Journal of the Academy of Hospital Administration

N. Prabhu(1), M. Sangeetha(1), P. Chinnaswamy(2), PI. Joseph(3)

Key Words: Nosocomial infection, bacteria, ethanol, concentration.

ABSTRACT

In order to reduce the nosocomial infections among hospitalized patients and visitors a study was conducted through isolation of microbes and analysis of the activity of ethyl alcohol against the isolated organisms. In our study we found that Streptococcus pyogenes, Pseudomonas aeruginosa, Escherichia coli and Klebsiella pneumoniae were found predominant. The Gram positive isolation by open plate method and swabbing from various areas showed the isolation of Gram positive pathogens and accounted for 58% of nosocomial infections and Gram negative pathogens accounted for 42%. As a result of this investigation, alcohol activity showed better inhibition against various isolated bacterium, where Gram positive bacteria showed more inhibition than Gram negative bacteria. Its clear that the Gram positive bacteria inhibited at the concentration of 60% of ethanol whereas the Gram negative showed partial inhibition even though at 80%. This study gives an idea about application of alcohol in health care industry, especially in cleaning of walls, tables and other inanimate objects available in the indoor environment.

INTRODUCTION

Nosocomial infection, result of treatment in the hospital or hospital like setting but secondary to the patient’s original condition appear within 48 hours after hospital admission¹. The nosocomial infection control have four key components viz an effective hospital epidemiologist, a well practiced infection controller for every 25 beds, active surveillance protocols and mechanisms and ongoing control efforts – reduce the nosocomial infection rate by one-third²). According to the period of Blue-bugs, the common most Gram positive pathogens like Staphylococcus aureus, coagulase negative staphylococci and Enterococci accounted for 34% and Gram negative pathogens like Escherichia coli, Pseudomonas aeruginosa, Enterobacter spp. and Klebsiella pneumoniae predominated for 32%³. Acquired anti microbial resistance is a major problem in hospital where Vancomycin Resistant Enterococci (VRE) and Methycillin Resistant S. aureus (MRSA) predominates ^4,5. The first observation in hospital environment of nosocomial inkling is MRSA with reduced susceptibility to vancomycin⁶. Nevertheless, the greatest challenge may yet prove is respiratory pathogens which are a major shift in strain type result in devastating pandemic community and other nosocomial outbreaks⁷.

In ICCUs the major nosocomial infection observed by National Nosocomial Infection Surveillance System is urinary Candidial infection⁸. Many health care personnel failed to follow the basic infection control measure like hand washing between patient contacts which leads to iatrogenic infection that may increase immunosupression⁹. The shift of surgical care to outpatient wards leaves the sickest patients in the hospitals which are becoming more like large ICCUs where there is observation of chronic infections¹⁰. The aggressive antibiotic control programs will lead to reduction in the outbreaks of multi drug resistant pathogenic infections and will be controlled by standard strategies¹¹. The application of alcohol on microorganisms especially the lysis of bacteria include examination of uptake¹², lysis and leakage of intracellular constituents¹³, perturbation of cell homeostasis¹⁴, effects of model memranes¹⁵ and interaction with macromolecules¹⁶. Alcohol exhibits rapid broad spectrum anti microbial activity against vegetative bacteria, virus and fungi known to inhibit sporulation and spore germination¹⁷, sometimes this effect may be reversible¹⁸. This is supported by specific reports of denaturation of E. coli dehydrogenases¹⁹, and an increased lag phase in Enterobacter aerogenes, speculated to be due to inhibition of metabolism required for rapid cell division²⁰. We have carried out a rapid method of evaluating microbial load in health care industry (hospitals) and reduce the nosocomial infection by various concentration of alcohol.

AIM AND OBJECTIVES

In order to reduce the high risk found in nosocomial infection through bacteria the study was conducted with the following objectives.

• To isolate and identify bacterial members found in General ward, Post surgical ward, ICCU, Labour ward and Pediatric ward.
• To analyze the activity of alcohol against the isolated organisms and also the concentration data included.

MATERIALS AND METHODS

The major problem found in the hospitals is to acquire diseases through the patients (carriers), doctors (iatrogenic), fomites and air²¹. The following methodology was adopted keeping in mind the aforementioned aim and objectives.

1. Isolation and identification: This invitro laboratory based study was conducted to collect the bacteriological information regarding various departments like General, Post surgical, ICCU, etc. The routine bacteriological investigation like isolation, identification and sensitivity analysis performed²².

2. Activity of alcohol: This procedure requires the heavy inoculation of an agar plate with test organism. Sterile filter paper discs with various concentrations of ethyl alcohol are impregnated and equally spaced on the inoculated agar plate. Following incubation, the agar plate is examined for zones of inhibition surrounding the discs. Absence of zone indicates the concentration of alcohol was ineffective against the isolated organisms²³.

RESULTS

As a result of this study the bacterial members isolated were Staphylococcus and Streptococcus found predominant at the rate of 58% where S. aureus, coagulase negative staphylococci, streptococci accounted. The four most common Gram negative pathogens like E. coli, P. aeruginosa, Enterobacter spp. and K. pneumoniae accounted for 42%. (Table 1).

