Paper Records of Patients in Isolation for Colonization or Infection With Special Organisms: A Potential Fomite?

To the Editor—The fear of paper records or order sheets as a potential fomite for the spread of organisms in healthcare facilities is not new ¹ but studies have revealed different findings based on the level of contamination in various settings. ^{1 – 4} Therefore we wanted to assess the degree of contamination of paper records from patients who were placed in single-room isolation precautions for colonization or infection with special organisms. Medical charts of clinical ward patients who were placed in isolation for more than 2 weeks, according to the hospital policy of a 696-bed tertiary care center, were included. No institutional review board approval was needed for this non–patient care study, and access to infection control surveillance data by staff is mandated by German federal infection law (IfsG). Descriptive data were analyzed by t test; P<.05 was considered significant.

From October 1, 2014, through March 1, 2015, eligible records were identified by infection control staff and examined upon patient discharge from the isolation room. Medical charts are kept outside of the room. Per hospital policy, healthcare workers should disinfect their hands after removal of personal protective equipment and before writing notes; however, adherence to this practice was not specifically monitored.

Paper records consist of a plastic cover (1 sample taken) and a paper insert (front page and 1 random page sampled). RODAC (replicate organism detection and counting) plates or appropriate special media were used according to the patients’ known organisms and the Microbiology Procedures Quality Standards. ⁵ Samples were cultivated for up to 8 weeks.

Fifteen paper records were identified and sampled. Figure 1 shows the distribution of organisms, with methicillin-resistant Staphylococcus aureus and multidrug-resistant Escherichia coli being the predominant species.

FIGURE 1 Distribution of special organisms in 15 patients with stay in single-room isolation for more than 2 weeks. Percentages do not add to 100 because of rounding. MDR, multidrug-resistant; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant Enterococcus.

On the plastic cover, we found a mean (range) of 10 (0–48) colony-forming units (CFU) of coagulase-negative staphylococci, 8 (0–27) CFU of micrococci, and 1 (0–4) anaerobic bacillus. On the paper sheets, we found a mean (range) of 5 (0–31) CFU of coagulase-negative staphylococci, 3 (0–15) CFU of micrococci, and 0.3 (0–2) CFU of anaerobic bacilli, which was significantly less than on the plastic cover (P<.001). No specific organisms from the patients were identified. Records from the 2 patients with tuberculosis who were under airborne precautions showed no growth of coagulase-negative staphylococci and only 1 CFU of Micrococcus on the plastic cover.

A limitation of our study was the small number of patients; many were excluded because they were in isolation for less than 2 weeks. Our definition for study inclusion was chosen to assure that multiple opportunities for chart contamination occurred.

Despite those multiple opportunities for contamination of medical charts in patients with special organisms placed under long-term isolation, we could not demonstrate transfer of these organisms onto their paper records. This result suggests that existing adherence to isolation precautions in our cases, although not formally observed and recorded, was sufficient to limit contamination. Only normal environmental bacteria in moderate or low numbers were found, with the plastic cover being more prone to contamination than the paper record itself.

To put these findings into perspective, studies of nonhospital environmental contamination, using culture of circulating bank notes and coins as an example, have yielded very different results. In those studies, coagulase-negative staphylococci (43.6% of the total bacterial count), including Staphylococcus saprophyticus, S. epidermidis, and S. hominis, and Enterococcus spp. (30.8% of the total bacterial count), including E. faecalis, E. faecium, and E. durans, were the most numerous causes of bacterial contamination. Penicillium spp. and Aspergillus spp. were the most frequently detected molds, whereas Candida spp. was the most frequent yeast isolated from currency. A marked inverse correlation between smaller banknote denomination and the physical condition of the paper currency and larger numbers of bacteria and fungi was found. The overall number of bacteria isolated from currency was a thousand-fold higher than that of fungal isolates. The total amount of bacteria and fungi recovered from coins was approximately 2.7-fold lower than that isolated from the notes. In this study by Kalita et al, ⁶ Polish currency notes were found to be contaminated mainly with commensal bacteria and fungi, whereas opportunistic pathogenic microorganisms Escherichia coli, Pseudomonas stutzeri, and Candida albicans were detected at a low frequency. The mean numbers of total viable bacteria recovered in this study were 1.6 × 10⁴ CFU per a 20-Zloty note, 1.8×10⁴ CFU per 10-Zloty note, and 6.5×10³ CFU per coin, which were much higher than our CFU counts.

We therefore agree with the recommendation of Panhotra et al ⁷ that the emphasis on hand hygiene after caring for the patient and before entering case notes in records for patients in isolation for special organisms is a good practice that needs to be followed. In contrast, special precautions for handling records of patients under isolation after discharge is not necessary, and they pose no risk to healthcare workers or administrative staff handling those files.