Can education influence stethoscope hygiene?

Stethoscope barriers narrative review; It's time for a strategy unfriendly to multi-drug resistant organisms (MDROs)

The current standard of stethoscope hygiene doesn't eliminate the transmission of harmful pathogens, including multi-drug resistant organisms (MDROs). In the era of the increasing prevalence of MDRO infections, the use of new systems providing touch free barriers may improve patient safety versus traditional stethoscope cleaning practices with chemical agents. Our purpose was to provide a narrative literature review regarding barriers as an improvement over the current standard of care for stethoscope hygiene. Searching PubMed, articles were identified if they were in English and published after 1990, using the search term "stethoscope barrier", or if they were from a previously published stethoscope hygiene article using "author's name + stethoscope". Included articles evaluated or discussed stethoscope barriers. Of 28 manuscripts identified, 15 met the inclusion criteria. Barriers were considered superior to alternatives if they were single use, disposable, applied in a touch free fashion, were impervious to pathogens, provided an aseptic patient contact, and were acoustically invisible. Use of a practitioner's personal stethoscope with a disposable diaphragm barrier should be recommended as a new standard of care as this represents an improvement in patient safety and patient experience when compared to the disposable stethoscope or isopropyl alcohol stethoscope diaphragm cleaning.

Implementation of stethoscope disinfection: an observational study on nursing staff practice and knowledge

Background

Healthcare-associated infections cause high mortality and morbidity, and lack of stethoscope disinfection is one of the reasons for healthcare-associated infections. Nurses who frequently use stethoscopes in the clinic do not disinfect stethoscopes at high rates. This study aimed to identify the frequency of stethoscope disinfection by nurses and their knowledge about the same.

Methods

This was a mixed-methods observational study. The quantitative part of the study included 202 nurses, the qualitative part included 12. Two researchers who made observations during stethoscope use recorded the procedures the nurses performed on the "Observation Form". Semi-structured in-depth interviews were conducted based on phenomenological methods.

Results

23.7% of the nurses disinfected their stethoscopes before contact with patients, 11.8% after contact with patients and 6.4% before and after contact with patients. The nurses used a stethoscope on an average of 7.42 patients without disinfecting it. In the qualitative interview, some nurses stated that they did not have information about the disinfectants to be used for stethoscopes and their effectiveness. Some of the participants in the present study stated that they did not receive training on stethoscope disinfection and that they did not know that there were guidelines about it.

Conclusion

Since there were deficiencies in the implementation of stethoscope disinfection as well as knowledge, the transfer of knowledge in this context must receive more attention in education and training.

Educational interventions to improve compliance with disinfection practices of noncritical portable medical equipment: A systematic review

OBJECTIVE

To describe educational interventions that have been implemented in healthcare settings to increase the compliance of healthcare personnel (HCP) with cleaning and disinfection of noncritical portable medical equipment (PME) requiring low-level disinfection (LLD).

DESIGN

Systematic review.

METHODS

Studies evaluating interventions for improving LLD practices in settings with HCP, including healthcare students and trainees, were eligible for inclusion.

RESULTS

In total, 1,493 abstracts were identified and 1,416 were excluded, resulting in 77 studies that underwent full text review. Among these, 68 were further excluded due to study design, setting, or intervention. Finally, 9 full-text studies were extracted; 1 study was excluded during the critical appraisal process, leaving 8 studies. Various forms of interventions were implemented in the studies, including luminescence, surveillance of contamination with feedback, visual signage, enhanced training, and improved accessibility of LLD supplies. Of the 8 included studies, 4 studies reported successes in improving LLD practices among HCP.

CONCLUSIONS

The available literature was limited, indicating the need for additional research on pedagogical methods to improve LLD practices. Use of visual indicators of contamination and multifaceted interventions improved LLD practice by HCP.

Personal stethoscope disinfection practices and bacterial contamination: A cross-sectional study at the University Hospital Emergency Department in Belgrade, Serbia

BACKGROUND

A significant reduction in bacterial growth on stethoscope membranes has been noticed after performing daily disinfection. Nevertheless, disinfection is rarely performed. We aimed to assess self-reported stethoscope disinfection practices among medical doctors, detect bacterial contamination on personal stethoscopes, and estimate the effectiveness of 70% ethanol as a stethoscope disinfecting agent.

