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    Investigation of diagnostic equipment as reservoirs for microbial growth and sources of microbial transfer, hygiene practices of students and efficacy of disinfectants
    (2018) Logtenberg, Johmari; Swalaha, Feroz Mahomed; Kell, Colette
    Background: Healthcare-associated infections (HCAIs) are a global concern as they affect millions of people worldwide. Poor hygiene practices and the use of microbial contaminated medical equipment by healthcare workers (HCWs) are common contributing factors to the development of HCAIs, which result in additional hospital costs, prolonged hospital stays, development of antibacterial resistance and increases in mortality and morbidity. Because Chiropractic students (CSs) at the Durban University of Technology Chiropractic Day Clinic (DUT CDC) make use of diagnostic equipment during their consultations with patients, this study aimed to determine if the stethoscopes and sphygmomanometers that were used in the DUT CDC served as reservoirs for bacterial growth, including antibiotic-resistant bacteria, and to correlate the findings with the hygiene practices of CSs and the efficacy of disinfectants. Method: This quantitative study comprised of two phases: a phase one pre-test post-test design and a phase two cross-sectional descriptive questionnaire design. Phase one required the collection of bacterial samples from the stethoscopes and sphygmomanometers of 29 CSs before and after performing the physical assessments on new patients (58 samples). These bacterial samples were incubated and analysed. The bacterial isolates were enumerated, identified and, where appropriate, tested for antibiotic-resistance. The modified AOAC use dilution method was used to test the efficacy of the selected disinfectants. Phase two required 29 CSs to complete the research questionnaire. The data were initially captured onto Excel spreadsheets and subsequently analysed using IBM SPSS version 24.0 (p-value <0.05 was considered statistically significant), with the application of Spearman’s rank correlation, an one-way ANOVA evaluation, Tukey post hoc and paired t-tests. Results: Although the majority of the CSs was knowledgeable and regarded disinfection as important, only 13.8% applied adequate disinfection practices. The most common reasons that were stated were inadequate education or training, forgetfulness, lack of time, and disinfectant unavailability. Bacterial growth was present on 96.6% and 100.0% of the pre-test and post-test stethoscope samples respectively, and on 94.8% and 100.0% of the pre- and post-test sphygmomanometer samples respectively. The total colony-forming units (CFUs) for both the post- test readings were higher compared to their respective pre-test samples. Paired t-tests indicated significantly (p< 0.01) higher mean values for the post-stethoscope group only, with a greater distribution of the total CFUs for stethoscope samples at the diaphragms’ edge. The bacteria that were isolated from both sets of pre- and post-test samples consisted predominantly of coagulase negative staphylococci (CoNS), Micrococcus spp. and Staphylococcus aureus, while the minority consisted of Bacillus spp., Corynebacterium spp., coliforms and Escherichia coli. Overall, the majority of the bacteria was considered potentially pathogenic, except for the post-test sphygmomanometer sample. The disinfectant efficacy testing revealed results that were in contrast with the literature, which caused the researcher to question the validity and reliability of the modified AOAC use dilution method in this study. Chloramphenicol was the most effective antibiotic with a bacterial susceptibility rate of 95.7%, (Ciprofloxacin (93.2%), Vancomycin (80.8%), Amoxicillin (AMO) (69.5%) and Erythromycin (57.7%)). The resistance of Micrococcus spp. isolates to the various antibiotics was of concern. The high resistance levels of CoNS and S. aureus to AMO suggests the presence of methicillin-resistant Staphylococcus aureus and methicillin-resistant CoNS isolates. The most susceptible specie in general was Micrococcus spp. at 60.9%, followed by S. aureus at 59.6%, E. coli at 53.8%, and CoNS at 48.7%, while the least susceptible was coliforms at 36.9%. No correlations (p> 0.05) were identified between the mean CFU isolates from the CSs’ equipment and their reported average disinfection rate. Conclusions and recommendations: Both stethoscopes and sphygmomanometers were contaminated with non-pathogenic and potential pathogenic bacteria (some were resistant to multiple antibiotic classes). Although knowledgeable about equipment disinfection procedures, only 13.8% of the CSs reported disinfecting their pieces of equipment after examining every patient. The provision of adequate equipment disinfection education, the placement of visual reminders and accessible disinfectants will assist in improving the practice of adequate equipment disinfection. Moreover, equipment disinfection before and after every patient consultation will minimise cross- contamination and thus the risk of the development of HCAIs.
