A quasi-experimental study on stethoscopes contamination with multidrug-resistant bacteria: Its role as a vehicle of transmission

Stethoscopes have been suggested to be a possible vector of contact transmission. However, only a few studies have focused on the prevalence of contamination by multidrug-resistant (MDR) bacteria and effectiveness of disinfection training to reduce. This study is to investigate the burden of stethoscope contamination with nosocomial pathogens and multidrug-resistant (MDR) bacteria and to analyze habit changes in disinfection of stethoscopes among healthcare workers (HCWs) before and after education and training. We performed a prospective pre and post quasi-experimental study. A total of 100 HCWs (55 doctors and 45 nurses) were recruited. HCWs were surveyed on their disinfection behavior and stethoscopes were cultured by pressing the diaphragm directly onto a blood agar plate before and after education on disinfection. Pulsed-field gel electrophoresis was performed to determine the relatedness of carbapenem-resistant Enterobacteriaceae. Most of the stethoscopes were contaminated with microorganisms before and after the intervention (97.9% and 91.5%, respectively). The contamination rate of stethoscopes with nosocomial pathogens before and after education was 20.8% and 19.2%, respectively. Stethoscope disinfection habits improved (55.1% vs 31.0%; p<0.001), and the overall bacterial loads of contamination were reduced (median colony-forming units, 15 vs 10; p = 0.019) after the intervention. However, the contamination rate by nosocomial pathogens and MDR bacteria did not decrease significantly. A carbapenemase-producing Klebsiella pneumoniae isolates from a stethoscope was closely related to isolates from the patients admitted at the same ward where the stethoscope was used. Stethoscopes were contaminated with various nosocomial pathogens including MDR bacteria and might act as a vehicle of MDR bacteria. Continuous, consistent education and training should be provided to HCWs using multifaceted approach to reduce the nosocomial transmission via stethoscopes.

Iranian Nurses' Knowledge of Neutropenia and Their Practice for Infection Prevention in Patients with Cancer

Neutropenia is one of cancer disease and treatment complications. Suboptimal management of neutropenia may interfere with cancer treatment and result in patient death. This study aimed to evaluate the nurses' knowledge of neutropenia and their practice for infection prevention in cancer patients in hospitals of Kerman, in southeast Iran. This study had a descriptive-analytical cross-sectional design. 203 nurses working in oncology, bone marrow transplantation, and medical wards of teaching hospitals of Kerman University of Medical Sciences participated in the study. A demographic questionnaire, a neutropenia knowledge questionnaire, and a checklist of nurses' care practice for infection control in cancer patients were used for data collection. The mean score of knowledge about neutropenia in nurses was 16.96 ± 2.8 which was moderate. Only 11.8% of the participants had good knowledge of neutropenia. The mean score of nurses' overall practice for infection control in cancer patients was 7.88 ± 4.63 which was moderate. Only 19.2% of nurses had a good care practice for infection control in patients with cancer. There was no significant correlation between nurses' knowledge of neutropenia and their practices for infection control in cancer patients (P = 0.05). Based on the results, nurses' knowledge of neutropenia and their practice for infection control in patients with cancer are not optimal. Therefore, in addition to promoting educational programs to enhance nurses' knowledge in this field, other factors affecting the promotion of nurses' practices in controlling infection in patients with cancer should also be identified.

Observation of stethoscope sanitation practices in an emergency department setting

BACKGROUND

Stethoscopes harbor pathogens that can be transferred to patients when proper sanitary measures are not taken. Our aim was to assess medical provider stethoscope cleaning and hand hygiene in an emergency department setting.

METHODS

The frequency and methods of stethoscope cleaning during and after provider-patient encounters were observed anonymously in an emergency department of the VA San Diego Healthcare System.

RESULTS

Among the total of 426 encounters, 115 (26.9%) involved the use of a personal stethoscope. In 15 of these 115 encounters (13.0%), the provider placed a glove over the stethoscope before patient contact. In 13 of these 115 encounters (11.3%), the provider cleaned the stethoscope with an alcohol swab after patient interaction. Stethoscope hygiene with water and a hand towel before patient interaction was observed in 5 of these 115 encounters (4.3%). Hand sanitizer use or handwashing was observed in 213 of the 426 encounters (50.0%) before patient interaction. Gloves were used before patient interaction in 206 of these 426 encounters (48.4%). Hand sanitizer or handwashing was used in 332 of the 426 encounters (77.9%) after patient interaction.

