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ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 253-257

Comparing the antimicrobial efficacy of different hand sanitizers: An In vitro Study


Department of Public Health Dentistry, I. T. S Dental College, Greater Noida, Uttar Pradesh, India

Date of Submission30-Apr-2018
Date of Acceptance18-Jun-2019
Date of Web Publication12-Sep-2019

Correspondence Address:
Dr. Bhuvan Deep Gupta
I.T.S Dental College Hospital and Research Centre, 47, Knowledge Park - 3, Greater Noida - 201 306, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaphd.jiaphd_97_18

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  Abstract 


Background: The hands of health-care workers are the primary mode of transmission of the pathogens to patients, so hand hygiene is considered to be the most important and least expensive means of preventing nosocomial infections. Aim: The aim of this study is to assess and compare the antimicrobial efficacy of different hand sanitizers. Subjects and Methods: An in vitro study was conducted in the Department of Public Health Dentistry in the Dental College, Delhi NCR, to evaluate the antimicrobial efficacy of Green Apple (Himalaya), Lemon (Lifebuoy), Aloe vera (Tempo) hand sanitizers and compared them with the antimicrobial efficacy of sterillium hand sanitizers which is considered as the gold standard in hand sterilization. Twenty five participants were divided into five groups. The Gloves worn by the participants were swabbed after oral prophylaxis using different hand sanitizers. The inoculation of the sample was done and incubated for 48 h at 37°C, and colony-forming units were counted. The data obtained were compiled systematically using Microsoft Excel and were analyzed using the SPSS version 19.0. Data were statistically analyzed using descriptive statistics to assess the mean, standard deviation, standard error of the mean, and ANOVA and post hoc test for group-wise comparisons. A value of P < 0.05 was considered statistically significant. Results: Sterillium group showed the highest antimicrobial effectiveness followed by lemon group (71.4 ± 11.80), Green Apple group (112 ± 13.78), and A. vera group (156.4 ± 34.37), respectively, against all the organisms in the study. Conclusion: Sterillium possessed maximum antimicrobial effect against all the Gram-positive as well as Gram-negative bacteria as compared to lemon, green apple, and A. vera hand sanitizers.

Keywords: Anti-infective agent, anti-microbial agent, hand hygiene, hand sanitizers, sterillium


How to cite this article:
Kotia P, Gupta BD, Gupta R, Sharma A, Raina K, Nissar I. Comparing the antimicrobial efficacy of different hand sanitizers: An In vitro Study. J Indian Assoc Public Health Dent 2019;17:253-7

How to cite this URL:
Kotia P, Gupta BD, Gupta R, Sharma A, Raina K, Nissar I. Comparing the antimicrobial efficacy of different hand sanitizers: An In vitro Study. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2019 Dec 16];17:253-7. Available from: http://www.jiaphd.org/text.asp?2019/17/3/253/266768




  Introduction Top




Hospital-acquired infection or nosocomial infections is a cross-infection of one patient by another or by doctors, nurses, and other hospital staff while in hospital.[1] It is a serious public health problem worldwide responsible for major portion of morbidity and mortality.[2] Even in developed countries, the extent of cross-infection in hospital is estimated to be in between 5.1% and 11.6%. The European Centre for Disease Prevention and Control reported an average prevalence of 7.1% in European countries and estimated that 4,131,000 patients are affected by approximately 4,544,100 episodes of hospital-acquired infection every year in Europe and in the USA was 4.5% in 2002, corresponding to 9.3 infections/1000 patient-days and 1.7 million affected patients.[3]

Dentists are exposed to different types of infectious microorganisms daily. A large number of pathogens are localized in the oral cavity, which can be transmitted in different ways during dental procedures,[4] usually by means of air/water syringe and high-speed instruments.[5] Two basic ways for spreading pathogenic microorganisms in a dental practice are blood and saliva through droplet aerosol of infected patients.[6] It has been shown that the most intensive aerosol and splash production occurs during the work of an ultrasonic scaling unit and high-speed handpiece.[7]

