Two Ways We Transmit Pathogens to Hospitalized Patients

Lauren M. DiBiase, MS; Valeria Fabre, MD


May 08, 2019

Editorial Collaboration

Medscape &

New Tricks: Bare Below the Elbows

We're still trying to work out how nosocomial drug-resistant pathogens from the environment, including healthcare personnel (HCP), are transmitted to patients to become a source of healthcare-associated infections. HCP-driven interventions can mitigate risk for pathogen transmission, for example, through improved hand hygiene. Another strategy is bare below the elbows (BBE), in which HCPs wear only short sleeves, without wristwatches, bracelets, neckties, or white coats during inpatient clinical care.

But can a voluntary BBE approach work? Compliance with BBE was evaluated by Godbout and colleagues[1] at an 865-bed academic medical center that recommended but did not mandate the BBE approach as part of a bundled horizontal infection prevention platform. Transitioning to BBE was encouraged by conducting intensive staff education and adopting black nylon vests for HCP to wear while on inpatient services. Assessments and feedback were implemented via direct observation by two trained hand hygiene monitors. Monitors observed HCP entering patient rooms and recorded observations using a Web-based application on an electronic device. Observations occurred throughout the hospital on general, acute, and intensive care units (ICUs).

The authors summarized BBE compliance frequencies among HCP during the years 2016 and 2017. The monitors made 74,796 observations of patient encounters across various HCP over the 2-year study period. Overall, HCP compliance with BBE nearly doubled from 2016 to 2017, increasing significantly from 40% to 84% (P < .0001). Each provider type demonstrated statistically significant increases in BBE compliance. Although physicians remained one of the least compliant provider groups, it is notable that they did achieve almost two thirds compliance.

This study demonstrates that although behavioral changes can take time, compliance can increase and a BBE approach can be implemented without a mandate in a large academic medical center. Based on biological plausibility that the BBE approach effectively reduces pathogen transmission at a low likelihood of harm, SHEA expert guidance encourages the adoption of BBE.

Stethoscope Contamination

New molecular techniques are allowing better estimates of causation in healthcare-associated infections. We're finding that it isn't only the hands of HCPs that have the potential to transmit pathogens to patients.

In a recent study, Knecht and colleagues[2] used next-generation sequencing to investigate bacterial contamination of several types of stethoscopes in a medical ICU and the impact of different stethoscope cleaning protocols on bacterial burden. Samples were obtained from 10 unused disposable stethoscopes directly from the box (clean stethoscopes), 20 disposable stethoscopes being used in patients' rooms (patient-room stethoscopes), and 20 standard stethoscopes carried by physicians, nurses, or respiratory therapists (practitioner stethoscopes). Ten additional ICU practitioner stethoscopes were sampled after being cleaned with a standardized protocol of hydrogen peroxide, and 20 additional ICU practitioner stethoscopes were sampled after being cleaned by practitioners using their preferred cleaning methods: hydrogen peroxide wipes (n = 14), alcohol swabs (n = 3), or bleach wipes (n = 3).

Bacterial concentration was highest on the practitioner stethoscopes, lower in patient-room stethoscopes, and lowest in the clean (new) stethoscopes. Practitioner stethoscope samples were characterized by Bacteroides, Granulicatella, Actinomyces, Prevotella, Streptococcus, Staphylococcus, Corynebacterium, and Propionibacterium. Stethoscope cleaning reduced bacterial contamination but could not match the bacterial levels of new, unused stethoscopes.

This study shows that stethoscopes can serve as vectors for nosocomial transfer of bacteria responsible for healthcare-associated infections. Further studies are needed to better understand optimal cleaning methods of nondisposable stethoscopes or the benefits of switching to universal one-time-use stethoscopes.


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