Biology in the News Explained

Stop using antibacterial soaps now. Really.

In recent years, there has been a small bit of backlash against the ubiquitous use of antibacterial soaps. Indeed, research beginning in 2002 has continued to confirm that based on both effectiveness and potential negative side effects, there really is no reason to use these soaps and plenty of reasons not to.

The active antibacterial agent in question is triclosan. The only real question that can result from numerous scientific studies about triclosan is whether or not its potential negatives are strong enough to stop using it. (Indeed, the only piece (opinion) questioning the validity of the research showing both potential resistance problems and toxic byproducts of triclosan (Swofford, 2005) was written by a member of the soap industry.) However, given unambiguous results showing that soap containing triclosan is indistinguishable in its effectiveness against bacteria as regular soap (and, frankly, given that most illnesses most household users of antibacterial soaps are concerned about are actually caused by viruses, which do not respond to antibacterials) any potentially negative side-effects of its use should be unacceptable.

Here is the problem. Humans are dumping all kinds of chemicals into our (and other organisms’) water supply, that are not removed during sewage treatment (even when the water properly goes through sewage treatment). Among these is triclosan (Gomez et al., 2007), which has been found in large proportions of human urinary samples (Calafat et al., 2008). Not only do we know nothing about how ingesting all these various chemicals may be affecting us over the long term, we cannot begin to know the complex ways in which they are interacting with each other to create new, and potentially more toxic compounds. Both laboratory (DeLorenzo et al., 2008) and field research (Kinney et al., 2008) suggests that triclosan bioaccumulates, which means its concentration could increase up the food chain (the same phenomenon responsible for the crash of bald eagle populations a few decades ago, due to DDT). Other laboratory studies suggest that it reacts with light and chlorine (ubiquitous in our drinking water) to form types of dioxin, a toxic compound (Sanchez-Prado et al., 2006). These studies are just scratching the surface of potential interactions between triclosan and other ubiquitous pharmaceuticals such as painkillers and sex hormones from birth control. Laboratory studies have also demonstrated that bacteria such as E coli and Salmonella can become resistant to triclosan (Yazdankhah et al., 2006).

Proponents of antibacterial soaps claim that none of these studies have shown that toxicity is common in the field, and resistance also has only been shown in the laboratory. So, let’s get this straight: we should continue to use this completely useless agent, because research has not yet shown that it is definitely harmful in the short term. Brilliant reasoning. The abstract of a recent review paper sums up the state of our knowledge quite nicely:

Abstract (Aiello et al., 2007)
Background. Much has been written recently about the potential hazards versus benefits of antibacterial (biocide)-containing soaps. The purpose of this systematic literature review was to assess the studies that have examined the efficacy of products containing triclosan, compared with that of plain soap, in the community setting, as well as to evaluate findings that address potential hazards of this use-namely, the emergence of antibiotic-resistant bacteria. Methods. The PubMed database was searched for English-language articles, using relevant keyword combinations for articles published between 1980 and 2006. Twenty-seven studies were eventually identified as being relevant to the review. Results. Soaps containing triclosan within the range of concentrations commonly used in the community setting (0.1%-0.45% wt/vol) were no more effective than plain soap at preventing infectious illness symptoms and reducing bacterial levels on the hands. Several laboratory studies demonstrated evidence of triclosan-adapted cross-resistance to antibiotics among different species of bacteria. Conclusions. The lack of an additional health benefit associated with the use of triclosan-containing consumer soaps over regular soap, coupled with laboratory data demonstrating a potential risk of selecting for drug resistance, warrants further evaluation by governmental regulators regarding antibacterial product claims and advertising. Further studies of this issue are encouraged.

If the only weapon we have to stop this idiotic dumping of even a potentially harmful chemical into our water systems and environment is consumer demand, then let’s use it. Stop using anti-bacterial soaps now, and maybe the fools producing them will stop, because it is no longer profitable.

References

Aiello, A.E., Larson, E.L. & Levy, S.B. (2007) Consumer antibacterial soaps: Effective or just risky? Clinical Infectious Diseases, 45:S137-S147.

