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African Journal of Microbiology Research Vol. 4(22), pp. 2343-2349, 18 November, 2010 Available online http://www.academicjournals.org/ajmr ISSN 1996-0808 2010 Academic Journals Full Length Research Paper Microbial flora on the hands of healthcare workers
Fahriye Eksi*, Aysen Bayram, Murat Mehli, Sadik Akgun and Iclal Balci
Gaziantep University, Faculty of Medicine, Department of Medical Microbiology, Universite Bulvari, Gaziantep, 27310, The aims of this study were to study the process of microbial contamination of healthcare workers’
(HCWs) hands during routine patient care and simultaneously to evaluate the state of antibiotic
susceptibility of microorganisms isolated from the hands of HCWs. Samples were collected from the
hands of 154 HCWs working at Gaziantep University Hospital. A standard bag broth technique was
employed. In addition to conventional methods, VITEK 2 automated system and API ID 32C kits were
used for identification of the isolated microorganisms. Antimicrobial susceptibility of bacterial agents
was performed by disc diffusion method. For antifungal susceptibility, ATB Fungus 2 kit was used. Of
154 specimens, 148 (96.1%) showed microbial growth and 160 microorganisms were isolated as single
or multiple members of the resident flora. Transient flora including one or more microorganisms (n =
47) were recovered from the hands of 39 (25.3%) HCWs. All gram-positive bacteria were detected to be
sensitive to vancomycin, teicoplanin and linezolid, however 30.1% of the coagulase-negative
staphylococci and 40% of Staphylococcus aureus isolates were resistant to methicillin. Multiple drug
resistance was determined in Acinetobacter and Pseudomonas isolates. It can be concluded that
transient flora members isolated from hands of HCWs can be causative agents of serious nosocomial
infections due to their high and multiple antimicrobial resistance patterns.
Key words: Healthcare workers, resident flora, transient flora, antimicrobial susceptibility.

INTRODUCTION

Hand hygiene remains the major preventive measure
and Bacillus spp. were considered to be elements of against nosocomial infections. In 2002, Centers for transient flora and, therefore, potentially pathogenic Disease Control and Prevention (CDC) revised the microorganisms (Kampf and Kramer, 2004). recommendations for hand hygiene to include the use of Investigators have documented that the number of alcohol-based products for standard hand hygiene transient and resident flora varies considerably from (Larson et al., 2007; Boyce and Pittet, 2002). person to person and is relatively constant (Hugonnet Three principal types of skin flora have been described. and Pittet, 2000; Boyce and Pittet, 2002). A higher pre- valence of antibiotic-resistant organisms on the hands of distinguished in 1938. In addition, the infectious flora was patient-care staff versus non-patient-care staff and/or described with species such as Staphylococcus aureus outpatients has been reported (Aiello et al., 2003). and beta-hemolytic streptococci which were frequently The purposes of this study were to describe the types isolated from abscesses, whitlows, paronychia, or and antimicrobial susceptibility patterns of hand flora infected eczema. Resident flora consists of strains, such among healthcare workers (HCWs) working in various as coagulase-negative staphylococci and diphtheroids. clinics and to examine whether job title and ward location of HCWs can affect the growth of hand flora staphylococci, Corynebacterium spp., Micrococcus spp. MATERIALS AND METHODS
*Corresponding
[email protected]. Tel: 90 342 3606060 77523. Fax: 90 This prospective study was conducted at the microbiology laboratory of a University Teaching Hospital in Gaziantep, Turkey. The Hospital’s Medical Ethics Committee approved the trial. The study hospital is occupied with 800 beds. Samples were collected glabrata n = 1 and Candida guillermondii n = 1), 9 (5.8%) from the hands of 154 (79 female and 75 male) HCWs during a Acinetobacter spp. (Acinetobacter lwoffii n = 7; three-month period from January to March 2008. HCWs were Acinetobacter baumannii n = 2), 9 (5.8%) Enterococcus classified according to their job titles and ward location. There were 55 (35.7%) nurses, 33 (21.4%) permanent physicians, 11 (7.1%) spp. (Enterococcus faecalis n = 5; Enterococcus faecium medical students, 25 (16.2%) nursing assistants and 30 (19.5%) n = 4), 5 (3.2%) S. aureus, 4 (2.6%) Pseudomonas spp. cleaning personnel. Forty-eight HCWs were employed at various (P. aeruginosa n = 2; Pseudomonas stutzeri n = 2), 4 surgical clinics, 32 at internal medicine ICU, 23 at internal medicine (2.6%) Enterobacter aerogenes, 3 (1.9%) Serratia and cardiology clinics, 21 at pediatrics and newborn clinics, 11 at marcescens and 2 (1.3%) Streptococcus pneumoniae. oncology division of internal medicine, 10 at surgical ICU, and 9 at Distribution of the transient flora members according to Both hands of all participants were washed in 50 ml of brain- heart infusion broth in a sterile plastic bag and kneaded for 30 s