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When did the doctors become fomites?

2011; Elsevier BV; Volume: 17; Issue: 6 Linguagem: Inglês

10.1111/j.1469-0691.2011.03499.x

1469-0691

Evelina Tacconelli,

Infection Control and Ventilation

The word ‘fomites’ was introduced early in the 19th century from the Latin fomes, to indicate objects or materials that are likely to carry infection, such as clothes, utensils and furniture. Indeed, the role of the environment as a likely significant contributor to hospital-acquired infections (HAI) was proposed even earlier [1Gerken A Cavanagh S Winner HI Infection hazard from stethoscopes in hospital.Lancet. 1972; i: 1214-1215Abstract Scopus (39) Google Scholar]. In 1873, Louis Pasteur in his lecture to the Academie de Médecine noted that, even after cleaning his hands and using heated sponges, he still had to fear germs surrounding patients’ beds [2Birch B Birmingham C Pasteur’s fight against microbes (Science stories series). Ed. Barrons, New York1996Google Scholar]. Today, headlines such as ‘Hospitals criticized over hygiene’ (BBC News, 20th December 2010) are common in the news and instigate a negative general public perception that fomites such as uniforms or stethoscopes represent an infection risk for hospitalized patients. Political interest has obviously been raised. An interesting example is the ‘bare below the elbows’ dress code for physicians that was promised to be introduced by the then Secretary of State for Health, Alan Johnson, in 2007, in all acute trusts in England, despite lack of conclusive evidence that white coats pose a significant threat for the spread of HAI [3British Medical Association Uniform and dress code for doctors.Available at: http://www.bma.org.uk/employmentandcontracts/working_arrangements/CCSCdresscode051207.jspDate: 6 December 2007Google Scholar]. Clear evidence does exist that pathogenic bacteria can survive for months in the hospital environment and can be isolated on clinical equipment, as well as on general surfaces, especially those close to the patient's area, such as curtains, beds, lockers and over-bed tables [4Kramer A Schwebke I Kampf G How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.BMC Infect Dis. 2006; 6: 130-138Crossref PubMed Scopus (1375) Google Scholar, 5Boyce JM Potter‐Bynoe G Chenevert C et al.Environmental contamination due to methicillin‐resistant Staphylococcus aureus: possible infection control implications.Infect Control Hosp Epidemiol. 1997; 18: 622-627Crossref PubMed Google Scholar]. Before contact precautions are implemented, methicillin-resistant Staphylococcus aureus (MRSA) carriers may have already contaminated their environment with MRSA. A recent observational study showed that 18% and 35% of MRSA-colonized patients had contaminated the surrounding environmental surfaces 25 h and 33 h after admission, respectively [6Chang S Sethi AK Stiefel U et al.Occurrence of skin and environmental contamination with methicillin‐resistant Staphylococcus aureus before results of polymerase chain reaction at hospital admission become available.Infect Control Hosp Epidemiol. 2010; 31: 607-612Crossref PubMed Scopus (28) Google Scholar]. Cross-transmission between patients may occur via the hands of healthcare workers after they have touched contaminated environmental surfaces [5Boyce JM Potter‐Bynoe G Chenevert C et al.Environmental contamination due to methicillin‐resistant Staphylococcus aureus: possible infection control implications.Infect Control Hosp Epidemiol. 1997; 18: 622-627Crossref PubMed Google Scholar, 7Dancer SJ Importance of the environment in methicillin‐resistant Staphylococcus aureus acquisition: the case for hospital cleaning.Lancet Infect Dis. 2008; 8: 101-113Abstract Full Text Full Text PDF PubMed Scopus (336) Google Scholar]. There is also some evidence that cleaning removes pathogenic bacteria from the hospital environment with benefit for the patients, especially in epidemic settings. Rampling et al. [8Rampling A Wiseman S Davis L et al.Evidence that hospital hygiene is important in the control of methicillin‐resistant Staphylococcus aureus.J Hosp Infect. 