Calafat, A.M., Ye, X., Wong, L.Y., Reidy, J.A. & Needham, L.L. (2008) Urinary concentrations of Triclosan in the US population: 2003-2004. Environmental Health Perspectives, 116:303-307.

DeLorenzo, M.E., Keller, J.M., Arthur, C.D., Finnegan, M.C., Harper, H.E., Winder, V.L. & Zdankiewicz, D.L. (2008) Toxicity of the antimicrobial compound triclosan and formation of the metabolite methyl-triclosan in estuarine systems. Environmental Toxicology, 23:224-232.

Gomez, M.J., Bueno, M.J.M., Lacorte, S., Fernandez-Alba, A.R. & Aguera, A. (2007) Pilot survey monitoring pharmaceuticals and related compounds in a sewage treatment plant located on the Mediterranean coast. Chemosphere, 66:993-1002.

Kinney, C.A., Furlong, E.T., Kolpin, D.W., Burkhardt, M.R., Zaugg, S.D., Werner, S.L., Bossio, J.P. & Benotti, M.J. (2008) Bioaccumulation of pharmaceuticals and other anthropogenic waste indicators in earthworms from agricultural soil amended with biosolid or swine manure. Environmental Science & Technology, 42:1863-1870.

Sanchez-Prado, L., Llompart, M., Lores, M., Fernandez-Alvarez, M., Garcia-Jares, C. & Cela, R. (2006) Further research on the photo-SPME of triclosan. Analytical And Bioanalytical Chemistry, 384:1548-1557.

Swofford, W. (2005) Triclosan research misreported? Environmental Science & Technology, 39:271A-272A.

Yazdankhah, S.P., Scheie, A.A., Hoiby, E.A., Lunestad, B.T., Heir, E., Fotland, T.O., Naterstad, K. & Kruse, H. (2006) Triclosan and antimicrobial resistance in bacteria: An overview. Microbial Drug Resistance-Mechanisms Epidemiology and Disease, 12:83-90.

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25 Responses to “Stop using antibacterial soaps now. Really.”

  1. Anonymous says:

    Last I heard, no scientific study had ever shown that all types of dioxin are even remotely toxic to humans in less than an absurd megadose. The WHO made a pretty wild determination a few years back on one particular type of dioxin, but that type isn’t implicated by antibacterial soap.

    You lose all scientific credibility when you jump on Greenpeace’s dioxin bandwagon without doing even basic background research.

  2. Anonymous says:

    Sorry, you lost it when you repeated the old claim that DDT causes bird death, or shell thinning, or whatever. That tired old story has long since been debunked, and Rachael Carson’s “research” is crap.

  3. Lexingtonian says:

    No way, Jozay. It was bad enough when the Germ Nannies and their greenie pals put the kibosh on PhisoHex, my all time favorite shower soap.

    They’ll get my Safeguard when they pry it from my warm, wet hand.

  4. Anonymous says:

    “given unambiguous results showing that soap containing triclosan is indistinguishable in its effectiveness against bacteria as regular soap”

    Why no citation to back that assertion?

  5. Dave Mastio says:

    Wouldn’t a better solution be for the manufacturers of regular soap to market it as antimicrobial (assuming your assertion that it is just as effective as soap with the additive) and sell it for the same price as current “anti-microbial” soaps with the expense of the additive going to profit instead?

    Maybe they could label it “organic” anti-microbial and sell plain soap for even more.

  6. Anonymous says:

    You can take your precautionary principle and cram it. “I can imagine some basis for X to be dangerous, even in the complete absence of evidence, so let’s ban X” is the thought process of those who don’t vaccinate their children. Is that the company you want to be in? Cite some research showing harm, then we’ll talk.

  7. Orion says:

    Something that’s always bothered me about antibacterial soaps and scrubs: They all proclaim they kill “99.9% of germs on contact!”, right?

