Observational Study Medicine ® OPEN SARS-CoV-2 could be spread through hospital medication dispensed to patients A prospective observational study ∗ Santiago Grau, PharmD, PhDa,b,c, , Olivia Ferrández, PharmD, PhDa,c, Daniel Echeverría-Esnal, PharmDa,c, Rafael Maldonado, MD, PhDd,e, Berta Puig, MDf, Aida Ramirez, MDf, Mireia Canal, MDf, Albert Montero, PharmDa, Cristina González, PhDg, Milagros Herranz, PhDg, Joan Ramon Masclans, MD, PhDh,i, Juan Pablo Horcajada, MD, PhDc,j, Eduardo Padilla, PharmDf Abstract Our objective was to analyze in vitro the persistence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the packaging material of the drugs dispensed to hospital wards. Additionally, to evaluate if the protection with a double plastic bag prevents the contamination of the medication dispensed to an intensive care unit (ICU). On the first part, different materials containing different drugs within an ICU were sampled to confirm the lack of contamination by SARS-CoV-2. The confirmation of the virus was performed using real time reverse transcription polymerase chain reaction. As a control group, in the microbiology laboratory we inoculated the virus into the different surfaces containing the same drugs included in the first part. Samples were obtained with a sterile swab at 3, 6, 8, 10, 14, 21, and 30 days after inoculation and analyzed through real time reverse transcription polymerase chain reaction. None of the studied materials containing the drugs within an ICU was contaminated by SARS-CoV-2. In the second part, SARS- CoV-2 was found in all surfaces for up to 30 days. The use of double-bag unit-dose system to deliver medication in a pandemic seems effective to prevent the potential transmission of SARS-CoV-2. A striking SARS-CoV-2 RNA stability of up to 30 days was found in the surfaces containing the drugs. Abbreviations: COVID-19 = the coronavirus disease-19, Ct = cycle threshold values, ICU = intensive care unit, RdRp = RNA- dependent RNA polymerase gene, RT-PCR = real time reverse transcription polymerase chain reaction, SARS-CoV-2 = severe acute respiratory syndrome coronavirus-2. Keywords: contamination, drugs, severe acute respiratory syndrome coronavirus-2, surfaces 1. Introduction evidence suggests that SARS-CoV-2 could remain viable for The coronavirus disease-19 (COVID-19), which is caused by the hours in aerosols and up to days in different surfaces.[1,4,5] In this severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), context, the touch of the mouth, nose or eyes after the contact has posed a global threat by causing an ongoing pandemic.[1] with this contaminated surfaces may also contribute to its Two modes of transmission have been mainly identified: direct transmission.[2,5] contact, mainly through the inhalation of droplets or small In a study conducted in Wuhan assessing the setting for particles, but also by the contact with feces, saliva or tears.[1–3] An transmission, among the 3410 patients included the 19.9% were indirect transmission has also been described.[3] Available infected in the healthcare setting.[6] Guo et al[4] assessed the Editor: Dongbo Wu. The authors have no funding and conflicts of interest to disclose. All data generated or analyzed during this study are included in this published article [and its supplementary information files]. a Pharmacy Department, Hospital del Mar, Barcelona, Spain, b Universitat Autònoma de Barcelona (UAB), Barcelona, Spain, c Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Spain, d Laboratory of Neuropharmacology, Department of Experimental and Health Sciences, Universitat Pompeu Fabra, PRBB, Barcelona, Spain, e IMIM (Hospital del Mar Medical Research Institute), PRBB, Barcelona, Spain, f Microbiology Department, Laboratori de Referència de Catalunya, Barcelona, Spain, g Epidemiology and Evaluation Department, Parc de Salut Mar, Barcelona, Spain, h Critical Care Department, Hospital del Mar, Barcelona, Spain, i Critical Ill Patient Research Group (GREPAC), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Spain, j Infectious Diseases Deparment, Hospital del Mar, Universitat Autònoma de Barcelona, Passeig Marítim 25, Barcelona, Spain. ∗ Correspondence: Santiago Grau, Department of Pharmacy, Hospital del Mar, Parc de Salut Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain (e-mail: sgrau@hospitaldelmar.cat). Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. How to cite this article: Grau S, Ferrández O, Echeverría-Esnal D, Maldonado R, Puig B, Ramirez A, Canal M, Montero A, González C, Herranz M, Masclans JR, Horcajada JP, Padilla E. SARS-CoV-2 could be spread through hospital medication dispensed to patients: a prospective observational study. Medicine 2021;100:45 (e27592). Received: 21 February 2021 / Received in final form: 2 August 2021 / Accepted: 8 October 2021 http://dx.doi.org/10.1097/MD.0000000000027592 1 Grau et al. Medicine (2021) 100:45 Medicine distribution of SARS-CoV-2 in surface and air samples from an considered a contaminated area, including the central area, intensive care unit (ICU) and a general COVID-19 ward in rooms, or the zone where the medication were stored. As a Wuhan. A wide distribution into the air and object surfaces was control infection measures, professionals within the ICU were found in both wards, with a higher contamination in the ICU.[4] asked to stay, when possible, in the ICU without going out to The higher viral load found in these severe patients may account diminish the risk of spreading the virus and all the personal was for these difference.[4,7] Other studies have shown that objects equipped with personal protection equipment. used on the infected person as thermometers or stethoscopes may The studied medication was located outside the patients’ also be contaminated.[3] rooms, in the available boxes per each patient that were located 4 Processes that encompass the drug dispensing circuits m away from the rooms, inside the bag. If any of the drugs was frequently involve the entry and exit of drugs from units. In a entered into patients’ room and was not administered, it was pandemic situation, it is of upmost importance the knowledge of immediately discarded. If medication did not enter the room, the potential contamination of medications, as they may increase unlike in routine practice, no returns were accepted and was the risk of shedding the virus to other units. This point is critical, stored throughout the pandemic in the ICU store and returned since the hypothetical contamination of the material containing once the first wave finished. the drugs could be involved in the transmission of the virus to not Potentially contaminated materials were chosen according to infected patients, physicians, nursing, and to an essential support previous studies showing different SARS-CoV-2 stability depend- service in this pandemic, hospital pharmacy staff. Unfortunately, ing on the analyzed surface.[4,5] The study was conducted from data are lacking on the contamination of the medication in the May 20, 2021 to May 26, 2021. COVID-19 pandemic. In our hospital the drug distribution is normally based on a During the first wave of COVID-19 pandemic pharmacies unit-dose system.[9] Briefly, the pharmacy department prepares adopted different strategies concerning the drug dispensing and the medications to provide patient-specific, individually pack- return: strictly dispensing the needed medications, discarding all aged medications to each patient, delivered for 24 hours. The unused medications or implementing the use of automated medication is normally distributed in carts, which contain dispensing cabinets.[8] The Institute for Safe Medication Practice the different packages. Once in the unit, they are available in the stated that some hospitals placed in a plastic bag the unused patient-area to be administered. After the 24 hours period, they medications that returned to pharmacy for 3 days (based on the are returned to the pharmacy with the leftover medication. study of Van Doremalen et al[5]), and then evaluated their use.[8] During the COVID-19 pandemic, due to concerns on the This was the strategy adopted in our hospital. However, potential contamination of the medication, our hospital modified recommendations concerning the best way to proceed with the usual medication dispensing routine and unit-dose system dispensing the drugs were unavailable. was interrupted. Instead, we placed the drugs directly in the boxes The hypothesis of our study was that, based on other studies of the unit dose carts and protected them in a double plastic bag, showing the contamination of different surfaces with SARS-CoV- appropriately labeled. Later, these bags were placed in cardboard 2,[5] the medication could also be contaminated with this virus boxes (unlike the normal carts) that were transported to the ICU and be a potential route of transmission. We therefore where the nursing staff proceeded to extract the double bag and implemented a double-bag dispensing strategy of medications relocate it to the boxes available to each patient. This strategy was to avoid the potential contamination of medications. used to replace the use of unit-dose cart boxes with the aim of The objective of this study was to analyze in vitro the reducing the potential contamination of drugs. The decision of persistence of SARS-CoV-2 in the packaging material of the drugs using a double instead of 