Do linens and environmental soft surfaces playing a role in the infection process?

Textile products, also called soft surfaces are widely used in the hospital environment. Some of these textiles products or soft surfaces are in direct contact with the patients, such as blankets, sheets, pyjamas, towels, gowns, and pillowcases. Other fabric or textile products are used by the healthcare personnel, such as uniforms or scrubs, surgical gowns, as well as a wide range of Personal Protective Equipment including barrier gowns, face masks, wipes,  head and shoe covers. Some products are also present in the patient wards, such drapes, table covers and privacy curtains.

Textiles in general, are an excellent substrate for microbial proliferation when in contact with the human body as they provide an ideal environment for microbial proliferation. Some of those characteristics include;

1. the very large surface area,
2. the capacity to retain oxygen,
3. the moisture and temperature conditions present between the skin and the textiles.

Humans shed bacteria directly from their skin, nasal cavities, genitalia area, and sweat onto the textiles they use (1). Bacterial shedding is greater in patients than in healthy individuals (2, 3). In addition, hospital textiles come into contact with a range of challenges and insults including spillages and body exudates, such as blood, stool, urine, nasopharyngeal secretions and vomit. These challenges can contain a large amount of bacteria,  and can also serve as a bacterial nutrient source.

Heavy microbial colonization of medical textiles including sheets, patient pajamas, healthcare worker uniforms, and privacy curtains, including by antibiotic resistant bacteria, has been reported [4-11].

Bacteria, fungi and viruses can remain viable on textiles, under ambient temperature and humidity, for very prolonged periods of time; even months [11-18]. Some microorganisms remain viable even after industrial laundering of medical textiles [19,20].Microorganisms that multiply or remain on the textiles can be a source of healthcare-acquired pathogens [5].

Figure 1 summarizes potential transmission routes of pathogens from a colonized or infected patient to a susceptible patient via hospital textiles. Contamination and healthcare-acquired infections (HAI) 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 (e.g. [7,11,13-15,21]).

When handling contaminated textiles hospital personnel can contaminate their gloves with micro-organisms and then contaminate other surfaces, such as door knobs, and even patients directly [3,7,12-14].

Furthermore, studies have shown that when the personnel change the bed linens or patients garments, large quantities of micro-organisms are released into the air, which then contaminate the immediate and non-immediate surroundings in the same room as well as throughout the building via the air conditioning system [3,22]. Healthcare workers who touch the aerosol contaminated surfaces can then contaminate patients [3]. Airborne transmission of pathogens such as Mycobacterium tuberculosis and Aspergillus niger is well documented [3]. It has also been implicated in healthcare-acquired outbreaks of A. baumannii, P. aeruginosa, Scedosporium prolificans, S. aureus, MRSA, and other Staphylococci spp (e.g. [14, 23, 24]).

As outlined in Figure 1, there are numerous routes for transmission of pathogenic organisms from soft surfaces to susceptible patients. We have also reviewed in this post how pathogenic organisms are present on a wide range of medical textiles, that those microorganisms can grow and proliferate on textiles as well as survive for months at a time. In addition we have also reviewed how contaminated textiles can lead to other surface contamination and patient contamination.

If you have any thoughts on linens as a source of infection please comment below.

 

References cited in this article

1. W. A. Noble, “Dispersal of microorganisms from skin. In: Microbiology of human skin, Second Edition.,”       London, Lloyd-Luke Ltd, Vol. 1981, pp. 77-85.
2. D. Coronel et al, “Infection et contamination bacterienne de l’environnement des patients: les draps,” Reanimation, Vol. 10S, No. 2001, pp. 43-44.
3. C. B. Beggs, “The airborne transmission of infection in hospital buildings: fact or fiction?,” Indoor Built Environ, Vol. 12, No. 2003, pp. 9-18.
4. J. M. Nordstrom, K. A. Reynolds and C. P. Gerba, “Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs,” Am.J Infect Control, Vol. 40, No. 6, 2012, pp. 539-543.
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.
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8. J. R. Babb, J. G. Davies and G. A. Ayliffe, “Contamination of protective clothing and nurses’ uniforms in an isolation ward,” J Hosp.Infect, Vol. 4, No. 2, 1983, pp. 149-157.
9. 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.
10.  Y. Wiener-Well et al, “Nursing and physician attire as possible source of nosocomial infections,” Am.J Infect Control, Vol. 39, No. 7, 2011, pp. 555-559.
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. M. Ohl et al, “Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria,” Am.J Infect Control, Vol. 40, No. 10, 2012, pp. 904-906.
13. 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.
14. 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.
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17. C. Coughenour, V. Stevens and L. D. Stetzenbach, “An evaluation of methicillin-resistant Staphylococcus aureus survival on five environmental surfaces,” Microb.Drug Resist., Vol. 17, No. 3, 2011, pp. 457-461.
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19. K. E. Orr, M. G. Holliday, A. L. Jones, I. Robson and J. D. Perry, “Survival of enterococci during hospital laundry processing,” J Hosp.Infect, Vol. 50, No. 2, 2002, pp. 133-139.
20. L. A. Hellickson and K. L. Owens, “Cross-contamination of Clostridium difficile spores on bed linen during laundering,” Amer.J.Infect.Control, Vol. 35, No. 2007, pp. E32-E33.
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22. T. Shiomori et al, “Evaluation of bedmaking-related airborne and surface methicillin-resistant Staphylococcus aureus contamination,” J Hosp.Infect., Vol. 50, No. 1, 2002, pp. 30-35.
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