    What does that say about the 0.01% of germs they DON’T? By killing off their competition, aren’t we really just encouraging these Superbugs to take over?

  8. Shannon Love says:

    Laboratory studies have also demonstrated that bacteria such as E coli and Salmonella can become resistant to triclosan

    On this basis, you should stop washing your hands all together because microbes will eventually evolve a resistance to soap and water.

    Life evolves constantly. Why are people so terrified when microbes inevitable evolve resistance to antibiotics, disinfectants etc? It’s always going to happen. Whenever we make life difficult for the microbes that try to kill us we create selection pressure that drive the evolution of a counter on the part of the microbes. That just how it works.

    Resistant microbes are no more dangerous than non-resistant, they merely evade whatever we use to try to kill them. They do aquire new superpowers that allow them to wreck the body faster.

  9. Shannon Love says:

    Sorry, that last sentence should have read “They don’t aquire new superpowers that allow them to wreck the body faster.

  10. Richard says:

    ” … we cannot begin to know the complex ways in which they are interacting with each other to create new, and potentially more toxic compounds.”

    This is just like the global warming debate. You have no frickin’ idea, and so you *assume* all possible consequences are (a) bad, and (b) are really happening. What happened to practicing science in this nation?

  11. Justin says:

    If triclosan is not helpful, and possibly harmful, it seems only natural to turn to dental research. Look at your bottle of toothpaste, that has a higher concentration and pretty much everyone uses. Does this research say it has an anti-bacterial effect?

    Personally, triclosan doesn’t keep me up at night, and I don’t think it should keep anyone else awake either. That said, if it’s useless, we could buy cheaper soap, which would be a universal good.

  12. CastoCreations says:

    “What does that say about the 0.01% of germs they DON’T? By killing off their competition, aren’t we really just encouraging these Superbugs to take over?”

    My reason against using anti-bacterial soaps is this – it kills bacteria right? So it is safe to assume that it kills the good with the bad.

    It’s the same with all the over prescribing of antibiotics. The bugs become immune to the effects.

    Give me plain old soap.

  13. SgtP_USMC says:

    How about this for a logical extension to your hyperventillating use of the precautionary principle:

    You don’t know if you will kill someone someday in a car or by some other means, so you should kill yourself now, after all, tomorow might be too late to save that unfortunate soul…

    Good grief, don’t you people ever get tired of your Chicken Little act?

  14. Anonymous says:

    Ordinary soap does not kill bacteria. Through simple chemical and mechanical processes, bacteria and their spores are removed from hands by washing. Antibacterial agents in soaps are completely useless, and could possibly lead to resistant strains of bacteria.

    Don’t take my word for it, read this instead:
    http://www.sciencedaily.com/releases/2007/09/070920111350.htm

    If average folks knew more about biology and chemistry, antibacterial soaps wouldn’t exist as there would be no demand for them. Using a chemical additive that has no positive effects makes no sense.

  15. Vaelin says:

    I don’t get why there’s so much hating on bacteria anyway. They’re a very important part of a healthy human. If you start killing them all off you can throw off the balance of your microflora… messing with your digestion, skin, and/or immune system.

    Bacteria can develop resistance to a specific antibiotic rendering the treatment useless when it’s needed in a truly serious case. This doesn’t mean you should stop washing your hands, regular soap is simply a surfactant that grabs the dirt and oil and bacteria and just about anything else not tied down to your skin, and binds it to water so it can wash it off easily. I’m not sure if bacteria can become resistant to that.

    This isn’t some fear-mongering ‘don’t vaccinate your kids’ claim. There’s lots of good science giving evidence that these soaps and cleaners are just a waste of time and money.

    PS. ‘Average folks’ don’t want to know more about biology and chemistry… they want someone to tell them what to do and think in such a way that when they do it they feel good. That anti-bacterial label makes people feel safer, and that’s why it sells more. It’s about marketing and politics (money), not science.

