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Evaluation of fungal contamination in operating rooms using a dusting cloth pad: Comparison among different sampling methods

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Evaluation of fungal contamination in operating rooms using a dusting cloth pad: Comparison among different sampling methods
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  Brief Report Evaluation of fungal contamination in operating rooms using a dusting cloth pad:Comparison among different sampling methods Daniela D ’ Alessandro MD, MPH, PhD a , *, Franco Cerquetani MD b , Maria Grazia Deriu ScD c ,Maria Teresa Montagna ScD d , Ida Mura MD c , Christian Napoli MD d , Nicoletta Vescia MD, ScD e a Department of Civil Building and Environmental Engineering,  “  Sapienza ”   University of Rome, Rome, Italy b Medical Direction,  “  San Filippo Neri ”   Hospital, Rome, Italy c Department of Biomedical Sciences, University of Sassari, Sassari, Italy d Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy e Department of Public Health and Infectious Diseases,  “  Sapienza ”   University of Rome, Rome, ItalyKey Words: Environmental surveillanceBio-contaminationControlled hospital environments To evaluate microbial contamination in hospitals environments, several methods are available, each onehaving its limitations. Therefore, the choice of system to use is open. This study compares the ability of a dusting cloth pad (DC pad) with 2 other methods (Rodac contact plate and air sampling) to detectcontamination because of   fi lamentous fungi in operating rooms, performing 110 sampling campaigns inhospitals of 3 Italian cities. Overall, 96% of the DC pad samples were positive compared with 51% of Rodacplates ( P   < .0001) and 35% of air samples ( P   < .0001). Authors conclude that the DC pad improves theability to detect an environmental contamination of   fi lamentous fungi.Copyright    2013 by the Association for Professionals in Infection Control and Epidemiology, Inc.Published by Elsevier Inc. All rights reserved. The health care facility environment is implicated in diseasetransmission, especially to immunocompromised patients, and theexposure of such patients to air molds spores can result in fatalinfections. The incidence of these infections can be minimized byadherence to ventilation standards for specialized care environ-ments, appropriate maintenance, and careful cleaning. 1 Different strategies are required for the surveillance of   fi la-mentous fungi (FF) in hospital to prevent nosocomial invasivefungal infections among high-risk patients, and microbiologicenvironmental sampling is an unresolved issue. 2-4 The lack of standardized protocols and reference values for fungal environ-mental surveillance leave the choice to each hospital in terms of where, when, why, and how to detect them. 5 With the aim to simplify and to improve surface sampling, wedeveloped a simple  fl at tampon (4.5 cm in diameter) by coveringacircularcottonpadwithacommondustingcloth(DCpad)selectedamongthoseinthemarket.Itsef  fi ciencytosampleFFfromsurfaces,in comparisonwith other surface sampling systems (contact platesand cotton swabs), was already described in experimentalconditions and in a  fi eld trial. 4,6 Nevertheless, with regard to envi-ronmental sampling in operating rooms (ORs), international stan-dards report not only surface samplings but also air sampling.Given this scienti fi c background, the aim of this report is tocompare DC pads to the most used systems for surface and airsampling (Rodac contact plates, Becton-Dickinson, Heidelberg,Germany and Surface Air System International PBI, Milan, Italy) intheir ability to detect an environmental contamination due to FF inthe ORs. METHODS The study refers to the results of 110 samplin ’ g campaignscarried out in the ORs of hospitals from 3 Italian cities: Bari, Rome,and Sassari, located in southern and central Italy, respectively.Samples were collected in the ORs before starting activity (at rest).Surface sampling with Rodac contact plates and DC pad followedthe method described in a previous study. 