Contamination of gowns, gloves, and stethoscopes with vancomycin-resistant enterococci

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.

Activity of antimicrobial examination gloves under realistic conditions: challenge not fulfilled

BACKGROUND

Antimicrobial materials or surfaces are advertised as part of infection prevention bundles. However, the efficacy of such antimicrobial surfaces has not been sufficiently investigated in hospitals. In this study, the antimicrobial activity of examination gloves with light-activated antimicrobial properties against Gram-positive microorganisms was investigated modelling real live conditions.

METHOD

In a standardized experimental set-up with dry and realistic contamination, the antimicrobial properties of gloves claiming light dependent antimicrobial activity against Gram-positive organisms were tested in comparison with conventional examination gloves. All gloves were contaminated through a standardized activity of the test persons for construction with contaminated building blocks. For contamination suspensions of Enterococcus faecium ATCC 6057, Acinetobacter baumannii (outbreak strain), methicillin resistant Staphylococcus aureus ATCC 43300 or E. faecium (VRE) patient isolate were dried on the surfaces. After the standardized activity, the gloves were held for 10 min in the light present in the room (bright conditions) and the grade of contamination was determined subsequently by quantitative culture. In one experimental series gloves were held in a dark box after contamination as a control (dark conditions).

RESULTS

The light intensity in all experiments under bright conditions was significantly above the limit value specified by the manufacturer for the activation of antimicrobial properties (> 500 lx). The mean values for experiments with antimicrobial active and non-active gloves were 955 and 935 lx, respectively. As claimed by the manufacture, the gloves showed no sufficient efficacy against A. baumannii under bright conditions. Against Gram-positive microorganisms such as E. faecium, E. faecium (VRE) and methicillin resistant S. aureus the gloves showed only very low antimicrobial activity with a reduction factor < 1 log10 even after 10 min in bright conditions. Interestingly, comparable results for experiments with A. baumannii and E. faecium were shown under dark conditions.

CONCLUSION

The lack of activity of the active principle against Gram-negative microorganisms could be confirmed. The reduction factors of > 4 log10 within 5 min for Gram-positive microorganisms claimed for the product using a standard test procedure (ASTM D7907) could not be confirmed in a realistic experimental test set-up even after 10 min of light exposure. The effectiveness against Gram-positive microorganisms should be further investigated under realistic (dry) conditions, including patient care. At this stage, the use of supposedly antimicrobial gloves should not be recommended, as the belief in their efficacy may encourage the misuse of gloves.

What's Up Your Sleeve? A Scoping Review of White Coat Contamination and Horizontal Microbial Transmission

OBJECTIVES

White coats have been suggested to serve as fomites carrying and transmitting pathogenic organisms and potentially increasing the risk of healthcare-associated infections (HAIs). We aimed to examine the current evidence regarding white coat contamination and its role in horizontal transmission and HAIs risk. We also examined handling practices and policies associated with white coat contamination in the reviewed literature.

METHODS

We conducted a literature search through PubMed and Web of Science Core Collection/Cited Reference Search, and manually searched the bibliographies of the articles identified in electronic searches. Studies published up to March 3, 2021 that were accessible in English-language full-text format were included.

RESULTS

Among 18 included studies, 15 (83%) had ≥100 participants, 16 (89%) were cross-sectional studies, and 13 (72%) originated outside of the United States. All of the studies showed evidence of microbial colonization. Colonization with Staphylococcus aureus and Escherichia coli was reported in 100% and 44% of the studies, respectively. Antibacterial-resistant strains, including methicillin-resistant Staphylococcus aureus and multidrug-resistant organisms were reported in 8 (44%) studies. There was a lack of studies assessing the link between white coat contamination and HAIs. The data regarding white coat handling and laundering practices showed inconsistencies between healthcare facilities and a lack of clear policies.

CONCLUSIONS

There is robust evidence that white coats serve as fomites, carrying dangerous pathogens, including multidrug-resistant organisms. A knowledge gap exists, however, regarding the role of contaminated white coats in HAI risk that warrants further research to generate the evidence necessary to guide the current attire policies for healthcare workers.

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.

Assessment of healthcare worker's hand hygiene and infection prevention practices of their personal belongings in a healthcare setting: a survey in pre COVID-19 era and literature review on standard disinfection practices

Background

Healthcare workers’ (HCW) hands and personnel belongings are vehicles of transmission of nosocomial infections. Knowledge, attitude, and practice of hand hygiene have been extensively studied suggesting adequate knowledge but poor compliance. Similar data on aprons, mobile phone and stethoscope disinfection practices are lacking. This becomes an extensively important topic of discussion in current COVID-19 pandemic where inadequacy in hygiene practices is devastating.

Aim

To study the knowledge, attitude, and infection prevention practices of HCWs aprons, electronic devices, stethoscopes, and hands.

Methods

A cross sectional questionnaire-based survey was conducted among HCWs of Medicine ward and ICU.