  16. SwissArmyD says:

    “It’s about marketing” -Vaelin

    THIS is the only thing that matters here. This is also the only reason you will have to stop using the stuff in the absense of concrete harm. You mentioned DDT, but failed to mention that it’s unilateral ban worldwide, has caused more human misery than any other act. INSTEAD of deciding when it should be used, and when not, the whole thing was simply shot down.

    This is the same thing. Triclosan probably has worthwhile uses. What makes it not worthwhile for soap is that it isn’t needed/effective. If the primary effect of soap is as surfacant, and it isn’t ON your skin long enough to kill anything…

    Well, now you have the thrust to get the stuff out of soap. You have to realize there are ways to get things out of the marketplace that don’t involve regulation or new laws.

    Going on, blah, blah, blah, about the chemistry… Has anyone actually studied the effectiveness at the microscopic level on hands? You’d think that would be where the scientific method would come in handy…

    People, us commoners, hate being told what to do, but we will vote with our feet if something isn’t worth it.

  17. David says:

    “Well, now you have the thrust to get the stuff out of soap. You have to realize there are ways to get things out of the marketplace that don’t involve regulation or new laws.”

    I believe that was part of the purpose of this post. He encouraged us to tell the marketers of soap we don’t want needless additives in our soap by purchasing the additive free form. This is different from telling us to ban it from the world and stop it from being used for worthwhile purposes. Chill.

  18. Biotunes says:

    What’s interesting about most of these comments is how much it shows selective reading based on pre-existing biases (something I will continue to watch out for in myself). For example, I made no comment on the question of whether or not DDT should be banned; I simply noted that like many chemicals it bioaccumulates, causing harm to animals higher on the food chain, which is a scientific fact, even if you can find someone who says it’s not. (Evolution is a scientific fact as well, even though many people claim it is not. Their claims do not undermine the science in any way.)

    I also cited Aiello et al, which make it clear in their abstract that scientific research (not laboratory, but field studies with actual users) shows no added benefit of using triclosan in soap.

    Of course there will always be people who think it is their god-given right to pollute as they see fit. If that is your point of view, perhaps a visit to some Chinese urban areas would alter it. Perhaps not.

  19. Anonymous says:

    Triclosan is a marketing gimmick. I remember when we started making triclosan liquid soaps in the early to mid 90′s. The head chemist and I just shrugged or shoulders.

    Dear consumers, it’s a stupid useless product that can only lead to possible resistance.

    Your message is correct. Too bad you mired in silly references to bald eagles and dioxins.

  20. Anonymous says:

    Stick with music – repeating the old tropes about DDT and dioxin suggests you have no talent for the scientific world.

  21. Anonymous says:

    Oh, fer Christ sakes. If everything claimed in “studies” by the “scientific community” were true, we’d all be extinct by now. It’s amusing to see all of the chemicals and foods they say are bad for us, and then do a 180 degree turn and redact everything the said. Frickin’ eggheads.

  22. Anonymous says:

    “Of course there will always be people who think it is their god-given right to pollute as they see fit.”

    Of course, some folks think it is their God-given right to dictate and control the actions of their fellow citizens as they see fit based on nothing more than reading a press release from a advocacy group.

    And they get a little testy when they’re called on the B.S. they are using to support their hysterical calls for boycotts.

    How about this, Chicken Little, withdraw your nose from everyone else’s business and try smelling your own.

    Seriously.

  23. Richard says:

    Of course there will always be people who think it is their god-given right to pollute as they see fit.

    I’ve heard your type before and your challenge is that you detest the fact that you even exist. This might surprise you but it really shouldn’t. For folks like you existence itself is pollution. Individuals like you go to enormous lengths to make yourself as small and environmentally meaningless (think “small carbon footprint”) as you can. It’s like you feel you don’t belong, you have no right to impact anything. It’s an amazingly self-loathing religion you practice. Must be awful stressful.

