While the focus on the prevention of multi-drug antibiotic-resistant
bacteria has been on getting doctors, nurses and other staff working with
patients to follow strict handwashing protocols, not much has been done to
expand this to patients themselves. A new study published in the journal
Clinical Infectious Diseases has now suggested that patient hand contamination
with multi-drug resistant organisms (MDROs) is common and correlates with
contamination on high-touch room surfaces.

In the study, 14% of 399 hospital patients tested were found
to have MDROs on their hands or nostrils very early in their hospital stay. And
nearly a third of tests for such bacteria on objects that patients commonly
touch in their rooms, such as the nurse call button, came back positive.

Another 6% of the patients who didn’t have multi-drug
resistant organisms, or MDROs, on their hands at the start of their hospitalisation
tested positive for them on their hands later in their stay. One-fifth of the
objects tested in their rooms had similar superbugs on them too.

The research team cautions that the presence of MDROs on
patients or objects in their rooms does not necessarily mean that patients will
get sick with antibiotic-resistant bacteria. And they note that healthcare
workers’ hands are still the primary mode of microbe transmission to patients.

“Hand hygiene narrative has largely focused on
physicians, nurses and other frontline staff, and all the policies and
performance measurements have centered on them, and rightfully so,” says
Lona Mody, MD, MSc, the University of Michigan geriatrician, epidemiologist and
patient safety researcher who led the research team. “But our findings
make an argument for addressing transmission of MDROs in a way that involves
patients, too.”

Mody and her colleagues report that of the six patients in
their study who developed an infection MRSA while in the hospital, all had
positive tests for MRSA on their hands and hospital room surfaces.

In addition to MRSA, the study looked for vancomycin-resistant
enterococcus and resistant Gram-negative bacteria.

Mody notes that the study suggests that many of the MDROs
seen on patients are also seen in their rooms early in their stay, suggesting
that transmission to room surfaces is rapid.

Additionally, since many patients arrive at the hospital
through the emergency room and may get tests in other areas before reaching
their hospital room, it will be important to study the ecology of MDROs in
those areas too, she says.

“This study highlights the importance of handwashing
and environmental cleaning, especially within a healthcare setting where
patients’ immune systems are compromised,” says infectious disease
physician Katherine Reyes, MD, lead author for Henry Ford Health System
researchers involved in the study.

“This step is crucial not only for healthcare
providers, but also for patients and their families. Germs are on our hands;
you do not need to see to believe it. And they travel. When these germs are not
washed off, they pass easily from person to person and objects to person and
make people sick.”

The team made more than 700 visits to the rooms of general
medicine inpatients at two hospitals, working to enroll them in the study and
take samples from their bodies and often-touched surfaces as early as possible
in their stay. They were not able to test rooms before the patients arrived,
and did not test patients who had had surgery, or were in intensive care or
other types of units.

Using genetic fingerprinting techniques, they looked to see
if the strains of MRSA bacteria on the patients’ hands were the same as the
ones in their rooms. They found the two matched in nearly all cases –
suggesting that transfer to and from the patient was happening. The technique
is not able to distinguish the direction of transfer, whether it’s from patient
to objects in the room, or from those objects to patients.

Cleaning procedures for hospital rooms between patients,
especially when a patient has been diagnosed with an MDRO infection, have
improved over the years, says Mody, and research has shown them to be effective
when used consistently. So lingering contamination from past patients may not
have been a major factor.

But the question of exactly where patients picked up the
MDROs that were found on their bodies, and were transmitted to the surfaces in
their rooms, is not addressed by the current study and would be an important
next step based on these results.

Also important, says Mody, is the fact that hospital
patients don’t just stay in their rooms – current practice encourages them to
get up and walk in the halls as part of their recovery from many illnesses, and
they may be transported to other areas of the hospital for tests and
procedures.

As they travel, they may pick up MDROs from other patients
and staff and leave them on the surfaces they touch.

So even if a relatively healthy person has an MDRO on their
skin, and their immune system can fight it off if it gets into their body, a
more vulnerable person in the same hospital can catch it and get sick. The
researchers are exploring studying MDROs on patients in other types of hospital
units who may be more susceptible to infections.

Patients and staff may also get colonised with MDROs in
outpatient care settings, including urgent care centers, freestanding imaging and
surgery centers, and others.

Mody and colleagues are presenting new data about MDROs in
skilled nursing facilities at an infectious disease conference in Europe later
this month. They showed that privacy curtains in wards are also often colonised
with superbugs.

“Infection prevention is everybody’s business,”
says Mody, a professor of internal medicine at the U-M Medical School. “We
are all in this together. No matter where you are, in a healthcare environment
or not, this study is a good reminder to clean your hands often, using good
techniques–especially before and after preparing food, before eating food,
after using a toilet, and before and after caring for someone who is sick– to
protect yourself and others.”

“While the burden of preventing infections has largely been
borne by healthcare personnel, our study shows that patient hands are an
important reservoir and play a crucial role in the transmission of pathogens in
acute care hospitals. Thus, patient hand hygiene protocols should be
implemented and tested for their ability to reduce environmental contamination,
pathogen transmission, and healthcare-associated infections as well as to
increase meaningful patient engagement in infection prevention,” the
researchers concluded. 

Reference: Mody
L, et all. Multidrug-resistant Organisms in Hospitals: What Is on Patient Hands
and in Their Rooms? Clinical Infectious Diseases. Published 13 April 2019. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciz092/5445425