Results

Sixty-six HCWs responded to the survey. Awareness that hands, aprons, mobile phones, stethoscopes could cause cross transmission and knowledge of correct practices was present in majority of the respondents. Hand hygiene was performed by 65.2% of the respondents before touching a patient and 54.5% after touching the patient surroundings while 13.6% performed only when it was visibly soiled. Mobile phones and stethoscopes were disinfected by 13.6 and 30.3% of the respondents after each patient encounter, respectively. Aprons were washed after using them at a stretch for a median duration of 5 days (1-30 days). Forgetfulness, lack of reinforcement, lack of time, inadequate awareness on standard disinfection practices and fear of damaging electronic devices from disinfectants use were reasons for poor compliance.

Conclusions

There is an urgent need to spread awareness and formulate standard guidelines on disinfection practices especially for mobile phones, stethoscopes, and aprons in addition to reinforcing hand hygiene practices.

Chemical disinfectants in ophthalmic practice

The instrumentation used in ophthalmic clinics can be a source of epidemics in health care set up. Contact tonometry with Schiotz or Applanation tonometer is associated with nosocomial epidemic keratoconjunctivitis outbreaks. Recently identified SARS-CoV-2 (COVID -19) spreads mainly via the respiratory route and fomites and can transmit through other body fluids, including tear film. Various ophthalmic instruments can become a common source of spreading cross infections. Chemical disinfection is one of the most common methods employed to decontaminate instruments and environmental surfaces and prevent transmission of infectious pathogens to patients through medical and surgical instruments. Various chemical disinfectants are available with a varied spectrum to work on a different group of organisms. In this article, we briefly cover commonly used chemical disinfectants in ophthalmic practice like Alcohol (Ethyl Alcohol, Isopropyl Alcohol), Chlorine-based solution (mainly Sodium Hypochlorite), Glutaraldehyde, Hydrogen Peroxide, Formaldehyde, Iodophors, and Quaternary Ammonium Compounds

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.

Disinfection of Stethoscope and Non-Infrared Thermometer: Practices of Physicians in Ethiopia in the Era of COVID-19

BACKGROUND

Stethoscopes and non-infrared thermometers are the customary medical equipment used by the physicians on a daily basis, among various patients. With the rise of potential infections in the healthcare facilities and the transmission nature of the current COVID-19 pandemic, consistent and correct disinfections of these devices after each use should not be pardoned. This study, therefore, aimed to assess the level of stethoscope and non-infrared thermometer disinfection practices among physicians involved in direct patient contact during the COVID-19 pandemic.

METHODS

A web-based cross-sectional survey was conducted among physicians working in Ethiopia to assess their practice of stethoscope and non-infrared thermometer disinfection. The online survey was circulated using an anonymous and self-reporting questionnaire via Google form with a consent form appended to it. The developed Google form link was shared with physicians through their email addresses and social media pages. A descriptive summary was computed and presented by tables and figures. Multivariable logistic regression model was used to identify factors associated stethoscope and non-infrared thermometer after every use.

RESULTS

The proportion of stethoscope and non-infrared thermometer disinfections after every use was 13.9% (95% CI: 10.9-17.6) and 20.4% (95% CI: 16.7-24.5), respectively. Taking COVID-19 training (AOR: 2.52; 95% CI: 1.29-4.92) and the availability of stethoscope disinfection materials at the workplace (AOR: 3.03; 95% CI: 1.29-7.10) were significantly increased the odds of stethoscope disinfection after every use. The odds of stethoscope disinfection after every use was significantly decreased for those who reported the use of shared stethoscope (AOR: 0.34; 95% CI: 0.12-0.92).

CONCLUSION

Only a wee share of the respondents reported that they have disinfected their stethoscopes and non-infrared thermometers after every use - possibly jeopardizing both patients and clinicians safety, particularly during the COVID-19 pandemic.

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.

Hygiene practices during clinical training: knowledge, attitudes and practice among a cohort of South Asian Medical students

BACKGROUND

Proper hygienic practices are important in preventing nosocomial infection. This study aimed to determine knowledge, attitudes and practices (KAP) on hand, attire and equipment hygiene during clinical training among medical students at a State Medical Institution in Sri Lanka.

METHODS

This cross-sectional study was conducted among 3rd, 4th and final (5th) year medical students of the Faculty of Medicine, University of Colombo, who had undergone at least 6 months of clinical training. KAP on hand hygiene (HH), attire hygiene (AH) and equipment hygiene (EH) were assessed using a pre-tested, self-administered questionnaire with a Likert-type scale. KAP scores were graded as follows: good ≥75; moderate:74.9-50; unsatisfactory:49.9-25; poor:< 25%. KAP based on duration of training and gender were compared using independent samples t-tests.

RESULTS

Three hundred thirty-three students participated (mean age 24 ± 1.1 years, male: female = 1: 1.2). Combined KAP scores on hand and attire hygiene were moderate (HH:73%, AH:65%) while equipment hygiene was unsatisfactory (EH:47%). Senior students (5th year) had higher combined KAP and knowledge (K) on hand hygiene (HH KAP 75% vs. 72%, p = 0.01; K:72% vs. 67%, p = 0.001) and equipment hygiene (EH KAP 50% vs. 44%, p = 0.001; K:47% vs. 35%, p = 0.001) compared to junior students (3rd/ 4th years). However, they had lower KAP and P scores on attire hygiene (AH KAP 63% vs. 67%, p = 0.006; P:60% vs. 67%, p = 0.004). Female students had better AH compared to male students (KAP:67% vs. 64% p = 0.01; K 71% vs. 66%, p = 0.048; P:66% vs. 62%, p = 0.05).

