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Medical textiles with silver/nanosilver and their potential application for the prevention and control of healthcare-associated infections

Medical textiles with silver/nanosilver and their potential application for the prevention and control of healthcare-associated infections

Medical textiles with silver/nanosilver
and their potential application for the prevention
and control of healthcare-associated infections – mini-review
INTRODUCTION
Healthcare-associated infections (HAI), especially
hospital (nosocomial) infections, can be regarded as an
important public health problem worldwide. These infec-
tions have a massive impact on morbidity and mortality,
and come with a substantial cost and burden on healthcare
institutions. According to the European Center for Disease
Prevention and Control (ECDC), approximately 4 million
patients are estimated to acquire HAI in the European Union
each year and approximately 37,000 deaths result directly
from these infections. A large proportion of these are due to
the life-threatening infections caused by the most common
multidrug-resistant bacteria, i.e. Staphylococcus aureus,
Enterobacteriaceae, Pseudomonas aeruginosa for which
the number of directly attributable deaths is currently esti-
mated at 25,000 [1].
L R, M J, A L, E W, A M*
1 Eko-Styl Rental Sp. z o.o. Sp. k., Spoldzielcza 13 B, 37-300 Lezajsk, Poland
2 Department of Pharmaceutical Microbiology with Laboratory for Microbiological Diagnostics, Medical University of Lublin, Chodzki 1,
20-093 Lublin, Poland
3 University Children`s Hospital, Prof. Gebali 6, 20-093 Lublin, Poland
HAI are due to the interaction of three factor groups:
(i) patient-associated factors, (ii) healthcare-associated
factors and (iii) environmental factors. There are three
basic principles for the prevention and control of HAI: (i)
remove sources of infection by treating infections and prac-
tising appropriate decontamination procedures, (ii) prevent
transmission by way of good hand hygiene, aseptic pro-
cedures and appropriate isolation, (iii) enhance immunity
with good nutrition and appropriate antibiotic prophylaxis
or vaccination. New approaches to combatting HAI have
been introduced recently, including antimicrobial medical
textiles. These serve as horizontal approaches that reduce
the potential risk of a broad range of infections as they are
not pathogen-specic [2].
Transmission of microorganisms, including HAI-asso-
ciated pathogens, involves three elements: a source, a sus-
ceptible host and a mode of transmission. In the healthcare
setting, the movement of pathogens between the patient,
healthcare providers and the environment, is known as
ARTICLE INFO ABSTR AC T
Received 20 November 2018
Accepted 12 January 2019 Healthcare-associated infections (HAI), especially those in hospitalized patients, can be
regarded as an important public health problem worldwide. In this article we presented
an overview on the use of antimicrobial textiles, including those with silver/nanosilver,
as a new approach to countering HAI by reducing the potential risk of the pathogen
transmission between patients and healthcare workers. e strong antimicrobial in vitro
activity of these engineered textiles was conrmed in vitro against several HAI-associated
pathogens, including multiresistant strains belonging to alert pathogens. However,
according to literature data, the sole use of antimicrobial clothing by healthcare workers
appears to not be sucient for the prevention and control of HAI. Further comprehensive
and controlled studies are needed to assess the real-time ecacy of the antimicrobial
textiles in healthcare settings. Moreover, there is a need to control the silver use not only
for medical applications, but also for non-medical purposes due to a possibility for the
emergence and spread of silver resistance among microorganisms, especially Gram-
negative bacteria.
Keywords:
healthcare-associated
infections (HAI),
prevention,
antimicrobial textiles,
silver/nanosilver.
DOI: 10.2478/cipms-2019-0020
* Corresponding author
e-mail: anna.malm@umlub.pl
Lukasz Rajski, Mar ek Juda, Adam Los, Elzbieta Witun, Anna Malm
Vol. 32, No. 2, Pages 104-107 105
the transmission or the epidemiologic triangle. Strate-
gies to decrease the pathogen`s movement in the trans-
mission triangle can be generally focused on the patient
(e.g. antimicrobial-impregnated clothing), the environment
(e.g. antimicrobial surfaces or textiles), or the healthcare
workers, including doctors, nurses, laboratory personnel
and technical professionals (e.g. antimicrobial-impregnated
clothing) [3,4].
