Fomites: Small Risk or Real Threat?
By John Roark
A fomite is an inanimate object that serves to transmit an infectious agent from person to person. Any healthcare environment provides a wealth of potential surfaces, and the list has gone from the mundane — table- and countertops — to the once overlooked. Stethoscopes, telephones, computer keyboards, even a physician’s necktie can harbor infectious agents waiting to make the leap.
A study conducted by the American Society of Microbiology sampled 42 neckties worn by male physicians, assistants and medical students in a 500-bed teaching hospital in New York City. The study demonstrated that 47.6 percent of the ties worn by clinicians harbored potential pathogens. “While there is no direct evidence to implicate neckties in the transmission of infection to patients,” the study concluded, “the link between a necktie and the potential for transmission must be considered.”1
Surfaces that come in contact with pathogen-colonized or infected patients can serve as a vector, and the healthcare setting presents a minefield of opportunity. “Germs don’t have feet,” says Tom Bowen, RN, president of Bowen Medical. “They don’t have wings. They don’t have taxicabs or cars. They have to be transported -- that’s the only way they are going to get around. They’ve evolved pretty well by other people moving them. They grow the best germs in a hospital, because of the population. You get all of the resistance, and that resistance is passed on. It’s a vicious circle.”
Bowen’s concerns over exposure to fomites led him to design and patent a disposable blood pressure cuff cover. “It’s a common thing, this contact, and we’re lax about it,” he says. “Everybody’s talking about nuclear biological germ warfare. We’re in it. We’ve got biological warfare going on right now, and we can’t control it. Look at the hospitals: there are 2 million nosocomial infections per year, about 100,000 deaths. The simple instruments that we use like stethoscopes and blood pressure cuffs are never cleaned — they go from person to person. I can see that the diseases just keep getting better and better — they’ve evolved from pretty innocuous little problems to really major dilemmas.”
“Obviously we still think that person-to-person transmission — that is, contaminated hands of healthcare workers — is the major avenue by which antibiotic-resistant pathogens go from patient to patient,” says David J. Weber, MD, MPH, professor of medicine, pediatrics and epidemiology at the University of North Carolina at Chapel Hill. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycinresistant enterocci (VRE), clostridium difficile, and hepatitis virus are able to survive on surfaces long enough to be picked up and passed on.
“You come into the hospital and in contact with healthcare workers, or other patients who have it carry it transiently on their hands,” says Weber. “You now colonize with a more drug-resistant organism. That doesn’t give you the infection; it just means when you get infection through breaches in the host’s defenses, you get a resistant organism that is in turn harder and more costly to treat. You stay longer in the hospital, and in many cases you have a higher mortality by virtue of having acquired the drug-resistant organism.
“There’s no question you can find these resistant bugs on lots of surfaces — small numbers on things like beepers, telephones and computers,” continues Weber. “That doesn’t necessarily mean that that is an important means of transmitting it to the next patient — that remains to be seen. There are certainly things we know. For instance, there are many, many outbreaks in the literature where a contaminated endoscope — be it a bronchoscope or colonoscope — lead to infections in the patient in which it was used. Despite a number of studies that show that there are a number of bacteria on peoples’ stethoscopes, I’m not aware that anyone could actually point to an outbreak and say, ‘It was the doctor’s stethoscope that actually led to the outbreak.’ It’s possible, and we need to watch for that, but that doesn’t necessarily mean that in such low numbers that it’s not significant.”
The Centers for Disease Control and Prevention (CDC)’s Guidelines for Environmental Infection Control in Health-Care Facilities state that, “although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens, these surfaces generally are not directly associated with transmission of infections either to staff or patients. The transferal of microorganisms from environmental surfaces to patients is largely via hand contact with the surface.”2
A risk, however great or small, exists, and products are making their way into the marketplace in response to the hazard. “We’re hearing from a number of different areas, certainly within infection control, that more and more hospitals are moving keyboards and computers into patient rooms,” says Tony Zavaleta, marketing director of IKEY, manufacturer of easy-to-clean industrial keyboards. “Keyboards, by their nature, have hands all over them, and when you throw in the fact that they’re dif.cult to clean, it’s becoming a bigger issue. Every day we hear about more need. Healthcare information technology is growing, and they need equipment that can be disinfected. That’s sometimes hard to come by.”
“You’re never going to give yourself an infection-free environment, but at least you’re trying to limit infection the best you can with something that’s coming in direct contact with the patient,” says Gary Weinberger, MD, FACS, a diplomate of the American Board of Urology, who worked with Ethox Corporation on the development of a disposable cover system for items in patient rooms that are not easily disinfected. “A bedrail or a tabletop is a smooth surface that can be wiped down. The table that patients eat on — it’s got little nooks and crannies, but predominantly what people are touching is the tabletop. Theoretically, you can wipe that down. Telephones and nurse call buttons, you can’t.”
One source of controversy lies in the differences between Europe and the United States when it comes to surface disinfection, says Weber. “In the United States, we recommend that surfaces around the patient — bedside tables, chairs, bedrails and so on — be cleaned with a disinfecting agent as part of the cleaning solution, something that will actually kill bacteria,” he says. “The belief is that we need to break the surfaces around the patient into low-risk surfaces like carpets and high-risk surfaces — things we actually touch, like the bedrails. The belief in the United States is that they potentially serve as a vector and may lead to transmission.
In addition, if you use mop water and you don’t have a disinfectant, very quickly the mop water gets contaminated, and you end up just spreading the contamination. The guidelines already recommend all around the world that certain areas like operating rooms and high-risk patient rooms should be cleaned with a disinfectant. And it’s hard to train people: ‘this room you do, this room you don’t,’ because many of our housekeeping people have a lower education level. It’s easier just to say, ‘do it for everybody.’”
Is the healthcare industry adequately addressing this situation? “I think that people are aware of this; there are debates in the literature,” says Weber. “In general in the United States, we do routine disinfection, terminal cleaning, we do use dinfectants. I think the major focus, and appropriately so, is the need to increase the level of handwashing. That is a big risk, and we do also know that compliance is less than ideal for that.”
“What you try to do is look for where there are breaks in the system,” says Weinberger. “You try to cover yourself for that eventuality.
You can put a sterile cover on everything you have. But if somebody walks in who hasn’t washed their hands and contaminates the cover, what good did you do? What we’ve decided is, let’s come up with a device. Provided that everybody in a hospital does what they’re supposed to do, this will close the loop.”
Bowen, for one, feels that the healthcare industry’s focus on bottom line hinders common sense. “Over the last two to three years, we’ve seen a lot more intelligence in infection control and hospitals in general,” he says. “It’s interesting: in this country we have to be proven that something is a problem.
Even though to me this is just common sense — that if you’ve got a blood pressure cuff and you’re going from one patient to the next and you’re not doing anything to that cover, you’re spreading something. In France, if they think something is useful, they buy it. We sell more outside of this country than we do in the United States. Our system here is more monetarily oriented, instead of patient-care oriented. We’re myopic — we’ve got this narrow vision that we have to have proof. Bottom line, it’s cheaper to do nothing.”
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