CONCLUSIONS

Overall, hand hygiene was moderate among medical students and improved with progression of training. Attire hygiene was also graded as moderate but to a lesser extent compared to hand hygiene, lower in males, and declined over time, indicating need for better reinforcement of attire hygiene practices with progression of clinical training. Equipment hygiene was unsatisfactory among most medical students and thus needs to be highlighted as a potential area to be improved during clinical training. This study suggests that knowledge, attitudes and practices on equipment and attire hygiene among medical students was less satisfactory and needs to receive greater emphasis during medical clinical training.

Staff Uniforms and Uniform Policy

Personnel in contact with patients or equipment and textiles should always use the hospital’s work attire. It includes anyone handling food, medicines, textile, waste or cleaning tools. By caring, treating, examining and transporting patients, there will be direct contact between own work clothes and the patient’s cloths/bedding or skin. The same is true when working with used patient equipment such as bedpans, toilet chairs, beds and other aids and working in patient rooms, toilets and bathrooms or when handling bedding and bandages, giving physiotherapy, etc. The work uniform is particularly exposed to organic matter and microbes, for example, in ambulances, in emergency services, in restless and anxious patients and children, during sampling and examination/treatment, etc. In acute wards, the staff is often exposed to splashes from patients, especially blood but also vomit, sputum, pus, faeces and urine. This chapter is focused on practical measures to prevent transmission of infections via contaminated staff uniforms.

Transfer of pathogens to and from patients, healthcare providers, and medical devices during care activity-a systematic review and meta-analysis

OBJECTIVE

The transfer of pathogens may spread antimicrobial resistance and lead to healthcare-acquired infections. We performed a systematic literature review to generate estimates of pathogen transfer in relation to healthcare provider (HCP) activities.

METHODS

For this systematic review and meta-analysis, Medline/Ovid, EMBASE, and the Cochrane Library were searched for studies published before July 7, 2017. We reviewed the literature, examining transfer of pathogens associated with HCP activities. We included studies that (1) quantified transfer of pathogens from a defined origin to a defined destination surface; (2) reported a microbiological sampling technique; and (3) described the associated activity leading to transfer. For studies reporting transfer frequencies, we extracted data and calculated the estimated proportion using Freeman-Tukey double arcsine transformation and the DerSimonian-Laird random-effects model.

RESULTS

Of 13,121 identified articles, 32 were included. Most articles (n=27, 84%) examined transfer from patients and their environment to HCP hands, gloves, and gowns, with an estimated proportion for transfer frequency of 33% (95% confidence interval [CI], 12%-57%), 30% (95% CI, 23%-38%) and 10% (95% CI, 6%-14%), respectively. Other articles addressed transfer involving the hospital environment and medical devices. Risk factor analyses in 12 studies suggested higher transfer frequencies after contact with moist body sites (n=7), longer duration of care (n=5), and care of patients with an invasive device (n=3).

CONCLUSIONS

Recognizing the heterogeneity in study designs, the available evidence suggests that pathogen transfer to HCPs occurs frequently. More systematic research is urgently warranted to support targeted and economic prevention policies and interventions.

Time Effectiveness of Ultraviolet C Light (UVC) Emitted by Light Emitting Diodes (LEDs) in Reducing Stethoscope Contamination

Today it is well demonstrated that stethoscopes can be as contaminated as hands, which are a recognized source of Health-Care Associated Infections (HCAIs). Ultraviolet C (UVC) light has proven disinfection capacity and the innovative UVC technology of Light Emitting Diode (LED) shows several potential benefits. To verify whether the use of UVC LEDs is effective and reliable in stethoscope membrane disinfection after prolonged use, a pre-post intervention study was conducted. A total of 1668 five-minute cycles were performed on two UVC LEDs to simulate their use; thereafter, their disinfection capacity was tested on stethoscope membranes used on a previously auscultated volunteer. Then, a further 1249 cycles were run and finally the LEDs were tested to assess performance in reducing experimental contamination by Staphylococcusaureus, Pseudomonasaeruginosa and Escherichia coli on the stethoscope membrane. Baseline volunteer contamination identified 104 Colony Forming Units (CFUs) while treated Petri dishes had 12 and 15 CFUs (p < 0.001). Statistically significant differences (p < 0.001) were also found relating to the reduction of specific bacteria: in particular, after treatment no CFU were observed for S. aureus and E. coli. UVC LEDs demonstrated the capacity to maintain high levels of disinfection after more than 240 h of use and they were effective against common microorganisms that are causative agents of HCAIs.

