The role of chiropractic adjusting tables as reservoirs for microbial diseases

doi:10.1016/j.ajic.2005.12.007

American Journal of Infection Control

Volume 34, Issue 3, April 2006, Pages 155-157

https://doi.org/10.1016/j.ajic.2005.12.007 Get rights and content

Background

Our goal was to enumerate the microbial flora on the headrest, armrest, and thoracic portion of chiropractic adjusting tables to determine the presence of pathogenic microorganisms and identify the potential for nosocomial transmission.

Methods

Defined portions of the headrest, armrest, and thoracoabdominal pieces from 9 chiropractic adjusting tables were randomly sampled using the ACT II culture transport system (Remel, Lenexa, KS). Samples were incubated using standard culture techniques for bacteriology and mycology that included 15 mL of heart infusion agar at 35°C for 24 hours and 15 mL of Sabouraud dextrose agar at 30°C up to 7 days.

Results

Identification of microorganisms by biochemical analysis yielded a wide variety of gram-positive (G+) and gram-negative (G−) cocci and bacilli as well as standard fungi. Many were of the genus Staphylococcus. Methicillin-resistant S. aureus (MRSA) isolates were recovered from 2 separate tables.

Conclusion

This study supports a growing consensus that those outpatient facilities that do not adhere to strict infection control protocols may become ecological reservoirs of potentially harmful human pathogens.

Section snippets

Sampling

Nine chiropractic adjusting tables from the National University outpatient clinic were randomly selected using a lottery and sampled using the ACT II culture transport system (Remel, Lenexa, KS). We opted to run the samples after the clinics' normal hours of operation so that no patients, interns, or clinicians would be conscious of the study and change their normal habits. Briefly, a 4 × 4-inch area of the leather and metallic components of the head, arm, thoracic, and abdominal pieces were

Results

Our results indicate that those surfaces that come into contact with patients' integument do harbor many organisms, including coagulase-positive staphylococci and gram-negative bacilli (Table 1). Two of these isolates in particular were methicillin-resistant Staphylococcus aureus (MRSA). Other commonly encountered isolates included nonpathogenic environmental fungi representing the species Cladosporium spp, Candida, Penicillium, and Rhodotorula rubra. The number of fungal colony-forming units

Discussion

A majority of the isolates recovered were of the family Micrococcaceae. The two isolates of MRSA is a significant cause of concern. Although these organisms usually cause mild superficial skin infections, they can progress to life-threatening systemic infections that are very difficult to treat. In fact, MRSA is emerging as an important cause of community-acquired skin and soft tissue infections.⁹ Although most of the isolated microorganisms are ubiquitous in the environment and pose no serious

Conclusions

All of the surfaces sampled on the chiropractic adjusting tables carried microorganisms. Most of these were harmless skin bacteria or environmental fungi. Some of the surfaces did harbor S. aureus, a human pathogen. Some of these strains of Staphylococcus were MRSA. Armrests and uncovered portions of headrests had the highest bacterial counts. The disinfection protocols must therefore address removal of staphylococci from these surfaces to prevent horizontal transmission in the outpatient

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Cited by (13)