The hands of health-care workers are the primary mode of transmission of the pathogens to patients, so hand hygiene is considered to be the most important and least expensive means of preventing nosocomial infections. Unfortunately, due to lack of knowledge and awareness about risks and nonavailability of hand hygiene facilities, poor hand hygiene practices are been observed.[8] To overcome the negative impact of microbial contamination in health-care settings, hand sanitizers are recommended. Use of hand sanitizers has gained popularity in the recent past years which has led to the development, production of several hand sanitizers by various companies.[9] With huge amounts spent for advertisements and false claims made by manufacturers, clinicians and common man do not have any clue regarding the effectiveness of these commercially available hand sanitizers. The present study was carried out to assess and compare the antimicrobial efficacy of Green Apple (Himalaya®), Lemon (Lifebuoy®), Aloe vera (Tempo®), and Sterillium® hand sanitizers.


  Subjects and Methods Top


The present study was an in vitro study conducted in the Department of Public Health Dentistry in the Dental Institution, Delhi NCR.

Sample size was determined using the formula n1= r + 1/rσ2 (Zpower+ Zα/2)2/difference2 where n1= size of smaller group, r = ratio of larger group to smaller group, σ = standard deviation of the characteristic, Zpower= corresponds to power (0.84 = 80% power), Zα/2= corresponds to two tailed significance level (1.96 for α =0.05).

Taking largest difference between the groups as two hundred and standard deviation to be 100 for the sample, at 95% confidence interval and 80% power, size came out to be four for each group.

The study population consisted of sixty interns working in the comprehensive care clinic of the institution. Out of sixty participants, a total of 25 participants were selected and divided into five groups consisting of five participants who were randomly allocated in each group. Ethical clearance for the study was obtained from the institutional permission was taken by the Institutional Review Board (Reference letter no: ITSCDSR/L/2017/080 dated 15-9-17) before the start of the study. Informed consent was obtained from the study participants. In this study, we selected three herbal hand sanitizers Green Apple (Himalaya), Lemon (Lifebuoy), A. vera (Tempo), and compared them with the antimicrobial efficacy of Sterillium (Bode Chemie, Hartmann Group, Germany) hand sanitizer which is considered as the gold standard [Figure 1].
Figure 1: Hand sanitizers

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The hand sanitizers were dispensed in identical bottles by the investigator to maintain the blinding. Twenty five participants were divided into five groups, i.e., (i) Placebo group (plain water mixed with the transparent gel), (ii) Green Apple, (iii) A. vera, (iv) Lemon, (v) Sterillium [Figure 2].
Figure 2: Blinding

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All the participants of the study were asked to perform oral prophylaxis for 20 min on the patients attending the comprehensive care clinic of the institution. The gloves worn by the treating doctor were swabbed by using sterile cotton swab stick dipped in normal saline on both sides after oral prophylaxis for the placebo group [Figure 3] and [Figure 4].
Figure 3: Oral prophylaxis

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Figure 4: Swabbing done on the gloves

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All participants were asked to take 1.5 ml of hand sanitizer from the bottle and rub thoroughly on the front and back of the gloves for 15 s and allowed to dry.

After 15 s of application, the swabs were taken by the same method and inoculation was done on trypticase soy agar plates. The culture plates were incubated for 48 h at 37°C in the Research Lab of the Hospital. After incubation, colony-forming units (CFUs) were counted [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], and after completion of the study, the codes of hand sanitizers were broken. The data obtained were compiled systematically, and a master table was prepared using Microsoft excel. The data were analyzed using the Statistical packages for Social Science version 19.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics was to assess the mean, standard deviation, standard error of the mean, and ANOVA and post hoc test for group-wise comparisons. Value of P < 0.05 was considered statistically significant.
Figure 5: Placebo group

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Figure 6: Green apple group

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Figure 7: Aloe vera group

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Figure 8: Lemon group

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Figure 9: Sterillium group

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  Results Top


The results of the study showed that hand sanitizers were effective against all the organisms. The antimicrobial effectiveness was assessed by measuring the mean CFU of the study groups.

