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CHAPTER 2

REVIEW OF RELATED LITERATURE



Over the year bacterial organisms find residence in equipments used by
medical professionals has been known for a long period of time but this has been
investigated only recently. Stethoscope is an extension of the hand in clinical settings and
should be cleaned with the same frequency like the hands that is, after and before contact
with each patient. The stethoscope is one of the medical equipments which are
universally used by Health Care Workers. As nursing students, basic infection control
protocols including hand washing techniques, glove use and sharps safety have been
taught, but not once has stethoscope disinfection been mentioned. On placement, Health
care workers are majorly observed to be placing stethoscopes on visibly unclean skins,
near wounds, and on patients with communicable diseases, without cleaning the
stethoscopes in between patients. Following assessment, the stethoscope is typically
placed in a laboratory coat pocket, draped around the neck, or suspended from a
medication cart. Thus in a single day, the stethoscope may come in direct contact with
multiple patients, clothing, and the environment.
Cleaning a stethoscope takes little time and effort, requires no special equipment,
and it could avoid a deadly infection. Thermometers, tongue depressors, otoscopes , BP
cuffs and particularly, stethoscope it is already implemented and a common knowledge
that it carries microorganisms which changes it into a vector itself of infection which can
harm the one who uses them.
Studies have been conducted in different countries to detect presence of
microorganism located in the stethoscopes. In some of the studies individual parts of the
stethoscopes like diaphragm, bell the tube and etc. Have been studied but the most
neglected part was the earpiece which is directly in contact with our auricular canal. The
sharing of stethoscopes over the year is already one of the most common practices
amongst the nursing staffs and other Healthcare Workers not to say including the student
nurses and medical interns, this may have led to the transmission of microorganisms to
them. The colonization in the ear may spread to the nose and skin and can lead to
Hospital acquired infection if they already have impaired skin integrity secondary to
broken skin in the ear or lets just say a wound in the ear which may become a port of
entry for opportunistic microorganisms which will then result to infection. The
stethoscope is a tool that every healthcare provider uses daily in the assessment of
patients. Thus, in a single day, the stethoscope earpiece may come in direct contact with
multiple patients, clothing and exposed to an open environment. It is already a common
knowledge that there are already a lot of microorganism residing on the earpiece of the
stethoscope but the thing is, microorganism in this part of the stethoscope are still
unknown ,are they aerobic or non aerobic? Can these microorganisms harmful or not?
Several studies have been conducted in different countries to detect presence of
organisms located in the stethoscope. It was found out that majority of health care
professionals stethoscopes are colonized with bacteria.
Just like a normal headphones, an earpiece of a stethoscope can be a breeding
ground for microorganisms and could lead to ear infections. Study shows that frequency
of using the stethoscope may increase bacterial growth in the ear, the more frequent, the
more the bacteria will multiply from 6o to 650 microorganisms. (Daily Express, 2009).
The organisms that are found on stethoscope earpiece were either skin
commensals or pathogenic organisms like Staphylococcus aureus, coliform group or
Pseudomonas aerugenosa. According to a study, none of the stethoscopes examined
showed enteric pathogens however there is a definite point to the origin of these
organisms on to the stethoscopes. They originate from superficial skin lesions and some
of them may also be among the skin commensals with which the stethoscope is in
intimate contact.(Kumaraswami V. et.al, 2009).
And In addition to this, AUS has had conducted study of 150 hospital
healthworkers indicated that 48% cleaned their stethoscopes between daily and weekly;
37% monthly; 7% yearly; and 7% never cleaned their stethoscopes. Stethoscopes in a
hospital setting are frequently contaminated with potentially pathogenic microorganisms,
with Staphylococcus aureus isolated from 4-25% of stethoscopes . Cleaning with alcohol
wipes is shown to be effective in immediate reduction of bacterial count by 94-100%.
(Trampuz A. et at. 2004).
According to a study of Berkovitch et.al most stethoscopes harbor potential
pathogens. The isolation of Gram-negative organisms poses a real risk of spreading
potentially serious infections, especially in the setting of intensive care departments. In
the study forty-three (43) stethoscopes belonging to senior physicians, residents, interns
and medical students at the pediatric ward were sampled and bacterial cultures and
antibiotic sensitivity testing were carried out. All but six bacterial cultures were positive
(85.7%). It was found out that Staphylococcal species were the most common
contaminants (47.5%). One case of methicillin-resistant Staphylococcus aureus was
encountered. Gram-negative organisms were also isolated in nine different samples
(21%) including one case of Acinetobacterbaumannii in the neonatal intensive care unit.
(Berkovitch M. et al. 2008).
In contrast to other studies, Coronnel et al.study showed that all the three agents
(soap and water, 70% alcohol and hypochlorous acid) used to clean the stethoscopes were
equally effective in disinfecting the stethoscope, while other authors showed that though
it is not statistically significant, there is a trend that alcohol was more effective in
reducing the bacterial count. The disadvantage of this is that there would be a possibility
that alcohol may dry out the rubber seals. Cleaning with soap and water would be the
simplest and most convenient method of disinfecting the stethoscope, while the use of
hospital disinfectants in the form of hypochlorous acid is less convenient because the
solution is more tedious to prepare. (Coronnel et al. 2010).