1 plastic bag was made by the that are dispensed to hospital wards. Secondly, we evaluated if Epidemiology and Evaluation department to reduce the risk of the protection with a double plastic bag prevents the contamina- contamination, to avoid possible problems with bag breaking tion of the medication dispensed to patients admitted in an ICU. and based on the recommendations available in that period. To try to elucidate the effectiveness of this system and consider the return of the drugs to the pharmacy, we assessed the 2. Methods contamination of the drugs available within the double bags in the ICU. For this purpose, serial daily samples were obtained This study was divided into 2 parts. On the first part we evaluated from the medication for 5 days. Specialized infection control the effectiveness of the medication protection strategy by nurses took the first samples in the ICU area and thereafter introducing them in plastic bags when preparing in the Pharmacy. carried to the pharmacy service, where were conserved in a sterile As a control group, we also carried out another study in the bell with the same temperature (room temperature, 21–25°C) and microbiology laboratory setting. This time, we inoculated the humidity that in the ICU. During the following days, the rest of virus into the different surfaces containing the same drugs the samples were obtained in the pharmacy service by trained included in the first part of the study in order to assess the stability staff. Two replicate experiments were performed for each of SARS-CoV-2 in the different packaging materials containing surface.[5] medications. The analyzed surfaces were sampled by premoistened swabs that were finally collected in sterile tubes containing 2 mL of 2.1. Part 1: potential contamination of the drugs in the Universal Transport Medium (Vircell S. L. Granada, Spain).[4] ICU Viral nucleic acid was extracted by using the QIAsymphony 2.1.1. Protocol. This was a prospective study on samples of drug fully automated nucleic acid isolation system (Qiagen GmbH, forms packaged in different materials carried out at the ICU of the Germany). Laboratory confirmation of the virus was performed Hospital del Mar, a 420-bed tertiary hospital in Barcelona, Spain. using real time reverse transcription polymerase chain reaction At the time of this study the ICU unit housed 20 COVID-19 (RT-PCR) using the LightMix Modular SARS-CoV-2 patients and was confined. The entire ICU unit was therefore (COVID19) kit (Roche Molecular Systems, Branchburg, NJ) in 2 Grau et al. Medicine (2021) 100:45 www.md-journal.com the LightCycler 480 II instrument (Roche Molecular Systems, The evaluation of RNA integrity was performed using RT-PCR Branchburg, NJ). The kit includes 2 probes targeting the RNA- with the Abbot SARS-CoV-2 RT-PCR detection kit system dependent RNA polymerase gene (RdRp) that is specific for (Abbot Molecular Inc. IL). The target sequences for this assay are SARS-CoV-2 (target 1), and the conserved, structural protein highly preserved and specific for this strain of coronavirus and envelope E gene that is shared by the Sarbecovirus subgenus. The includes RdRp and N genes of SARS-CoV-2.[11] The viral load limit of detection of this assay was 5.2 and 3.8 copies per reaction was controlled with Ct as indicator of viral load. for E and RdRp gene, respectively.[10] 2.2.2. Virus. The SARS CoV-2 virus used in this study were 2.1.2. Surfaces. A total of 9 different surfaces of drug containers collected from nasopharyngeal PCR positive patients received in were chosen according to previous studies showing different our microbiology laboratory. This samples had a high viral load SARS-CoV-2 stability depending on the analyzed material[4,5] and were preserved in UTM at 80°C until surface inoculation. and constitute the most common packaging materials for drugs available in hospitals. 2.2.3. Surfaces. To conduct this part of the study the same No other studies have assessed the potential contamination of medications and the same surfaces were chosen (Table 1). The drugs by SARS-CoV-2. However, based on previous data in other drugs had been dispensed from the stock of the pharmacy service surfaces in the ICU, to detect at least a 17% of positivity,[4] with a of Hospital del Mar in Barcelona. two-sided 5% significance level and a statistical power of 80%, a The STROBE guideline was followed during the writing of the sample size of 80 samples (40 in each group) was deemed manuscript. Approval by the ethics committee was not consid- necessary. ered necessary as this study was not conducted with human beings. 