Professional Documents
Culture Documents
net/publication/51797411
CITATIONS READS
29 4,308
4 authors, including:
Ojan Assadian
Regional Hospital Wiener Neustadt
320 PUBLICATIONS 4,611 CITATIONS
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
All content following this page was uploaded by Claudia Hübner on 07 December 2017.
original research
By Nils-Olaf Hübner, MD, Claudia Hübner, PhD, Axel Kramer, MD, PhD, and Ojan Assadian, MD, DTMH
W
hile electronic medical records and METHODS
information systems are increasingly Design. We performed a two-step experimental study
found in hospitals and other clinical set- of bacterial survivability and transmission under labo-
tings, paper may still be one of the most ratory conditions simulating a “worst-case scenario” (a
common materials on any hospital unit. high number of colony-forming units [CFU] per cm2,
Paper is used as a recording medium in medical and and optimal transmission by wet finger and pressure
nursing charts, patient files, notes, and reports, and against paper) for the spread of pathogens.
may be introduced into the clinical setting by patients Preparation of paper swatches. One-centimeter-
and visitors in the form of books, newspapers, maga- square swatches were cut from white all-purpose print-
zines, and other items. Paper documents are used every ing paper (80 g/m 2, Future multitech, UPM, Helsinki,
day and in every way, not only by nurses and physicians, Finland) and steam sterilized. The paper was shown
but by many other people involved in patient care. to be free of antibacterial properties in an agar diffu-
Disinfection of paper, unlike most other equipment, sion assay in accordance with standard DIN 58940-
is not an easy task because of its porous surface and 2-3 of the German Institute for Standardization.11, 12
incompatibility with liquid disinfectants. Evidence is Test of organism survivability on paper. To test
abundant from studies of paper money that paper can the survival of bacterial organisms on paper, we used
transmit pathogens in nonclinical settings.1-3 standard procedures for preparing bacterial cultures.
Much research has been conducted on the trans- Four organisms—Escherichia coli, Staphylococcus
mission of pathogens from hands to inanimate sur- aureus, Pseudomonas aeruginosa, and Enterococcus
faces. However, it remains unclear how long bacteria hirae—were cultured overnight in tryptic soy broth
can survive on paper and how many organisms may (TSB, a growth medium commonly used in the cultiva-
be transferred in a full hand-to-paper-to-hand trans- tion of aerobic bacteria) and prepared to 109 CFU/mL.
mission cycle.1, 4-10 Paper documents could be an im- For each strain, 18 swatches were inoculated with
portant vehicle for cross-contamination and infection 0.25 mL of test suspension and air dried at room tem-
in clinical settings, but data are scarce. The aim of our perature. Immediately after drying, each sample was
study was to investigate how long bacterial pathogens placed in a vortexer (a device used to agitate microbial
can survive on regular office paper and to quantify the samples in solution) with 10 mL of 0.9% saline solution.
proportion of pathogens transferred from hand to Volumes of 0.1 mL of undiluted sampling solution and
paper and back to another hand. 0.1 mL from 1:10 and 1:100 dilutions in TSB were plated
onto Columbia blood agar plates (Becton Dickinson, through files) and pressed on the contaminated swatches
Heidelberg, Germany), incubated at 36±1°C for 24 hours, for 30 seconds to simulate cross-contamination. A ster
and plate counted. Samples were stored, while protected ile Eppendorf tube filled with 1 mL of saline solution
from direct sunlight and contamination, under standard was then pressed to the fingertip of each of the second
room conditions (23±2°C, 55±5% relative air humidity). volunteers and shaken for one minute; volumes of 0.1 mL
They were then sampled and plate counted after 48, 72, of this undiluted sampling solution were plated onto
96, 144, and 168 hours, to test for bacterial growth. Columbia blood agar and incubated as described above.
Tests for bacterial growth were repeated three times. Tests were repeated six times.
Test of bacterial transmissibility. To test the trans-
missibility of bacteria from one hand to paper and back
to another hand, we adapted the classic finger-pad
method developed by Ansari and Sattar and specified in
the American Society for Testing and Materials (ASTM) Bacteria can be transferred to paper,
Standards E-1838-96 and E-1838-02 for testing viru-
cidal activity of hand antiseptics.5, 13-15 The nonpatho-
genic E. coli strain NCTC 10538 (from the National
survive on it, and subsequently
Collection of Type Cultures [NCTC], a part of the
Health Protection Agency of the United Kingdom) contaminate hands.
was used as the test organism. Volunteers washed their
hands in tap water without soap, dried them with single-
use paper towels, and waited 10 minutes to ensure that
they were dry.16 The tip of each volunteer’s index finger
was inoculated with 25 microliters of test suspension RESULTS
(109 CFU/mL) and air dried. Survival of test organisms on paper over time. All
After drying, volunteers pressed the inoculated finger test strains survived on the inoculated paper. Figure 1
tips on paper swatches for 30 seconds. The index finger- shows the changes in recoverable organisms for each
tips of another group of volunteers were then irrigated individual organism. There were notable differences in
with sterile 0.9% saline (to simulate the common bad the survival of different pathogens over time. E. coli
habit of licking the finger before turning pages or going was reduced by almost 5 log10 in 24 hours (a reduction
(NCTC 10538)
-1.00
S. aureus
(ATCC 6538)
-2.00
P. aeruginosa
(ATCC 15442)
-3.00
E. hirae
(ATCC 10541)
-4.00
-5.00
-6.00
Inoculum After 24 hours 48 hours 72 hours 144 hours 168 hours
drying
after seven days. Thus, hands can become contami- suspension, implying a higher transmission rate. Fur-
nated by these pathogens when paper is handled. ther research should be focused on whether our results
Limitations. Our study has several limitations. De- are reproducible under real-world conditions. More
signed as a pilot study, we wanted to assess whether investigation is also needed to explore whether hand-
paper can promote cross-infection. We therefore cre- washing with soap and water or hand disinfection
ated conditions that are considered “worst case” in terms with alcohol-based hand rubs (hand sanitizers) more
of hygiene and optimal in terms of pathogen transmis- effectively decreases transmission from hand to paper
sion (high inoculum, wet finger) but with a very small and vice versa in health care settings.
contaminated spot (just one fingertip) to test transmis- Conclusions. Our research shows that bacteria can
sibility, as previously described by other authors.19 This be transferred to paper, survive on it, and subsequently
may not well represent real-world conditions, but our contaminate hands. Paper, therefore, can serve as a ve
results are supported by those of other studies.18 hicle for the cross-contamination of bacterial pathogens
The uncoated paper used in this study bound most if current recommendations on hand hygiene aren’t
of the bacterial suspension by adsorption and absorp- meticulously followed. Once contaminated, paper is
tion, thus reducing transfer. Coated paper, on the other hard to disinfect, because it cannot be disinfected by
hand, which is often used for printed material includ- chemical means, as other inanimate surfaces can. Thus,
ing paper currency, adsorbs and absorbs less bacterial the best way to minimize the spread of pathogens is
AJN1211.Hubner.CE.2nd.indd
View publication stats 6 10/29/11 7:16 PM