TEXTILES WITH SILVER/NANOSILVER AND THEIR
ANTIMICROBIAL PROPERTIES  PROS AND CONS
Textiles impregnated/coated with silver/nanosilver take
an important place among those with antibacterial and/or
antifungal properties. These engineered textiles have
multiple medical and non-medical applications [5-8].
Silver has been used for centuries for certain supposed
benecial effects, often for hygienic purposes and more
recently as antimicrobial agents. The antimicrobial activity
of silver ions is due to the targeting macromolecules such as
proteins and DNA or RNA. Sulfhydryl groups from cysteine
(Cys) residues, being a ligand for metal and/or cofactors,
is the main molecular bulls-eye for silver ions in several
metalloproteins, including those involved in cell respiration
and energy conservation. The effect results in enzyme inac-
tivation and disturbance of vital cell processes. Apart from
sulfur, silver has a high afnity to phosphorus as well. Silver
ions binds to the bases of nucleic acids, forming complexes
with DNA or RNA, followed by gene mutations and/or
inhibition of replication. What is more, silver ions may
cause morphological and structural changes of the cell
envelope, i.e. the cell wall and cell membrane, together with
the enhancement of their permeability – which leads to cell
lysis. Silver can be also regarded as an agent predisposing
to oxidative stress in bacterial cells. Due to these reasons,
silver can be regarded as an important biocidal agent with
a wide spectrum of activity against both Gram-positive
and Gram-negative bacteria, as well as fungi [9].
Silver particles having at least one dimension that
is less than 100 nm and containing 20-15,000 silver atoms
are termed ‘nanosilver particles’ or ‘nanosilver’. Nanosil-
ver particles (nanosilver) are increasingly used in a variety
of products, primarily for their strong antimicrobial prop-
erties. It is supposed that in aqueous solutions, nanosilver
releases the silver ions responsible for its antimicrobial
activity. However, comparative studies on the antimicro-
bial effect of silver salts such as nitrate, citrate and chloride
have revealed that nanosilver have stronger activity than
silver ions themselves. This can be explained by the fact
that nanosilver possesses extremely large surface area which
allows better contact with microbial cells [10].
The increasing use of silver/nanosilver textiles may result
in the growing problem of microbial resistance analogous
to that observed for antibiotics. However, it should be noted
that due to the pleiotropic molecular basis of antimicro-
bial silver/nanosilver effect, the development or selection
of resistance appeared to be limited. In recent literature data
[6], two types of silver resistance in Gram-negative bacteria
have been described – endogenous resistance based on muta-
tions, and exogenous resistance associated with horizontal
transfer of resistance genes. Mechanisms of both endo- and
exogenous resistance involve the limitation of silver accu-
mulation in the periplasm, including silver efux. Gram-neg-
ative bacteria can also develop resistance to nanosilver after
repeated exposure, but this resistance could evolve without
any genetic changes [11,12]. It should be stressed that
several important nosocomial pathogens, including multi-
resistant strains belong to Gram-negative bacteria, in particu-
lar, the carbapenemases-producing Enterobacteriacae [1].
Due to these observations, there is a need to monitor the
emergence and spread of silver- and nanosilver-resistant
isolates, especially among Gram-negative bacteria, in order
to preserve silver’s utility for various applications.
There are several studies showing the signicant anti-
bacterial and antifungal inhibitory effect in vitro of silver/
nanosilver containing textiles. In the experiments, the micro-
bial growth reduction reached almost 100% after 24h-incu-
bation. These textiles were also revealed to possess inhibi-
tory effect against several pathogenic bacterial and fungal
species, including resistant/multi-resistant strains [13-15].
The wide range of applications of silver/nanosilver holds
potential risk for human health. Thus, in order to dene
the health-risk assessment of silver/nanosilver textiles,
it is important to quantify and to characterize the silver
species released from a textile, as well as to determine and
to characterize the silver species penetrating into the skin.
