Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2010 | Month : August | Volume : 4 | Issue : 4 | Page : 2685 - 2690

An investigation of the Bacterial contamination of ultrasound equipments at a university hospital in Saudi Arabia

MATTAR EH , HAMMAD LF , AHMAD S, EL-KERSH T A

*Radiologic Sciences Dept., College of Applied Medical Sciences, King Saud University, Saudi Arabia **Dept. of Medical Lab. Sciences, College of Applied Medical Sciences, AlKharj University, Saudi Arabia ***Clinical Lab Sciences Dept., College of Applied Medical Sciences, King Saud University, Saudi Arabia

Correspondence Address :
* Dr. Essam H. Mattar
Assisstant Professor of Radiologic Sciences
Radiologic Sciences Dept.
College of Applied Medical Sciences
King Saud University
Kingdom of Saudi Arabia
E-mail: emattar@ksu.edu.sa
Mobile: +966-504788991

Abstract

Objective: Nosocomial infections present a widespread problem in today's healthcare environment, with a significant number of patients acquiring an infection annually. With the contemporary transition of immunocompromised and high-risk patients to community-based care, ultrasound has the potential to be a vector of infection in the Radiology setting. The purpose of the present study was to determine the degree of contamination on ultrasound equipment and gel after routine clinical use and to determine the effectiveness of three different methods of ultrasound probe cleaning for the prevention of nosocomial infections.

methods: A total of 444 culture swabs from different parts of the three ultrasound machines and from the gels were taken. All samples were tested in a microbiology laboratory at King Khalid University Hospital, Riyadh, Saudi Arabia, using different culture media. The isolates were identified by using standard techniques. All isolates were subjected to antimicrobial susceptibility testing using the Kirby-Bauer disc diffusion technique on Muller-Hinton agar and commercial antibiotic discs were used for antimicrobial testing. In addition to this, MIC was performed for all isolates according to the Clinical and Laboratory Standards Institute (CLSI) interpretative criteria.
Results: The majority of organisms which are found in normal skin and environmental flora were isolated from different parts of the ultrasound machines. The gels were heavily contaminated with opportunistic and potentially pathogenic organisms like Staphylococcus aureus and Enterococcus faecalis. No multi-resistant organisms were identified. There was a significant reduction in the bacterial count after applying either of all the three cleaning methods for the ultrasound probe as compared to the count on the probes before cleaning (p<0.001). However, the soap cleaning method was the most effective one in decreasing the bacterial count to the minimum level in comparison to other two methods (p<0.001). The overall reduction in the pathogenic bacterial count after performing each cleaning method was 46%, 75% and 97% for the paper cleaning, the normal saline and the soap cleaning methods, respectively.
Conclusion: The non-invasive ultrasound equipment is a potential vector for nosocomial infection in Radiology patients. Cleaning the ultrasound probe after performing each procedure is a cost-effective practice with a potential for reducing nosocomial infections. The soap cleaning technique is the most effective method for reducing the bacterial count which is acquired due to the patients’ body contact with the ultrasound probes. Further research into the possible strategies to reduce the risk of infection from the ultrasound gels is needed.

Keywords

Ultrasound, Nosocomial infection, Cleaning methods, Disinfection.

introduction
through into the patient’s body and back ag
Nosocomial infections either develop in hospitals or occur due to microorganisms which are acquired from hospitals, leading to significant patient morbidity and mortality (1),(2). The Radiology department in the hospital is a potential source of nosocomial infections as it is an integral part of the medical services for the admitted as well as for the walk-in patients. The ultrasonography suite is one of the busiest areas and the most commonly used imaging modality and a large number of sonographic examinations are performed in tertiary care hospitals. Many studies have shown that ultrasound (US) probes are an ideal vector for transmitting the pathological organism from one patient to another vulnerable patient, unless there are effective cleaning methods (3),(4),(5),(6),(7),(8),(9),(10). This is particularly relevant in interventional ultrasound procedures and endocavitary sonographical examinations. The limited literature is divided, regarding the potentiality of US probes to act as a vector for cross infection and its prevention (4), (6), (7). Aylirffe (11) summarized the infection control guidelines in hospitals, which needs to be tailored in sonographical practice and there are no clear international guidelines regarding the cleaning methods of the ultrasound probes.

