Disinfection of iPad to reduce contamination with Clostridium difficile and methicillin-resistant Staphylococcus aureus

Review of microbial touchscreen contamination for the determination of reasonable ultraviolet disinfection doses

Background: Touchscreens are usually microbially contaminated and can therefore act as fomites inside and outside healthcare environments. Due to the increasing use of such touchscreens and the growing awareness of infection risks, approaches that allow safe and automatic disinfection are desired. Ultraviolet (UV) irradiation, with its known antimicrobial efficacy, could achieve this goal, but should be executed with limited touchscreen degradation, disinfection duration, and energy consumption. It should also pose as little harm as possible to humans even in case of failure. Materials and methods: A literature search was performed first to identify the microorganisms most commonly found on touchscreens. Then, the 90% reduction doses (D90 doses) for the different relevant microorganisms and UV spectral ranges were determined from the literature, and irradiation doses are suggested that should reduce most of these important microorganisms by 5 log-levels. Results: The most frequent microorganisms are staphylococci, bacilli, micrococci, enterococci, pseudomonads and E. coli with small differences between hospital and community environments, if antibiotic resistance properties are ignored. The determined irradiation doses for a 5 log-reduction of the most frequent microorganisms are about 40 mJ/cm2, 80 J/cm2, 500 J/cm2 and 50 mJ/cm2 for the UV spectral ranges UVC, UVB, UVA and far-UVC, respectively. These doses are also sufficient to inactivate all nosocomial ESKAPE pathogens on touchscreens by at least 99.999%. Conclusion: Disinfection is achievable in all UV spectral ranges, with UVC being the most effective, enabling automatic disinfection within a minute or less. The much higher doses required in the UVB and UVA spectral range result in much longer disinfection durations, with the advantage of a reduced risk to humans. For all kinds of UV irradiation, the doses should be limited to reasonable values to avoid irradiating an already more or less sterile surface and to prevent degradation of touchscreen devices.

Staphylococcal bacterial contamination of portable electronic devices in a large veterinary hospital

BACKGROUND

Portable electronic devices are used regularly within the veterinary and medical environments. Use of these in clinical areas may predispose them to bacterial contamination and they could act as fomites, transmitting infection between clinicians and patients.

AIM

To determine the prevalence, origin and nature of Staphylococcal bacterial contamination on the surface of portable electronic devices used in a large small animal hospital.

MATERIALS AND METHODS

Staff were surveyed on the frequency of portable electronic device use and device-cleaning routines. Portable electronic devices were swabbed for staphylococcus species. Cultured cocci were tested for antimicrobial resistance and identified at the species level to help determine the likely source (human or animal).

FINDINGS

Forty one of 48 (85%) of staff used a portable electronic device every day within the hospital. Useable swabs were obtained from 47 portable electronic devices. Staphylococci were found on 68% of portable electronic devices. Vancomycin and Oxacillin resistance were seen in 17 of 46 (37%) and 1 of 46 (2%) isolated colonies respectively, including four vancomycin resistant, coagulase-positive staphylococci. 44% of staff never cleaned their device.

CLINICAL SIGNIFICANCE

Portable electronic devices are commonly used in veterinary hospitals, but few staff routinely disinfect them. The use of disinfectant to reduce colony counts should be implemented when forming protocols for these devices in the hospital. The majority of staphylococci found were of likely human origin. It is suggested that contamination is therefore more likely to be originating from staff rather than patients.

