There has been a rise in the data that supports the environment as one of the important modes of pathogen transmission that contributes significantly to hospital acquired infections (HAI).  For example, Gastmeier and his colleagues attributed the source of outbreaks to contaminated surfaces in 21.1% of the 1561 nosocomial outbreaks that they examined (1).

Textiles or environmental soft surfaces are an important part of the infection vector pathway, especially as textile products are widely used in the healthcare industry, and as such can directly contaminate patients and healthcare workers. Textiles can also indirectly contaminate other surfaces, patients and healthcare workers via aerosolization during the bed making process. In addition textiles are an excellent substrate for microbial growth and proliferation, and are also heavily contaminated by patients who typically have higher shedding of microorganisms than healthy individuals.

Textiles as infection vectors

 

 

To help summarize some of the information from today’s blog and our previous blog post reviewing the role of soft surfaces we have created the following infographic which is free for download and available here.

More detail about textiles as a significant risk factor in the environment is outlined below.

 

Textile surfaces or soft surfaces are one of the most environmental surfaces for the following reasons;

  1. Textiles are an excellent substrate for bacterial and fungal growth (discussed in my previous blog post).
  2. The moisture and temperature in the textile microenvironment between the patient and the bed, either in his pajama or directly in the sheet, promotes bacterial proliferation.
  3. Heavy pathogen contamination of medical textiles has been documented (5,6).
  4. Microbial growth in medical textiles can be an important source of pathogenic bacteria that may contaminate patients, personnel and the environment.

Hospital staff, even by using protective equipment such as gloves, can contaminate them by touching the contaminated textiles and then transfer the micro-organisms to other patients directly or indirectly by contaminating other surfaces, such as door knobs.

65% of the nurses who performed activities on patients with MRSA in wounds or urine, contaminated their nursing uniforms or gowns with MRSA. This in turn, readily contaminated the clothing and hands of the healthcare workers (2,7). Similarly, it was found that 42% of personnel who had no direct contact with patients, but had touched different surfaces including bed linens, contaminated their gloves with MRSA (7).

In Japan during a nosocomial outbreak it was found that transmission of Streptococcus pyogenes occurred via contact with a contaminated surface of a vinyl sheet that covered the bed on which the patients were treated (8). The CDC reported that a MRSA spread occurred though indirect contact by touching objects such as towels, sheets, wound dressings and clothes contaminated by the infected skin of a person with MRSA (9). Similarly, an investigation regarding a nosocomial outbreak of Norwalk gastroenteritis revealed that bedding was a significant risk factor (10).

Contamination and infection of patients and hospital personnel via contaminated towels, gowns, sheets, cleaning wipes and other hospital textiles with a variety of pathogens, including antibiotic resistant bacteria, has been widely reported (7,11,12-15).

Contaminated textiles can also contribute to aerosol transmission of pathogens. It was found that bed making releases large quantities of micro-organisms into the atmosphere. Greene et al (16) found that the total viable count (TVC) in a patient room exceeded 6000 CFU/m3 of air during vigorous bed making, which was more than 10 fold higher than the background levels of bacteria found in the air prior to the bed making. Interestingly, they also found approximately two-fold increase in the TVC in the hallways following bed making indicating that the bed making process dispersed micro-organisms around the building. The bacterial count in the air fell back to background levels only 30 min after bed making. Shiomori et al (17) found a 25-26 fold increase in the number of MRSA in the air immediately following bed making. The bacteria levels in the air fell back to background levels within 30 minutes. MRSA was detected following the bed making also on many surfaces, such as bed sheets, over bed tables, and patients’ clothing. Solberg (18) found strong positive correlation between the air counts of staphylococci and patient bed making. Similar results were reported by Noble and Davies (19) in patients following undressing and redressing.

These studies strongly support the notion that disturbance of textiles in clinical settings contribute to the dispersal of pathogens to the air, which then settle down and contaminate the immediate and non-immediate environment. Healthcare workers that touch pathogens in aerosol contaminated surfaces can then transport these pathogens to patients. It has been estimated that the airborne route of transmission accounts for between 10 and 20% of endemic nosocomial infections (20). It has been implicated in nosocomial outbreaks of S. aureus and MRSA in operating theaters, intensive care, burns and orthopedic units (21-23).