If any part of the ultrasound transmission media (gel), (which acts as a coupling medium that enables the transmission of sound from the ultrasound probe ain), the probe that is placed onto the gel to scan, or even the keyboard that the practitioners touch during scanning, then there is a risk of cross-contamination from the equipment to the patient. In a public health care facility, a single ultrasound machine can be used to scan over 30 patients on a normal day, including both patients who may act as a source of infection and those patients who are susceptible to infections (3). A study (12) carried out in 1998 confirmed that it was apparent that ultrasound procedures transferred colonizing Staphylococci from the patient’s skin onto the ultrasound instruments. It has also been demonstrated that the bacterial colonization of probes with pathogenic bacteria occurs under in-use conditions (13). A recent study has incriminated the ultrasound gel as a potential source of infection (14).

Paper wipe and alcohol wipes have been recommended as sufficient to clean the ultrasound probe, hence, reducing the risk of cross-infection. The use of dry wipe is effective for abdominal scanning, whereas alcohol wipes are recommended for the axillar and the inguinal regions (15). A more recent study recommends the cleaning of the ultrasound probes with disinfectant spray and the other areas with a 70% alcohol wipe (16). The prevention of disease transmission between patients is of primary importance in any busy sonography department. The department of ultrasonography at King Khalid University Hospital in Riyadh, Saudi Arabia, examines more than 16,000 patients annually. In a significant number of sonograms, the probe is placed adjacent to or directly over the disrupted skin, as well as within the scanning fields which are contaminated with bacteria. The ultrasound probes are routinely cleaned after each procedure, simply by wiping them until they are visibly clean with a dry, nonsterile, soft, absorbent paper towel. Additionally, alcohol wipes are used to clean the probes.

The present study was planned to assess (i) the microbiological contamination of the ultrasound equipments which were used for non-invasive examinations (ii) efficacy of the present decontamination regimes for the ultrasound equipment and (iii) to formulate effective cross-trust decontamination guidelines for the ultrasound equipment.

Material and Methods

Radiology had three different ultrasound machines. The following sites- – keyboard, probe holder, probe and gel - of each ultrasound machine were swabbed. The swabs were kept in Stuart’s transport The Dept. of medium and were sent to the Microbiology laboratory for culture. The three swabs from the same site were pooled and inoculated in Brain Heart Infusion broth for 48 hours at 37oC. The broth was then cultured on the following media: Sheep blood agar, chocolate agar, MacConkey’s agar plates and Sabouraud’s Dextrose agar and was incubated aerobically at 37oC for 24-48 hours. The resulting growth on anyof these media was reported and the isolates were identified using standard techniques (17). In addition, API 20 E and API 20NE (BioMerieux, France) were used for the identification of gram negative bacilli.

Antibiotic susceptibility testing was carried out using the Kirby-Bauer disc diffusion technique on Muller-Hinton agar and commercial antibiotic discs (Oxoid Limited, Hampshire, United Kingdom) were used for antimicrobial testing (18). The antibiotic discs used were: Ampicillin (10 µg), Amoxicillin-Clavulanic Acid (20/10 µg), Tetracycline (30 µg), Gentamicin (10 µg), Amikacin (30µg), Tobramycin (30 µg), Trimethoprim-Sulphamethoxazole (1.25/ 23.75 µg), Cefotaxime (30 µg), Ceftazidime (30 µg), Ceftriaxone (30 µg), Ciprofloxacin (5 µg), Cefoxitin (30 µg), Cefuroxime (30 µg), Aztreonam (30 µg) Imipenem (10 µg), Oxacillin disc (1µg), Penicillin G (10U), Erythromycin (15µg), Cephalothin (30µg), Clindamycin (2µg) and Vancomycin (30µg) and different combinations of these were chosen for different organisms according to the Clinical and Laboratory Standards Institute (CLSI) recommendations. The antibiotic disc impregnated culture plates were incubated at 37oC overnight. The diameter of the zone of inhibition was measured and recorded as resistant or susceptible according to the Clinical and Laboratory Standards Institute (CLSI) interpretative criteria (19). In addition to this, MIC was performed for all isolates according to the Clinical and Laboratory Standards Institute (CLSI) interpretative criteria (19).

