Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

The stethoscope as a vector of infectious diseases in the paediatric division

I Youngster ([email protected])1 , M Berkovitch2 , E Heyman3 , Z Lazarovitch4,5 , M Goldman1
1.Division of Paediatrics, Assaf Harofeh Medical Center, Zerifin, Israel
2.Clinical Pharmacology and Toxicology Unit, Assaf Harofeh Medical Center, Zerifin, Israel
3.Neonatal Intensive Care Unit, Assaf Harofeh Medical Center, Zerifin, Israel
4.Department of Microbiology, Assaf Harofeh Medical Center, Zerifin, Israel
5.Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

Keywords Abstract
Hygiene, Infection control, Paediatrics, Stethoscopes
Aim: Nosocomial infections are of great concern in hospital settings, and even more so in the
Correspondence paediatric ward. Health professionals and their medical equipment have long been known to act as
Ilan Youngster, M.D., Division of Paediatrics,
Assaf Harofeh Medical Center, Zerifin, 70300, Israel. vectors of infectious diseases. This study aimed at evaluating the presence of bacterial pathogens on
Tel: 972-54-7939066 | the stethoscopes of medical personnel in the paediatric division.
Fax: 972-8-9779136 | Methods: Forty-three stethoscopes belonging to senior physicians, residents, interns and medical
Email: [email protected]
students at the paediatric ward were sampled. Bacterial cultures and antibiotic sensitivity testing were
Received
14 February 2008; accepted 20 May 2008.
carried out.
Results: All but six bacterial cultures were positive (85.7%). Staphylococcal species were the most
DOI:10.1111/j.1651-2227.2008.00906.x
common contaminants (47.5%). One case of methicillin-resistant Staphylococcus aureus was
encountered. Gram-negative organisms were isolated in nine different samples (21%) including one
case of Acinetobacter baumannii in the neonatal intensive care unit.

Conclusion: Most stethoscopes harbour potential pathogens. The isolation of Gram-negative organisms pose a
real risk of spreading potentially serious infections, especially in the setting of intensive care departments.
Apparently, the current recommendations of regular disinfection of stethoscopes are not carried out by health
personnel that participated in the study.

caused by viral infections. A recent report estimated that 15–

INTRODUCTION
20% of patients on the paediatric ward acquire a nosocomial
It has long been known that health professionals, despite
viral infection during their hospital stay (11,12). The role of
their best intentions, sometimes act as vectors of disease,
the stethoscope in transmission of viral diseases is unknown.
disseminating new infections among their patients (1). As
Blydt-Hansen et al. showed that respiratory syncytial virus
early as the 1860s, Dr. Ignaz Semmelweis, head of Vienna
(RSV) could be cultured from the diaphragm of stethoscopes
General Hospital’s First Obstetrical Clinic, published a pa-
up to 6 h after they had been contaminated with secretions
per claiming that hand washing reduced mortality from
containing the virus (11).
puerperal fever dramatically (2). Semmelweis’ practice only
These studies were followed by publication of strict rec-
earned widespread acceptance years after his death, when
ommendations regarding infection control and disinfec-
Louis Pasteur confirmed the germ theory. Even today, an
tion of stethoscopes. This study, conducted a decade later,
estimated 5–10% of hospitalized patients acquire a noso-
aimed at re-evaluating the presence of bacterial pathogens
comial infection, resulting in approximately 120 000 deaths
on the stethoscopes of medical personnel in the paediatric
yearly in the United States alone, resulting in 4.5–5.7 billion
division.
U.S.$ in additional patient care costs (3). Several studies per-
formed in hospital settings have shown physician’s stetho-
scopes to be important vectors of infection. Madar et al. MATERIALS AND METHODS
found colonization with Staphylococcus spp. in 85% of sam- The study was carried out at the paediatric division of As-
pled stethoscopes, 20% of them methicillin-resistant species saf Harofeh Medical centre on two consecutive days in
(MRSA) (4). Marinella et al. sampled 40 stethoscopes and December 2006. A total of 43 stethoscopes belonging to
showed colonization with different bacteria in all samples senior physicians, residents, interns and medical students
taken – mostly coagulase-negative Staphylococcus aureus (Table 1) were sampled by swabbing the surface of the di-
(CONS) (3). Several authors have shown the presence of aphragm with a sterile cotton-tipped applicator moistened
highly pathogenic bacteria on membranes of stethoscopes – in physiological solution. The samples were collected in
mainly vancomycin-resistant E.coli, and MRSA (5–10). the general paediatric ward, the paediatric intensive care
Among paediatric populations the burden of nosocomial unit, the neonatal intensive care unit (NICU) and the pae-
infections is likely even higher. A possible cause is the fact diatric emergency ward (Table 2), and were then promptly
that up to 60% of hospital admissions among children are transferred to the laboratory. The solution was inoculated


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Stethoscopes and infections Youngster et al.

