Triclosan - Myers Supply & Chemical

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not specifically state the source of volunteers included in their studies [20, 24, 28], because there was no indication that these subjects were derived from the clinical setting. Because of our focus on the community, we also excluded studies that assessed exposure to triclosan in the clinical setting and the emergence of antibiotic resistance. Two of the studies by Luby et al. [21, 23] did not present a statistical comparison of the antiseptic treatment arm and the plain soap treatment arm, so we computed statistical comparisons by use of the data available from the study. Therefore, it is possible that these 2 studies did not have adequate sample sizes to detect differences between treatment arms using biocide-containing versus plain soap. The differences, however, were very small and showed an even slightly higher level of infectious illness symptoms, for some of the outcomes, among the biocide-containing soap users compared with the plain soap users. Because hand soaps are one of the most commonly available hygiene products containing triclosan, we limited our review to studies that provided the results of exposure to these products among isolates of bacteria from humans. Two of the studies included in our review isolated bacterial species from humans and the environment [33, 43]. For these studies, we reported only the results regarding the isolates from humans. Importantly, the results were similar regardless of isolate source [33, 43]. In addition, our search did not include studies that were published in languages other than English. PubMed was the only search database utilized; therefore, print sources such as conference abstracts were excluded. CONCLUSIONS The results of our review call into question the marketing of soaps containing triclosan as a product providing efficacy beyond the use of plain soap in the community setting. Soaps containing triclosan at concentrations used in the community setting (0.2% or 0.3% wt/vol) were generally no more efficacious than plain soap at preventing infectious illness symptoms and reducing bacterial levels on the hands. Several studies demonstrated laboratory evidence of triclosan-adapted cross-resistance with antibiotics among multiple species of bacteria. There are still too few studies that have been conducted in the community setting to adequately assess whether the emergence of antibiotic resistance in that setting is associated with the use of consumer soaps containing triclosan. Longitudinal studies are needed to assess changes in levels of antibiotic resistance associated with use of soap containing triclosan over time, and large databases of isolates are required to examine within-species changes in antibiotic-resistance profiles. Still, current findings warrant actions by the FDA for evaluating consumer product advertising claims. Future research should be directed at addressing both the efficacy of and risks associated with the use of triclosan. For instance, data are needed to assess whether S146 • CID 2007:45 (Suppl 2) • Aiello et al. products containing triclosan provide an added level of protection among high-risk groups, such as immunocompromised individuals living in the household setting. Acknowledgments We are grateful to Rebecca M. Coulborn for editing the manuscript. Supplement sponsorship. This article was published as part of a supplement entitled “Annual Conference on Antimicrobial Resistance,” sponsored by the National Foundation for Infectious Diseases. Potential conflicts of interest. All authors: no conflicts. References 1. Perencevich EN, Wong MT, Harris AD. National and regional assessment of the antibacterial soap market: a step toward determining the impact of prevalent antibacterial soaps. Am J Infect Control 2001; 29: 281–3. 2. Bhargava HN, Leonard PA. Triclosan: applications and safety. 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Evaluation of the skin disinfecting activity and cumulative effect of chlorhexidine and triclosan handwash preparations on hands artificially contaminated with Serratia marcescens. Infect Control 1987; 8:163–7. 18. Luby S, Agboatwalla M, Schnell BM, Hoekstra RM, Rahbar MH, Keswick BH. The effect of antibacterial soap on impetigo incidence, Karachi, Pakistan. Am J Trop Med Hyg 2002; 67:430–5. 19. Lindhe J. Triclosan/copolymer/fluoride dentifrices: a new technology for the prevention of plaque, calculus, gingivitis and caries. Am J Dent 1990; 3(Spec No):53–4. 20. Bartzokas CA, Gibson MF, Graham R, et al. A comparison of triclosan and chlorhexidine preparations with 60 per cent isopropyl alcohol for hygienic hand disinfection. J Hosp Infect 1983; 4:245–55.
