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Does using a cellular mobile phone increase the risk of nosocomial infections in the Neonatal Intensive Care Unit: A systematic review

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The aim of this systematic review is to determine if the cellular mobile phone increases a Neonates risk of contracting a nosocomial infection while admitted to the Neonatal Intensive Care Unit. The following databases were searched: The Cumulative Index to Nursing and Allied Literature (Cinahl) with full text, Medline, Embase, Scopus, Pubmed, The Cochrane Library and Web of Science. Search terms include: Neonates, Neonatal Intensive Care Unit, Nosocomial Infection, Health Care Associated Infection and Mobile Phones. The reference list of relevant research was hand searched. The search was conducted from September 2017–January 2018. 6 studies of various methodologies reveal a growth or contamination pathogenic rate of 40%–100% on surfaces of mobile phones. Studies indicate the majority of these bacteria are potentially nosocomial pathogens and some are multi drug resistant. Secondarily, it appears cleaning the mobile phone and adhering to appropriate hand hygiene after handling the mobile phone does reduce a risk of transmission.
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Journal of Neonatal Nursing
journal homepage: www.elsevier.com/locate/jnn
Review
Does using a cellular mobile phone increase the risk of nosocomial infections
in the Neonatal Intensive Care Unit: A systematic review
Aine Curtis
a,
, Professor Zena Moore
b
, Dr. Declan Patton
b
, Dr. Tom O'Connor
b
, Dr. Linda Nugent
b
a
Neonatal StaNurse in Our Lady of Lourdes Hospital, Drogheda, Co. Louth, Ireland
b
Royal College of Surgeons in Ireland, School of Nursing and Midwifery, 123 St. Stephens Green, Dublin 2, Ireland
ARTICLE INFO
Keywords:
Neonates
Neonatal Intensive Care Unit
Nosocomial infection
Health care associated infection
Mobile phones
ABSTRACT
The aim of this systematic review is to determine if the cellular mobile phone increases a Neonates risk of
contracting a nosocomial infection while admitted to the Neonatal Intensive Care Unit. The following databases
were searched: The Cumulative Index to Nursing and Allied Literature (Cinahl) with full text, Medline, Embase,
Scopus, Pubmed, The Cochrane Library and Web of Science. Search terms include: Neonates, Neonatal Intensive
Care Unit, Nosocomial Infection, Health Care Associated Infection and Mobile Phones. The reference list of
relevant research was hand searched. The search was conducted from September 2017January 2018. 6 studies
of various methodologies reveal a growth or contamination pathogenic rate of 40%100% on surfaces of mobile
phones. Studies indicate the majority of these bacteria are potentially nosocomial pathogens and some are multi
drug resistant. Secondarily, it appears cleaning the mobile phone and adhering to appropriate hand hygiene after
handling the mobile phone does reduce a risk of transmission.
Introduction
Nosocomial infections (NI) are causing concern in hospitals, in both
developed and non developed countries. A nosocomial or health care
associtaed infection (HCAI) may be classed as an infection occuring
within 48 h of admission to hospital, 3 days after getting discharged
from hospital or 30 days after undergoing an operation (Inweregbu
et al., 2005). The World Health Organisation (WHO) state a HCAI is
termed as such because the patient acquires the infection during the
hospital incubation period, which was not present at time of admission.
Many studies have conrmed the mobile phone (MP) is a reservoir for
nosocomial infections (Brady et al., 2011 &Mark et al., 2014).
Sumritivanicha et al. (2011) add the MP may not only be a pathogenic
reservoir for NI, but that these bacteria may also be multi drug re-
sistant. Pillet et al. (2016) add respiratory epidemic viruses with a
possible known nosocomial association can live on surfaces for days or
even months. These surfaces include the MP.
Babies admitted to the NICU often have immature immune systems
leaving them susceptible to infections (Polin et al., 2012). It is well
known infections can produce poor outcomes in neonates, from neu-
rodevelopmental impairment to death (Strunk, 2014). In healthcare
settings, copious literature states healthcare workers play a signicant
part in spreading infections (Strunk, 2014;Heyba et al., 2015;Kirkby
and Biggs, 2016). In 1861, Semmelweis demonstrated bacteria is
transmitted via contaminated hands from HCW to patients.