  24. Anonymous says:

    Here at work we have a system for safety “close calls”, basically, you submit a safety hazard you’ve noticed , and it will probably get taken care of before someone does get hurt, not a bad idea, in theory. well, some poorly educated fool (scary, since our industry is medical diagnostics devices) submitted one saying that we needed antibacterial soaps in the bathrooms, which the safety department dutifully had facilities put in. Not long later, anyone with a a microbiology background submitted more close calls demanding that they be removed due to resistance hazards. Which happened. The whole situation is just so corporate-level stupid it almost makes me cry.

  25. Rev. K. L. Maines says:

    JUNE-JULY 2008 MESSAGE

    Greetings! Since the beginning of history, God has been revealing events to come to His people. On June 19, 2008 the Lord strongly impressed on me the need for His people to educate themselves concerning the products they buy and consume. I am writing this because I believe the Lord is warning His people of days to come. There are certain chemicals found in everyday products that are going to wreak havoc on our environment and well-being. One such chemical is Triclosan. Triclosan is an excellent product when used to protect healthcare providers treating patients with contagious diseases, such as medical professionals who are working in third-world countries during serious disease outbreaks. It can be a lifesaver to medical workers under those circumstances; however, the use of triclosan has not been tightly regulated, and it is now being overused in many products you and I use every day.

    The warning cry is that this chemical and similar compounds will end up killing us if we continue to misuse and overuse them. Overuse puts us all at risk at contracting antibiotic-resistant superbugs, and individually, triclosan-based products weaken our immune systems. Please do not use or purchase triclosan-based products.

    I hope you will take the time to read this brief message about the dangers of the chemical Triclosan and similar tricloson-like products (such as Triclocarban and quaternary ammonium compounds):

    *Triclosan is found in hundreds of common everyday products, including nearly half of all commercial soaps.

    *It is used so frequently that triclosan has made its way into the human body – a Swedish study found triclosan in human breast milk in three out of five women.

    *Numerous studies have found that triclosan promotes the emergence of bacteria that are resistant to antibiotics.

    *Dioxin, a highly carcinogenic, endocrine disrupting compound, may be formed during the manufacturing process of triclosan, and thus is a likely contaminant. More alarmingly, researchers found that when sunlight is shined on triclosan in water and on fabric, a portion of triclosan is transformed into dioxin. Because of its ubiquitous nature, the conversion to dioxin is of major concern.

    *Triclosan is one of the most frequently detected compounds in rivers, streams, and other bodies of water, often in high concentrations. Triclosan is highly toxic to a number of different types of algae. Since algae are the primary producers in many aquatic ecosystems, high levels of triclosan may have destructive effects on aquatic ecosystems.

    *The American Medical Association took an official stance against adding antimicrobials to consumer products in 2000 and has repeatedly urged the Food and Drug Administration (FDA) to better regulate these chemicals.
    For more information google.com: “Triclosan.”

    The single most important thing you can do in your life is to establish a personal relationship with Jesus, in which He is your personal Lord and Savior. If you have not yet accepted Jesus into your life, you can do so now, by praying this prayer:

    “Father, I know that I have broken your laws and my sins have separated me from you. I am truly sorry, and now I want to turn away from my past sinful life toward you. Please forgive me, and help me avoid sinning again. I believe that your son, Jesus is the Messiah and He died for my sins, was resurrected from the dead, is alive, and hears my prayer. I invite Jesus to become the Lord of my life, to rule and reign in my heart from this day forward. Please send your Holy Spirit to help me obey You, and to do Your will for the rest of my life. Amen.”

