INFECTION PREVENTION & CONTROL


specialist centres set up to deal with patients displaying symptoms. In a speech shortly afterwards, Lord Warner, the then health minister stated: “The scientific evidence proves that persistent products mark a step- change in the fight against the Swine Flu pandemic. The long-lasting nature of the product, combined with its safety, means that persistent hygiene products have the potential to revolutionise the way we deal with flu and superbugs.”


There has been a great deal written about alternatives to alcohol, including the use of Triclosan, and Quaternary Ammonium Compounds (QAC’s).17,18,19,20,21,22,47,48,49 The data in graph 3, demonstrates that


after an initial application of the SiQAC, the most cost effective and particle method of interpatient decontamination, is the use of alcohol liquid hand rub. Alcohol gels are again shown to display less efficacy over time than alcohol liquid rubs even when used after the SiQAC. Alcohol gel in isolation, or as a method of interpatient decontamination produces poor results over time. This is due to the significant sugars left in the residue after the alcohol has evaporated.56


Conclusions and discussion


In an ideal world every patient would be in their own room with hand washing facilities at the entrance/exit to the room. Other areas in the hospital, such as operating theatres and out patient’s clinics would also have far more hand wash facilities available to staff in convenient places. It would, however, be impractical to retro fit most hospitals to this new standard. Other ways have to be found to decontaminate hands between patient contacts.45,46,50,51,52


The data in these latest studies shows that, when used in isolation, in the short term and over time, alcohol is less effective than the 5th generation SiQAC. The data also shows, it is still possible to use the 5 moments in hand hygiene recommended by the WHO,14


to include the use of a persistent compound in the form of a 5th generation SiQAC which will improve efficacy in the short term and over time. It is also clear now that what happens to skin and surfaces over extended time periods is a very important question to have answered before the wholesale introduction of any disinfecting products, let alone products associated with hand hygiene.


There can be no doubt that test methods used by both regulatory bodies and clinical microbiology labs are in need of a significant overhaul. The fact that there is no commonality between the efficacy tests regulators require from skin sanitisers and surface disinfectants, and those individual hospital laboratories are able to perform, speaks volumes about the lack of a connection between the two types of institution. The WHO acknowledges the inefficiencies and inadequacies of current test methods in its latest guidance.14


At the


moment it is therefore, incumbent on the researcher to choose the method they think


1800 1700 1600 1500 1400 1300 1200 1100 1000 900 800 700 600 500 400 300 200 100 0


Comparison over time After 5th Generation Si Quat 1700 1611


Average Bacterial CFU Counts per cm2


70% Alcohol Gel Group 72% Alcohol Liquid Group


400 381


163 40 41 Pre Wash Post wash 5 mins Post 81 25


Pre Application 5th Generation Si Quat 1 x alcohol Treatment


15 mins Post Treatment


14


1 hour Post 4 x alcohol Treatment


Graph 3 (above) shows the effect of applying a 5th generation SiQAC after hand washing with soap and running water. 15 mins later and for the next hour at regular 15 min intervals staff re apply either an alcohol hand gel, or an alcohol liquid.


will best demonstrate the hypothesis they are testing.


adapted


When the increase in the use of alcohol gels occurred more than 20 years ago, there was very little evidence of efficacy in use available. The conclusion must be drawn that its large-scale introduction was not based on either clinical outcome evidence, or on efficacy evidence from the regulators. It is hoped that this would not be the case if these products were launched for use today. In retrospect, it is now difficult to understand the reasons the healthcare profession around the world seems to have simply accepted the pressure to continue to use these products without anything like the amount of scrutiny that would be required for their introduction today. It is therefore most likely that it was a political reaction to the public, fuelled by the media pressure of the day. This could possibly have been helped by significant lobbying on behalf of the chemical industry that produces alcohol gels. The introduction of new testing methods


There can be no doubt that test methods used by both regulatory bodies and clinical microbiology labs are in need of a significant overhaul.


54 I WWW.CLINICALSERVICESJOURNAL.COM


previously only available to the military have given us sight not just on initial efficacy, but also on the efficacy over time of these products.3,6,7,8


A significant additional problem, to determining the best choice of antimicrobial, is that there are a multitude of tests required by various regulators that look for Minimum Inhibitory Concentrations (MIC’s) of antimicrobial skin disinfectants. It is clear that the MIC of these chemicals bears no relationship to the killing time when actually applied to hands in clinical situations,14,15,16,28,29 nor does it look at their effects over extended periods of time. Although field testing is difficult to control for extraneous influences, it does appear to give a clearer picture of actual bacterial bioburden in practice.4


Use


of a BSRMA, although not seen until recently due to its delayed release by the military for civilian use, has not only revolutionised the speed of testing of skin bacterial CFU’s, it has accurately shown levels of bacterial contamination never seen before using standard methods.3


Although a number of


studies have demonstrated the effect of hand sanitation on HAI rates, none find a positive link between hand cleansing efficacy and surface contamination rates.14,18,23,26 As a result we still do not fully understand the effect different hand sanitation techniques have on surface contamination levels, and significantly, we still do not know exactly how much of a role surfaces play in the transmission of HAIs. We therefore need more large-scale studies that integrate all these factors to help answer these most important questions.


References for this article can be found at: www.clinicalservicesjournal.com


JUNE 2018


CSJ


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