Maximum CFU were seen in placebo group (332.2 ± 106.01) and minimum in sterillium (47.8 ± 9.91). Sterillium group showed the highest antimicrobial effectiveness followed by Lemon group (71.4 ± 11.80), Green Apple group (112 ± 13.78), and A. vera group (156.4 ± 34.37), respectively, against all the organisms in the study. When the intergroup comparison was made to see the reduction in microbial growth by calculating CFU, a statistically significant difference was found between the placebo group and different hand sanitizers group which showed that on using different hand sanitizers there was marked reduction seen in the microbial counts [Table 1] and [Table 2].
Table 1: Comparison of mean scores between the groups

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Table 2: Inter group comparison between the different hand sanitizers

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When sterillium was compared with the other test groups, statistically significant difference was found between them which were Green Apple ( P = 0.04), A. vera ( P = 0.02), and Lemon group ( P = 0.03). However, there was no statistically significant difference found when Green Apple A. vera, Lemon group were compared with each other ( P = 1.000) [Table 2].


  Discussion Top


Human hands harbor microorganisms are ranging from normal microbiota to pathogenic species. Human skin provides optimum growth conditions for most disease-causing organisms and also the opportunistic pathogens. These bacteria evidently could develop resistance to the cleaning agents, thus contributing to their persistence in an ecosystem. The use of hand sanitizer is one of the means of reducing the microbial load present on the hands.[10]

Three different brands of hand sanitizers were selected out of many available in the market. Selected hand sanitizers were Green Apple (Himalaya), Lemon (Lifebuoy), A.vera (Tempo) and compared them with the antimicrobial efficacy of Sterillium (Bode Chemie, Hartmann Group, Germany) hand sanitizer, which is considered as the gold standard.

In this study, we found that sterillium which is a gold standard has the highest antimicrobial efficacy than the other herbal agents used as a sanitizer which was not in accordance with the results observed by David et al.,[10] Mondal and Kolhapure,[2] Jain et al.,[11] and Onyeagba et al.[12] According to David et al.,[10] which stated that the formulated herbal hand sanitizer completely inhibited the growth of microorganisms on agar medium and also exhibited a high antimicrobial efficacy in inhibiting the growth of all the test organisms when used on glass bead. According to Mondal and Kolhapure[2] herbal hand sanitizer was found to be effective, safe, and less likely to cause adverse skin reactions and saves time and human resources.

Onyeagba et al.[12] who reported that Citrus aurantiifolia Linn. Lime juice has the highest effect on the test organisms; although, its effect on the Gram-positive organisms was found to be higher than that of the Gram-negative organisms. According to Jain et al.[11] commercially available hand sanitizer also showed antimicrobial activity against the organisms; however, the exact and valid comparison could not be done with other studies due to the lack of scientific literature.

The results of the present study are in concordance with those of the studies by Reena Rajkumari[13] and Jain et al.[11] who established that sterillium was the most effective disinfectant among all the hand sanitizers against all the bacteria used. This might be attributed to the presence of alcohol (propanol 75%) in liquid form that soaks and penetrates the skin creases and nail folds, unlike the gel form sanitizers that glide over and coat the skin. It also contains mecetronium ethyl sulfate to contribute for residual effect for approximately 3–5 h, which is lacking among other hand sanitizers.

Limitations of this study are that only the antimicrobial efficacy of different hand sanitizers was assessed. Identification of specific types of bacterial response was not taken in the study.

Further studies are required to assess the exact quantity and duration of application of hand sanitizer.