    Blessings to you,

    Rev. K. L. Maines

    Rev. K. L. Maines

    Duly Ordained Pastor/Evangelist

    For Prayer email me at : RevMaines@aol.com

    Triclosan is found in the following products:
    Soaps:
    * Dial® Liquid Soap* Softsoap® Antibacterial Liquid Hand Soap* Tea Tree Therapy™ Liquid Soap* Provon® Soap* Clearasil® Daily Face Wash* Dermatologica® Skin Purifying Wipes* Clean & Clear Foaming Facial Cleanser* DermaKleen™ Antibacterial Lotion Soap* Naturade Aloe Vera 80® Antibacterial Soap* CVS Antibacterial Soap* pHisoderm Antibacterial Skin Cleanser
    Dental Care:
    * Colgate Total®; Breeze™ Triclosan Mouthwash* Reach® Antibacterial Toothbrush* Janina Diamond Whitening Toothpaste
    Cosmetics:
    * Supre® Café Bronzer™* TotalSkinCare Makeup Kit* Garden Botanika® Powder Foundation* Mavala Lip Base* Jason Natural Cosmetics* Blemish Cover Stick* Movate® Skin Litening Cream HQ* Paul Mitchell Detangler Comb* Revlon ColorStay LipSHINE Lipcolor Plus Gloss* Dazzle
    Deodorant:
    * Old Spice High Endurance Stick Deodorant* Right Guard Sport Deodorant* Queen Helene® Tea Trea Oil Deodorant and Aloe Deodorant* Nature De France Le Stick Natural Stick Deodorant* DeCleor Deodorant Stick* Epoch® Deodorant with Citrisomes* X Air Maximum Strength Deodorant
    Other Personal Care Products:
    * Gillette® Complete Skin Care MultiGel Aerosol Shave Gel* Murad Acne Complex® Kit®* Diabet-x™ Cream* T.Taio™ sponges and wipes* Aveeno Therapeutic Shave Gel
    First Aid:
    * SyDERMA® Skin Protectant plus First Aid Antiseptic* Solarcaine®* First Aid Medicated Spray;Nexcare™ First Aid* Skin Crack Care* First Aid/Burn Cream* HealWell® Night Splint* 11-1X1: Universal Cervical Collar with Microban
    Kitchenware:
    * Farberware® Microban Steakknife Set and Cutting Boards* Franklin Machine Products FMP Ice Cream Scoop SZ 20 Microban* Hobart Semi-Automatic Slicer* Chix® Food Service Wipes with Microban* Compact Web Foot® Wet Mop Heads
    Computer Equipment:
    * Fellowes Cordless Microban Keyboard and Microban Mouse Pad
    Clothes:
    * Teva® Sandals* Merrell Shoes* Sabatier Chef’s Apron* Dickies Socks* Fruit of the Loom Socks* Biofresh® Socks
    Children’s Toys:
    * Playskool® :o Stack ‘n Scoop Whaleo Rockin’ Radioo Hourglasso Sounds Around Drivero Roll ‘n’ Rattle Ballo Animal Sounds Phoneo Busy Beads Palo Pop ‘n’ Spin Topo Lights ‘n’ Surprise Laptop
    Other:
    * Bionare® Cool Mist Humidifier* Microban® All Weather Reinforced Hose* Thomasville® Furniture* Deciguard AB Ear Plugs* Bauer® 5000 Helmet* Aquatic Whirlpools* Miller Paint Interior Paint* QVC® Collapsible 40-Can Cooler* Holmes Foot Buddy™ Foot Warmer* Blue Mountain Wall Coverings* California Paints®* EHC AMRail Escalator Handrails* Dupont™ Air Filters* Durelle™ Carpet Cushions* Advanta One Laminate Floors* San Luis Blankets* J Cloth® towels* JERMEX mops

    Source: BeyondPesticides.org

    References taken from the CDC website:http://www.cdc.gov/ncidod/eid/vol7no3_supp/levy.htm

    1Neu HC. The crisis in antibiotic resistance. Science 1992;257:1064-73.

    2.Levy SB. The antibiotic paradox. How miracle drugs are destroying the miracle. New York: Plenum; 1992.

    3.McMurry LM, Oethinger M, Levy SB. Triclosan targets lipid synthesis. Nature 1998;394:531-2.

    4.McMurry LM, Oethinger M, Levy SB. Overexpression of marA, soxS or acrAB produces resistance to triclosan in Escherichia coli. FEMS Microbiol Lett 1998;166:305-9.

    5.Suller MT, Russell AD. Triclosan and antibiotic resistance in Staphylococcus aureus. J Antimicrob Chemother 2000;46:11-8.