by No statistically significant difference was observed the standard bag broth technique (Larson, 1985; Larson et al., according to job titles among number of transient-flora- 1980). After removal of the hands from the bag, the broth was member microorganisms isolated from HCWs’ hands (p = transferred to a sterile container. An inoculum of 0.1 ml from each 0.312); however, a statistically significant difference was sample was plated within 1 h or after storage at 4°C for up to 5 h recorded according to ward location (p = 0.038). No onto Columbia sheep blood agar (5%), Eosin-methylene blue agar, Sabouraud’s agar with chloramphenicol and gentamicin and bile statistical difference was determined between number of aesculin agar. All culture media were incubated at 37°C and transient-flora-member microorganisms isolated from observed daily for growth over 48 h for bacteria and up to 7 days for hands of HCWs working in intensive care unit and non yeast. Microorganisms grown on cultures were identified with intensive care unit areas (p = 0.391). Moreover, there conventional methods, VITEK 2 (BioMerieux, USA) automated was also no significant difference between oncology and system and API ID 32C (BioMerieux, France) kits as needed. intensive care clinics (p = 0.071). However, a statistically staphylococci (CNS) and transient bacterial flora members were significant difference (p = 0.000) was recorded among performed by disc diffusion method according to Clinical and HCWs who worked in other clinics except intensive care Laboratory Standards Institute’s (CLSI) recommendations (Clinical unit and oncology clinics. Distribution of HCWs according and Laboratory Standards Institute, 2005). Quality control was to ward location and growth of transient flora is shown in performed with S. aureus ATCC 25923 and Pseudomonas aeruginosa ATCC 27853 strains; inhibition zone diameters were in the ranges stipulated by the CLSI (Clinical and Laboratory Growth of coagulase-negative staphylococci (CNS) Standards Institute, 2005). We determined the antibiotic sensitivity occurred on hands of 143 out of 154 HCWs. Among 143 pattern for coagulase-negative staphylococci because these CNS, 43 were (30.1%) methicillin resistant coagulase- organisms were present in almost all subjects as part of the negative staphylococci (MRCNS), 100 were (69.9%) staphylococci (MSCNS). Antibiotic susceptibilities of staphylococcal strains, cefoxitin (30 µg) and oxacillin discs (1 µg) were used. CNS isolates that were clindamycin-susceptible (CL-S) isolated CNS strains are shown in Table 3. In our study, and erythromycin-resistant (ER-R) were tested for inducible all CNS were sensitive to vancomycin and linezolid and clindamycin resistance (ICR) by the D-test as described by CLSI 96% of MSCNS strains were resistant to penicillin. It was (Clinical and Laboratory Standards Institute, 2005). found out that 41 (95.3%) of MRCNS strains were antifungal susceptibility, ATB Fungus 2 (BioMerieux- France) kit erythromycin-resistant, and 16 (37.2%) of them showed was used. Candida parapsilosis ATCC 22019 was used as the quality control strain. constitutive clindamycin resistance. In 8 (18.6%) MRCNS Results were analyzed using Chi-square test. Statistical analysis strain ICR was detected. It was found out that 68% of were performed with Epi Info (version 3.4.3), and values of p < 0.05 MSCNS strains were erythromycin-resistant. Constitutive were considered to indicate statistical significance. clindamycin resistance was seen in 13% of MSCNS strains and ICR was detected in 11% cases (Table 3). Antibiotic resistance among isolated gram positive and gram negative bacteria are shown in Tables 4 and 5, respectively. All gram positive bacteria were sensitive to Specimens were collected from 154 HCWs and 148 vancomycin, teicoplanin and linezolid. Two of five (40%) (96.1%) of them showed microbial growth. One hundred isolated S. aureus strains were detected to be MRSA. Two and sixty microorganisms from 148 HCWs were isolated strains of five (40%) isolated E. faecalis were resistant to as single or multiple members of the resident flora. Of quinupristin/dalfopristine; besides, all strains of E. 160 isolates, 143 (89.4%) were CNS and 10 (6.3%) were faecalis and 3 E. faecium strains out of 4 (75%) were Corynebacterium spp. and 7 (4.4%) were Bacillus spp. detected to be resistant to co-trimoxazole. All S. aureus No growth was observed in samples of 6 (3.9%) HCWs. strains were resistant to penicillin and all S. pneumoniae Transient flora including one or more microorganisms strains were resistant to erythromycin, clindamycin, was recovered from the hands of 39 (25.3%) (21 male, ampicillin and gentamicin. All strains of Serratia 18 female) HCWs. Members of the transient flora (n = 47; marcescens were detected to be resistant to ampicillin, 30.5%) isolated from the hands of 154 HCWs were as follows; 11 (7.1%) Candida spp. (C. parapsilosis n = 4, Besides, Acinetobacter spp. and Pseudomonas spp. Candida tropicalis n = 3, Candida albicans n = 2, Candida
Table 1. Transient bacterial flora of HCWs according to job title.
