- Email: [email protected]
Flowers and healthcare-associated infection
Letters to the Editor obstetric, intensive care units and outpatient departments, and were in use by medical and nursing staff and phlebotomists. A 1-cm length from the side in contact with the patient’s skin was sampled by pressing on to a blood agar plate. The plates were incubated aerobically at 37 C and examined at 24 and 48 h. Colonies with the morphological appearance of S. aureus were subcultured for identification and sensitivity testing. Twentyseven of the 30 tourniquets yielded skin flora, one yielded meticillin-susceptible S. aureus and one yielded MRSA. Only one tourniquet had no significant growth; it had been replaced recently and may never have been used. It is clear, therefore, that tourniquets present a potential risk for transmitting MRSA or other pathogens from patient to patient unless cleaned or replaced regularly. Hospital equipment is increasingly seen as a method by which pathogens such as MRSA can be spread. Items such as blood pressure cuffs,1 computer terminals,2 stethoscopes3 and pens4 can all carry MRSA and so present a risk. A recent document produced by the British Medical Association recommended that ‘any equipment used for more than one patient (e.g. commode, bath hoist) is cleaned following each and every episode of use’.5 This advice should be applied to tourniquets. As a result of our study, we plan to increase the availability of disposable tourniquets in the trust and produce hospital guidelines for their use. Whenever fabric tourniquets are used, they will be decontaminated regularly according to manufacturers’ instructions.
References 1. Walker N, Gupta R, Cheesbrough J. Blood pressure cuffs: friend or foe? J Hosp Infect 2006;63:167e169. 2. Wilson APR, Hayman S, Folan P, et al. Computer keyboards and the spread of MRSA. J Hosp Infect 2006;62:390e392. 3. Hill C, King T, Day R. A strategy to reduce MRSA colonization of stethoscopes. J Hosp Infect 2006;62:122e123. 4. French G, Rayner D, Branson M, Walsh M. Contamination of doctors’ and nurses’ pens with nosocomial pathogens. Lancet 1998;351:213. 5. British Medical Association. Healthcare associated infections: a guide for healthcare professionals. London: British Medical Association; 2006.
J.O.M. Ormeroda J. Williamsa J. Lewisb S.J. Dawsonb,* a Department of Surgery, Great Western Hospital, Swindon, UK
301 b
Department of Microbiology, Great Western Hospital, Swindon, UK E-mail address: susan.dawson@ smnhst.swest.nhs.uk Available online 14 September 2006 * Corresponding author. Address: Department of Microbiology, Great Western Hospital, Marlborough Road, Swindon, Wiltshire SN3 6BB, UK. Tel.: þ44 1793604802; fax: þ44 1793604803. ª 2006 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2006.07.016
Flowers and healthcare-associated infection
Madam, Professor Humphreys argues eloquently against the policy of banning cut flowers that has been adopted by many hospitals because of a presumed infection control hazard.1 As he points out, there is a lack of conclusive evidence to associate plants and flowers with fungal infection in immunocompromised patients. Current guidance, however, is in favour of their removal from clinical areas;2 a recommendation that many units which care for these patients appear to follow.3 Evidence that flowers are implicated directly in healthcare-associated infection (HCAI) in nonimmunocompromised individuals, despite the findings of numerous investigators who have consistently reported contamination of flowers and vase water with Gram-positive and Gram-negative bacteria, is hard to find, although Ansorg et al. reported a case of fatal Erwinia sp. sepsis in a neonate that they attributed to a plant source.4 It may be assumed that as many of these isolates are environmental bacteria rather than unequivocal human pathogens, they represent a low risk for non-immunosuppressed patients. Nevertheless, Taplin and Mertz described a case of Aeromonas hydrophila wound infection in which the same bacterium was isolated from vases in the patient’s room.5 Evidence that implicates Gram-positive bacteria from flowers and HCAI is lacking, although a recent report that meticillin-resistant Staphylococcus aureus can survive and multiply within the free living amoeba, Acanthamoeba polyphaga is noteworthy.6 If we are to wait for a definitive study to demonstrate an unequivocal link between plants
302
Letters to the Editor
and vase water and HCAI, then the debate is likely to continue indefinitely. Nevertheless, we must continue to question whether it is prudent to leave sources of known HCAI-associated pathogens on our hospital wards.
References 1. Humphreys H. On the wrong scent: banning fresh flowers from hospitals. J Hosp Infect 2006;62:527e528. 2. Centers for Disease Control, Infectious Disease Society of North America and American Society for Blood and Bone Marrow Transplantation. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Morb Mortal Wkly Rep 2000;49(RR10): 1e128. 3. Poe S, Larson E, McGuire D, Krumm S. A national survey of infection prevention on bone marrow transplant units. Oncol Nurs Forum 1994;21:1687e1698. 4. Ansorg R, Thomssen R, Stubbe P. Erwinia species bei letaler Neugeborenensepsis. Med Microbiol Immunol 1974;159: 161e170. 5. Taplin D, Mertz P. Flower vases in hospitals as reservoirs of pathogens. Lancet 1973;302:1279e1281. 6. Huws S, Smith AW, Enright MC, Wood PJ, Brown MRW. Amoebae promote persistence of epidemic strains of MRSA. Environ Microbiol 2006;8:1130e1133.
