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

Given the importance of creating a surgical environment which is as clean as possible, and the emphasis by payors to decrease cross-contamination and HAIs in healthcare facilities at large, the subject of where and how surgical attire is laundered becomes an extremely important issue. A survey of healthcare staff in the UK’s NHS trust revealed that 90 percent of that staff took responsibility for the laundering of their uniforms. They reported that home-laundering of healthcare workers’ uniforms deserves close scrutiny.⁵ Some studies have shown no significant evidence suggesting that home-laundering in general is inferior to facility or commercial laundering, particularly if combined with tumble drying and/or ironing.^{6-7, 22} The CDC, in its Guidelines for Environmental Infection Control, does not currently prohibit home-laundering; however, it concedes that there is a paucity of data studying the issue.²³

There have been several studies which have raised troubling questions about the safety and efficacy of the home-laundering of surgical attire.^{4, 8-10} The issue is complicated by the introduction of potentially contaminated garments into the home environment. A recent French study demonstrated transmission of MRSA from healthcare workers who had acquired it in their hospital to members of their households.²⁴ The fact that MRSA has been documented on healthcare workers’ uniforms previously¹⁸ combined with evidence of MRSA cross-contamination in the home environment, certainly suggests that exposing households to contaminated uniforms poses significant threats. Furthermore, how effective is home-laundering? Gerba and Kennedy looked at the virucidal capacity of a typical home-laundering process (wash cycle with detergent alone, rinse cycle and a 28-minute permanent press drying cycle) and found that significant concentrations of the tested viruses (adenovirus, rotavirus, and hepatitis A virus) survived the process.⁹ They further demonstrated that these viruses could be transferred from the contaminated garments to uncontaminated garments.⁹ Perry, Marshall and Jones documented the presence of Vancomycin-resistant enterococcus (VRE), methicillin resistant Staphylococcus aureus (MRSA), and Clostridium difficile on home-laundered uniforms prior to the commencement of duty, suggesting the inadequacy of the home-laundering process in eradicating these organisms.⁸ Treakle et al., in a study looking at the prevalence of Staphylococcus aureus (S. aureus) on physicians’ white coats, demonstrated that those coats colonized with S. aureus were more likely to have been laundered in a “personal facility.”²⁵

Guidelines have been set for home-laundering of soiled surgical attire, particularly that contaminated with body fluids, by several authoritative associations and organizations such as AAMI, AORN, CDC, and OSHA.^3,12-13,23 There remains, for obvious reasons, an inability to ensure that these guidelines are followed. Furthermore, while some data suggests that insufficient temperature control in home-laundering cannot guarantee uniform decontamination,¹⁰ other investigators suggest that, even when guidelines are followed, newer energy-saving domestic washing machines may actually provide lower wash temperatures than indicated.⁸ These same machines may also offer less vigorous washing cycles.⁸

In light of the potential risks associated with home-laundering and the paucity of evidence surrounding it, this study was undertaken to provide additional insight into the subject. The aim was to compare the aerobic bacterial bioburden associated with surgical scrub attire separated into different categories based on their single-use/reusable status, use (worn versus clean) status, and, for the reusable scrubs, laundering mechanism (facility-laundered, third-party/commercial-laundered, and home-laundered).