Research Article | Open Access
E. Nivedhitha1, M. Duraivel2 , K.K. Kayalvili3 and S. Arul Selvan4
1Department of Microbiology, SRM Medical College Hospital & Research Centre, Faculty of Medicine, SRM Institute of Science and Technology, SRM Nagar, Kattankulathur,  603203, Kanchipuram, Chennai, Tamilnadu, India.
2Department of Pharmacology, Chettinad Hospital & Research Institute, Chettinad Academy of Research and Education, Kelambakkam, 603103, Chengalpattu, Tamilnadu, India.
3Orbito Asia Diagnostics, St. Thomas Mount, Chennai, Tamilnadu, India.
4Department of Forensic Medicine, Govt. Mohan Kumaramangalam Medical College, Salem, Tamilnadu, India.
J Pure Appl Microbiol. 2021;15(3):1150-1155 | Article Number: 6903
https://doi.org/10.22207/JPAM.15.3.04 | © The Author(s). 2021
Received: 23/02/2021 | Accepted: 04/06/2021 | Published: 23/06/2021
Abstract

The main objective of the study was to find out the contamination of different types of microbial organisms and their resistance pattern on the dresses and stethoscopes of the health care workers in order to evaluate the risk of transmission of microbial organisms and its consequences on safety of the patient and control of hospital acquired infections (HAIs). Swabs were taken from the dresses of 100 different healthcare workers from 4 different areas namely collar, pocket, sleeves and sides and 100 stethoscopes (diaphragm) were tested for bacteriological analysis using standard techniques. Then each health care worker were given a structured questionnaire and requested to fill the form which includes his or her speciality/unit, cadre, practice of hand hygiene, white-coat or uniform usage (Example: duration of usage, frequency of washing, type of washing etc). The collar and pockets were found to be the most contaminated areas. Gram-positive cocci such as Staphylococcus aureus and Coagulase-negative Staphylococci (CONS) were the important organisms isolated from the dresses and stethoscopes of health care workers followed by Gram-negative bacilli such as Pseudomonas aeruginosa and Klebsiella species. Among the microbial organisms, Staphylococcus aureus and CONS were resistant to the drugs like Co-trimoxazole and Penicillin-G. Organisms isolated from the dresses and stethoscopes of health care workers could be a source of infection to immunocompromised patients. Hence, frequent washing of the dresses and strict disinfectant practices of the stethoscopes will minimize the contamination with microbial organisms and the patient safety is improved in the hospital environment.

Keywords

Microbial contamination, dresses of health care workers, stethoscope

Introduction

Transmission of infections from one patient to other in the hospital environment remains to be a major concern for the hospitalized patients.1 Patients can shed infectious microbial organisms into the healthcare environment and pose a risk of transmission of infection to the other inpatients. Healthcare workers also can transmit infection by virtue of their constant contact with the patients. There has been a growing concern that the dresses of the health-care workers2-3 and devices such as stethoscopes4 may actually play a vital role in transmitting the pathogenic microorganisms in a hospital setting. This has yet to be studied in developing countries as there is an increasing incidence of Hospital acquired infections (HAIs) and for which there is a dire need to introduce effective patient-safety initiatives to decrease HAI. Hence, this study is planned to identify the occurrence of microbial contamination in the dresses and stethoscopes of health care workers and to emphasize the importance of these microorganisms in control of HAIs.

Materials and Methods

A total of 100 health care workers from different specialities or cadres participated in this study. Swabs were taken from dresses of the health care workers in 4 different areas namely collar, pocket, sleeves and sides and also from 100 different stethoscopes (diaphragm), for bacteriological analysis. Sterile, cotton tipped and plain swabs were used for the bacteriological culture. Normal saline was used to wet the swabs and samples were taken by rolling the swabs up and down twice in the preferred areas. Then the swabs were placed in a sterile test tube and transported immediately to the laboratory. They were streaked on to 5% blood agar and Macconkey agar plate and left for overnight incubation at 37°C. Next day, culture plates were examined for the presence of bacterial colonies followed by biochemical reactions for the species level identification and antimicrobial sensitivity test were done by standard laboratory methods. After the samples were taken from the health care workers, a brief, structured questionnaire was given to all of them to fill the form which includes his or her speciality/unit, cadre, practice of hand hygiene, white-coat or uniform usage (Example: duration of usage, frequency of washing, type of washing etc).

RESULTS

The results of the present study are tabulated in table 1-5.