Results

A total of 444 swabs were taken from different parts ( keyboard, probe holder, probe) of the three ultrasound machines and from the gels. No organisms were isolated from 67% of the swabs from the gel, while only 8.1% of swabs from the keyboard were sterile. Around one third of the swabs from the probe and the probe holder were also sterile. Aerobic spore bearers were the commonest isolates from all specimens and the least from the gel. About 54% of the swabs from the keyboard grew Bacillus Sp. as compared to only 8.1% from the gel. Similarly, the skin flora (Staphylococcus epidermidis, diphtheroids , and Micrococcus sp. ) was present more on the keyboard, probe and probe holder and least in the gel. However, Staphylococcus aureus was isolated more from the gel (13.5%) than from the keyboard (8.1%), probe and the probe holder (2.7% each). It was also noted that 2 isolates of enterococci grew only from gel specimens. Gram negative rod bacteria were isolated from the keyboard (21.6%), probe holder (8.1%), and the probe (2.7%), but not from the gel. Acinetobacter spp. (Acinetobacter lwoffii and Acinetobacter baumanii) and Pseudomonas spp. (Pseudomonas stutzerii and Pseudomonas aeruginosa) were the commonest isolates (40% each). None of the specimens yielded the growth of yeasts. All strains of Staph.aureus were fully sensitive to all the antibiotics tested. Similarly, all the gram negative bacteria were fully sensitive to all the common antibiotics tested, with the exception of one strain of Acinetobacter baumanii which showed resistance to Ciprofloxacin.


Discussion

with Nosocomial infections are hospital-acquired infections that occur 48 hrs after the admission of the patients to the hospital (20). They are a significant cause of morbidity and mortality in the hospitalized patient (21). The prevalence of nosocomial infections reported from the hospitals of South-East Asia is 10%, which is the second highest regional distribution in the world (2). Medical instruments including bronchoscopes, gastrointestinal endoscopes and stethoscopes have all been previously implicated in the transmission of nosocomial infections (22), (23). Recently, an electronic thermometer was also implicated as the vehicle of transmission in an outbreak of nosocomial infections due to a multidrug-resistant strain of Enterococcus faecium (24). Ultrasound probes can be a potential source of nosocomial infections which can act as vectors for transferring pathogenic organisms (commonly Staphylococcus aureus), which is particularly risky for immunocompromised patients (13), (25). The department of ultrasonography at our institution has 7 sonography units in full-time operation and examines more than 16,000 patients yearly. Each standard ultrasound probe is used for more than 8 examinations each day. Because of the limited number of ultrasound probes and machines and the limited number of sonographical technologists, the department must adopt a time-efficient protocol for probe decontamination that will ensure the optimal control of infection. Avoidance of disease transmission is of particular concern in departments that performcanning fields procedures on patients disrupted skin or contaminated s, which may increase the potential for contamination of the probe with microorganisms. These issues have led some departments to adopt measures which are aimed at reducing the potential risk of probe contamination. These measures include covering the ultrasound probe with a clean plastic bag for each study, routinely washing the probes with various antiseptic solutions and advising all technologists to wear gloves. These precautions may contribute to a significant and unnecessary increase in the operating costs. In our department, the ultrasound probes are wiped after each procedure with a dry, clean, soft paper towel. This ensures a basic standard of probe decontamination. Furthermore, it maintains a clean, neat, practical working environment for examining a large volume of patients. It was unclear, however, whether this low level of disinfection was sufficient to prevent cross-contamination between patients. The purpose of our study was to investigate the potential for the ultrasound probe and the coupling gel to serve as a vehicle of nosocomial infection and to devise a time-efficient and cost effective protocol for the decontamination of these instruments that would also minimize the risk of cross-contamination.

