Toys from hospital playrooms as a source of pathogens in nosocomial infections

"...it is play that is universal, and that belongs to health: playing facilitates growth and therefore health."

Winnicott

Playing is part of the child's life, and it is through play that the child often expresses nonverbal feelings. This form of expression is of great importance when subjected to injuries, such as hospitalization. To deprive the child of her language is to worsen the injury. Thus, an appropriate space for playing within the hospital environment is highly recommended. In Brazil, since 2005, hospitals providing pediatric care are required by law to have playrooms.¹

If, on the one hand, the playroom provides a place for children to express their feelings during hospitalization and minimize suffering, being a place within the hospital environment that is recalled with joy, on the other hand, the socialization and close contact with toys handled by other children can facilitate the acquiring of infections. Unfortunately, toy contamination can occur and hospital infection outbreaks have been attributed to it.^2-4

Children have some particular characteristics that predispose them to infectious processes, such as immunological immaturity, lack of previous contact with pathogens, lack of sphincter control in young children and the oral phase of child development. These are added to the very close interaction with healthcare team and family members and, therefore, greater contact with potentially contaminated hands and utensils. Moreover, infectious causes very often predominate in pediatric hospitalizations.⁵

Although the increased vulnerability of children and pathogen exposure are well known, the role of contamination of surfaces and particularly of toys has received little attention from hospital infection control and research teams and it is considered a priority.^6,7

Boretti et al,⁸ in an article published in the present issue of this journal, showed that microorganisms of the Staphylococcus genus, both coagulase-negative and positive, with high resistance to antimicrobials commonly used in the treatment of hospitalized patients, were present in 87% of the toys they analyzed immediately after they were handed by the child. It has the merit of showing that contamination is high by resistant microorganisms and that contamination is more intense in some materials, such as plastic and rubber.

Some limitations are identified and can be used for the continuation of this line of research. The study design does not allow knowing where the contamination occurred, whether the toys were already contaminated before being handled by the child. It is known that staphylococci remain viable for many days in fomites and surfaces.^9,10 The origin of the microorganisms cannot be analyzed either and a curious fact is the finding of coagulase-positive staphylococci, such as S. Intermedius, S. schleiferi and S. hyicus.^5,11

These species are commonly found in pets, such as dogs and cats;^5,11 would the origin of the microorganisms found in the toys be the children exposed to animals before admission? Or do these hospitals allow animal assisted activity? The presence of microorganisms does not prove that they can infect patients, but studies using molecular biology technology could certify the origin of the strains that infect patients.⁵

In any case, preventive measures to prevent the spread of microorganisms should be taken. In addition to the classical measures of cleaning and disinfecting toys and therefore the choice of washable toys and hand hygiene, one should not forget the hand hygiene of children¹² and cleaning and disinfection of surfaces and furniture in the environment.¹⁰ Innovative technologies, such as self-cleaning surfaces, care methods with little manipulation, specific areas intended for recreation, should be assessed in pediatric hospitals.^6,7,10

Referências

• ¹
  Brasil - Presidência da República. Lei nº 11.104, de 21 de março de 2005. Dispõe sobre a obrigatoriedade de instalação de brinquedotecas nas unidades de saúde que ofereçam atendimento pediátrico em regime de internação. Brasília: Casa Civil; 2005. Available from: HYPERLINK "http://www.planalto.gov.br/ccivil_03/_Ato2004-2006/2005/Lei/L11104.htm" www.planalto.gov.br/ccivil_03/_Ato2004-2006/2005/Lei/L11104.htm
  » www.planalto.gov.br/ccivil_03/_Ato2004-2006/2005/Lei/L11104.htm"» www.planalto.gov.br/ccivil_03/_Ato2004-2006/2005/Lei/L11104.htm
• ²
  Avila-Aguero ML, German G, Paris MM, Herrera JF; Safe Toys Study Group. Toys in a pediatric hospital: are they a bacterial source? Am J Infect Control 2004;32:287-90.
• ³
  Freitas AP, Silva MC, Carvalho TC, Pedigone MA, Martins CH. Brinquedos em uma brinquedoteca: um perigo real? Rev Bras Anal Clin 2007;39:291-4.
• ⁴
  Merriman E, Corwin P, Ikram R. Toys are a potential source of cross-infection in general practitioners' waiting rooms. Br J Gen Pract 2002;52:138-40.
• ⁵
  Safdar N, Anderson DJ, Braun BI, Carling P, Cohen S, Donskey C et al The evolving landscape of healthcare-associated infections: recent advances in prevention and a road map for research 2014;35:480-93.
• ⁶
  Cardoso MF. Humanização. In: Ramalho MO, Costa SF, editor. Como instruir um programa de controle de infecção hospitalar. São Paulo: APECIH; 2007. p. 193-206.
• ⁷
  Boretti VS, Corrêa RN, Santos SS, Leão MV, Silva CR. Sensitivity profile of Staphylococcus spp. and Streptococcus spp. Isolated from toys used in a teaching hospital playroom. Rev Paul Pediatr 2014;32:151-6.
• ⁸
  Desai R, Pannaraj PS, Agopian J, Sugar CA, Liu GY, Miller LG. Survival and transmission of community-associated methicillinresistant Staphylococcus aureus from fomites. Am J Infect Control 2011;39:219-25.
• ⁹
  Weber DJ, Rutala WA. Understanding and preventing transmission of healthcare-associated pathogens due to the contaminated hospital environment. Infect Control Hosp Epidemiol 2011;32:687-99.
• ¹⁰
  Kelesidis T, Tsiodras S. Staphylococcus intermedius is not only a zoonotic pathogen, but may also cause skin abscesses in humans after exposure to saliva. Int J Infect Dis 2010;e838-41.
• ¹¹
  Loeffler A, Lloyd DH. Companion animals: a reservoir for methicillin-resistant Staphylococcus aureus in the community? Epidemiol Infect 2010;138:595-605.
• ¹²
  Randle J, Metcalfe J, Webb H, Luckett JC, Nerlich B, Vaughan N et al Impact of an educational intervention upon the hand hygiene compliance of children. J Hosp Infect 2013;85:220-5.

Publication Dates

• Publication in this collection
  Sept 2014