Permanent
physicians
Cleaning
students
assistant
Microorganism
personnel
n = 30 (100%)

Table 2. Distribution of HCWs according to ward location and growth of transient flora.
Pediatrics
Internal
Coronary
Surgical
Pediatric
medicine +
ICU+ Internal
Surgical ICU
oncology oncology
Microorganism
Cardiology
medicine ICU
Eleven species of Candida were isolated from 154 and Kramer, 2004). In the present study, 143 CNS, 10 HCWs’ hands. Antifungal susceptibilities of Candida spp. Corynebacterium spp. and 7 Bacillus spp. were isolated from 154 HCWs’ specimens. Thirty-three (30.1%) of 143 CNS were MRCNS while 100 (69.9%) were MSCNS. The incidence of oxacillin resistance among isolates of S. DISCUSSION
epidermidis was up to 64.3% (Lee et al., 1994) and was higher in health care workers who have direct contact The resident flora consists of permanent inhabitants of with patients than in those who do not (Slight et al., the skin. They are found mainly on the surface of the skin 1987). One study reported that methicillin-resistant CNS and under the superficial cells of the stratum corneum. was significantly higher among nurses with closest and These bacteria are not regarded as pathogens on intact most frequent patient contact (Klingenberg et al., 2001). skin but may cause infections in sterile body cavities, in In previous studies, rates of oxacillin resistance among the eyes, or on non-intact skin. The dominant species is CNS from nurses’ hands ranged from 26 - 79% (Horn et Staphylococcus epidermidis, which is normally found on al., 1988; Cook et al., 2007). CNS, such as S. almost every person's hand (Kampf and Kramer, 2004; epidermidis, mainly causes catheter-associated primary Lee et al., 1994). Other regular residents are bloodstream infections. In ICUs, approximately one-third Staphylococcus hominis and other CNS, followed by of all blood culture isolates from patients with nosocomial bloodstream infections were found to be CNS (Kampf corynebacteria, dermabacteria, and micrococci (Kampf Table 3. Antibiotic susceptibilities of MRCNS and MSCNS strains.
MRCNS (n = 43)
MSCNS (n = 100)
Antibiotics
Resistant n (%)
Sensitive n (%)
Resistant n (%)
Sensitive n (%)
MRCNS: Methicillin resistant coagulase-negative staphylococci; MSCNS: Methicillin susceptibility coagulase-negative staphylococci. Table 4. Antibiotic resistance of gram positive transient flora members.
S. aureus (n = 5)
E. faecalis (n = 5)
E. faecium (n = 4)
S. pneumonia (n = 2)
Antibiotics
Resistance n (%)
Resistance n (%)
Resistance n (%)
Resistance n (%)
In the current study, all CNS were sensitive to streptogramin B (MLSB) family of antibiotics is commonly vancomycin and linezolid and 96% of MSCNS strains used in the treatment of staphylococcal infections were resistant to penicillin. The macrolide-lincosamide- (Fiebelkorn et al., 2003). However, this widespread use
Table 5. Antibiotic resistance of gram negative transient flora members.
Acinetobacter spp.
Pseudomonas spp.
Serratia marcescens
Enterobacter
Antibiotics
aerogenes (n = 4)
Resistance n (%)
Resistance n (%)
Resistance n (%)
Resistance n (%)
Table 6. Antifungal susceptibilities of Candida spp.

Flucytosine
Amphotericin B
Fluconazole
Itraconazole
Candida spp.
