David Levine, PhD, DPT is a professor and the Walter M. Cline Chair of Excellence in Physical Therapy at the University of Tennessee at Chattanooga. His research includes public health epidemiology, control of clinical infectious disease, and Ehlers-Danlos syndrome. He has

David Levine, PhD, DPT

Health care professionals know anything you touch can serve as a reservoir for pathogens. They also know you can transmit or contract a pathogen by coming in contact with a contaminated fomite (inanimate object). As part of our medical education, we were taught fomites can play important roles in the spread of infectious disease.

 Doorknobs and light switches are the usual suspects, but fomites also include countertops, handrails, mobile phones, and clothing.

These items are present in most indoor environments. However, when considering health care facilities, the number and types of fomites increase dramatically, as does the presence of infectious pathogens present in those facilities.

Protocols for the proper disinfection of fomites have been in place for decades. Routine procedures for disinfecting surfaces in health care and other facilities were seriously tested when SARS-CoV-2 appeared in 2020. The spread of COVID-19 prompted questions about its mechanisms of transfer. What was more important to address: person-to-person contact, airborne transfer, or fomite transfer? Not knowing exactly how individuals became infected with COVID-19, early studies suggested the virus could survive on plastic or stainless steel for days, resulting in advice to disinfect everything.

Table. Potential fomites in a neonatal intensive care unit of a children's hospital inpatient clinic

However, even though the COVID-19 virus can survive for days on surfaces, epidemiological data did not support contact with contaminated fomites as the greatest risk for spread of infection. Later studies on the importance of social distancing and mask wearing helped provide a better mechanism to avoid spread of the virus in indoor environments.

 Vaccination is now recognized as the best mechanism to avoid the spread of COVID-19.

Airborne mechanisms are more responsible for the spread of COVID-19 than contact with contaminated fomites, evidence suggests. However, the automatic reaction to disinfect surfaces opened up discussion on fomites as transmission vectors for infectious disease.

For a recent study of a neonatal intensive care unit (NICU) in a local children’s hospital, swab samples were taken from 20 sites in the unit by researchers from the University of Tennessee at Chattanooga’s Clinical Infectious Disease Control (CIDC) Research Unit (

). Results of this study indicated that of the 20 NICU surfaces swabbed, 12 sites (60%) had viable staphylococci and 4 of those sites (20%) had methicillin-resistant 

 However, Centers for Disease Control and Prevention (CDC) guidelines on routine environmental sampling for pathogens in hospitals deemed swab sampling not cost-effective, discouraging its use unless certain criteria (eg, ongoing bacterial infections of unknown etiology) were met.

 As a result, surface contamination of MRSA within this NICU would have gone unnoticed without the work of the CIDC.

Many outpatient clinics also have surfaces that come in contact with patients and act as vectors for infection. The CIDC also conducted studies of selected fomites in a children’s outpatient clinic and physical therapy clinics and looked at devices linked to recovery for hip replacement surgery.

Figure. Inpatient NICU sites with repeated positive swabs for staphylococci

In the children’s outpatient clinic, 72 of 208 (35%) swabs taken over a 6-month period found viable MRSA on the floors and toys that patients played with in the waiting room.

 In general medicine and pulmonary unit rooms of this outpatient clinic, similar levels of contamination were found, with significantly higher levels of MRSA on the general medicine floors than on the pulmonary unit floors (

 In both the inpatient and outpatient clinics, floors are generally not off limits to children sitting or playing. Additionally, any medical instrument in clinic rooms (eg, blood pressure cuff or pen/pencil) that falls to the floor may become contaminated with pathogens present on the floors. Clinics should consider implementing protocols about contact with floors and dropped items.

For outpatient health care workers, including physical therapists (PTs) and occupational therapists (OTs), specific instruments play a critical role in patient therapy. For example, a common therapy in PT clinics is therapeutic ultrasound. This therapy involves not only the ultrasound head but also a coupling gel (usually contained in a bottle) that enhances the efficacy of the ultrasound. In a 2014 study, viable MRSA was observed on nearly 4% of the tips of gel bottles sampled.

