Multidrug-Resistant Bacteria Found on Patient Hands, Surfaces

Veronica Hackethal, MD

April 16, 2019

Multidrug-resistant organisms (MDROs), or "superbugs," are commonly found on hospitalized patients' hands, investigators report.

The researchers found that 13.3% of patients had MDROs on their hands and that 39.8% of commonly touched surfaces in patients' rooms had MDROs at any time during the patients' hospital stays.

The study is the first to use traditional and advanced molecular testing to show that the organisms on the patients' hands and on room surfaces were the same, suggesting that the organisms spread back and forth.

The study, by Lona Mody, MD, Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School and Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, and colleagues, was published online April 13 in Clinical Infectious Diseases.

"This study highlights the importance of handwashing and environmental cleaning, especially within a healthcare setting where patients' immune systems are compromised. This step is crucial not only for healthcare providers, but also for patients and their families," author Katherine Reyes, MD, said in a press release. Reyes is an infectious disease physician with the Henry Ford Health System in Detroit, Michigan.

"Germs are on our hands; you do not need to see [it] to believe it. And they travel. When these germs are not washed off, they pass easily from person to person and objects to person and make people sick," she added.

For more than 100 years, efforts to control the spread of infections within hospitals have been focused on proper hand hygiene among healthcare workers.

But with that limited focus, the role patients play as reservoirs for infection has been overlooked. As healthcare systems place more emphasis on early mobility of patients, and as more treatments are administered outside of patients' rooms, there is a potential for patients to spread these bugs farther afield in the hospital.

Patients' rooms are thoroughly cleaned between patients. Cleaning techniques are usually effective when used consistently, according to information in a press release provided by Mody.

But that may not be enough to control infections caused by bacteria brought in by patients on admission. Nor might it be enough to control infections that arise after a patient becomes contaminated while in the hospital.

"Hand hygiene narrative has largely focused on physicians, nurses, and other frontline staff, and all the policies and performance measurements have centered on them, and rightfully so," Mody said. "But our findings make an argument for addressing transmission of MDROs in a way that involves patients, too."

The researchers suggest that patient hand hygiene protocols may be needed to decrease transmission of hospital-acquired infections.

They cautioned in a press release that finding MDROs on patients' hands and in their rooms does not mean that the patients will necessarily become infected with drug-resistant organisms. They stressed that proper hand hygiene among healthcare workers remains crucial and that hand transmission remains the primary way bacteria are spread to patients.

"Infection prevention is everybody's business," said Mody. "We are all in this together. No matter where you are, in a healthcare environment or not, this study is a good reminder to clean your hands often, using good techniques — especially before and after preparing food, before eating food, after using a toilet, and before and after caring for someone who is sick — to protect yourself and others."

The study included 399 adults newly admitted to the general medicine floor at two hospitals in southeast Michigan. The mean age of the patients was 60.8 years; 49% were male, 64.4% were white, and 25.3% were African American.

Researchers swabbed the dominant hand and inside the nostrils of patients and sampled six high-touch surfaces in their rooms (bed control/bed rail; call button/television remote; bedside tray tabletop; telephone; toilet seat; and bathroom doorknob). They took samples within 24 hours of the patients' arrivals in their rooms, on days 3 and 7 of hospitalization, and weekly until discharge.

They used traditional methods of microbial surveillance (pulsed field gel electrophoresis) and DNA fingerprinting (polymerase chain reaction) to test samples for the most common MDROs in hospitals: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), and resistant gram-negative bacilli (RGNB), such as Acinetobacter species and Pseudomonas aeruginosa. These techniques allowed the investigators to see whether the bacterial strains on the patients' hands matched those on room surfaces.

The analysis included 710 hand cultures from patients and 4269 room cultures.

At baseline, 10% of patients (56/399) had MDROs on their hands; 7.5% (30/399) had MDROs in their nostrils; and 3.5% (14/399) had MDROs on both. Fourteen of 225 patients (6.2%) acquired new MDROs on their hands during hospitalization, and 13.3% (53/399) had MDROs at any point during admission.

Of those patients with MDROs, 57% (32/56) had MRSA, 36% (20/56) had RGNB, and 14% (8/56) had VRE.

Among the room surfaces that were sampled, 28.8% (n = 115) had MDROs within 24 hours of the patient's arrival in the room, and 21.8% (49/225) acquired new MDROs. At any point during admission, 39.8% (159/399) were contaminated with MDROs.

Among contaminated surfaces, 15% had RGNB, 8.5% had MRSA, and 8% had VRE.

Genetic analysis showed that in most cases, the bacteria that were isolated from patients' hands were the same as those found on high-touch room surfaces. In a subanalysis of 25 visits in which MRSA was found on patients' hands and on high-touch surfaces at the same time, there was 100% similarity for MRSA strains.

That suggests that contamination occurred back and forth between patients and room surfaces, but from the results, it cannot be determined whether the patients contaminated the room surfaces or vice versa.

The authors note several other study limitations. The study could not test rooms before patients arrived in them and could not determine the timing and the means of surface contamination (eg, whether contamination was due to spread from patients or from healthcare workers). The study excluded surgical patients and those transferred from the intensive care unit.

The study was funded by the Centers for Disease Control and Prevention. One or more authors report committee membership and/or personal fees, other fees, or grants from one or more of the following: Xenex, the National Institutes of Health, Doximity, Jvion, Genentech, Medimune, and Contrafect. A complete list of relevant financial relationships is available on the journal's website.

Clin Infect Dis. Published online April 13, 2019. Full text

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