CONCLUSIONS

Rates of stethoscope and hand hygiene performance were lower than expected. Further investigation of stethoscope contamination and the associated risk of nosocomial infection are needed. Perhaps clearer guidelines on proper stethoscope cleaning would reduce this risk.

Bacterial Contamination of Military and Civilian Uniforms in an Emergency Department

INTRODUCTION

The emergency department is a fast-paced, high-volume environment, serving patients with diverse and evolving acuities. Personnel providing direct care are continually exposed to pathogenic microorganisms from patients and everyday surfaces, to which the organisms may spread. Indeed, hospital items-such as electronic devices, stethoscopes, and staff clothing-have demonstrated high rates of contamination. Despite this, policies governing the use, disinfection, and wear of various environmental surfaces remain relaxed, vague, and/or difficult to enforce. This study aimed to examine the bacterial contamination on 2 hospital uniform types in a large military hospital within the emergency department.

METHODS

Environmental sampling of military and civilian nursing staff uniforms was performed on 2 separate occasions. Emergency nurses wore hospital-provided freshly laundered scrubs on the first sampling day and home-laundered personally owned uniforms complicit with ED policy on the second sampling day. Samples were collected by impressing of contact blood agar growth medium at arrival (0 hour), 4 hours, and 8 hours of wear. Microbiological methods were used to enumerate and identify bacterial colonies.

RESULTS

Bacterial contamination of personally owned uniforms was significantly higher than freshly laundered hospital-provided scrubs on 4 different sampling sites and across the span of an 8-hour workday. No significant differences were observed between military and civilian personally owned uniforms. However, several risk factors for nosocomial infection were increased in the military subgroup.

DISCUSSION

Re-evaluating organizational factors (such as uniform policies) that increase the propensity for pathogenic contamination are critical for mitigating the spread and acquisition of multidrug-resistant organisms in the emergency department.

A meta-analysis of the rates of Staphylococcus aureus and methicillin-resistant S aureus contamination on the surfaces of environmental objects that health care workers frequently touch

BACKGROUND

Health care workers may potentially spread Staphylococcus aureus and methicillin-resistant S aureus (MRSA) to patients by contaminated high-touch items. We aimed to determine the pooled rates of S aureus and MRSA contamination and influencing factors.

METHODS

A literature search of the PubMed, ScienceDirect, Embase, Ovid, and Scopus databases was performed. Pooled contamination rates were determined using random effect models. Subgroup and meta-regression analyses were conducted to identify factors potentially influencing the rates of S aureus and MRSA contamination. Sensitivity and publication bias analyses were performed.

RESULTS

Thirty-eight studies were included in the meta-analysis. The pooled contamination rates were 15.0% (95% confidence interval [CI], 9.8%-21.1%) for S aureus and 5.0% (95% CI, 2.7%-7.7%) for MRSA. The subgroup analyses indicated that the pooled rate of S aureus contamination was significantly higher for studies conducted in South America, in developing countries, and during 2010-2015. The pooled rate of MRSA contamination was significantly higher for studies conducted in Africa. The meta-regression analysis suggested that the pooled rate of S aureus contamination was lower for studies conducted in developed countries (odds ratio, 0.664; 95% CI, 0.509-0.867; P = .004). No bias was found in the publication of the rates of S aureus and MRSA contamination.

CONCLUSIONS

S aureus and MRSA contamination statuses of high-touch items are worrisome and should be paid greater attention. Developing country status was a risk factor for S aureus contamination.