Assessment of Bacterial Transfer From Patient to Chiropractor During Spinal Manipulation
2021, Journal of Chiropractic Medicine
Citation Excerpt :
Thus far, there have been no reported cases of infections in chiropractic practice, which may to attributed to the low likelihood of such transmission,19 or to limited tracing and follow-up to establish causality from both the provider and patient perspectives. Nevertheless, the potential for horizontal pathogenic transmission via surfaces, equipment, and hands has been reported in studies in other healthcare settings.6,30,45-47,50 Decontaminants tested were most effective against gram-positive bacteria (96% of total bacteria isolated) such as Bacillus, Micrococcus, Staphylococcus, S aureus, and Streptococcus.
This study aimed to measure the amount of bacteria that may be transferred from patient to chiropractor during spinal manipulation and the efficacy of decontaminants commonly used by chiropractic practitioners.
We chose Kwazulu-Natal, South Africa as the location, which is an area with an increased burden of immunocompromised patients resulting from HIV and tuberculosis. In this region, we obtained samples from 40 chiropractors’ hands before and after spinal manipulation. Viable counts of colony-forming units were enumerated to verify the presence of bacteria. A modified Kirby-Bauer technique was used to ascertain the efficacy of the top 5 decontaminants used by chiropractors in this area against the bacteria isolated from their hands.
Both normal microflora and potentially pathogenic bacteria were found. These included Staphylococcus spp., Micrococcus spp., Bacillus spp., Pseudomonas spp., Escherichia coli, Streptococcus spp., and Staphylococcus aureus. Higher bacterial counts were found on chiropractors’ hands after patient contact for spinal manipulation, which are similar to findings from studies of other healthcare personnel. The 5 commonly used disinfectants tested in a lab setting were not as effective against bacterial samples when compared with an antimicrobial pharmaceutical medication.
The net transfer of bacteria to chiropractors’ hands from the patient to the practitioner during spinal manipulation included primary and opportunistic pathogens. The detergents commonly used by chiropractors in this region showed varying efficacies against microbial growth when tested in vitro.
Hand Hygiene Practices, Attitudes, and Microbial Hand Populations of Practicing Doctors of Chiropractic
2020, Journal of Chiropractic Medicine
Citation Excerpt :
Finally, the provider contacts another patient or fomite that the patient may come into contact with.1 Researchers have demonstrated the presence of pathogens on the surfaces of chiropractic treatment tables, including methicillin-resistant Staphylococcus aureus (MRSA).2-6 Additionally, some chiropractic treatment tables are cloth covered, and therefore not easily disinfected.6
Hand hygiene practice is important in health care settings to reduce the spread of infection. To date, no hand hygiene study has been conducted with doctors of chiropractic that included microbiological analysis of hand specimens. The primary objective of this study was to examine the relationship between self-reported hand hygiene practices and attitudes of chiropractors with the number and type of pathogenic bacteria and yeast present on their hands.
In this cross-sectional study, a microbiological analysis of the chiropractor's dominant hand was performed along with completion of a survey concerning practices and attitudes regarding hand hygiene. The relationship between self-reported measures with laboratory findings was conducted using generalized linear modeling.
Participants who responded to the survey indicated that hand hygiene was important, and most reported performing hand hygiene before and/or after patient contact. However, 7 (26.9%) participants had multidrug-resistant bacteria isolated from their hands. There was no correlation between the survey responses and hand specimens with the exception of the number of handwashing episodes. From the hand specimens, 16 (45.7%) coagulase-negative staphylococci isolates were oxacillin resistant, and 9 (25.7%) were multidrug resistant.
This study found that like other health care workers, chiropractors had antimicrobial-resistant bacteria on their hands, some of which were multidrug resistant. Multidrug resistant bacteria have the potential to be transferred to patients and patient contact surfaces. These findings indicate that chiropractic offices could play a role in health care-associated infections. Formal hand hygiene training should be included as part of the chiropractic education curriculum and continuing education for doctors of chiropractic.
Infection Control Practices and Methicillin-Resistant Staphylococcus aureus Skin Infections: A Survey of Students in US Chiropractic Programs
2018, Journal of Chiropractic Medicine
Citation Excerpt :
Risks for MRSA exposure and transmission in medical settings are documented.6,7,19-22 Despite parallel MRSA environmental contamination rates in chiropractic23-27 and medical28 settings, there has not been a study of MRSA infection history in chiropractic settings. This lack of study of MRSA infection in chiropractic is remarkable, given the size of the chiropractic profession,29 the treatment and training provided via skin contact30,31 in millions of patient visits,32,33 and hundreds of hours of skin contact during student training31,34 —all in an era of antibiotic-resistant organisms such as MRSA.
The purpose of this study was to assess the incidence of self-reported history of physician-diagnosed methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infection (SSTI) among chiropractic students and any association with infection control behaviors (hand and table hygiene, sharing gowns, and sharing lotion) and initiation of patient care.
Questionnaires were obtained from 312 students attending half (9/18) of US chiropractic campuses. The questionnaire was derived from earlier studies led by Bearman in 2010 and Evans in 2007. Associations were assessed with Fisher exact test. Crude odds ratios were calculated for each of the variables. Two logistic regression models were produced.
Attendance at 1 campus was associated with postmatriculation MRSA SSTI in univariate analysis (P = .010). The logistic regression model was significant (P < .05), but the composing variables were not.
Fewer than 5 cases of MRSA SSTI were detected overall, revealing a low rate of reported postmatriculation MRSA SSTI among these students. There was a univariate association with postmatriculation MRSA SSTI at 1 chiropractic college.
