accordance with the literature. According to the results of the study, a measure that must be taken in order to improve the patient safety climate is to remove work stress, or at least reduce the level to a minimum. Factors increasing the stress level in the operating room should be determined, and steps should be taken to eliminate them. Employees should be trained to cope with stress and all employees should participate. It is recommended that the whole team regularly attend training programs in order to form a culture of patient safety. Operating theater employees should be encouraged to join an orientation program before beginning to work in the hospital. It is also suggested that sufficient well-educated employees and equipment be provided, that working hours be adjusted, directors be provided with support, and operating room team cooperation and communication be improved.

Acknowledgements: The study was presented as a free paper at the 7th European Operating Room Nurses Association Congress in Rome, May 4-10, 2015. Conflict of interest: None declared. Peer-review: Externally peer-reviewed. Authorship contributions: Concept - Design - Supervision - Resource - Materials - Data collection - Literature search - Writing: F.S.Ö, T.Ö. References 1. Hakverdioğlu YG. Patient safety culture. Journal of Ege University School of Nursing 2011;27:77–82. 2. Institue of Medicine (I.O.M.). To Err is Human: Building a Safer Health System 2000. Accessed: 22.05.2014 http:// www.nap.edu/catalog/9728.html. 3. Mitchell PM. Defining patient safety and quality care 2008. Accessed: 15.03.2014 http://www.ncbi.nlm.nih.gov/books/ NBK2681/. 4. Yıldız T, Eriten G, Erdem İ, Gökay NS, Kulaç M, Alp R. Graduation and work as health professionals effects on patient safety awareness. Kafkas J Med Sci 2012;2:94–8. Crossref 5. Karaca A, Arslan H. A study for the assessment of patient safety culture in nursing services. Journal of Health and Nursing Management 2014;1:9-18. 6. Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care 2002;11:76-80. Crossref 7. Etchells E, O’Neill C, Bernstein M. Patient safety in surgery: error detection and prevention. World J Surg 2003;27:93642. Crossref 8. Demir F. Patient safety in surgery. In: Turkish Surgical and Operating Room Nursing Congress (with international participation) Gaziantep, 2007;28-33. 9. Dursun S, Bayram N, Aytaç S. An application on patient safety culture. Celal Bayar University Journal of Social Sciences 2010;8:1-14. 10. Hergül KF, Özbayır T, Gök F. Patient safety in the operating room: systematic review. Pamukkale Medical Journal 2016;9:87-8. Crossref 11. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 2006;6:44. Crossref 12. Makary MA, Sexton JB, Freischlag JA, Millman A, Pryor D, Holzmueller CG, et al. Patient safety in surgery. Ann Surg 2006;243:5. Crossref 13. Patterson PD, Huang DT, Fairbanks RJ, Wang HE. The emergency medical services safety attitudes questionnaire. Am J Med Qual 2010;25:109–15. Crossref 14. Shteynberg G, Sexton B, Thomas E. Test retest reliability of the safety climate scale. Technical report 2005. Accessed

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22.05.2014, www.uth.tmc.edu/...safety/.../ Safety-ClimateTest-Retest-Tech-Report.doc. 15. Önler E, Akyolcu N. Evaluation of operating room staff ’s attitudes related to patient safety. İstanbul University, Institute of Health Science, Department of Surgical Nursing. Doctorate Dissertation, İstanbul 2010. 16. Flin R, Yule S, McKenzie L, Paterson-Brown S, Maran N. Attitudes to team work and safety in the operating theatre. Surgeon 2006;4:145-51. Crossref

17. Flin R, Fletcher G, McGeorge P, Sutherland A, Patey R. Anaesthetists’ attitudes to team work and safety. Anaesthesia 2003;58:233-42. Crossref 18. Prati G, Pietrantoni L. Attitudes to teamwork and safety among Italian surgeons and operating room nurses. Work 2014;49:669-77. 19. Van Beuzekom M, Boer F, Akerboom S, Dahan A. Perception of patient safety differs by clinical area and discipline. Br J Anaesth 2013;110:107–14. Crossref ÖZET

Ameliyathane çalışanlarının hasta güvenliği tutumları Fatma SUSAM ÖZSAYIN, Türkan ÖZBAYIR

Amaç: Bu çalışma, ameliyathane çalışanlarının hasta güvenliği tutumlarını değerlendirmek amacıyla yapıldı. Yöntemler: İzmir Katip Çelebi Üniversitesi Atatürk Eğitim ve Araştırma Hastanesi çalışanı 200 kişi (cerrah, anestezist, anestezi hemşiresi, anestezi teknisyeni ve ameliyathane hemşiresi) araştırma kapsamına alındı. Veriler Güvenlik Tutumları Ölçeği ve Çalışan Bilgi Formu kullanılarak elde edildi. Güvenlik Tutumları Ölçeği-GTÖ (Safety Attitudes Questionnaire-SAQ-Operating RoomVersion) Teksas Üniversitesinde Sexton ve arkadaşları tarafından ameliyathane çalışanlarının hasta güvenliğine ilişkin tutumlarını ölçmek amacıyla geliştirilmiş ve geçerlik güvenirlik çalışması 2006 yılında yapılmış bir ölçektir. Ekip işbirliği, iş memnuniyeti, yönetimle ilgili düşünceler, güvenli ortam, çalışma koşulları ve stres düzeyinin belirlenmesi gibi güvenliğin sağlanmasıyla ilgili 6 alanda veri toplamamızı sağlayan ölçeğin, bazı maddeleri olumsuz ifadeler içermektedir. Olumsuz ifadeler ters çevrilerek puanlandığı için; daha yüksek puan, daha olumlu tutumlar anlamına gelmektedir. Verileri betimsel olarak sunmak için frekans, yüzde, ortalama ve standart sapma kullanıldı. Veriler arasındaki ilişkiyi belirlemek amacıyla tek yönlü varyans analizi (ANOVA), t testi, Kruskall Wallis H Testi, Mann Whitney U Testi kullanıldı. Araştırma öncesi Ege Üniversitesi Hemşirelik Fakültesi Bilimsel Etik Kurulundan, araştırmanın yapılabilmesi için Kamu Hastaneler Birliği Güney Sekreterliğinden yazılı izin ve ameliyathane çalışanlarından sözlü izin alındı. Bulgular: Ameliyathane çalışanların %42,5’i 30-39 yaşları arasında idi. Çalışma grubunun %33.5’i cerrah, %14.5’i anestezist, %41’i ameliyathane hemşiresiydi ve %37’si bulundukları uzmanlık alanında 11 yıl ve üstü deneyimleri olduklarını belirttiler. Çalışanların %46.5’i işe yeni başladıklarında oryantasyon programı uygulandığını belirtmiştir. Çalışma grubundaki personelin Güvenlik Tutumları Ölçeği ortalama puanları incelendiğinde, iş memnuniyeti için ortalama puanı 63.13±20.27, stres düzeyinin belirlenmesi için ortalama puanı 28.55±14.67 ve hasta güvenliği tutumlarının toplam puanlarının ortalamaları 52.51±11.78 olarak saptandı. Ameliyathane çalışanlarının pozisyonları ile hasta güvenliği tutum puanları ortalaması Kruskal Wallis analizi ile karşılaştırıldığında; pozisyon gruplarının puan ortalamaları arasında istatistiksel olarak anlamlı fark olduğu saptanmıştır. Ameliyathanede çalışanların tanıtıcı özellikleri ile, güvenlik tutumları karşılaştırıldığında; 6-10 yıl ve 11 yıl ve daha fazla süreyle uzmanlık deneyimi olanlar, kurumda çalışmaya başlarken oryantasyon programına katılanlar ile kurumda hizmet içi eğitim programlarına katılanların güvenlik tutumları puan ortalamalarının yüksek, aralarındaki farkın anlamlı olduğu belirlendi. Sonuç: Çalışanların stres düzeyini azaltacak uygulamaların planlanması, çalışma saatlerinin yasalara göre düzenlenmesi, kurumda çalışmaya başlamadan önce tüm çalışanların oryantasyon programına katılması, meslek gruplarının birbirleri ve diğer ekip üyeleri ile iletişim ve işbirliğini geliştirecek uygulamaların düzenlenmesi, hasta güvenliği ile ilgili hizmet içi eğitim programları hazırlanıp yönetim kadrosu da dahil edilerek tüm çalışanların katılması önerilir. Anahtar sözcükler: Hasta güvenliği; hasta güvenliği kültürü; hasta güvenliği tutumları. Int J Antisep Disinfect Steril 2016;1(1):1–6 doi: 10.14744/ijads.2016.98608

www.ijads.org

INTERNATIONAL JOURNAL OF ANTISEPSIS DISINFECTION STERILIZATION

RESEARCH ARTICLE Int J Antisep Disinfect Steril 2016;1(1):7–12 doi: 10.14744/ijads.2016.08208

Biofilm production and biocidal efficacy in multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii isolates Burcu SEBİT, Burak AKSU, Ayşegül KARAHASAN YAĞCI Marmara University Faculty of Medicine, Department of Microbiology and Medical Microbiology, İstanbul-Turkey

SUMMARY

Objective: Nosocomial infections caused by resistant Gram-negative bacilli have become a major problem for hospitals in recent years. Antiseptics and disinfectants play an important role in the prevention of nosocomial infections and in the management of infections. Some Gram-negative bacilli also show resistance to antiseptics and disinfectants. Therefore, the selection of proper antiseptics and disinfectants is crucial to prevent nosocomial infections produced by these resistant organisms. In this study, we investigated the biofilm production, antimicrobial susceptibility, and biocidal activity of commonly used antiseptics and disinfectants in our hospital setting against Pseudomonas aeruginosa and Acinetobacter baumannii isolates. Methods: Between January and December-2014, a total of 50 Pseudomonas aeruginosa and 50 Acinetobacter baumannii strains, which were multidrug-resistant (MDR) strains, were included in this study. Biofilm production was identified spectrophotometrically by the microplate assay. Activity of sodium hypochlorite, chlorhexidine, orthophthalaldehyde (OPA), peracetic acid (PA), and peracetic acid/hydrogen peroxide was studied with suspension tests. Results: Commonly used disinfectant-antiseptics were found to be effective against multi-drug resistant A. baumannii and P. aeruginosa strains as follows, chlorhexidine 98%, sodium hypochlorite 90%, OPA 96%, PA and peracetic acid/hydrogen peroxide 94%. The rates of efficacy against the antibioticsusceptible A. baumannii and P. aeruginosa were found to be 100% for chlorhexidine, OPA and PA, 98% for sodium hypochlorite, and 94% for peracetic acid/ hydrogen peroxide. Considering the relationship between the biofilm production and biocidal activity, 22% of biofilm-producing strains of A. baumannii were found to be resistant to any all disinfectants-antiseptics tested, while this rate was 2% in the P. aeruginosa strains. Disinfectant resistance rates were 2% and 6% for biofilm-negative A. baumannii and, P. aeruginosa strains, respectively. Biofilm production and disinfectant resistance were found to be significantly associated with A. baumannii, compared to P. aeruginosa (p<0.05). Conclusion: Tested antiseptics-disinfectants showed 90% efficacy to Gram-negative non-fermentative bacteria isolated in the intensive care unit in our hospital. It would be reasonable to perform further efficacy tests for commonly used antiseptics and disinfectants on a regular basis. Keywords: Acinetobacter baumannii; biofilms; disinfectants; Pseudomonas aeruginosa; resistance. How to cite: Sebit B, Aksu B, Karahasan Yagcı A. Biofilm production and biocidal efficacy in multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii isolates. Int J Antisep Disinfect Steril 2016;1(1):7–12.

