February 1982, Volume 32, Issue 2

Editorial

Disinfection Agents

Fatema Jawad  ( Sugbrabai Millwalla Hospital, Karachi. )

Disinfection in the operating and delivery rooms, applied with rigid discipline, has achieved much success with the development of new techniques and highly effective antimicrobial agents.
The most common antiseptic agents fall into four groups. Hexachiorophene is a chlorinated bisphenol compound. It is a strong bacteriostatic agent being very effective against Gram positive bacteria. It has little action on Gram negative organizms and spores. This brings about an easy contamination of soaps and creams containing hexachiorophene with Kliebsella, Pseudomonas aeruginosa, E. coli and candida albicans (Alyiffe et. al. 1969, Brunn and Degrones, 1971, Simmons 1969).
Compounds of iodine or lodophors arc of two types. Poloxameriodine, a complex of iodine and Pluronic 188 and Povi-done-iodine, a combination of iodine and polyvinylpyrrolidone. Both have a wide range of anti-microbial actions. Contamination of products containing these compounds has not been reported. Bacterial cultures from hands and operation sites scrubbed with lodophors yielded lower counts when compared with hexachiorophene (Crowder et. al. 1967).
Chiorhexidine gluconate is very effective against both Gram positive and negative bacteria and fungi at a pH between 5 and 8. It is available as a 4 percent detergent for scrubbing hands and skin cleansing where it is quicker acting than hexachiorophene and iodophors (Lowbury and Lilly, 1974). It is well tolerated (Maki, et. al., 1979), and contamination has not been reported (Rosenberg and Alatary, 1976). Benzalkonium chLoride, an organic ammonium compound, acts against both Gram positive and negative organizms along with some fungi and protozoa, It has been found to be very effective for penĀ­uretheral skin disinfection prior to catheterization and for the care of the indwelling catheter (Desautels et. al. 1969). Contamination of this product with Pseudomonas and Enterobacter has been reported. (Dixon et. al., 1976 Frank and Schaffner, 1976, Kaslow et. al., 1976, Plotkin and Austrian, 1958).
Toxicity studies have revealed the development of a vacuolar encephalupathy in premature infants bathed in a 3 percent hexachiorophene solution (Kundsin and WaIter, 1973). Repeated use of detergents containing hexachiorophene for washing hands by pregnant nurses brought about an increased incidence of mal formations in their newborns. (Check, 1978, Halling, 1978). But as yet the teratogen activity is not fully established. Ganerick, 1979). Severe metabolic acidosis has been observed in burn cases treated with povidone iodine (Lavelle, et al., 1975, Reitsch and Meakins, 1976). Absorption from the peritoneal cavity when used for irrigation in laparotomies can give significantly raised serum iodine levels.
Benzalkonium Chloride is a relatively safe germicide when used in solutions of 0.1 to 0.5 percent for topical application. Contact dermatitis has been reported. Strong solutions of 10 to 15 percent when inhaled can corrode the mucous membrane of the gastro-intestinal tract and pulmonary tree. Chiorhexidine gluconate given orally produces hepatocellular and renal damage. (Chow et al. 1977). But dermal exposure does not have this danger as the absorption through the intact human skin is of a very small degree, if at all. (Case et al., 1976). Contaet sensitivity has been observed to be minimal. (Rosenberg and Alatary, 1976).
These four ielatively sak and effective antiseptics and disinfectaƱts are utilised in most of the hospitals for preoperative skin preparation, as a hand disinfectant, in the management of wounds and burns as an obstetric cream, for bladder irrigation and for oral hygiene. But still it could be said, with the toxicity, side effects and sensitivity reactions in view, that the ideal agent is vet to be found.

References

1. Ayliffe, G.A.J., Barrowcliff, D.F. and Lowbury, E.J.C. (1969) Contamination of disinfectants. Br. Med. J., 1:505.
2. Brunn, J.N. and Degrones, A. (1971) Survival of gram negative bacilli and candida albicans in hexachoirophene preparations and other disinfectants. Scand. J. Infect. Dis., 3:235.
3. Case, D.E. Mc Ainsh, J., Rushton, A. and Winrow, M.J. Chiorhexidine; attempts to detect percutaneous absorption in man, in chemotherapy. Edited by J.D. Williams and A.M. Geddes. Vol. III. New York, Plenum, 1976, pp. 367-74.
4. Check, W. (1978) New study shows hexachiorophene is teratogenic in humans. JAMA., 24:513.
5. Chow, A.Y.K., Hirsch, G.H. and Buttar, H.S. (1977) Nephrotoxic and hepatotoxic effects of triclosan and chiorhexidine in rats. Toxicol. Appi. Pharmacol., 42:1.
6. Crowder, V.H. Jr., Welsh, J.S., Bornside, G.H. and Cohn, I. Jr. (1967) Bacteriological comparisons of hexachlorophene and polyvinylpyrrolidone-iodine surgical scrub soaps. Am. Surg., 33:906.
7. Desautels, R.E. (1969) The causes of catheter-induced urinary infection and their prevention. J. Urol., 101:757.
8. Desautels, R.E. Walter, C.W., Graves, R.C. and Harrison, J.F1. (1961) Technical advances in the prevention of urinary tract infection. Trans. Am. Ass. Genitourin. Surg., 53:184.
9. Dixon, R.E., Kaslow, R.A., Mackel, D.C. and Fulkerson, C.C. (1976) Aqueous quaternary ammonium antiseptics and disinfectants. Use and misuse. JAMA., 236:2415.
10. Frank, M.J. and Schaffner, W. (1976) Contaminated aqueous benzalkonium chloride. An unnecessary hospital infection hazard. JAMA., 236:2418.
11. Hailing, H. Suspected link between exposure to hexachlorophene and malformed infants. Presented at the New York Academy of Science, New York.
12. Janerich, D.T. (1979) Environmental causes of birth defects; the hexachiorophene issue. JAMA., 241:830.
13. Kaslow, R.A., Mackel, D.C. and Mallison, G.F. (1976) Nosocomial pseudobacteremia. Positive blood culture due to contaminated benzalkonium antiseptic. JAMA., 236:2407.
14. Kundsin, R.B. and Walter, C.W. (1973) The surgical scrub; practical consideration. Arch. Surg., 107:75.
15. Lavelle, K.J., Doedens, D.J., Kleit, S.A. and Forney, R.B. (1975) Iodine absorption in burn patients treated topically with povidone-iodine. Clin. Pharmacol. Ther., 17:355.
16. Lowbury, E.J.L. and Lilly, H.A. (1973) Use of 4% chlorhexidine detergent solutin (Hibiscrub) and other methods of skin disinfection. Br. Med. J., 1:510.
17. Maki, D.G., Zily, M.A. and Alvardo, C.J. (1979) Evaluation of theantibacterial efficacy of four agents for handwashing. Presented at the Eleventh International Congress of Chemotherapy and the Nineteenth Interscience Conference on Antimicrobial Agents and Chemotherapy, Boston.
18. Plotkin, S.A., and Austrian, R. (1958) Bacteremia caused by pseudomonas species following the use of materials stored in solutions of a cationic surface-active agent. Am. J. Med., Sci., 235:621.
19. Reitsch, J. and Meakins, J.L. (1976) Complications of povidone-iodine abscorption in topically treated burn patients. Lancet, 1:280.
20. Rosenberg, A. and Alatary, S.D. (1976) Letter; chlorhexidine and contaminants. Ann. Intern Med., 84:752.
21. Simmons, N.A. (1969) Contamination of disinfectants. Br. Med.J., 1:842.

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