References cited in this article

  1. Gastmeier P, Stamm-Balderjahn S, Hansen S et al. Where should one search when confronted with outbreaks of nosocomial infection? Am J Infect Control. 2006;34:603-605.
  2. Beggs CB. The airborne transmission of infection in hospital buildings: fact or fiction? Indoor Built Environ. 2003;12:9-18.
  3. Noble WA. Dispersal of microorganisms from skin. In: Microbiology of human skin, Second Edition. London, Lloyd-Luke Ltd. 1981;77-85.
  4. Coronel D, Escarment J, Boiron A et al. Infection et contamination bacterienne de l’environnement des patients: les draps. Reanimation. 2001;10S:43-44.
  5. S. Fijan and S. S. Turk, “Hospital textiles, are they a possible vehicle for healthcare-associated infections?,” Int.J Environ.Res.Public Health, Vol. 9, No. 9, 2012, pp. 3330-3343.
  6. S. Malnick, R. Bardenstein, M. Huszar, J. Gabbay and G. Borkow, “Pyjamas and sheets as a potential source of nosocomial pathogens,” J Hosp.Infect., Vol. 70, No. 1, 2008, pp. 89-92.
  7. Boyce JM, Potter-Bynoe G, Chenevert C, King T. Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications. Infect Control Hosp Epidemiol. 1997;18:622-627.
  8. Takahashi A, Yomoda S, Tanimoto K, Kanda T, Kobayashi I, Ike Y. Streptococcus pyogenes hospital-acquired infection within a dermatological ward. J Hosp Infect. 1998;40:135-140.
  9. CDC. Fact Sheet. 2007, 
  10. Gustafson TL, Kobylik B, Hutcheson RH, Schaffner W. Protective effect of anticholinergic drugs and psyllium in a nosocomial outbreak of Norwalk gastroenteritis. J Hosp Infect. 1983;4:367-374.
  11. G. A. Noskin, P. Bednarz, T. Suriano, S. Reiner and L. R. Peterson, “Persistent contamination of fabric-covered furniture by vancomycin-resistant enterococci: implications for upholstery selection in hospitals,” Am.J Infect Control, Vol. 28, No. 4, 2000, pp. 311-313.
  12. D. J. Morgan et al, “Transfer of multidrug-resistant bacteria to healthcare workers’ gloves and gowns after patient contact increases with environmental contamination,” Crit Care Med., Vol. 40, No. 4, 2012, pp. 1045-1051.
  13. D. J. Morgan et al, “Frequent multidrug-resistant Acinetobacter baumannii contamination of gloves, gowns, and hands of healthcare workers,” Infect Control Hosp.Epidemiol., Vol. 31, No. 7, 2010, pp. 716-721.
  14. M. Pilonetto et al, “Hospital gowns as a vehicle for bacterial dissemination in an intensive care unit,” Braz.J Infect Dis, Vol. 8, No. 3, 2004, pp. 206-210.
  15. T. Sasahara et al, “Bacillus cereus bacteremia outbreak due to contaminated hospital linens,” Eur.J Clin Microbiol.Infect Dis, Vol. 30, No. 2, 2011, pp. 219-226.
  16. Greene VW, Bond RG, Michaelsen GS. Air handling systems must be planned to reduce the spread of infection. Mod Hosp. 1960;95:136-144.
  17. Shiomori T, Miyamoto H, Makishima K et al. Evaluation of bedmaking-related airborne and surface methicillin-resistant Staphylococcus aureus contamination. J Hosp Infect. 2002;50:30-35.
  18. Solberg CO. A study of carriers of Staphylococcus aureus with special regard to quantitative bacterial estimations. Acta Med Scand Suppl. 1965;436:1-96.
  19. Noble WC, Davies RR. Studies on the dispersal of Staphylococci. J Clin Pathol. 1965;18:16-19.
  20. Brachman PS. Nosocomial respiratory infections. Prev Med. 1974;3:500-506.
  21. Walter CW, Kundsin RB, Brubaker MM. The incidence of airborne wound infection during operation. JAMA. 1963;186:908-913.
  22. Farrington M, Ling J, Ling T, French GL. Outbreaks of infection with methicillin-resistant Staphylococcus aureus on neonatal and burns units of a new hospital. Epidemiol Infect. 1990;105:215-228.
  23. Rutula WA. Environmental study of a methicillin-resistant Staphylococcus aureus epidemic in a burn unit. J Clin Microbiol. 1983;18:683-688.