This study demonstrated that the prevalence of Gram-negative bacterial contamination on patients’ visitors’ hands was 21.1% on entry and 30.2% on exiting the hospital. This indicates that visitors not only bring a significant number of pathogenic bacteria when they enter the ward but importantly, they also take pathogenic bacteria back into the community when they leave the hospital. Due to paucity of data on prevalence of visitors’ hands contamination with bacteria, the findings of this study have been compared to studies on HCWs and patients.
This prevalence is similar to the reported prevalence of bacterial contamination of hands among HCWs in Mwanza (26.4%)(Rayson et al., 2021), in Brazil (37.8%)(Cairo et al., 2008) and Iran (39.3%)(Sepehri et al., 2009). The prevalence observed in this study differs from the prevalence of Gram negative pathogens isolated from neonate mother’s hands at Bugando Medical Center (18.5%)(Silago et al., 2020), this could be because mothers’ of neonates are subjected to and are more conscious of taking precautions before they handle their babies than other visitors with their adult patients. The prevalence in this study also differs from that reported from Bugando Medical Center from samples taken from June 2013 to May 2015 which was 13.2% (Moremi et al., 2018). This could be because these samples were not from visitors’ hands, but also it could indicate an increase in Gram-negative colonization at hospitals. The prevalence also differs from that reported of tertiary hospital health care workers in Greece (45.6%)(Tselebonis et al., 2016) and on patient’s hands contamination in Iran (39.3%) (Sepehri et al., 2009).This disparity could indicate that the magnitude of contamination is higher among HCWs and patients. But it could also be due to differences in wards where the HCWs were sampled from, in this study the visitors were selected mainly from medical and surgical wards. None the less, the prevalence of contamination observed indicates the contribution of visitors to the pathogen pool in wards they visit and the magnitude of bacteria they possibly take home after visiting these hospitals.
In this study the most common isolated bacterial species was Klebsiella pneumoniae in both entry and exit samples (41% and 43%, respectively). This finding is similar to those reported in several other studies on bacteria isolated from hands of HCW and patients where Klebsiella species have always shown prominence (July et al., 2022; Tselebonis et al., 2016). Klebsiella pneumoniae is responsible for many blood stream infections and is known to be resistant in many cases to several classes of antimicrobial drugs. Klebsiella species are also known to be commonly transmitted through individuals’ skin or shared items and further worsened by not washing hands after offering services to a patient (July et al., 2022) which is a factor associated with this contamination.
The isolated bacteria in the entry and exit sample showed similar resistance pattern to antibiotics: penicillins and cephalosporins. Few studies have assessed the antibiotic resistance pattern of isolates from relatives’ hands; however, we may compare our results with those done on hospital surfaces and from clinical samples. Similar resistance patterns have been reported in a recent study on contaminated surfaces at tertiary hospitals in Dar es Salaam where highest resistances were observed to Ceftriaxone (63–100%) (Joachim et al., 2023). Other studies in Tanzania and Zimbabwe have also reported an increase of resistance of Gram-negative bacteria in clinical samples to third-generation cephalosporins over recent years (Agaba et al., 2017; Chakraborty et al., 2016; Manyahi et al., 2014) by Klebsiella and Acinetobacter species. The demonstration of Klebsiella species resistance to cephalosporins, augumentin and ampicillin is not new(Chakraborty et al., 2016). This depicts the difficulty in treating this kind of infection, leading to longer hospital stays, increased economic burden and even increased mortality.
The proportion of MDR bacteria found in this study were 36.3% at entrance and 30.8% at exit. This finding is different from that reported of MDR bacteria causing surgical site infection at Muhimbili National Hospital 61.4%(Manyahi et al., 2014), and MDR reported in an ICU in a study done in Uganda 58% (Agaba et al., 2017) and in Zimbabwe (75%) on close contact surfaces and health care workers(Mbanga et al., 2018). This disparity could be due to differences in sampled ward: The Zimbabwe study was conducted in ICU, and among HCWs who are more likely to be contaminated as they have more contact time with patients. The proportion of ESBL producers in this study was 18.1% with majority being Klebsiella pneumoniae. This finding is similar to that reported from a study done on skilled care residents where ESBL Klebsiella were 18.0% (Van Duin et al., 2015) and 18.6% for ESBL Klebsiella in ICU. Apparently, these findings suggest that visitors to hospitals contribute significantly to the MDR bacteria circulating in the hospitals and by deduction, that circulating in the community.
The proportion of MDR at entrance was higher than exit of ward in this study. This is different from what is expected since the hospital is known to be a reservoir of infection (Solomon et al., 2017). A proportion test showed that this difference was not statistically significant, but also indicates that this is a vicious cycle since the visitors seem to be carrying around the same proportion of MDR. On the other hand, proportion of ESBL producing Gram-negative bacteria was significantly higher among those exiting than those entering the hospital supporting the above-mentioned theory. This supports the hypothesis that visitors carry significant proportions of resistant bacterial strains back in to the community and later into the hospital, creating a vicious cycle of MDR bacterial infections.
There was a statistically significant association between Gram-negative bacterial growth in sample B and hospital stay duration. This compares well with the findings of other studies that showed that staying longer in hospitals increases the likelihood of getting an infection(Loke et al., 2019; Nair V, Sahni AK, Sharma D, Grover N, Shankar S, Chakravarty A, Patrikar S, Methe K, Jaiswal SS, Dalal SS, Kapur A, Verma R, Prakash J, Gupta A, Bhansali A, Batura D, Rao GG, Joshi DP, n.d.; Saviteer et al., 1988). The longer a patient is admitted the higher the likelihood of getting in contact with infectious pathogenic bacteria from the hospital premises, HCWs or other patients.
This study showed a significant association between visitors offering services like feeding, turning patients, changing patients’ clothes, and growth of Gram-negative bacteria in sample B. This finding tallies with the knowledge of contact with patients with persistent and or resistant bacteria facilitating the spread of bacteria(Istenes et al., 2013).
Lack of hand washing at entrance and exit was associated with visitors’ hand contamination. This finding is similar to that reported in several studies that have demonstrated that contaminated hands are couriers of infectious agents when not properly decontaminated (Damani et al., 2017; Istenes et al., 2013; Patarakul et al., 2005). There was an association between washing hands and having Gram-negative bacteria on hands at entrance which does not tally with scientific knowledge that hand washing reduces or removes bacterial contamination. This disparity could be due to not washing hands properly thus visitors retaining bacteria on their hands.
These study findings underscore the need to strengthen IPC implementation in the hospital setting to prevent spread of pathogenic and multidrug resistant bacteria that lead to multidrug infections that can result in adverse outcomes like increased morbidity and mortality.
Study limitations
This research is subject to some limitations. Firstly, participants were swabbed at the ward entrance rather than at the hospital entrance, this implies that the contamination found on their hands may not have originated from the community, as some had already touched hospital surfaces. Secondly, since visitors' hands were not sanitized after the initial swab at the ward entrance, the bacteria isolated at the exit cannot be definitively traced back to the hospital Mitigation: Prevalence obtained was not reported as coming from the hospital directly. All practices at the hospital were self-reported and thus could not be verified. Mitigation: All practices were reported as self-reported to avoid misleading.