When did the doctors become fomites?

Abstract

The word ‘fomites’ was introduced early in the 19th century from the Latin fomes, to indicate objects or materials that are likely to carry infection, such as clothes, utensils and furniture. Indeed, the role of the environment as a likely significant contributor to hospital-acquired infections (HAI) was proposed even earlier [1]. In 1873, Louis Pasteur in his lecture to the Academie de Medecine noted that, even after cleaning his hands and using heated sponges, he still had to fear germs surrounding patients’ beds [2]. Today, headlines such as ‘Hospitals criticized over hygiene’ (BBC News, 20th December 2010) are common in the news and instigate a negative general public perception that fomites such as uniforms or stethoscopes represent an infection risk for hospitalized patients. Political interest has obviously been raised. An interesting example is the ‘bare below the elbows’ dress code for physicians that was promised to be introduced by the then Secretary of State for Health, Alan Johnson, in 2007, in all acute trusts in England, despite lack of conclusive evidence that white coats pose a significant threat for the spread of HAI [3]. Clear evidence does exist that pathogenic bacteria can survive for months in the hospital environment and can be isolated on clinical equipment, as well as on general surfaces, especially those close to the patient’s area, such as curtains, beds, lockers and over-bed tables [4,5]. Before contact precautions are implemented, methicillin-resistant Staphylococcus aureus (MRSA) carriers may have already contaminated their environment with MRSA. A recent observational study showed that 18% and 35% of MRSA-colonized patients had contaminated the surrounding environmental surfaces 25 h and 33 h after admission, respectively [6]. Cross-transmission between patients may occur via the hands of healthcare workers after they have touched contaminated environmental surfaces [5,7]. There is also some evidence that cleaning removes pathogenic bacteria from the hospital environment with benefit for the patients, especially in epidemic settings. Rampling et al. [8] documented an outbreak of MRSA in a urology ward, which was resistant to the promotion of hand hygiene and contact isolation; it ended only after doubling the number of ward-cleaning hours. However, conclusive proof of the link between environmental contamination and rate of HAI is still lacking. Wilson et al. [9] sampled six environmental sites around randomly selected patients in intensive care units plus two communal sites during periods when MRSA-colonized patients were isolated or not. Study results showed that, although MRSA-colonized patients frequently contaminated their environment, transmission of MRSA from the environment to the patient was not commonly identified [9]. The risk that personnel equipment (white coat, stethoscope, mobile phones, or pagers) used at point of care might be responsible or co-responsible for cross-transmission of pathogenic bacteria to patients was signalled early in the 1970s for the use of stethoscopes [1]. In 1972, Gerken et al. [1] demonstrated that coagulase-positive staphylococci were isolated from 21% of the stethoscopes in a British teaching hospital. The Centers for Disease Control and Prevention advises stethoscope cleanings between patient examinations and the use of dedicated room equipment for patients carrying a communicable disease and in isolation [10]. However, compliance with those procedures is still very low. Whittington et al. [11] showed that while all the intensive care unit nursing staff reported cleaning stethoscopes at least daily, only one-third of medical staff, cleaned their stethoscope at best every month. To further increase the complexity of the problem recent advances in engineering have brought into hospitals a series of new technologies (smartphones, personal digital assistants, mobile phones) usually worn by the doctors, even when attending patients [12]. Interestingly, a market research study found that 65% of physicians in the USA believe that mobile computing devices pose significant risks for the spreading of pathogenic bacteria in hospitalized patients [13]. A systematic review on bacterial contamination of physicians’ mobile phones showed that 9–25% of mobile devices are contaminated with pathogenic bacteria. Levels of MRSA (0–10%), Acinetobacter species (1–12%) and other pathogens range widely according to the local ecology [14]. Ulger et al. sampled 200 mobile phones and the hands of 200 healthcare workers. In total, 94.5% of phones demonstrated evidence of bacterial contamination with different types of bacteria. MRSA was isolated in 13% of mobile phones and 10% of healthcare workers’ hands. Distributions of the