Semmelweis (1861) and WHO (2010) state nosocomial infections result
in longer hospital stays, increased resisitance of micro organisms to
antibiotics and disability longterm on a daily basis. Additionally, this
adds to costs in the healthcare system, for patients and families and
even deaths unnecessarily. For example, WHO (2010) estimate HCAI
costs USD $6.5 Billion in the United States and 7 Billion in Europe
annually indirectly and 16 million extra days of hospital stay.
It is noted, there is very little research specically relating to the
risk of nosocomial infections in the NICU which may be caused by use
of the MP. With regards to published systematic reviews (SRs) relating
to the same topic, as far as the authors are aware there is none available
at present, therefore motivating the justication for our systematic re-
view.
Background
A global telecommunication system was established in Europe in
1982. The idea was to improve the network of communications.
Because of this and ongoing changes in society, the desire for easy ac-
cess to communication and information; the mobile phone has now
become an indispensible tool used by professionals (Haghbin et al.,
2015). Technology's impact on International healthcare has in general
been very positive. Evidence exists suggesting mobile hand held
https://doi.org/10.1016/j.jnn.2018.05.008
Received 10 April 2018; Received in revised form 10 May 2018; Accepted 27 May 2018
Corresponding author.
E-mail addresses: ainecurtis@rcsi.ie (A. Curtis), zmoore@rcsi.ie (Z. Moore), declanpatton@rcsi.ie (D. Patton), tomoconnor@rcsi.ie (T. O'Connor), lindanugent@rcsi.ie (L. Nugent).
Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
1355-1841/ © 2018 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Curtis, A., Journal of Neonatal Nursing (2018), https://doi.org/10.1016/j.jnn.2018.05.008
technology improves eciency, aids error prevention and speeds ac-
cessibility of information to health care workers (Mickan et al., 2013).
Therefore, use of such devices is increasing (Ventola, 2014). Until re-
cently, the MP was not permitted within the Neonatal Intensive Care
Unit (NICU)/Intensive Care Unit (ICU) environment as it caused in-
tereference with vital medical equipment. Now, this interefence is not a
problem and the ban has been removed (Haghbin et al., 2015).
Resistance to nosocomial pathogenic bacteria is increasing
(Bockstael and Van Aerschot, 2009). The Health Service Executive
(HSE) in Ireland considers tackling Healthcare Associated Infection
(HCAI) a priority. In 2010, a national clinical programme for preven-
tion of antimicrobial resistance and health care associated infection was
established (HSE, 2010). Included in this programme was education for
health care sta, patients and the general public on HCAI and Anti-
microbial resistance (AMR). AMR has become a considerable threat to
public health and is a growing risk. Over prescribing of antibiotics in-
creases this threat (HSE, 2017).
Allegranzi et al. (2011) found neonatal infection rates are 320
times higher in undeveloped countries than in industrialised nations.
HCAI in Brazil for example, is 9 times higher than in the United States.
They also state very high rates of HCAI in neonatal and paediatric po-
pulations were noted not only in NICUs and Paediatric ICUs but, it was
also evident in paediatric wards and children's hospitals. The European
Centre for Disease and Control (ECDC, 2015) statistics state within the
ICU, 8.3% of patients staying in an intensive care unit for more than
two days contracted at least one ICU-acquired healthcare-associated
infection (HAI). This is up on 8% from 2014. Burns et al. (2012) convey
in their report that 10% of babies admitted under the care of a neo-
natologist was due to the presence of a HCAI.
As stated, it is not practical to ban the MP due to its uses in speed
and accessibility to both parents and sta(Beckstrom et al., 2013;
Haghbin et al., 2015). Hartz et al. (2015) convey every piece of
equipment in the NICU is a potential reservoir for NI. They highlight
how immunocompromised infants admitted to the NICU actually are.
However, after copious researching, there are suggestions that MP are a
huge source of HCAI that do in fact cause an increased risk of NI to the
Neonate. Ulger et al. (2009) notes studies at present do not include
direct comparisons of transmission rates of bacteria from surfaces to
hands. These studies state MP which are not cleaned properly, or hands
not washed properly after touching the MP may be the cause of infec-
tion. More importantly, they may be contaminated with nosocomial
pathogens.
Methods
Bettany-Saltikov (2012) states the PEO format is more often used in
qualitative research but it can also be used in quantitative research
depending on the search framework. PEO format was deemed most
suitable for this SR as there was no comparing of interventions in this
review. PEO stands for; P: Population, who is being aected, E: Ex-
posure, what is the specic use of the study and O: Outcomes of the
study. The target population is Neonates. The exposure is the risk of the
mobile phone. The outcome is to determine if the mobile phone causes
increased risk of nosocomial infection.