Reinventing Palliative Care Delivery in the Era of COVID-19: How Telemedicine Can Support End of Life Care

Telemedicine technology has become essential to healthcare delivery in the COVID-19 era, but concerns remain regarding whether the intimacy and communication that is central to high-quality palliative care will be compromised by the use of this technology. We employed a business model approach to identify the need for system innovation in palliative care, and a quality improvement approach to structure the project. Products from this project included a standard operating procedure for safe use of tablet computers for inpatient palliative care consultations and family visitations; tablet procurement with installation of video telehealth software; and training and education for clinical staff and other stakeholders. We describe a case illustrating the successful use of palliative care telehealth in the care of a COVID-19-positive patient at the end of life. Successful use of video telehealth for palliative care involved overcoming inertia to the development of telehealth infrastructure and learning clinical video telehealth skills; and engaging front-line care staff and family members who were open to a trial of telehealth for communication. Information gleaned from family about the patient as a person helped bedside staff to tailor care toward aspects meaningful to the patient and family and informed best practices to incorporate intimacy into future palliative video consultations and family visit.

Prevalence, Mechanisms, and Implications of Gastrointestinal Symptoms in COVID-19

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The infection started as an outbreak of pneumonia-like symptoms in Wuhan, China. Within a few weeks, it spread across the entire globe resulting in millions of cases and thousands of deaths. While respiratory symptoms and complications are well-defined and can be severe, non-respiratory symptoms of COVID-19 are increasingly being recognized. Gastrointestinal manifestations such as nausea, vomiting, diarrhea, and abdominal pain have been added to the list of common COVID-19 symptoms. Their prevalence has been increasing, probably due to increased recognition and experience with the pandemic. Furthermore, diarrhea and stool testing may change prevalence and transmission rates due to suspicion for fecal-oral transmission of the COVID-19. Due to this risk, various countries have started testing wastewater and sewage systems to examine its role in the spread of SARS-CoV-2 among communities. In this review article, we describe the common gastrointestinal manifestations in COVID-19, their prevalence based upon the current literature, and highlight the importance of early recognition and prompt attention. We also note the role of fecal-oral transmission. Furthermore, the mechanisms of these symptoms, the role of medications, and potential contributing factors are also elaborated.

A review on mobile phones as bacterial reservoirs in healthcare environments and potential device decontamination approaches

Mobile communication devices (MCDs), including cell phones and smart phones, have become an essential part of everyday life. Despite their frequent usage, most people, even healthcare personnel, often ignore the possibility that these devices might accumulate to carry a variety of microbial flora during and after the inspection of patients. The handling of MCDs with unwashed hands and/or their seldom cleaning can aggravate potential health risks. Many of the harbored bacteria species can be harmful to immune-suppressed patients for whom the disinfection precautions should be taken more seriously. In this review, we discuss the significance of maintaining the cleanliness of mobile devices, especially in healthcare settings, to prevent the spread of nosocomial infections in patients. Furthermore, we discuss strategies to address microbial contamination of MCDs to maintain good hand hygiene for the users of smartphones or other mobile communication devices. These techniques are capable of providing instant disinfection of the devices along with residual effects over prolonged periods.

Investigation into the cleaning methods of smartphones and wearables from infectious contamination in a patient care environment (I-SWIPE)

BACKGROUND

Many health care workers are using smartphones and wearable devices without an enforced cleaning standard to prevent the spread of bacteria to patients. To our knowledge, no real-world trials have been performed to date, examining bacterial elimination on these devices in a hospital setting. The primary objective was to determine if ultraviolet wavelength C (UV-C) was more effective at eliminating bacteria on smartphones and wearable devices when compared with usual care.

METHODS

This prospective before-and-after study included clinicians who used smartphones or wearable devices during their daily clinical practice. Devices underwent two 30-second UV-C disinfection cycles, at the beginning and end of clinician shifts. Swabs were collected at predetermined intervals both prior to and following a UV-C disinfection cycle to determine the extent of bacterial growth.

RESULTS

Following a run-in period of twice-daily UV-C disinfection, 20% of devices grew pathogenic bacteria prior to UV-C use. Comparatively, only 4% of devices grew bacteria post-UV-C; therefore, the decrease in bacterial growth was statistically significant (P = .002).

