Bacterial Assessment and Their Antibiotic Sensitivity Patterns of Nasal and Hand Swab Specimens From Food Handlers in Hospital Compounds in Mandalay, Myanmar: A Cross-sectional Descriptive or Observational Study

Background: Microbial contamination of food can occur from contaminated or infected food handlers. Methods: This study aimed to assess type of bacteria and their antibiotic sensitivity pattern of nasal and hand swab samples from food handlers working in hospital compounds, Mandalay city, Myanmar. All eligible food handlers working in the government hospital compound, Mandalay City, Myanmar, were subjected to a cross-sectional study conducted from May to August 2018. Hand and nasal swabs were collected from of food handlers for bacterial isolation and identication. Antibiotic sensitivity patterns of isolated bacteria were determined. Results: Among 111 participants, 92 (82.9%) were bacteria-positive by hand swabs and 77(69.37%) were positive by nasal swab. Among Staphylococcus aureus isolated from nasal swabs, just over a half (51.2%) were resistant to oxacillin (probably methicillin resistant Staphylococcus aureus). There were association between hand contamination and nasal bacterial growth (p<0.001). Conclusion: Bacterial contamination status of the food handler working in hospital compound, Mandalay city, Myanmar, was extremely high.

In Ethiopia, Staphylococcus aureus (S. aureus) and other bacteria such as Klebsiella spp., Escherichia coli, Enterobacter spp., Pseudomonas aeruginosa were the common bacterial contaminants among food handlers [12]. Food handlers can transmit infection directly from their hands to eye, nose, mouth and skin or indirectly transmitting microbes via handling of food or water. In addition, hands cleanliness is one of the most signi cant and e cient points to achieve safe food handling to avoid contamination with dangerous microorganisms. In this research, we determined bacterial types and their antibiotic sensitivity pattern isolated from nose and hands of food handlers working in the government hospital compounds, Mandalay City, Myanmar. The data generated will deliver us important evidence and information for development and determination of further approaches or projects to be taken to progress healthiness of food handlers proposing to improve food safety in the government hospitals in Myanmar. practice (p) of 54.1% was based on the data among 172 food handlers of selected restaurants in Nay-pyitaw with z 1.96 (95% con dence interval) and precision (d) 5%. Therefore, the calculated minimum required sample size (n) is 108.

Methods
Study Design This was a cross-sectional descriptive or observational study designed to determine type of bacteria and their antibiotic sensitivity patterns of nasal and hand swab samples collected from food handlers working in the eating establishments in the government hospital compounds, Mandalay city,

Myanmar
Selection Criteria Myanmar food handlers working in hospital compounds for preparation and cooking of food were selected.

Data Collection Method and Tools
Firstly, the investigator explained pros and cons of this study and obtained written informed consents from the participants. The investigators cleaned and washed his hands with soap and water and wore gloves before sample collection using hand and nasal swabs to prevent cross contamination. Hand swab samples were taken from the participants by rolling several times over the inter-digital spaces, dorsal and ventral aspect of hands. In brief, a sterile cotton wool swab soaked with sterilised normal saline were applied to the indicated sites after the participant washed their hands with water and dried in the air. Nasal swab samples were taken from both anterior nares by touching 2 cm inside from the nasal ori ce and softly rotate in contradiction of the anterior nasal mucosa for three to ve times according to the guideline of "Specimen Collection Procedures Manual For National Health And Nutrition Examination Survey, 2000" [13]. The swab stick was put in Stuart's transport media and location, age, sex, date and sample numbers are labelled. After that collected samples were sent to the Department of Microbiology Laboratory, University of Medicine, Mandalay (UMM) as soon as possible for bacterial isolation and identi cation. These procedures were completed with the support of microbiologist from this Microbiology department.
The swab samples were inoculated onto Blood, MacConkey and Nutrient agar plate. All the plates were incubated at 37°C for overnight. After inoculation onto culture plates, the specimens were smeared on clean glass slides, heat xed, stained with Gram's stain and examined under an ordinary light microscope tted with x100 oil immersion lens to examine the presence of in ammatory cells and bacteria. If grampositive cocci arranged in grape like clusters were present, the colony was sub-cultured onto mannitol salt agar (MSA) plate supplemented with 5% v/v egg yolk and incubated at 37ºC for 24 hours. Five common clinically used antibiotic (amikacin, levo oxacin, ceftriaxone, clindamycin and amoxicillinclavulanic acid) discs were placed in equal spacing with a sterile needle tip. Other three antibiotic (cefoperasone-sulbactam, vancomycin and oxacillin) discs were tested randomly. Each disc was pressed down to ensure complete contact with the agar surface. Then the plate was inverted and placed in an incubator set at 37ºC. After overnight incubation, the diameter of each inhibitory zone was measured in millimetre using a ruler. The size of inhibitory zone was interpreted according to the chart of inhibitory zone sizes of the Clinical and Laboratory Standards Institute (CLSI, 2011).
Data Processing and Analysis Data was checked daily after collection for completeness and correction. Data entry was done by using the software EpiData 3. Antibiotics susceptibility of S. aureus (Fig. 1) isolates were tested against amikacin, levo oxacin, ceftriaxone, clindamycin, cefoperasone-sulbactam, vancomycin, amoxicillin-clavulanic acid and oxacillin.
In this study, the second most prevalent contaminant isolated from the hands of the studied group was Escherichia coli (8.11%). It is considered an enteric pathogen that are supposed to be capable of being spread by the food handlers in hospital compounds. The current nding has higher prevalence than the study (3.1% and 2.5% respectively) [19,20]. This result which re ects hand contamination with faecal matter pointed to insu cient and poor handwashing habits among the food handlers.
Nasal bacterial growth of the food handlers When nasal swab culture was examined, S. aureus was found in (54.95%) and coagulase negative staphylococcus was in (5.41%). The prevalence of nasal staphylococci carrier in this study is higher than that in the study [24] in Brazil (40.8%) and in Iraq (30.1%) [17]. In the study in Spain, 27.6% of 300 food handlers were found to be nasal coagulase positive staphylococci carriers [25]. The study in Kuwait city [26] revealed that (26.6%) of 500 restaurant workers were nasal S. aureus carriers. In Brazil, (24.4%) and (75.6%) of nasal and hand swabs of 82 food handlers were positive for coagulase-positive and coagulase-negative staphylococci [27]. There were (19.8%) and (10.4%) isolates from the nasal cavity of the food handlers respectively [22,23]. In contrast, the result of the present study is higher than those studies.
The current results presented that (1.8%) of the nasal swabs of the food handlers were Acinetobacter spp. It is a common cause of nosocomial or hospital acquired infection in Serbia. It is becoming a problematic due to their quick progress of drug resistance and high fatality rates (20-60%). Its transmission is possible via person-to-person connection, water contamination, food borne and contaminated hospital and surgical equipment [28].