Correspondence: Ayşegül Karahasan Yagcı. Marmara Üniversitesi Tıp Fakültesi, Mikrobiyoloji ve Klinik Mikrobiyoloji Anabilim Dalı, 34640 İstanbul. Tel: +90 532 – 582 35 82 e-mail: aysegulkarahasan@gmail.com Submitted: March 30, 2016 Accepted: April 25, 2016 Available online date: June 01, 2016 Society of Disinfection Antisepsis Sterilization ©2016 Production by Kare Publishing on behalf of the Owner. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

seudomonas aeruginosa and Acinetobacter baumannii are common agents responsible for nosocomial infections among other Gram-negative bacteria. A.baumannii ranks the first as the causative agent of nosocomial infections in most centers.[1] This infectious agent is important not only for being the cause of outbreaks associated with a high mortality in the intensive care unit (ICU), but also emergence of multidrug-resistant strains. There has been a significant increase in the prevalence of multidrugresistant strains in recent years. The outbreaks caused by Acinetobacter strains are associated with the ability of bacteria to remain viable for prolonged periods in a dry environment and emergence of antibiotic-resistant infections.[2] P. aeruginosa accounts for 10 to 25% of all nosocomial infections.[3] This agent, in particular, causes nosocomial infections in patients who receive long-term broad-spectrum antibiotherapy and in those who receive chemotherapy or undergo mechanical ventilation and surgical procedures.[4] It is well-established that bacterial resistance can be acquired not only against antibiotics, but also against disinfectants and antiseptic materials used. Disinfection of the environment and materials with the selection of appropriate disinfectants, and proper use are helpful to prevent the development of many nosocomial infections. [5] In addition, biofilm protects bacteria from phagocytosis and effects of the complement, and this layer forms a physical barrier rendering bacterial resistance to the effects of antibiotics and disinfectant materials.[6] In this study, we aimed to investigate the biofilm production, antimicrobial susceptibility, and biocidal activity of commonly used antiseptics and disinfectants in our hospital setting against P. aeruginosa and A. baumannii isolates. Materials and methods Between January and December 2014, 164 Pseudomonas spp. and 395 Acinetobacter spp. strains were isolated from patients hospitalized in the intensive care unit at Republic of Turkey MoH, Marmara University, Pendik Training and Research Hospital. Of these isolates, 50 Pseudomonas aeruginosa and 50 Acinetobacter baumannii strains were found to be multidrug-resistant (MDR) strains. The strains were identified using the mass spectrophotometry (VITEK MS, bioMérieux, France). The antibiotic susceptibility was tested using the disc diffusion test.[7] P. aeruginosa strains[8] resistant to all carbapenem, aminoglycoside, and fluoroquinolone groups and A. baumannii strains resistant to all penicillin antibiotics plus at least three of the cephalosporin, quinolone, carbape-

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nem, and fluoroquinolone groups were considered multidrug-resistant strains.[9] In the study, biofilm forming was tested using A. baumannii ATCC19606 and P. aeruginosa PAO-1 strains positive controls and P. aeruginosa PAO-JP3 strain as negative control.[10-12] Clinical strains incubated overnight in the MacConkey agar (BioMerieux, France) and a colony of control strains were inoculated into tubes containing a 5-ml fresh Luria Bertani (LB, Sigma, USA) liquid medium at 37°C for 24 hours to calculate the biofilm production. After incubation, 1:100 dilution was performed in a fresh LB liquid medium and the dilution was transferred to three wells each containing 100 ml on a sterile, flat-bottomed 96-well polystyrene microplate (Greiner, Germany). The plates were incubated at 37°C for 24 hours, and, then the content of the wells was removed and irrigated three times with distilled water. After irrigation, each well was filled with 100 μl crystal violet solution (0.1%) and the plates remained in room temperature for 10 minutes. The plates were, then, irrigated three times with distilled water to remove excess dye solution and the wells were added 200 μl ethanol 95% to quantify the biofilm layer. Following five minutes of incubation, the absorbance was read in an optic reader (Labsystem Multiskan MS, Thermo Scientific, USA) at 550 nm. The mean absorbance of three wells was recorded for each strain and the experiments were repeated three times. The cut-off value of biofilm production was estimated using the mean absorbance values and standard deviation for non-biofilm forming P. aeruginosa PAO-JP3. A mean + two standard deviations were considered as the cut-off value.[11] Sodium hypochloride (1%), OPA (Orto-Phthalaldehyde) (0.5%) (Anios), chlorhexidine (4%) (Anios), Peracetic acid (2%) (EcoLab), Peracetic acid + hydrogen peroxide (0.2% + 7.5%) (EcoLab) were used in the disinfectant activity studies. The disinfectant concentrations used in the experiments were as 1%, 4%, 0.5%, 2%, 0.2%+7.5% freshly prepared in sterile distilled water. The suspension test method reported by Michel and Zach was used to evaluate the effects of antiseptic and disinfectants on selected strains.[13,14] This method is a modified version of qualitative and quantitative suspension test recommended by the German Society for Hygiene and Microbiology. A suspension was prepared from Pseudomonas aeruginosa ATCC 15442, Escherichia coli ATCC 10536, Staphylococcus aureus ATCC 6538, clinical A.baumannii (n=50), and clinical P. aeruginosa (n=50) strains reproduced in the MacConkey agar at 0.5 McFarland standard in a phosphate buffer and the suspension was, then, diluted to 1/100. A 100 μl of this suspension was transferred into sterile Eppendorf tubes

Sebit B et al. Biofilm pruduction and biocidal efficiency

containing 100 μl disinfectant solution at room temperature (20-25°C) and serial dilutions were performed after five minutes (eight times). A 10 μl of each serial dilution was transferred on tryptic soy agar (TSA) using the drip inoculation method and incubated at 37°C for 18 hours. Disinfectant was considered effective in the absence of growth in a specified contact time and concentration; disinfectant solution was considered ineffective, if there was no 99.999% decline (≥10 colony), compared to the positive control. The suspensions of each strain without a disinfectant solution were used as the positive controls. Statistical analysis was performed using SPSS v15 software (SPSS Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically significant. Results The experiments performed on the negative control strain (P. aeruginosa PAO-JP3) showed a cut-off value of 0.169 for the biofilm production. The biofilm production of P. aeruginosa and A. baumannii was evaluated on the basis of this cut-off value. Biofilm production was positive in 42.8% of MDR P. aeruginosa strains and 75.6% of MDR A. baumannii strains. Biofilm production was also positive in 37.9% of antibiotic resistant P. aeruginosa strains and 71.4% of

A. baumannii strains (Table 1). Biofilm production and disinfectant resistance were significantly higher in the A. baumannii group, compared to the P. aeruginosa group (p<0.05). The rates of efficacy against MDR A. baumannii and P. aeruginosa strains (n=50) were found to be 98% (n=49/50) for chlorhexidine, a commonly used hand antiseptic at our hospital, 90% (n=45/50) for sodium hypochlorite, 96% (n=48/50) for OPA, 94% (n=47/50) for PA, and 96% for peracetic acid/hydrogen peroxide. The rates of efficacy against susceptible A. baumannii and P. aeruginosa strains (50%) were 100% (n=50/50) for chlorhexidine, OPA, and PA, 98% (n=49/50) for sodium hypochlorite, and 94% (n=47/50) for peracetic acid/hydrogen peroxide (Table 2). Three out of 50 P. aeruginosa strains showed resistance against various disinfectants, while only one strain was found to be positive for the biofilm production. The relationship between the biofilm production and disinfectant susceptibility was not significant in P. aeruginosa strains. One non-biofilm forming P. aeruginosa strain was found to be resistant to both chlorhexidine and peracetic acid/hydrogen peroxide. A total of 10 strains among A. baumannii isolates were resistant to more than one disinfectant, while only

Table 1. Biofilm production in multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii strains.

Pseudomonas aeruginosa (n=50)

Acinetobacter baumannii (n=50)

MDR Sensitive Total MDR Sensitive Total n % n % n % n % n % n %

Biofilm- positive 9 42.8 11 37.9 20 40 22 75.8 15 71.4 37 74 Biofilm- negative 12 57.2 18 62.1 30 60 7 24.2 6 28.6 13 26 Total 21 29 50 29 21 50 MDR: Multidrug-resistant.

Table 2. The efficacy rates of disinfectants against P. aeruginosa and A. baumannii strains.

Pseudomonas aeruginosa MDR (n=21)

Sensitive (n=29)

Acinetobacter baumannii MDR (n=29)

Sensitive (n=21)

Biofilm- Biofilm- Biofilm- Biofilm- Biofilm- Biofilm- Biofilm- Biofilmpositive negative positive negative positive negative positive negative (n=9) (n=12) (n=11) (n=18) (n=22) (n=7) (n=15) (n=6)

Sodium hypochlorite E 1 E E 4 E 1 E OPA E E E E 2 E E E Chlorhexidine E 1 E E E E E E Peracetic acid (PA) E E E E 3 E E E PA+Hydrogen peroxide E 1 1 E 1 E 1 1 MDR: Multidrug-resistant; OPA: Orto-Phthalaldehyde; E: Effective.

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Disinfectant resistant

Disinfectant susceptibility

35 30 25

20 30

15 10

17 12

9 1 Biofilm + Biofilm â&#x20AC;&#x201C; A. baumannii

Fig. 1.

2 1 Biofilm + Biofilm â&#x20AC;&#x201C; P. aeruginosa

Disinfectant susceptibility and biofilm production in multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii strains.

%100

A. baumannii P. aeruginosa

p<0.001 80

p=0.037 36 18

Fig. 2.

Biofilm production

6 Disinfectant resistant

Disinfectant susceptibility in P. aeruginosa and A. baumannii strains.

one strain was negative for the biofilm production. Of 10 disinfectant-resistant A. baumannii strains, nine were found to be positive for the biofilm production. In the A. baumannii group, three strains were resistant to two disinfectants. Of these strains, two were resistant to sodium hypochlorite and peracetic acid, whereas one strain was resistant to OPA and peracetic acid. Disinfectant susceptibility and biofilm results are presented in Figure 1. The rate of disinfectant resistance was significantly higher in A. baumannii strains, compared to P. aeruginosa strains (Figure 2). Discussion The presence of bacteria in the hospital setting leads to continuous contamination of the patients and hospital staff which makes impossible to control hospital infec-

tions related to contamination. Thus, disinfection of the environment and hand washing practices are of utmost importance. Pseudomonas aeruginosa and A. baumannii are the most common agents responsible for nosocomial infections among other Gram-negative bacteria.[15] The importance of these agents has been increasing day by day due to their ability to develop antibiotic resistance, which remain viable for prolonged periods on the surfaces and the ability to cause outbreaks.[1] Inappropriate use of antiseptic and disinfectant solutions in terms of contact time with an adequate concentration leads to the selection and emergence of microorganisms resistant to these materials in the hospital setting. In addition, bacteria enclosed with a biofilm layer are more known to be resistant to disinfectant materials, compared to free planktonic form. Several studies have shown that inactivation of microorganisms in the biofilm layer requires the use of up to 1000-fold higher concentrations.[16,17] When the isolates in the present study were analyzed in terms of biofilm production, 40% of P. aeruginosa strains and 74% of A. baumannii strains produced a biofilm layer. The rate of biofilm production was 75.8% in multidrug-resistant A. baumannii strains and the rate in P. aeruginosa strains was 42.8%, showing an inverted trend. When the relationship between the biofilm production and antiseptic/disinfectant materials used in the study was examined, three out of four resistant strains in the P. aeruginosa group were biofilm-negative, while nine out of ten resistant strains in the A. baumannii group were biofilm-positive, as expected (90%). The efficacy of the disinfectants in the present study was tested on the planktonic form of the bacteria. The study by Spoering and Lewis[18] showed that both planktonic cells and biofilm layer of P. aeruginosa exhibited similar resistance to the germicide effects of antibiotics and peracetic acid. The authors emphasized that biocidal efficacy of the bacteria depends on its metabolic activity and bacteria in steady state showed the highest degree of resistance. Among the materials tested, OPA and peracetic acid showed the highest efficacy against P. aeruginosa strains. Using a method similar to that used in the present study, Ekizoglu et al.[19] reported that chlorhexidine 4% and sodium hypochlorite at a dilution rate of 1:50 (1000 ppm) were the most efficient materials against P. aeruginosa strains, while sodium hypochlorite at a dilution rate of 1:500 (100 ppm) did not exert efficacy adequately. Considering A. baumannii strains, chlorhexidine 4% was found to be the most effective disinfectant in

Sebit B et al. Biofilm pruduction and biocidal efficiency

this group (100%). Similarly, Ekizoglu et al.[5] found chlorhexidine 4% to be highly efficient against this agent, while sodium hypochlorite at a dilution rate of 1:50 (1000 ppm) did not show an adequate efficacy. In the present study, sodium hypochlorite showed the lowest efficacy against A. baumannii strains with a 90% success rate. However, sodium hypochlorite 5% at dilution rates of 1:10 and 1:100 was found to be among the most efficient disinfectant against clinical P. aeruginosa and A. baumannii strains in the study by Inan et al.[20] In the present study, five-minute contact time was used in the efficacy tests considering the routine daily practices. Both the rate of the biofilm production and resistance to antiseptic/disinfectant materials were significantly higher in the A. baumannii group, compared to the P. aeruginosa group (p<0.05 and p<0.001, respectively). The most efficient disinfectant against all study strains was chlorhexidine (99%), followed by OPA (98%) and PA (97%). Sodium hypochlorite showed the lowest efficacy (94%) based on the clinical isolates. In another study, Gorgul et al.[21] studied sodium chlorite at a dilution rate of 1:100 and reported efficacy against clinical isolates within 15-minute contact time. In conclusion, antiseptic/disinfectant solutions tested in the present study yielded 90% and higher efficacy rates, compared to non-fermentative Gram-negative bacteria recovered from the intensive care unit of our hospital. The importance of antisepsis and disinfection must be further emphasized considering patients hospitalized in the intensive care units. Proper application and appropriate concentration are the key drivers for success in disinfection and antisepsis. It would be reasonable for each unit to test the efficacy of antiseptic/disinfectant materials used against the isolated agents on a regular basis. Conflict of interest: None declared. Peer-review: Externally peer-reviewed. Authorship contributions: Concept - A.K.Y.; Design - A.K.Y.; Supervision - A.K.Y.; Resource - A.K.Y.; Materials - B.S.; - Data collection - B.S.; Literature search A.K.Y., B.A.; Writing - A.K.Y., B.A. References 1. Fournier PE, Richet H. The epidemiology and control of Acinetobacter baumannii in health care facilities. Clin Infect Dis 2006;42:692–9. Crossref 2. Souli M, Galani I, Giamarellou H. Emergence of extensively drug-resistant and pandrug-resistant Gram-negative bacilli in Europe. Euro Surveill 2008;13(47).

