Does the “Holism theory” Explain the Increase in Antimicrobial Efficacy and the Lack of Acquired or Innate Resistance to 5 th Generation Silane Quaternary Compounds?

The “Holism theory” is credited to Aristotle, who said “the whole is greater than the sum of the parts”. From a purist point of view, it is unlikely that he actually said those exact words. individually and, can be of mind-boggling complexity. The activity of disinfectants against microorganisms depends on a number of factors, some of which are intrinsic qualities of the organism, others of which are the chemical and external physical environment.


Background
There are essentially two main groups of quaternary ammonium compounds (Quats), those that have a silane attached, and those that do not. Whilst their mode of action (MOA) is essentially the same, the spectrum of species kill and the level of persistence are very different for each variation. The silane versions of the Quats (SiQuats) will bond to surfaces and skin and become, in some cases, almost impossible to remove without wearing away the surface to which they are bonded. The resultant effect, therefore, is an antimicrobial compound that remains in place killing microbes for days months or years [1,2,3].

Properties of Quats and SiQuats
The biggest problem with these compounds is the difficulty in mixing them together to form multiple SiQuat compounds that have a full spectrum of kill. They either stick to each other and not the intended surface, or break apart leaving an unstable, unpredictable compound [4]. Since 1952, many chemical manufacturers have tried and failed to produce these multiple 5 th generation compounds, the goal being to produce a persistent, rapid acting compound with a full spectrum of microbial kill. There are two main reasons why this goal has been so keenly sought after. a.
b. Decreased potential for microbial resistance to build up against the compound.
Organisations such as NASA, have combined Quat compounds in an effort to kill bacteria on the International Space Station (ISS), only to find that they produce bacteria that are resistant to Quats and now multiple Quats [5]. One of the mechanisms that bacteria can use to become resistant to disinfectants is known as the Efflux pump [6]. If a bacterium comes into contact with a disinfectant at becoming resistant to either one, it has been proved that it can then become resistant to both [7]. It is possible that had NASA used a 5 th generation SiQuat compound, instead of a simple multiple Quat combination, that resistance could have been avoided, as SiQuats do not reduce in therapeutic efficacy over time.

SiQuat Generational Differences
Quats first appeared in around 1915 and were used in many areas of industry and in the military as surfactants and disinfectants.
It is difficult to trace exactly, but it is likely that resistance to these was first seen early in the 2 nd world war, when combinations were tried to reduce resistance and improve disinfection. SiQuats did not arrive until after the midpoint of the century, with continued improvement in efficacy. The following are the approximate years when generational improvements occurred.  4 th Gen -Developed from the mid 70's onwards, they have improved bonding, becoming much more difficult to remove from a surface. With multiple long chain lengths, they achieve a broader spectrum of kill, within a much greater temperature range. Again, they will see some reduction in efficacy in the presence of anionic soaps, surfactants. Is the "Holism theory" relevant for the 5th generation SiQuats?
There are numerous comparisons that could all point to this simple yet complex truth. The most compelling and closely relat-ed theory is probably the "entourage effect" [8,9]. The entourage effect is a proposed mechanism by which cannabis compounds act synergistically to modulate the overall psychoactive effects of the plant, primarily by the action of tetrahydrocannabinol (THC). The current wave of excitement in Cannabis commerce has translated into a flurry of research on alternative sources, particularly yeasts, and complex systems for laboratory production have emerged, but these presuppose that single compounds are a desirable goal.
Rather, the case for Cannabis synergy via the "entourage effect" is currently sufficiently strong as to suggest that one molecule is unlikely to match the therapeutic and even industrial potential of Cannabis itself as a phytochemical factory. The astounding plasticity of the Cannabis genome additionally, obviates the need for genetic modification techniques. In 1998, Professors Raphael Mechoulam and Shimon Ben-Shabat posited that, the endocannabinoid system demonstrated an "entourage effect" in which a variety of "inactive" metabolites and closely related molecules markedly increased the activity of the primary endogenous cannabinoids, anandamide and 2-arachidonoylglycerol (10). This and many other studies support the hypothesis that, greater efficacy is obtained when combining the multiple anticonvulsant components, rather than using individual known anticonvulsants in the cannabis plant.
When this same hypothesis is applied to the 5 th generation Si-Quats, we see a similar picture. Bacteria and viruses, in particular, that are normally considered to be resistant to Quats and SiQuats, are being killed by the 5 th generation SiQuats. These differences in resistant microbes, and the lack of acquired resistance were not seen initially, as there were issues surrounding accurate testing of efficacy.
There were three main problems with differentiating the efficacy and longevity of the 5 th generation SiQuats when compared to previous generations of individual SiQuats; a. In

