Bacterial Contamination of Antiseptics, Disinfectants, and Hand Hygiene Products Used in Healthcare Settings in Low- and Middle-Income Countries—A Systematic Review

Abstract

We conducted a systematic review of healthcare-associated outbreaks and cross-sectional surveys related to the contamination of antiseptics, disinfectants, and hand hygiene products in healthcare settings in low- and middle-income countries (PROSPERO CRD42021266271). Risk of bias was assessed by selected items of the ORION and MICRO checklists. From 1977 onwards, 13 outbreaks and 25 cross-sectional surveys were found: 20 from Asia and 13 from Africa. Products most associated with outbreaks were water-based chlorhexidine, chlorhexidine-quaternary ammonium compound combinations (7/13), and liquid soap products (4/13). Enterobacterales (including multidrug-resistant Enterobacter cloacae, Klebsiella pneumoniae, and Serratia marcescens) and non-fermentative Gram-negative rods were found in 5 and 7 outbreaks and in 34.1% and 42.6% of 164 isolates, respectively, from cross-sectional surveys. Risk factors included preparation (place, utensils, or tap water high and incorrect dilutions), containers (reused, recycled, or inadequate reprocessing), and practices (topping-up or too long use). Potential biases were microbiological methods (neutralizers) and incomplete description of products’ identity, selection, and denominators. External validity was compromised by low representativeness for remote rural settings and low-income countries in sub-Saharan Africa. Outstanding issues were water quality, biofilm control, field-adapted containers and reprocessing, in-country production, healthcare providers’ practices, and the role of bar soap. A list of “best practices” to mitigate product contamination was compiled.

Knowledge, awareness, and risk practices related to bacterial contamination of antiseptics, disinfectants, and hand hygiene products among healthcare workers in sub-saharan Africa: a cross-sectional survey in three tertiary care hospitals (Benin, Burkina Faso, and DR Congo)

“…The questionnaire was drafted by the principal investigator (PL) and co-author A-SH and commented for content, context-adapted formulation and clarity and readability by co-authors KO and JJ. It consisted of multiple-choice questions inspired by relevant references from a literature review [ 14 ], and by findings of the microbiological survey of AS, DI and HH products in CHU-YO and CNHU-HKM [ 10 ].…”

“…This possibility is often overlooked but contamination of AS, DI and HH products has been documented in cross-sectional studies and been implicated in numerous healthcare-associated outbreaks, but with considerable underreporting from LMIC [ 3 , 12 , 13 ]. Despite an anticipated decline [ 13 ], published reports have persisted during past decades and in addition reports of contaminated liquid soap have emerged [ 11 , 14 ].…”

“…Factors conducive to bacterial contamination of AS, DI and HH products are numerous and intertwined: they are frequently co-present in LMIC [ 11 , 14 ]. Water-based products are more vulnerable to contamination, particularly if (over)diluted or diluted with non-sterile water, like tap water [ 11 , 14 ]. Further, some contaminating bacteria (mainly Gram-negative bacteria) are intrinsically (naturally) resistant to certain products.…”

“…If not possible, the containers should be soaked in a biofilm-active agent [ 19 ] such as chlorine 0.5%, after which abundant rinsing with safe water and subsequent drying is needed. Most recycled product containers (disposable container which was originally used for another product) and soft-drink bottles are made from high density polyethylene (HDPE) and respectively polyethylene terephthalate (PET), which do not withstand autoclaving [ 14 ]. Furthermore, reprocessing is often only partially or not at all done [ 14 ].…”

“…Most recycled product containers (disposable container which was originally used for another product) and soft-drink bottles are made from high density polyethylene (HDPE) and respectively polyethylene terephthalate (PET), which do not withstand autoclaving [ 14 ]. Furthermore, reprocessing is often only partially or not at all done [ 14 ].…”