3. Driscoll JA, Brody SL, Kollef MH. The epidemiology, pathogenesis and treatment of Pseudomonas aeruginosa infections. Drugs 2007;67:351–68. Crossref 4. Pier GB, Ramphal R. Pseudomonas aeruginosa. In: Mandell GL, Bennett JE, Dolin R, (eds). Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 7th ed. Philadelphia: Churchill-Livingstone-Elsevier; 2010. p. 2587. Crossref 5. Kuzucu Ç, Baktır E, Uncu H, Acar N, Erdinç Ş. Comparison of the Effectiveness of Antiseptics and Disinfectants against Gram-Negative and Nonfermentative Gram-Negative Bacteria Causing Nosocomial Infections. Turkish J Hosp Infect 2001;5;308–13. 6. Cowen RA. Kelsey-Sykes capacity test: A critical review. Pharm J 1978;220:202–4. 7. Clinical and Laboratory Standards Institute (CLSI): Performance Standards for Antimicrobial Susceptibility testing; Twenty-Fourth Informational Supplement. CLSI document M100-S24, CLSI, Wayne, PA; 2014. 8. Nakamura I, Yamaguchi T, Tsukimori A, Sato A, Fukushima S, Mizuno Y, et al. Effectiveness of antibiotic combination therapy as evaluated by the Break-point Checkerboard Plate method for multidrug-resistant Pseudomonas aeruginosa in clinical use. J Infect Chemother 2014;20:266–9. Crossref 9. Manchanda V, Sanchaita S, Singh N. Multidrug resistant acinetobacter. J Glob Infect Dis 2010;2:291–304. Crossref 10. Holloway BW, Krishnapillai V, Morgan AF. Chromosomal genetics of Pseudomonas. Microbiol Rev 1979;43:73–102. 11. Merritt JH, Kadouri DE, O’Toole GA. Growing and analyzing static biofilms. Curr Protoc Microbiol 2005;Chapter 1:Unit 1B.1. Crossref 12. Pearson JP, Pesci EC, Iglewski BH. Roles of Pseudomonas aeruginosa las and rhl quorum-sensing systems in control of elastase and rhamnolipid biosynthesis genes. J Bacteriol 1997;179:5756–67. 13. Külah C, Doğan B, Gökdal İİ, Yalınay Çırak M, Rota S. The susceptibilities of nonfermentative Gram negative bacteria isolated from intensive care units to various antiseptics and disinfectants. Ankem Derg 2002;16;31–5. 14. Michel D, Zäch GA. Antiseptic efficacy of disinfecting solutions in suspension test in vitro against methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli in pressure sore wounds after spinal cord injury. Dermatology 1997;195 Suppl 2:36–41. Crossref 15. Chemaly RF, Simmons S, Dale C Jr, Ghantoji SS, Rodriguez M, Gubb J, et al. The role of the healthcare environment in the spread of multidrug-resistant organisms: update on current best practices for containment. Ther Adv Infect Dis 2014;2:79–90. Crossref 16. Mataracı E, Gerçeker A. Evaluation of the Minimum Bactericidal Concentrations of Various Disinfectants against Pseudomonas aeruginosa in Biofilm Cultures. Ankem Derg 2011;25:209–14. Crossref 17. Sultan N. Factors effect activity of disinfectants and tests used

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for disinfectant efficacy. Congress book of 6th National Sterilization and Disinfection, Antalya 2009. p. 121. 18. Spoering AL, Lewis K. Biofilms and planktonic cells of Pseudomonas aeruginosa have similar resistance to killing by antimicrobials. J Bacteriol 2001;183:6746–51. Crossref 19. Ekizoglu MT, Ozalp M, Sultan N, Gür D. An investigation of the bactericidal effect of certain antiseptics and disinfectants on some hospital isolates of gram-negative bacteria. Infect

Control Hosp Epidemiol 2003;24:225–7. Crossref 20. İnan A, Akçay SŞ, Özyürek SÇ, Tekin ST, Erdoğmuş P, Erdem İ, et al. The efficacy of various anticeptics and disinfectants againts some nosocomial pathogens. Türk Mikrobiyol Cem Derg 2009;39:97–102. 21. Görgül G, Başbuğ N, Omürlü H. An evaluation of the antibacterial effectiveness of bisdequalinium acetate and sodium hypochlorite. Mikrobiyol Bul 1987;21:289–95. ÖZET

Çoklu ilaç dirençli Pseudomonas aeruginosa ve Acinetobacter baumannii izolatlarında biyofilm üretimi ve biyosidal etkinlik Burcu SEBİT, Burak AKSU, Ayşegül KARAHASAN YAĞCI

Amaç: Dirençli Gram-negatif bakterilerin neden olduğu nozokomiyal infeksiyonlar, son yıllarda hastanelerin önemli problemi haline gelmiştir. Antiseptikler ve dezenfektanlar, nozokomiyal infeksiyonlarının önlenmesinde ve infeksiyon kontrol çalışmalarında önemli bir rol almaktadır. Gram-negatif bakterilerin bir kısmı antiseptik ve dezenfektanlara direnç göstermektedir. Bu nedenle, bu dirençli mikroorganizmalar tarafından oluşturulan nozokomiyal infeksiyonları önlemek için, uygun antiseptik ve dezenfektanların seçimi önemlidir. Bu çalışmada Pseudomonas aeruginosa ve Acinetobacter baumannii izolatlarında antimikrobiyal duyarlılığı ve hastanemizde kullanılan antiseptik ve dezenfektan maddelerin etkinliği ve biyofilm üretiminin dirençle ilişkisi araştırıldı. Yöntemler: Bu çalışmaya Ocak - Aralık 2014 tarihleri arasında çoklu ilaç dirençli 50 Pseudomonas aeruginosa ve 50 Acinetobacter baumannii suşu alındı. Biyofilm üretimi, mikroplak yöntemi ile spektrofotometrik olarak saptandı. Sodyum hipoklorit, klorhekzidin, orto-fitalaldehit (OPA), perasetik asit (PA) ve perasetik asit/hidrojen peroksit için aktivite süspansiyon yöntemi ile tayin edildi. Bulgular: Çoklu ilaç dirençli A. baumannii ve P. aeruginosa suşlarında, hastanemizde sıklıkla kullanılan antiseptik ve dezenfektanlardan klorhekzidin %98, sodyum hipoklorit %90, OPA %96, PA %94, perasetik asit/hidrojen peroksit %96 oranında etkili bulundu. Antibiyotik duyarlı A. baumannii ve P. aeruginosa suşlarında ise, klorhekzidin, OPA ve PA %100, sodyum hipoklorit %98, perasetik asit/hidrojen peroksit ise %94 oranında etkin olduğu saptandı. Biyofilm üretimi ile biyosidal direnç ilişkisi incelendiğinde, biyofilm üreten A. baumannii suşlarında herhangi bir dezenfektan-antiseptik direnci %22 iken, bu oran P. aeruginosa suşlarında %2’dir. Biyofilm negatif suşlarda dezenfektan-antiseptik direnci A. baumannii için %2, P. Aeruginosa için ise %6 idi. Biyofilm üretimi ve dezenfektan direnci, P. aeruginosa’ya kıyasla, A. baumannii grubunda anlamlı düzeyde yüksek bulundu (p<0.05). Sonuç: İncelenen antiseptik/dezenfektanların hastanemiz yoğun bakım ünitesinden izole edilen nonfermentatif Gram-negatif bakterilere karşı %90 ve üzeri oranda etkin olduğu saptandı. Periyodik aralıklarla, izole edilen patojenler üzerinde kullanılan antiseptik/dezenfektanların etkinliğinin test edilmesi akılcı olacaktır.

Anahtar sözcükler: Acinetobacter baumannii; biyofilm; dezenfektan; direnç; Pseudomonas aeruginosa. Int J Antisep Disinfect Steril 2016;1(1):7–12 doi: 10.14744/ijads.2016.08208

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REVIEW Int J Antisep Disinfect Steril 2016;1(1):13–8 doi: 10.14744/ijads.2016.76486

Dare to change Wim RENDERS World Federation for Hospital Sterilization Sciences, Brugge, Belgium

SUMMARY

As departing president of the World Forum for Hospital Sterile Supply (WFHSS), now the World Federation for Hospital Sterilization Sciences, I would like to offer my view on the world of sterilization. I would first like to underline the important role national sterilization associations have played and continue to play. Established in the 1970s to the 1990s, they have been a major catalyst for the evolution of sterilization. International contact between them became more and more frequent and it was soon apparent that cooperation between associations could lead to better national practice. That was the basis for the creation of the European Forum for Hospital Sterile Supply (EFHSS), from which WFHSS originated. What certainly must not be overlooked is that Central Sterile Supply Departments (CSSD) are responsible for the most critical step, namely the conversion of theory into practice. In order to do this well, an evidence-based definition of “state of the art” is essential and this definition should be globally applicable. To grow with a rapidly changing hospital environment, sterilization professionals must be willing to change. In the future, investments will have to be made in uncompromising quality, a high degree of flexibility and excellent service, attention to members of staff, and especially patient care. This requires an open mind and courage - the courage to change! Keywords: Central Sterile Supply Departments; change; future of sterilization; WFHSS.

rom 1999 until 2014, I was president of the World Forum for Hospital Sterile Supply (WFHSS), now known as the World Federation for Hospital Sterilization Sciences. At the 2014 congress in Prague, my mandate ended. Therefore, you can consider this article my retrospective, my philosophical view on the world of sterilization. For me - after all, every individual is the center of his own universe - I can safely say that these 15 years have been, on a human level anyway, very enriching. The presidency has given me the opportunity to explore the

parameters of my personality, to scan my own limits and to get the utmost, and hopefully the best, out of myself. Based on this experience, I recommend that everyone think about what the motto of the Gruuthuuse lineage, a medieval noble family from Bruges, Belgium, might mean to him or her.[1] After 500 years, their motto: “Plus est en vous,” or, “More is in you,” is still valid. It invites us to leave our comfort zone. It invites us to not evade the challenges that we encounter in our life, but rather to face them and address them positively. This way, one grows as a person. This way, we give more sense

How to cite: Renders W. Dare to change. Int J Antisep Disinfect Steril 2016;1(1):13–8.

Correspondence: Wim Renders, PhD, MD. Collaert Mansionstraat 16 8000 Brugge, Belgium. e-mail: w.y.m.renders@gmail.com Submitted: April 05, 2016 Accepted: April 26, 2016 Available online date: May 10, 2016 Society of Disinfection Antisepsis Sterilization ©2016 Production by Kare Publishing on behalf of the Owner. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

and depth to our existence. Only in this way can we penetrate to the core of our being. We have to demolish the psychological and other walls that we have gradually built within ourselves. From time to time, we come to the conclusion that we do not succeed from behind those walls, and we must accept that. Confucius already knew, 2500 years ago, that “Our greatest victory is not that we never fail, but that we, whenever we stumble, rise again.”[2] Indeed what is worse than to admit that we are limited? The answer to this question is that we did not even try to push our boundaries. This leaves us behind, frustrated, and dissatisfied with ourselves. WFHSS gave me the opportunity to undertake this journey. I can only recommend that you go on the same internal expedition. I can assure you that it will be an exciting adventure. In fact, the most important thing is taking on the challenges, both professional and private, that we come across in our life. The rest will follow by itself, automatically. Along the way, encounters with colleagues have given my trip a particular added value. They are special as individuals, but most of all, they are ordinary people. They are fellow workers in sterilization departments and hospitals, heads of associations and representatives of industry. They all have a passion and enthusiasm to advance sterilization, scientifically and/or organizationally, in common. Their authenticity, their drive, is something touching for me. They have been a reason to go on and not to give up, because they counted on me, and I could not let them down. Thanks to them I was not alone in the ongoing struggle for better sterilization. But even more importantly, it is mainly thanks to such people that the field of sterilization has changed. I would like to take this opportunity to engage all of you in this. After all, all of you who are interested in sterilization are also part of my story. I not only want to thank you for your support, but even more so for your commitment, through sterilization, to a better life for our patients, and therefore for your commitment to a better world. Your efforts, your example of cooperation, may be a positive signal that gives hope to others. In light of the current tragedies that increasingly grip the world - I am referring here to the increasing number of armed conflicts resulting in unprecedented refugee flows, and the inability to solve those conflicts in a nonviolent way - the belief that you can secure a positive future is a matter of survival. Your dedication can have the same effect as the flapping of the wings of a butterfly and can bring change, because if everyone is sweeping his or her own doorstep, the whole street will be clean. It is only given to exceptional people to change the

