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STUDY OF BACTERIAL FLORA OF HANDS OF HEALTH CARE GIVERS IN A TERTIARY CARE HOSPITAL IN EASTERN INDIA

Bacterial contamination of palm of hand of health care givers like doctors and nurses can be an important source of nosocomial infections. Proper hand hygiene is hence key to prevent spread of such cross-infection. We studied the bacterial flora of palm of hand of 101 clinical staff (Doctors of clinical specialties and nurses) and compared it with bacterial flora of 99 non-clinical staff (Doctors of non-clinical specialties and lab technicians and attendants). Hand swab was collected by a sterile swab moistened with sterile normal saline. Out of 101 clinical staff, 63(62.37%) showed hand swab positivity for bacteria. On the other hand, out of 99 non-clinical staff, 72 showed hand swab positivity for bacteria (72.72%). Among clinical staff, hands of 60.3% doctors (38 out of 63) and 65.7% nursing staff (25 out of 38) was contaminated with bacteria. The bacterium most commonly isolated from hands of clinical staff was Staphylococcus aureus, while the bacteria most frequently recovered from hands of non-clinical staff were Acinetobacter lwoffii. Only 1 isolate of Methicillin resistant Staphylococcus aureus (MRSA) was recovered, from hand of a doctor in Pediatrics department. Antibiotic susceptibility test of the isolates was also performed against 3 antibiotics: Cotrimoxazole, Amikacin and Levofloxacin; in addition, Cefoxitin (30 μg) disk was used to check for MRSA (Methicillin Resistant Staphylococcus aureus). Most of the strains were sensitive to all the 3 antibiotics. This study highlights the importance of proper hand washing and awareness of its importance and monitoring among hospital staff.

soap and water ("scrub"); most antimicrobial soaps contain a single active agent and are usually available as liquid preparations; and (iii) the hygienic hand disinfection, which normally consists of the application of an alcohol-based hand rub into dry hands without water. (3) Keeping in mind the above factors, we planned this study to evaluate the bacterial load of palm of hands of clinical staff (Doctors + nurses) and compare findings with that of non-clinical staff (non-clinical doctors, lab technicians and others).

AIM:
To study the bacterial load of palm of hand of clinical staff.

OBJECTIVES:
• To collect hand swab from the subjects and culture on suitable media.
• To observe colonies, identify the isolates and perform antibiotic susceptibility.
• To find out different resistotypes in the isolates retrieved and compare and correlate them with resistotypes recovered from lesions and samples of patients.

MATERIALS AND METHODS: Type of Study:
Laboratory and OPD (Outpatient Department) based observational study.

Ethical Issues:
This was an inter-departmental study within the institute. Written informed consent was obtained from the volunteers after explaining them duly, the importance of carrying out this study. Permission was taken from institutional ethics committee prior to conduction of the study.

Time of Study:
The work was carried out from April 2014 to January 2015 (9 months).

Sample Collection:
Hand swab was collected from the subjects using sterile cotton swab-stick, moistened with autoclaved normal (0.85%) saline. Palmar creases and interdigital spaces were also swabbed, and sample was collected by gently rolling the swab stick over the areas for 6-7 seconds. The volunteers were also asked when they last washed their hands before this procedure.
Inoculation: After collection, samples were inoculated on 5% sheep blood agar and MacConkey agar, streaked and incubated aerobically for 24 hours.

OBSERVATION:
After incubation the plates were observed for colony morphology and colony count; suitable tests like Gram stain, catalase, Coagulase and a panel of biochemicals (Indole production, Citrate utilisation, motility using semisolid agar stab, Urease and TSI) were put up for identification. For example, if Gram positive cocci in clusters was recovered, catalase and slide coagulase along with mannitol fermentation (using 1% w/v Andrade's indicator) were performed. If Gram negative bacilli were found, biochemical tests were carried out. Antibiotic susceptibility test was performed by Kirby-Bauer disk diffusion method as per CLSI protocol using the following antibiotic disks: Cotrimoxazole (25 µg), Amikacin (30 µg) and Levofloxacin (5 µg) disks (Hi Media Labs, New Delhi, India); Cefoxitin disk (30 µg) was used to detect MRSA. (4) Resistotyping: The resistotypes of the isolates was noted. The same for clinical isolates was noted, and compared with resistotypes retrieved from hand swab isolates.
everywhere on the skin of doctors and nurses: Diphtheroids (e. g. corynebacteria other than Corynebacterium diphtheriae), micrococci (which include the staphylococci such as Staphylococcus epidermidis), streptococci (either alpha (α) or gamma (γ) hemolytic), and the enterococci. (7) Besides bacteria the skin also is the home to yeast (like Candida spp. ) and fungi. (6) Washing reduces the transient flora (contaminating flora) by about 2 to 3 log10 levels. (6) Pioneering works of Semmelweis and Florence Nightingale proved that proper sanitation and hand washing with general cleanliness of doctors and supporting staff like nurses could prevent nosocomial transmission of infections. (8) Despite efforts to promote hand washing amongst medical staff, Hand hygiene compliance rates in different developed countries rarely exceed 50%. (8) Our study shows that the same bacterial flora was found from hands of clinical staff and patients' lesions. This could be due to improper hand wash, lack of facilities of adequate hand washing or lack of related awareness among the concerned persons. Furthermore, common resistotype patterns were found in clinical isolates and isolated from hands of clinical staff, highlighting that the flora could have come from the patients' lesions to the health care givers' hand, or vice versa. This study is the first of its kind in this region and emphasizes the importance of meticulous hand washing to prevent cross-transmission and nosocomial transmission of pathogenic bacteria.
A similar study from Western India found that 60% of mobile phones of resident doctors had surface contamination with harmful bacteria like Coagulase negative Staphylococcus spp. Diphtheroids and Aspergillus niger. (9) Another Indian study from Gujarat mentions high rate of bacterial colonization of hands of health care workers, predominantly by S. aureus, much like our findings, which were reduced by 95-99% by proper alcohol hand rub. (10) We also found that although frequency of bacterial colonisation of hands of clinical personnel was lower than non-clinical personnel, clinical staff had significantly higher bacterial load on their hands. Further such studies are required to address these issues.