CONCLUSIONS

UV-C appears to be more effective at eliminating bacteria on smartphones and wearable devices when compared with usual care and is a useful disinfection device in a hospital setting. Further studies are needed to determine the interval at which UV-C should be used to prevent bacterial growth and spread.

The effectiveness of germicidal wipes and ultraviolet irradiation in reducing bacterial loads on electronic tablet devices used to obtain patient information in orthopaedic clinics: evaluation of tablet cleaning methods

BACKGROUND

Electronic tablet devices are commonly used in outpatient clinics to obtain patient information for both clinical and research purposes. These devices are often colonized with bacteria; there are many cleaning methods to reduce this bacterial load.

AIM

The primary purpose of this study was to evaluate whether regular cleaning with either germicidal wipes or ultraviolet (UV) irradiation leads to lower bacterial levels compared with irregular cleaning.

METHODS

A randomized blinded trial was conducted of tablet cleaning strategies between each patient encounter in orthopaedic clinics. The cleaning method was randomized to either germicidal wipes, UV irradiation, or cleaning only when the tablet was visibly soiled. Research assistants (blinded to the treatment) obtained bacterial cultures from the tablets at the beginning and end of each clinic day.

FINDINGS

Using germicidal wipes between each patient encounter vs no routine cleaning resulted in a marked decrease in the amount of bacterial contamination (risk ratio (RR) = 0.17 (0.04-0.67)). Similarly, using UV irradiation between each patient encounter led to significantly lower bacterial contamination rates (RR = 0.29 (95% confidence interval (CI) = 0.09-0.95)) compared with no routine cleaning. The majority of bacteria identified were normal skin flora. No meticillin-resistant Staphylococcus aureus was identified and only sparse colonies of meticillin-sensitive S. aureus.

CONCLUSION

Electronic tablets used in orthopaedic trauma clinics are colonized with bacteria if no routine cleaning is performed. Routine use of either UV irradiation or germicidal wipes significantly decreases this bacterial burden. Providers should implement routine cleaning of tablets between each patient encounter to minimize exposure to potential pathogens.

Perceptions and needs regarding technologies in nursing homes: An exploratory study

Two of the most salient problems in nursing homes are the responsive behaviours and falls of older people living with Alzheimer's disease and related disorders. Intelligent videomonitoring and mobile applications are potential technologies that may help prevent and manage these problems. However, evidence for the needs for technologies in nursing homes is scarce. This study aimed to explore the perceptions and needs of care managers, and of formal and family caregivers in nursing homes regarding these potential technologies. With an exploratory qualitative design based on Rogers' diffusion of innovation theory, individual interviews and a content analysis were conducted. Results show that the potential users of these technologies consider them relevant in nursing homes. The characteristics that would make these technologies useful in nursing homes are described. These results could be used to develop useful technologies to improve the quality of clinical practice in nursing homes.

What's on your keyboard? A systematic review of the contamination of peripheral computer devices in healthcare settings

OBJECTIVE

To determine the extent and type of microbial contamination of computer peripheral devices used in healthcare settings, evaluate the effectiveness of interventions to reduce contamination of these devices and establish the risk of patient and healthcare worker infection from contaminated devices.

DESIGN

Systematic review METHODS: We searched four online databases: MEDLINE, CINAHL, Embase and Scopus for articles reporting primary data collection on contamination of computer-related equipment (including keyboards, mice, laptops and tablets) and/or studies demonstrating the effectiveness of a disinfection technique. Pooling of contamination rates was conducted where possible, and narrative synthesis was used to describe the rates of device contamination, types of bacterial and viral contamination, effectiveness of interventions and any associations between device contamination and human infections.

