Bacterial Contamination of Surgical Scrubs and Laundering Mechanisms: Infection Control Implications

Background

Surgical attire has evolved extensively from the days when surgeons would literally enter the operating theater in their street clothes and, at best, don an operating apron. In fact, it wasn’t until the turn of the 20th century that the importance of surgical barriers was routinely recognized.^1-2 While there is general consensus today as to what is considered acceptable surgical attire,³ there remains a significant lack of organizational consensus, even in today’s highly infection-control conscious environment, as to where and how surgical attire is laundered and stored.^4-7

The issue of surgical attire laundering and storage is not new. There have been several studies, albeit primarily small-scale studies, which have looked at the laundering issue and drawn conflicting conclusions over the years.^4-10 However, as healthcare economic pressures worsen, requiring facilities to repeatedly trim operating budgets, and as the risk of HAIs, particularly with resistant bacteria, rises, the issue becomes one worthy of renewed study.

Numerous healthcare governing bodies and advisory organizations, including the Association for Professionals in Infection Control and Epidemiology (APIC), the Association for the Advancement of Medical Instrumentation (AAMI), the Association of periOperative Registered Nurses (AORN), the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA), agree that all surgical attire should be changed whenever it becomes visibly soiled, contaminated, or wet, or at least daily.^3,12-15 Several studies have shown, however, that healthcare workers do not always change their uniforms daily; in fact, one study surveying 196 nurses found that 30 percent did not wear a fresh uniform daily.⁴ One would expect that this applies more commonly to healthcare workers’ uniforms that are not visibly soiled. However, this raises concerning questions in light of the 1991 Wong, Nye, and Hollis study which showed that bacterial contamination of physicians’ white coats that were perceived to be “dirty” did not differ significantly from those that were perceived to be “clean.”¹⁵

It is generally accepted that healthcare workers’ uniforms become contaminated with bacteria during the administration of care, particularly during surgical procedures and wound care.^{6, 8, 16-21} Studies have repeatedly isolated bacteria from the uniforms of healthcare workers, including bacteria that were multi-drug resistant.^{4-6, 8, 15, 18-20} In fact, in Boyce’s 1997 study of the role of contaminated environmental surfaces as reservoirs of methicillin-resistant Staphylococcus aureus (MRSA), 65 percent of nurses caring for a patient with MRSA in a wound or urine were found to have contaminated their uniforms with MRSA.¹⁸ Osawa et al. documented the presence of MRSA on 80 percent of physicians’ white coats during two MRSA outbreaks at a teaching hospital.¹⁹ Other studies, such as Copp, Mailhot, et al.’s 1986 study, have shown that where scrubs are worn throughout the work day and whether or not they are removed and put on again significantly impacts the bacterial contamination of the attire.¹⁶ What is concerning, however, is the data that suggests uniforms “enter” healthcare facilities already contaminated. Callaghan, in her 1998 study, looked at the bacterial colony counts on surgical uniforms at varying time points during a shift and found no statistically significant difference in the degree of bacterial contamination of uniforms sampled at several sites and at several times throughout the day, including the start of shift.⁴ Alarmingly, another study found that 39 percent of healthcare workers’ uniforms tested were positive for VRE, MRSA, and C. difficile at the start of shift.⁸ Assuming surgical attire is changed daily, and laundered attire is worn to work each day, these findings would certainly suggest that the laundering mechanism is potentially failing to achieve uniform decontamination.