K.G. Kerr* Microbiology Department, Harrogate District Hospital, Harrogate, UK E-mail address: [email protected] Available online 21 August 2006 * Address: Microbiology Department, Harrogate District Hospital, Lancaster Park Road, Harrogate HG2 7SX, UK. Tel.: þ44 1423 553077; fax: þ44 1423 55565. ª 2006 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2006.06.017
Reply to Professor Kerr
Madam, I welcome Professor Kerr’s contribution to the debate on the banning of flowers to control and prevent healthcare-associated infection (HCAI). His final assertion that we must continue to question whether it is prudent to leave sources of known HCAI-associated pathogens, i.e. cut flowers, on our hospital wards greatly exaggerates
the risk. Flowers have rarely been associated with HCAI, and when this has occurred, it has been confined to case reports or to very specific small groups of patients who are prone to opportunistic infections. Few doubt that the environment is a potential reservoir of organisms that can cause HCAI. However, any resulting infections often arise because of inadequate decontamination/cleaning or failure to comply with good professional practice such as hand hygiene. It has been shown that isolates of meticillin-resistant Staphylococcus aureus (MRSA) recovered from patients and from the environment are indistinguishable,1 thus suggesting that greater efforts at environmental cleaning may reduce the bio-burden of MRSA in the environment of hospital wards, leading to lower rates of colonization and infection. Acinetobacter baumannii is an opportunistic pathogen that causes infections in intensive care units and some other patients. When patient and environmental isolates of a multi-drug-resistant outbreak of A. baumannii were genotyped, those isolates from patients and suctioning apparatus were similar.2 Better cleaning/decontamination regimens and improved professional practice are likely to help reduce the chances of such outbreaks recurring. Patients with cystic fibrosis are living longer but are prone to respiratory infections with some environmental bacteria and fungi, such as Alcaligenes xylosoxidans and Aspergillus spp., and it is therefore prudent to consider monitoring for environmental contamination.3 With this particular group of patients, it may be appropriate to consider minimizing exposure to flowers, despite the absence of hard evidence that this will reduce infections, because it is known that these patients can develop respiratory infections caused by lowgrade environmental pathogens. However, a ‘blanket ban’ on flowers on all hospital wards is not justified because of the minimal risk for the vast majority of patients. When a patient receives flowers in hospital, they are usually placed on a window ledge or on a locker so that the patient can enjoy the sight of the flowers and inhale their scent. When disposed of appropriately by hospital staff or relatives, there is no reason to consider that they represent a significant risk of infection to the patient, irrespective of whether or not the flowers or the water are colonized with potential pathogens. Professor Kerr states that current guidance is in favour of the removal of flowers from clinical
References 1. Walker N, Gupta R, Cheesbrough J. Blood pressure cuffs: friend or foe? J Hosp Infect 2006;63:167e169. 2. Wilson APR, Hayman S, Folan P, et al. Computer keyboards and the spread of MRSA. J Hosp Infect 2006;62:390e392. 3. Hill C, King T, Day R. A strategy to reduce MRSA colonization of stethoscopes. J Hosp Infect 2006;62:122e123. 4. French G, Rayner D, Branson M, Walsh M. Contamination of doctors’ and nurses’ pens with nosocomial pathogens. Lancet 1998;351:213. 5. British Medical Association. Healthcare associated infections: a guide for healthcare professionals. London: British Medical Association; 2006.