RESULTS

Of the 4432 records identified, a total of 75 studies involving 2804 computer devices were included. Of these, 50 studies reported contamination of computer-related hardware, and 25 also measured the effects of a decontamination intervention. The overall proportion of contamination ranged from 24% to 100%. The most common microbial contaminants were skin commensals, but also included potential pathogens including methicillin-resistantStaphylococcus aureus, Clostridiumdifficile, vancomycin-resistantenterococci and Escherichia coli. Interventions demonstrating effective decontamination included wipes/pads using isopropyl alcohol, quaternary ammonium, chlorhexidine or dipotassium peroxodisulfate, ultraviolet light emitting devices, enhanced cleaning protocols and chlorine/bleach products. However, results were inconsistent, and there was insufficient data to demonstrate comparative effectiveness. We found little evidence on the link between device contamination and patient/healthcare worker colonisation or infection.

CONCLUSIONS

Computer keyboards and peripheral devices are frequently contaminated; however, our findings do not allow us to draw firm conclusions about their relative impact on the transmission of pathogens or nosocomial infection. Additional studies measuring the incidence of healthcare-acquired infections from computer hardware, the relative risk they pose to healthcare and evidence for effective and practical cleaning methods are needed.

Cultivable Microbial Diversity Associated With Cellular Phones

A substantial majority of global population owns cellular phones independently to demographic factors like age, economic status, and educational attainment. In this study, we investigated the diversity of microorganisms associated with cellular phones of 27 individuals using cultivation-based methods. Cellular phones were sampled using cotton swabs and a total of 554 isolates representing different morphotypes were obtained on four growth media. Matrix-assisted laser desorption ionization time of flight (MALDI-TOF) mass spectrometry could generate protein profiles for 527 isolates and species-level identification was obtained for 415 isolates. A dendrogram was constructed based on the protein profiles of the remaining isolates, to group 112 isolates under 39 different proteotypes. The representative strains of each group were selected for 16S rRNA gene and ITS region sequencing based identification. Staphylococcus, Bacillus, Micrococcus, and Pseudomonas were the most frequently encountered bacteria, and Candida, Aspergillus, Aureobasidium, and Cryptococcus were in case of fungi. At species-level the prevalence of Micrococcus luteus, Staphylococcus hominis, Staphylococcus epidermidis, Staphylococcus arlettae, Bacillus subtilis, and Candida parapsilosis was observed, most of these species are commensal microorganisms of human skin. UPGMA dendrogram and PCoA biplot generated based on the microbial communities associated with all cellular phones exhibited build-up of specific communities on cellular phones and the prevalence of objectionable microorganisms in some of the cellular phones can be attributed to the poor hygiene and sanitary practices. The study also revealed the impact of MALDI-TOF MS spectral quality on the identification results. Overall MALDI-TOF appears a powerful tool for routine microbial identification and de-replication of microorganisms. Quality filtering of MALDI-TOF MS spectrum, development of better sample processing methods and enriching the spectral database will improve the role of MALDI-TOF MS in microbial identifications.

Evaluation of an automated ultraviolet-C light disinfection device and patient hand hygiene for reduction of pathogen transfer from interactive touchscreen computer kiosks

Touchscreens are a potential source of pathogen transmission. In our facility, patients and visitors rarely perform hand hygiene after using interactive touchscreen computer kiosks. An automated ultraviolet-C touchscreen disinfection device was effective in reducing bacteriophage MS2, bacteriophage ϕX174, methicillin-resistant Staphylococcus aureus, and Clostridium difficile spores inoculated onto a touchscreen. In simulations, an automated ultraviolet-C touchscreen disinfection device alone or in combination with hand hygiene reduced transfer of the viruses from contaminated touchscreens to fingertips.