Table (1):
Basic variables.

Basic variables n=100 Samples   (Collars, Pockets, Sleeves and Sides) Culture positive Culture negative
Gender
Male 59 236 165 71
Female 41 164 120 44
Total 100 400 285 115
Designation
Doctors 47 188 157 31
Nurses 31 124 109 15
Paramedical staffs 22 88 19 69
Total 100 400 285 115

Most of the health care workers were doctors (47%) followed by nurses (31%) and paramedical staffs (22%).
Females (41%) were less in number when compared to males (59%)
Females had higher rate of culture positive (73%) than males (70%)

Table (2):
Isolates from the culture positive samples of the dresses of health care workers.

Organisms Collar
n=100
Pocket
n=100
Side
n=100
Sleeve
n=100
Total
N=400
Monomicrobial
Staphylococcus aureus 28 27 26 15 96
CONS* 18 16 12 14 60
Pseudomonas aeruginosa 10 9 13 9 41
Klebsiella sp. 2 4 3 3 12
Total 58 56 54 41 209
Polymicrobial
Staphylococcus aureus +  CONS* + Micrococci 8 8 8 16 40
Staphylococcus aureus + Pseudomonas aeruginosa 6 7 4 3 20
CONS* + diphtheroides 4 2 2 8 16
Total 18 17 14 27 76
Culture Positive 76 73 68 68 285
Culture Negative 24 27 32 32 115

*CONS – COagulase Negative Staphylococci
The overall prevalence of microbial contamination in the dresses of health care workers was 71% (285 culture positive samples).
Collar and pocket were found to be the most contaminated areas (26%).
Among 285 culture positive samples, single organism (monomicrobial) was found in 209 samples and 76 samples had multiple organisms (polymicrobial).
In the monomicrobial samples (n=209), Staphylococcus aureus (46%) was found to be the most common organism isolated. Whereas, in the case of polymicrobial samples (n=76), Staphylococcus aureus, CONS and Micrococci (53%) were the most commonly isolated combination.

Table (3):
Isolates from the stethoscopes of health care workers (n=100).

Monomicrobial Total Polymicrobial Total
Staphylococcus aureus 31 Staphylococcus aureus + CONS* +  Micrococci 23
CONS* 12 Staphylococcus aureus + Pseudomonas aeruginosa 6
Pseudomonas aeruginosa 9 CONS* + Diphtheroides 3
52 32
Culture Positive 84
Culture Negative 16

*CONS – COagulase Negative Staphylococci
The overall prevalence of microbial contamination found in the stethoscopes of different Health care workers was found to be 84%
Among the 84 culture positive samples, 52 were monomicrobial and 32 were polymicrobial in nature.
In the monomicrobial samples (n=52), Staphylococcus aureus (60%) was found to be the most important organism isolated. Whereas, Staphylococcus aureus, CONS and Micrococci (72%) were the most common combination of organisms encountered in the polymicrobial samples (n=32).
Overall 3% of Staphylococcus aureus were found to be MRSA.

Table (4):
Antibiotic resistance pattern of the isolates obtained from both the dresses and stethoscopes of healthcare workers.

Antibiotics
Staph. aureus n=216
CONS* n=154
Pseudomonas aeruginosa n= 76
Klebsiella Sp. n=12
Cotrimoxazole
192
120
NT
7
Penicillin G
168
123
NT
NT
Gentamicin
149
111
30
3
Erythromycin
80
51
NT
NT
Ciprofloxacin
86
70
52
10
Cefoxitin
6
0
NT
NT
Amikacin
NT
NT
27
2
Cefotaxime
NT
NT
NT
0
Ceftriaxone
NT
NT
NT
0
Ceftazidime
NT
NT
0
NT
Piperacillin
NT
NT
0
NT

*CONS – COagulase Negative Staphylococci; NT- Not tested.
Cotrimoxazole and Penicillin G were found to have maximum resistance for Gram-positive cocci such as Staphylococcus aureus and Coagulase negative Staphylococci (CONS) whereas, Ciprofloxacin have the maximum resistance for the Gram-negative bacilli such as Klebsiella sp and Pseudomonas aeruginosa

Table (5):
Questionnaires.