 Although viable MRSA was not found on the ultrasound heads, other species of bacteria were found on 35% of the ultrasound heads tested. When ultrasound heads were disinfected using an approved quaternary ammonium-type disinfectant for 30 seconds, only 1 ultrasound head had any living bacteria.9 One option to reduce potential contamination from ultrasound coupling gels would be to use sterilized, single-use packets of gel for each patient.

In a study of physical therapy clinics, 16 of 81 (20%) bottles of lotion and cream used in massage therapy (soft tissue mobilization) had viable bacteria including 

 on the threads of previously opened bottles.

 New bottles of lotion and cream did not have viable bacterial contamination. If protocols are in place to properly disinfect these bottles, risk of infection will decrease.

OTs must be careful with therapy devices that go home with patients, including those for patients recovering from hip replacement surgery. To limit the need for patients to bend over, reacher tools and sock aids help them pick up items from the floor or put their socks on. Both items, particularly during the training period in a clinic, may be shared with other patients.

In a CIDC-sanctioned study of these OT devices, a different tack was taken. By adding living bacterial cultures (

in known quantities to surfaces of these 2 OT devices, the CIDC researchers determined potential survival of the bacteria.

 The reacher tool handles were made of metal, and the sock aids were made of nylon plastic.

Survival of these 3 bacterial species differed on each device. For the plastic sock aids, 7.5% of 

, survival on sock aids was less than 1% after 48 hours. However, when looking at survival of these 3 bacterial species on the metal handle of the reacher tools, the highest percentage of survival at 48 hours was for 

 also survived on the reacher tool handle (4%), but at a lower percentage than for the sock aids. Essentially no surviving 

 was found on the reacher tool after 30 minutes.

Interestingly, results of an earlier study of 

 survival on therapeutic ultrasound heads found close to 25% survival of these cells after 72 hours on the metal surfaces.

 Whether therapeutic devices for PT or OT act as fomites in the spread of infectious disease hinges on disinfection techniques used by the therapists or other end users. Consideration of pathogenic bacteria survival on fomite surfaces should include knowledge of the materials used to make the devices.

Research emphasizes the potential role that fomites play in the spread of infectious disease in inpatient and outpatient clinical environments. This threat is not limited to hospitals; it also spreads via facility floors and any devices patients take home. We should not only ramp up cleaning and disinfection protocols in response to rapidly spreading pathogens such as the COVID-19 virus but also be proactive by minimizing the role fomites play in the spread of infectious diseases.

Zoppi L. What are fomites? News Medical. Updated February 18, 2021. Accessed August 3, 2022.https://www.news-medical.net/health/What-are-Fomites.aspx

Lewis D. COVID-19 rarely spreads through surfaces. So why are we still deep cleaning? 

. 2021;590(7844):26-28. doi:10.1038/d41586-021-00251-4

Science brief: SARS-CoV-2 and surface (fomite) transmission for indoor community environments. Centers for Disease Control and Prevention. Updated April 5, 2021. Accessed August 5, 2022. https://www.cdc.gov/coronavirus/2019-ncov/more/science-and-research/surface-transmission.html

Jayaweera M, Perera H, Gunawardana B, Manatunge J. Transmission of COVID-19 virus by droplets and aerosols: a critical review on the unresolved dichotomy. 

. 2020;188:109819. doi:10.1016/j.envres.2020.109819

Spratt HG, Levine D, Sinha A, See D. Surveillance of staphylococci presence in and around neonate Isolette beds in a neonatal intensive care unit of a children’s hospital. Abstract presented at: Association for Professionals in Infection Control and Epidemiology Annual Meeting; June 13-15, 2022; Indianapolis, IN.

Guidelines for environmental infection control in health-care facilities. Centers for Disease Control and Prevention. 2003. Updated July 2019. Accessed August 5, 2022. https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf

Spratt H, Levine D, Hanks J, et al. Colonization of environmental methicillin-resistant 

 in a newly constructed children’s outpatient clinic. 