Methicillin-resistant Staphylococcus aureus: An overview for manual therapists
2012, Journal of Chiropractic Medicine
Citation Excerpt :
Few articles exist on the topic of MRSA as they are pertinent to practitioners of manual therapy. Research efforts have focused on the importance of treatment table and hand hygiene15-18 and risk reduction in athletic environments,19-21 and one article22 has discussed the rising importance of MRSA for physical therapists. However, we did not find any articles that provided a clinically oriented practical overview of this topic for manual therapists and believe that this is the first such article.
Methicillin-resistant Staphylococcus aureus (MRSA) is associated with difficult-to-treat infections and high levels of morbidity. Manual practitioners work in environments where MRSA is a common acquired infection. The purpose of this review is to provide a practical overview of MRSA as it applies to the manual therapy professions (eg, physical and occupational therapy, athletic training, chiropractic, osteopathy, massage, sports medicine) and to discuss how to identify and prevent MRSA infections in manual therapy work environments.
PubMed and CINAHL were searched from the beginning of their respective indexing years through June 2011 using the search terms MRSA, methicillin-resistant Staphylococcus aureus, and Staphylococcus aureus. Texts and authoritative Web sites were also reviewed. Pertinent articles from the authors' libraries were included if they were not already identified in the literature search. Articles were included if they were applicable to ambulatory health care environments in which manual therapists work or if the content of the article related to the clinical management of MRSA.
Following information extraction, 95 citations were included in this review, to include 76 peer-reviewed journal articles, 16 government Web sites, and 3 textbooks. Information was organized into 10 clinically relevant categories for presentation. Information was organized into the following clinically relevant categories: microbiology, development of MRSA, risk factors for infection, clinical presentation, diagnostic tests, screening tests, reporting, treatment, prevention for patients and athletes, and prevention for health care workers.
Methicillin-resistant S aureus is a health risk in the community and to patients and athletes treated by manual therapists. Manual practitioners can play an essential role in recognizing MRSA infections and helping to control its transmission in the health care environment and the community. Essential methods for protecting patients and health care workers include being aware of presenting signs, patient education, and using appropriate hand and clinic hygiene.
An investigation of bacterial contamination on treatment table surfaces of chiropractors in private practice and attitudes and practices concerning table disinfection
2011, American Journal of Infection Control
Citation Excerpt :
This study is the first to survey private chiropractic clinics with regard to the bacterial flora found on their treatment tables, as well as the underlying attitudes and behaviors of chiropractors with respect to table disinfection. Consistent with previous findings from chiropractic teaching clinics,22-25 the majority of the isolated bacteria in this study represent normal human microflora and ubiquitous environmental bacteria. A wider variety of bacteria were identified in this study, possibly due to the sensitivity of the isolation/identification method used.
The attitudes and behaviors of chiropractors regarding table disinfection have not yet been investigated. The purpose of this study was to evaluate (1) the bacterial contaminants present on treatment tables in private chiropractic clinics, (2) the effectiveness of the paper barrier in preventing bacterial deposition, and (3) chiropractors’ attitudes and practices regarding table disinfection.
Defined portions of treatment tables from 14 private clinics in Alberta, Canada were sampled for the presence of bacteria. Growth characteristics and 16S rRNA gene sequencing were used for bacterial identification. In addition, a 12-item survey was administered to southern Alberta chiropractors (n = 79; 81% response rate) inquiring about their attitudes and behaviors regarding table disinfection.
Respondents favored the idea of table disinfection (84%), but only 62% had a routine disinfection protocol. Table sampling revealed the presence of a number of bacteria, including methicillin-resistant Staphylococcus aureus, which were recovered from 3 separate clinics. The paper covering on table headpieces was an effective barrier to bacteria.
Chiropractors have a positive attitude regarding disinfection; however, the risk of infection from treatment tables remains. Modification of the positioning of facial piece paper may be indicated, along with increased emphasis on disinfection.
The Impact of Microbial Surveys on Disinfection Protocols in a Chiropractic College Environment
2009, Journal of Manipulative and Physiological Therapeutics
A baseline microbial survey was conducted to identify the microbes present on the headpieces of chiropractic adjusting tables from across the Western States Chiropractic College, Portland, Ore, facilities. This included the instructional adjustive technique laboratories, the student health center, the campus outpatient clinic, and an off-site clinic. The objective of this study was to evaluate the effect of disinfection protocols over time at a chiropractic college.
Four samplings were done for a 12-month period. A total of 69 treatment tables were tested. Sampling was done directly to blood agar (5% sheep blood) plates. Data obtained from the clinic locations were analyzed using linear regression models.
Identification of microbes by differential staining and biochemical analysis yielded a variety of gram-positive bacteria in all 4 surveys. The numbers of bacterial colonies decreased in the second survey after changes to disinfection protocols. The number of colonies continued to remain below baseline in the third and fourth surveys. Methicillin-resistant Staphylococcus aureus was found in the clinics in 3 of 4 surveys. Methicillin-resistant S aureus was not detected in the technique laboratories.
Various microbes were identified on the headpieces of adjusting tables in the college instructional technique laboratories and college clinics. Changing the disinfection protocols reduced the number of bacteria found in the second survey. In addition, the third and fourth surveys showed fewer bacterial colonies than baseline, suggesting that compliance with disinfection protocols continued over time.