1.
How often do you wash your coat/ uniform?
n=100
a.     Daily
17
a.     Twice a week
51
b.     Once a week
11
c.     Once in 15 days
13
d.     Once a month
8
2.
Where all do you wear your coat/ uniform?
      a.  Only in wards
28
b.  Wards and also within campus including canteen and mess
63
      c.  Inside and outside campus
9
3.
How often do you use sanitizer during working hour?
a.     Immediately after handling a patient
31
b.     Before handling a patient
16
c.     Before and after attending patients
29
d.     Never
24
4.
How do you wash your uniform/coat?
a.     Autoclave
b.     Self-washing
100
5.
Do you usually carry articles in your coat/uniform pocket?
a.     Yes
89
b.     No
11
6.
Is your coat half sleeve or full sleeve?
a.     Half sleeve
92
b.     Full sleeve
8

63% of the health care workers used their white coats in wards, within campus including canteen and mess.
All the health care workers were found to wash their coats on their own and 51% of them wash their coats twice a week. Hand hygiene using sanitizers was practiced by 29% of the health care workers before and after attending patients.

DISCUSSION

The high rates of the microbial contamination in the dresses and stethoscope of health care workers may be related to the fact that patients may continuously shed the infectious microbial organisms into the hospital environment, and the health care workers are in constant contact with these patients. It has also been established that, the microbial organisms can survive for 10 to 98 days on fabrics such as polyesters and cotton which are used to make white coats.5

Since the dresses and stethoscopes of health care workers can transmit the infections from one to another, we have designed this present study in around 100 different health care workers from various specialities or cadres in the hospital. From each individuals, one swab from the stethoscope (n=100) and four swabs from different parts of their dresses such as collar, pocket, sleeves and sides (n=400) were taken for bacteriological analysis.

Among the 100 health care workers, most of them were doctors (47) followed by nurses (31) and paramedical staffs (22). Though females (41%) were less in number compared to males (59%), they had higher rate of bacterial contamination (73%). [Table 1] This finding was similar to the study findings by Muhadi et al6 and contrary to the study findings of Banu et al7 who found out that male worker dresses are more contaminated than females.

Our study result showed, out of 400 samples, 285 samples (71%) were found to be contaminated with micro-organisms which is much lower compared to the study done by Moravvej et al8 (94%) and Uneke & Ijeoma9 (91.3%).

Collar and pocket of the dresses of health care workers were equally contaminated (26%) and was slightly more than the contamination on the sides and sleeves of the dresses (24%). This observation was similar to the study findings of Muhadi et al6 and Banu et al7 who showed that the collar and pockets are the most contaminated areas. [Table 2]

All the health care workers wash their coats on their own and more than 50% of the hospital workers wash their coats twice a week. The data from washing practices of dresses of health care workers revealed that the microbial organism contamination varied with the duration of the coats in use. This was contrary to the findings of Wong et al10 who showed that the level of bacterial contamination did not vary with the length of time a dress had been in use.

Among the participants 28% of them used their white coats only in the wards, while 63% used it both in wards and as well as within campus including canteen/mess and 9% used both inside and outside the hospital premises. Similar reports were observed in the study done by Muhadi et al6.

76% of the health care workers claimed to use hand sanitizer before and after attending patients and the microbial contamination were found to be much less when compared with the non-users (24%). [Table 5]

In this present study, the most common organism isolated from the dresses of the health care workers was found to be Staphylococcus aureus. This was similar to the study findings of Muhadi et al6, Wong et al10 and Treakle et al11 and different from the study findings by Uneke and ijeoma9 in which diphtheroids was found to be the most commonly isolated organism.[Table 4]

Among the samples taken from the stethoscope of 100 different health care workers, as many as 84% of the stethoscope [Table 3] were contaminated with microorganisms which was comparable to the observations from the previous studies done by Youngster et al12, Zuliani et al13 and Wood et al14 which showed that 71-100% of stethoscopes were contaminated by different microorganisms. Among them, Staphylococcus aureus was found to be the most common isolate followed by the Coagulase negative Staphylococcus (CONS).

The antimicrobial susceptibility pattern of the Gram-positive cocci such as Staphylococcus aureus and Coagulase negative Staphylococci (CONS) showed that most of the organisms were resistant to the drug Co-trimoxazole and Penicillin. Whereas, Ciprofloxacin was found to have maximum resistance for the Gram-negative bacilli such as Pseudomonas aeruginosa and Klebsiella sp. These findings are consistent with the study results shown by Uneke and Ijeoma9.