Healthcare Personnel Attire and Devices as Fomites: A Systematic Review

BACKGROUND Transmission of pathogens within the hospital environment remains a hazard for hospitalized patients. Healthcare personnel clothing and devices carried by them may harbor pathogens and contribute to the risk of pathogen transmission. OBJECTIVE To examine bacterial contamination of healthcare personnel attire and commonly used devices. METHODS Systematic review. RESULTS Of 1,175 studies screened, 72 individual studies assessed contamination of a variety of items, including white coats, neckties, stethoscopes, and mobile electronic devices, with varied pathogens including Staphylococcus aureus, including methicillin-resistant S. aureus, gram-negative rods, and enterococci. Contamination rates varied significantly across studies and by device but in general ranged from 0 to 32% for methicillin-resistant S. aureus and gram-negative rods. Enterococcus was a less common contaminant. Few studies explicitly evaluated for the presence of Clostridium difficile. Sampling and microbiologic techniques varied significantly across studies. Four studies evaluated for possible connection between healthcare personnel contaminants and clinical isolates with no unequivocally direct link identified. CONCLUSIONS Further studies to explore the relationship between healthcare personnel attire and devices and clinical infection are needed. Infect Control Hosp Epidemiol 2016;1-7.

Diversity of Bacterial Communities on Four Frequently Used Surfaces in a Large Brazilian Teaching Hospital

Frequently used hand-touch surfaces in hospital settings have been implicated as a vehicle of microbial transmission. In this study, we aimed to investigate the overall bacterial population on four frequently used surfaces using a culture-independent Illumina massively parallel sequencing approach of the 16S rRNA genes. Surface samples were collected from four sites, namely elevator buttons (EB), bank machine keyboard buttons (BMKB), restroom surfaces, and the employee biometric time clock system (EBTCS), in a large public and teaching hospital in São Paulo. Taxonomical composition revealed the abundance of Firmicutes phyla, followed by Actinobacteria and Proteobacteria, with a total of 926 bacterial families and 2832 bacterial genera. Moreover, our analysis revealed the presence of some potential pathogenic bacterial genera, including Salmonella enterica, Klebsiella pneumoniae, and Staphylococcus aureus. The presence of these pathogens in frequently used surfaces enhances the risk of exposure to any susceptible individuals. Some of the factors that may contribute to the richness of bacterial diversity on these surfaces are poor personal hygiene and ineffective routine schedules of cleaning, sanitizing, and disinfecting. Strict standards of infection control in hospitals and increased public education about hand hygiene are recommended to decrease the risk of transmission in hospitals among patients.

The stethoscope and healthcare-associated infection: a snake in the grass or innocent bystander?

There is a concern that stethoscopes may transmit infectious agents which could result in healthcare-associated infection (HCAI). The aim of this review was to evaluate the available literature as to the role of the stethoscope in the development of HCAI. A literature search was conducted across several databases for relevant studies and reports. Stethoscopes were consistently shown to harbour bacteria. The mean rate of stethoscope contamination across 28 studies was 85% (range: 47-100%). The majority of bacteria isolated were deemed to be non-pathogenic. The most frequently isolated organisms were coagulase-negative staphylococci. The mean level of contamination was in excess of the French Normalization standard for cleanliness (which equates to <20 colony-forming units per membrane) in all six studies in which contamination levels were quantified. Potentially pathogenic organisms cultured from stethoscopes included: Staphylococcus aureus, Pseudomonas aeruginosa, vancomycin-resistant enterococci, and Clostridium difficile. There was evidence that bacteria can transfer from the skin of the patient to the stethoscope and from the stethoscope to the skin. However, studies were not designed to detect a correlation between stethoscope contamination and subsequent HCAI. Surveys assessing cleaning practices revealed a suboptimal commitment to stethoscope disinfection among doctors and medical students. The optimum method for stethoscope cleaning has not been defined, although alcohol-based disinfectants are effective in reducing bacterial contamination. In conclusion, a link between contaminated stethoscopes and HCAI has not yet been confirmed, but transfer of bacteria between skin and stethoscope has been shown. The available information would suggest that stethoscopes should be decontaminated between patients.

Infection prevention in the emergency department

Infection prevention remains a major challenge in emergency care. Acutely ill and injured patients seeking evaluation and treatment in the emergency department (ED) not only have the potential to spread communicable infectious diseases to health care personnel and other patients, but are vulnerable to acquiring new infections associated with the care they receive. This article will evaluate these risks and review the existing literature for infection prevention practices in the ED, ranging from hand hygiene, standard and transmission-based precautions, health care personnel vaccination, and environmental controls to strategies for preventing health care-associated infections. We will conclude by examining what can be done to optimize infection prevention in the ED and identify gaps in knowledge where further research is needed. Successful implementation of evidence-based practices coupled with innovation of novel approaches and technologies tailored specifically to the complex and dynamic environment of the ED are the keys to raising the standard for infection prevention and patient safety in emergency care.

