Does using a cellular mobile phone increase the risk ...

Journal of Neonatal Nursing xxx (xxxx) xxx–xxx

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Review

Does using a cellular mobile phone increase the risk of nosocomial infections in the Neonatal Intensive Care Unit: A systematic review Aine Curtisa,∗, Professor Zena Mooreb, Dr. Declan Pattonb, Dr. Tom O'Connorb, Dr. Linda Nugentb a b

Neonatal Staff Nurse in Our Lady of Lourdes Hospital, Drogheda, Co. Louth, Ireland Royal College of Surgeons in Ireland, School of Nursing and Midwifery, 123 St. Stephens Green, Dublin 2, Ireland

A R T I C LE I N FO

A B S T R A C T

Keywords: Neonates Neonatal Intensive Care Unit Nosocomial infection Health care associated infection Mobile phones

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.

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 confirmed 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 resistant. 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 neurodevelopmental impairment to death (Strunk, 2014). In healthcare settings, copious literature states healthcare workers play a significant part in spreading infections (Strunk, 2014; Heyba et al., 2015; Kirkby and Biggs, 2016). In 1861, Semmelweis demonstrated bacteria is

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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 specifically 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 justification for our systematic review. 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 access 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

Corresponding author. E-mail addresses: [email protected] (A. Curtis), [email protected] (Z. Moore), [email protected] (D. Patton), [email protected] (T. O'Connor), [email protected] (L. Nugent).

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 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


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appropriate hand hygiene can prevent transmission of bacteria.

technology improves efficiency, aids error prevention and speeds accessibility of information to health care workers (Mickan et al., 2013). Therefore, use of such devices is increasing (Ventola, 2014). Until recently, the MP was not permitted within the Neonatal Intensive Care Unit (NICU)/Intensive Care Unit (ICU) environment as it caused intereference 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 prevention of antimicrobial resistance and health care associated infection was established (HSE, 2010). Included in this programme was education for health care staff, patients and the general public on HCAI and Antimicrobial resistance (AMR). AMR has become a considerable threat to public health and is a growing risk. Over prescribing of antibiotics increases this threat (HSE, 2017). Allegranzi et al. (2011) found neonatal infection rates are 3–20 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 populations 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 neonatologist 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 staff (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 infection. More importantly, they may be contaminated with nosocomial pathogens.

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 studies relating to the general population or general/surgical wards. They were not specific to neonates. Those not relating to the primary outcome 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 completed. A narrative synthesis was conducted. The six studies were reviewed, analysed and discussed in a thematic manner as recommended by The Centre for Evidence Based Intervention (CEBI, 2017).

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 affected, E: Exposure, what is the specific 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.

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).

Review question ‘Does using a cellular mobile phone increase the risk of nosocomial infection in the Neonatal Intensive Care Unit’. Primary outcome & secondary outcomes

Results

The primary outcome of this SR was to discern if mobile phones can be a potential source for pathogenic bacteria capable of causing nosocomial infections in the NICU. Secondary outomes sought to ascertain if cleaning the mobile phone eradicates bacteria. Further, to identify if

The search identified 51 articles which were then screened by two independent reviewers through reading titles and abstracts. This 2


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Fig. 1. PRISMA 2009 flow diagram for all databases.

(Beckstrom et al., 2013).

resulted in the exclusion of 46 articles. 6 quantitative studies are included in this review (See Fig. 1) (Moher et al., 2009).

Study settings Overview of the included articles 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.

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).

Participants Geographical location All participants in the studies were parents of babies admitted to the NICU or staff caring for babies in the NICU. Staff included 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

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 3


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Although this is a non-significant finding, 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 ‘pre’ clean sample in this study. Most of the participants in the study admit to never cleaning their MP. 56% of the sample conveyed 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 Enterobacteriaceae were isolated. Included are Escherichia coli (E. coli) 12.4%, klebsiella pneumoniae and Klebsiella oxytoca 9.5% and Enterobacter spp 32.4%. Half of the bacteria isolated are multi drug resistant. They state staff MP in the ICU's were contaminated with many diverse bacteria suggesting they may act as bacterial reservoirs of nosocomial 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.

Table 1 Percentage of MP contaminated with organisms and bacterial growth. Study

Growth/contamination

Percentage

Beckstrom et al. (2013) Haghbin et al. (2015) Heyba et al. (2015) Loyola et al. (2016) Kirkby and Biggs (2016) Daoudi et al. (2017)

CoNS CoNS CoNS Enterobacteriaceae Unknown CoNS Klebsiella Pneumoniae Escheria Coli

72% 40% 62.9% 53.5 100% 65% 66.6% 33.3%

staff participants in the studies. Kirkby and Biggs (2016) study involves both parents and staff in the NICU. All studies involve the MP of either staff or 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).