Infection Prevention and Control Guideline for Cystic Fibrosis: 2013 Update

The 2013 Infection Prevention and Control (IP&C) Guideline for Cystic Fibrosis (CF) was commissioned by the CF Foundation as an update of the 2003 Infection Control Guideline for CF. During the past decade, new knowledge and new challenges provided the following rationale to develop updated IP&C strategies for this unique population:

1.The need to integrate relevant recommendations from evidence-based guidelines published since 2003 into IP&C practices for CF. These included guidelines from the Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC), the World Health Organization (WHO), and key professional societies, including the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). During the past decade, new evidence has led to a renewed emphasis on source containment of potential pathogens and the role played by the contaminated healthcare environment in the transmission of infectious agents. Furthermore, an increased understanding of the importance of the application of implementation science, monitoring adherence, and feedback principles has been shown to increase the effectiveness of IP&C guideline recommendations.

2.Experience with emerging pathogens in the non-CF population has expanded our understanding of droplet transmission of respiratory pathogens and can inform IP&C strategies for CF. These pathogens include severe acute respiratory syndrome coronavirus and the 2009 influenza A H1N1. Lessons learned about preventing transmission of methicillin-resistantStaphylococcus aureus(MRSA) and multidrug-resistant gram-negative pathogens in non-CF patient populations also can inform IP&C strategies for CF.

[Contamination of workwear in medical doctors and nursing stuff]

BACKGROUND

The hands of medical stuff are the most important vectors for the transmission of pathogens in the hospital. Furthermore a "bare below the elbows dress code" has been introduced in Great Britain.

OBJECTIVES

Aim of this study was to investigate whether workwear contamination of the medical stuff by pathogens is similar to the contamination of their hands and whether wearing workwear is associated with increased transmission risk.

MATERIAL AND METHODS

In total 54 swabs were collected from nursing stuff, medical doctors, patients and hospital work material.

RESULTS

Patients had a statistically significant more dense colonization with bacteria (median = 73 colony-forming units (CFU)), than the sleeves of the doctor's coat (median = 36 CFU, p = 0,005), followed by workwear of the nursing stuff at the end of a shift (median = 23 CFU, p < 0,001) and the hospital work material (median = 15 CFU, p < 0,001). Isolated pathogens were coagulase-negative staphylococci, Staphylococcus aureus, Enterobacter cloacae and Acinetobacter species.

CONCLUSIONS

Contaminated work wear presents a relevant risk for the transmission of pathogens. A "bare below the elbow dress-code" or the daily change of the doctor's coat appear both to represent reasonable measures to reduce the transmission risk of pathogens in hospitals.

Review of a two-year methicillin-resistant Staphylococcus aureus screening program and cost-effectiveness analysis in Singapore

Background

Methicillin-resistant Staphylococcus aureus (MRSA) poses an increasingly large disease and economic burden worldwide. The effectiveness of screening programs in the tropics is poorly understood. The aims of this study are: (i) to analyze the factors affecting MRSA colonization at admission and acquisition during hospitalization and (ii) to evaluate the cost-effectiveness of a screening program which aims to control MRSA incidence during hospitalization.

Methods

We conducted a retrospective case–control study of patients admitted to the Communicable Disease Centre (CDC) in Singapore between Jan 2009 and Dec 2010 when there was an ongoing selective screening and isolation program. Risk factors contributing to MRSA colonization on admission and acquisition during hospital stay were evaluated using a logistic regression model. In addition, a cost-effectiveness analysis was conducted to determine the cost per disability-adjusted life year (DALY) averted due to implementing the screening and isolation program.

Results

The average prevalence rate of screened patients at admission and the average acquisition rate at discharge during the study period were 12.1 and 4.8 % respectively. Logistic regression models showed that older age (adjusted odds ratio (OR) 1.03, 95 % CI 1.02–1.04, p < 0.001) and dermatological conditions (adjusted OR 1.49, 95 % CI 1.11–1.20, p = 0.008) were independently associated with an increased risk of MRSA colonization at admission. Age (adjusted OR 1.02, 95 % CI 1.01–1.03, p = 0.002) and length of stay in hospital (adjusted OR 1.04, 95 % CI 1.03–1.06, p < 0.001) were independent factors associated with MRSA acquisition during hospitalization. The screening and isolation program reduced the acquisition rate by 1.6 % and was found to be cost saving. For the whole study period, the program cost US$129,916, while it offset hospitalization costs of US$103,869 and loss of productivity costs of US$50,453 with −400 $/DALY averted.

Discussion

This study is the first to our knowledge that evaluates the cost-effectiveness of screeningand isolation of MRSA patients in a tropical country. Another unique feature of the analysis is the evaluationof acquisition rates among specific types of patients (dermatological, HIV and infectious disease patients)and the comparison of the cost-effectiveness of screening and isolation between them.

Conclusions

Overall our results indicate high MRSA prevalence that can be cost effectively reduced by selective screening and isolation programs in Singapore.

Gloves, gowns and masks for reducing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in the hospital setting

BACKGROUND

Meticillin-resistant Staphylococcus aureus (MRSA; also known as methicillin-resistant S aureus) is a common hospital-acquired pathogen that increases morbidity, mortality, and healthcare costs. Its control continues to be an unresolved issue in many hospitals worldwide. The evidence base for the effects of the use of gloves, gowns or masks as control measures for MRSA is unclear.