4 In each OR, next to thesurgical table, active sampling was performed using a surface airsystem (SAS) (International PBI, Milan, Italy), with a  fl ow rate of 180 L/min and a suction volume of 500 L. 2,3,7 The sampler wasplaced in the operating theater approximately 1 m above the  fl oorand approximately 1 m from the operating table. 7 The  c 2 test was used to compare the overall proportions of samples found to be positive for FF. The McNemar test was used to * Address correspondence to Daniela D ’ Alessandro, MD, MPH, PhD, Departmentof Architecture and Planning for Engineering, Sapienza University of Rome, ViaEudossiana, 18, 00186 Rome, Italy. E-mail address:  daniela.dalessandro@uniroma1.it (D. D ’ Alessandro).Con fl icts of interest: None to report. Contents lists available at ScienceDirect American Journal of Infection Control journal homepage: www.ajicjournal.org American Journal of Infection Control 0196-6553/$36.00 - Copyright    2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.ajic.2012.10.006 American Journal of Infection Control xxx (2013) 1-3  test the difference between paired proportions of samples bysampling methods and venue. RESULTS Overall,110samplingcampaignswereperformed.DCpadshowsthe highest percentage of positive samples in all venue, with theexception of Sassari where the positivity of air samples was aboutthe same of those with DC pad (Fig 1). Sixteen sampling campaigns(14.5%) were negative for all the sampling methods. Overall, 96%(90/94) of the DC pad samples were positive compared with 51%(48/94) of Rodac plates samples ( P  < .0001) and 35% (33/94) of airsamples ( P  < .0001).The difference persists stratifying by venue (Table 1), with theexception of the results collected in Sassari ORs, not signi fi cantlydifferent from the DC pads. Both contact plates and air samplingshowed the highest differences in respect to DC pads in cleaner(with the lowest percentage of positive samples) ORs (Bari venue).It has also to be underlined that Bari collected the greatest numberof samples; therefore, the results could be more consistent. DISCUSSION Environmental microbiologic sampling in health care facilitiesremains controversial because of currently unresolved technicallimitations and the need for substantial laboratory support. 1 Despite these limitations, several authors have opted to usemicrobiologic sampling in several situation. 1,8,9 Regarding sampling methods, the international standards14698-1 (Cleanrooms and associated controlled environments  – Biocontamination control) provided by the International Organi-zation for Standardization (ISO)contemplate2 differenttechniques(an activeanda passive sampling) whoseresults, insome cases,areconsistent. 2,7 Each of the 2 methods shows limitations. In partic-ular, the active air sampling shows a high variability of results,in fl uenced by the sampling condition and the type of samplerused. 1 Air sampling canproduce a false sense of security because of the narrow range of the results, 5 the difference in level of contamination related to the point of collection, 7 the inability of this method to detect conidia, 5 and the possibility to miss the peakperiodofthecontamination. 10 Theseevidencessupportourresults:the comparison of the proportion of positive sampling for FF showsa signi fi cant difference between air sampling and DC pads, mainlyin cleaner ORs.The Centers for Disease Control and Prevention report thatsurface sampling tends to select for larger particles, with a scarcesensitivity for inhalable fraction. 1 On the contrary, severalresearcherssupport the mycologic samplingofsurfaces ratherthenair sampling for several reasons already described in a previousreport. 4 Inthesamereport, wealsodescribedwhy DCpads identifya surface contamination signi fi cantly more often than Rodacplates. 4 A limit of the study is the lack of comparison in terms of colony-forming units (CFU) captured. Regarding sampling surface, thecomparison of CFU per square centimeter measured with DC padsand Rodac Contact plates is only possible when the size of thesampled area is identical. This aspect has already been demon-strated inprevious studies. 