American Journal of Infection Control 1 journal homepage: www.ajicjournal.org Major article Anew UV-LED device for automatic disinfection of stethoscope membranes ® Gabriele Messina DrPH, MSc Epid, MD**, Sandra Burgassi BSc*, Daniele Messina LLB®, Valerio Montagnani BEng‘, Gabriele Cevenini BME* 2 aoraory of fnvironmentl gene, Department of Molecular nd Developmental Mec, Universi of Siena, Siena aly Monte dt aici Foundation of sea, ly “AutamateSpech Recognition Research (ASR) Sea aly «Deparment af Medical Botechnolony. Univesity of Sena Sen, tly a Wort Background: Setboscopes are widely wed by doctors and nurses, Foor stethoscope hysie Botechnlory tential source of nosocomial infection. This sty aimed eo propose an innovative soliton, bs Disiaection Jatest advances in ultraviolet (UV) light-emitting diodes (LEDs), for disinfecting stethoscope n_ Hei essed fron automatially and efficient Sth Methods: Staphylococcus aureus, Escherichia col, Peudomanas aeruginosa and Enterococcus fa sown on28 stethoscope membranes and then transferred to Pet dishes. Treatmentinvolvedil exposed Petr dishes with a UVCLED for 1 minute. For each microbe, the number of colony for (au) at 36°C was comparad in control and treated dishes using the Wikorwn signee The Kruskal-Wallis test was used fo assess percent reductions in bacteria, Statistical signi set at 98. Results: A significant reduction in cfu counts after UV treatment (P< .01) was found for a Reh Se Fea Sh Wels Were aida veted aces (PL gefses Nose Conclusion; The stethoscope, symbol of medicine and healthcare professional, has been det tobe a carrer of microorganisms. The treatment technique was effective and efficent i disin ‘membranes, These promising results represent a step forward toward eliminating stethos« brane contamination with an innovative approach, Copyright © 2015 by the Association for Profesional in Infection Control and Epiden Published by Elsevier Inc.All ight ‘The medical literature has demonstrated the importance of ‘nosocomial infections and their negative consequences, including damage to patient health, clinical complications. mortality, and longer admissions, with the need for extended care and corre- sponding increased costs.! A 2012 meta-analysis of studies con- ducted in various settings and countries showed that the cost per case of infections acquired in hospital is typically between $2,000 and $15,000 and increasing.” Patients wino contract nosocomial infections during admission to intensive cate units cost an average 7 Aaress correspondence o Gabriele Messina. DrPH. MS¢ Epi. MD, Deparment of Molecuar and Developmental Medicine. University of Siena, $3100 Sina aly. Email addres gable messinaBunvsst (G Messina}. Cont of interes: The authors ae cofounder ofa tar up company, which developed in years of research about the issues described inthe article of $10,000, compared with an average of $4,000 for t remain infection-free? Another recent meta-analysis onthe financial impac comial infections on the US healthcare systema found ao cost of $98 billion for the 5 major health care~asso fections: surgical site infection, central line-associats stream infection catheterassociated urinary tract ventilator-associated pneumonia, and Clostridium diff tion.‘ These high figures actually may be underestimates considering the opinion that an accredited academic jout that published outbreaks of infection are only the “t iceberg’ of all nosocomial epidemics * Nosocomial infections often result from inadequate © cial management of cleaning, disinfection, and steriizati hands of healthcare persomnelare themain vehide of tra cof microbes and virusesS All objects that come into cor 0196-6552/836 0 - Copyright® 2015 bythe Asvolton for Professionals in Infection Conte nd EpAemloogy In. Published by Elsevier nc Alright ese Downloadest Messina eta American Journal of ectinn Control 452015} 61-485 and are shared between personnel and patients are possible car- riers of microorganisms, Stethoscopes are widely used by health professionals, and it has been conclusively demonstrated that their membranes can trans- mitmicrobesand viruses from 1 patient to ancther andfrom health care worker to patient.°"> Crespo et al! recovered the same strain of P aeruginosa (serotype O12) from skin and stethoscopes in affected units, although not from the hands of staf€ Gastmeier et all” reported the same strain of Klebsiella pneumonia on the stethoscopes of incubators of a neonatal intensive care unit as in clinical isolates from? patients with bloodstream infections caused by this bacterium. ‘The simplest solution to the problem is to disinfect the stethoscope membrane before each use, to avoid contamination and its buildup with repeated uses (Fig 1). Unfortunately, this is rarely done in clinical practice, for various reasons, including poor hygiene practices by medical staff, forgetfulness in managing the various stages of medical care, ack of awareness|consideration of the importance of the procedure, and the cumbersome process of disinfecting with swabs moistened with chemical disinfectant." ‘The stethoscope has become so important in spreading bacteria that a recent article highlighting major strategies for preventing hospital infections dedicated a special recommendation to cleaning, of stethoscopes between patients to avoid increasing contamina- tion Another study found that the substantial bacterial contamination level on stethoscopes is similar to that on physi cians’ hands a known major source of nosocomial infections!