OBJECTIVES

To assess the effectiveness of wearing gloves, a gown or a mask when contact is anticipated with a hospitalised patient colonised or infected with MRSA, or with the patient's immediate environment.

SEARCH METHODS

We searched the Specialised Registers of three Cochrane Groups (Wounds Group on 5 June 2015; Effective Practice and Organisation of Care (EPOC) Group on 9 July 2013; and Infectious Diseases Group on 5 January 2009); CENTRAL (The Cochrane Library 2015, Issue 6); DARE, HTA, NHS EED, and the Methodology Register (The Cochrane Library 2015, Issue 6); MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations (1946 to June week 1 2015); EMBASE (1974 to 4 June 2015); Web of Science (WOS) Core Collection (from inception to 7 June 2015); CINAHL (1982 to 5 June 2015); British Nursing Index (1985 to 6 July 2010); and ProQuest Dissertations & Theses Database (1639 to 11 June 2015). We also searched three trials registers (on 6 June 2015), references list of articles, and conference proceedings. We finally contacted relevant individuals for additional studies.

SELECTION CRITERIA

Studies assessing the effects on MRSA transmission of the use of gloves, gowns or masks by any person in the hospital setting when contact is anticipated with a hospitalised patient colonised or infected with MRSA, or with the patient's immediate environment. We did not assess adverse effects or economic issues associated with these interventions.We considered any comparator to be eligible. With regard to study design, only randomised controlled trials (clustered or not) and the following non-randomised experimental studies were eligible: quasi-randomised controlled trials (clustered or not), non-randomised controlled trials (clustered or not), controlled before-and-after studies, controlled cohort before-after studies, interrupted time series studies (controlled or not), and repeated measures studies. We did not exclude any study on the basis of language or date of publication.

DATA COLLECTION AND ANALYSIS

Two review authors independently decided on eligibility of the studies. Had any study having been included, two review authors would have extracted data (at least for outcome data) and assessed the risk of bias independently. We would have followed the standard methodological procedures suggested by Cochrane and the Cochrane EPOC Group for assessing risk of bias and analysing the data.

MAIN RESULTS

We identified no eligible studies for this review, either completed or ongoing.

AUTHORS' CONCLUSIONS

We found no studies assessing the effects of wearing gloves, gowns or masks for contact with MRSA hospitalised patients, or with their immediate environment, on the transmission of MRSA to patients, hospital staff, patients' caregivers or visitors. This absence of evidence should not be interpreted as evidence of no effect for these interventions. The effects of gloves, gowns and masks in these circumstances have yet to be determined by rigorous experimental studies, such as cluster-randomised trials involving multiple wards or hospitals, or interrupted time series studies.

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.

Eradication of a Large Outbreak of a Single Strain of vanB Vancomycin-ResistantEnterococcus faeciumat a Major Australian Teaching Hospital

Objective:

To demonstrate that nosocomial transmission of vancomycin-resistant enterococci (VRE) can be terminated and endemicity prevented despite widespread dissemination of an epidemic strain in a large tertiary-care referral hospital.

Interventions:

Two months after the index case was detected in the intensive care unit, 68 patients became either infected or colonized with an epidemic strain of vanB vancomycin-resistantEnterococcus faeciumdespite standard infection control procedures. The following additional interventions were then introduced to control the outbreak: (1) formation of a VRE executive group; (2) rapid laboratory identification (30 to 48 hours) using culture and polymerase chain reaction detection ofvanA andvanBresistance genes; (3) mass screening of all hospitalized patients with isolation of carriers and cohorting of contacts; (4) environmental screening and increased cleaning; (5) electronic flagging of medical records of contacts; and (6) antibiotic restrictions (third-generation cephalosporins and vancomycin).

Results:

A total of 19,658 patient and 24,396 environmental swabs were processed between July and December 2001. One hundred sixty-nine patients in 23 wards were colonized with a single strain of vanB vancomycin-resistantE. faecium.Introducing additional control measures rapidly brought the outbreak under control. Hospital-wide screening found 39 previously unidentified colonized patients, with only 7 more nonsegregat-ed patients being detected in the next 2 months. The outbreak was terminated within 3 months at a cost of $2.7 million (Australian dollars).

Conclusion:

Despite widespread dissemination of VRE in a large acute care facility, eradication was achievable by a well-resourced, coordinated, multifaceted approach and was in accordance with good clinical governance.

Colonization of Personal Digital Assistants Carried by Healthcare Professionals

This study evaluated personal digital assistant (PDA) microbial colonization before and after cleaning with alcohol. Samples from 75 PDAs were processed. Before cleaning, 96% of the samples were culture positive. After cleaning, 75% became culture negative. PDAs cleaned with an alcohol swab demonstrated significant reduction in colonization.

Stethoscope Hygiene: Practice and Attitude of Medical Students

OBJECTIVE

The purpose of this study was to evaluate the frequency and attitude of medical students towards cleaning their stethoscopes.

SUBJECTS AND METHODS

A cross-sectional study was carried out in the first week of December 2013. The study included 771 students (397 in their fourth and 374 in their sixth year) from the Faculty of Medicine, University of Belgrade, Serbia. An anonymous questionnaire was distributed to students before the start of compulsory lessons in classrooms.