Review question
Does using a cellular mobile phone increase the risk of nosocomial
infection in the Neonatal Intensive Care Unit.
Primary outcome & secondary outcomes
The primary outcome of this SR was to discern if mobile phones can
be a potential source for pathogenic bacteria capable of causing noso-
comial infections in the NICU. Secondary outomes sought to ascertain if
cleaning the mobile phone eradicates bacteria. Further, to identify if
appropriate hand hygiene can prevent transmission of bacteria.
Inclusion & exclusion criteria
Glynn's Evidence-based librarianship (EBL) checklist was used in
this SR to ensure inclusion of relevant studies only. Additionally, all
studies relating to nosocomial infections in the neonate caused by hand
held technology were considered. Articles excluded comprised of stu-
dies relating to the general population or general/surgical wards. They
were not specic to neonates. Those not relating to the primary out-
come were also excluded. This enabled accurate SR development. No
ethical approval was required.
Search strategy
A search of the following databases was conducted; The Cumulative
Index to Nursing and Allied Literature (Cinahl) with full text, Medline,
Embase, Scopus, Pubmed, The Cochrane Library and Web of Science.
This was to ensure all published data relating to the topic is included for
consideration in the SR. Open Grey was searched for any full text
conference papers. LENUS was searched for publications within the
HSE, as the authors are based in Ireland. Also searched was The
National Institute for Health and Care Excellence (NICE) website for
any guidelines or standards of relevance. Medical subject heading
(MeSH) were used to search the terms within Pubmed. Varying limits
were applied depending on the databases. All clinical nurse specialists
in infection control across various Units were contacted but no further
research was achieved in this manner. There were no limits applied to
the year of publication. All publication types were accepted to gather as
much research as possible. Limitations included publications in English
language and publications in full text due to time constraints.
Data extraction
Data was extracted from 6 articles that met the inclusion criteria. All
6 were of quantitative design. No meta-analyses were found and no
qualitative studies were found.
Data analysis
No RCT's were found therefore no meta-analysis could be com-
pleted. A narrative synthesis was conducted. The six studies were re-
viewed, analysed and discussed in a thematic manner as recommended
by The Centre for Evidence Based Intervention (CEBI, 2017).
Quality appraisal
Evidence based literature (EBL) critical appraisal tool (Glynn, 2006)
was used to evaluate the validity of the studies. If overall validity of
study (yes/total) is > 75% or (no + unclear/Total) is < 25% then
study is valid (Glynn, 2006). Included are four cross sectional studies
(Haghbin et al., 2015;Heyba et al., 2015;Beckstrom et al., 2013;
Daoudi et al., 2017), One cohort study (Loyola et al., 2016) and one
convenience sample study (Kirkby and Biggs, 2016). 4 studies received
75% or higher validity score of the EBL Critical Appraisal Checklist and
are as follows; Beckstrom et al., 2013, (80.7%), Haghbin et al., 2015,
(80.7%), Heyba et al., 2015, (80.7%) and Loyola et al., 2016, (88%). Of
the four studies recording greater than 75%, it can be stated conclusions
from these studies are generalizable. 2 studies that did not achieve >
75% overall validity, include Kirkby and Biggs (2016) and Daoudi et al.
(2017).
Results
The search identied 51 articles which were then screened by two
independent reviewers through reading titles and abstracts. This
A. Curtis et al. Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
2
resulted in the exclusion of 46 articles. 6 quantitative studies are in-
cluded in this review (See Fig. 1)(Moher et al., 2009).
Overview of the included articles
Study design
Four articles used a cross sectional study design (Beckstrom et al.,
2013;Heyba et al., 2015;Haghbin et al., 2015 and Daoudi et al., 2017).
One study was a cohort design Loyola et al. (2016). One study was a
convenience sample study Kirkby and Biggs (2016).
Geographical location
Studies were conducted internationally. The countries include Peru
(Loyola et al., 2016), Iran (Haghbin et al., 2015), Kuwait (Heyba et al.,
2015) and Morocco (Daoudi et al., 2017). Two studies were conducted
in the USA, Pennsylvania (Kirkby and Biggs, 2016) and Washington
(Beckstrom et al., 2013).