® ‘These findings are a first step toward reiting guidelines and regulations for proper use and cleaning medical devices, especially stethoscopes. ‘A plausible approach could involve ultraviolet (UV) light, which has already been used for such therapeutic purposes as stimulating. vitamin D production and treating psoriasis as well as for sanitizing, air, water, and the environment. At its typical wavelength of 200- 280 nm, UVC radiation induces pyrimidine dimers in thymine and cytosine, breaking DNA molecules, inactivating germs and pre- venting them from growing or reproducing °°" Several previous studies have demonstrated that the use of UVC on a wheeled device to disinfect hospital rooms and envi~ ronments is plausible, fast, and practicable??? In another study, Nerandzic et al? tested portable units emitting UVC for disinfection of the environment. In contrast, there has been litle study of the use of UVC with innovative techniques and equip- ment, such as light-emitting diodes (LEDs), which allows the creation of small, portable, low-energy, easy-to-use devices for disinfection, In this article, we propose an innovative technological approach, based on the latest advances in ultraviolet LEDs, that enables automatic and efficient disinfection and sterilization of | stethoscope membranes. MATERIALS AND METHODS Ultraviolet LED We chose UVC light because of its good biocidal effect. UVC inactivates microbes with a few seconds and prevents their replication (spores induded) on exposed surfaces under the following conditions: (1) reduced distance between surface to be disinfected and the UVC source; (2) wavelength preferably in the 255.280 nm range: (3) appropriate exposure time: and (4) ho. Sensor Electronic Technology, Columbia, SC), with a peal length of 260:nm, a lighting power of 300 uW, a forward ve 65 V, and an irradiation angle of 120°. Device prototyping A prototype, intended for use in an experimental envire was created with a view toward developing a portable devic safe for health professionals and patients alike. Its confign simple circular cover for application to the head of the stett The size of the cover was obtained by analyzing the cla mensions of stethoscope membranes. The design was real Sketchup 3D modeling software (Sketchup, Boulder, CO) a printer, The microelectronic component of the device was d Using the latestembedded system technology with UVCLEL principal components. It included a battery power supp microcontroller that supplies a constant direct current of Figure 2 shows the prototype hardware, Note the circulz with the UV LED in the center. When a flat circular surface, suchas a stethoscope mem placed in front of the LED. the irradiation angle of 120° r possible to fully illuminate the surface when the LEDis ata: of d = 7/V3, where r is the radius of the membrane, Laboratory analysis and experimental design Our analysis was performed in the hygiene and enviror laboratory ofthe University of Siena. All precautions were ensure that the experiment was conducted under safe cor LUVC light can be hazardous for the skin and eyes of the o Although the possibility of exposure to the radiation was ‘he emission of UVC light was very limited in space, all prec were taken to avoid any possible risk. The experimental | was conducted using the UVC LED prototype. illuminating stethoscope membranes of 40 mm diameter (260 = 12 nm We tested the efficacy of the device with 4 strains of | that are common stethoscope contaminants* "2": Escheri Staphylococcus aureus, Pseudomonas aeruginosa, and Ente ‘faecalis. The membranes were cultured on plate count agar ‘90-mm Petri dishes, as in previous studies. Several colon withdrawn from each culture to prepare bacterial suspen phosphate-bufiered saline up toa 0.5 McFarland turbidity From these initial suspensions. which were shaken in : mixer. the following dilutions were macle: 10-1.10°?, and 1 latter dilution was used for testing, ‘A.50-u1 suspension of each species of bacteria was un sown on the stethoscope membranes using sterile swab ‘membranes, 2 per bacterial species, served as controls, a placed in contact with fresh PCA in other 60-mm Pett di at least 20 seconds, The other 20 stethoscope membrane bacterial species, were illuminated with UVC for 1 min distance of 11.5 mm and then placed in contact with frest other Petri dishes for at least 20 seconds. The distance b the LED and the stethoscope membrane was such that t cone illuminated the entire membrane surface. UVC expost was set to 60 seconds to achieve an exposure dose (fluer ficient to kill the microorganisms at a maximum dist 23 mm, that is, the distance from the LED to the me perimeter.”* DownloadMessin American Journal of fection Canta 432015} e665 Fig. Ptr ses showing stethoscope contamination afer us on 1.2, ané 3 patients respectivey Fig 2. Device rotorpe (crear shape with the UV LED in the center) nsiop-The plates were read a4 and 48 hours after sow fe spied tor a Nauble count at 24 hours to prevent vigorous bacterial growth from rendering some colonies uncountable at 448 hours, and at 48 hours to avoid missing bacterial species/col- onies with slower growth, Statistical analysis We double-checked the database for input errors before sta- tistical analysis. Descriptive statistics included median, inter- range, and range of variation of all 4 species of bacteria Continue Reading ‘rable Median 18 ange of vaation,peeentredueton, and Wileoxon P val between contractures anaetesfromUVC seated sethorcpe: forthe 4 baceria suse ange of Percent Median venation reduction bacteria gency“ “Stapylococeusspp Fypowdtowve 7382 TS. 2013 1k 9a sage" ag ae Expoedouve 223 TSH Enterococcus spp ‘control 22s 0261 762 Exposed UVC 332535185885 