Secondary outcome results Interventions 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 effectiveness of an anti-microbial hand gel. Kirkby and Biggs (2016) collected data regarding hand hygiene practices in addition to questioning MP cleaning. Kirkby and Biggs (2016) also collected a survey from participants regarding 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-microbial 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 staff cleaned the phone prior to entering the ward with 23% of staff washing their hands before handling the MP. They include that the small sample was a particular limitation 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 bacteria. Only 56% cleaned their hands with anti-microbial gel after touching the MP. Kirkby & Biggs state also that the small sample size

In this SR, no studies involved experimental or control groups relating to an intervention. Results of data analysis Primary outcome results Of the six studies included, a significant percentage of MP were contaminated with organisms and bacterial growth (See Table 1). Although results varied, most studies indicate contaminate growths diverging 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 organisms 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 identified bacteria with 90% of same organism isolated from the MP. After hand hygiene, 26% grew nothing on the cultures. The questionnaire noted no significance 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 contaminate growth in this study with a specific organism evolution of 33.7%. 40% of growth included CoNS and 6% of MP grew MethicillinResistant Staphylococcus Aureus (MRSA). Heyba et al. (2015) discovered out of 213 MP, 73.7% (95% CIconfidence interval) were contaminated. 4 phones were excluded; however, it did not change the results noticeably. 62.9% of contaminants 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-significant 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%). 4


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difficult 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 effective when needed to treat a certain disease. However, these also effect the neonate's microbiome and can increase the risk of Necrotising enterocolitis (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 decontaminated phone when compared to those who never cleaned the MP. Kirkby and Biggs (2016) are confident cleaning the MP does decrease contamination risks. They discuss the benefits of MP cleaning stations and use of guidelines to this effect. Haghbin et al. (2015), Loyola et al. (2016) and Daoudi et al. (2017) all suggest daily cleaning and decontamination 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 flora reducing the effectiveness 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, findings in this paper are remarkable. They also discuss their findings regarding bacterial 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 resistant organisms by 7.7%. Hartz et al. (2016) conveys almost all objects and equipment in the NICU may be considered a source of microbial contamination. They suggest following practices within the NICU to optimise the neonates skin care and recommend staff follow all infection control procedures to prevent high risk babies getting infected by pathogens. Many studies suggest parents and HCW are aware the MP is contaminated, 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 effects 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) confirm the NICU is a location which harbours potential NI threats to such an immunocompromised population. It is worth noting that while the HCW is thought to be aware of the possible pathogenic transmission capability

adds to the limitations of this study and that the samples were not tested for the types of growing organisms. However, they have implemented a MP cleaning station in the NICU and various other wards with a specific 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 staff reported never cleaning their MP but 47.4% reported using the MP in the ICU setting. A significant finding indicated the ρvalue was (< 0.05) for reporting the use of MP disinfection. A nonsignificant finding 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 staff use 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 specific to neonates. The data is notable however and is in line with Kirkby and Biggs (2016) findings in this SR. Most of the included studies suggest that only a small percentage of staff and parents occasionally clean their phones. Haghbin et al. (2015) states that only 23% of staff washed their hands after touching the MP. Heyba et al. (2015) suggest the possibility of the Hawthorne effect 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 significant finding 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 influenza viruses. These viruses effect the Neonatal population also. Again, the RNA viruses are known NI and this study indicates the MP is an effective way for these viruses to travel. Most studies in this SR, documented findings 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 broadspectrum 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 5


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of the MP, only 63% of staff clean 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 difficulty 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 bacteria 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 beneficial. 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 knowledge of the practice itself (Beckstrom et al., 2013). Otherwise, all studies promote the five moments of hand hygiene and/or alcohol hand gel as promoted by WHO (2009).

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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 difficulties 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 instruments in the NICU and further afield 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. Conflicts of interest None. References Allegranzi, B., Bagheri Nejad, S., Combescure, C., Graafmans, W., Attar, H., Donaldson, L., Pitter, D., 2011. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet 377 (9761) 228–24. Bassetti, M., Pecori, D., Peghin, M., 2016. Multidrug-resistant gram-negative bacteriaresistant infections: epidemiology, clinical issues and therapeutic options. Ital. J Med. 10 (4). Beckstrom, A., Cleman, P., Cassis-Ghavami, F., Kamitsuka, M., 2013. Surveillance study of bacterial contamination of the parents cell phone in the NICU and the effectiveness of an anti-microbial gel in reducing transmission to hands. J. Perinatol. 33, 960–963. Bettany-Saltikov, J., 2012. How to Do a Systematic Literature Review in Nursing: a Stepby-step Guide. RCN Publishing Company, Berkshire. Bockstael, K., Van Aerschot, A., 2009. Antimicrobial resistance in bacteria. Cent. Eur. J. Med. 4 (2), 141–155. Borer, A., 2005. Cell phones and Acinetobacter transmission. Emerg. Infect. Dis. 11 (7), 1160–1161. Brady, R., Hunt, A., Visvanathan, A., Rodrigues, A., Graham, C., Rae, C., Kalima, P., Gibb, A., 2011. Mobile phone technology and hospitalized patients: a cross-sectional surveillance study of bacterial colonization, and patient opinions and behaviours. Clin. Microbiol. Infect. 17, 830–835. Burns, K., Foley, M., Donlon, S., 2012. Point Prevalence Survey of Hospital-acquired Infections & Antimicrobial Use in European Acute Care Hospitals: May 2012 Republic of Ireland. National Report – November 2012.

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