J.O.M. Ormeroda J. Williamsa J. Lewisb S.J. Dawsonb,* a Department of Surgery, Great Western Hospital, Swindon, UK
301 b
Department of Microbiology, Great Western Hospital, Swindon, UK E-mail address: susan.dawson@ smnhst.swest.nhs.uk Available online 14 September 2006 * Corresponding author. Address: Department of Microbiology, Great Western Hospital, Marlborough Road, Swindon, Wiltshire SN3 6BB, UK. Tel.: þ44 1793604802; fax: þ44 1793604803. ª 2006 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2006.07.016
Flowers and healthcare-associated infection
Madam, Professor Humphreys argues eloquently against the policy of banning cut flowers that has been adopted by many hospitals because of a presumed infection control hazard.1 As he points out, there is a lack of conclusive evidence to associate plants and flowers with fungal infection in immunocompromised patients. Current guidance, however, is in favour of their removal from clinical areas;2 a recommendation that many units which care for these patients appear to follow.3 Evidence that flowers are implicated directly in healthcare-associated infection (HCAI) in nonimmunocompromised individuals, despite the findings of numerous investigators who have consistently reported contamination of flowers and vase water with Gram-positive and Gram-negative bacteria, is hard to find, although Ansorg et al. reported a case of fatal Erwinia sp. sepsis in a neonate that they attributed to a plant source.4 It may be assumed that as many of these isolates are environmental bacteria rather than unequivocal human pathogens, they represent a low risk for non-immunosuppressed patients. Nevertheless, Taplin and Mertz described a case of Aeromonas hydrophila wound infection in which the same bacterium was isolated from vases in the patient’s room.5 Evidence that implicates Gram-positive bacteria from flowers and HCAI is lacking, although a recent report that meticillin-resistant Staphylococcus aureus can survive and multiply within the free living amoeba, Acanthamoeba polyphaga is noteworthy.6 If we are to wait for a definitive study to demonstrate an unequivocal link between plants
302
Letters to the Editor
and vase water and HCAI, then the debate is likely to continue indefinitely. Nevertheless, we must continue to question whether it is prudent to leave sources of known HCAI-associated pathogens on our hospital wards.
References 1. Humphreys H. On the wrong scent: banning fresh flowers from hospitals. J Hosp Infect 2006;62:527e528. 2. Centers for Disease Control, Infectious Disease Society of North America and American Society for Blood and Bone Marrow Transplantation. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Morb Mortal Wkly Rep 2000;49(RR10): 1e128. 3. Poe S, Larson E, McGuire D, Krumm S. A national survey of infection prevention on bone marrow transplant units. Oncol Nurs Forum 1994;21:1687e1698. 4. Ansorg R, Thomssen R, Stubbe P. Erwinia species bei letaler Neugeborenensepsis. Med Microbiol Immunol 1974;159: 161e170. 5. Taplin D, Mertz P. Flower vases in hospitals as reservoirs of pathogens. Lancet 1973;302:1279e1281. 6. Huws S, Smith AW, Enright MC, Wood PJ, Brown MRW. Amoebae promote persistence of epidemic strains of MRSA. Environ Microbiol 2006;8:1130e1133.
K.G. Kerr* Microbiology Department, Harrogate District Hospital, Harrogate, UK E-mail address: [email protected] Available online 21 August 2006 * Address: Microbiology Department, Harrogate District Hospital, Lancaster Park Road, Harrogate HG2 7SX, UK. Tel.: þ44 1423 553077; fax: þ44 1423 55565. ª 2006 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2006.06.017
Reply to Professor Kerr
Madam, I welcome Professor Kerr’s contribution to the debate on the banning of flowers to control and prevent healthcare-associated infection (HCAI). His final assertion that we must continue to question whether it is prudent to leave sources of known HCAI-associated pathogens, i.e. cut flowers, on our hospital wards greatly exaggerates
the risk. Flowers have rarely been associated with HCAI, and when this has occurred, it has been confined to case reports or to very specific small groups of patients who are prone to opportunistic infections. Few doubt that the environment is a potential reservoir of organisms that can cause HCAI. However, any resulting infections often arise because of inadequate decontamination/cleaning or failure to comply with good professional practice such as hand hygiene. It has been shown that isolates of meticillin-resistant Staphylococcus aureus (MRSA) recovered from patients and from the environment are indistinguishable,1 thus suggesting that greater efforts at environmental cleaning may reduce the bio-burden of MRSA in the environment of hospital wards, leading to lower rates of colonization and infection. Acinetobacter baumannii is an opportunistic pathogen that causes infections in intensive care units and some other patients. When patient and environmental isolates of a multi-drug-resistant outbreak of A. baumannii were genotyped, those isolates from patients and suctioning apparatus were similar.2 Better cleaning/decontamination regimens and improved professional practice are likely to help reduce the chances of such outbreaks recurring. Patients with cystic fibrosis are living longer but are prone to respiratory infections with some environmental bacteria and fungi, such as Alcaligenes xylosoxidans and Aspergillus spp., and it is therefore prudent to consider monitoring for environmental contamination.3 With this particular group of patients, it may be appropriate to consider minimizing exposure to flowers, despite the absence of hard evidence that this will reduce infections, because it is known that these patients can develop respiratory infections caused by lowgrade environmental pathogens. However, a ‘blanket ban’ on flowers on all hospital wards is not justified because of the minimal risk for the vast majority of patients. When a patient receives flowers in hospital, they are usually placed on a window ledge or on a locker so that the patient can enjoy the sight of the flowers and inhale their scent. When disposed of appropriately by hospital staff or relatives, there is no reason to consider that they represent a significant risk of infection to the patient, irrespective of whether or not the flowers or the water are colonized with potential pathogens. Professor Kerr states that current guidance is in favour of the removal of flowers from clinical