When I started in the infection prevention world 15 years ago, fomites (or the patient environment) was still being debated in terms of the contribution to infection transmission. Most would agree that the potential role of fomites in the transmission of disease required further study. No one was really ready to take a stance.
In 2002, Infection Control Today (ICT) published an article “Fomites’ Role in Disease Transmission is Still Up for Debate” concluding that the transmission of infectious diseases from fomites is still being contested in the infection control community, with no conclusive decision emerging from clinical studies. Dr. Weber and Dr. Rutala agreed that the key concept in considering the hospital environment as an infectious hazard for patients is to find definitive proof that inanimate objects played a role in transmitting in human disease. In order to support fomites as a causative agent several areas needed to be proven, including:
- Proof that an organism can survive after inoculation on to the fomite
- Proof that a pathogen can be cultured from fomites in use
- Proof that a pathogen can proliferate on the fomite
- Proof that at least some small part of acquisition of infection cannot be accounted for by other methods of transmission
- Peer reviewed studies showing an association between exposure to the contaminated fomite and infection
In 2006, German researchers conducted a systematic review of the literature, looking at the ability of infectious organisms to survive on inanimate surfaces. The review found that Gram-negative bacteria persist for longer periods of time than Gram-positive bacteria. The data was mounting.
Today, I think it’s safe to say that we’ve all drank the Kool-Aid and believe (or at least agree) that pathogens can be transmitted from fomites and that fomites have been directly related to outbreaks. Unfortunately, while we know this, our ability to ensure that fomites do not lead to transmission continues to plague us. Case in point is a recent study published by a group of researchers from the UK looking at what is being touted as being one of the largest outbreaks of Candida auris. In investigating the outbreak, researchers found that axillary thermometers (armpit thermometers) had been used in 57 of the 66 patients (86%) of the patients infected with C. auris. While C. auris was rarely detected in the general ward environment, researchers were able to culture samples from the medical equipment and see it on the surface of thermometers using a scanning electron microscope. The only way the outbreak was controlled was removing the thermometers from use.
This outbreak is not the only outbreak associated with thermometers. Similar to the focus over the last several years of ensuring that the environment is being effectively cleaned and disinfected through verification programs, so too is the need to have programs and processes in place to ensure that multi-use patient care equipment is being properly and effectively cleaned and disinfected between use. Infectious pathogens are opportunistic. If we let our guards down, they will find a way to proliferate, contaminate and infect our patients.