METHODS

To determine stethoscope disinfection practices, participants filled out a questionnaire (N = 47), followed by providing stethoscopes for bacterial analysis. Differences in bacterial contamination were observed through the self-reported frequency and method of stethoscope disinfection. The effect of disinfecting with 70% ethanol was evaluated by comparing the presence of bacterial growth before and after disinfection.

RESULTS

The presence of bacterial growth was found in 78.7% of the stethoscope samples, with the median (interquartile range) number of colony-forming units at 25 (10-105). The frequency of disinfection greatly impacted the number of colony-forming units, and the method affected the presence of bacterial growth. Disinfection of stethoscope membranes using 70% ethanol resulted in a compelling 97.3% reduction of bacterial growth.

CONCLUSIONS

Adequate stethoscope disinfection is highly efficient in reducing bacterial contamination and as such should be considered a critical step in hygienic practices.

Hospital Physicians’ Stethoscopes: Bacterial Contamination After a Simple Cleaning Protocol

BACKGROUND

Stethoscope surfaces become contaminated with bacteria due to inconsistent cleaning practices,​ as​​ ​​​​cleaning frequency and practical clean​s​ing approaches are not well-established.

METHODS

We investigated bacterial contamination of stethoscopes at baseline, after simple cleaning, and after examining one patient. We surveyed 30 hospital providers on stethoscope cleaning practices and then measured bacterial contamination of stethoscope diaphragm surfaces before cleaning, after cleaning with alcohol-based hand sanitizer, and after use in examining one patient.

RESULTS

Only 20% of providers reported cleaning stethoscopes regularly. Before cleaning, 50% of stethoscopes were contaminated with bacteria, compared with 0% after cleaning (p<0.001) and 36.7% after examining one patient (p=0.002). Among providers who reported not cleaning stethoscopes regularly, 58% had bacterial-contaminated stethoscopes compared with 17% who did report cleaning regularly (p=0.068).

CONCLUSIONS

Hospital providers' stethoscopes had a high probability of bacterial contamination at baseline and after examining one patient. We recommend decontamination with alcohol-based hand sanitizer immediately before each patient examination.

Assessing Changes in Stethoscope Hygiene During COVID-19: A Multicentre Cross-Sectional Study

Background

The COVID-19 (SARS-CoV-2) pandemic has increased infection control vigilance across several modes of patient contact. However, it is unknown whether hygiene pertaining to stethoscopes, which carry the potential for pathogenic contamination, has also shifted accordingly.

Aim

To characterize pandemic-related changes in stethoscope hygiene.

Methods

We surveyed healthcare providers at three major medical centres. Questions quantitatively (Likert scale and frequency) assessed stethoscope hygiene beliefs and practices with two components: before and during COVID-19. Participants were grouped based on performance of optimal stethoscope hygiene (after every patient) before and during COVID-19. Groups were compared using χ² and analysis of variance (ANOVA).

Findings

Of the 515 (10%) who completed the survey, 55 were excluded (N = 460). Optimal hygiene increased from 27.4% to 55.0% (P < 0.001). There were significant increases in Likert scores for all questions pertaining to knowledge of stethoscope contamination (P < 0.001). Belief in stethoscope contamination increased (P < 0.001) despite no change in perceived hygiene education. Resident physicians were less likely compared with attending physicians and nurses to have adopted optimal hygiene during COVID-19 (P < 0.001).

Conclusion

Despite a positive shift in stethoscope hygiene during COVID-19, optimal hygiene was still only performed by around half of providers. Educational interventions, particularly targeting early-career providers, are encouraged.

Stethoscope hygiene: A legal consideration for cardiologists practicing in a new era of infection control (COVID-19)

The stethoscope is a tool cherished by the field of cardiology and ubiquitous throughout medicine. However, little consideration has been given to its safe usage regarding its potential for pathogenic contamination despite thorough evidence that stethoscopes can harbor pathogens that can be transmitted to patients upon contact. The COVID-19 (SARS-COV-2) pandemic has led to increased infection control vigilance, including toward the stethoscope, as evidenced by a recent increase in literature highlighting stethoscope hygiene/contamination. A consequence of this increase in awareness is that stethoscopes may be implicated in medical malpractice lawsuits as a potential cause of healthcare-associated infections (HAIs). While there is limited evidence demonstrating a direct connection between stethoscope contamination and HAIs, malpractice lawsuits often do not require direct causative evidence. Regardless, efforts should be made to bolster stethoscope hygiene to not only mitigate patient harm, but also prevent providers from potential medical-legal conflicts. The continued relevance and utility of the stethoscope as a rapid, cost-effective diagnostic tool needs to be appropriately balanced with increased hygiene performance. Providers should anticipate increased scientific evidence and patient awareness regarding stethoscope contamination in the post-COVID-19 era.

