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

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.

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.

A clinical study to evaluate the safe and effective use of a new, single use stethoscope cover to enable reduction in pathogen transmission during auscultation

Objectives

Stethoscopes carry a significant risk for pathogen transmission. Here, the safe use and performance of a new, non-sterile, single-use stethoscope cover (SC), that is impermeable for pathogens, was investigated by different healthcare professionals (HCPs) in the postoperative care setting of an intensive care unit (ICU).

Methods

Fifty-four patients underwent routine auscultations with the use of the SC (Stethoglove^®, Stethoglove GmbH, Hamburg, Germany). The participating HCPs (n = 34) rated each auscultation with the SC on a 5-point Likert scale. The mean ratings of acoustic quality and the SC handling were defined as primary and secondary performance endpoint.

Results

534 auscultations with the SC were performed (average 15.7/user) on the lungs (36.1%), the abdomen (33.2%), the heart (28.8%), or other body-sites (1.9%). No adverse device-effects occurred. The acoustic quality was rated at 4.2 ± 0.7 (mean) with a total of 86.1% of all auscultations being rated at least as 4/5, and with no rating as below 2. The SC handling was rated at 3.7 ± 0.8 (mean) with a total of 96.4% of all auscultations being rated at least 3/5.

Conclusion

Using a real-world setting, this study demonstrates that the SC can be safely and effectively used as cover for stethoscopes during auscultation. The SC may therefore represent a useful and easy-to-implement tool for preventing stethoscope-mediated infections.Study Registration: EUDAMED no. CIV-21-09-037762.

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.

Microbiological Impacts of Decontamination of Stethoscopes and Assessment of Disinfecting Practices among Physicians in Pakistan: A Quality Improvement Survey

The study was conducted to determine bacterial contamination of stethoscopes used by doctors before and after disinfecting with isopropyl alcohol and analyze their practices of disinfecting stethoscopes. Samples from stethoscopes were taken before and after disinfecting with 70% isopropyl alcohol swab with the help of a sterile swab. All swabs were inoculated on Blood and MacConkey agar plates and were examined for growth. Stethoscopes of 78 doctors were sampled which included 45 (58%) males and 33 (42%) females. Before decontamination of diaphragms with isopropyl alcohol, 27 (34.6%) diaphragms had "growth" while 51 (65.4%) had "no growth." After decontamination with isopropyl alcohol, 5 (6.4%) had "growth" while 73 (93.6%) had "no growth." The most common microorganism isolated from stethoscopes' diaphragms was methicillin-resistant Staphylococcus epidermidis (MRSE), that is, 14 out of 78 (17.9%). The survey also evaluated factors associated with contamination of stethoscopes. Most doctors 71(91%) believe that stethoscopes can be a source of infection and 55.1% (N = 43) responded that both diaphragm and bell of stethoscopes can transmit infections. Many doctors (41%, N = 32) reported that "forgetfulness/laziness" was the barrier which they faced regarding stethoscope hygiene followed by "lack of time" (21.8%, N = 17). The contamination rate (66.6%) is highest in those doctors who are using their stethoscopes for 3-5 years. Of them, 30 doctors (38.5%) never decontaminated their stethoscopes among which 17 had growth in their stethoscopes before cleaning with isopropyl alcohol, while three had growth even after decontamination. Most doctors used sanitizer (29.5%) and isopropyl alcohol (25.6%) as cleaning agents.

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.

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.

Community hospital stethoscope cleaning practices and contamination rates

BACKGROUND

In the United States, nosocomial infections are estimated to cause 72,000 annual deaths. The stethoscope, commonly used, is rarely reported as a potential vector. Our study aims to describe stethoscope contamination and the effect of self-reported cleaning practices among health care providers in a community hospital setting.

METHODS

Stethoscopes were collected at random times from health care providers and cultured per standard techniques. Providers answered a structured questionnaire related to their cleaning practices. Differences in bacterial growth rates and the impact of profession, cleaning frequency, and prior sanitization were evaluated.

RESULTS

Of 104 cultured stethoscopes, 44% were from residents and medical students, from which 76% had bacterial growth, and 56% were from attendings, nurses, and respiratory therapists who had 91.4% growth (95% = confidence interval 0.62-0.86 and 0.81-0.96, respectively). Overall, 86.5% of providers claimed disinfection frequency compliant with Center for Disease Control and Prevention guidelines but there were no statistical differences between self-reported cleaning frequency or methods, and the presence of bacteria.

CONCLUSIONS

Most stethoscopes are contaminated with bacteria, the presence of which was not affected by reported cleaning strategies.

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.

Hand Hygiene Among Doctors in Transplant Departments in Poland: A Cross-sectional Survey

INTRODUCTION

Hand hygiene (HH) is often under-discussed in clinical work, but it is hard to overestimate its role in preventing health care associated infections (HCAIs), especially among immunocompromised populations such as transplant patients.