Study settings
Studies varied in settings, some studies included Paediatric ICU or
ICU but all studies involved the environment of the NICU. One study
was performed in a tertiary level NICU (Beckstrom et al., 2013). Four
studies were from general NICU's across various hospitals (Haghbin
et al., 2015;Heyba et al., 2015;Loyola et al., 2016 and Daoudi et al.,
2017). It is unclear what level NICU (Kirkby and Biggs, 2016) is from.
Participants
All participants in the studies were parents of babies admitted to the
NICU or stacaring for babies in the NICU. Staincluded doctors,
nurses, healthcare professionals and students. Beckstrom et al. (2013)
study involves parents of infants in the NICU. Haghbin et al. (2015),
Heyba et al. (2015),Loyola et al. (2016) and Daoudi et al. (2017) all use
Fig. 1. PRISMA 2009 ow diagram for all databases.
A. Curtis et al. Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
3
staparticipants in the studies. Kirkby and Biggs (2016) study involves
both parents and stain the NICU. All studies involve the MP of either
staor parents.
Sample size
The total sample size of included studies was N = 498. The mean
was 83. The largest sample was N = 203 (Heyba et al., 2015) and the
smallest was N = 17 (Daoudi et al., 2017).
Interventions
In this SR, no studies involved experimental or control groups re-
lating to an intervention.
Results of data analysis
Primary outcome results
Of the six studies included, a signicant percentage of MP were
contaminated with organisms and bacterial growth (See Table 1). Al-
though results varied, most studies indicate contaminate growths di-
verging from CoNS to Enterobacteriaceae (Beckstrom et al., 2013;
Haghbin et al., 2015;Heyba et al., 2015 and Daoudi et al., 2017).
Kirkby and Biggs (2016) do not indicate what types of bacteria or or-
ganisms were found but they state 100% growth of bacteria on the MP
in this study. Loyola et al. (2016) found Enterobacteriaceae was the
most common growth in this study.
Beckstrom et al. (2013) state 28% MP grew various other bacteria as
well as pathogens such as gram-positive cocci and gram-negative rods
and yeast. Before parents performed hand hygiene, 96% of cultures
identied bacteria with 90% of same organism isolated from the MP.
After hand hygiene, 26% grew nothing on the cultures. The ques-
tionnaire noted no signicance using the Fisher's exact test regarding
the growth of pathologic organisms. The results of this study show all
MP transport bacteria.
Haghbin et al. (2015) noted that 77.11% of MP observed con-
taminate growth in this study with a specic organism evolution of
33.7%. 40% of growth included CoNS and 6% of MP grew Methicillin-
Resistant Staphylococcus Aureus (MRSA).
Heyba et al. (2015) discovered out of 213 MP, 73.7% (95% CI-
condence interval) were contaminated. 4 phones were excluded;
however, it did not change the results noticeably. 62.9% of con-
taminants were due to CoNS, 28.6% due to Micrococcus. 1.4% of MP
were contaminated with MRSA and Acinetobacter from 2.8%. In the
NICU, the MP contamination rate was 79.9% compared to ICU's and
PICUs. They also state 63% of clinicians thought the MP is a cause of
possible infection risk. Yet, clinicians continue to use the MP in this
high-risk area. Data was analysed using SPSS and they found a 95% CI
using exact binomial distribution. Also used was Chi-squared test or
Fisher's exact test for investigating variables categorically. A non-sig-
nicant ρ-value 0.213 was noted regarding a higher MP contamination
rate in NICU (79.6%) compared to PICU (72.1%) or ICU (65.9%).
Although this is a non-signicant nding, it is remarkable because the
MP contamination is higher in the NICU in comparison to the PICU or
ICU across the various hospitals included in the study.
Kirkby and Biggs (2016) found 100% contamination of bacteria on
the MP in the preclean sample in this study. Most of the participants in
the study admit to never cleaning their MP. 56% of the sample con-
veyed they do perform hand hygiene after touching the MP.
Loyola et al. (2016) found 53.5% of MP were colonised with at least
1 Enterobacteriaceae during the study time. A total of 105 En-
terobacteriaceae were isolated. Included are Escherichia coli (E. coli)
12.4%, klebsiella pneumoniae and Klebsiella oxytoca 9.5% and En-
terobacter spp 32.4%. Half of the bacteria isolated are multi drug re-
sistant. They state staMP in the ICU's were contaminated with many
diverse bacteria suggesting they may act as bacterial reservoirs of no-
socomial infection.