Table 1: Percentage distribution of Bacteria on various places of Hospitals

Place	Gram Positive		Gram Negative Bacteria
	Staphylococcus	Streptococcus	Escherichia coli	Pseudomonas aeruginosa	Enterobacter spp.	Klebsiella pneumoniae
General Ward	35	22	18	12	09	10
Post Surgical Ward	40	26	13	13	10	08
ICCU	36	22	14	12	08	06
Labour Ward	26	25	16	14	09	05
Pediatric Ward	31	26	12	10	06	05

In this study blood stream infections and pneumonias have increased in frequency where tracking nosocomial infection by site has become difficult because of shorter inpatient stays. It is surprising to note that the average post operative stay, now approximately 5 days, is usually shorter than the 5-7 day incubation period for S. aureus involved in surgical wound infections. The comparative analysis of various sites of nosocomial infections among different health care industry is depicted in Table 2.

Table 2: Percentage distribution of sites of Nosocomial infection

Industry	Urinary Tract	Surgical Wound	Lower Respiratory	Blood Stream	Others
Hospital 1	41	24	11	06	18
Hospital 2	36	33	15	4	12
Hospital 3	34	19	13	14	20
Hospital 4	42	24	05	10	19

Although several alcohol have been shown to be effective antibacterial, ethanol is most widely used that exhibit rapid broad spectrum antibacterial activity including Mycobacteria. In this study, concentration data of 60% is effective against Gram positive whereas Gram negative showed partial inhibition even though at 80%. The detailed inhibitory action of various concentration of alcohol against Gram positive and Gram negative bacteria is depicted in Table 3.

Table 3: Effect of Various Concentrations of Ethanol against isolated Nosocomial Bacteria

Organism	Inhibition at Various Concentrations (%)
	10	20	30	40	50	60	70	80
Gram Positive Bacteria
Staphylococcus aureus	-	-	-	20	50	100	100	100
Coagulase negative staphylococci	-	-	10	30	60	100	100	100
Streptococcus spp.	-	-	-	40	60	100	100	100
Gram Negative Bacteria
Escherichia coli	-	-	-	-	10	30	50	60
Pseudomonas aeruginosa	-	-	-	-	-	20	40	50
Enterobacter	-	-	-	-	-	10	30	50
Klebsiella pneumoniae	-	-	-	-	10	20	50	60

DISCUSSION

Microorganisms are transmitted in hospitals by several routes, and the same organism may be transmitted by more than one route – contact (direct and indirect), droplets, airborne, common vehicle and vector borne (24). People in hospitals are usually already in a poor state of health, impairing their defense against bacteria (aged, premature birth and immunodeficiency) present a general risk¹. Three major forces involved in nosocomial infection are antimicrobial usage²⁵, failure to follow basic infection control measures²⁶, and increase in immunocompromised patients²⁷. Isolation precautions are designed to prevent transmission of microorganisms in hospitals. Wiping with alcohol on equipments or articles will reduce infection in hospital environment. Washing hands thoroughly as possible between patient contacts and after contact with blood, body fluids, secretions, excretions and equipment contaminated by them is an important component of infection control and isolation procedure². As an indirect method, in addition to hand washing, gloves play an important role in reducing the risks of transmission of microorganisms as protective barrier, prevent gross contamination. It must be changed between patient contacts and hands should be washed after gloves removed. Failure to change gloves between patient contacts is an infection control hazard. Antiseptics and disinfectants are used extensively in hospitals and other health care settings for a variety of topical and hard surface applications. In particular they are an essential part of infection control practices and aid in the prevention of nosocomial infections^28,29. Because of the lack of sporicidal activity, alcohols are not recommended for sterilization but they are widely used for skin antiseptic and surface disinfection³⁰. In the present study, Gram positive bacteria inhibited by 60% ethanol whereas Gram negative get showed resistance. Generally, the antimicrobial activity of alcohols significantly lowers at concentrations below 50% and is optimal in 60–90% range³¹. Little is known about specific mode of action of alcohols³², so the current study is selected for analyzing the activity of alcohol with various concentrations.

In conclusion, a great deal remains to be learned about the mode of action of ethanol. Although significant process has been made with bacterial investigations, the greater understanding of these mechanisms is clearly lacking for other chemicals. This study is not merely of academic significance they are also associated with efficient use of these agents clinically and with the potential design of newer and more effective compounds and the products.

IMPLICATIONS OF THE STUDY

• This study will aid to identify the etiology of nosocomial infection.
• This study will help to do research on controlling the causes of nosocomial infection.
• It will help the knowledge of controlling the usage of antibiotics.
• To determine the prevalence and incidence of nosocomial infection.
• To do research on the design and architecture of hospitals, operating rooms and central sterilization.
• To make statistics.

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(1) N. Prabhu, M. Sangeetha - Postgraduate and Research Department of Microbiology, Dr. N.G.P. Arts and Science College, (An Institution of) Kovai Medical Centre and Hospital, Coimbatore, Tamilnadu-641035, India.
(2) P. Chinnaswamy is Director, Institute of Laboratory Medicine, Kovai Medical Centre and Hospital, Coimbatore, Tamilnadu- 641035, India.
(3) PI. Joseph is Division of Microbiology, Rajah Multhiah Medical College and Hospital, Annamalai University, Chidambaram, Tamilnadu, India.