Discussion
The most relevant nosocomial pathogens can persist on dry inanimate surfaces for months. In addition to the duration of persistence, some studies have also identified factors influencing persistence. A low temperature, such as 4°C or 6°C, was associated with longer persistence for most bacteria, fungi and viruses. High humidity (e.g., > 70%) was also associated with longer persistence for most bacteria, fungi, and viruses, although for some viruses conflicting results were reported. A few studies also suggest that a higher inoculum is associated with longer persistence. The type of surface material and the type of suspension medium, however, reveal inconsistent data. Overall, a high inoculum of the nosocomial pathogen in a cold room with high relative humidity will have the best chance for long persistence.
In most reports with experimental evidence, persistence was studied on dry surfaces using artificial contamination of a standardized type of surface in a laboratory. In most studies, bacteria were prepared in broth, water or saline. Viruses were usually prepared in a cell culture medium [48]. The main advantage is that the environmental conditions are consistent regarding temperature and air humidity. In addition, the effect of temperature or relative humidity can only be determined under controlled conditions, which are much easier to ensure in the laboratory. However, this may not always reflect the clinical situation, in which surfaces can be simultaneously contaminated with various nosocomial pathogens and different types of body fluids, secretions etc. Yet the question remains: what is the clinical evidence for the role of surfaces in nosocomial infections?
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In hospitals, surfaces with hand contact are often contaminated with nosocomial pathogens [49-51], and may serve as vectors for cross transmission. A single hand contact with a contaminated surface results in a variable degree of pathogen transfer. Transmission to hands was most successful with Escherichia coli, Salmonella spp., Staphylococcus aureus (all 100%) [52], Candida albicans (90%) [53], rhino virus (61%) [54], HAV (22% – 33%) [55], and rota virus (16%) [56,57]. Contaminated hands can transfer viruses to 5 more surfaces [58] or 14 other subjects [59]. Contaminated hands can also be the source of re-contaminating the surface, as shown with HAV [55,58]. Compliance rates of healthcare workers in hand hygiene are known to be around 50% [7]. Due to the overwhelming evidence of low compliance with hand hygiene, the risk from contaminated surfaces cannot be overlooked (Figure (Figure11).
The main route of transmission is via the transiently contaminated hands of the healthcare worker [60-62]. An outbreak of nosocomial infections due to Acinetobacter baumannii in a neurosurgical intensive care unit may serve as an example. A direct correlation was found between the number of environmental isolates obtained during screening and the number of patients who were colonized or infected with the same strain during the same calender month [63].
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During outbreaks, the environment may play a significant role for transmission of nosocomial pathogens, as suggested by observational evidence. This has been described for various types of microorganisms, such as Acinetobacter baumannii [64-66], Clostridium difficile [67-69], MRSA [65,70], Pseudomonas aeruginosa [4,65], VRE [65,71-77], SARS [78,79], rota- [80,81], and norovirus [82]. However, the evidence to support a role of environmental contamination is not equally strong for all types of nosocomial pathogens. For Clostridium difficile, MRSA, and VRE, data are stronger than for other pathogens, such as Pseudomonas aeruginosa or Acinetobacter baumannii, of which multiple types were detected in the environment, and which did not always correlate with the acquired strain [83].
The role of surface disinfection for the control of nosocomial pathogens has been a contentious issue for some time [3]. Routine treatment of clean floors with various types of surface disinfectants (some of them had rather poor bactericidal activity) has been described to have no significant impact on the incidence of nosocomial infections [84]. Disinfection of surfaces in the immediate environment of patients, however, has been described to reduce acquisition of nosocomial pathogens such as VRE [85] or Acinetobacter baumannii [86]. It is therefore advisable to control the spread of nosocomial pathogens at least in the direct inanimate environment of the patient by routine surface disinfection.
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