Stethoscope hygiene: A call to action. Recommendations to update the CDC guidelines

Healthcare-acquired infections are a tremendous challenge to the US medical system. Stethoscopes touch many patients, but current guidance from the Centers for Disease Control and Prevention does not support disinfection between each patient. Stethoscopes are rarely disinfected between patients by healthcare providers. When cultured, even after disinfection, stethoscopes have high rates of pathogen contamination, identical to that of unwashed hands. The consequence of these practices may bode poorly in the coronavirus 2019 disease (COVID-19) pandemic. Alternatively, the CDC recommends the use of disposable stethoscopes. However, these instruments have poor acoustic properties, and misdiagnoses have been documented. They may also serve as pathogen vectors among staff sharing them. Disposable aseptic stethoscope diaphragm barriers can provide increased safety without sacrificing stethoscope function. We recommend that the CDC consider the research regarding stethoscope hygiene and effective solutions to contemporize this guidance and elevate stethoscope hygiene to that of the hands, by requiring stethoscope disinfection or change of disposable barrier between every patient encounter.

An Examination and Comparison of Stethoscope Hygiene in Nursing Education Programs

BACKGROUND

Improper stethoscope hygiene has been found to contribute to the development of health care associated infections, which affects approximately one in every 30 hospitalized patients. Various pathogens have been found on the stethoscopes of health care workers.

METHOD

A correlational descriptive design was used to compare stethoscopes from 117 nursing students. Sterile swab samples were obtained from four separate areas of each stethoscope. Samples were plated and incubated for 24 to 48 hours.

RESULTS

Bacteria were found on all parts of the stethoscopes from both undergraduate and graduate nursing students, with the earpiece having the highest percentage of contamination. Staphylococcus was the most prevalent microbe found on all four swab sites.

CONCLUSION

Educating students about stethoscope hygiene and consistently reinforcing it in practice are essential to reduce the transmission of pathogens in the health care environment. Nurses can model best practice with students and other disciplines to increase the likelihood of adherence. [J Nurs Educ. 2021;60(5):277-280.].

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.

Aseptic Stethoscope Barriers Prevent C difficile Transmission In Vitro

Objective

To evaluate whether Clostridioides (formerly Clostridium) difficile–contaminated stethoscope diaphragms remained aseptic by the placement of an aseptic diaphragm barrier.

Methods

On November 1, 2019, fresh cultures of C difficile were diluted to 10⁷ colony-forming units (CFU)/mL and used to inoculate 16 stethoscope diaphragms; 8 had an aseptic diaphragm barrier applied and 8 served as nonbarrier controls. Contaminated stethoscopes were anaerobically incubated, then swabbed at 15 and 30 minutes, 2 and 4 hours, and 1, 2, 3, and 7 days after inoculation and subsequently plated onto blood, chocolate, and cycloserine-cefoxitin fructose agar. Plates were incubated for 48 hours and on November 9, 2019, the resulting colonies were manually counted. Statistical analyses (RStudio, version 1.0.153) used analysis of variance with post hoc Tukey honestly significant difference.

Results

Overall, mean colony count was 33 CFU on stethoscopes without barriers vs zero on those with barriers (P≤.05). Growth was greatest at 48 hours, with colony counts as high as 160 CFU. The presence of the barrier resulted in no growth in 100% of stethoscope diaphragms for up to 1 week.

Conclusion

We found that stethoscope diaphragm barriers provide an aseptic patient contact point, thus reducing the potential for transmission of C difficile during the physical examination. In critical care environments, in which many hospitals use acoustically inferior disposable stethoscopes, the option of a disposable aseptic stethoscope barrier may allow high-quality auscultation while reducing the potential for pathogen transmission.