In the initial part of this study, we evaluated the likelihood of the ultrasound probe to become colonized with bacteria after scanning patients with disrupted skin.

A significantly high number of bacteria were identified in this study in the US probe before they were cleaned, highlighting the importance of the proper cleaning of the probe before applying it to the next patient. An uncleaned sonographical probe may become a source of bacteria for the next patient and may lead to nosocomial infections. In this study, it was proved that by applying appropriate simple cleaning methods, the number of bacteria on the US probes can largely be reduced. The paper wipe technique may not be highly effective as it only reduces 45% of the bacteria and these results are consistent with those reported by Spencer, Tesch and Fröschle (3),(7),(8). However, other studies considered paper towel cleaning as a simple and effective method for ultrasound probe cleaning (4), (14). This method may not be appropriate for our patients where poor hygienic conditions prevail in our population. Moreover, another study suggested that the paper cleaning method can be applicable with acceptable effectiveness in outpatients but not for admitted patients who already are at a higher risk of nosocomial infections and the single paper cleaning method might not be effective enough for routine use (26). Paper wipe followed by normal saline wipe is 76% effective and appeared to be better as compared to simple paper towel cleaning. However, the soap wipe technique was found to be the most effective of the cleaning methods tested, with an effectiveness of 98% and this is comparable to the alcohol effectiveness of 99% (25),(26). It can be used routinely as the soap will not degrade the rubber seal as alcohol does and it also increases the working life of the probe. However, large longitudinal studies are required to see the long-term effects of the soap on the probe. Findings of this study support the use of soap in probe cleaning like hand washing, which is a simple, easily available and cost-effective way of decontamination.

Furthermore, a cleaning method needs to be tailored for the clinical situation to achieve an appropriate cost-to benefit ratio and we are in the process of adopting the following approach towards infection control in the ultrasound department. Before the examination of outpatients and short-stay inpatients, the soap wipes technique is ensured to be an adequate cleaning method. Before the examination of patients who are at a risk for contracting infection (i.e. neonates or immunocompromised patients, those undergoing genital examination, or those with unhealed wounds), the covering of the probe with a simple plastic glove is appropriate. After the examination of the patients who may be a potential source of infection (those with MRSA-positive results, those who are in the intensive therapy unit, or those who have undergone multiple antibiotic courses), paper wipe followed by an alcohol wipe provides adequate cleaning to protect the next patient from cross infection. Frequent hand washing by sonographers and the use of disposable hand gloves would also be helpful in preventing nosocomial infections. Furthermore, some of the studies suggest that prior cleaning of the body surface of the patient undergoing the sonographical examination with disinfectant is a better option for preventing nosocomial infections through the ultrasound probes (27), but this technique may be inconvenient to the patient as well as for operator and needs to be tested in our population. Although the sonographical gels used for examination were standardized and aseptic, microbiological testing of the gels showed the presence of pathogenic bacteria. Our gels were contaminated with different bacterial pathogens which are associated with different diseases. Our findings were in agreement with those of others (3),(28). So, the use of a gel having antibacterial properties is recommended in order to further reduce the risk of the transfer of microorganisms from the equipment to the patient. Effects of the chemical components of soap on the ultrasound probes were not tested and needed further exploration to establish their long-term impact.

In conclusion, applying simple cleaning methods can prevent nosocomial infections from ultrasound probes; all the three methods of cleaning like the paper towel, alcohol and soap wipes can reduce the pathogenic bacterial count up to a certain extent. However, the soap wipes technique is the most effective and the cost-effective method of cleaning which can be used in routine clinical practice for cleaning ultrasound probes. Special infection control measures should also be taken in a high-risk group of patients. It is highly recommended that other ultrasound departments must review their probe cleaning and sterilizing procedures to assess whether they are safe. In particular, do they provide a safe working environment for the practitioner, do they comply with the manufacturer’s requirements and restrictions and do they ensure that the risk of cross infection is minimized?

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