Pattern of antibiotic sensitivity of Staphylococcus aureus isolates from nasal carriers of the food handlers
The detection of antibiotics-resistant S. aureus in nasal specimen is a public health attention as they can serve as sources of drug resistant S. aureus transmission in the community. In the present study, (1.64%) were resistant to amikacin. The study in Brazil stated (4.0%) were resistant to amikacin and those were higher than this study [24]. There was no resistant strain for cefoperasone-sulbactam antibiotic in the current study. Amikacin and cefoperasone-sulbactam are antibiotics most often used for intending to treat severe respiratory infections or multidrug-resistant tuberculosis in Myanmar. The reason of few percentage of drug resistant is that there are no oral form and also needs doctor prescriptions.
In the current study, (1.64%) was resistant to levo oxacin and (6.56%) was resistant to ceftriaxone. These two drugs are also used as rst line drugs in respiratory tract and gastro-intestinal tract infections according to hospital infection control guideline before getting speci c antibiotics sensitivity results. In other study, (97.68%) isolates were resistant to ceftriaxone [29]. Therefore, those were so higher resistant percentage than the current study.
In the present study, (9.84%) and (18.7%) isolates were resistant to clindamycin and amoxicillinclavulanic acid, respectively. Clindamycin and amoxicillin-clavulanic acid are antibiotics most often used for the treatment of respiratory tract infection in Myanmar. Most Myanmar people takes these two drugs to relieve signs and symptoms of upper respiratory tract infection (e.g. sneezes, cough, sputum production) without prescription of doctors. In the study of Udo in Kuwait city, only (2.0%) were resistant to clindamycin [30]. Other study stated (27.14%) of nasal swab samples were resistant to amoxicillinclavulanic acid and those were higher than this study [31].
(5.56%) isolates in the present study was resistant to vancomycin but there were no resistant to vancomycin tested in food handlers working the community study [22]. In the study in Botswana, (6.0%) were resistant to vancomycin [32]. In the current study, the prevalence of nasal carriers of ORSA (probably MRSA) was found to be 21 (18.92%) of total 111 food handlers and (51.22%) of S. aureus were resistant to oxacillin. But S. aureus strains were resistant to oxacillin (22.4 %) [32] and (0%) [22]. The current study result was higher than the previous studies. This difference might be due to different microbiological method of con rming MRSA. In the current study, MRSA is identi ed only by oxacillin disc diffusion test and not con rmed by cefoxitin disc diffusion test, MRSA latex agglutination test and PCR. Foods may be contaminated by human strains of MRSA present in meat processors and other food handlers [33]. Due to regional variation, choice of antibiotics should be guided by local susceptibility patterns.

Association of bacterial contamination among the food handlers in hospital compounds
There was an association between hand contamination and nasal contamination (p<0.001). Similar to the present study, food handlers who carry S. aureus in their noses are a likely source of hand contamination in their workplace [34].

Conclusions
This study revealed high in bacterial contamination and antibacterial resistance to S. aureus from the food handlers, justifying the screening testing methods to detect carriers and protect people from staphylococcal food poisoning before appointing and during working as food handlers in hospital compound. Misuse of antibiotics pave the way for the S. aureus to cause infections and to develop drug resistance. Moreover, there was seen signi cant association between hand contamination and nasal bacterial growth, and high in bacterial contamination status of the food handler working in hospital compound, Mandalay city, Myanmar.

List Of Abbreviations
CDC American Centers for Disease Control and Prevention Pattern of antibiotic sensitivity of Staphylococcus aureus isolates from nasal carriers

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