Persistent Value of the Stethoscope in the Age of COVID-19

The stethoscope has long been at the center of patient care, as well as a symbol of the physician-patient relationship. While advancements in other diagnostic modalities have allowed for more efficient and accurate diagnosis, the stethoscope has evolved in parallel to address the needs of the modern era of medicine. These advancements include sound visualization, ambient noise reduction/cancellation, Bluetooth (Bluetooth SIG Inc, Kirkland, Wash) transmission, and computer algorithm diagnostic support. However, despite these advancements, the ever-changing climate of infection prevention, especially in the wake of the COVID-19 pandemic, has led many to question the stethoscope as a vector for infectious diseases. Stethoscopes have been reported to harbor bacteria with contamination levels comparable with a physician's hand. Although disinfection is recommended, stethoscope hygiene compliance remains low. In addition, disinfectants may not be completely effective in eliminating microorganisms. Despite these risks, the growing technological integration with the stethoscope continues to make it a highly valuable tool. Rather than casting our valuable tool and symbol of medicine aside, we must create and implement an effective method of stethoscope hygiene to keep patients safe.

Comparison of Effectiveness of 70%-isopropanol, 65%-ethanol and 1%-chlorhexidine for Stethoscope Decontamination

Stethoscopes are potential vector for health care associated infections worldwide. Ethyl alcohol (EA), isopropyl alcohol (IPA) and chlorhexidine (CH) are widely used for disinfecting stethoscope, however, comparative analysis of these disinfectants are scarce. Hence this paper aims to compare the reduction in bioburden with respect to stethoscope decontamination. A randomized, double-blind study was undertaken from various categories of health care workers (HCW) working in various departments. Each participant was asked to fill a questionnaire and diaphragms of their stethoscopes were imprinted on blood agar and sabourauds dextrose agar before and after disinfection with either 65%-EA, 70%-IPA or 1%-CH. The culture plates were incubated aerobically and the growth was further identified. 384 HCW participated in the study. 168 participants never cleaned their stethoscope, out of which 147 respondents (91.6%) comprised of students. EA (47%) and IPA (23%) were the two major types of alcohols used as disinfecting agents. 280 samples showed growth among which 51.8% were potent pathogens. Before disinfection, Staphylococcus aureus (27%) was the predominant pathogen, followed by Klebsiella (6.8%), Enterococcus and Candida respectively. Among the disinfectants used, maximum antimicrobial activity was exhibited by IPA (92.5%) compared to EA (82.5%) and CH (77.8%). Huge lacunae regarding knowledge, attitude and practice of stethoscope maintenance was found among student community. The microbial growth varies at various department. Disinfecting stethoscope with 70%-IPA for just 30 seconds is equally efficient compared to 1 minute and IPA was superior to EA and CH for decontaminating stethoscope. Stethoscopes are potential vector for health care associated infections worldwide. Ethyl alcohol (EA), isopropyl alcohol (IPA) and chlorhexidine (CH) are widely used for disinfecting stethoscope, however, comparative analysis of these disinfectants are scarce. Hence this paper aims to compare the reduction in bioburden with respect to stethoscope decontamination. A randomized, double-blind study was undertaken from various categories of health care workers (HCW) working in various departments. Each participant was asked to fill a questionnaire and diaphragms of their stethoscopes were imprinted on blood agar and sabourauds dextrose agar before and after disinfection with either 65%-EA, 70%-IPA or 1%-CH. The culture plates were incubated aerobically and the growth was further identified. 384 HCW participated in the study. 168 participants never cleaned their stethoscope, out of which 147 respondents (91.6%) comprised of students. EA (47%) and IPA (23%) were the two major types of alcohols used as disinfecting agents. 280 samples showed growth among which 51.8% were potent pathogens. Before disinfection, Staphylococcus aureus (27%) was the predominant pathogen, followed by Klebsiella (6.8%), Enterococcus and Candida respectively. Among the disinfectants used, maximum antimicrobial activity was exhibited by IPA (92.5%) compared to EA (82.5%) and CH (77.8%). Huge lacunae regarding knowledge, attitude and practice of stethoscope maintenance was found among student community. The microbial growth varies at various department. Disinfecting stethoscope with 70%-IPA for just 30 seconds is equally efficient compared to 1 minute and IPA was superior to EA and CH for decontaminating stethoscope.

Stethoscope hygiene: Using cultures and real-time feedback with bioluminescence-based adenosine triphosphate technology to change behavior

BACKGROUND

Stethoscope hygiene is rarely done despite guideline recommendations. We wanted to determine whether demonstrating what is growing on the stethoscopes of providers via culture or bioluminescence technology alters perceptions and improves compliance.