4,6 Regarding the CFU collected using airsampling versus DC pad, the comparison does not make sensebecause it compared a surface with a volume, and the contamina-tion can be different in terms of srcin and behaviors.For these reasons, our goal has been limited to verifying theability of the proposed method to detect an environmentalcontamination, independently from the level of contamination,considering that, in clean environments such as ORs or other “ controlled environment ”  where hygiene is considered to becrucial, 3 the environmental fungal contamination has to be absent,both from air and surfaces, and the sampling method has to be assensible as possible.Therefore, we believe that the DC pad is a sensitive approach toenvironmental control of FF when compared with other surfacesampling, 4 but also to air sampling methods, providing usefulinformation regarding air conditioning system activity andmaintenance. References 1. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventinghealth-care-associated pneumonia, 2003: recommendations of CDC and theHealthcare Infection Control Practices Advisory Committee. MMWR RecommRep 2004;53:1-36.2. Pasquarella C, Veronesi L, Napoli C, Castiglia P, Liguori G, Rizzetto R, et al.Microbial environmental contamination in Italian dental clinics: a multicentrestudy yielding recommendations for standardized sampling methods andthreshold values. Sci Total Environ 2012;420:289-99.3. Pasquarella C, Vitali P, Saccani E, Manotti P, Boccuni C. Microbial air monitoringin operating theates: experience at the University Hospital of Parma. J HospInfect 2012;81:50-7.4. Vescia N, Brenier-Pinchart MP, Osborn JF, Cerquetani F, Cavarischia R, Grillot R,et al. Field validation of a dusting cloth for mycological surveillance of surfaces.Am J Infect Control 2011;39:156-8.5. Grillot R, Nolard N. Surveillace de l ’ environement des malades à risque fongi-que: méthodes d ’ évalutuation et utilité. Hygiènes 2000;6:408-17.6. Vescia N, D ’ Alessandro D, Osborn JF, Grillot R. Development of an innovativemethod for the evaluation of fungal contamination of surfaces. Ann Ig 2008;20:3-8. 57,166,729,0100,085,274,252,477,88,10,020,040,060,080,0100,0 BariSassariRome Rodac platesDC pads Air samples % Fig 1.  Percentage of positive samples by venue and sampling method.  Table 1 Comparison between DC pads and other methods of sampling for FF by venueNo. DC pad þ  DC pad þ  DC pad- DC pad - % PositiveVenue pairsOther þ ,nOther-,nOther þ ,nOther-,nDCpad Other P  value*DC pads versus contact platesBari 62 17 29 2 14 74.2 30.6  < .0001Rome 21 11 10 0 0 100.0 52.4 .0044Sassari 27 17 6 1 3 85.2 66.7 n.sTotal 110 45 45 3 17 81.8 43.6  < .0001DC pads versus air samplingBari 62 1 45 0 16 74.2 1.6  < .0001Rome 21 10 11 0 0 100.0 47.6 .0026Sassari 27 20 3 1 3 85.2 77.8 n.s.Total 110 31 59 1 19 81.8 29.1  < .0001 n.s. , Not signi fi cant.*McNemar test. D. D ’   Alessandro et al. / American Journal of Infection Control xxx (2013) 1-3 2  7. Napoli C, Tafuri S, Montenegro L, Cassano M, Notarnicola A, Lattarulo S, et al. Airsampling methods to evaluate microbial contamination in operating theatres:results of a comparative study in an orthopaedics department. J Hosp Infect2012;80:128-32.8. Moretti B, Larocca AM, Napoli C, Martinelli D, Paolillo L, Cassano M, et al. Activewarming systems to maintain perioperative normothermia in hip replacementsurgery: a therapeutic aid or a vector of infection? J Hosp Infect 2009;73:58-63.9. Gangneux JP, Bretagne S, Cordonnier C, Datry A, Derouin F, Grillot R, et al.Prevention of nosocomial fungal infection: the French approach. Clin Infect Dis2002;35:343-6.10. Mahieu LM, De Dooy JJ, Van Laer FA, Jansens H, Ieven MM. A prospectivestudy on factors in fl uencing aspergillus spore load in the air duringrenovation works in a neonatal intensive care unit. J Hosp Infect 2000;45:191-7. D. D ’   Alessandro et al. / American Journal of Infection Control xxx (2013) 1-3  3

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