2.2. Part 2: RNA stability of SARS-CoV-2 on the different 3. Results surfaces containing the drugs after inoculation 3.1. Part 1 As a control group, and to test if surfaces that contain the drugs could get contaminated with SARS-CoV-2, we also studied the A total of 6 active principles were collected to perform the study, RNA stability of SARS-CoV-2 after inoculating them with the which included 9 different materials. All the studied drugs and the virus. SARS CoV-2 RNA stability was defined by a positive RT- different materials conditioning them were presented in Table 1. PCR result. The studied materials used in this study were: aluminum, glass, cardboard, polyolefin, paper, stainless steel, polypropylene, 2.2.1. Protocol. A prospective study of RNA SARS-CoV-2 cellophane, and polyvinyl chloride. stability on drug formulations conditioned in 9 different surfaces Over the study period, a total of 80 samples were obtained (2 (Table 1) was carried out at Laboratori de Referència de from each surface per day). We were unable to find any trace of Catalunya (Parc de Salut Mar) in Barcelona (Spain). This study SARS-CoV-2 in any of the samples, even in the first ones taken in was conducted from August 19 to September 17. Temperature the ICU. and relative humidity were controlled throughout the entire study. 3.2. Part 2 Seven inoculations of 25 mL of a universal transport medium UTM (Miraclean Technology Co.,Ltd.) positive PCR SARS- The temperature and humidity remain constant during all the CoV-2 sample were performed in each surface. The cycle experiment, with a mean temperature of 24.3 (1.3) °C and threshold values (Ct) of initial inoculum were 8.98. Surface humidity of 55.6 (2.5)%. The RT-PCR results from all the samples were collected with a sterile swab at 3, 6, 8, 10, 14, 21, samples have been described in Table 2. The collected samples and 30 days after inoculation. were RT-PCR positive in SARS-CoV-2 in all surfaces for 30 days. Excepting for clonidine 0.15 mg repacked tablets, in all the surfaces a slight increase in the Ct was noticed, which suggests a Table 1 modest reduction of viral load. However, in all the samples the Ct Studied drugs and different materials conditioning them. was inferior to 30. Pharmaceutical Active principle form Material 4. Discussion Ipratropium bromide 250 mcg for inhalation Inhalator Aluminum/ To the best of our knowledge, this is the first study addressing the stainless potential contamination by SARS-CoV-2 of the surfaces steel containing the drugs. The potential implication of this study is Clonidine 0.15 mg for intravenous perfusion Vial Glass huge given the potential risk of spreading SARS-CoV-2 in a Clonidine 0.15 mg repacked tablet Tablet Paper Clonidine 0.15 mg repacked tablet Tablet Cellophane hospital setting. In the first part of the study, we were unable to Fluconazole 200 mg/100 mL for intravenous Bottle Polyvinyl detect SARS-CoV-2 RNA on the studied surfaces. In the second perfusion chloride part, a striking stability of up to 30 days of SARS-CoV-2 RNA Fluconazole 200 mg/100 mL for intravenous Bottle Polyolefin was found in the materials containing the drugs. perfusion First studies conducted in February-March assessed the Acetylsalicylic acid 100 mg blister pack Tablet Aluminum potential contamination of different surfaces in an ICU, where Linezolid 600 mg/300 mL for intravenous Bag Polyolefin they reported air and surface (computer mice, trash cans, sickbed perfusion handrails, doorknobs) contamination.[4] More strikingly, the Linezolid 600 mg/300 mL for intravenous Bag Cardboard virus was detected in the pharmacy floor, which was located near perfusion the ICU, suggesting that the walk of medical staff may be 3 Grau et al. Medicine (2021) 100:45 Medicine Table 2 Real time polymerase chain reactions of the different surfaces along the study period. Pharmaceutical Day Day Day Day Day Day Day Active principle form Material 3 6 8 10 14 21 30 Ipratropium bromide 250 mcg for inhalation Inhalator Aluminum/stainless steel 10.56 9 10.1 10.27 10.25 9.86 12.13 Clonidine 0.15 mg for intravenous perfusion Vial Glass 10.08 9.59 9.77 10.55 10.35 9.5 16.52 Clonidine 0.15 mg repacked tablet Tablet Paper 10.53 10.42 10.73 10.96 17.68 16.63 29.29 Clonidine 0.15 mg repacked tablet Tablet Plastic 9.98 9.7 9.53 10.61 10.78 10.8 14.43 Fluconazole 200 mg/100 mL for intravenous perfusion Bottle Polyvinyl chloride 10.29 8.96 9.97 11.06 10.49 11.91 15.06 Fluconazole 200 mg/100 mL for intravenous perfusion Bottle Polyolefin 10.8 10.48 11.26 12.39 13.5 14.73 16.26 Acetylsalicylic acid 100 mg blister pack Tablet Aluminum 12.37 10.53 10.72 12.17 12.26 12.75 14.43 Linezolid 600 mg/300 mL for intravenous perfusion Bag Polyolefin 11.2 11.36 11.65 13.3 13.14 15.54 15.98 Linezolid 600 mg/300 mL for intravenous perfusion Bag Cardboard 11.65 10.83 12.39 11.9 12.73 13.91 16.06 The results are expressed in cycle threshold values (Ct). responsible of the spread of the virus.