Results using 5th generation SiQuats
Whilst we do not yet fully understand the impact of persistent disinfectant technologies on the number and type of surgical site infections (SSI), the type of organism as opposed to the species of organism infecting a wound is rarely seen to be an issue in most studies. It must be questioned as to why not? Surely the type of organism, will give an indication of where it came from, whether from the air, surfaces, or the skin of the operating staff. Species alone does in some respects give an indication, but genetic sequencing would give us a much better idea of the source of the organism [8].
In early 2018 over a 3-month period, a problem appeared in a specialist orthopaedic surgery unit, where 252 primary joint replacements were completed. 115 were hip replacements with 137 knee replacements. The SSI rates for each were hips 6.1% and knees 5.8%. Prior to this, the SSI rates had been below 0.5% for both types of surgery. The spike in infection rates was of great concern to all working in the unit. It was felt that the environmental microbial contamination must be to blame, although swabbing and standard culture produced no conclusive results. Using standard culture techniques, no relationship could be found between bacteria in the air or on surfaces and those colonising the surgical wounds. After swab testing using the BSRMA technique [8], one of the operating rooms was treated with a 5 th generation SiQuat, and one was not.
The standard daily cleaning regime continued, and after the first week the 2nd room was then treated. As the BSRMA tests had revealed a similar number of bacteria left alive after cleaning with hypochlorite, a species study showed a streptococcus that was resistant to hypochlorite (this result was not available until Friday of the first week).

Figure 1
BSRMA surface testing continued at various times of the day, most notably, prior to operating lists commencing each morning.
The Veri Quat tests (Aqua tests) were also used to verify the presence of the SiQuats, and this testing continued for 6 months after treatment. Over the next 6 months 593 primary joint replacements were undertaken (294 hips, 299 knees); SSI rates were reduced to zero. Whilst there can be no doubt that the Hawthorn effect used in Goodhearts law [1] had some part to play in the reduction, most notably a further 6 months later the Veri Quat tests started to show that the SiQuat was beginning to wear away, and infection rates began to rise again. Over that 6 months period (

Results
The following are a selection of test results of 5 th generation Si-Quats, as compared to more widely used disinfecting chemistries using the BSRMA surface tests.

Hands Sanitisers
The graph below, shows the results of CFU counts on hands when comparing, washing with soap and water, alcohol 70% gel, alcohol 70% in water, Clinisept and a 5 th generation SiQuat. Each group had 100 participants (200 hands), and the counts were averaged for each participant, and then in each group (Figure 2).
There are now, numerous papers describing the poor results of bioburden on hands after using alcohol on its own [1,12,13], yet it is still the number one choice of hand sanitiser in most healthcare facilities around the world. It is clear from the above results, and from numerous papers, that the effect of alcohol is limited to both time and species kill (Enterococcus, Norovirus etc). The fact that it also causes a dominant species change from Staphylococcus epidermidis to a much more pathogenic Bacillus cereus is an added cause of great concern [12]. Again, because hospitals do not routinely test surfaces for numbers or species of bacteria (and if they do, they rarely publish the results), we have no way of knowing how this negative effect on hands is affecting the surfaces in hospitals.

Family Doctors Surgery
Swab samples were taken from 6 separate high touch, high risk surfaces, in a GP Practice. Prior to testing, standard cleaning was performed daily and all high touch surfaces were cleaned with "allpurpose" disinfectant wipes. After the initial testing, a 5 th generation SiQuat was introduced and applied once every 30 days. Standard cleaning was performed daily using only a mild detergent (no disinfectant) to remove surface dust, dirt and debris ( Figure 4).

Figure 4
In the home For many years, there has been an understanding that that food chopping boards were less contaminated if wood were chosen as the material instead of plastic. The following are the results of BSR-MA testing on these types of chopping boards ( Figure 5).  Candida auris is causing a new and deadly fungal infection that it is spreading across the United States. The only types of skin and surface disinfectants currently available that are proven to kill all of these microbes are the 5th generation SiQuats. There are two final points to make, without proper guidance on both type and frequency of surface and skin testing, it is difficult to see how healthcare systems around the world will reduce infection rates. It would also seem pointless to spend enormous amounts of money on the development of new antibiotics, to see resistance to them emanating at least in part from the poor choice and/ or use of surface and skin disinfectants.