Despite the claims of efficacy and 99.9% bacterial reduction by hand sanitizer manufacturers, there still exists a need for verification of these claims by regulatory bodies and higher authorities for the enforcement of good-quality measures.


  Conclusion Top


The hands of health-care workers are the common mode of transmission of pathogens to patients and hand hygiene can avoid healthcare-associated infections. Scientific evidence supports the use of alcohol-based hand sanitizer for hand cleanliness during patient care.

From the present study, it was concluded that sterillium possessed maximum antimicrobial effect against all the Gram-positive as well as Gram-negative bacteria, followed by Lemon, Green Apple, A. vera group, respectively.

Dental public health significance

Hand sanitizer proved to be the most efficient in preventing the transmission of the pathogens and to achieve asepsis conditions for health-care workers in clinical practices. It also saves time and resources.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Park K. TextbookPreventive and Social Medicine. 24th ed. Jabalpur: Banarsidas Bhanot; 2017.  Back to cited text no. 1
    
2.
Mondal S, Kolhapure SA. Evaluation of the antimicrobial efficacy and safety of pure hands herbal hand sanitizer in hand hygiene and on inanimate objects. Antiseptic 2004;101:55-7.  Back to cited text no. 2
    
3.
World Health Organization. Burden of Healthcare-Associated Infection Worldwide Fact Sheet: World Health Organization; 2010. Available from: http://www.who.int/gpsc/country_work/summary_20100430_en.pdf. [Last accessed on 2018 Apr 16, 3:00 PM].  Back to cited text no. 3
    
4.
Decraene V, Ready D, Pratten J, Wilson M. Air-borne microbial contamination of surfaces in a UK dental clinic. J Gen Appl Microbiol 2008;54:195-203.  Back to cited text no. 4
    
5.
Sotiriou M, Ferguson SF, Davey M, Wolfson JM, Demokritou P, Lawrence J, et al. Measurement of particle concentrations in a dental office. Environ Monit Assess 2008;137:351-61.  Back to cited text no. 5
    
6.
Nejatidanesh F, Khosravi Z, Goroohi H, Badrian H, Savabi O. Risk of contamination of different areas of dentist's face during dental practices. Int J Prev Med 2013;4:611-5.  Back to cited text no. 6
    
7.
Leggat PA, Kedjarune U. Bacterial aerosols in the dental clinic: A review. Int Dent J 2001;51:39-44.  Back to cited text no. 7
    
8.
Larson E. Skin hygiene and infection prevention: More of the same or different approaches? Clin Infect Dis 1999;29:1287-94.  Back to cited text no. 8
    
9.
Ochwoto M, Muita L, Talaam K, Wanjala C, Ogeto F, Wachira F, et al. Anti-bacterial efficacy of alcoholic hand rubs in the Kenyan market, 2015. Antimicrob Resist Infect Control 2017;6:17.  Back to cited text no. 9
    
10.
David OM, Olatunji FJ, Alese MO, Babalola TO, Alese OO. Antimicrobial activity, safety and acceptability of formulated ginger-fortified hand sanitizer gel. Int J Trop Dis Health 2017;22:1-11.  Back to cited text no. 10
    
11.
Jain VM, Karibasappa GN, Dodamani AS, Prashanth VK, Mali GV. Comparative assessment of antimicrobial efficacy of different hand sanitizers: An in vitro study. Dent Res J (Isfahan) 2016;13:424-31.  Back to cited text no. 11
    
12.
Onyeagba RA, Ugbogu OC, Okeke CU, Iroakasi O. Studies on the antimicrobial effects of garlic (Allium sativum Linn), Ginger (Zingiber officinale Roscoe) and lime (Citrus aurantiifolia Linn). Afr J Biotechnol 2004;3:552-4.  Back to cited text no. 12
    
13.
Reena Rajkumari B. Evaluation of the efficacy of six different hand sanitizers commonly available on the Indian market. Int J Pharm Biol Sci 2015;6:984-91.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2]



 

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