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Adhesive tape in the health care setting: Another high-risk fomite?

MJA 196 (1) · 16 January 201 234
The Medical Journal of Australia
ISSN: 0025-729X 16 January 2012
196 1 1-1
©The Medical Journal of Australia
Adhesive tape in the
health care setting: another
high-risk fomite?
TO THE EDITOR: We read with
interest the article by Pinto and
colleagues regarding colonisation of
reusable tourniquets by
multiresistant organisms (MROs).1
We highlight that surgical adhesive
tape also has the potential to act as a
significant fomite in health care
We collected partially used
surgical tape rolls from several
clinical areas of three hospitals in the
Hunter New England Area Health
Service. Using hands disinfected
with alcohol gel, tape rolls from
different locations in each area were
placed into 21 clean collection bags
(up to three tapes per bag).
Tapes from each batch were placed
in 21 sterile containers with 15 mL of
brain–heart infusion broth and
incubated overnight at 35C in
carbon dioxide. The broths were
subcultured onto Columbia horse-
blood agar (Oxoid Australia,
Adelaide, SA), MacConkey agar
(Oxoid) and differential selective
media to detect vancomycin-
resistant enterococci (VRE)
(chromID VRE; bioMérieux, Marcy
L’Étoile, France), methicillin-
resistant Staphylococcus aureus
(MRSA) (Brilliance MRSA; Oxoid)
and multiresistant gram-negative
bacteria (chromID ESBL;
bioMérieux). A multiplex tandem
polymerase chain reaction assay
(MRSA4; AusDiagnostics, Sydney,
NSW) to detect MRSA and
methicillin-susceptible S. aureus
(MSSA) was also performed on all
broth cultures. Routine species level
identification was performed (VITEK
MS; bioMérieux). Susceptibility was
determined in accordance with
Clinical and Laboratory Standards
Institute criteria.2
In 11 of the 21 tape batches,
MRSA and/or VRE were identified.
Of these, four were positive for
MRSA and 10 for VRE, with three
positive for both. MSSA was
identified in two, both in association
with VRE. All batches showed
evidence of contamination with
other bacteria such as Bacillus cereus,
coagulase-negative staphylococci,
Enterobacteriaceae, Pseudomonas
spp, Acinetobacter spp and other
Our results indicate that surgical
adhesive tapes are frequently
contaminated with MROs.
Interpretation of these results is
limited by the small number of tapes
and clinical areas sampled, and the
difficulty of proving a relationship to
clinical infection. However, items
such as intravenous cannulae,
surgical drains and wound dressings
are frequently fixed using surgical
adhesive tape. This may lead to
colonisation and subsequent
infection. Furthermore, tape rolls are
often left lying on contaminated
surfaces, are handled by multiple
individuals and cannot be
Surgical adhesive tape is a
potential reservoir of pathogenic
bacteria3 and fungi4 and was
implicated in a prolonged S. aureus
outbreak in a neonatal unit.5 The
role of surgical tape as a potential
fomite was reported in 19746 but has
not been widely acknowledged
Removing the outer layer of the
tape roll is unlikely to reduce
contamination, given visible
contamination of the side of many
rolls (Figure).3 Short rolls of surgical
adhesive tape should be supplied in
sealed packets and used for
individual patients, only after hand
disinfection, and discarded after use.
Patrick N A Harris Infectious Diseases and
Microb iology Advance d Trainee
Chris As hhurst-Smit h Senior Scientist,
Microb iolog y
Sandy J Berenger Infection Prevention and Control
Clinical Nurse Consultant
Alison Shoobert Infection Prevention and Control
Clinical Nurse Consultant
John K Ferguson Infectious Diseases Physician and
Microb iolog ist
Hunter Area Pathology Service, John Hunter Hospital,
Newcastle, NSW.
patrick .harris @hneheal
Competing interests: No rel evant d isclos ures.
doi: 10.5694 /mja11.11211
1Pinto AN, Phan T, Sala G, et al. Reusable venesec-
tion tourniquets: a potential source of hospital
transmission of multiresistant organisms. Med J
Aust 201 1; 195 : 276-27 9.
2Clinical and Laboratory Standards Institute.
Perform ance stand ards for an timicrobi al
suscept ibility testing; twentieth infor mational
supplement. C LSI documen t M100-S20. Wayne,
Pa: CLSI, 2010.
