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Different scenarios, a common thread
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Allow me to sketch several scenarios for you. All are true, and all have occurred only recently.
Scenario 1: In the January issue of American Journal of Infection Control, the journal of the Association of Professionals in Infection Control and Epidemiology (APIC), there was published a brief note by researchers in London titled, “Bacterial counts from hospital doctors’ ties are higher than those from shirts.” (I kid you not!) The investigators sampled shirts and ties from 25 physicians and 25 surgeons and found significantly higher bacterial counts on ties than on the paired shirts. There was a non-significant trend for more surgeons than physicians to have Staphylococcus aureus recovered from their ties or shirts.
The presumed reason for this difference was that the shirts were washed at regular intervals, whereas ties were only rarely cleaned, if ever. This finding appeared to lend support to recent recommendations of the British Medical Association that doctors in hospital settings not wear ties at all. Presumably, wearing bow ties would accomplish the same goal (ie, avoiding ties hanging down and touching the patient during examination, for example.)
Scenario 2: A brief report was published in the February 15 issue of Clinical Infectious Diseases describing the detection of influenza virus particles in air sampling procedures carried out in a hospital emergency department, while patients with influenza-like illness were present. Air sampling was carried out with particle sizing capability, and it was established that more than 50% of the airborne particles that were positive for influenza virus RNA were less than 1 to 4 microns in size, and thus fully respirable. This work supports the belief that influenza may be spread by the airborne route. This work was done in February 2008, a period when influenza A (H3N2) was circulating in the United States.
Scenario 3: On January 8, 2009, The Wall Street Journal published an op-ed piece by Betsy McCaughey, who some readers will recognize as a former lieutenant governor of New York. She also happens to be the chair of the Committee to Reduce Infection Deaths (RID), one of several lay organizations whose goal is to reduce the morbidity and mortality resulting from nosocomial infections. Her column was titled “Hospital Scrubs Are a Germy, Deadly Mess,” with a subtitle “Bacteria on doctor uniforms can kill you.”
The organism causing most concern is Clostridium difficile, though S. aureus and Enterococcus are given passing mention. McCaughey decries wearing hospital scrubs and lab coats in places that they should not be worn, particularly public places, eg, restaurants, outside the hospital.
The common thread
And the common thread: There is a complete lack of clinical correlation in each of them. Normally, most of us would consider the absence of clinical correlation to be a criticism or a deficiency. Indeed, it is intended as a criticism in two of these scenarios, but not in all.
Start with Scenario 2. This is really an exciting bit of research and represents, the investigators believe, the first demonstration of airborne influenza virus particles in a health care environment. And the lack of clinical correlation? The technology simply does not yet exist to quantify the number of viral particles per volume unit of air. Furthermore, we do not yet have a good understanding of the infective dose, which presumably varies somewhat with the level of immunity, if any, of the host. Finally, even if one could maintain close surveillance on a potentially exposed population, there is no good way to rule out other potentially infective exposures in schools, workplaces, homes, etc. Thus the lack or correlation in this instance underscores how much we have yet to learn.
The situation is quite different in scenarios 1 and 3. The infection control literature is replete with examples of this kind of problem; that is, the finding of potential pathogens, sometimes multiply drug-resistant, being found on this or that surface or fomite, with the implication that nosocomial infection will result unless this or that environmental source is controlled – or better yet – eliminated.
Over-bed tables, side curtains, stethoscopes, lab coats, scrubs, plants, cut flowers and the like all have, at one time or another, come under suspicion of being a source of infection. Now add ties. A current favorite is computer keyboards, especially on COWs (computers on wheels), so commonly-used in intensive care units. The keyboards are, not surprisingly, contaminated with MRSA, VRE and, likely, C. difficile as well.
Scenario 3 clearly establishes that the public are concerned about the hospital environment as well. Yet we can hardly fault the Betsy McCaugheys of this world for not worrying too much about clinical correlation when we don’t do it either! We have set the example – and it’s not a good one. The headlines in her editorial (which she may not have written) are simply calculated to scare, to inflame, to alarm and, of course, to attract readers. That said, however, I agree with her main thesis: Scrubs are worn in far too many places and should never be worn outside the hospital in restaurants. It is simply a poor practice that invites public concern.
Interested readers would do well to visit the website of the “Committee to Reduce Infection Deaths” at www.hospitalinfection.org. Many readers will be surprised, not necessarily happily, by its scope. There are “infection prevention kits” containing alcohol rubs, hand washes, alcohol gels, gloves, etc, for patients to use themselves, and presumably also for the use of health care workers who fail to observe the usual precautions. There are also links to states that mandate hospital infection reporting, and up-to-date reports, so that patients may easily compare their hospital to others.
As a health care consumer, I would certainly desire an environment as clean as reasonably possible. How clean is reasonable? Certainly free of visible soiling, especially soiling of human origin, but beyond that? If there were a shred of evidence that the pathogens in the environment that we so readily detect and write about – that they leaped off the surface and into the patient causing infection – without the intermediary of someone’s hands – then I would feel more comfortable about spending the millions of dollars that we do on environmental disinfection. Until there is such evidence, however, I believe we would be ahead of the game if most of the time and resources currently spent on environmental cleaning were devoted instead to hand hygiene programs and promotion.
If this reads like a rant on my part, then it probably is.