bacterial contamination before and after UV disinfectior Kruskal-Wallis test was used to detect differences am: bacteria studied. A statistical significance level of 98% (P <.01) was appl inferential analyses. All statistical analyses were perforr Stata version 12.1 (StataCorp, College Station, TX), RESULTS Median, interquartile range, and range variation of cor UV-irradiated samples are reported together with th reduction in cfu for all 4 species of bacteria in Table 1.1n the Wikoxon signed-rank test showed significant diftere: count after UV disinfection (P < .01 for all comparis percent reductions were very high, all above 85%. As Figure 3, residual bacteria were found around the periph Downloadwere conducted to verily differences with respect to controls ‘The Wilcoxon signed-rank test was used to reveal differences in Almost 35% of epidemic nosocomial infections are att direct contact between doctor and patient, 12% are associ ost Messina eta American Journal of fectinn Control 42015} 61-68 Fig. Pets lishes in whieh stethoscope membranes ha been placed in contact wih the clare medium fr atleast 20 seconds. The frst Petri dishon the eis Residual bacteria remained ony around the periphery ofthe stethoscope membranes after UVC eaten the environment, 11% are linked to biomedical/care instruments, and as many as 40% are related to unknown causes.” The large latter proportion could hide sources that are rarely disinfected, owing to a perception of low contamination and a minor role in ‘nosocomial infections. Many routine hygienic practices, such as sterilization of surgical instruments, use of gloves and masks during medical procedures, and disinfection of the skin before injections, became established only after many years ot ard work. Inthenineteenthcentury, Ignac Flap Semmelweis introduced handwashing, a significant advance in hygiene practice. This procedure was intially disputed by many colleagues, despite its positive results in term of avoidable mor- tality. The same may be true for the cleaning of stethoscopes, an extension of health professionals’ hands, which is not yet standard practice. Figure 1 shows stethoscope contamination after use on 1, 2, and 3 patients. At the third use without any cleaning procedure, contamination was high and similar to that found on contol plates in the present laboratory experiment. ‘Also noteworthy is the fact that today doctors deal with informed patients, capable of assessing not only the outcome of hospital treatment, butalso the medical and nursing care that they receive. Ifthe quality of service falls short of expectations, patients may take legal action for damages caused by bad practice or omissions, such as poor standards of cleaniness or steriiza- tion2529 Elimination of hospital infections is in the best interest not only of doctors and patients, but also of hospitals themselves, to reduce the cost of extended hospital stays for additional treatments.” ‘Our present results show that itis possible to disinfect stetho- scope membranes with UVC emitted by a LED. The percent reduc- ‘tion in cfuwas between 85.5% and 949% (084-1.29log;oreduction) for all 4 bacteria tested, and considering the magnitude of the iffocences detested the saniole size ensiunesd sufficient statistical Continue Reading radiant dose of 100 mJjem? for ~S seconds reduced the of methicillin-resistant $ aureus (MRSA) by 54 logio vancomycin-resistant Enterococcus (VRE) by 6.9 logie S wheeled devices for environmental disinfection, based or xenon ultraviolet or pressure mercury bulbs, achieved a 1 reduction in MRSA and a 0.6-1.68 logo reduction in VF kalling efficacy dropping dramatically with increasing dista ‘Those studies were conducted with devices that radiate w energy using conventional types of bulbs. Our research, b the same physical approach to disinfection, is different by the LED source of UVC light, which provides good disinfe properly used and is more eco-friendly than mercury bulb | hhas a low-energy starter, and its lifespan is not decre frequent switchingon and off In addition, LEDs canbe inse1 narrow inaccessible spaces and can be controlled more ac and safely ‘Our results could be further improved by exposure time than 60 seconds and the use of a more powerful LED and angle of illumination, such as 140°. Infact, these paramete speed up and increase the disinfection{steriization effect, It also should be noted that our cfu reductions may bi what ofan underestimate, owing tothe large distance from and the fact that in the laboratory experiment, the membr: placed with its outer edge on a cardboard support that shi from irradiation (Fig 3). Another approach would be to us ‘nm LED, which, although less biocidal, can emit higher re power. One advantage of the present method is that itis a} rather than chemical method of disinfecting or sterilizati croorganisms and spores may resist disinfectants in differe and even develop resistance, whereas when used proper radiation produces steilizationof all exposed surfaces?™*" a “green” or ecologically sound method, producing no res Snecial waste mnenlucterenuiting disanea Downloadenvironmentsin general. Depending on the bacteria. exposuredose and time, distance between the light source and its target, and surface characteristics, reductions in efu count ranging from <1 logia to ~7 logio have been reported For example, Nerandzic etal" reported that a hand-held far-UV radiation device delivering. health professionals could carry one, attached to a coat po ‘example, so that it can be quickly coupled to a stethos¢oy around the neck. 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