Daoudi et al. (2017) found of the 17 MP, 35% were contaminated by
multi drug resistant organisms, Klebsiella pneumoniae totalled a 66.6%
contamination rate and a 33.3% contamination rate of Escheria Coli.
CoNS was isolated in 65% of MP.
It can thus be seen all studies include the contamination of the MP
and the NICU environment is the base for all of these studies.
Secondary outcome results
Beckstrom et al. (2013),Heyba et al. (2015),Haghbin et al. (2015),
Loyola et al. (2016) and Kirkby and Biggs (2016) all collected data
regarding participants and the frequency of their MP cleaning.
Beckstrom et al. (2013) also collected data regarding eectiveness of an
anti-microbial hand gel. Kirkby and Biggs (2016) collected data re-
garding hand hygiene practices in addition to questioning MP cleaning.
Kirkby and Biggs (2016) also collected a survey from participants re-
garding known germs harbouring the MP. Findings can be noted in the
discussion.
Beckstrom et al. (2013) used SPSS and Fisher's exact test when
analysing the questionnaires of the participants. The participants in this
study were parents of infants in the NICU. They found that only 12% of
parents clean their phone daily, while only 26% clean their phones
weekly. In this study, it is noted that 92% of parents were aware the MP
carried bacteria and 94% used the MP at the baby's bedside. Although
Beckstrom et al. (2013) admit the sample size of the study is small, it
suggests there is a dangerous lack of public knowledge with regards to
how dangerous these bacteria are. Beckstrom et al. (2013) also state,
anti-microbial gel applied by the parent does not always eradicate the
possibility of bacterial transmission from phone to hands. They found
only 22% of parents had no growth on their hands after the anti-mi-
crobial gel was applied. They state this is probably due to inadequate
teaching regarding how to use the gel.
As stated previously, Heyba et al. (2015) used Chi-squared tests and
Fisher's exact to investigate the variables. Heyba et al. (2015) found
only 33.3% of participants or clinicians have ever disinfected their
phones. Half of these clinicians would disinfect the MP daily or weekly
and only 41.1% of clinicians disinfect their phones when they get dirty.
To clean the MP, 73.5% used alcohol wipes and 13.2% used hand
disinfectant.
Haghbin et al. (2015) state data was collected using SPSS software
and that only 10% of HCW clean their MP occasionally with an alcohol
wipe. They also state no member of stacleaned the phone prior to
entering the ward with 23% of stawashing their hands before hand-
ling the MP. They include that the small sample was a particular lim-
itation to this study.
Kirkby and Biggs (2016) found only 1 participant out of 18 cleaned
the MP regularly. Of course, of further note, methods and cleaning
products also varied. All participants used the MP within the NICU
setting although they were aware the phone may be harbouring bac-
teria. Only 56% cleaned their hands with anti-microbial gel after
touching the MP. Kirkby & Biggs state also that the small sample size
Table 1
Percentage of MP contaminated with organisms and bacterial growth.
Study Growth/contamination Percentage
Beckstrom et al. (2013) CoNS 72%
Haghbin et al. (2015) CoNS 40%
Heyba et al. (2015) CoNS 62.9%
Loyola et al. (2016) Enterobacteriaceae 53.5
Kirkby and Biggs (2016) Unknown 100%
Daoudi et al. (2017) CoNS 65%
Klebsiella Pneumoniae 66.6%
Escheria Coli 33.3%
A. Curtis et al. Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
4
adds to the limitations of this study and that the samples were not
tested for the types of growing organisms. However, they have im-
plemented a MP cleaning station in the NICU and various other wards
with a specic guideline for cleaning the MP.
Loyola et al. (2016) used χ
2
and Fisher's exact tests. They estimated
the risk ratios using a binomial family generalized linear model. They
found 76% of stareported never cleaning their MP but 47.4% reported
using the MP in the ICU setting. A signicant nding indicated the ρ-
value was (< 0.05) for reporting the use of MP disinfection. A non-
signicant nding of a risk ratio of 1.47 with ρ-value (0.43) suggested a
weak association between disinfectant use and increased rates of MP
contamination. They suggest this may indicate that disinfecting the MP
may not reduce the risk of contamination. Limitations of this study also
include the small sample size and incomplete sampling.