3Redelmeier DA, Livesley NJ. Adhesive tape and
intravascular-catheter-associated infections.
J Gen Intern Med 1999; 14: 373-375.
4Everett ED, Pearson S, Rogers W. Rhizopus
surgical wound infection with e lasticized
adhesive tape dressings. Arch Surg 1979; 114:
5Wilcox MH, Fitzgerald P, Freeman J, et al. A five
year outbreak of methicillin-susceptible
Staphylo coccus aureus phage type 53,85 in a
regional neonatal unit. Epidemiol Infect 2000;
124: 37-45.
6Berkowitz DM, Lee WS, Pazin GJ, et al. Adhesive
tape: potential source of nosocomial bacteria.
App l Mi cr obi ol 1974; 28: 651-654.
adhesive tape
is a potential
reservoir of
pathogeni c
Harris et al
... Also, a single roll may be manipulated by multiple healthcare workers, including but not limited to, physicians, nurses, and OR technicians. Often a medical tape is handled with ungloved hands [1]. Furthermore, there are no existing practices or methods to ensure cleanliness, sterility, or prevent cross-contamination as far as OR tape is concerned [2]. ...
... A contaminated adhesive placed in close contact with IV catheters and mucous membranes of the patient's respiratory and urogenital tract for extended periods could contribute to local or systemic infections [1,2]. The potential for this increases manifold in immunocompromised patients and those with longer indwelling catheter times [3]. ...
... Redelmeier and Livesley reported that 74% of the medical tape collected in one hospital was colonized by pathogenic bacteria [2]. Besides commensals, surgical tape is reported to be frequently contaminated with multidrugresistant organisms [1,3]. There are multiple reports of infectious disease outbreaks in intensive care units and general hospital floors in which the source was traced back to medical tape [10][11][12]. ...
... To maintain patient safety, extra tape at the insertion site requires extra surveillance to detect any increase in adverse skin events or infection. Tape under the dressing could act as a fomite and increase infectious complications (Harris et al., 2012;Redelmeier & Livesley, 1999). Furthermore, the exposure of skin to additional tape and adhesive could result in an increase in medical adhesive-related skin injuries (MARSI) through mechanical and chemical processes, resulting in skin tears, bruising, blisters, contact dermatitis, erythema and pain (Broadhurst et al., 2017;Thayer, 2012;Ullman et al., 2019). ...
... Nonsterile tape rolls are not designed for single patient use, are carried from patient to patient and are often visibly contaminated (Harris et al., 2012). These multiuse tapes are a vector for microorganisms (Cady & Gross, 2011;Harris et al., 2012;Redelmeier & Livesley, 1999) Nonsterile tape as an adjunct to the primary dressing is very prevalent in nursing practice (Alexandrou et al., 2018;Marsh et al., 2018;Russell et al., 2014). ...
... Nonsterile tape rolls are not designed for single patient use, are carried from patient to patient and are often visibly contaminated (Harris et al., 2012). These multiuse tapes are a vector for microorganisms (Cady & Gross, 2011;Harris et al., 2012;Redelmeier & Livesley, 1999) Nonsterile tape as an adjunct to the primary dressing is very prevalent in nursing practice (Alexandrou et al., 2018;Marsh et al., 2018;Russell et al., 2014). In fact, two thirds of interventions tested in the included studies used a combination of dressing and secondary securement products to secure the PIVC. ...
