KNOWLEDGE OF MICROBIAL CONTAMINATION OF SPHYGMOMANOMETERS IN HEALTHCARE FACILITIES IN BENIN CITY

osocomial infections are infections that patients acquire while receiving treatment for other health conditions within a healthcare setting or facility. This study aims to determine the level of awareness of healthcare providers on the role sphygmomanometers play in the spread of nosocomial infections and to isolate microorganisms in sphygmomanometer cuffs used in healthcare facilities. A structured, selfadministered questionnaire was designed and administered to healthcare practitioners of two tertiary hospitals and community pharmacies in Benin City. Microbial contamination of sphygmomanometer cuffs was investigated following the standard isolation and identification techniques for microorganisms. A total of 217 responded; 27.2% pharmacists, 33.2% doctors and 39.6% nurses. The majority (50.2%) were between the ages of 20 – 30 years. 65.4% were females and 51.6% were single. Ninety-four percent (94%) of the total respondents said that microorganisms are present in the inner cuffs of sphygmomanometers, 76% said microorganisms on the cuffs are sources of nosocomial infections while 80.6% said patients can be infected with the use of sphygmomanometers. A total of 192 swabbed samples were collected from 64 cuffs in the healthcare facilities, 46.5% were bacteria and 53.5% fungi. The most isolated organisms were candida species 42(21%), Staphylococcus aureus 41(20.5% of which 28(68.3%) were methicillin resistant.), Mucor 34(17%), Aspergillus species 23(11.5%). Ninety four percent (94%) of respondents had good knowledge that blood pressure cuffs play a role in the spread of nosocomial infections. The sphygmomanometer cuffs were contaminated with pathogenic microorganisms implicated in nosocomial infections.


INTRODUCTION
Nosocomial infections or healthcare associated infections are infections that patients acquire while receiving treatment for other health conditions within a healthcare setting or facility. They are usually not present in the patient at the time of admission to the healthcare facility (Azeez-Akande, 2012; Hassan et al., 2017). Bacteria account for most cases of nosocomial infections (often 80% of all cases). However, fungi, viruses and parasites, are also causative organisms (Hassan et al., 2017).
Nosocomial infections can be spread in a number of ways; through direct or indirect contact, droplet, airborne, common vehicles or vector-borne. Transmission through the sphygmomanometers is by indirect contact with the patients' skin where the organisms can then move to other sites of the body to cause harm.
Sphygmomanometers are used on multiple patients in medical facilities, and during each use microorganisms can settle on the cuffs of the sphygmomanometers which can spread from one patient to another since their routine disinfection is not always performed (Matsuo et al., 2013) The objectives of this study were to determine the knowledge of healthcare providers on the role sphygmomanometers play in the spread of nosocomial infections and to isolate microorganisms in sphygmomanometer cuffs used in healthcare facilities.
While many studies have been carried out on the microbial contamination of sphygmomanometers used on patients in hospital settings in developed and developing countries (United Kingdom, Ethiopia, India), not much has been done particularly in Nigeria. No work has also been done in community settings like the community pharmacies in Nigeria. This research work did not only consider the bacterial isolation but also the fungal isolation of the sphygmomanometers used in both hospital and community settings.

STUDY DESIGN
This was a cross-sectional study conducted in major health facilities in Benin City. Sampling places included Central Hospital, University of Benin Teaching Hospital, and randomly selected and highly busy Community Pharmacies from the four Local Government Areas in Benin City (Egor, Ovia, Oredo and Ikpoba-Okha). The sample size from the hospital was based on the number of sphygmomanometers available in the various units visited.

DATA COLLECTION
A structured, self-administered questionnaire was designed and administered to healthcare practitioners (pharmacists, doctors and nurses) of two tertiary hospitals and community pharmacies in Benin City. The questionnaire consisted of three segments; sociodemographics (age, marital status, religion, profession and years of experience), knowledge of microbial presence on the blood pressure cuffs of sphygmomanometers and disinfection practice by the healthcare practitioners. Data generated were both quantitative and qualitative and analyzed using SPSS version 22 and presented using descriptive statistics such as frequencies and percentages of the identified organisms. Differences between the proportions were assessed using Chi square analysis. P-value ≤ 0.05 was considered statistically significant. Ethical approval was obtained from Central Hospital Benin City (A732/T/1), University of Benin Teaching hospital (ADM/E 22/A/VOL II/14775) and administrative approval from the pharmacies.

SAMPLE COLLECTION
Three sterile swab sticks were used for each sphygmomanometer and before being used, were moistened with 0.9% normal saline. The first two sticks were used to wipe the inner surface (the part that comes in direct contact with the patient's upper arm) and the outer surface (the part the healthcare provider touches while handling the blood pressure cuffs) of the sphygmomanometer cuffs respectively. The third sterile swab stick was used to wipe the inner surface again, but this time, after disinfecting it with 70% isopropyl alcohol and allowed to stand for 10minutes, following slightly modified method of Jeyakumari et al. (2016). All swabbed samples were immediately transported to the Pharmaceutical Microbiology Laboratory of the University of Benin, Benin City for analysis.
Serial dilutions of the swabbed samples were carried out by aseptically transferring the swab sticks into 10ml diluent (sterile distilled water) and subsequently inoculated into 1: 10, 1: 100, and 1: 1000 diluents. The dilutions were inoculated on already set nutrient agar (Titan Biotech Limited, India) plates using Miles and Misra method allowed to diffuse and then incubated at 37 degrees Celsius for 48 hours.
For the fungi isolation, the dilutions were transferred into Petri dishes and molten potato dextrose agar (Titan Biotech Limited, India) was poured on each plate using the pour plate method, allowed to set and then incubated at room temperature for 48 hours. After 48 hours, the plates were observed for growth, the colonies were counted and the results recorded. Gram staining was done and based on the Gram stain reaction, the following biochemical tests; catalase, slide and tube coagulase, oxidase, citrate, indole, sugar and hemolytic tests were performed to identify the bacteria isolates while the fungi isolates were identified using the Atlas (Bernward and Gabriele 1980).