Discussion
From the results of our systematic review it has been demonstrated
that the MP is a reservoir for bacteria. Yet, most NICU stause their
phones in an area where they care for high risk patients. Considering
the immature immune system of the Neonate, this is a serious concern.
Although Kirkby and Biggs (2016) received a validity score of 73% in
the EBL checklist, they did receive a validity score of 83% in part C,
results. On reading other studies relating to MP and contamination
rates, not pertained to NICU, high percentages were also noted. Pal
et al. (2015) for example, found in their study a 100% contamination
rate on the MP. This study was conducted in relation to general mobile
phone use and not specic to neonates. The data is notable however and
is in line with Kirkby and Biggs (2016) ndings in this SR.
Most of the included studies suggest that only a small percentage of
staand parents occasionally clean their phones. Haghbin et al. (2015)
states that only 23% of stawashed their hands after touching the MP.
Heyba et al. (2015) suggest the possibility of the Hawthorne eect in
their study. It was a possibility that some clinicians may have cleaned
their phones upon hearing of the study, thus underestimating the MP
contamination rate. Both of these studies were of cross sectional design
and both included data regarding HCW and MP contamination. Borer,
2005 suggest that some bacteria even survive for weeks when in a warm
environment. Such bacteria include gram-negative bacilli, which are
known to cause nosocomial infections and are multidrug resistant.
It is also documented in studies which were excluded from this SR,
that CoNS contaminate varies from 76.5% to 80.6% (Brady et al., 2011;
Pal et al., 2015). This is a signicant nding as Ronnestad et al. (2005)
and Sgro et al. (2011) note, CoNS is the principal cause of late onset
sepsis in the developed world. Sgro et al. (2011) state in Canada CoNS is
the most common cause for early onset neonatal infections. In the USA
Frymoyer et al. (2009) also agree stating CoNS is the most frequent
source of early onset sepsis in the neonate. Pillet at al. (2016) found one
third of MPs in their study were contaminated with the RNA group of
viruses, which is inclusive of varied epidemic respiratory viruses such
as rotavirus (RV), metapneumovirus, norovirus and inuenza viruses.
These viruses eect the Neonatal population also. Again, the RNA
viruses are known NI and this study indicates the MP is an eective way
for these viruses to travel.
Most studies in this SR, documented ndings of MRSA or found a
high percentage of bacteria discovered on surfaces of MPs were multi
drug resistant. MRSA infection has grounds to cause huge concern in
any ICU, General Paediatrics or Neonatal. MRSA is the source of high
morbidity and mortality rates in the critically ill patient. Only broad-
spectrum antibiotics will treat this infection (Bassetti et al., 2016).
Pierce et al. (2017) actually consider MRSA as a principal source of NI
in the NICU. As stated previously, AMR is a concern in the Irish and
Global healthcare system (HSE, 2010;WHO, 2018). The concern with
AMR is that microorganisms develop resistance to antimicrobials and
are then denoted as superbugs. The potential detriments are multi
problematic both in illness and in cost. These superbugs are very
dicult to treat and very expensive (WHO, 2018). Bearing in mind the
already immunocompromised infant in the NICU, antibiotic use is
considered both controversial and disparate. Antibiotics are eective
when needed to treat a certain disease. However, these also eect the
neonate's microbiome and can increase the risk of Necrotising en-
terocolitis (Hartz et al. 2016). Necrotising enterocolitis is a serious
condition in the neonate which can at best result in life long morbidity
and at worst is fatal (Thompson and Bizzaro, 2008).
Beckstrom et al. (2013) also scored 80.7% and Loyola et al. (2016)
scored 88% on the EBL checklist. The high validity scores again suggest
high quality papers. Beckstrom et al. (2013) found 90% of participants
in the study had the same bacteria grow on their hands as on the MP.
This is particularly alarming if parents do not wash their hands between
holding the MP and touching the baby. Parents use the MP to take
pictures and often update families upon arrival to the baby's bedside
and this increases transmission risk. Heyba et al. (2015) record that
clinicians who did clean the MP, were more likely to have a deconta-
minated phone when compared to those who never cleaned the MP.
Kirkby and Biggs (2016) are condent cleaning the MP does decrease
contamination risks. They discuss the benets of MP cleaning stations
and use of guidelines to this eect. Haghbin et al. (2015),Loyola et al.