Aim: To synthesise evidence related to medical adhesive tapes and supplementary securement products for peripheral intravenous catheters in adults, to prevent complications and device failure. Design: Integrative review informed by Whittemore and Knafl and reported in accordance with the PRISMA 2020 statement. Data sources: The Cochrane Central Register of Controlled Trials, US National Library of Medicine National Institutes of Health, EMBASE/MEDLINE and Cumulative Index to Nursing and Allied Health were searched from 2000-21 September 2020. Review methods: Studies enrolling hospitalised participants >16 years with peripheral intravenous catheters secured by medical adhesive tapes, or supplementary products (bandage, splint and sutureless securement device), were eligible. Quality appraisal was performed using Critical Appraisal Skills Program checklists. Results: Nineteen studies met criteria, including 43,683 peripheral intravenous catheters. Quality appraisal identified high or unclear risk of bias in 58% of studies. Nonsterile tape was the most common intervention tested (14 studies), alone or in multiproduct combinations. Nonsterile tape directly over insertion sites was associated with increased PIVC failure and complications. Sutureless securement devices potentially reduce failure and complications. Multiproduct combinations were very common. Practice recommendations regarding other tapes and secondary securement products are challenging, due to conflicting, or lack of, evidence. Conclusion: Tapes and secondary securement product evidence are limited, and over half of the studies are of low methodological quality. This review found nonsterile tape was associated with increased failure and complications; multiproduct dressing and securement bundles were prevalent; and significant evidence gaps exist particularly regarding bandages and splints. The results provide nurses with evidence of medical adhesive tapes and supplementary product effectiveness for peripheral intravenous catheter securement, and future research directions to reduce unacceptably high failure and complication rates. Larger rigorously conducted randomised controlled trials are needed to add to current evidence.
... Improving quality in healthcare involves enhancing the quality and safety of the medical devices used by health professionals in different complex procedures 4 . Contamination of medical devices has been identified in outbreaks and crosstransmission of pathogens among hospitalized patients in different clinical settings [5][6][7][8] . Contamination occurs either by transfer of microorganisms contaminating health workers' hands or direct patient shedding of microorganisms into the equipment used during care delivery 9 . ...
... Therefore, medical device contamination is a major public health concern as the reusable medical devices are being extensively used for diagnostic and therapeutic purposes 6 . Several studies show that highly portable medical devices are associated with high contamination rates, often linked with bacterial cultures that are MDR to conventional antibiotic therapy [7][8][9] . ...
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Introduction: The tourniquet used in venipuncture appears as a potential vehicle for the transmission of microorganisms that interferes with safety and the quality of clinical services. Objective: Mapping the scientific evidence on the microbiological contamination of the tourniquets used in peripheral venipuncture. Methodology: Scoping review following the Joanna Briggs Institute methodology. Results: 20 studies have been included, in which of 1477 tourniquets were analyzed. The rates of microbiological contamination varied between 10-100% and 19 studies reported the presence of S. aureus, 11 of them detected methicillin-resistant strains with prevalence between 3.3-58.3%. Conclusion: The contamination rate in the majority of studies was ≥70%, including 4 studies which had sampled ≥100 tourniquets. The evidence of our study is that the tourniquets are reservoirs of potential pathogens and can be transmitted to patient on staff hands. We recommend studies that confirm the reusable tourniquets can be responsible to healthcare associated infections.
... Nosocomial infections can be induced by fomites-surfaces which carry contaminants-and rolls of tape can act as fomites in a hospital setting. [1][2][3] The purpose of this study was to assess the bacterial load on rolls of adhesive tape readily available in operating theatres and the corresponding outpatient clinics in a single hospital surgical practice, and to explore existing literature for the rationale behind the application of unsterile adhesives onto a surgical wound. ...
Full-text available
Fomites are surfaces that carry contaminants and may cause infection. We wanted to assess the bacterial load on rolls of nonsterile microporous tape in a hospital setting and explore the scientific rationale behind the existing practice of applying unsterile adhesives onto a surgical wound. Methods: We analyzed the aerobic bacterial contamination in rolls of microporous tape collected from surgical theaters, outpatient clinics, and storage rooms at St. Olav's University Hospital, Trondheim, Norway between 2018 and 2020. We also reviewed the literature for relevant publications. Results: A total of 58 rolls were collected; 55 were included for final analysis. Exposed tape surfaces were significantly more contaminated than unexposed surfaces. Tape rolls from outpatient clinics were significantly more contaminated and contained a significantly greater variety of microbes than rolls from operation theaters and storage rooms. Unexposed surfaces from both operation theaters and storage rooms demonstrated very little contamination. Conclusions: Rolls of tape may act as fomites, but widespread use of adhesives is inevitable in hospital settings. Removing the outer layer of a tape roll before use may significantly reduce bacterial contamination. Given sufficient vigilance to avoid cross-contamination, inner layers of tape may represent a close-to-sterile alternative as surgical dressing. However, the economic savings constitute a negligible fraction of the total costs of the surgery, and the risk of contamination seems apparent. Scientific support of dressing a fresh surgical wound with unsterile microporous tape is lacking, and we therefore do not recommend the practice except in situations with very limited resources.