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world alone. As a group, it is much easier. As a group, we are strong enough to make progress that is both universal and lasting. For me, that is the explanation for the creation of national sterilization associations. Without the binding framework of an association, sterilization departments worked and sometimes still work in a kind of vacuole, each by itself, each for itself. Since quality is dependent on the individual, this naturally leads to wide variation in the output of departments. This situation was, and is, as it still exists in various countries, unacceptable. It is unacceptable for patients, for sterilization departments, for hospitals, and for ministries of health. The establishment of national sterilization associations has reversed this. Indeed, the big jump forward in many departments only happened when they started collaborating within the framework of a national society. - A collective approach is the fastest route to our goal: to put a device that meets a high quality standard at the disposal of the care provider and the patient. - A collective approach is a condition sine qua non for individual departmental progress. - Or, “Unity is strength.” A national association provides the ideal channel for the transfer of knowledge to the Central Sterile Supply Departments (CSSD) by organizing study days and congresses, and setting up training courses, and thus creating a higher level of awareness and expertise. An association can also function as a partner with whom the authorities can discuss relevant matters. As a result, it is possible to draw up guidelines and codes of conduct, and even more importantly, their application can be made compulsory. This is, of course, a catalyst for change and the progress of CSSD. An association is the lynchpin for nationwide good sterilization practice. That’s why I’ve always tried to support the activities of local associations by attending congresses. Most European societies were created in the 1970s and 1980s. These associations explored their own backyard without really having structural contact with one another. For a small association, like that of Belgium, where little expertise was available, no research was performed; this was not an ideal situation because we had to rely mainly on commercial information from industry. We soon realized the need for international cooperation to objectify the available information. We realized the need for international contacts in order to improve national practice. That was the basis for the creation of the European Forum for Hospital Sterile Supply (EFHSS) in 1999, an organization of national European societies. But soon

Renders. Dare to change

it became apparent that sterilization does not stop at the borders of the old continent. Other continents were also making serious efforts to improve the quality of sterilization departments, and in the meantime, the Comite Europeen de Normalisation (CEN) and the International Standards Organisation (ISO) started collaborating very closely, with the aim of arriving at a worldwide harmonization of norms.[3] Globalization had become an irrepressible force in the field of sterilization as well. The EFHSS board recognized this and it adopted the name of the forum during the board meeting held in Lillehammer, Norway: World Forum for Hospital Sterile Supply (WFHSS). The primary role of a national or international association is to introduce change to sterilization departments by giving information and by converting information into knowledge. Jan Hoborn[4] once said: “Knowledge is the best medical device.” The departments are and will remain responsible for the most critical step in the process, namely the conversion of theory into practice. Indeed, if we do not succeed in bringing about change on the shop floor, the existence both of a national society and of the WFHSS is useless. Bruce Lee also underlined the importance of this step, saying: “Knowing is not enough, we must apply. Willing is not enough, we must do.”[5] My first advice to sterilization departments, therefore, is the following: Work together within the framework of the national sterilization association and together with the authorities on constant improvement and upgrading of the practice. It should be ensured that the information and guidelines distributed are the same for the entire country. This will, in the end, lead to a univocal practice. It is, for me, an absolute necessity for an efficient organization and more standardization, as well as the safe operation of all departments. That there is an urgent need to define evidence-based practice in sterilization, the “state of the art,” is exemplified in a statement made by Peter Hooper. He told me once that he was surprised that “although he had already visited a great many sterilization departments, he had never seen a department that is identical to another. They are all different.” Despite the fact that we draw on the same sources, namely directives, norms, guidelines, recommendations and more or less standardized training, it seems that the texts are interpreted differently and thus put into practice differently. Sometimes sterilization seems to be “A most individual expression of a most individual emotion.”[6] Of course local factors, such as access roads, available space, and resources play an important role. Nevertheless, the question remains, should we not be

searching for consensus about what an ideal department and an ideal way of working might be, and evolve in that direction? Standardization at the department level has led to improved quality and has reduced costs.[7] If we can do the same at a higher echelon and achieve standardization between departments, this could lead to a uniform and better national and international practice. In the margins of this, it remains an important task for associations and for ministries of health to ensure that the quest for the ideal sterilization department is not limited to a few leading hospitals with exemplary performance. Elsewhere, too, the patient has the basic right to be treated with a medical device of high quality, and the hospital has the same duty. My second piece of advice is addressed to national associations for sterilization: Integrate and commit yourselves more on the international stage. This is too often not the case. Only in this way will you be able, together with members of WFHSS, to decide the direction sterilization will take. We have to engage in a dialogue in which all parties involved are equal partners. It is a reactive model that can only work, and will only last, if it is reciprocal. But when that is the case, sterilization can make quick, real progress everywhere. Whether we like it or not, globalization is a fact that must be taken into account. Nowadays everything is interconnected. It is not possible to turn back time. Looking back does not help us either. It only makes us doubt. We must dare to look ahead and prepare for the future today. An anecdote I recently read in a newspaper confirms this vision. It goes as follows: An engineer visited a site in a developing country where a canal was being built. He saw, to his astonishment, instead of excavators, hundreds of people working with shovels and wheelbarrows. When he asked why they were doing so, he was told that the intention was to give work to as many people as possible. He replied, why then didn’t they work with spoons and buckets? This would surely create even more jobs. The conclusion of the article was that we have no other choice but to go with the times, to make optimal use of the current opportunities, and develop them further. In this way, we avoid awakening one day in an environment in which we are no longer competitive, let alone one with which we are compatible. Sterilization professionals have to be open to change. But when visiting sterilization departments, I sometimes get the impression that we still often work with shovels and wheelbarrows, and perhaps even with spoons and buckets. Producing sterile surgical dressings ourselves,

the manual cleaning of instruments, the use of linen as packaging material, and other processes and equipment that are not approved cannot be seen as truly innovative activities. In the field of sterilization, change is too often postponed for fear that we will be held responsible for what might go wrong. This reflects a culture of conservatism, petty economy and fear. To leave everything as it was before is “good.” Sterilization then trudges cautiously along in a tunnel without vision and toward nowhere. We have to take off the blinders that prevent us from seeing how to work better. The status quo is no longer an option. Sterilization has to focus on change management. Progress must be made on the basis of evidence, knowledge, and experience, or on a fundamental attitude like that described by Immanuel Kant, an 18th century German philosopher, as “Sapere aude,” or “dare to know.”[8] In other words, progress must be made using the courage to listen to your own mind. I would like to add another dimension here: We also must have the courage to then implement our knowledge and expertise. The field of sterilization needs this because it has trouble letting go of traditions and habitual routines, and with making the final step to a becoming a contemporary department. Two more examples and questions: During my visits to departments, I often record that not all instruments are treated in the CSSD. The belief and confidence in one’s own knowledge and skills must surely be enough by now for the CSSD to also adequately treat, for example, delicate ophthalmological instruments. And is it really necessary to build in a control of the control of the control? Once again, we must be prepared to take up our responsibilities. Choosing security should suffice. To overemphasize security is not what is required. It is time to rediscover the essence of sterilization. I agree that innovation and change are current buzzwords that should, or must, be used to solve the problems of our contemporary society, especially our economic problems. Growth can be created. Growth provides more income for governments who have become dependent on it. For companies, innovation is the quest for new and better products, more turnover and efficiency, and lower costs. It is also a necessary element in the fierce struggle for the survival of the company. For a hospital, this is less often the case, as its finances are usually guaranteed by the government. This should not prevent it from using these public financial resources carefully, however, as they are becoming more and more scarce. In this, albeit special biotope, innovation is necessary in order to continue to realize the

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primary, social mission of the hospital, which is to provide up-to-date care to each patient within a changing framework of reference. The hospital of the future will have general practitioners and external specialists. It will be a hub in a network. The service a hospital provides will no longer stop at the exit. Today there are already pilot projects that consist of a quick discharge followed by continuous follow-up of the patient at his home via mobile devices and cloud solutions.[9] This provides better results because patients run less risk of catching a hospital-acquired infection and can recover in their own, trusted environment. Innovation is necessary for sterilization in order to continue to develop in an ever- changing environment. Change should have become a natural habitat for our department because during recent decades sterilization has undergone a permanent and fast evolution. It moved away from being an appendage to the operating room to an independent CSSD. It moved away from being an open area to a department that is strictly divided into different zones. It moved from being mainly manual work toward automated instrument and device reprocessing. It moved from unrestricted and uncontrolled reuse of medical devices meant for single use to responsible reuse or to a total ban on reuse. It moved from the use of chemical and biological indicators toward physical validation of sterilization processes. It moved from a quality check at the end of the sterilization process toward monitoring each step of decontamination. It moved from using untrained staff to having highly qualified members of staff. In other words, the CSSD developed from a department concentrating on the sterilization process itself to a department with the holistic approach of decontamination. Within the general framework of Medical Devices Directive (MDD) 93/42/EEC, European and ISO norms have consolidated the first wave of change by imposing minimal norms on sterilizers for medical purposes and on the sterilization of medical devices, among other things.[10] Later, information related to quality systems was added. This was an attempt to get control over variability in the output of the CSSD, which was often considered too high, and in order to safeguard quality on a constant basis. Quality systems were introduced in the industry after the conclusion was reached that it was not only cheaper, but also much more efficient not to check the quality of the finished product at the end of the process, but to come to a better result through command and control of the constituent processes. This concept is perfectly suited to and applicable to sterilization, since the quality of the end product is no longer visible at the end of the process. Any lack of quality can only be dem-

Renders. Dare to change

onstrated when it is, in actual fact, already too late. For example, when the packaging is opened in the operating theatre, or the flaw becomes apparent after the medical device is used. The parallels that can be drawn between sterilization and a company provide indirect proof that decontamination too, is, in essence, an industrial process, the outcome of which can be perfectly predicted if the essential requirements of process control are met. Or, as Axel Kramer recently formulated it, “Validated reprocessing is a fully controllable risk.”[11] To create the conditions to make this possible is the essential task of the CSSD. Reprocessing then becomes measurable, and hence, an objective, rational process. Industrialization should not be restricted to sterilization but should also apply to other aspects of care in general. To illustrate the necessity of this, I quote Dr. Marcus Froehling, who said, “The industrialization of care is the only way to increase the human touch of care.” In addition to attention to change, industrialization also includes professionalism. The professionalism of hospital staff has to create the necessary space for a human, empathic approach to each patient. As a result, the patient can receive the attention and warmth he is in need of while experiencing traumatic circumstances in a structured way. The CSSD can play an important facilitating role in this process by providing the correct medical device to the provider of care and to the patient in a timely fashion. The ongoing flexibility of the CSSD team will be critical in bringing this about. In the near future, the adaptability of the CSSD will be further tested. Experts predict that as a result of automation and robotics, by 2030, 30% of today’s jobs will disappear.[12] The CSSD should prepare for these developments now. This is happening in a number of departments where innovation is heartily embraced. The automatic tracing of an instrument set with radio-frequency identification (RFID) is already possible today.[13] Tracing at the instrument level with data matrix codes is being added more and more. On the basis of this coding, the CSSD of the University Hospital of Geneva, Switzerland, is testing a robot that can compose sets. At the last WFHSS congress in Prague, Pia Hilsberg and her Danish colleagues gave a presentation called “The use of robotics and automation to achieve a better work environment and efficiency.” They discussed possibilities for the CSSD, including the use of a robot for the automatic handling of instrument containers, the packing of case carts, and the use of case cart trolleys that can be steam sterilized. Bear in mind that some caution is called for in the process of decision-making and implementation: Inno-

vation should not be implemented for innovation’s sake. Innovation has to be directed at improvement, change, and progress. It has to be supported by scientific analysis and by motivated personnel. I just pointed out that the CSSD provides a facilitating service in the hospital. This does not mean that its contribution can be minimized; this does not mean that our department is not important. On the contrary, the CSSD is an important partner in the total care of the patient. But we should not forget that we ourselves decide whether or not we are taken seriously. We can only be as important as the service we provide and the commitment we demonstrate. Therefore, our product should be of the highest possible quality. We can and must be big in something small; we should be 100% committed to this task. The greater our conviction to do this, the more important the CSSD will be, not in, but for, the hospital. This requires constant alertness and a lot of empathy for the patient. The latter is not always easy, as we never get the stimulating emotional feedback of direct patient contact. Our motivation and the dedication of the staff members in our departments has to come from the realization of the importance of our service within the framework of the total care provided in the hospital and the recognition of that by management. To the extent that the members of staff of sterilization departments feel valued, they will also perform better, and their identification with a high quality end product will be higher. Their sense of self-esteem and self-respect reflects on the end product and the department, and vice versa. The extent to which the CSSD is given the recognition it deserves is directly related to the quality of that end product. The challenge for sterilization departments is thus to create a working environment in which our members of staff love to do their jobs, where they have the opportunity to develop themselves and where they can realize the objectives of the sterilization department. This should be our contribution to the wellbeing of the patients, our brick in the wall of a better world. It is clear that in the future, sterilization will have to put its money on uncompromising quality, high flexibility, and excellent service; on attention to its members of staff; and especially on care for the patient. This requires an open mind and courage - the courage to change! Conflict of interest: None declared. Peer-review: Externally peer-reviewed. Authorship contributions: Concept - Design - Supervision - Resource - Materials - Data collection - Literature search - Writing: W.R.