Common infection control practices in the emergency department: a literature review

BACKGROUND

Health care-associated infections (HAIs) are a major health concern, despite being largely avoidable. The emergency department (ED) is an essential component of the health care system and subject to workflow challenges, which may hinder ED personnel adherence to guideline-based infection prevention practices.

METHODS

The purpose of this review was to examine published literature regarding adherence rates among ED personnel to selected infection control practices, including hand hygiene (HH) and aseptic technique during the placement of central venous catheters and urinary catheters. We also reviewed studies reporting rates of ED equipment contamination. PubMed was searched for studies that included adherence rates among ED personnel to HH during routine patient care, aseptic technique during the placement of central venous catheters and urinary catheters, and rates of equipment contamination.

RESULTS

In total, 853 studies was screened, and 589 abstracts were reviewed. The full texts of 36 papers were examined, and 23 articles were identified as meeting inclusion criteria. Eight studies used various scales to measure HH compliance, which ranged from 7.7% to 89.7%. Seven articles examined central venous catheters inserted in the ED or by emergency medicine residents. Detail of aseptic technique practices during urinary catheterization was lacking. Four papers described equipment contamination in the ED.

CONCLUSION

Standardized methods and definitions of compliance monitoring are needed to compare results across settings.

Bacterial contamination of medical devices in a Greek emergency department: impact of physicians' cleaning habits

We investigated the bacterial contamination of physicians' stethoscopes, electrocardiography machines, cardiac monitors, and pulse oximeters, as well as physicians' self-reported cleaning habits in the emergency department of a university hospital. Among 100 devices evaluated (stethoscopes included), 99% developed a positive bacterial culture. Coagulase-negative staphylococci predominated (80.3%). Only 13% of physicians reported cleaning their stethoscope after each patient examination; multinomial regression analysis found less contamination on those stethoscopes (P < .001). Studies on the implementation of hygiene measures are needed.

Contamination of stethoscopes and physicians' hands after a physical examination

OBJECTIVES

To compare the contamination level of physicians' hands and stethoscopes and to explore the risk of cross-transmission of microorganisms through the use of stethoscopes.

PATIENTS AND METHODS

We conducted a structured prospective study between January 1, 2009, and May 31, 2009, involving 83 inpatients at a Swiss university teaching hospital. After a standardized physical examination, 4 regions of the physician's gloved or ungloved dominant hand and 2 sections of the stethoscopes were pressed onto selective and nonselective media; 489 surfaces were sampled. Total aerobic colony counts (ACCs) and total methicillin-resistant Staphylococcus aureus (MRSA) colony-forming unit (CFU) counts were assessed.

RESULTS

Median total ACCs (interquartile range) for fingertips, thenar eminence, hypothenar eminence, hand dorsum, stethoscope diaphragm, and tube were 467, 37, 34, 8, 89, and 18, respectively. The contamination level of the diaphragm was lower than the contamination level of the fingertips (P<.001) but higher than the contamination level of the thenar eminence (P=.004). The MRSA contamination level of the diaphragm was higher than the MRSA contamination level of the thenar eminence (7 CFUs/25 cm(2) vs 4 CFUs/25 cm(2); P=.004). The correlation analysis for both total ACCs and MRSA CFU counts revealed that the contamination level of the diaphragm was associated with the contamination level of the fingertips (Spearman's rank correlation coefficient, ρ=0.80; P<.001 and ρ=0.76; P<.001, respectively). Similarly, the contamination level of the stethoscope tube increased with the increase in the contamination level of the fingertips for both total ACCs and MRSA CFU counts (ρ=0.56; P<.001 and ρ=.59; P<.001, respectively).

CONCLUSION

These results suggest that the contamination level of the stethoscope is substantial after a single physical examination and comparable to the contamination of parts of the physician's dominant hand.