21. Luby SP, Agboatwalla M, Feikin DR, et al. Effect of handwashing on child health: a randomised controlled trial. Lancet 2005; 366:225–33. 22. Larson E, Lin SX, Gomez-Pichardo C, Della-Latta P. Effect of antibacterial home cleaning and handwashing products on infectious disease symptoms: a randomized, double-blind trial. Ann Intern Med 2004; 140:321–9. 23. Luby SP, Agboatwalla M, Painter J, Altaf A, Billhimer WL, Hoekstra RM. Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial. JAMA 2004; 291:2547–54. 24. Sickbert-Bennett EE, Weber DJ, Gergen-Teague MF, Sobsey MD, Samsa GP, Rutala WA. Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses. Am J Infect Control 2005; 33:67–77. 25. Larson E, Aiello A, Lee LV, Della-Latta P, Gomez-Duarte C, Lin S. Short- and long-term effects of handwashing with antimicrobial or plain soap in the community. 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Surgical hand disinfection: comparison of 4% chlorhexidine detergent solution and 2% triclosan detergent solution. J Hosp Infect 1990; 15:143–8. 31. Larson E, Mayur K, Laughon BA. Influence of two handwashing frequencies on reduction in colonizing flora with three handwashing products used by health care personnel. Am J Infect Control 1989; 17: 83–8. 32. Bartzokas CA, Corkill JE, Makin T, et al. Assessment of the remanent antibacterial effect of a 2% triclosan-detergent preparation on the skin. J Hyg (Lond) 1983; 91:521–8. 33. Ledder RG, Gilbert P, Willis C, et al. Effects of chronic triclosan exposure upon the antimicrobial susceptibility of 40 ex-situ environmental and human isolates. J Appl Microbiol 2006; 100:1132–40. 34. Sanchez P, Moreno E, Martinez JL. The biocide triclosan selects Stenotrophomonas maltophilia mutants that overproduce the SmeDEF multidrug efflux pump. Antimicrob Agents Chemother 2005; 49:781–2. 35. Braoudaki M, Hilton AC. Mechanisms of resistance in Salmonella enterica adapted to erythromycin, benzalkonium chloride and triclosan. Int J Antimicrob Agents 2005; 25:31–7. 36. Braoudaki M, Hilton AC. Low level of cross-resistance between triclosan and antibiotics in Escherichia coli K-12 and E. coli O55 compared to E. coli O157. FEMS Microbiol Lett 2004; 235:305–9. 37. Braoudaki M, Hilton AC. Adaptive resistance to biocides in Salmonella enterica and Escherichia coli O157 and cross-resistance to antimicrobial agents. J Clin Microbiol 2004; 42:73–8. 38. Randall LP, Cooles SW, Piddock LJ, et al. Effect of triclosan or a phenolic farm disinfectant on the selection of antibiotic-resistant Salmonella enterica. J Antimicrob Chemother 2004; 54:621–7. 39. Walsh SE, Maillard JY, Russell AD, et al. Development of bacterial resistance to several biocides and effects on antibiotic susceptibility. J Hosp Infect 2003; 55:98–107. 40. Fraise AP. Susceptibility of antibiotic-resistant cocci to biocides. 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Emerg Infect Dis 2005; 11:1565–70. 46. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002; 23:S3–40. 47. Aiello AE, Larson EL. What is the evidence for a causal link between hygiene and infections? Lancet Infect Dis 2002; 2:103–10. 48. Global Health Council. Infectious diseases. Available at: http:// www.globalhealth.org/view_top.php3?idp228. Accessed 13 September 2006. 49. Sickbert-Bennett EE, Weber DJ, Gergen-Teague MF, et al. The effects of test variables on the efficacy of hand hygiene agents. Am J Infect Control 2004; 32:69–83. 50. American Society for Microbiology. A survey of handwashing behavior. Available at: http://washup.org/. Accessed 13 September 2006. Antibacterial Soap Use: Efficacy and Risks • CID 2007:45 (Suppl 2) • S147
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