S: susceptible; I: intermediate; R: resistant. has led to an increase in the number of staphylococci isolated from hands of nurses and 3 strains of strains being resistant to MLSB antibiotics (Lim et al., Pseudomonas out of 4 were isolated from hands of per- 2002). Consequently, ICR was investigated beside manent physicians respectively. No statistical difference constitutive resistance for clindamycin in our study. It was found out that 41 (95.3%) of MRCNS strains were organisms isolated from HCWs’ hands was observed in erythromycin-resistant, and 16 (37.2%) of them showed job title (p = 0.312) but statistically significant difference constitutive clindamycin resistance. In 8 (18.6%) of was noticed in ward location (p = 0.038). Some clinical MRCNS strains ICR was detected. It was found out that situations are associated with a higher bacterial load on 68% of MSCNS strains were erythromycin-resistant. the hands of health care workers: direct contact with Constitutive clindamycin resistance was seen in 13% of patients, respiratory tract care, contact with body fluids, MSCNS strains and ICR was detected in 11% cases. The and after being interrupted while caring for a patient transient skin flora consists of bacteria, fungi, and viruses (Pittet et al., 1999). Due to immunosuppressive patient that may be found on the skin only at times. They usually population in oncology clinic, it was considered that do not multiply on the skin, but they survive and various microorganisms could be more frequently occasionally multiply and cause disease (Kampf and colonized in skin flora of these patients and HCWs Kramer, 2004). In our study, transient flora was working in this clinic can be easily contaminated with recovered from hands of 39 (25.3%) HCWs. When these microorganisms. Since 2006, HCWs at this hospital evaluated in terms of job titles, maximum yeast growth have been advised to use non-medicated soap and dry occurred in nurses, additionally 3 S. marcescens strains paper towels for hand washing and to use an alcohol- based disinfectant as hand hygiene procedure during Most reports of cross-transmission of specific gram- routine patient care. We think that health care staff negative bacteria come from critical-care areas, such as should be controlled periodically for the proper and neonatal ICUs and burn units (Kampf and Kramer, 2004). Enterobacter agglomerans (n = 5) was the frequently In the present study, transient-flora-member gram detected gram negative bacteria species in the study of positive bacteria isolated from hands of 154 HCWs were Aiello et al. (2003). In this study, multi-drug resistance Enterococcus spp. in 9 (5.8%), S. aureus in 5 (3.2%), was observed in strains of Acinetobacter spp. and Streptococcus pneumoniae in 2 (1.3%). Aiello et al. Pseudomonas spp. but all strains of S. marcescens were (2003) reported in their study that there were 12 different resistant to ampicillin, ampicillin/sulbactam, cefazolin and species of gram negative bacteria and 11 different species of CNS on the nurse hand samples (n = 119); Yeasts (n = 11) isolated from HCWs' hands were and there were four nurses with S. aureus on their hands. identified as follows: 4 C. parapsilosis, 3 C. tropicalis, 2 Enterococcus species were the most frequently isolated C. albicans and a single strain of C. glabrata as well as gram positive bacteria species in our study. Strains of C. guillermondii strains. In another study, Candida enterococci causing nosocomial infections have occa- carriage was found in 34.1% of 214 HCWs (Yıldırım et sionally been found on the hands of medical personnel al., 2007) and the most frequently yielded isolates were and have frequently been isolated from environmental C. parapsilosis (38.4%), C. tropicalis (26.0%) and C. sources in hospitals and nursing homes. The importance albicans (23.3%). C. parapsilosis is an important of these findings is difficult to assess, because the pathogen as it implies the possibility of nosocomial trans- mission of fungaemia by the hands of HCWs (Levin et al., contaminated by stool or urine from infected patients 1998). In a long-term-care facility, 41% of 42 health care (Moellering, 2000). According to literature, vancomycin- workers were found to have Candida spp. on their hands resistant enterococcus can be found on the hands of up (Mody et al., 2003). Lupetti et al. (2002) concluded that to 41% of health care workers (Hayden, 2000). horizontal transmission of C. parapsilosis occurred In our study, out of 9 isolated Enterococcus species, 5 through direct interaction between nurses and the were E. faecalis and 4 were E. faecium. Being a patients. With respect to antifungal susceptibility, it was satisfactory result, no vancomycin resistance was found out that C. parapsilosis and C. albicans are highly susceptible to the studied antifungals. In the present In our study, two of 5 S. aureus strains (40%) were study the susceptibility of C. tropicalis to antifungals determined to be MRSA. Colonization of HCWs’ hands except itraconazole was a satisfactory result for the with S. aureus ranged between 10.5 and 78.3%. MRSA was isolated from the hands of up to 16.9% of HCWs. In conclusion, transient flora members were isolated Hand carriage of pathogens such as S. aureus, MRSA, or mostly from HCWs working in oncology clinic. Bacterial S. epidermidis has repeatedly been associated with contamination of HCWs’ hands was likely to occur due to different types of nosocomial infections (Kampf and immunosuppressive patient population in oncology clinic. Kramer, 2004). A study by Cespedes et al. (2002) Acinetobacter spp. and Pseudomonas spp. strains were reported that significantly more medical personnel multi-drug resistant. The role of the hand flora of HCWs compared with non-medical hospital personnel were in the development of nosocomial infections is significant. colonized with antibiotic-resistant S. aureus. All gram These results, suggest that transient flora members positive bacteria were found to be sensitive to isolated from hands of HCWs can be causative agents of vancomycin, teicoplanin and linezolid and most were serious nosocomial infections due to their high and detected to be sensitive to quinupristin/dalfopristine. multiple antimicrobial resistance patterns. 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