[4] Unfortunately, the The integrity of SARS-CoV-2 RNA could have been biased potential contamination of the drugs was not assessed in any of because of inoculating the virus with UTM. Our hypothesis is these studies. that UTM creates a preservative environment for SARS-CoV-2, We did not find contamination of SARS-CoV-2 in any of the lengthening the integrity of its RNA through crystallization. surfaces of the medication available in the ICU. This finding Further studies should be performed considering the effect of the allowed us to verify that the double-bag dispensing system inoculating media on SARS-CoV-2 RNA stability. Performing prevents the contamination of the drugs, reducing the risk of the experiment using an inoculation media with an osmolality transmission of SARS-CoV-2. We believe that the main reason of and ion concentration match those of the human nasopharyngeal this finding is that the bag would protect these surfaces of the fluids, would provide a closer approach to reality. contamination present in the air. Unfortunately, we did not Our study is not without limitations. One of the main limitations sample these bags, which would have confirmed this hypothesis. is that, unfortunately, no appropriate controls in the first part of the Other studies performed with bacteria have confirmed our study were conducted, so other potential confounding factors hypothesis, as the use of plastic bags was protective in preventing could be present. We tried to do so in the second part, but we the contamination of mobile phones.[12] acknowledge that these controls may not be the more appropriate, Other reasons include the location of the drugs, which were given that were not studied in the same manner. Although the study outside the patient rooms. Recent evidence has shown that the was conducted with a double bag system, the use of a single bag is environmental contamination of ICU may not be as higher as an interesting approach that deserves further study. The fact that previously thought, being limited to patient rooms and high touch UTM was employed may have biased the results, as in this medium areas.[7,13,14] The enhancement of the infection control practi- the stability of the virus may be overestimated. In the first part, the ces,[13] the course of the disease when patients are admitted in the lack of sample of the double-bag plastic and of the air and other ICU (viral shedding appears to peak in the first week of illness and surfaces contamination in the ICU is an important limitation to decrease after, coinciding with the time when most patients are address the potential contamination of drugs. In the second part, admitted in the ICU),[7] the fact that most ICU patients are confined we did not perform viral cultures, so the potential infectiousness of to their bed and the use of closed ventilator circuits in mechanical the detected virus is unknown. SARS-CoV-2 could be therefore ventilated patients are some of the proposed reasons.[7] However, spread through hospital, although the transmission through this contamination comparation is limited by the different sampling route remains uncertain. However, we believe that the findings of techniques, patient characteristics or cleaning methods.[7] In this our study are important as they confirm the effectiveness of the regard, we did not assess air or any other contamination within the double-bag unit-dose dispensing system to prevent the contami- ICU, which would have been of interest. nation of drugs containing surfaces by SARS-CoV-2 and its Our study has only been focused on the unit-dose drug potential transmission. Furthermore, the stability of up to 30 days distribution to which special protective measures were applied, so in the different surfaces deserves further study, as this may be a this evidence does not apply to other systems as automated route of transmission if no precautions are taken. dispensing cabinets that may also be used to deliver the drugs into To conclude, the use of double-bag unit-dose system to deliver the different wards. Although specific evidence is lacking, the medication in a pandemic seems effective to prevent the potential Institute for Safe Medication Practice recommended a clean transmission of SARS-CoV-2. Up to 30 days stability of SARS- hands approach to access the cabinet, traffic decrease, cross- CoV-2 RNA was found in the surfaces containing the drugs, contamination limit, critical items secure storage and return of which merits further study to discard this route as a potential medications avoidance have been recommended.