    6.Hoang TT, Schweizer HP. Characterization of Pseudomonas aeruginosa enoyl-acyl carrier protein reductase (FabI): a target for the antimicrobial triclosan and its role in homoserine lactone synthesis. J Bacteriol 1999;181:5489-97.

    7.Russell AD, Tattawasart U, Maillard J-Y, Furr JR. Possible link between bacterial resistance and use of antibiotics and biocides. Antimicrob Agents Chemother 1998;42:2151.

    8.Mereghetti L, Quentin R, Marquet-van der Mee N, Audurier A. Low sensitivity of Listeria monocytogenes to quaternary ammonium compounds. Appl Environ Microbiol 2000;66:5083-6. 9.*McMurry LM, McDermott PF, Levy SB. Genetic evidence that InhA of Mycobacterium smegmatis is a target for triclosan. Antimicrob Agents Chemother 1999;43:711-3.

    10.*Heath RJ, Roch CO. A triclosan-resistant bacterial enzyme. Nature 2000;406:145-6.

    11.Radosti-Slater C, Aller GV, DeWolf W, Greenwood R, Nicholas R, Payne D, et al. Mode of action of triclosan in S. aureus [abstract]. American Society for Microbiology annual meeting, Los Angeles, California, 2000 May 21-24. Abstract 101, p. 26.

    12.Meade MJ, Callahan TM. Unique mechanism of triclosan resistance identified in environmental isolates [abstract]. American Society for Microbiology annual meeting, Los Angeles, California, 2000 May 21-24. Abstract 73, p. 19.

    13.Suzangar S, Allison DG, Gilbert P. An evaluation of biocide-containing materials for their surface colonization-resistance and other properties [abstract] American Society for Microbiology annual meeting, Los Angeles, California, 2000 May 21-24. Abstract 53, p. 17.

    14.Alekshun MN, Levy SB. The mar regulon: multiple resistance to antibiotics and other toxic insults. Trends Microbiol 1999;7:410-3.

    15.Barbosa T, Levy SB. Differential expression of over 60 chromosomal genes in Escherichia coli by constitutive expression of MarA. J Bacteriol 2000;182:3467-74.

    16.Chuanchuen R, Beinlich K, Schweizer HP. Multidrug efflux pumps and triclosan resistance in Pseudomonas aeruginosa [abstract]. American Society for Microbiology annual meeting, Los Angeles, California, 2000 May 21-24. Abstract 31, p. 8.

    17.Akimitsu N, Hamamoto H, Inoue R, Shoji M, Akamine A, Takemori K, et al. Increase in resistance of methicillin-resistant Staphylococcus aureus to beta-lactams caused by mutations conferring resistance to benzalkonium chloride, a disinfectant widely used in hospitals. Antimicrob Agents Chemother 1999;43:3042-3.

    18.*Strachan DP. Hay fever, hygiene, and household size. BMJ 1989;299:1259-60.

    19.*Braun-Fahrl*nder CH, Gassner M, Grize L, Neu U, Sennhauser FH, Varonier HS, et al. Prevalence of hay fever and allergic sensitization in farmer’s children and their peers living in the same rural community. Clin Exp Allergy 1999;29:28-34.

    20.*Rook GAW, Stanford JL. Give us this day our daily germs. Immunol Today 1998;19:113-6. 21.*Matricardi PM, Rosmini F, Riondino S, Fortini M, Ferrigno L, Rapicetta M, et al. Exposure to foodborne and orofecal microbes versus airbone viruses in relation to atopy and allergic asthma: epidemiological study. BMJ 2000;320:412-7.

    22.*Aaby P, Shaheen SO, Heyes CB, Goudiaby A, Hall AJ, Shiell AW, et al. Early BCG vaccination and reduction in atopy in Guinea-Bissau. Clin Exp Allergy 2000;30:644-50.

    23.*Folkerts G, Walzl G, Openshaw PJM. Do common childhood infections “teach” the immune system not to be allergic? Immunol Today 2000;21:118-20. }

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