RESULTS

317 of the 397 fourth-year students (79.8%) and 306 of the 374 sixth-year students (81.9%) cleaned their stethoscope. The stethoscope diaphragm was most commonly cleaned, while the flexible tubing was the least commonly cleaned area, mainly using ethyl alcohol-based agents. The strongest positive attitude was observed for the statement 'It is important that my stethoscope is clean' (4.3 out of 5.0). A positive correlation (Spearman's x03C1; = 0.105) was observed between a higher frequency of cleaning and the stronger positive notion that a stethoscope should be cleaned.

CONCLUSION

A considerably high proportion of the students studied had ever cleaned their stethoscopes. Based on the students' responses, it would be useful to implement instructions on stethoscope hygiene in the regular practical curriculum with the aim of applying stethoscope disinfection in daily work.

Controlling hospital-acquired infection: focus on the role of the environment and new technologies for decontamination

There is increasing interest in the role of cleaning for managing hospital-acquired infections (HAI). Pathogens such as vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), multiresistant Gram-negative bacilli, norovirus, and Clostridium difficile persist in the health care environment for days. Both detergent- and disinfectant-based cleaning can help control these pathogens, although difficulties with measuring cleanliness have compromised the quality of published evidence. Traditional cleaning methods are notoriously inefficient for decontamination, and new approaches have been proposed, including disinfectants, steam, automated dispersal systems, and antimicrobial surfaces. These methods are difficult to evaluate for cost-effectiveness because environmental data are not usually modeled against patient outcome. Recent studies have reported the value of physically removing soil using detergent, compared with more expensive (and toxic) disinfectants. Simple cleaning methods should be evaluated against nonmanual disinfection using standardized sampling and surveillance. Given worldwide concern over escalating antimicrobial resistance, it is clear that more studies on health care decontamination are required. Cleaning schedules should be adapted to reflect clinical risk, location, type of site, and hand touch frequency and should be evaluated for cost versus benefit for both routine and outbreak situations. Forthcoming evidence on the role of antimicrobial surfaces could supplement infection prevention strategies for health care environments, including those targeting multidrug-resistant pathogens.

Antimicrobial and biocide resistance of bacteria in a Lebanese tertiary care hospital

The environment in a Lebanese tertiary-level care hospital was examined for bacterial contamination. In total, 8 open-air and 62 surface samples were taken and CFU were enumerated. Morphologically different isolates (n=104) were obtained and tested for resistance to a wide range of antibiotics by the Kirby-Bauer disc diffusion method. Minimum bactericidal concentrations of isolates to seven different biocides used within this facility were also determined using both qualitative and quantitative methods. Gram-positive bacteria (82.7% of isolates) were encountered more often than Gram-negative bacteria (17.3%), and the genus Staphylococcus was most prevalent among isolates (59.6% of the isolates). Gram-positive isolates showed the highest resistance to penicillin (60.6%), clindamycin (54.5%) and ceftazidime (39.4%); the lowest frequencies of resistance were seen with vancomycin (0% of isolates), nitrofurantoin (3.5%), tetracycline (12.1%) and ciprofloxacin (12.1%). The prevalence of meticillin-resistant Staphylococcus aureus (MRSA) and meticillin-resistant coagulase negative staphylococci among all environmental samples was 3.8% and 11.5% of isolates, respectively. All Gram-negative isolates were multidrug-resistant (MDR). With respect to biocides, the highest frequency of resistance was to quaternary ammonium compounds (QACs) (13.5% of isolates) and the lowest frequency of resistance was to QAC/biguanide complex (<1% of isolates) and Anios DVA (3.8%). MDR bacteria can pose a serious threat in the hospital environment, showing the need for prudent use of antibiotics and correct infection control procedures.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Improving stethoscope disinfection at a children's hospital

OBJECTIVE

Stethoscopes are contaminated with pathogenic bacteria and pose a risk for transmission of infections, but few clinicians disinfect their stethoscope after every use. We sought to improve stethoscope disinfection rates among pediatric healthcare providers by providing access to disinfection materials and visual reminders to disinfect stethoscopes.

DESIGN

Prospective intervention study.

SETTING

Inpatient units and emergency department of a major pediatric hospital.

PARTICIPANTS

Physicians and nurses with high anticipated stethoscope use.

METHODS

Baskets filled with alcohol prep pads and a sticker reminding providers to regularly disinfect stethoscopes were installed outside of patient rooms. Healthcare providers' stethoscope disinfection behaviors were directly observed before and after the intervention. Multivariable logistic regression models were created to identify independent predictors of stethoscope disinfection.

RESULTS

Two hundred twenty-six observations were made in the preintervention period and 261 in the postintervention period (83% were of physicians). Stethoscope disinfection compliance increased significantly from a baseline of 34% to 59% postintervention (P < .001). In adjusted analyses, the postintervention period was associated with improved disinfection among both physicians (odds ratio [OR], 2.3 [95% confidence interval (CI), 1.4-3.5]) and nurses (OR, 14.3 [95% CI, 4.6-44.6]). Additional factors independently associated with disinfection included subspecialty unit (vs general pediatrics; OR, 0.5 [95% CI, 0.3-0.8]) and contact precautions (OR, 2.3 [95% CI, 1.2-4.1]).