(2016) and Daoudi et al. (2017) all suggest daily cleaning and decon-
tamination of the MP. Sumritivanicha et al. (2011) &Pal et al. (2015)
also suggest regular MP decontamination. It is also noteworthy,
Haghbin et al. (2015) and Loyola et al. (2016) state it is unknown if
bacteria found on phones are transient or if they are permanent. Loyola
et al. (2016) suggest the value of the MP as a potential surveillance
means in the NICU. Both studies recommend further research in this
area. Loyola et al. (2016) sample included 114 HCW's across varied
ICU's in Peru. Limitations of this study included incomplete sampling
and a small sample size.
All studies in this SR state hand hygiene is the most important
strategy in preventing HCAI. Worth mentioning is the statistic in
Beckstrom et al. (2013) study, as they found only 22% of non-bacterial
growth on parent's hands, even after hand hygiene. They do state this
was possibly due to improper instructions given to parents on how to
perform appropriate hand hygiene. However, it may also have been due
to the complex hand ora reducing the eectiveness of the hand gel.
Daoudi et al. (2017) score 67% on EBL checklist. This is a limitation
to this study along with the small sample size. However, ndings in this
paper are remarkable. They also discuss their ndings regarding bac-
terial contamination of stethoscopes in this study. They found a 100%
bacterial growth on stethoscopes. Again, this is an instrument used
regularly in any ICU. They were also contaminated by multi drug re-
sistant organisms by 7.7%. Hartz et al. (2016) conveys almost all ob-
jects and equipment in the NICU may be considered a source of mi-
crobial contamination. They suggest following practices within the
NICU to optimise the neonates skin care and recommend stafollow all
infection control procedures to prevent high risk babies getting infected
by pathogens.
Many studies suggest parents and HCW are aware the MP is con-
taminated, yet continue to use it at the bedside. Beckstrom et al. (2013)
state the best prevention of NI via MP is to ban the use of MP at the
bedside. However, Brady et al. (2011) and Haghbin et al. (2015) are of
the view this is not practical. Beckstrom et al. (2013) suggest the public
are unaware pathogens discussed in this SR can cause harmful eects to
an infant in the NICU. However, it appears HCW are aware and yet
continue to use the MP without appropriate disinfection. All studies in
this SR recommend MP cleaning and appropriate hand hygiene. As
Hartz et al. (2016) state all environments in the NICU are potential NI
reservoirs.
As Polin et al. (2012) convey, infants in the NICU are high risk and
already immunocompromised. Hartz et al. (2016) conrm the NICU is a
location which harbours potential NI threats to such an im-
munocompromised population. It is worth noting that while the HCW is
thought to be aware of the possible pathogenic transmission capability
A. Curtis et al. Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
5
of the MP, only 63% of staclean it (Heyba et al., 2015). Beckstrom
et al. (2013) found that very few parents clean the MP, however they
are possibly unaware of the disease potential.
This SR set out to question if using a MP increases the risk of NI in
the NICU. All studies state the MP is a substantial carrier of nosocomial
bacteria and organisms. The diculty with some of the pathogens is the
inability to treat them with antimicrobials. When they can be treated,
they then leave the neonate more susceptible to perhaps worse illnesses.
AMR is internationally a cause of serious concern (WHO, 2018).
Secondarily, this SR questioned if cleaning the MP eradicates bac-
teria and if appropriate hand hygiene practices prevent transmission.
All studies overwhelmingly state appropriate cleaning and disinfection
of the MP can prevent transmission of pathogens. Brady et al. (2011),
Haghbin et al. (2015),Heyba et al. (2015) and Daoudi et al. (2017) all
recommend MP cleaning guidelines and policies. Kirkby and Biggs
(2016) agree and add that an MP cleaning station would be benecial.
Considering that the bacteria or organism can live on a surface for
lengthy periods of time, this is paramount (Borer, 2005;Heyba et al.,
2015).
One study suggested hand hygiene did not prevent the growth of
pathogens but the authors suggest this was due to inadequate knowl-
edge of the practice itself (Beckstrom et al., 2013). Otherwise, all stu-
dies promote the ve moments of hand hygiene and/or alcohol hand
gel as promoted by WHO (2009).
Conclusion
It is thought if practiced correctly, transmission of pathogens from
the MP to the baby will be prevented. All studies reviewed suggest
further research is needed and thus recommend same in this area.