Bianco et al. [16] applying the in vitro model of skin sample
preparation, found that the use of commercially available,
nanosilver-containing textiles leads to the release of silver
and to its penetration into the skin, followed by the for-
mation of aggregates in the epidermis and dermis. It is
supposed that these aggregates may slow down systemic
absorption of silver, being simultaneously a reservoir
of silver with prolonged release and being responsible for
its local effects. However, the presence of silver within the
skin makes it systematically available, allowing for the dis-
tribution throughout the organism, especially in case of the
damaged skin. This may lead to toxic effects. In addition,
nanosilver was shown to induce the production of proin-
ammatory cytokines such as interleukin-6 and interleu-
kin-10 and to inuence selenium metabolism, leading to
the decreased incorporation of selenium into selenoproteins,
e.g. glutathione peroxidase or thioredoxin reductase. The
mentioned enzymes play a vital role in the defense against
oxidative stress.
On comparing the toxicity of silver and nanosilver,
it should be noted that the toxic effects of nanosilver are
dependent not only on the dose, but also on the particle
size. Indeed, smaller nanosilver particles (10 and 20 nm) are
more toxic than that the larger ones (40, 60, and 100 nm).
Moreover, the evaluation of safety of the nanosilver-contain-
ing products requires a comprehensive approach – includ-
ing ascertaining the inuence of nanosilver on the human
body, together with its biotransformation in the organism and
in the environment [10].
Despite these limitations, textiles with silver/nanosilver
impregnation, due to their strong antimicrobial activity,
as well as the relatively low risk of biological toxicity and
environmental toxicity, possess a wide spectrum of applica-
tions, including that for medical purposes. These engineered
Medical textiles with silver/nanosilver and their potential application for the prevention and control of healthcare-associated
infections – mini-review
Lukasz Rajski, Marek Juda, Adam Los, Elzbieta Witun, Anna Malm
Medical textiles with silver/nanosilver and their potential application for the prevention and control of healthcare-associated infections – mini-review
106 Current Issues in Pharmacy and Medical Sciences
textiles can be regarded as a new approach to reducing
surcial microbial contamination [2,3,5-8].
THE PRACTICAL USE OF ANTIMICROBIAL
TEXTILES IN HEALTHCARE SETTINGS
Medical textiles can be regarded as an important res-
ervoir of potential and opportunistic pathogens involved
in HAI, hence, contributing to their transmission. Micro-
organisms colonizing the patient skin, nasal cavity and the
anus/ genitalia areas, as well as that present in the body
uids, secretions and/or excreta often contaminate these
items. Textiles may, hence, be regarded as a good substrate
for growth of microorganisms under appropriate moisture
and temperature conditions [4]. Antimicrobial textiles have,
therefore, attracted a great deal of interest in recent years
due to their antimicrobial properties and thus the potential
for reducing the transmission of HAI-associated pathogens.
Medical textiles include protective cloths, mattresses, bed
cloths, wound dressings or bandages, etc. [2,3,5-8].
However, little literature data are available concerning
the effect of antimicrobial silvered/nanosilvered medical
textiles in hospital settings in the aspect of the reduction
of the prevalence of HAI-associated pathogens, and thus
the reduction of HAI incidence. Of note, most articles were
focused on their use in the hospital staff clothes to reduce
their bacterial contamination and transmission [17-20].
Openshaw et al. [17] undertook an experiment in which
hospital patient textiles were laundered by way of a novel
silver-based procedure. In this study, two samples were
collected from each textile: upper and lower areas on cen-
terline of bottom tted sheets and areas corresponding to
chest and suprapubic area of gowns. According to the data
obtained, the treatment resulted in a signicant decrease
in microbial contamination as compared to conventional treat-
ment (e.g. from 83% to 48%). Herein, the textiles sampled
post-patient use had decreased contamination in terms
of total aerobic bacteria count, as well as in the prevalence
of Staphylococcus aureus and methicillin-resistant S. aureus
(MRSA). However, while statistically signicant reduction
was observed in case of total aerobic bacteria and S. aureus,
the low prevalence of MRSA was a limitation to drawing
a statistically signicant conclusion in this case.