CONCLUSIONS

Providing stethoscope disinfection supplies and visible reminders outside of patient rooms significantly increased stethoscope disinfection rates among physicians and nurses at a children's hospital. This simple intervention could be replicated at other healthcare facilities. Future research should assess the impact on patient infections.

Strategies to minimize antibiotic resistance

Antibiotic resistance can be reduced by using antibiotics prudently based on guidelines of antimicrobial stewardship programs (ASPs) and various data such as pharmacokinetic (PK) and pharmacodynamic (PD) properties of antibiotics, diagnostic testing, antimicrobial susceptibility testing (AST), clinical response, and effects on the microbiota, as well as by new antibiotic developments. The controlled use of antibiotics in food animals is another cornerstone among efforts to reduce antibiotic resistance. All major resistance-control strategies recommend education for patients, children (e.g., through schools and day care), the public, and relevant healthcare professionals (e.g., primary-care physicians, pharmacists, and medical students) regarding unique features of bacterial infections and antibiotics, prudent antibiotic prescribing as a positive construct, and personal hygiene (e.g., handwashing). The problem of antibiotic resistance can be minimized only by concerted efforts of all members of society for ensuring the continued efficiency of antibiotics.

Microbial colonization of electrocardiographic telemetry systems before and after cleaning

BACKGROUND

Nosocomial infections caused by multidrug-resistant organisms are commonly associated with longer hospital stays up to 12 to 18 days and annual estimated costs of $5.7 billion to $6.8 billion. One common mode of transmission is cross-contamination between patients and providers via surface contaminants on devices such as telemetry systems.

OBJECTIVES

To determine the effect of a cleaning protocol on colonization of surface contaminants on electrocardiographic telemetry systems in 4 cardiovascular step-down units and to compare colonization in medical vs surgical units.

METHODS

A prospective, randomized, case-controlled study (the Descriptive Evaluation of Electrocardiographic Telemetry Pathogens [DEET] study) was designed to evaluate microbial colonization on telemetry systems before and after cleaning with sodium hypochlorite wipes. Each randomly selected telemetry system served as its own control. Nurses used a standardized culture technique recommended by personnel in infection control. Colonization before and after cleaning was analyzed by using the McNemar test and frequency tables. A standard cost-comparison analysis was conducted.

RESULTS

A total of 30 telemetry systems in medical units and 29 in surgical units were evaluated; 41 telemetry systems (69%) were colonized before the intervention, and 14 (24%) were colonized after it (P < .001). Before cleaning, surface organisms were present in 14 instances (35%) in surgical units and in 27 instances (66%) in medical units (P < .001). The cleaning strategy was cost-effective.

CONCLUSIONS

The cleaning intervention was effective, and cost-comparison analysis supported implementing a cleaning strategy for reusable leads rather than investing in disposable leads.

The effect of glove material upon the transfer of methicillin-resistant Staphylococcus aureus to and from a gloved hand

BACKGROUND

Although disposable gloves can protect the hands of a health care worker from acquiring bacteria, during patient care the glove surface itself can become heavily contaminated making cross transmission via contaminated gloved hands likely. The aim of this study was to determine whether the type of glove worn by health care workers could influence the spread of methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

Laboratory studies were conducted to assess the ease with which MRSA was transferred between different types of glove and surfaces likely to be found within the ward environment.

RESULTS

In the absence of simulated body fluid, mean bacterial transfer to and from the different gloves ranged from 0.1% to 16% and from 0.01% to 19.5%, respectively. Glove material and glove hydrophobicity were identified as the 2 most important factors influencing bacterial transfer. Nitrile gloves were associated with the lowest transfer rates. The highest numbers of bacteria were transferred to and from the most hydrophilic and most hydrophobic glove, respectively. The adsorption of simulated body fluids altered the physiochemical properties of the gloves. Bacterial transfer significantly increased and was similar to and from all glove types.

CONCLUSION

Disposable glove type can affect cross-contamination rates among patient, health care worker, and environment. Nonetheless, choice of glove should be considered less important than the correct use of gloves and proper hand hygiene.

Predictors of stethoscope disinfection among pediatric health care providers

BACKGROUND

Stethoscopes are contaminated with bacteria, but predictors of stethoscope disinfection frequency are unknown. We sought to describe health care provider stethoscope disinfection attitudes and practices and determine predictors of frequent disinfection.

METHODS

We used an anonymous online survey of nurses, nurse practitioners, and physicians at a pediatric hospital. We assessed frequency and methods of disinfection, perceptions of contamination, and barriers to disinfection. Multivariate logistic regression models were used to identify independent predictors of disinfecting after every use.

RESULTS

One thousand four hundred one respondents completed the survey: 76% believed that infection transmission occurs via stethoscopes, but only 24% reported disinfecting after every use. In multivariate analyses, belief that infection transmission occurs via stethoscopes significantly increased the odds of disinfection after every use (odds ratio [OR], 2.06 [95% confidence interval (CI): 1.38-3.06]). The odds of disinfection after every use were significantly decreased in those who perceived the following barriers: lack of time (OR, 0.31 [95% CI: 0.18-0.54]), lack of access to disinfection material (OR, 0.41 [95% CI: 0.29-0.57]), or lack of visual reminders to disinfect (OR, 0.22 [95% CI: 0.14-0.34]).