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References 1. de Vries A. Flanders: A Cultural History. London: Oxford University Press; 2007. 2. Burgan M. Confucius Chinese philosopher and teacher. Mankato: Compass Point Books; 2009. 3. Malcorps G, Quintana-Soria I. The Vienna Agreement – CEN as an International Partner (PDF). CEN StandarDays (Day 2 –Session 5). CEN, 2007. 4. Hoborn J. Humans as dispersers of microorganisms: Dispersion Pattern and Prevention. Sweden: University of Göteborg; 1981. 5. Lee B. Striking thoughts. Tokyo: Tuttle Publishing; 2000. 6. Knuvelder G. Handboek tot de geschiedenis der Nederlandse letterkunde van de aanvang tot heden, Volume 4. Malmberg: L.C.G., 1953. p. 20–30. 7. Weekers F. Outsourcing the CSSD of an academic hospital: Opportunity identification and financial analysis. Master Thesis in Business Administration. Vlerick Leuven Ghent Management School, Leuven-Belgium, 2006. 8. Guyer P, Wood A (editors.) The Cambridge Edition of the

Works of Immanuel Kant, Cambridge: Cambridge University Press; 1992. 9. it2it. De 5 belangrijkste ICT-trends in de zorg. Available at: http://www.it2it.nl/it-blog/5-belangrijkste-ict-trends-zorg (Accession date: 15/06/2015). 10. Council Directive 93/42/EEC of 14 June 1993 concerning medical devices. Official Journal L 169, 12/07/1993 P. 0001 – 0043. Available at: http://eur-lex.europa.eu/legal-content/ EN/TXT/?uri=OJ:L:1993:169:TOC. 11. Assadian O, Kramer A, Meyer G. Infection control and quality management in dental medicine and maxillofacial surgery. GMS Krankenhhyg Interdiszip 2012;7:Doc16. 12. Elkins K. Experts predict robots will take over 30% of our jobs by 2025 - and white-collar jobs aren’t immune. Available at: http://www.businessinsider.com/experts-predict-thatone-third-of-jobs-will-be-replaced-by-robots-2015-5 (Accession date: 01/05/2015). 13. Swedberg C. Nutrace, Belintra Market RFID-based Surgical-Tool Tracking Solution in the U.S. Available at: http:// www.rfidjournal.com/articles/view?13416 (Accession date: 25/08/2015). ÖZET

Değişime cesaret Wim RENDERS

Bu yazıda, World Forum for Hospital Sterile Supply (WFHSS) eski başkanı olarak, sterilizasyon dünyası hakkındaki görüşlerimi paylaşmak istiyorum. Öncelikle ulusal sterilizasyon derneklerinin ne kadar önemli bir rol oynadığının ve oynamakta olduğunun altını çizmek isterim. Bu dernekler geçen yüzyılın 70-80 ve 90’lı yıllarında kurulmuş ve sterilizasyonun evrimi için önemli bir katalizör olmuşlardır. Uluslararası temaslar da giderek artmıştır. Dernekler arasındaki işbirliğinin daha iyi ulusal uygulamalara yol açtığı hızla anlaşılmıştır. Bu durum daha sonradan World Federation for Hospital Sterilization Sciences’a dönüşen EFHSS’nin (European Forum for Hospital Sterile Supply) kurulması için temel olmuştur. Kesinlikle göz ardı edilmemesi gereken nokta Merkezi Sterilizasyon Ünitelerinin steril malzeme hazırlama sürecindeki en kritik adım olan teorinin pratiğe dönüştürülmesinden sorumlu olmalarıdır. Bunun en iyi şekilde yapılabilmesi için en yüksek düzeyde ve teknolojide kanıta dayalı uygulama esastır. Bu uygulamalar küresel boyutta uygulanabilir olmalıdır. Hızla değişen hastane ortamı içinde, sterilizasyon da değişime istekli olmalıdır. Gelecekteki sterilizasyon üniteleri yatırımını tartışmasız kalite, yüksek esneklik, mükemmel servis ve hasta bakımındaki personelin dikkati üzerine yapmak zorundadır. Bu, açık bir görüş ve değişim için cesaret gerektirir! Anahtar sözcükler: Merkezi sterilizasyon ünitesi; değişim; sterilizasyonun geleceği; WFHSS. Int J Antisep Disinfect Steril 2016;1(1):13–8 doi: 10.14744/ijads.2016.76486

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REVIEW Int J Antisep Disinfect Steril 2016;1(1):19–22 doi: 10.14744/ijads.2016.76476

Sterilization practices and hospital infections: Is there a relationship? Duygu PERÇİN Erciyes University Faculty of Medicine, Department of Clinical Microbiology, Kayseri, Turkey

SUMMARY

Reprocessing of medical instruments is a series of steps involving transfer, pre-cleaning and decontamination, preparation and maintenance, packaging, sterilization, and storage until the moment of use. Good sterilization practices in hospitals require written standard operational procedures (SOP), compliance with national and international guidelines and norms, employing trained staff and continuing their education, validating and monitoring the process, recording all steps taken during the process, and maintaining successful quality management. All of the literature reporting a relationship between hospital infections and sterilization are, in fact, cases or epidemics originating from poor or bad sterilization practices. Keywords: Hospital infection; reprocessing of medical instruments; sterilization.

very day numerous surgical procedures are performed at hospitals all around the world; infection is a major risk for patients if medical instruments are not reprocessed the way they should be.[1-4] Failure to properly reprocess medical instruments risks cross infection from other patients or the environment,[5-9] as has been reported in the literature following instances of infection that occurred due to poor sterilization practices. Reprocessing medical instruments is a series of steps involving transfer, pre-cleaning and decontamination, preparation and maintenance, packaging, sterilization, and storage until the moment of use. In each of these steps, it is essential to adhere to defined rules of national and/or international guidelines.[1-4] The best way to ensure that rules are followed by all mem-

bers of staff is to have written standard operating procedures (SOP) and to define the required workflow of the Central Sterile Supply Department (CSSD). SOP give more structure to activities. Well-written SOP explained visually through a flowchart or annotated illustrations, if needed, help staff members to do their jobs well.[1] Medical devices used in hospitals are guaranteed by the Medical Device Directive (MDD) in European Union (EU) member countries. According to this directive, member countries must take all necessary steps to ensure that devices are only placed on the market and put into service if they do not compromise the safety and health of patients, users and, where applicable, other persons, when properly installed, maintained and used in accordance with their intended purpose.[10]

How to cite: Perçin D. Sterilization practices and hospital infections: Is there a relationship? Int J Antisep Disinfect Steril 2016;1(1):19-22.

Correspondence: Duygu Perçin, MD. Prof. Erciyes University Faculty of Medicine, Department of Microbiology, Kayseri, Turkey. Tel: +90 352 – 207 66 66 / 23383 e-mail: duygu.percin@hotmail.com Submitted: March 25, 2016 Accepted: April 08, 2016 Available online date: May 05, 2016 Society of Disinfection Antisepsis Sterilization ©2016 Production by Kare Publishing on behalf of the Owner. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

The elimination of microorganisms from a device during the sterilization process is time-dependent, inﬂuenced by the intensity of the process and level of initial microbial contamination. After every operation, surgical instruments are contaminated with blood and microorganisms to varying degrees, depending on the type of operation. There are few studies of accurate estimates of number of microorganisms on used medical surgical instruments. Lumened instruments are more challenging for the CSSD staff. Controversy exists concerning degree of microbial contamination associated with use of rigid lumened medical devices, efficacy of standard cleaning techniques used to remove pathogenic microorganisms from lumen channels, and risk of cross infection because of microbial contamination. Chan-Myers et al.[11] conducted research on the level and types of microorganisms found on rigid lumened medical devices pre and post cleaning. The bioburden level after clinical use was found to be relatively low, ranging from 10 to 104 colony-forming units (CFU) per device. The bioburden level was also related to the anatomical site where the device was used, with fewer organisms found on devices exposed to sterile body sites and the respiratory tract. In addition to initial number of microorganisms, time before reprocessing is also critical for effective cleaning and to achieve sterility assurance level. Perçin et al.[12] reported that cleaning surgical instruments in first 6 hours after use is essential in order to ensure effective disinfection and sterilization. They proved that bacterial count on a used instrument starts to increase logarithmically after 6 hours at room temperature and reaches up to 3log10 CFU/cm2 after 12 hours. Inadequate cleaning of reusable surgical instruments is a common error. One of the most important reasons for inadequate cleaning is lack of sufficient number of instruments at the hospital. Staff is forced to shorten reprocessing time because of the large number of patients. In particular, special attention is required to clean lumened and complex instruments, such as those used for arthroscopy. In a case-control study following a surgical site infection due to Pseudomonas aeruginosa in a patient who underwent arthroscopic surgery in 2009 in Texas, it was proven that the lumens of the complex, structured instruments used during arthroscopy had not been cleaned well.[8] Routine sterilization in CSSDs always includes a number of uncertainties linked to noncondensable gases, insufficient cleaning and excessive condensate. These risks may lower sterilization efficacy, consequently endangering the patient’s life and can lead to outbreaks of infection in surgical departments. Perçin et al.[13] con-

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firmed with an experimental study using large numbers of spores that excessive condensate has a high impact on sterilization efficacy. This impact could only be seen with spore inoculum of more than 108. While the appropriate size and weight of sterilization packs to be used are clearly defined in all sterilization guidelines and norms, sometimes these guidelines are not consistently followed. Microbiological results of an epidemiological survey focused on central sterilization unit proved that the cause of an outbreak of Serratia marcescens mediastinitis in a cardiac surgery intensive care unit (ICU) was the use of inadequately decontaminated theatre linen. Aside from lack of control and monitoring of sterilization processes, the most important problem reported was excessive weight of theatre linen packs.[7] It should also be noted that classic cotton textile drapes have no efficient microbial barrier according to International Organization for Standardization (ISO) standard 13795.[14] In addition to its inefficient bacterial barrier, folding and packaging textile drapes increases the number of particles in clean area of CSSD, which must comply with ISO 8 cleanroom standards.[1,15] A scandal occurred in Oklahoma in March 2013 because dental instruments were used without being sterilized. Some 7000 patients were screened for Hepatitis B virus (HBV), Hepatitis C virus (HCV), and human immunodeficiency virus (HIV) as a result of this scandal. [6] Deviating from best practices in sterilization process or failing to comply with basic rules can lead to infection. Moreover, bad sterilization practices that are not compatible with national or international guidelines increase the risk. Brophy et al.[16] reported another problem that may affect decontamination procedures. They examined 4800 new surgical instruments ordered by several hospitals in United Kingdom (UK). They reported that 15% of the instruments had potential problems, including machining burrs and debris in the teeth of tissue-holding areas, ratcheting, deficient cutting action, protruding guide pins, and corrosion. This study demonstrates the value of quality control for new surgical instruments. Blood and tissue debris may collect in an imperfect surface and be impossible to clean adequately. There is added concern because prion diseases may survive routine sterilization processes.[17] Misuse of immediate-use sterilization (flash sterilization) is another example of bad practice. This process is complex and requires a facility to consistently follow the necessary steps to ensure sterility of instruments to the point of use. Improper technique can result in use of contaminated instruments in surgery, which could have

Perçin. Sterilization and infection

serious consequences, including surgical site infections.[4] Hutzler et al.[18] designed a system to reduce immediateuse sterilization at their hospital by instituting a policy requiring nursing leaders to approve use of immediateuse sterilization, developing guidelines, and monitoring compliance daily. The use of immediate-use sterilization decreased from 79% in 2010 to 7.5% in 2012. There was also improvement in incidence of surgical site infection, decreasing from 5.4% in 2010 to 1.4% in 2012. Facilities should increase their surgical instrument inventory, employ a scheduling conflict mechanism, improve communication between operating room and sterile processing personnel, and educate all those employing immediateuse steam sterilization.[1,4] A final, but no less important, problem regarding poor sterilization practices is reuse of single-use devices. Medical devices may only be reused if the manufacturer provides information about the appropriate process, including cleaning, disinfection, packaging, and sterilization. MDD[10] therefore prohibits reuse of medical devices labeled “single-use” and therefore have no instructions for reuse. Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR)[19] provided a report to European Commission in 2010 concluding that reusing single-use devices presents risk of infection, toxic reaction due to disinfectant residue, and changes to physical and chemical characteristics of the devices that may eventually impact their performance. In conclusion, for good sterilization practices, it is necessary to have written SOP, to comply with national and international guidelines and norms, to employ trained staff and to continue their education, to not reprocess single-use devices, to monitor and validate reprocessing cycles, to record all steps performed during the process and to sustain successful quality management. There is no relationship between sterilization and hospital infections when good sterilization practices are followed. Conflict of interest: None declared. Peer-review: Externally peer-reviewed. Authorship contributions: Concept - Design - Supervision - Resource - Materials - Data collection - Literature search - Writing: D.P. References 1. McDonnell GE. Antisepsis, Disinfection and Sterilization. Washington DC, USA: ASM Press, American Society for Microbiology, 2007. Crossref 2. Günaydın M, Perçin D, Esen Ş, Zenciroğlu D. Dezenfeksiyon ve Sterilizasyon Rehberi. İstanbul: Gülmat Matbaacılık;