Considering the growing risk of AMR and the diculties in treating
many nosocomial infections presently, it is our responsibility as HCW to
continue research in this area. As stated, MP use along with other in-
struments in the NICU and further aeld within healthcare will only
continue to rise. Therefore, it is paramount that all HCW and families
are aware of the dangers they actually pose and how we can prevent
transmission, thereby preventing treatments which can aid minimising
AMR.
Ethical statement
Ethical approval was not required.
Conicts of interest
None.
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Background: Infants admitted to the neonatal intensive care unit (NICU) are more susceptible to infections due to immature immune systems or invasive procedures that compromise protection from bacteria. These infants may stay in the NICU for extended periods of time, are exposed to many caregivers, and may be exposed to other infections. Cell phone use by both family and staff introduce unwanted bacteria into the NICU environment, thereby becoming a threat to this high-risk population. Purpose: A quality improvement initiative to evaluate and improve the cleanliness of cell phones used in the NICU. Methods: A convenience sample of 18 NICU parents and staff. The participants' cell phones were sampled for bacteria pre- and postcleaning with disinfectant wipes and sent to the microbiology laboratory for a 2-day incubation period. In addition, each participant completed a survey on cell phone cleaning habits. Results: Microbial surface contamination was evident on every phone tested before disinfecting. All phones were substantially less contaminated after disinfection. Implications for practice: A standardized cleaning process with a surface disinfectant reduced the amount of germs and potential transmission of nosocomial pathogens within the NICU. The simple exercise illustrated the importance of cell phone hygiene in a high-risk population. The implementation of a simple cleaning process has been an easy and effective way to rid unwanted organisms from this high-risk population. Implications for research: Further research evaluating transmission of nosocomial infections from cell phones would enhance the evidence to establish hospital policies on cleaning devices.
Article
Mobile phones (MPs) have been proved to be potential reservoirs of nosocomial bacteria. Few data are available concerning viruses. We aimed to evaluate the presence of viral RNA from epidemic viruses including metapneumovirus (hMPV), respiratory syncytial virus (RSV), influenza viruses, rotavirus (RV) and norovirus (NV) on the MPs used by healthcare workers (HCWs) and to rely it with hygiene measures. An anonymous behavioral questionnaire about MP use at hospital was proposed to the HCWs of 4 adult and pediatric departments of a University hospital. After sampling of personal (PMP) and/or professional MPs (digital enhanced cordless telephone, DECT), viral RNAs were extracted and amplified by one step reverse transcription/real time PCR assays (RT-qPCR). The molecular results were analyzed blindly to the behavioral survey. Questionnaires of 114 HCWs (35 senior physicians, 30 residents, 32 nurses, 27 nurses assistant) working either in adults (n=58) or pediatric (n=56) departments were recorded. Medical personnel used their PMP more frequently than paramedical HCWs (33/65 vs 10/59, P<0.001). MPs were used during care more frequently in adult wards than in pediatric ones (46/58 vs 27/56, P<0.001). Viral RNA was detected on 42 phones of the 109 collected ones (38.5%), with RV=39, RSV=3, hMPV=1. The presence of viral RNA was significantly associated with MPs from the pediatric HCWs (P<0.001). MPs routinely used in hospital, even during care, can host viral RNA, especially RV. Promotion of frequent hand hygiene before and after MP use associated to frequent cleaning of the MPs should be encouraged.
Article
To identify how the neonatal intensive care unit (NICU) environment potentially influences the microbiome high-risk term and preterm infants. Electronic databases utilized to identify studies published in English included PubMed, Google Scholar, Cumulative Index for Nursing and Allied Health Literature, and BioMedSearcher. Date of publication did not limit inclusion in the review. Two hundred fifty articles were assessed for relevance to the research question through title and abstract review. Further screening resulted in full review of 60 articles. An in-depth review of all 60 articles resulted in 39 articles that met inclusion criteria. Twenty-eight articles were eliminated on the basis of the type of study and subject of interest. Studies were reviewed for information related to environmental factors that influence microbial colonization of the neonatal microbiome. Environment was later defined as the physical environment of the NICU and nursery caregiving activities. Studies were characterized into factors that impacted the infant's microbiome-parental skin, feeding type, environmental surfaces and caregiving equipment, health care provider skin, and antibiotic use. Literature revealed that various aspects of living within the NICU environment do influence the microbiome of infants. Caregivers can implement strategies to prevent environment-associated nosocomial infection in the NICU such as implementing infection control measures, encouraging use of breast milk, and decreasing the empirical use of antibiotics.