2001; 49: 109-116Abstract Full Text PDF PubMed Scopus (203) Google Scholar] documented an outbreak of MRSA in a urology ward, which was resistant to the promotion of hand hygiene and contact isolation; it ended only after doubling the number of ward-cleaning hours. However, conclusive proof of the link between environmental contamination and rate of HAI is still lacking. Wilson et al. [9Wilson AP Hayman S Whitehouse T et al.Importance of the environment for patient acquisition of methicillin‐resistant Staphylococcus aureus in the intensive care unit: a baseline study.Crit Care Med. 2007; 35: 2275-2279Crossref PubMed Scopus (24) Google Scholar] sampled six environmental sites around randomly selected patients in intensive care units plus two communal sites during periods when MRSA-colonized patients were isolated or not. Study results showed that, although MRSA-colonized patients frequently contaminated their environment, transmission of MRSA from the environment to the patient was not commonly identified [9Wilson AP Hayman S Whitehouse T et al.Importance of the environment for patient acquisition of methicillin‐resistant Staphylococcus aureus in the intensive care unit: a baseline study.Crit Care Med. 2007; 35: 2275-2279Crossref PubMed Scopus (24) Google Scholar]. The risk that personnel equipment (white coat, stethoscope, mobile phones, or pagers) used at point of care might be responsible or co-responsible for cross-transmission of pathogenic bacteria to patients was signalled early in the 1970s for the use of stethoscopes [1Gerken A Cavanagh S Winner HI Infection hazard from stethoscopes in hospital.Lancet. 1972; i: 1214-1215Abstract Scopus (39) Google Scholar]. In 1972, Gerken et al. [1Gerken A Cavanagh S Winner HI Infection hazard from stethoscopes in hospital.Lancet. 1972; i: 1214-1215Abstract Scopus (39) Google Scholar] demonstrated that coagulase-positive staphylococci were isolated from 21% of the stethoscopes in a British teaching hospital. The Centers for Disease Control and Prevention advises stethoscope cleanings between patient examinations and the use of dedicated room equipment for patients carrying a communicable disease and in isolation [10Sehulster L Chinn RY Center for Disease Control and Prevention HICPAC Guidelines for environmental infection control in healthcare facilities: recommendations of CDC and the Healthcare Infection Control Practice Advisory Committee (HICPAC).MMWR Recomm Rep. 2003; 52: 1-42PubMed Google Scholar]. However, compliance with those procedures is still very low. Whittington et al. [11Whittington AM Whitlow G Hewson D Thomas C Brett SJ Bacterial contamination of stethoscopes on the intensive care unit.Anaesthesia. 2009; 64: 620-624Crossref PubMed Scopus (54) Google Scholar] showed that while all the intensive care unit nursing staff reported cleaning stethoscopes at least daily, only one-third of medical staff, cleaned their stethoscope at best every month. To further increase the complexity of the problem recent advances in engineering have brought into hospitals a series of new technologies (smartphones, personal digital assistants, mobile phones) usually worn by the doctors, even when attending patients [12Singh S Acharya S Bhat M Rao SK Pentapati KC Mobile phone hygiene: potential risks posed by use in the clinics of an Indian dental school.J Dent Educ. 2010; 74: 1153-1158PubMed Google Scholar]. Interestingly, a market research study found that 65% of physicians in the USA believe that mobile computing devices pose significant risks for the spreading of pathogenic bacteria in hospitalized patients [13Davidson SJ Malkary G Dangerous Devices. Mobile computers can bring both information and infection to the point of care. January 9, 2008 in HHN’s Magazine online site (.available at: http://www.hhnmostwired.com/hhnmostwired_app/jsp/articledisplay.jsp?dcrpath=HHNMOSTWIRED/Article/data/Fall2007/080109MW_Online_Davidson&domain=HHNMOSTWIREDGoogle Scholar]. A systematic review on bacterial contamination of physicians’ mobile phones showed that 9–25% of mobile devices are contaminated with pathogenic bacteria. Levels of MRSA (0–10%), Acinetobacter species (1–12%) and other pathogens range widely according to the local ecology [14Brady RR Verran J Damani NN Gibb AP Review of mobile communication devices as potential reservoirs of nosocomial pathogens.J Hosp Infect. 