. 2020;48(8)(suppl):S15-S58. doi:10.1016/j.ajic.2020.06.023

Levine D, Spratt H, Brunton L, et al. Comparison of viable environmental bacterial prevalence and species in outpatient general medicine and pulmonary units. 

 2020;48(8)(suppl):S15-S58. doi:10.1016/j.ajic.2020.06.024

Spratt HG Jr, Levine D, Tillman L. Physical therapy clinic therapeutic ultrasound equipment as a source for bacterial contamination. 

. 2014;30(7):507-511. doi:10.3109/09593985.2014.900836

Spratt HG Jr, Levine D, Bage J, Giles DK, Collier AG. Topical lotions utilized in outpatient rehabilitation clinics as a potential source of bacterial contamination. 

. 2019;35(2):163-170. doi:10.1080/09593985.2018.1441935

Analyzing the Survival Rate of Clinically Pathogenic Bacteria on Occupational Therapy Devices Used During Full Hip Replacement Rehabilitation

. Honors thesis. The University of Tennessee at Chattanooga; 2021.

Spratt HG Jr, Levine D, McDonald S, et al. Survival of 

. 2019;47(9):1157-1159. doi:10.1016/j.ajic.2019.02.019

Articles

Thorough cleaning and disinfection reduce the role fomites play in the spread of disease.

Inpatient and Outpatient Clinics Must Monitor Fomites as Part of IPC Protocols

Infection Prevention in the NICU From the Physician's Point of View

The neonatal intensive care unit (NICU) in a children’s hospital contains some of the most medically fragile patients in the hospital. Many neonates should also be considered immunocompromised because of incompletely developed immune systems or congenital defects.

 As a result of their immature immune systems, babies in NICUs may develop health care–associated infections (HAIs). The most common HAIs for these neonates are linked to specific indwelling devices, such as central line–associated bloodstream infections (CLABSIs) and pediatric ventilator-associated events (PedVAEs). In a comprehensive study of critically ill children in US hospitals from 2013 to 2018, CLABSI infections in NICU neonates were principally caused by 

 and coagulase-negative staphylococci, with other CLABSI infections caused by 

Because of the immunocompromised nature of these infants, the NICU team must focus on prevention of disease as any infection in a neonate can cause
significant long-term morbidity and possible mortality. Preventing infections in the NICU relies on every member of the NICU team effectively doing their part. Infection preventionists (IPs) assist in leading the multidisciplinary care teams to reduce the threat of infection. These teams include physicians, advanced practice registered nurses, registered nurses, respiratory therapists, and others. According to the American Association of Post-Acute Care Nursing, IPs must establish a program that provides a “safe, sanitary, and comfortable environment” that will help prevent “transmission of communicable diseases and infections” in any hospital unit.

 In the NICU, IPs will help develop protocols to minimize potential transfer of pathogens to neonates. This will include precautions to prevent spread of infections, written standards detailing surveillance of the unit for diseases, and how infections are to be reported. These protocols should include how infected neonates should be isolated to prevent further spread of disease in the unit. IPs will also maintain detailed records of the incidence and type of disease in the unit. They will work with the unit’s medical director to help evaluate the effectiveness of the infection prevention protocols in place, producing periodic reports on the efficacy of the program. Through established methods of quality improvement such as “plan-do-study-act” cycles, IPs will help determine the effectiveness of current practices and how they should be modified to help reduce levels of infection.

In the NICU, the IP will help develop educational materials that will keep unit personnel up-to-date on hand hygiene, cleaning and disinfection procedures, specific procedures to ensure safe use of devices unique to the unit, how to use personal protective equipment, environmental cleaning and disinfection, and verification of staff immunizations.

 When new information on emerging pathogens (eg, multidrug–resistant organisms or novel pathogens) or new environmental disinfectants becomes available, the IP should help disseminate it to the NICU team.