... Rammaert et al, 2012 13 Livesley and Richardson,1993 14 Bundy, 1989 15 Powell et al, 1987 16 CDC, 1978 17 Diaz et al, 1986 18 Love, 2013 19 Krug et al, 2016 20 Oldman, 1991 21 James et al, 2000 22 Gartemberg et al, 1978 23 Stiller et al, 1994 24 Krug et al, 2014 25 Lindberg et al, 2017 6 Redelmeier & Livesley, 1999 26 Arpin et al, 2002 27 Bauer and Densen, 1979 28 Hughes et al, 1995 29 Mantyh et al, 2017 30 Cady et al, 2011 31 Lipscombe and Juma, 2007 32 Everett et al, 1979 33 du Plessis et al, 1997 34 Spencer et al, 2018 35 Harris et al, 2012 36 Bottone et al, 1979 37 Dickinson et al, 1998 38 Hooker et al, 2020 7 Mead et al, 1979 39 Alsuwaida 2002 40 Dennis et al, 1980 42 Garg et al, 2009 43 Patterson et al, 1986 44 McClusky et al, 2015 41 Endoh et al, 2004 45 Christiaens et al, 2005 46 Lalayanni et al, 2012 47 Foster et al, 2019 48 ...
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Background Medical tapes are ubiquitous in healthcare and there are currently no guidelines for their storage and use. Tapes cannot be cleaned or disinfected; yet, several clinicians may use a given roll for any number of patients. Reports of tape contamination associated with clinical infection have been published. Purpose We reviewed the literature reporting microbiological studies, case reports of infections, and nosocomial outbreaks associated with the use of medical tapes and other adhesive devices to assess the prevalence of this problem. Methods We conducted a literature search for cross-contamination due to medical tape use in 6 databases in June 2020 using indexing terms for surgical tape, adhesive agent, adhesives or the keyword for tape. We compiled available evidence on tape contamination as a cause for healthcare-associated infections (HAIs). Main findings Forty-two publications reported relevant microbiological studies, case reports of infections, and/or nosocomial outbreaks. Results demonstrated that tape rolls handled with questionable practices can harbor pathogens. Some studies showed the association between contaminated tape and HAIs, which in some cases even led to death. Conclusions The time has come to establish national guidelines to help reduce the risk of cross-contamination from medical tapes. We offer suggested elements for these guidelines. The COVID-19 pandemic brings greater scrutiny to eliminate any avoidable cause of infection transmission.
... Some of the greatest concerns for antibiotic-resistant bacteria transmission occur in healthcare environments where contamination and transmission are possible through numerous fomites, ranging from mobile phones [89] to medical devices [90] to surgical tape [91] to doctors' handbags [92]. While it has been hypothesized that many of these fomites have been important sources, closer investigation often reveals a more nuanced understanding. ...
Full-text available
Purpose of Review Fomites are inanimate objects that become colonized with microbes and serve as potential intermediaries for transmission to/from humans. This review summarizes recent literature on fomite contamination and microbial survival in the built environment, transmission between fomites and humans, and implications for human health. Recent Findings Applications of molecular sequencing techniques to analyze microbial samples have increased our understanding of the microbial diversity that exists in the built environment. This growing body of research has established that microbial communities on surfaces include substantial diversity, with considerable dynamics. While many microbial taxa likely die or lay dormant, some organisms survive, including those that are potentially beneficial, benign, or pathogenic. Surface characteristics also influence microbial survival and rates of transfer to and from humans. Recent research has combined experimental data, mechanistic modeling, and epidemiological approaches to shed light on the likely contributors to microbial exchange between fomites and humans and their contributions to adverse (and even potentially beneficial) human health outcomes. Summary In addition to concerns for fomite transmission of potential pathogens, new analytical tools have uncovered other microbial matters that can be transmitted indirectly via fomites, including entire microbial communities and antibiotic-resistant bacteria. Mathematical models and epidemiological approaches can provide insight on human health implications. However, both are subject to limitations associated with study design, and there is a need to better understand appropriate input model parameters. Fomites remain an important mechanism of transmission of many microbes, along with direct contact and short- and long-range aerosols.