Table 1 Results of bacterial cultures in different sectors of health professionals in accordance with the standards set out by the National
Committee for clinical laboratory standards.
Number of Positive Main
samples cultures (%) pathogens RESULTS
Medical 8 5(62%) CONS (n = 2) All but six bacterial cultures were positive (85.7%). Staphy-
students Bacillus spp. (n = 2) lococcal species were the most common contaminants
Sarcina lutea (n = 2) – mainly coagulase-negative staphylococci (16 samples –
Interns 7 6(85%) CONS (n = 2) 38%) and S. aureus (4 cases – 9.5%). One case of methicillin-
Bacillus spp. (n = 2) resistant S. aureus was encountered. Other frequently iso-
Sarcina lutea (n = 3) lated bacteria included Sarcina lutea (22 samples – 52.3%)
E. coli (n = 2)
and Gram-positive Bacillus species (14 samples – 33.3%).
MRSA (n = 1)
Gram-negative organisms were isolated in nine different
Residents 15 14(93%) CONS (n = 7) samples (21%): 4 cases of E. coli, 2 cases of Pseuodomonas
Bacillus spp. (n = 4)
aeruginosa, 1 isolate positive for Burkholderia cepacia, and
Sarcina lutea (n = 9)
Pseuodomonas aeruginosa 1 positive for Citrobacter diversus. Finally, one isolate was
(n = 1) positive for Acinetobacter baumannii (Tables 1 and 2).
E.coli (n = 2)
Acinetobacter baumannii
(n = 1) DISCUSSION
Seniors 13 12(92%) CONS (n = 5) The results of our study confirm the findings of previous re-
Bacillus spp. (n = 6) ports, showing that virtually all stethoscopes sampled were
Sarcina lutea (n = 8) contaminated. Almost half the cultures grew staphylococcal
Pseuodomonas aeruginosa
species, with one case of MRSA. However, unlike previ-
(n = 1)
ous studies – in our survey 21% of the samples were pos-
CONS = coagulase-negative staphylococci: MRSA = methicillin-resistant itive for Gram-negative organisms, a fact that is especially
Staphylococcus aureus. worrisome. In the setting of intensive care units the possi-
ble consequences of nosocomial Gram-negative infections
Table 2 Results of bacterial cultures in different wards are grave. Acinetobacter spp. is currently the most com-
mon pathogen associated with multiple resistance to an-
Number of Positive Main
tibiotics in hospital infections (6). At the time the study
samples cultures (%) pathogens
was conducted there was an outbreak of antibiotic-resistant
Paediatric general 24 21(88%) CONS (n = 8) Acinetobacter infections in our NICU with two cases of bac-
ward Bacillus spp. (n = 7) teremia, and three more cases of asymptomatic colonization
Sarcina lutea (n = 14) in neonates. The sample that was positive for Acinetobac-
Pseuodomonas aeruginosa
(n = 1) ter was collected from a resident during her rotation in the
E.coli (n = 1) NICU, and it is theoretically possible that the stethoscope
contributed to the spread of the disease. The microorganism
Paediatric intensive 6 5(83%) CONS (n = 2)
that was cultured from the stethoscope was sensitive only to
care unit Bacillus spp. (n = 2)
Sarcina lutea (n = 4) Unasyn (ampicillin/sulbactam), as were the organisms re-
E. coli (n = 1) covered in the neonates during the outbreak. In addition,
Pseuodomonas aeruginosa one culture collected in the emergency ward was positive
(n = 1)
for MRSA sensitive only to vancomycin – totalling two (4%)
Neonatal intensive 7 6(86%) CONS (n = 2) highly resistant microbial cultures. Even though numerous
care unit Bacillus spp. (n = 1) studies have shown similar colonization rates, some health
Sarcina lutea (n = 4) personnel have difficulty in accepting that stethoscopes may
Acinetobacter baumannii
(n = 1) actually be a vector of disease. It has been shown that clean-
ing the stethoscope’s diaphragm results in an immediate re-
Paediatric emergency 6 5(83%) CONS (n = 4) duction in the bacterial count – by 94% with alcohol swabs,
ward Bacillus spp. (n = 3)
MRSA (n = 1)
90% with a nonionic detergent and 75% with soap (9). Even
so, most studies to date have shown that only 48% of health
CONS = coagulase-negative staphylococci: MRSA = methicillin-resistant care providers surveyed clean their stethoscopes daily or
Staphylococcus Aureus. weekly. In our study, we did not survey the habits of the par-
ticipants, but clearly the current recommendations of regu-
onto a blood agar plate and a Mannitol-salt-agar plate. The lar (at least once daily) disinfection of stethoscopes were not
plates were then incubated at 37◦ C for 48 h and examined carried out.
for colony growth at 24 and 48 h. The culture results were We found no significant differences in stethoscope con-
recorded as mean numbers of colony-forming units. Sensi- tamination rates among the different health care providers
tivity testing was performed using the disc diffusion methods surveyed (Table 1). Nor did we find a significant difference

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Youngster et al. Stethoscopes and infections

in the overall rate of positive cultures in the different de- 3. Marinella MA, Pierson C, Chenoweth C. The stethoscope. A
partments sampled (Table 2). It is worth noting though, potential source of nosocomial infection? Arch Intern Med
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4. Madar R, Novakova E, Baska T. The role of non-critical
resistant pathogens were present on the stethoscopes of in-
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terns or residents. As opposed to senior physicians, they Bratisl Lek Listy 2005; 106: 348–50.
rotate between the different wards, sometimes daily, and are 5. Cohen AH, Amir J, Matalon A, Mayan R, Beni S, Barzilai A.
thus at a much higher risk of spreading nosocomial infec- Stethoscopes and otoscopes–a potential vector of infection?
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120: 13–5.
from previous studies that must be taken seriously. Clearly,
7. Wright IMR, Orr H, Porter C. Stethoscope contamination
our study emphasizes the importance of adequate hospi- in the neonatal intensive care unit. J Hosp Infect 1995; 29:
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DISCLOSURE 144.
The authors state that no financial support or author in- 9. Jones JS, Hoerle D, Riekse R. Stethoscopes: a potential vector
volvement with organizations with financial interest in the of infection? Ann Emerg Med 1995; 26: 296–9.
subject matter exists, and that no actual or potential conflict 10. Núñez S, Moreno A, Green K, Villar J. The stethoscope in the
of interest exists. emergency department: a vector of infection? Epidemiol
Infect 2000; 124: 233–7.
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