Brief report

Evaluation of fungal contamination in operating rooms using a dusting cloth pad:

Comparison among different sampling methods
Daniela DAlessandro 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, Italy
Key Words:
Environmental surveillance
Bio-contamination
Controlled hospital environments
To evaluate microbial contamination in hospitals environments, several methods are available, each one
having 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 detect
contamination because of lamentous fungi in operating rooms, performing 110 sampling campaigns in
hospitals of 3 Italian cities. Overall, 96% of the DC pad samples were positive compared with 51% of Rodac
plates (P < .0001) and 35% of air samples (P < .0001). Authors conclude that the DC pad improves the
ability to detect an environmental contamination of 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 disease
transmission, especially to immunocompromised patients, and the
exposure of such patients to air molds spores can result in fatal
infections. The incidence of these infections can be minimized by
adherence to ventilation standards for specialized care environ-
ments, appropriate maintenance, and careful cleaning.
1
Different strategies are required for the surveillance of la-
mentous fungi (FF) in hospital to prevent nosocomial invasive
fungal infections among high-risk patients, and microbiologic
environmental 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, we
developed a simple at tampon (4.5 cm in diameter) by covering
a circular cottonpad witha commondusting cloth(DC pad) selected
among those in the market. Its efciency to sample FF fromsurfaces,
in comparison with other surface sampling systems (contact plates
and cotton swabs), was already described in experimental
conditions and in a 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 scientic background, the aim of this report is to
compare DC pads to the most used systems for surface and air
sampling (Rodac contact plates, Becton-Dickinson, Heidelberg,
Germany and Surface Air System International PBI, Milan, Italy) in
their ability to detect an environmental contamination due to FF in
the ORs.
METHODS
The study refers to the results of 110 sampling campaigns
carried 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 followed
the method described in a previous study.
4
In each OR, next to the
surgical table, active sampling was performed using a surface air
system (SAS) (International PBI, Milan, Italy), with a ow rate of
180 L/min and a suction volume of 500 L.
2,3,7
The sampler was
placed in the operating theater approximately 1 m above the oor
and 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 DAlessandro, MD, MPH, PhD, Department
of Architecture and Planning for Engineering, Sapienza University of Rome, Via
Eudossiana, 18, 00186 Rome, Italy.
E-mail address: daniela.dalessandro@uniroma1.it (D. DAlessandro).
Conicts of interest: None to report.
Contents lists available at ScienceDirect
American Journal of Infection Control
j ournal homepage: www. aj i cj ournal . 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 41 (2013) 658-60
test the difference between paired proportions of samples by
sampling methods and venue.
RESULTS
Overall, 110 sampling campaigns were performed. DC pad shows
the highest percentage of positive samples in all venue, with the
exception of Sassari where the positivity of air samples was about
the 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 air
samples (P <.0001).
The difference persists stratifying by venue (Table 1), with the
exception of the results collected in Sassari ORs, not signicantly
different from the DC pads. Both contact plates and air sampling
showed 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 number
of samples; therefore, the results could be more consistent.
DISCUSSION
Environmental microbiologic sampling in health care facilities
remains controversial because of currently unresolved technical
limitations and the need for substantial laboratory support.
1
Despite these limitations, several authors have opted to use
microbiologic sampling in several situation.
1,8,9
Regarding sampling methods, the international standards
14698-1 (Cleanrooms and associated controlled environments
Biocontamination control) provided by the International Organi-
zation for Standardization (ISO) contemplate 2 different techniques
(an active and a passive sampling) whose results, in some cases, are
consistent.
2,7
Each of the 2 methods shows limitations. In partic-
ular, the active air sampling shows a high variability of results,
inuenced by the sampling condition and the type of sampler
used.
1
Air sampling can produce 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 peak
period of the contamination.
10
These evidences support our results:
the comparison of the proportion of positive sampling for FF shows
a signicant difference between air sampling and DC pads, mainly
in cleaner ORs.
The Centers for Disease Control and Prevention report that
surface sampling tends to select for larger particles, with a scarce
sensitivity for inhalable fraction.
1
On the contrary, several
researchers support the mycologic sampling of surfaces rather then
air sampling for several reasons already described in a previous
report.
4
In the same report, we also described why DC pads identify
a surface contamination signicantly more often than Rodac
plates.
4
A limit of the study is the lack of comparison in terms of colony-
forming units (CFU) captured. Regarding sampling surface, the
comparison of CFU per square centimeter measured with DC pads
and Rodac Contact plates is only possible when the size of the
sampled area is identical. This aspect has already been demon-
strated in previous studies.
4,6
Regarding the CFU collected using air
sampling versus DC pad, the comparison does not make sense
because it compared a surface with a volume, and the contamina-
tion can be different in terms of origin and behaviors.
For these reasons, our goal has been limited to verifying the
ability of the proposed method to detect an environmental
contamination, independently from the level of contamination,
considering that, in clean environments such as ORs or other
controlled environment where hygiene is considered to be
crucial,
3
the environmental fungal contamination has to be absent,
both from air and surfaces, and the sampling method has to be as
sensible as possible.
Therefore, we believe that the DC pad is a sensitive approach to
environmental control of FF when compared with other surface
sampling,
4
but also to air sampling methods, providing useful
information regarding air conditioning system activity and
maintenance.
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57,1
66,7
29,0
100,0
85,2
74,2
52,4
77,8
8,1
0,0
20,0
40,0
60,0
80,0
100,0
Bari Sassari Rome
Rodac plates
DC 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 venue
No. DC pad DC pad DC pad- DC pad - % Positive
Venue pairs
Other ,
n
Other-,
n
Other ,
n
Other-,
n
DC
pad Other
P
value*
DC pads versus contact plates
Bari 62 17 29 2 14 74.2 30.6 <.0001
Rome 21 11 10 0 0 100.0 52.4 .0044
Sassari 27 17 6 1 3 85.2 66.7 n.s
Total 110 45 45 3 17 81.8 43.6 <.0001
DC pads versus air sampling
Bari 62 1 45 0 16 74.2 1.6 <.0001
Rome 21 10 11 0 0 100.0 47.6 .0026
Sassari 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 signicant.
*McNemar test.
D. DAlessandro et al. / American Journal of Infection Control 41 (2013) 658-60 659
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