2015. 3. Robert Koch Institute. Recommendations by the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute and the Federal German Institute for medical drugs and medical products concerning the “Hygienic requirements for processing of medical devices.” Bundesgesundheitsbl. Gesundheitsforsch. Gesundheitsschutz 2001, 44: 1115-1126, Springer Verlag. (www.rki.de). 4. Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. 5. Schmidt PT. Hygiene-Skandal im Klinikum Bogenhausen. Available at: http://www.merkur.de/lokales/muenchen/ stadt-muenchen/hygiene-skandal-klinikum-bogenhausen-833838.html (Accession date: 09/07/2016). 6. LeBlonde L. Oklahoma dental clinic may have infected thousands with HIV and Hepatitis. Available at: http://www.redorbit.com/news/health/1112812993/hiv-hepatitis-instruments-oklahoma-dental-clinic (Accession date: 29/03/2013). 7. Esel D, Doganay M, Bozdemir N, Yildiz O, Tezcaner T, Sumerkan B, et al. Polymicrobial ventriculitis and evaluation of an outbreak in a surgical intensive care unit due to inadequate sterilization. J Hosp Infect 2002;50:170–4. Crossref 8. Tosh PK, Disbot M, Duffy JM, Boom ML, Heseltine G, Srinivasan A, et al. Outbreak of Pseudomonas aeruginosa surgical site infections after arthroscopic procedures: Texas, 2009. Infect Control Hosp Epidemiol 2011;32:1179–86. Crossref 9. Dancer SJ, Stewart M, Coulombe C, Gregori A, Virdi M. Surgical site infections linked to contaminated surgical instruments. J Hosp Infect 2012;81:231–8. 10. Council Directive 93/42/EEC of 14 June 1993 concerning medical devices. Official Journal L 1993;169:1–43. Available at: http://eur-lex.europa.eu/legal-content/EN/ TXT/?uri=OJ:L:1993:169:TOC. 11. Chan-Myers H, McAlister D, Antonoplos P. Natural bioburden levels detected on rigid lumened medical devices before and after cleaning. Am J Infect Control 1997;25:471–6. Crossref 12. Percin D, Sav H, Hormet-Oz HT, Karauz M. The relationship between holding time and the bacterial load on surgical instruments. Indian J Surg 2015;77:16–8. Crossref 13. Percin D, Kozin P, Renders W. The impact of excessive condensate on the sterility assurance level. Central Service 2015;1:40–3. 14. EN 13795:2011. Surgical drapes, gowns and clean air suits, used as medical devices for patients, clinical staff and equipment - General requirements for manufacturers, processors and products, test methods, performance requirements and performance levels, 2011. 15. ISO 14644-1:2015. Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness by particle concentration, 2015. 16. Brophy T, Srodon PD, Briggs C, Barry P, Steatham J, Birch MJ. Quality of surgical instruments. Ann R Coll Surg Engl

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2006;88:390–3. Crossref 17. Lemmer K, Mielke M, Pauli G, Beekes M. Decontamination of surgical instruments from prion proteins: in vitro studies on the detachment, destabilization and degradation of PrPSc bound to steel surfaces. J Gen Virol 2004;85(Pt 12):3805– 16. Crossref 18. Hutzler L, Kraemer K, Iaboni L, Berger N, Bosco JA 3rd. A

hospital-wide initiative to eliminate preventable causes of immediate use steam sterilization. AORN J 2013;98:597–607. Crossref 19. Scientific Committee on Emerging and Newly Identified Health Risks. The Safety of Reprocessed Medical Devices Marketed for Single-Use. European Commission 2010 ISSN 1831-4783 ISBN 978-92-79-12729-8. ÖZET

Sterilizasyon uygulamaları ve hastane enfeksiyonları: Bir ilişki var mı? Duygu PERÇİN

Tıbbi aletlerin yeniden kullanıma hazırlanması işlemi, transfer, ön-temizlik ve dekontaminasyon, hazırlık ve bakım, paketleme, sterilizasyon, depolama, kullanım anına kadar sterilliği korunarak saklama basamaklarının tümünü içeren bir işlemler dizisidir. Hastanelerde iyi sterilizasyon uygulamaları için yazılı protokollerin oluşturulması, ulusal ve uluslararası kılavuzlara uyulması, eğitimli personel istihdamı ve eğitimin devamlılığı, tüm sürecin kontrolü ve validasyonu, tüm işlemlerin kayıt altına alınması ve başarılı bir kalite yönetimi zorunludur. Literatürde hastane enfeksiyonları ile sterilizasyon uygulamaları arasında bağ olduğunu gösteren tüm vakalar aslında kötü veya yanlış uygulamalardan kaynaklanan olgular ve salgınlardır. Anahtar sözcükler: Hastane enfeksiyonları; sterilizasyon; tıbbi aletlerin yeniden kullanıma hazırlanması. Int J Antisep Disinfect Steril 2016;1(1):19–22 doi: 10.14744/ijads.2016.76476

www.ijads.org

INTERNATIONAL JOURNAL OF ANTISEPSIS DISINFECTION STERILIZATION

REVIEW Int J Antisep Disinfect Steril 2016;1(1):23–32 doi: 10.14744/ijads.2016.32042

Surgical hand washing: A systematic review Fadime GÖK1, Filiz KABU HERGÜL1, Türkan ÖZBAYIR2 Department of Surgical Nursing, Pamukkale University Faculty of Health Sciences, Denizli-Turkey 2 Department of Surgical Nursing, Ege University Faculty of Nursing, İzmir-Turkey

SUMMARY

Objective: Hand antisepsis has an important place in the prevention of surgical site infections. In this review, we aimed to systematically examine the studies on the comparison between the efficiency of surgical hand washing method and the antiseptics being used. Methods: Between August 2009 and September 2014, 23,450 studies which were published were screened. The databases of “EBSCO”, “Pubmed”, “Medline”, “Cochrane Library”, “Science Direct,” “Google Academic” and “ULAKBIM” were screened by using the keywords “Surgical hand washing” “comparison of surgical hand scrubbing solutions” and “operating room”. Among the acquired studies, only 14 randomized-controlled (RC) and experimental articles were examined. These articles were given in a chronological order containing the authors, years, titles, objectives, samples, methods, findings, discussions and conclusions. Results: Considering the findings that were acquired according to this systematic examination, we observed that majority of studies preferred alcohol-based washing products instead of traditional hand washing products (scrubbing with a soap or a povidone iodine), as traditional methods causes less and even no complications such as hand cracks and scrapes, saves time and, above all, it shows an antibacterial effect in a short time. Recent experimental studies suggest that scrubbing fingernails and hands with an antiseptic solution has no use in surgical decontamination; thus, it is sufficient to scrub until the hand dries and the most efficient alcohol-based hand washing product is chlorhexidine gluconate. Efficiency of antiseptics used in surgical hand washing differs according to the technique of surgical hand washing and the sample group being used. Conclusion: Procurement of surgical hand antisepsis is one of the most important principles in preventing the surgical site infections. Efficiency and preference of surgical hand washing solutions is still a disputable issue. Thus, it is recommended to repeat relevant randomized-controlled and experimental studies in a different sample group. Keywords: Comparison of surgical hand washing/scrubbing solutions; operating room; surgical hand washing; systematic review.

How to cite: Gök F, Kabu Hergül F, Özbayir T. Surgical hand washing: A systematic review. Int J Antisep Disinfect Steril 2016;1(1):23–32.

Correspondence: Türkan Özbayır. Ege Üniversitesi Hemşirelik Fakültesi, Cerrahi Hastalıkları Hemşireliği Anabilim Dalı, 35100 Bornova, İzmir. Tel: +90 232 – 311 55 39 e-mail: turkanozbayir@gmail.com Submitted: March 08, 2016 Accepted: April 22, 2016 Available online date: June 01, 2016 Society of Disinfection Antisepsis Sterilization ©2016 Production by Kare Publishing on behalf of the Owner. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

and hygiene forms the basis of antiseptic techniques aimed at reducing the incidence of nosocomial and surgical site infections.[1–3] The contaminated hands of health workers are known to result in nosocomial and surgical site infections. These infections lead to severe morbidity and mortality, prolonged hospital stay, and increased hospital costs.[1–4] Surgical hand washing has an important place in preventing the development and transfer of nosocomial infections, and also in the development of surgical site infections.[2,4] Cleaning of hand and arms with an antiseptic solution was first initiated in the 1860s by Joseph Lister’s surgical team, which used carbonic acid for hand disinfection.[5] The aim of surgical hand washing is to clean up microorganisms, prevent their transfer or to reduce the amount of permanent flora of the hands, which would ultimately prevent surgical wound contamination from microorganisms found on the hands of the surgical team. Even a small amount of microorganism found on the hands can trigger the development of infection. This is particularly pronounced in patients with implants. The incidence of surgical site infection can markedly be reduced through appropriate hand washing procedures.[6,7] Earlier, Mangram et al.[8] reported that in the first surgical cases scrubbing including that of nail beds was necessary in surgical hand washing, and later suggested that the hands could be washed surgically without the scrubbing procedure. Inadequate scrubbing of the hands with an appropriate antiseptic agent may lead a rapid growth of microorganisms. The use of alcohol-based hand antiseptics was initiated towards the end of the year 2008.[6] Alcohol-based hand washing solutions have a broad spectrum of antimicrobial effect. They are also considered in the first-line of use due to their rapid effective nature and a better skin tolerance compared to soap-based hand washing solutions.[4] However, in the absence of included moisturizers, alcohol-based solutions tend to cause dryness of the skin. As a result, there are still controversies concerning the advantages and disadvantages of alcohol-based solutions.[4,6] Although surgical hand washing has been in routine practice for many years now, no acceptable standard protocol has been clearly described as to the scrubbing procedure and the antiseptic solution to be used. Several studies have suggested that any antiseptic agent can be used together with a nail cleaner and scrubbing. However, many studies suggest that there is no need for a nail cleaner or scrubbing and that scrubbing with a good antiseptic agent would be adequate.[3,9–12] Debates con-

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cerning the method and solutions used in surgical hand washing are still being carried out. In this review, we aimed to examine randomized controlled and experimental studies concerning the comparison of the efficiency of surgical hand washing methods and the antiseptic agents used. Materials and methods Inclusion criteria The following criteria were considered in the selection of articles: • Availability of a plan for the method of surgical hand washing and hand washing solutions • Publication language of either Turkish or English • Publication within the past five years (August 2009 and December 2014) • Accessibility to the full text • Being a randomized controlled and experimental study Exclusion criteria • Absence of a full text article • Articles which do not examine the efficacy of the method of surgical hand washing and hand washing solutions • Publication language not being in either English or Turkish • Non-original studies • Lack of reviews and out-of-scope studies investigated in case studies, guidelines, and systematic reviews were not reconsidered and excluded from the study. Selection of studies In this review, 23,450 studies published between August 2009 and September 2014 were examined. The databases of “EBSCO”, “Pubmed”, “Medline”, “Cochrane Library”, “Science Direct,” “Google Academic” and “ULAKBIM” were screened using the keywords such as “Surgical hand washing” “comparison of surgical hand scrubbing solutions” and “operating room” between August-September 2014. Only 14 randomized-controlled and experimental articles were examined from among the studies obtained. These articles were chronologically outlined accordingly to include authors, years, titles, objectives, samples, methods, results, discussions and conclusions. The full texts of all articles considered for investigation were examined to evaluate whether inclusion criteria were met. Results

Gรถk F et al. Surgical hand washing

Table 1. Analysis of studies on surgical hand washing (in a chronological order of articles).

Author/year

Title

Study design

Sample

Method

Limitations

Results

Conclusion

Tanner et al., 2009

Brushes and picks used on nails during the surgical scrub to reduce bacteria: a randomized trial

Randomized controlled

164 operation room personnel

To investigate if scrubbing

Every participant was permitted to take part in the study only once. Those who took part more than once and those who were sensitive to chlorhexidine, latex or any other surgical cleaning product were excluded. The study was performed every day and lasted for a period of six weeks.

No statistically significant difference was found between the three groups. Chlorhexidine was found to be more effective alone in decontamination.

The amount of bacteria was not found to be reduced by scrubbing nails with particularly chlorhexidine.

Individuals below the age of 18 years, those with scratches on their hands, or those with any skin disease, those who refused to use any antiseptic solution

A statistically

and the use of nail cleaners were effective in bacterial reduction, during surgical hand washing. Three different methods were compared. 1. Hands were scrubbed with chlorhexidine. 2. Nails were cleaned with chlorhexidine and nail cleaner. 3. Nails were brushed using chlorhexidine.

Scrubbing is not necessary for surgical hand washing. The technique of scrubbing was suggested to be removed from the procedure of surgical hand washing.

4. Culture products were collected one hour after, using the glove-fluid method. 2

Suchomel et al., 2011

Ethanol in pre-surgical hand rubs: concentration and duration of application for achieving European Norm EN 12791

Randomized controlled

20 individuals

A total of 20 volunteered were divided into three randomized controlled groups. Every volunteer used each antiseptic only once. At least one week was expected to elapse for the skin flora to be renewed when an individual test was repeated. All two hands were washed for three minutes in 75%, 85% and 95% Ethanol.

or anybody who did not perform any of the tests one week before was excluded from sampling.

significant difference was observed between the three antiseptic solutions (75%, 85%, 95% ethanol), during the evaluation performed three hours later.

Ethanol-based hand cleaning solutions were convenient for surgical hand washing and the use of the 95% form of the solution was more appropriate for surgical hand washing of less than three minutes.

Bacteria on the hands of those with gloves were found to be significantly reduced in those who used 85% ethanol, following a three-hour antisepsis.