On-Demand Gas-to-Liquid Process To Fabricate Thermoresponsive Antimicrobial Nanocomposites and Coatings

Antimicrobial material is emerging as a major component of the mitigation strategy against microbial growth on abiotic surfaces. In this work, a newly designed process is proposed to fabricate thermoresponsive antimicrobial nanocomposites (TANs) and coatings (TACs) as an on-demand system. Thermoresponsive polymer (TRP)-incorporated silver (Ag) nanocomposites with silica nanoparticles (SNPs) or carbon nanotubes (CNTs; Ag-SNP@TRP or Ag-CNT@TRP) were produced by a single-pass gas-to-liquid process. The SNPs or CNTs were first produced by spark ablation and successively injected for dispersal in a liquid cell containing polydimethylsiloxane, poly(N-isopropylacrylamide), and silver nitrate under ultrasound irradiation. Suspensions of Ag-SNP@TRP or Ag-CNT@TRP nanocomposites were then deposited on a touch screen panel (TSP) protection film via electrohydrodynamic spray to form transparent antibacterial coatings. Fundamental antibacterial activities of TANs were evaluated against Escherichia coli and Staphylococcus epidermidis. The TANs showed stronger antibacterial activities at the higher temperature for all testing conditions. Lower minimum inhibitory concentrations of Ag-SNP@TRP and Ag-CNT@TRP nanocomposites were required against the two bacteria at 37 °C compared to those at 27 °C. The TACs on display showed elevated antimicrobial activity when the panel was turned on (38.1 °C) compared with when the panel was turned off (23.8 °C). This work provides a utilizable concept to continuously fabricate TANs and TACs, and it specifically offers stimuli-sensitive control of antimicrobial activity on TSPs, including other frequently touched surfaces.

Apps and intensive care medicine

Technological advances have played a key role over the last century in the development of humankind. Critical Care Medicine is one of the greatest examples of this revolution. Smartphones with multiple sensors constitute another step forward, and have led to the development of apps for use by both professionals and patients. We discuss their main medical applications in the field of Critical Care Medicine.

Evaluation of an enclosed ultraviolet-C radiation device for decontamination of mobile handheld devices

Mobile handheld devices used in health care settings may become contaminated with health care-associated pathogens. We demonstrated that an enclosed ultraviolet-C radiation device was effective in rapidly reducing methicillin-resistant Staphylococcus aureus, and with longer exposure times, Clostridium difficile spores, on glass slides and reducing contamination on in-use mobile handheld devices.

Clostridium difficile infection: Early history, diagnosis and molecular strain typing methods

Recognised as the leading cause of nosocomial antibiotic-associated diarrhoea, the incidence of Clostridium difficile infection (CDI) remains high despite efforts to improve prevention and reduce the spread of the bacterium in healthcare settings. In the last decade, many studies have focused on the epidemiology and rapid diagnosis of CDI. In addition, different typing methods have been developed for epidemiological studies. This review explores the history of C. difficile and the current scope of the infection. The variety of available laboratory tests for CDI diagnosis and strain typing methods are also examined.

Use of portable electronic devices in a hospital setting and their potential for bacterial colonization

Portable electronic devices are increasingly being used in the hospital setting. As with other fomites, these devices represent a potential reservoir for the transmission of pathogens. We conducted a convenience sampling of devices in 2 large medical centers to identify bacterial colonization rates and potential risk factors.

Surface microbiology of the iPad tablet computer and the potential to serve as a fomite in both inpatient practice settings as well as outside of the hospital environment

Background

The use of tablet computers and other touch screen technology within the healthcare system has rapidly expanded. It has been reported that these devices can harbor pathogens in hospitals; however, much less is known about what pathogens they can harbor when used outside the hospital environment compared to hospital practice.

Methods

Thirty iPads belonging to faculty with a variety of practice settings were sampled to determine the presence and quantity of clinically-relevant organisms. Flocked nylon swabs and neutralizer solution were used to sample the surface of each iPad. Samples were then plated on a variety of selective agars for presence and quantity of selected pathogens. In addition, faculty members were surveyed to classify the physical location of their practice settings and usage patterns. Continuous variables were compared via an unpaired Student's t test with two-tailed distribution; categorical variables were compared with the Fisher's exact test.