METHODS

Providers were given the opportunity to (1) culture their stethoscopes before and after disinfection with alcohol pads, alcohol-based hand rub, or hydrogen peroxide disinfectant wipes and (2) swab stethoscopes for bioluminescence-based adenosine triphosphate testing before and after disinfection. Outcomes were observed for hand and stethoscope hygiene rates and before and after intervention survey responses. The bacteria that were isolated, colony-forming units (CFU), and bioluminescence scores were tracked.

RESULTS

A total of 1,245 observed hand hygiene opportunities showed that compliance improved from 72.5%-82.3% (P < .001). In addition, 590 observed patient-provider encounters revealed no significant change in stethoscope hygiene rates of 10% initially and 5% afterward (P = .08), although self-reported rates trended from 56%- 67% postintervention (P = .06). Perceptions regarding stethoscope hygiene importance improved (8.5/10 to 9.3/10; P = .04). Disinfection with alcohol pads, alcohol-based hand rub, and hydrogen peroxide disinfectant wipes were equivalent in CFU reduction (P = .21).

CONCLUSIONS

Showing providers what is growing on their stethoscopes via cultures and bioluminescence technology before and after disinfection improved "buy in" regarding stethoscope hygiene importance. Both methods were rated as having an equal impact, however, objective observations failed to show improvement.

Aseptic Barriers Allow a Clean Contact for Contaminated Stethoscope Diaphragms

Objective

To determine whether a single-use stethoscope diaphragm barrier surface remains aseptic when placed on pathogen-contaminated stethoscopes.

Methods

From May 31 to August 5, 2019, we tested 2 separate barriers using 3 different strains of 7 human pathogens, including extended-spectrum β-lactamase-producing Escherichia coli, methicillin-resistant Staphylococcus aureus, and vancomycin resistant Enterococcus faecium.

Results

For all diaphragms with either of the 2 barriers tested, no growth was recorded for any of the pathogens. Stethoscopes with aseptic barriers remained sterile for up to 24 hours. These single-use barriers also provided aseptic surfaces when stethoscope diaphragms were inoculated with human specimens, including saliva, stool, urine, and sputum.

Conclusion

Disposable aseptic diaphragm barriers may provide robust and efficient solutions to reduce transmission of pathogens via stethoscopes.

Effectiveness and cost-effectiveness of a Clostridium difficile vaccine candidate in a hospital setting

Toxoid vaccines against Clostridium difficile infections (CDI) appear promising in reducing the risk of developing toxin-mediated symptoms. We sought to evaluate the effectiveness and cost-effectiveness of a vaccine candidate in a hospital setting. We developed an agent-based simulation model of nosocomial CDI in a 300-bed hospital. Targeting high-risk patients for vaccination, we estimated the reduction of symptomatic CDI. Using the net reduction of CDI-associated isolation days, we evaluated the vaccine's cost-effectiveness from a healthcare provider perspective over a 2-year period with an average monthly incidence of 5 cases per 10,000 patient-days pre-vaccination. Assuming a vaccine efficacy in the range 60-90%, vaccinating 40% of high-risk patients pre-admission reduced symptomatic CDI by 16.6% (95% CI: 15.2, 17.9). When the vaccine coverage increased to 80%, the reduction of symptomatic CDI was 34.6% (95% CI: 33.7, 35.9). For a willingness to pay (WTP) of CDN$1000 (corresponding to the average costs of case isolation per day), vaccine was cost-effective for vaccination costs per individual (VCPI) up to CDN$111 in the scenario of 40% vaccine coverage. With the same WTP, vaccine was cost-effective for VCPI up to CDN$121 when the vaccine coverage increased to 80%. A significant portion (~80%) of hospital colonization is caused by environmental transmission of C. difficile, which markedly reduced the effectiveness of vaccine below its assumed efficacy. However, due to the number of CDI-associated isolation days averted, vaccination of high-risk patients can be cost-effective depending on the WTP and the VCPI.

Respiratory viruses on personal protective equipment and bodies of healthcare workers

Objective:

To characterize the magnitude of virus contamination on personal protective equipment (PPE), skin, and clothing of healthcare workers (HCWs) who cared for patients having acute viral infections.

Design:

Prospective observational study.

Setting:

Acute-care academic hospital.

Participants:

A total of 59 HCWs agreed to have their PPE, clothing, and/or skin swabbed for virus measurement.