Cunha et al., 2011

The efficacy of three hand aseptic techniques using chlorhexidine gluconate (CHG 2%)

Experimental ross-over study

A total of 29

A total of 29 individuals

individuals

were included in this study.

completed

The aim was to compare

the study out

the antimicrobial effect of

of the 32

chlorhexidine gluconate

individuals

through the use of three

who were

different hand washing

enrolled (an

techniques.

allergic

The hands were washed

reaction

with 2% chlorhexidine

developed in

gluconate with brush,

one person,

2% chlorhexidine gluconate

while two

with sponge, and

persons were

scrubbing with 2%

excluded from

chlorhexidine gluconate

the study

alone.

following inability to respect the antiseptic technique prescribed)

Individuals with allergic reactions, those with scratches on their hands, or those with any skin disease, and those who did not respect the antiseptic technique prescribed were excluded from sampling.

No statistically significant was found between the three methods with regards to colonies on the hands. There was no difference in the effect of scrubbing with chlorhexidine gluconate in reducing the colony size on the hands.

The scrubbing technique may not be used for surgical hand washing. Chlorhexidine gluconate may be used without any scrubbing apparatus.

Int J Antisep Disinfect Steril

Table 1. Analysis of studies on surgical hand washing (in a chronological order of articles). (Cont.)

Author/year

Title

Study design

Sample

Method

Limitations

Results

Conclusion

Chen et al., 2012

Effect of surgical site infections with waterless and traditional hand scrubbing protocols on bacterial growth

Experimental

A total of 100 operation room personnel were randomly selected for the study.

In this study, 100

None

Analysis of microorganisms was performed from the sample collected 48 hours after. About 1-9 colony plaques were demonstrated in the water-free scrubbing group whereas 1-5 colony plaques were demonstrated in the traditional soapwashing group. No statistically significant difference was found between the groups. Decontamination of microorganism was observed in nine patients who had contact with 14 individuals following the scrubbing procedure. Of these patients, one underwent amputation.

Results showed that

Olson et al., 2012

Prospective, randomized in vivo comparison of a dual-active waterless antiseptic versus two alcohol-only waterless antiseptics for surgical hand antisepsis

Prospective randomized controlled experimental study

A total of 82 individuals completed the study out of the 129 individuals who were enrolled, following the inability of others to fulfill the study inclusion criteria.

Comparison was made between the three water-free hand washing products found in the market to understand if the efficacy of adding chlorhexidine gluconate to alcohol-based products changed. Alcohol+1% chlorhexidine gluconate alcohol+ 61% ethyl alcohol alcohol+ 80% ethyl alcohol

A statistically significant difference was demonstrated between alcohol-based solutions containing 1% chlorhexidine gluconate and the other alcohol-based products (61% ethyl alcohol and 80% ethyl alcohol). Alcohol + 1% chlorhexidine gluconate has a higher bactericidal permanent effect.

Immediately after using three water-free surgical hand antiseptics their effects were found to be similar.

investigators were divided into equal groups. Comparison was made between traditional hand washing and alcohol-based water-free hand washing durations, and between the mode of washing and the effect of solution used. Samples for microorganisms were obtained 48 hours after surgical hand washing performed in two different ways.

A total of 12 measurements were performed during a period of five days. Cultures were collected using the glove-fluid method, immediately after and again six hours after washing.

Individuals below the age of 18 years, those with scratches on their hands, those allergic to latex, alcohol, detergent, soap, or any hand antiseptic, those who have used any antimicrobial agent on the hand or arms within the past week, those with any allergic condition, those using artificial nails or nail polish, those treated for any nail or nail bed condition, individuals who have visited thermal springs or similar places for treatment purposes, those who have used any hand lotion within two hours of surgical hand washing, individual with asthma, hepatitis or any such contagious disease, those who have received antibiotic treatment within one week, or pregnant women, were excluded from sampling.

alcohol-based water-free hand washing was more efficient and that it was as effective as traditional scrubbing of hands in terms of growth of microorganisms.

However, after six hours, products containing alcohol plus chlorhexidine gluconate were reported to have a higher bactericidal permanent effect.

Gök F et al. Surgical hand washing

Table 1. Analysis of studies on surgical hand washing (in a chronological order of articles). (Cont.)

Author/year

Title

Study design

Sample

Method

Limitations

Results

Conclusion

Okgün Alcan et al., 2012

Comparison of the efficiency of nail pick and brush used for nail cleaning during surgical scrub on reducing bacterial counts

Experimental

60 nurses

The study was conducted to determine whether there was any difference between 4% chlorhexidine gluconate and surgical hand washing. A total of 60 nurses were divided randomly into three equal groups. - Those who used routine hand washing methods (1) Control group - Those who used brushes to clean nail beds (2) Study group and - Those who used nail cleaners (3) Study group Culture samples were collected from the nails and hands before surgical scrubbing Culture sampling was repeated one hour after scrubbing, using the glove-fluid method.

Individuals allergic to chlorhexidine gluconate, those who had any scratches on their hands, persons allergic to latex, those with any systemic allergic disease, those who developed allergic reactions during the period of data collection or those with punctured gloves within a one-hour period, were excluded from sampling.

The amount of bacteria after one hour of surgical scrubbing was found to be lower in the control group compared to the study group.

Nail cleaning and the use of brushes were not found to have any advantage in the decontamination of bacteria during surgical hand washing, and no difference was reported between scrubbing and normal hand washing.

No statistically significant difference was found between the study and control groups.

Lai et al., 2012

Surgical Hand Experimental Antisepsis–A Pilot Study comparing Povidone Iodine Hand Scrub and Alcohol-based Chlorhexidine Gluconate Hand Rub

20 Volunteers

Twenty volunteers were divided into two groups. 1. Traditional group performed scrubbing using 7.5% povidone iodine (PVP-I) for three minutes. 2. Avagard group used 61% ethyl alcohol and 1% chlorhexidine gluconate by scrubbing for three minutes until the hands were dry. Colony formation was left to the Colony Forming Units (CFU) immediately before and after the procedure, and one hour after putting on gloves.

Participants with infections on their upper extremity, those with any scratches or wounds, and those allergic to povidone iodine and chlorhexidine gluconate were excluded from sampling.

The colony size on the hands washed with povidone iodine within one hour and immediately after the procedure was found to be significantly smaller than that observed with chlorhexidine gluconate. However, this difference was not found to be statistically significant. Avagard was reported in many studies to be more effective.

Consistent with previous study findings, chlorhexidine containing alcohol-based hand washing solutions were found to be superior, compared to povidone iodine containing products. It can be used in the operation for surgical hand antisepsis alternatively to the traditionally used method (PVP-I).

Shen et al.,

Comparative

Prospective

128 healthy

antimicrobial efficacy of alcohol-based hand rub and conventional surgical scrub in a medical center

observational study/ Experimental

personnel

The study was conducted with 65 test subjects and 63 control individuals. Culture samples were collected from both group pre- and post-operatively to investigate the antimicrobial effects of alcohol-based hand washing solution and the conventional surgical scrubbing.

Individuals who

2013

Growth of pathogenic microorganisms was reported to be low in those who used alcohol-based hand lotions for two minutes pre- and post-operatively. The antimicrobial effect of alcoholbased products has been shown to be faster than observed in conventional hand washing. The antiseptic effect was reported to be higher than conventional hand washing methods. No statistically significant difference was found between the two groups in respect of the occurrence of allergic reactions.

Alcohol-based antiseptics have been reported to be more effective than conventional hand scrubbing. Alcohol-based products affect bacteria faster. They can be considered as an alternative to the hand washing techniques preferred in the operation rooms due to this rapid antibacterial effect, rendering scrubbing unnecessary.

refused to provide culture samples before and after the operation were excluded from sampling.

Int J Antisep Disinfect Steril

Table 1. Analysis of studies on surgical hand washing (in a chronological order of articles). (Cont.)

Author/year

Title

Sample

Method

Limitations

Results

Conclusion

Mahmoud et al., 2013

Experimental Hand rubbing and scrubbing in relation to microbial count among surgical team members in a Saudi Hospital

Study design

72 Individuals

A total of 72 individuals were divided randomly into three groups, in the study aimed at comparing the effect of povidone iodine, alcohol and conventional hand washing in reducing the flora found on the hands of the surgical staff. Group 1. 7.5% povidone iodine used for three minutes to scrub by conventional method, Group 2. 70% ethyl alcohol used to scrub for three minutes until the hands were dry, Group 3. Avagard (2% chlorhexidine gluconate +70% ethyl alcohol) used to scrub for three minutes until the hands were dry. Culture samples were obtained from every group when gloves were removed before, immediately after and three hours after scrubbing.

Those who participated in the surgical procedure in the operation room and performed surgical hand washing, those allergic to chlorhexidine gluconate or alcohol, patients with upper respiratory tract infection, those with any trauma, scratch or infection on the hand, and those who could not contribute to the study for a period of three months were excluded from sampling. Participants were instructed about dressing and hand washing procedures before the study.

No statistically significant difference was found between the three groups immediately after scrubbing. There was also no statistically significant difference after scrubbing with alcohol and Avagard; however, in those who used Avagard the reduction in colony size was reported to be statistically significant during measurements performed three hours later.

Avagard was reported to be more effective in reducing colony size on the skin when compared to 70% ethyl alcohol and 7.5% povidone iodine. Avagard was suggested as an alternative in operation rooms to the conventionally used povidone iodine (PVD-I).

10 Macias et al., 2013

Chlorhexidine is a better antiseptic than povidone iodine and sodium hypochlorite because of its substantive effect

Experimental

30 volunteers

The study was conducted in two steps. First step: evaluation according to the skin colony-forming units (CFU), Second step: investigation of the effect of 10% sodium hypochlorite or % chlorhexidine gluconate, and isopropyl alcohol. Each volunteer was tested four times.

Participants were advised not to enter swimming pools for two weeks; to use neutral shampoo and shower jells free of antiseptic effects. They were also advised not to bath within 24 hours before the experiment.

Demonstrations were made 120 times to check on the antiseptics. No difference was reported between chlorhexidine gluconate and sodium hypochlorite with regards to CFU. The two antiseptics were found to have marked different effects from the control group. Only chlorhexidine gluconate demonstrated variable effects.

Although isopropyl alcohol, sodium hypochlorite and povidone iodine and chlorhexidine gluconate did not demonstrate the similar long lasting effect. chlorhexidine gluconate has been reported to be preferable during pre-operational skin cleaning, catheter installation and surgical hand washing.

11 Suchomel et al., 2013

Glycerol significantly decreases the three hour efficacy of alcohol-based surgical hand rubs

Randomized controlled Experimental study

24 volunteers

Three cross-over examinations were made to test if all alcohol products contained glycerol or not. Every formulation of the cross-over examination was performed randomly in two groups. The first person in the first group used pure alcohol, the first person in the second group used glycerol-containing alcohol, while the second person used pure alcohol. The test continued for one week. At the end of the experiment everybody must have used every formulation once.

Individuals below the age of 18 years, those with scratches, scratch infections or wounds on their hands, those who had not used any antibacterialcontaining antiseptic or antibiotic within one week, pregnant women, and those who had not performed the required tests before one week of the study were excluded from sampling.

All formulations containing 1.45% glycerol were found to significantly reduce a three-hour bactericidal effect (p<0.01); and alcohol was reported to be more effective alone. The three-hour bactericidal effect of pure alcoholbased formulations were found to be significantly higher the formulations containing glycerol (p<0.01).

This study demonstrated that addition of glycerol to alcohol-based hand washing products reduced the bactericidal effect of surgical hand washing antiseptics. Another study showed that the effect of glycerol was high.

Gรถk F et al. Surgical hand washing

Table 1. Analysis of studies on surgical hand washing (in a chronological order of articles). (Cont.) Author/year

Title

Study design

Sample

Method

Limitations

Results

Conclusion

Kareem et al., 2014

Alcohol Based Hand-rub versus Traditional Hand Scrub as Surgical Hand Disinfection in a Tertiary Eye Teaching Hospital in Iraq

Experimental

50 Individuals

The study was performed in a single center for a period of four weeks. One group used the standard hand washing method by washing with water, and soap and scrubbing for five minutes, rinsing and drying. The other group used alcohol-based hand washing solution for 1.5 minutes.

None

Those using alcohol-based hand washing solutions were reported to present with a significantly reduces colony size (CFU), compared to those who used the standard hand washing method.

Alcohol-based hand washing solutions were reported to significantly reduce the colony size (CFU), compared to the standard hand washing method. Alcohol-based hand washing solutions were suggested to deserve preference over the standard hand washing method.

Barbadoro et al., 2014

In vivo comparative efficacy of three surgical hand preparation agents in reducing bacterial count

Experimental

7 Individuals

Comparison was made between alcohol-based hand washing solutions (40%; isopropyl alcohol, 25%; N-propyl alcohol, 1.74% glycerin, 1% < triethanolamine carbomer salt), chlorhexidine gluconate and povidone iodine solutions, with regards to surgical contamination.

Individuals with scratches, wounds and desquamations on their hands, and those allergic to antiseptics were excluded from sampling.

The best results within the three-hour period were obtained from alcohol-based products. However, bacterial growth was reported on the hands of those who scrubbed and experienced irritation with alcohol-based products.

Alcohol-based products were found to have a higher bactericidal effect; the bactericidal effect of chlorhexidine gluconate was reported to be higher than that of povidone iodine. The fact that alcohol-based hand antiseptics cause desquamation on the hands may lead to marked colonization. This reaction demonstrated by the skin of health personnel should be investigated.

Participants who obtained antibiotic treatment within seven days, those who had sever skin injuries and those who were sensitive to alcohol-based products were excluded from sampling.