 While helping keep NICU staff knowledgeable about new pathogens or new procedures relevant to the unit, the IP must also be knowledgeable about the changing landscape of federal (eg, OSHA), state, and local laws and regulations that have bearing on the operation of the unit. In theory, if the IP has adequate resources and works proactively with physicians, nurses, and other staff in the unit, development of HAIs in the unit should be kept to a minimum. However, as noted above, HAIs in NICUs continue to be a problem.

One interesting dilemma related to infection prevention in NICUs and other hospital units has been how to deal with pathogens found on environmental surfaces. During the 1970s, as advocated by both the US Centers for Disease Control and Prevention (CDC) and the American Hospital Association, general monitoring of pathogens on surfaces in health care facilities was discontinued because of a perception that HAI rates did not correlate with environmental contamination.

 As a result, between 1970 and 1975 it was estimated that 25% of hospitals in the US reduced their routine environmental culturing.

 Eventually, the CDC established 4 conditions where environmental sampling would be warranted in hospital units. 

One situation in which sampling has been encouraged is to help with outbreaks of disease in a unit when epidemiological evidence points to possible environmental links. This is a situation where a NICU IP would need to obtain new data based on swab sampling of specific sites within the unit. In 1 such study of a NICU, in response to sporadic increases of methicillin-resistant 

 (MRSA) infections in neonates, microbiologists from the University of Tennessee at Chattanooga’s Clinical Infectious Disease Control Research Unit (CIDC) sampled nearly 50 different NICU environmental surfaces and found widespread contamination. In that NICU, the 2 most MRSA-contaminated sites were the return air ducts, which were contaminated with dust, and unit floors.

 By having data to help focus cleaning and disinfecting in the NICU, the IP and medical director were able to reduce the problem that dust plays in the unit, while floor contamination with MRSA remains a continuing problem.1 Additional studies of staphylococcal contamination within this NICU have indicated that other sites, including locations within Isolettes where neonates sleep, have viable MRSA present. Of Isolette sample sites, 25.7% of suction Yankauers swabbed had high levels of viable MRSA (

 This suggests that the work of the IP and the CIDC had not been completed in this NICU. As suggested in CDC guidelines, routine environmental sampling for pathogens in health care facilities is warranted as part of an ongoing process focused on reducing the threat of patient infection.

Henry G. Spratt, Jr, PhD, is the senior microbiologist and professor in the Department of Biology, Geology, and Environmental Science at the University of Tennessee at Chattanooga. His microbial ecologically based research, which now focuses on the presence of viable pathogens in clinic environments, has resulted in over 110 presentations at conferences and over 25 publications.

David Levine, PhD, DPT is a professor and the Walter M. Cline Chair of Excellence in Physical Therapy at the University of Tennessee at Chattanooga. His research includes public health epidemiology, control of clinical infectious disease, and Ehlers-Danlos syndrome. He has presented at over 100 conferences and has over 120 published works.

Silvia Weiss-Reed, MT (ASCP), CIC, is a board-certified infection preventionist at Erlanger Health System and Children’s Hospital with 17 years’ experience. She has a bachelor of science degree in medical technology from Southern Adventist University and served as president of the Greater Chattanooga Area Chapter of the Association for Professionals in Infection Control and Epidemiology in 2012 and 2018. Her previous roles include clinical microbiologist and microbiology supervisor.

Anuj Sinha, DO, is a fellowship-trained neonatologist who serves as neonatology/NICU medical director for Children’s Hospital at Erlanger. Working with the NICU infection preventionist, he has focused on quality improvements aimed at reducing patient infections in the unit.

Infection Prevention in the NICU From the Infection Preventionist's Point of View

Our smallest and often most fragile patients are in the neonatal intensive care unit (NICU). It’s a special place where these patients often face tremendous challenges under the care of dedicated health care workers. As an infection preventionist (IP), I am honored to work alongside the nurses, physicians, and other clinicians in the NICU. I have worked for over 8 years at Presbyterian/St. Luke’s Medical Center and Rocky Mountain Hospital for Children. Our hospital is a regional center for high-risk obstetrics and houses over 70 NICU beds, including 34 beds in the level IV NICU.