SOCIODEMOGRAPHIC DATA
The Cronbach's Alpha of reliability of the questionnaire was 0.650. A total of 217 respondents (pharmacists, doctors, and nurses) filled the questionnaire; 27.2% were pharmacists, 33.2% were doctors and 39.6% nurses. Majority of the respondents, 50.2% were between the ages of 20 -30 years, 65.4% were females and 51.6% were single. Almost all 95.4% were Christians and more than an average of the respondents 126 (58.1%) had less than 5 years working experience, 44(20.3%) had between 6-10years experience, 22(10.1%) 11-15years experience, 12(5.5%) had 16-20 experience and 13(6.0%) had over 20years experience. ( Table 1 ) AJHSE-OWSD-2(2) Okaekwu et al., 2021 | 185 On the measures to reducing the microbial loads on the BP cuffs of sphygmomanometers, 87.6% of the respondents said that disinfecting the patient's upper arm before using the sphygmomanometer can reduce microbial load, 88.0% said disinfecting the inner surface of the blood pressure can reduce the microbial load, while 95.9% said wearing of hand gloves by healthcare practitioners and then 76.0% said placing a thin sterile physical barrier between patients' upper arms and the BP cuffs, can reduce microbial load and transmission of nosocomial infection (Table 2). there are patients with obvious skin infections and those whose skin infections have remitted but still come for followup, because of the limited number of sphygmomanometers, these patients are still checked with the same sphygmomanometers used for those with obvious skin infections.
The majority of the respondents do not take any precautionary measures to avert the transmission of microorganisms from infected to non-infected patients when using the sphygmomanometer (Table3).

AJHSE-OWSD-2(2)
Okaekwu et al., 2021 | 188 alcohol. This finding was in line with a study by Agam et al(2018), out of the 62 health workers (doctors, nurses and medical students) who participated in the study, 53.22% had never disinfected their stethoscopes before and among those who disinfected, 86.2% used alcohol-based disinfectant while none of the respondents disinfected their stethoscopes after seeing each patient.
Lack of time and lack of access to disinfectants were the major barriers to disinfecting the blood pressure cuffs of sphygmomanometers (Table 4). However, lack of time shouldn't be a barrier to disinfecting the blood pressure cuffs of sphygmomanometers because from this study, disinfecting with 70% isopropyl alcohol and allowing it to stand for 10 minutes before using it on the patients was found to eliminate the microorganisms and in few cases drastically reduced the microbial load on the sphygmomanometers. This was in line with a study done by Jeyakumari et al, (2016) to investigate the bacterial colonization of sphygmomanometers. In their study, they found out that disinfecting the blood pressure cuffs with 70% isopropyl alcohol either reduced or eliminated the microorganisms present on the blood pressure cuffs. So, allocating 10 minutes every working day to disinfect the blood pressure cuffs before starting the day's work will go a long way in reducing the microbial loads on these sphygmomanometers and thus reduce the risk of transmission of nosocomial infections among patients.

AJHSE-OWSD-2(2)
Okaekwu et al., 2021 | 190 Staphylococcus aureus while candida species were the most frequent fungi isolated. The inner surfaces of the blood pressure cuffs of the sphygmomanometers were more contaminated than the outer surfaces. This was similar to the findings of the study carried out by Baruah et al., (2008) in which the inner surfaces were also more contaminated than the outer surfaces. It was also found that the 70% isopropyl alcohol was effective in either reducing the microbial load or eliminating the microorganisms on the blood pressure cuffs.
Bacteria, fungi, viruses, parasites are all responsible for health care associated infections, however, bacteria have been found to be the most implicated (Hassan et al, 2017). In this particular study, on the overall, fungi were the most isolated organisms accounting for 53.5%. Among the bacteria isolated, Staphylococcus aureus was the most isolated which was in line with studies done by Fitsum et al. (2019), on non-critical healthcare tools as a potential source of healthcare-acquired bacterial infections and Uneke and Ijeoma (2011) , in which thermometers and blood pressure cuffs used in different units of the hospital were investigated for microbial growth.
The However, the organisms isolated from this study and those of other studies sited (Baruah et al., 2008, Uneke and Ijeoma 2011, Umegbolu 2019). varied from one healthcare facility to the other. This could be attributed to variation in geographical location, the way the sphygmomanometers are being handled by the different healthcare practitioners and also the healthcare environment in which the studies were conducted.

CONCLUSION
A high proportion of the respondents had good knowledge that the blood pressure cuffs can play a role in the spread of infections. However, they did not engage in good disinfection practice of the sphygmomanometers. Thus, more education and enlightenment should be done to enable the healthcare practitioners engage more in the disinfection of the instrument to reduce microbial load and by extension reduce the risk of transmission of nosocomial infections This study has also confirmed that most of the sphygmomanometers used in the investigated healthcare facilities were contaminated with pathogenic organisms that are implicated in healthcare-associated infections as the organisms isolated are found to cause serious systemic infections that require the hospitalization of the patients to effectively treat.