Methods:

The PPE worn by HCW participants, including glove, face mask, gown, and personal stethoscope, were swabbed with Copan swabs. After PPE doffing, bodies and clothing of HCWs were sampled with Copan swabs: hand, face, and scrubs. Preamplification and quantitative polymerase chain reaction (qPCR) methods were used to quantify viral RNA copies in the swab samples.

Results:

Overall, 31% of glove samples, 21% of gown samples, and 12% of face mask samples were positive for virus. Among the body and clothing sites, 21% of bare hand samples, 11% of scrub samples, and 7% of face samples were positive for virus. Virus concentrations on PPE were not statistically significantly different than concentrations on skin and clothing under PPE. Virus concentrations on the personal stethoscopes and on the gowns were positively correlated with the number of torso contacts (P < .05). Virus concentrations on face masks were positively correlated with the number of face mask contacts and patient contacts (P < .05).

Conclusions:

Healthcare workers are routinely contaminated with respiratory viruses after patient care, indicating the need to ensure that HCWs complete hand hygiene and use other PPE to prevent dissemination of virus to other areas of the hospital. Modifying self-contact behaviors may decrease the presence of virus on HCWs.

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.

Contemporary stethoscope cleaning practices: What we haven't learned in 150 years

BACKGROUND

Stethoscopes can be microorganism reservoirs. The US Centers for Disease Control and Prevention (CDC) has published medical equipment disinfection guidelines to minimize infection transmission risk, but studies of guideline adherence have been predominately survey based, with little direct observation of disinfection practices.

METHODS

We performed an observational, cross-sectional, anonymous study of patient-provider interactions, assessing practitioners' frequency and methods of stethoscope and hand disinfection practices.

RESULTS

Stethoscopes were disinfected in 18% of 400 observed interactions, with less than 4% verified as conforming to CDC guidelines. None was disinfected before patient examinations involving open chest or abdominal wounds, as recommended by the CDC. Hands were cleaned before and after encounters 27 times (6.8%) but were not cleaned at all in 231 (58%) encounters, although gloves were worn in 197 (85.3%) of these cases.

DISCUSSION

Stethoscope disinfection is grossly overlooked, possibly jeopardizing patient safety, particularly in acute care interactions. Periodic stethoscope disinfection, although inconvenient, helps reduce bacterial contamination and may reduce health care-associated infections.

CONCLUSIONS

Stethoscopes were disinfected per CDC guidelines in less than 4% of encounters and were not disinfected at all in 82% of encounters. Although hands were rarely cleaned (6.8%) per CDC guidelines, gloves were usually worn, but no convenient stethoscope equivalent exists. Stethoscope cleanliness must be addressed.

Molecular analysis of bacterial contamination on stethoscopes in an intensive care unit

BACKGROUND

Culture-based studies, which focus on individual organisms, have implicated stethoscopes as potential vectors of nosocomial bacterial transmission. However, the full bacterial communities that contaminate in-use stethoscopes have not been investigated.

METHODS

We used bacterial 16S rRNA gene deep-sequencing, analysis, and quantification to profile entire bacterial populations on stethoscopes in use in an intensive care unit (ICU), including practitioner stethoscopes, individual-use patient-room stethoscopes, and clean unused individual-use stethoscopes. Two additional sets of practitioner stethoscopes were sampled before and after cleaning using standardized or practitioner-preferred methods.

RESULTS

Bacterial contamination levels were highest on practitioner stethoscopes, followed by patient-room stethoscopes, whereas clean stethoscopes were indistinguishable from background controls. Bacterial communities on stethoscopes were complex, and community analysis by weighted UniFrac showed that physician and patient-room stethoscopes were indistinguishable and significantly different from clean stethoscopes and background controls. Genera relevant to healthcare-associated infections (HAIs) were common on practitioner stethoscopes, among which Staphylococcus was ubiquitous and had the highest relative abundance (6.8%-14% of contaminating bacterial sequences). Other HAI-related genera were also widespread although lower in abundance. Cleaning of practitioner stethoscopes resulted in a significant reduction in bacterial contamination levels, but these levels reached those of clean stethoscopes in only a few cases with either standardized or practitioner-preferred methods, and bacterial community composition did not significantly change.

CONCLUSIONS

Stethoscopes used in an ICU carry bacterial DNA reflecting complex microbial communities that include nosocomially important taxa. Commonly used cleaning practices reduce contamination but are only partially successful at modifying or eliminating these communities.