Groß et al. [18] performed a study in emergency medical
settings in order to test whether the wearing of silver-impreg-
nated clothes by emergency service workers would reduce
microbial contamination. The experiment had a duration of
one week. They found no signicant differences in the extent
of microbial contamination between conventional and the
silver-impregnated clothes. These authors concluded that a
larger sample size should be considered in order to verify
this results.
Similar studies were performed by Condó et al. [19].
They evaluated the microbial contamination of hospital
staff uniforms made from silver-containing textiles in a
comparison to conventional uniforms; these uniforms were
used by doctors, nurses and allied health assistants working
in different hospital wards (pediatrics, surgery and long-
term care unit). Evaluation of the contamination was carried
out comparing the number of colony forming units (CFU)
recovered at the beginning and at the end of the work shift
in terms of the prevalence of bacterial species from Micro-
coccaceae, Enterococcaceae, Enterobacteriaceae and Pseu-
domonadaceae families. For each uniform, six samplings
were performed (three at the beginning and three at the end
of the work shift) choosing as contact points three areas
frequently in contact with hands and at risk of contamina-
tion: right pocket, left pocket and small pocket. In this exper-
iment, the increase in the total viable counts from beginning
to end of the work shift was slightly lower for experimental
than traditional uniforms, but this difference was not statis-
tically signicant. The authors concluded that despite the
not entirely encouraging results, the use of silver as a anti-
microbial agent has potential in countering HAI through
the breakdown of hospital pathogen transmission routes.
In the data obtained during the Antimicrobial Scrub
Contamination and Transmission (ASCOT) trial [20], anti-
microbial-impregnated scrubs, including silver-containing
cloths, were not effective at reducing bacterial contamina-
tion as compared to traditional cloths measured as the sum
of colony-forming units (CFU) of bacteria identied on
nurse scrubs from each clothing location. These studies
enrolled nurses from medical and surgery intensive care
units of the university hospital, and samples for microbio-
logical analysis were collected during 3 consecutive 12-hour
shifts in the intensive care unit. The obtained results con-
rmed that the clothing of healthcare providers regularly
becomes contaminated with important HAI-associated
pathogens and, as a result, can act as their reservoir or route
for transmission. The authors proposed that future studies
of antimicrobial-impregnated textiles should be focused
on textiles that have frequent and long-term contact with
patients, such as bed linens and gowns.
CONCLUSION
The presented overview on antimicrobial textiles, includ-
ing those with silver/ nanosilver, that used by healthcare
workers, reveals that this strategy alone appears to be not
sufcient for the prevention and control of HAI. This is
despite the strong antimicrobial in vitro activity of these
engineered textiles. However, further comprehensive and
controlled studies are needed to assess the real efcacy
of such antimicrobial textiles in healthcare settings. It must
be underlined that the silver used for medical applications
should be controlled to avoid its overuse, while the silver
used for non-medical purposes should be restricted in order
to prevent the emergence and spread of silver resistance
among microorganisms, especially Gram-negative bacteria.
ACKNOWLEDGEMENT
This work was co-financed by the National Center
for Research and Development from the Intelligent Devel-
opment Operational Programme 2014-2020, under Priority
I: Support for R&D project conducting by enterprises,
Measure 1.1: R&D projects of enterprises, Sub-mea-
sure 1.1.1: Industrial research and developmental works
carried out by enterprises: Project “Innovative technol-
ogy for fabric renement with antimicrobial properties”
No. POIR.01.01.01-00-0637/17.
Lukasz Rajski, Mar ek Juda, Adam Los, Elzbieta Witun, Anna Malm
Vol. 32, No. 2, Pages 104-107 107
ORCID iDs
Łukasz Rajski https://orcid.org/0000-0002-6588-1289
Marek Juda https://orcid.org/0000-0002-0340-5463
Adam Łoś https://orcid.org/0000-0001-5537-6759
Anna Malm https://orcid.org/0000-0003-1503-7634
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https://www.researchgate.net/publication/334198599_Medical_textiles_with_silvernanosilver_and_their_potential_application_for_the_prevention_and_control_of_healthcare-associated_infections_-_mini-review