Neonates are vulnerable and susceptible to infection, making infection prevention in the NICU a top priority. Three important lessons come to mind as I recall my years helping oversee our NICU patients. Caring for patients in the NICU is a team sport. Physicians, nurses, and all health care workers must collaborate to reduce the risk of infection in the NICU. When we have encountered outbreaks or increases in hospital-acquired infections in our NICU, the entire team comes together to form a plan to prevent infections. We all work constantly to maintain that plan. I often receive after-hours calls when patients are admitted with unusual infections, and we must act quickly to implement the most recent guidelines to prevent the spread of a transmissible disease. As IPs, we rely on clinicians to help us understand the care of NICU patients. Clinicians rely on the IP team to notify the NICU of any important public health alerts, present updates from the latest evidence-based guidelines, and share the results of any new infection prevention studies from other NICUs. This means communication and team buy-in are critical. IPs need to make sure their voices are heard and that they understand the concerns of all. It is important that IPs form trusting relationships with clinicians and that it is easy for doctors and nurses to contact IPs with questions. At my facility we always have an IP on call so that on nights, weekends, or holidays an IP can jump in, answer questions, and support the team.

Complex care means thinking outside the box, and as IPs, we love to take best practices from 1 unit and share the lessons learned across the hospital. But not every infection prevention tactic can be implemented in the NICU the same way it can be in an adult care unit, or even pediatric units. Early in my IP career, I spent the day shadowing 1 of the most experienced NICU nurses at our hospital. I learned so much that day. We looked at many central lines and I was amazed that peripherally inserted central catheter lines could be placed in babies who were so tiny, some just 700 g in weight. I was also introduced to umbilical lines, a special type of central line placed in the umbilicus at birth. Today, I round in the NICUs frequently, but it still amazes me how tiny these patients are. For example, we love products that help stabilize central venous catheters for adult patients, but those products are often too large to use on a neonate, so instead we must make sure that our dressings are able to stabilize catheters or change the way we dress a central line to reduce the risk of dislodgement. Another important consideration in the NICU is that the skin of very premature neonates may be more permeable to topical agents. So when looking at products used in bathing or skin disinfection, it is sometimes pertinent to understand at what gestational age it is safe to use a particular product. As I think through NICU care, I always keep in mind that the products and policies we know and love elsewhere in the hospital may not be appropriate in the NICU.

It is always important to include the patient and their family in the care plan. In the NICU, parents/caregivers play an especially important role in helping ensure infection prevention practices are followed. At our hospital, when a patient in the NICU is identified as infected or colonized with an organism of concern, the IP team meets with the patient’s caregivers. We share how organisms are spread and answer any questions the caregivers have. We demonstrate how to properly wash hands and discuss why transmission-based precautions are important in the hospital to protect all patients. We also spend time talking to parents about central lines or other invasive devices and why it is so important to keep devices secure and ensure dressings are clean to reduce the risk of infection. We believe that caregivers play an important role in reducing the risk of infection.

What I love the most about working in the NICU is that I learn something new every day. I am grateful for the experienced NICU clinicians who have shared their knowledge with me through the years, and I am proud to be a part of the team that serves these patients. We all celebrate every time any of our NICU miracle babies leaves the hospital ready for their new life at home with their family, and know that the hard, smart, and timely work of an IP probably contributed to their success.

Emma Waymire, MPH, CIC, is the director of infection prevention at Presbyterian/St. Luke’s Medical Center and Rocky Mountain Hospital for Children, which serves many specialty populations including adult and pediatric bone marrow transplant programs, high-risk obstetrics, and a level IV NICU. Waymire is passionate about helping protect vulnerable patients from preventable infections.

The smallest hospital patients need extra care to be protected from infectious disease. This article series examines the NICU from both a physician and infection preventionist perspective. 

David Levine, PhD, DPT

Articles

Inpatient and Outpatient Clinics Must Monitor Fomites as Part of IPC Protocols

Infection Prevention Is Key in a Neonatal Intensive Care Unit