... This practice resulted in: 4-fold higher odds of pain and tenderness at the insertion site, the development of a palpable vein cord, and the presence of a streak or red line along the vein; and double the odds of insertion site swelling. Non-sterile tape is a vector for microorganisms ( Redelmeier and Livesley, 1999 ;Cady and Gross, 2011 ;Harris et al., 2012 ), substantially increasing risk of insertion site and bloodstream infection. Alarmingly, 1 in 10 catheters in this study was covered with non-sterile tape alone, and 1 in 5 was secured with non-sterile tape under the primary dressing, practices more widespread in paediatric settings and lower income countries. ...
Background: With over 2 billion peripheral intravenous catheters used globally each year, avoiding complications is crucial for patients and healthcare organisations. Effective catheter dressing and securement is a key nursing strategy to reduce catheter failure and resultant patient harm. Objectives: To describe global catheter dressing and securement practices and policy; and identify factors associated with catheter insertion site complications, and suboptimal dressing and securement. Design: Secondary analysis of a global cross-sectional study of peripheral intravenous catheter characteristics, management and outcomes. Setting: Four hundred and seven rural, regional and metropolitan hospitals in 51 countries. Participants: Paediatric and adult patients with 40,637 catheters. Methods: Patient-, catheter-, and institution-related factors which could be associated with catheter site complications and suboptimal dressings were extracted from the parent database. Global trends in catheter dressing and securement policy and practice were described. Potential predictors of catheter and dressing complications were explored using logistic regression. Results: Dressing and securement practices, and local hospital policy regarding dressing change frequency varied. One fifth of dressings (21%, n = 8519) were not clean, dry and intact. The prevalence of catheter insertion site complications was 16% (n = 6503), with signs of phlebitis commonly observed (11.5%, n = 4587). Compared to non-bordered polyurethane dressings, sterile gauze and tape dressings were associated with fewer insertion site complications (odds ratio 0.58, 95% confidence interval 0.50-0.68) and better dressing integrity (odds ratio 0.68; 95% confidence interval 0.59-0.77); whereas, compared with no securement, non-sterile tape at the insertion site was associated with more site complications (odds ratio 2.39, 95% confidence interval 2.22-2.57) and poorer dressing integrity (odds ratio 1.64, 95% confidence interval 1.51-1.75). Two 'bundled' dressing and securement combinations were associated with fewer site and dressing complications, when compared with the reference category. Local catheter care guidelines which advocate 4th hourly insertion site inspection and dressing replacement between 1-3 days were associated with better catheter dressing integrity. Conclusion: Modifiable risk factors for peripheral intravenous catheter site and dressing complications were identified and are amendable to further interventional testing.
... Medical devices contamination is a major public health concern, since their extensive reprocessing and reuse between patients may hamper the care provided (6) . Several studies show that highly portable medical devices, such as tourniquets, are associated with high contamination rates, often linked with bacterial cultures that are multidrug resistant to conventional antibiotic therapy (7)(8)(9) . However, there is evidence pointing to a wide gap between health professionals knowledge and practices in this field (10) . ...
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Objectives during peripheral venipuncture, health professionals are recommended to use a tourniquet above the puncture site in order to potentiate venous distension. Given its characteristics and use in clinical settings, tourniquets may represent a source of microorganism dissemination. However, the results of scientific studies in this area are scattered in the literature. This scoping review aims to map the available evidence on health professionals’ practices related with tourniquet use during peripheral venipuncture and associated microbiological contamination. Methods scoping review following the Joanna Briggs Institute methodology. Two independent reviewers analyzed the relevance of the studies, extracted and synthesized data. Results fifteen studies were included in the review. Overall, tourniquets were reused without being subject to recurring decontamination processes. It has been found that practitioners share these devices among themselves and use them successively for periods between two weeks and seven and half years. Conclusion nursing practices related to tourniquet use during peripheral venipuncture are not standard. Reuse of tourniquets may jeopardize the patient’s safety if reprocessing (cleaning and disinfection/sterilization) is not adequate, given the type of tourniquet material and microbiota found. New studies are needed to assess the impact of various types of reprocessing practices on tourniquet decontamination and patient safety.
Using adhesive tape for patient positioning Key words: adhesive tape, surgical tape, patient positioning, pressure injury, contamination. Border sterility of open sterile wrappers Key words: wrapped sterile item, unsterile border, wrapper flap, contaminated, aseptic technique. Cost per minute of OR time Key words: cost comparison, direct costs, cost savings, perioperative efficiency, product evaluation. Packages containing an incorrect number of suture needles Key words: multipack, retained surgical item (RSI), counting, needle, package.