[8] transmitter of SARS-CoV-2. In the second part of our study, we found that the stability of SARS-CoV-2 RNA remains intact, at least, for 30 days. This was Author contributions a striking finding considering that SARS-CoV-2 is a RNA virus. The performance of RT-PCR has also demonstrated that this Conceptualization: Santiago Grau, Rafael Maldonado, Eduardo virus can be detected for a long time in different scenarios: upper Padilla. respiratory tract (mean of 17 days but a maximum of 83 days),[15] Data curation: Santiago Grau, Olivia Ferrandez, Rafael aerosols (3 hours),[5] copper (8 hours),[5] plastic or stainless steel Maldonado, Eduardo Padilla. (72–96 hours),[5,16] cardboard (48 hours),[5] wood (48 hours)[16] Formal analysis: Santiago Grau, Olivia Ferrandez, Daniel and the outer layer of a surgical mask (7 days).[16] Echeverria-Esnal, Berta Puig, Eduardo Padilla. 4 Grau et al. Medicine (2021) 100:45 www.md-journal.com Funding acquisition: Santiago Grau, Olivia Ferrandez, Juan [2] How Coronavirus Spreads _ CDC. Available at: https://www.cdc.gov/ coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html. Pablo Horcajada, Eduardo Padilla. Accessed May 25, 2020. Investigation: Santiago Grau, Olivia Ferrandez, Rafael Maldo- [3] Karia R, Gupta I, Khandait H, Yadav A, Yadav A. COVID-19 and its nado, Berta Puig, Ana Ramirez, Mireia Canal, Albert modes of transmission. SN Compr Clin Med 2020;1–4. doi:10.1007/ Montero, Cristina González, Daniel Echeverria-Esnal, Mila- s42399-020-00498-4. gros Herranz, Juan Pablo Horcajada, Eduardo Padilla. [4] Guo ZD, Wang ZY, Zhang SF, et al. Aerosol and surface distribution of severe acute respiratory syndrome Coronavirus 2 in hospital wards, Methodology: Daniel Echeverria-Esnal, Santiago Grau, Olivia Wuhan, China, 2020. Emerg Infect Dis 2020;26:1586–91. Ferrandez, Rafael Maldonado, Eduardo Padilla. [5] Van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface Project administration: Santiago Grau, Berta Puig, Ana Ramirez, stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med Mireia Canal, Albert Montero, Joan Ramon Masclans, Juan 2020;382:1564–7. [6] Luo L, Liu D, Liao X, et al. Contact settings and risk for transmission in Pablo Horcajada, Eduardo Padilla. 3410 close contacts of patients with COVID-19 in Guangzhou, China. Resources: Santiago Grau, Albert Montero, Eduardo Padilla. Ann Intern Med 2020;173:879–87. Software: Santiago Grau, Eduardo Padilla. [7] Ong SWX, Lee PH, Tan YK, et al. Environmental contamination in a Supervision: Santiago Grau, Ana Ramirez, Joan Ramon coronavirus disease 2019 (COVID-19) intensive care unit-What is the Masclans, Juan Pablo Horcajada, Eduardo Padilla. risk? Infect Control Hosp Epidemiol 2021;42:669–77. [8] Cohen MR. Institute for safe medication practices. In: Encyclopedia of Validation: Santiago Grau, Olivia Ferrandez, Daniel Echeverria- Clinical Pharmacy 2002;476–7. doi:10.3109/9780824706081.079. Esnal, Rafael Maldonado, Ana Ramirez, Mireia Canal, Juan [9] ASHPASHP statement on unit dose drug distribution. Am J Hosp Pharm Pablo Horcajada, Eduardo Padilla. 1989;46:2346. Visualization: Santiago Grau, Olivia Ferrandez, Daniel Eche- [10] Corman VM, Landt O, Kaiser M, et al. Detection of 2019-nCoV by RT- PCR. Euro Surveill 2020;25:1–8. verria-Esnal, Rafael Maldonado, Eduardo Padilla. [11] Degli-Angeli E, Dragavon J, Huang ML, et al. Validation and verification Writing – original draft: Santiago Grau, Olivia Ferrandez, Daniel of the Abbott RealTime SARS-CoV-2 assay analytical and clinical Echeverria-Esnal, Eduardo Padilla. performance. J Clin Virol 2020;129:104474. Writing – review & editing: Santiago Grau, Olivia Ferrandez, [12] Wu YH, Chen CJ, Wu HY, et al. Plastic wrap combined with alcohol Daniel Echeverria-Esnal, Rafael Maldonado, Berta Puig, Ana wiping is an effective method of preventing bacterial colonization on mobile phones. Medicine (Baltimore) 2020;99:e22910. Ramirez, Mireia Canal, Albert Montero, Cristina González, [13] Tan L, Ma B, Lai X, et al. Air and surface contamination by SARS-CoV-2 Milagros Herranz, Joan Ramon Masclans, Juan Pablo virus in a tertiary hospital in Wuhan, China. Int J Infect Dis 2020;99:3–7. Horcajada, Eduardo Padilla. [14] Lomont A, Boubaya M, Khamis W, et al. Early view environmental contamination related to SARS-CoV-2 in ICU-patients. ERJ Open Res 2020;6:595. References [15] Cevik M, Kuppalli K, Kindrachuk J, Peiris M. Virology, transmission, and pathogenesis of SARS-CoV-2. BMJ 2020;371:m3862. [1] Dhama K, Khan S, Tiwari R, et al. Coronavirus disease 2019–COVID- [16] Chin AWH, Chu JTS, Perera MRA, et al. Stability of SARS-CoV-2 in 19. Clin Microbiol Rev 2020;33:1–48. different environmental conditions. Lancet Microbe 2020;1:e10. 5