CONCLUSION

Only a minority of pediatric health care providers reported disinfecting their stethoscopes after every use. Increasing access to disinfection materials and visual reminders in health care facilities may improve stethoscope disinfection practices.

Comparison of PCR/electron spray ionization-time-of-flight-mass spectrometry versus traditional clinical microbiology for active surveillance of organisms contaminating high-use surfaces in a burn intensive care unit, an orthopedic ward and healthcare workers

Background

Understanding nosocomial pathogen transmission is restricted by culture limitations. Novel platforms, such as PCR-based electron spray ionization-time-of-flight-mass spectrometry (ESI-TOF-MS), may be useful as investigational tools.

Methods

Traditional clinical microbiology (TCM) and PCR/ESI-TOF-MS were used to recover and detect microorganisms from the hands and personal protective equipment of 10 burn intensive care unit (ICU) healthcare workers providing clinical care at a tertiary care military referral hospital. High-use environmental surfaces were assessed in 9 burn ICU and 10 orthopedic patient rooms. Clinical cultures during the study period were reviewed for pathogen comparison with investigational molecular diagnostic methods.

Results

From 158 samples, 142 organisms were identified by TCM and 718 by PCR/ESI-TOF-MS. The molecular diagnostic method detected more organisms (4.5 ± 2.1 vs. 0.9 ± 0.8, p < 0.01) from 99% vs. 67% of samples (p < 0.01). TCM detected S. aureus in 13 samples vs. 21 by PCR/ESI-TOF-MS. Gram-negative organisms were less commonly identified than gram-positive by both methods; especially by TCM. Among all detected bacterial species, similar percentages were typical nosocomial pathogens (18-19%) for TCM vs. PCR/ESI-TOF-MS. PCR/ESI-TOF-MS also detected mecA in 112 samples, vanA in 13, and KPC-3 in 2. MecA was associated (p < 0.01) with codetection of coagulase negative staphylococci but not S. aureus. No vanA was codetected with enterococci; one KPC-3 was detected without Klebsiella spp.

Conclusions

In this pilot study, PCR/ESI-TOF-MS detected more organisms, especially gram-negatives, compared to TCM, but the current assay format is limited by the number of antibiotic resistance determinants it covers. Further large-scale assessments of PCR/ESI-TOF-MS for hospital surveillance are warranted.

White coats as a vehicle for bacterial dissemination

INTRODUCTION

White coats are known to be potential transmitting agents of multi-drug resistant organisms. This study was conducted to determine the level and type of microbial contamination present on the white coats of medical students in order to assess the risk of transmission of pathogenic micro-organisms by this route in a hospital setting.

MATERIALS AND METHODS

A cross sectional survey of the bacterial contamination of white coats in a tertiary care hospital. 100 medical students working in various specialties were included in the study. Swabs were taken from 4 different areas of the white coat - collar, pocket, side and lapel and processed in the Microbiology department according to standard procedures.

RESULTS

Although most of the white coats had been washed within the past 2 weeks, the sides of the coats were the most highly contaminated areas followed closely by the collar and pockets. Staphylococcus aureus was the most common isolate followed by coagulase negative Staphylococci and Gram negative non fermenters. Most of the Gram positive cocci were resistant to Penicillin, Erythromycin and Clindamycin.

CONCLUSION

White coats have been shown to harbor potential contaminants and may have a role in the nosocomial transmission of pathogenic microorganisms. Thus, a yearly purchase of white coats and the possession of two or more white coats at any point in time should be made compulsory. There is pressing need to promote scrupulous hand washing before and after attending patients and alternatives to white coats, including universal use of protective gowns, should be considered.

Vestuário de profissionais de saúde como potenciais reservatórios de microrganismos: uma revisão integrativa

Objetivou-se identificar na literatura, artigos sobre a ocorrência de contaminação por microrganismos, em jalecos, aventais e uniformes dos profissionais de saúde, e a similaridade com aqueles associados às Infecções Relacionadas à Assistência à Saúde, considerando o perfil de resistência aos antimicrobianos. Realizou-se busca por artigos nas seguintes bases de dados: MEDLINE, LILACS e SCOPUS, publicados entre 2000 e 2010. Foram selecionados nove artigos. Os estudos evidenciaram a contaminação dos jalecos, aventais e uniformes. Nos estudos analisados, verificou-se a presença de bactérias, principalmente, nos bolsos, punhos e região abdominal. Quanto ao perfil de sensibilidade, verificou-se recuperação de Staphylococcus aureus meticilina resistente, seguidos dos Gram negativos resistentes aos antimicrobianos. Identificou-se semelhança entre as cepas isoladas no vestuário dos profissionais de saúde e aquelas relacionadas à ocorrência de infecções. Assim, jalecos, aventais e uniformes devem ser considerados na cadeia de disseminação de microrganismos resistentes.