OBJECTIVES

This study aimed to investigate the compliance of doctors in transplant departments in Poland with HH and other selected infection control measures.

MATERIAL AND METHODS

An on-line cross-sectional survey was carried out among doctors from all Polish transplant departments listed by POLTRANSPLANT. The questionnaire addressed HH in different clinical settings and based on the World Health Organization (WHO) "My 5 Moments for Hand Hygiene."

RESULTS

Completed questionnaires were obtained from 204 physicians (49% women; response rate: 24.7%). The lowest proportion of doctors who always comply with HH was observed in 2 out of 5 critical moments for hand hygiene: "before touching a patient" (40.2%) and "after contact with patient surroundings" (21.6%). Most respondents declared correct HH action that they would apply in a particular clinical situation as listed in the survey. More than half of doctors (57.4%) declared disinfecting stethoscopes "before and/or after each use." The lack of alcohol-based hand-rub nearby or nonfunctional containers, daily rush, and occurring emergencies were identified as the main reasons for noncompliance with HH recommendations.

CONCLUSION

Doctors in transplant departments in Poland have a satisfactory level of knowledge about HH in various situations. However, further organizational and educational activities are needed to promote compliance with HH recommendations in health care facilities.

Methods of Disinfecting Stethoscopes: Systematic Review

The aim of this systematic review was to investigate the effectiveness of various disinfection methods available for stethoscopes. In March 2019, we performed a search in PubMed and Scopus using the search terms: "reducing stethoscopes contamination" and "disinfection stethoscopes"; the Mesh terms used in PubMed were "Decontamination/methods" or "Disinfection/methods" and "Stethoscopes/microbiology". Selection criteria were: English language; at least one disinfection method tested. A total of 253 publications were screened. After title, abstract, and full-text analysis, 17 papers were included in the systematic review. Ethanol at 90%, Ethanol-Based Hands Sanitizer (EBHS), triclosan, chlorhexidine, isopropyl alcohol, 66% ethyl alcohol, sodium hypochlorite, and benzalkonium chloride have been proven to lower the presence of bacteria on stethoscopes' surfaces. In addition, alcohol wipes show effective results. A wearable device emitting ultraviolet C by Light-Emitting Diode (LED) resulted efficacious against common microorganisms involved in Healthcare Associated Infections. The cover impregnated with silver ions seemed to be associated with significantly higher colony counts. Instead, copper stethoscopes surface reduced bacterial load. The disinfection of stethoscopes appears to be essential. There are many valid methods available; the choice depends on various factors, such as the cost, availability, and practicality.

Stethoscope disinfection is rarely done in Ethiopia: What are the associated factors?

Introduction

The stethoscope, which is non-critical medical devices and a symbol of healthcare, is likely to be contaminated by pathogenic microorganisms and can play a contributory role in the transmission of hospital-acquired infection. And regular cleaning of the diaphragm of the stethoscope with a suitable disinfectant is decisive. However, in the resource-constrained setting like many healthcare facilities in Ethiopia healthcare provider’s stethoscope disinfection practice and its associated factors have not been well studied so far. Therefore, this study sought to determine stethoscope disinfection practice and associated factors among the healthcare providers in Addis Ababa, Ethiopia.

Methods

A facility-based cross-sectional study was carried out between April and May 2016. For this study, 576 healthcare providers (physicians, health officers, nurses, midwives, and anesthesiologist) were included from 21 healthcare facilities in Addis Ababa. A pre-tested structured questionnaire was used for data collection. Descriptive statistics were computed. Bivariate and multivariable logistic regression analyses were used to identify factors that were significantly associated with stethoscope disinfection after every use.

Results

A total of 546 healthcare providers participated in this study, for a response rate of 94.7%. Two-fifths, 39.7% (95%CI: 35.9, 44.0%) of healthcare providers disinfecting their stethoscope after every use. And a significant number of participants 34.6% (95%CI: 30.8, 38.5%) never disinfect their stethoscope. Three out of four (76.0%) healthcare providers believe that stethoscope contamination can contribute to the transmission of infections. Safe infection prevention practice (AOR = 3.79, 95%CI: 2.45–5.84), awareness on infection prevention guideline (AOR = 1.93; 95%CI: 1.31, 2.82), and favorable attitude towards infection prevention (AOR = 1.73, 95%CI: 1.02, 2.93) were significantly associated with stethoscope disinfection after every use. The study also found that the odds of stethoscope disinfection were likely to be reduced by 79% among physicians than nurses (AOR = 0.21; 95%CI: 0.09, 0.49).

Conclusions

Only a small proportion of healthcare providers disinfect their stethoscopes after every use. Factors such as safe infection prevention practice, awareness on infection prevention guidelines, and favorable attitude towards infection prevention were the independent predictors of stethoscopes disinfection after every use. Hence, promotion of stethoscope hygiene along with an educational program to enhance disinfection compliance in healthcare facilities may have a positive effect.