No statistically significant difference was found in terms of the amount of bacteria. The amount of microorganism was reported to be reduced when alcohol and chlorhexidine were separately used after 30 minutes.

It has been suggested that the use of alcohol together with chlorhexidine is more effective.

Random selection was made for the choice of fluid. Culture sample were obtained three hours after wearing sterile gloves.

14 Howard et al., 2014

New method for Randomized Controlled/ assessing hand Experimental disinfection shows that pre-operative alcohol/ chlorhexidine rub is as effective as a traditional surgical scrub

20 Volunteer Anesthetists

The Mc Kenzie method was used in the study. The procedure was initiated using the glove-fluid method, after removing jewelry such as rings and bracelets from the hands and doing nothing else. Then after, and in a randomized controlled manner (subsequent removal of gloves), 4% watered chlorhexidine was used on one hand which stayed on for three minutes. The other hand was scrubbed for 60 seconds using 70% isopropyl alcohol/0.5% chlorhexidine solution. Bacteria samples were obtained 30 minutes later from both hands using the glove-fluid technique. Comparison was then made between the two groups.

Int J Antisep Disinfect Steril

Discussion

the antibacterial effects of surgical hand washing antiseptics.

The common goal of all surgical staff is to provide bacterial decontamination in the operation room.[13] Preoperative washing of hands by the surgical team with an antimicrobial solution is known to play an important role in the prevention of nosocomial infections.[14]

The antibacterial effects of surgical hand washing antiseptics have been reported to be as important as the surgical hand washing technique itself in the reduction of surgical site infections. Many literature studies compared the effect of various antiseptics, as well as various forms of the same antiseptic. To illustrate, Suchomel et al.[11] demonstrated that 85% ethanol had a higher bactericidal effect than the others. In another study, three different methods were used with chlorhexidine gluconate (classical scrubbing, scrubbing with sponge, and scrubbing without using any apparatus) for surgical hand washing and it was reported that there was no statistically significant difference between the three methods.[10] According to results of this study, the use of brush and sponge did not increase the bactericidal effect of chlorhexidine gluconate. The authors concluded that chlorhexidine gluconate can be used in surgical hand washing without the need for any scrubbing apparatus.[10]

Povidone iodine and chlorhexidine gluconate are the common solutions used in surgical hand washing. Recent RC experimental studies have demonstrated that the scrubbing technique frequently used in conventional surgical hand washing is not very necessary. Although the conventional brushing/scrubbing technique provides an effective antisepsis, it has been shown to increase complications such as cracks and scratches of the hand. As a result, scrubbing has been suggested to be unnecessary during surgical hand washing. Scrubbing and particularly the use of special apparatus to scrub nails has been shown not to reduce the amount of bacteria; hence, it has been suggested that the scrubbing technique may be removed from the surgical hand washing guidelines.[2,9,12,15] In the study by Okgun Alcan et al.,[3] the use of nail cleaners and scrubbing did not have any advantage in bacterial decontamination during the process of surgical hand washing, and that there was no difference between scrubbing and normal hand washing. In another study where the conventional hand washing was compared with hand washing using alcohol-based solution, washing time, washing method and the effect of solution were investigated, alcohol-based hand washing was found to be as effective as the conventional scrubbing technique. [12] Another study compared the antimicrobial effect of alcohol-based hand washing and the conventional scrubbing technique and demonstrated that alcohol-based hand antiseptics were more effective than conventional scrubbing.[2] Kareem et al.[15] reported similar results in their study. Although washing with alcohol-based solution shortened the duration of washing, a smaller colony size was demonstrated on the hands of participants compared to the conventional method. Apart from several advantages of alcohol-based hand washing products such as the rapid bactericidal effect, being easy-to-use and its less time consuming nature, they also have several disadvantages of scrubbing such as irritation of hands, development of allergic reactions and skin dryness. To reduce these unwanted effects, a study was conducted where glycerol was added to the alcoholbased products.[4] The study results demonstrated that addition of glycerol to alcohol-based products reduced

In another study investigating whether there was any change in the effect of adding chlorhexidine gluconate to the alcohol-based products, chlorhexidine gluconate containing products provided a longer lasting bactericidal effect.[16] Chlorhexidine gluconate was also shown to have a higher bactericidal effect, compared to povidone iodine and other alcohol-based products in many studies carried out among varying samples groups, varying time periods, and with varying techniques.[17â&#x20AC;&#x201C;21] Furthermore, recent experimental studies have demonstrated that conventional hand washing/scrubbing techniques are no longer necessary, and that the use of alcohol-based hand antiseptics would instead be more appropriate.[17â&#x20AC;&#x201C;21] In conclusion, the technique of surgical hand washing, effect of the solution used and the preference of one over the other is still a controversial issue. Therefore, there is a need for repeated RC experimental studies in a varying sample size. Acknowledgements This study was presented as an oral presentation at the 2nd National Operating Room Sterilization Disinfection Congress, held in Antalya, between 6-9 November 2014. We would like to express our thanks to all readers for their contribution. Conflict of interest: None declared. Peer-review: Externally peer-reviewed.

Gök F et al. Surgical hand washing

Authorship contributions: Concept - F.G., F.K.H., T.Ö.; Design - F.G., F.K.H., T.Ö.; Supervision - F.G., F.K.H., T.Ö.; Resource - F.G., F.K.H., T.Ö.; Materials F.G., F.K.H., T.Ö.; Data collection - F.G., F.K.H., T.Ö.; Literature search - F.G., F.K.H., T.Ö.; Writing - F.G., F.K.H., T.Ö. References 1. Kuzu N, Ozer F, Aydemir S, Yalcin AN, Zencir M. Compliance with hand hygiene and glove use in a university-affiliated hospital. Infect Control Hosp Epidemiol 2005;26:312–5. Crossref 2. Shen NJ, Pan SC, Sheng WH, Tien KL, Chen ML, Chang SC, et al. Comparative antimicrobial efficacy of alcohol-based hand rub and conventional surgical scrub in a medical center. J Microbiol Immunol Infect 2015;48:322–8. Crossref 3. Okgün Alcan A, Demir Korkmaz F. Comparison of the efficiency of nail pick and brush used for nail cleaning during surgical scrub on reducing bacterial counts. Am J Infect Control 2012;40:826–9. Crossref 4. Suchomel M, Rotter M, Weinlich M, Kundi M. Glycerol significantly decreases the three hour efficacy of alcohol-based surgical hand rubs. J Hosp Infect 2013;83:284–7. Crossref 5. Katz DI, Watson JT. Surgical hand antisepsis for the hand surgeon. J Hand Surg Am 2011;36:1706–7. Crossref 6. Asensio A, de Gregorio L. Practical experience in a surgical unit when changing from scrub to rub. J Hosp Infect 2013;83 Suppl 1:40–2. Crossref 7. Spruce L. Back to basics: hand hygiene and surgical hand antisepsis. AORN J 2013;98:449–60. Crossref 8. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250–80. Crossref 9. Tanner J, Khan D, Walsh S, Chernova J, Lamont S, Laurent T. Brushes and picks used on nails during the surgical scrub to reduce bacteria: a randomised trial. J Hosp Infect 2009;71:234–8. Crossref 10. da Cunha ÉR, Matos FG, da Silva AM, de Araújo EA, Ferreira KA, Graziano KU. The efficacy of three hand asepsis techniques using chlorhexidine gluconate (CHG 2%). Rev Esc Enferm USP 2011;45:1432-7.

11. Suchomel M, Rotter M. Ethanol in pre-surgical hand rubs: concentration and duration of application for achieving European Norm EN 12791. J Hosp Infect 2011;77:263–6. Crossref 12. Chen CF, Han CL, Kan CP, Chen SG, Hung PW. Effect of surgical site infections with waterless and traditional hand scrubbing protocols on bacterial growth. Am J Infect Control 2012;40:15–7. Crossref 13. Howard JL, Hanssen AD. Principles of a clean operating room environment. J Arthroplasty 2007;22(7 Suppl 3):6– 11. Crossref 14. Gupta C, Czubatyj AM, Briski LE, Malani AK. Comparison of two alcohol-based surgical scrub solutions with an iodinebased scrub brush for presurgical antiseptic effectiveness in a community hospital. J Hosp Infect 2007;65:65–71. Crossref 15. Kareem SA, Mahmood AA, Hussein ZR. Alcohol Based Handrub versus Traditional Hand Scrub as Surgical Hand Disinfection in a Tertiary Eye Teaching Hospital in Iraq. J Clin Exp Ophthalmol 2014;5:1–3. 16. Olson LK, Morse DJ, Duley C, Savell BK. Prospective, randomized in vivo comparison of a dual-active waterless antiseptic versus two alcohol-only waterless antiseptics for surgical hand antisepsis. Am J Infect Control 2012;40:155–9. Crossref 17. Lai KW, Foo TL, Low W, Naidu G. Surgical hand antisepsisa pilot study comparing povidone iodine hand scrub and alcohol-based chlorhexidine gluconate hand rub. Ann Acad Med Singapore 2012;41:12–6. 18. Mahmoud MH, Asaad AM, Qureshi MA. Hand rubbing and scrubbing in relation to microbial count among surgical team members in a Saudi Hospital. Journal of American Science 2013;9:457–64. 19. Macias JH, Arreguin V, Munoz JM, Alvarez JA, Mosqueda JL, Macias AE. Chlorhexidine is a better antiseptic than povidone iodine and sodium hypochlorite because of its substantive effect. Am J Infect Control 2013;41:634–7. Crossref 20. Barbadoro P, Martini E, Savini S, Marigliano A, Ponzio E, Prospero E, et al. In vivo comparative efficacy of three surgical hand preparation agents in reducing bacterial count. J Hosp Infect 2014;86:64–7. Crossref 21. Howard JD, Jowett C, Faoagali J, McKenzie B. New method for assessing hand disinfection shows that pre-operative alcohol/chlorhexidine rub is as effective as a traditional surgical scrub. J Hosp Infect 2014;88:78–83. Crossref

Int J Antisep Disinfect Steril

ÖZET

Cerrahi el yıkama: Sistematik derleme Fadime GÖK, Filiz KABU HERGÜL, Türkan ÖZBAYIR

Amaç: El antisepsisi cerrahi alan enfeksiyonlarının önlenmesinde önemli bir yere sahiptir. Bu derlemede, cerrahi el yıkama yöntemi ve kullanılan antiseptiklerin etkinliğinin karşılaştırılması ile ilgili çalışmaların sistematik olarak incelenmesi amaçlandı. Yöntemler: Bu çalışmada Ağustos 2009 – Eylül 2014 tarihleri arasında yayınlanmış 23.450 çalışma incelendi. “EBSCO”, “Pubmed”, “MEDLINE”, “Cochrane Library”, “Science Direct,” “Google Akademik” “ULAKBIM” veri tabanları “Surgical hand washing” “comparison of surgical hand scrubbing solutions” ve “operating room” anahtar kelimeleri kullanılarak tarandı. Elde edilen çalışmalardan sadece randomize kontrollü (RKÇ) ve deneysel 14 makale incelemeye alındı. Bu makaleler, yazarları, yıl, başlık, amaç, örneklem, yöntem, bulgular, tartışma ve sonuçları içeren bir düzen içerisinde kronolojik sıraya göre verildi. Bulgular: Bu sistematik inceleme doğrultusunda elde edilen bulgulara bakıldığında, çalışmaların çoğunda geleneksel el yıkama (sabun ya da povidon iyot ile fırçalama) yerine alkol bazlı el yıkama ürünlerinin tercih edildiği görüldü. Tercih edilme nedenlerine bakıldığında, geleneksel fırçalama yöntemine göre ellerde, çatlak, sıyrık gibi komplikasyonların daha az olduğu, hatta hiç görülmediği, zaman tasarrufu yarattığı ve kısa sürede antibakteriyel etkisinin görüldüğü bildirilmektedir. Son yıllarda yapılan deneysel çalışmalarda tırnakların ve ellerin antiseptik bir solüsyonla fırçalanmasının cerrahi dekontaminasyonda yararının olmadığı, bu nedenle el kuruyana kadar ovulmasının yeterli olduğu, alkol bazlı el yıkama ürünlerinden en etkili olanın ise, klorheksidin glukonat olduğunu belirtilmektedir. Cerrahi el yıkamada kullanılan antiseptiklerin etkinliği, cerrahi el yıkama tekniği ve kullanılan örneklem grubuna göre farklılık göstermektedir. Sonuç: Cerrahi el antisepsisinin sağlanması cerrahi alan enfeksiyonların önlenmesinde en önemli ilkelerden biridir. Cerrahi el yıkama solüsyonlarının etkinliği ve birinin diğerine göre tercih edilme durumu hala tartışmalı bir konu olarak güncelliğini koruduğu görülmektedir. Bu nedenle, bu konu ile ilgili randomize kontrollü deneysel çalışmaların farklı örneklem grubunda tekrarlanmasının uygun olduğu düşünülmektedir. Anahtar sözcükler: Ameliyathane; cerrahi el yıkama; cerrahi el yıkama solüsyonlarının karşılaştırılması; sistematik derleme. Int J Antisep Disinfect Steril 2016;1(1):23–32 doi: 10.14744/ijads.2016.32042