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    Origins and control of bacterial contamination during spinal manipulation
    (2018) Amod, Fariya; Swalaha, Feroz Mahomed; Reddy, Poovendhree
    Background: Research has revealed that healthcare workers’ hands serve as a source and vehicle for the transmission of micro-organisms within the healthcare sector, thus resulting in nosocomial infections, better known as healthcare-associated infections. The chiropractic profession is traditionally known as a hands-on profession, where the fundamental treatment protocol includes manual manipulation of the spine. In order to perform these procedures hand-to-patient interaction is required, resulting in skin-to-skin contact. Poor hand hygiene practice has been attributed by the World Health Organization as the primary cause for the spread of micro-organisms within the healthcare environment. Unwashed hands harbour microbes, thus increasing contamination levels and subjecting patients to these potential pathogens. This study aimed to determine the presence and transfer of bacterial contamination occurring during spinal manipulation, as well as analysing the efficacy of decontaminants used by chiropractic practitioners against the isolated bacteria cultivated. Research design: The study was located in the quantitative experimental paradigm and conducted as a cross-sectional investigation. Method: Samples were obtained from chiropractors’ hands before and after spinal manipulation. Samples were then serially diluted, plated in duplicate (using the spread plate technique) and incubated for 24-48 hours at 37°C. Viable counts of colony forming units (CFUs) were then enumerated in order to verify the presence of bacteria on the chiropractors’ hands, as well as to establish the direction of transfer occurring during spinal manipulation. Macroscopic and microscopic characteristics of each bacterial isolate were used to identify the bacteria cultivated. A modified Kirby Bauer technique was used to ascertain the efficacy of decontaminants commonly used by chiropractors, against the isolated bacteria obtained from their hands. Results: Bacterial flora were present on 100% of the chiropractors hands both pre- and post-spinal manipulation. A mean of 16,456 (27,718) cfu/ml⁻¹ were enumerated from the samples collected from the chiropractors’ hands during manipulation. A paired t-test indicated a significant difference noted in the viable count of bacteria found on the chiropractors’ hands before and after manipulation (p<0.001). A significant difference was observed in the viable count of bacteria post-manipulation (70%), as opposed to the pre- manipulation readings (30%).This was indicative of a higher rate of bacteria being transferred from the patient to the chiropractor during spinal manipulation. The majority of the microorganisms identified were either primary or opportunistic pathogens. Staphylococci were most prevalent in the pre-spinal manipulation readings accounting for 53% of the colonies, followed by micrococci with 39%, bacilli with 4%, Staphylococcus aureus with 3% and streptococci with 1%. Pseudomonas spp. were present but uncommon. Escherichia coli were not present on the chiropractors’ hands in any of the samples obtained pre-manipulation. The post-manipulation readings constituted a high prevalence of micrococci accounting for 57% of the colonies, followed by staphylococci with 32%, Pseudomonas spp. with 5%, E. coli with 3%, Staphylococcus aureus with 2% and bacilli with 1%. Streptococci were present but uncommon. The decontaminants tested were most effective against gram-positive bacteria such as Bacillus, Micrococcus, Staphylococcus, Staphylococcus aureus and Streptococcus. The bacteria isolated were most susceptible to the D-Germ hand disinfectant, while the Dis-Chem instant hand sanitizer was the least effective decontaminant tested. Ciprofloxacin was the antibiotic used as a positive control. A significant difference was noted between the performance of the positive control and the decontaminants on the bacteria isolated. Conclusions and recommendations: The study proved the presence of primary and opportunistic pathogens found on the chiropractors’ hands. These included Staphylococcus spp., Micrococcus spp., Bacillus spp., Pseudomonas spp., E. coli, Streptococcus spp. and Staphylococcus aureus. A higher rate of bacteria was observed being transferred from the patient to the chiropractor during spinal manipulation. The majority of the microorganisms identified were either primary or opportunist pathogens, thus predisposing both the patient and the chiropractor to potential infection. A significant difference was noted between the performance of the positive control and the decontaminants on the bacteria isolated. None of the decontaminants were as effective against the bacteria isolated as the positive control. It can therefore be deduced that each bacterial flora was not removed by some of the decontaminants currently used by chiropractic practitioners in practice.
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    Development of a disinfection protocol for the public sector Emergency Medical Services in the eThekwini District of KwaZulu-Natal
    (2013) Williams-Claassen, Natalee Jean; Sibiya, Maureen Nokuthula; Naguran, Sageshin
    Background In the Emergency Medical Services (EMS), paramedics play a vital role in the treatment of critically ill or injured patients, as they are often the first link or point of contact for the patient in the healthcare setting. They may therefore also play a vital role in the prevention and control of the transmission of communicable diseases, provided that proper infection control measures are in place. The objectives of the study There is presently no national policy on communicable diseases and infection control that is specifically designed for use in the South African prehospital environment. Given the paucity of research in the area, qualitative multiple case studies were conducted to develop an ambulance specific disinfection protocol and to evaluate its effectiveness in the public sector EMS in the eThekwini District of KwaZulu-Natal. Methodology The study comprised of three phases. In the first phase focus group discussions were conducted to identify the factors needed to develop a disinfection protocol. The study population consisted of both operational and management staff from the EMS under study. The first four focus groups consisted of eight to ten EMS operational staff each and the fifth focus group consisted of five EMS management staff. Thereafter, the information gathered was used in conjunction with internationally accepted guidelines to develop an ambulance specific disinfection protocol (Phase Two). The third phase entailed the implementation of the protocol at seven ambulance bases in the eThekwini health district and the evaluation of the protocol with the use of an open-ended questionnaire at two weeks and four weeks after implementation. A single ambulance crew and their immediate supervisor from each base were utilized in this phase. Conclusion and recommendations An ambulance specific disinfection protocol was developed and implemented in the EMS under study. During the development, implementation and evaluation of the protocol, many themes with regard to infection control in EMS were identified. These themes were used to better understand the present situation in EMS in relation to infection control and in the formulation of recommendations to assist in the improvement of the present situation. The researcher recommended that all EMS staff require training and education with regard to infection control and prevention. The development and implementation of a protocol and policy document for infection control specifically for EMS is required. There is a need for the deployment of more ambulances and the employment of more operational EMS staff together with the appointment of Infection Control Supervisors at all ambulance bases. Without adequate infrastructure needed to meet infection control and prevention requirements, there may be a serious risk to both staff and the patients they serve.