Results

Of the iPads sampled, 16 belonged to faculty practicing within a hospital and 14 belonged to a faculty member practicing outside a hospital. More faculty within the hospital group used their iPads at their practice sites (78.6% vs. 31.3%; p = 0.014) and within patient care areas (71.4% vs. 18.8%; p = 0.009) than the non-hospital group. There were no differences in the presence, absence, or quantity of, any of the pathogens selectively isolated between groups. Problematic nosocomial pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and P. aeruginosa were isolated from both hospital and non-hospital faculty iPads.

Conclusions

Gram positive and Gram negative organisms were recovered from the surfaces of iPads regardless of practice setting; these included problematic multidrug-resistant pathogens like MRSA, VRE, and Pseudomonas aeruginosa. Healthcare personnel in all settings should be aware of the potential for tablet computers to serve as a nidus for microorganism transmission.

Practicability of hygienic wrapping of touchscreen operated mobile devices in a clinical setting

Background

To prove effectiveness of wrapping tablet computers in order to reduce microbiological contamination and to evaluate whether a plastic bag-covered tablet leads to impaired user satisfaction or touchscreen functionality.

Materials and Methods

Within a period of 11 days 115 patients were provided with a tablet computer while waiting for their magnetic resonance imaging examination. Every day the contamination of the surface of the tablet was determined before the first and after the final use. Before the device was handed over to a patient, it was enclosed in a customized single-use plastic bag, which was analyzed for bacterial contamination after each use. A questionnaire was applied to determine whether the plastic bag impairs the user satisfaction and the functionality of the touchscreen.

Results

Following the use by patients the outside of the plastic bags was found to be contaminated with various bacteria (657.5 ± 368.5 colony forming units/day); some of them were potentially pathogenic. In contrast, the plastic bag covered surface of the tablet was significantly less contaminated (1.7 ± 1.9 colony forming units/day). Likewise, unused plastic bags did not show any contamination. 11% of the patients reported problems with the functionality of the touchscreen. These patients admitted that they had never used a tablet or a smartphone before.

Conclusions

Tablets get severely contaminated during usage in a clinical setting. Wrapping with a customized single-use plastic bag significantly reduces microbiological contamination of the device, protects patients from the acquisition of potentially pathogenic bacteria and hardly impairs the user satisfaction and the functionality of the touchscreen.

Best practice in healthcare environment decontamination

There is now strong evidence that surface contamination is linked to healthcare-associated infections (HCAIs). Cleaning and disinfection should be sufficient to decrease the microbial bioburden from surfaces in healthcare settings, and, overall, help in decreasing infections. It is, however, not necessarily the case. Evidence suggests that there is a link between educational interventions and a reduction in infections. To improve the overall efficacy and appropriate usage of disinfectants, manufacturers need to engage with the end users in providing clear claim information and product usage instructions. This review provides a clear analysis of the scientific evidence supporting the role of surfaces in HCAIs and the role of education in decreasing such infections. It also examines the debate opposing the use of cleaning versus disinfection in healthcare settings.

Mobile phones carry the personal microbiome of their owners

Most people on the planet own mobile phones, and these devices are increasingly being utilized to gather data relevant to our personal health, behavior, and environment. During an educational workshop, we investigated the utility of mobile phones to gather data about the personal microbiome - the collection of microorganisms associated with the personal effects of an individual. We characterized microbial communities on smartphone touchscreens to determine whether there was significant overlap with the skin microbiome sampled directly from their owners. We found that about 22% of the bacterial taxa on participants' fingers were also present on their own phones, as compared to 17% they shared on average with other people's phones. When considered as a group, bacterial communities on men's phones were significantly different from those on their fingers, while women's were not. Yet when considered on an individual level, men and women both shared significantly more of their bacterial communities with their own phones than with anyone else's. In fact, 82% of the OTUs were shared between a person's index and phone when considering the dominant taxa (OTUs with more than 0.1% of the sequences in an individual's dataset). Our results suggest that mobile phones hold untapped potential as personal microbiome sensors.