2009; 71: 295-300Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar]. Ulger et al. sampled 200 mobile phones and the hands of 200 healthcare workers. In total, 94.5% of phones demonstrated evidence of bacterial contamination with different types of bacteria. MRSA was isolated in 13% of mobile phones and 10% of healthcare workers’ hands. Distributions of the microorganisms isolated from mobile phones were similar to those isolated from hands [15Ulger F Esen S Dilek A Yanik K Gunaydin M Leblebicioglu H Are we aware how contaminated our mobile phones with nosocomial pathogens?.Ann Clin Microbiol Antimicrob. 2009; 8: 7Crossref PubMed Scopus (100) Google Scholar]. What physicians are missing is evidence of a link between the colonization of mobile devices used in daily clinical life and rate of HAI. The lack of these data substantially contributes to the absence of compliance with existing, although limited, guidelines on the topic. This issue of Clinical Microbiology and Infection includes two papers that substantially add to the available evidence on the risks for infection control posed by doctors’ mobile devices. The first study is a prospective study investigating the potential of physicians’ writing pens as fomites for HAI. Clinical investigators received a new writing pen each day. The intervention group was randomly assigned to clean the pens between patients’ visits with an alcohol-based hand-sanitizing agent whereas the nonintervention group did not use the hand-sanitizing agent. Bacterial growth was significantly higher in the non-intervention group (92% vs 40%; 370 vs 130 CFU) [16Halton K Arora V Singh V et al.Bacterial colonization on writing pens touched by healthcare professionals and hospitalized patients with and without cleaning the pen with alcohol‐based hand sanitizing agent.Clin Microbiol Infect. 2011; 17: 868-869Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. The second study, a cross-sectional study, provides evidence on demographics and characteristics of mobile phone use by inpatients and microbiological contamination of phone surfaces. The majority of swabs taken from patients’ mobile phones were positive for microbial contamination and 12% grew bacteria known to cause HAI. Methicillin-susceptible S. aureus and MRSA contamination of mobile phones was associated with concomitant nasal colonization [17Brady RR Hunt AC Visvanathan A et al.Mobile phone technology and hospitalized patients: a cross‐sectional surveillance study of bacterial colonization, and patient opinions and behaviours.Clin Microbiol Infect. 2011; 17: 830-835Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar]. Meta-analysis clearly showed that the risk of infection is increased fourfold in subjects previously colonized with MRSA [18Safdar N Bradley EA The risk of infection after nasal colonization with Staphylococcus aureus.Am J Med. 2008; 121: 310-315Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar]. Available evidence is becoming more likely to link small portable devices to the spreading of pathogenic bacteria from doctors to patients. Major concerns, in my opinion, rely on the low compliance with the existing guidelines (as demonstrated by the low percentages of doctors regularly cleaning their hands or their stethoscopes) and on the lack of formal infection control policies for mobile devices in most hospitals. Specific addenda to prevention strategies should be planned according to local ecology and case-mix of the ward. Reinforcement of the importance of hand hygiene policy implementation would also play a pivotal role in relation to this issue. Protocols should be defined for the regular disinfection of computing devices with alcohol swabs, in particular if they are used at point of care. Patients might be involved in the prevention programme and ask their physicians to clean the stethoscope and not to use their mobile phone after cleaning their hands. Introduction of stethoscope covers should also be considered. Future studies need to be designed on strict collaboration between intelligence technology leaders and infection control officers to improve the evidence and to evaluate the benefit of such protocols on medical device colonization and rate of HAIs. No conflict of interest.