The standard of practice for perioperative hair removal is largely based on research that is outdated and underpowered. Although there is evidence to support the practice of clipping instead of shaving, current recommendations are to remove hair only when absolutely necessary. Human hair is bacteria‐laden and challenging to disinfect, and clipping can be a safe method of hair removal that does not damage the skin. This article considers the removal of hair at the incision site with clippers, either before the patient enters the OR or in a manner that completely contains clipped hair, for every procedure, not just when absolutely necessary. There have been only two studies to date comparing clipping with no hair removal; more research is needed on this subject.
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To determine the prevalence of multiresistant organism (MRO) colonisation of reusable venesection tourniquets. A prospective study in a tertiary hospital to collect and analyse reusable venesection tourniquets for the presence of MROs - methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and extended-spectrum β-lactamase and metallo-β-lactamase-producing Enterobacteriaceae - using a sensitive enrichment method. Tourniquets were collected and tested during a 10-week period between September and November 2010. Prevalence of MRO colonisation of tourniquets. The overall colonisation rate of 100 tourniquets randomly collected from general wards, ambulatory care areas and critical care areas was 78%. MROs were isolated from 25 tourniquets collected from a variety of hospital locations, including general wards, the intensive care unit, burns unit and anaesthetic bay. MRSA was isolated from 14 tourniquets and VRE from 19; both MRSA and VRE were isolated from nine tourniquets. There were no microorganisms isolated from 22 tourniquets. Reusable tourniquets can be colonised with MROs and may be a potential source of transmission of MROs to hospitalised patients.
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We identified a 5-year outbreak of a methicillin-susceptible Staphylococcus aureus (MSSA) strain, affecting 202 babies on a neonatal unit, by routine weekly phage typing all S. aureus isolates. Multiple staged control measures including strict emphasis on hand hygiene, environmental and staff surveillance sampling, and application of topical hexachlorophane powder failed to end the outbreak. S. aureus PT 53,85 (SA5385) was found on opened packs of Stomahesive®, used as a neonatal skin protectant. Only following the implementation of aseptic handling of Stomahesive®, and the use of topical mupirocin for staff nasal carriers of SA5385, and for babies colonized or infected with S. aureus, did the isolation rate of SA5385 decline. DNA fingerprinting indicated that [gt-or-equal, slanted]95% of SA5385 isolates were clonal. In vitro death rates of SA5385 on Stomahesive® with human serum were significantly lower than on Stomahesive® alone (P = 0·04), and on cotton sheet with serum (P = 0·04), highlighting the potential of this material as a survival niche. Phage typing remains a valuable, inexpensive and simple method for monitoring nosocomial MSSA infection.
We report a case of cutaneous Rhizopus infection associated with the use of an elasticized adhesive tape (Elastoplast) bandage over a surgical wound. At the present time, it is recommended that such dressings not be used on open wounds.
During a 7-day period, a variety of bacteria, including opportunistic ones, were recovered from 23 rolls of adhesive tape being used in a 16-bed intensive care unit. All rolls of tape were sterile when received from the manufacturer. Mixed flora was recovered from a total of 15 rolls, whereas eight rolls yielded pure cultures. Organisms recovered included Staphylococcus aureus, Pseudomonas aeruginosa, and various species of Enterobacteriaceae. Although no illness or infection arising directly from contaminated adhesive tape has been documented, we feel that a potential source of infection has been identified. Most important is the fact that such tape may contaminate the hands of personnel who handle it. Also, the adhesive tape may directly contaminate a patient since it is widely used to secure artificial airways and various drainage tubes which results in the tape coming into close contact with the mucous membranes lining the patient's respiratory and urogenital tracts.
Adhesive tape is placed in close contact with intravascular catheters for extended periods and could theoretically contribute to local infections. We found that 74% of specimens of tape collected in one hospital were colonized by pathogenic bacteria. However, only 5% of specimens had significant growth from an inner layer obtained by discarding the outside layer from each roll. We suggest that adhesive tape is a potential source of pathogenic bacteria and that discarding the outer layer from a partially used roll might be a simple method for reducing the risk of infection to patients.