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American Journal of Infection Control

Background

Methods

Results

Conclusion

Section snippets

Sampling

Results

Discussion

Conclusions

References (10)

A microbiologist's view of commissioning operation theaters

J Hosp Infect

Measles outbreak in a pediatric practice: airborne transmission in an office

N Engl J Med

Mycobacterium tuberculosis transmission from a pediatrician to patients

Pediatrics

Infection control in the outpatient setting

Transmission of infectious diseases in outpatient health care settings

JAMA

Cited by (13)

Assessment of Bacterial Transfer From Patient to Chiropractor During Spinal Manipulation

Hand Hygiene Practices, Attitudes, and Microbial Hand Populations of Practicing Doctors of Chiropractic

Infection Control Practices and Methicillin-Resistant Staphylococcus aureus Skin Infections: A Survey of Students in US Chiropractic Programs

Methicillin-resistant Staphylococcus aureus: An overview for manual therapists

An investigation of bacterial contamination on treatment table surfaces of chiropractors in private practice and attitudes and practices concerning table disinfection

The Impact of Microbial Surveys on Disinfection Protocols in a Chiropractic College Environment

Brief ReportThe role of chiropractic adjusting tables as reservoirs for microbial diseases

Background

Methods

Results

Conclusion

Section snippets

Sampling

Results

Discussion

Conclusions

A microbiologist's view of commissioning operation theaters

J Hosp Infect

Measles outbreak in a pediatric practice: airborne transmission in an office

N Engl J Med

Mycobacterium tuberculosis transmission from a pediatrician to patients

Pediatrics

Infection control in the outpatient setting

Transmission of infectious diseases in outpatient health care settings

JAMA

Brief Report
The role of chiropractic adjusting tables as reservoirs for microbial diseases