Even though most of the organisms isolated in this present study were considered to be non-pathogenic, a considerable fraction of the isolates were pathogenic. Some of the pathogenic organisms like Methicillin Resistant Staphylococcus Aureus (MRSA), Klebsiella sp and Pseudomonas aeruginosa are infectious to the patients who are admitted in the hospital and play a very important role in transmitting the infections from one patient to another. In this study, the percentage of MRSA isolated was 3% which was significantly lower than the study findings done by Treakle et al11 where it was reported that 18% of MRSA are found in the dresses of health care workers.

CONCLUSION

This hospital based cross-sectional surveillance study revealed that a large proportion of the dresses of health care workers and stethoscope were contaminated with microbial organisms that can result in infections as well as in the spread of resistant strains in the hospital settings. As a result, there is an increasing need to promote a meticulous hand washing and use of hand sanitizers before and after attending the patients. Frequent washing of the uniform and disinfectant of stethoscopes by the health care workers will definitely minimize the cross-contamination with microorganisms and also decrease the chance of hospital acquired infections.

Declarations

ACKNOWLEDGMENTS
We owe our heartfelt thanks to the doctors and other health care workers for giving consent to take the samples. We express our deep gratitude for the technical staffs for their assistance in this work.

CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.

AUTHORS’ CONTRIBUTION
All the authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

FUNDING
None.

ETHICS STATEMENT
This study involves only the collection of samples from the dresses and stethoscopes of health care workers and the personal information of the participants were not revealed in any part of the study. This article does not contain any studies with human participants or animals performed by any of the authors.

AVAILABILITY OF DATA
All datasets generated or analyzed during this study are included in the manuscript.

References
  1. Collins AS. Preventing Health Care-Associated Infections. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008. Chapter 41. https://www.ncbi.nlm.nih.gov/books/NBK2683/
  2. Oliveira AM, Silva MD, Garbaccio JL. Clothing of health care professional as potential reservoirs of micro-organisms: an integrative review. Texto & Contexto Enfermagem. 2012;21(3):684-691.
    Crossref
  3. Lavanya J, Jais M, Rakshit P, Kumar V, Dutta R, Gupta RK. Correlation between Bacterial Pathogens Transfer in Healthcare Workers and Patients: A Study from Paediatric ICU and Nursery of a Tertiary Care Hospital. J Microb Biochem Technol. 2014;6:35-37.
    Crossref
  4. Uneke CJ, Ogbonna A, Oyibo PG, Onu CM. Bacterial contamination of stethoscopes used by health workers: public health implications. J Infect Dev Ctries. 2010;4(7):436-441.
    Crossref
  5. Chacko L, Jose S, Isac A, Bhat KG. Survival of nosocomial bacteria on hospital fabrics. Indian J Med Microbiol. 2003;21(4):291.
    Crossref
  6. Muhadi SA, Aznamshah NA, Jahanfar S. A cross sectional study on the microbial contamination of the medical student’s white coats. Malays J Microbiol. 2007;3(1):35-38.
    Crossref
  7. Banu A, Anand M, Nagi N. White coats as a vehicle for bacterial dissemination. J Clin Diagn Res. 2012;6(8):1381-1384.
    Crossref
  8. Moravvej Z, Fakhar Y, Naderi-Nasab M, Askari E. Study on Bacteria Associated with White Coats of Healthcare Workers in Two Tertiary Hospitals, Mashhad, Iran. J Med Bacteriol. 2013;2(3-4):17-25.
  9. Uneke CJ, Ijeoma PA. The potential for nosocomial infection transmission by white coats used by physicians in Nigeria: implications for improved patient-safety initiatives. World Health Popul. 2010;11(3):44-54.
    Crossref
  10. Wong D, Nye K, Hollis P. Microbial flora on doctors’ white coats. BMJ (Clinical Research ed.). 1991;303(6817):1602-1604.
    Crossref
  11. Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Bacterial contamination of health care workers’ white coats. Am J Infect Control. 2009;37(2):101-105.
    Crossref
  12. Youngster I, Berkovitch M, Heyman E, Lazarovitch Z, Goldman M. The stethoscope as a vector of infectious diseases in the paediatric division. Acta Paediatr. 2008;97(9):1253-1255.
    Crossref
  13. Zuliani Maluf ME, Maldonado AF, Bercial ME, Pedroso SA. Stethoscope: a friend or an enemy? Sao Paulo Med J. 2002;120(1):13-15.
    Crossref
  14. Wood MW, Lund RC, Stevenson KB. Bacterial contamination of stethoscopes with antimicrobial diaphragm covers. Am J Infect Control. 2007;35(4):263-266.
    Crossref

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