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The Role of Clothing in the

Transmission of Infection

Michael Edmond, MD, MPH, MPAChief Quality Officer

Clinical Professor of Infectious Diseases

Goals• To examine the literature on

clothing contamination in

clinical care

• To review the experimental

evidence on transmission of

pathogens from clothing

• To examine interventions

designed to reduce

transmission of infection by

clothing

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The patient-provider encounter

• Common points of physical contact

– Hands/wrists

– Sleeves

– Stethoscope

– Wristwatch

Contact precautions• Patients with epidemiologically important organisms:

– Placed in a private room or cohorted with another patient

infected or colonized with the same organism

– All persons don gowns & gloves on entry to the room

• Based on:

• Evidence that clothing can become

contaminated

• Assumption that pathogens on

contaminated clothing can be

transmitted to patients

Bare below the elbows:

How it began

• In January 2008, the UK’s NHS mandated measures to

decrease MRSA & C. difficile in the healthcare setting

– Public reporting by hospitals on:

• compliance with infection control & cleanliness standards

• all MRSA BSIs & C. difficile cases

– Greater use of single rooms, cohort nursing & better

management of isolated patients

– Extension of the hand hygiene campaign to the outpatient

setting

– Bare below the elbows

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Bare below the elbows

• Short sleeves

• No wrist watch

• No jewelry except wedding band

• No neck ties

• No white coats

• Intent: allow good hand/wrist washing, & avoid

contamination of sleeve cuffs

Infection prevention strategies

Horizontal Vertical

Wenzel RP, Edmond MB. Int J Infect Dis 2010;14(S1):S3-S5.

Edmond MB, Wenzel RP. N Engl J Med 2013;368:2314-2315.

Strategic Approaches to Infection PreventionVertical Horizontal

GoalReduce infection or colonization due to specific

pathogen(s) [pathogen-based]

Reduce all infections

[population-based]

Application Selective or universal Generally universal

Interventions Unipotent Multipotent

Resource utilization/

opportunity costTypically high Lower

Philosophy Exceptionalism Utilitarianism

Values favored Hospital, infection prevention experts, advocates Patient

Temporal effectiveness Present Present & future

Examples MDRO active detection & isolation

Hand hygiene

Bare below the elbows

Chlorhexidine bathing

Universal decolonization

Care bundles

Environmental hygiene

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Postulated role of clothing in

the transmission of pathogens

Patients’ skin & environment are

contaminated with pathogens

Clothing becomes contaminated via contact with

patient or environment + infrequent laundering

Pathogens are transmitted from HCW

clothing to a subsequent patient

60% of physician-patient encounters involve the potential for contamination

of clothing

Kanwar A et al. Am J Infection Control 2019;47:577-9.

Contamination in the clinical setting:

Neckties Study Pathogen N % positive

Steinlechner C2002

S. aureus

Gram-negative bacilli26

8

23

Nurkin S2005

S. aureus

Gram-negative bacilli

Aspergillus spp

42

29

12

2

Ditchburn I 2006

S. aureus 40 20

Koh K2009

S. aureus

Gram-negative bacilli50

52

32

Lopez PJ2009

S. aureus 50 26

McGovern B2010

S. aureus

Gram-negative bacilli95

11

11

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Study Pathogen N % positive

Perry C

2001

MRSA

VRE57

14

38

Weiner-Well Y

2011

S. aureus

Acinetobacter75

41

10

Munoz-Price LS

2012

S. aureus

Acinetobacter

Enterococcus

97

11

11

3

Krueger CA

2012S. aureus 268 33

Bearman G

2012MRSA 31 52

Williams C

2015

S. aureus, Enterococcus,

pathogenic GNRs169 30

Scott E

2015S. aureus 85 18

Contamination in the clinical setting:

Scrubs & Uniforms

Contamination

in the clinical setting:

White coats

Pathogen % positive

Wong D, 1991; n=100 S. aureus 29

Loh W, 2000; n=100S. aureus

Acinetobacter

5

7

Osawa K, 2003; n=14 MRSA 79

Treakle AM, 2008; n=149 S. aureus 23

Uneke CJ, 2010; n=103S. aureus

Ps. aeruginosa

19

10

Weiner-Well Y, 2011; n=60S. aureus

Acinetobacter

18

31

Munoz-Price LS, 2012; n=22

S. aureus

Acinetobacter

Enterococcus

32

32

5

Romano-Bertrand S, 2014; n=35 S. aureus 23

Williams C, 2015; n=44S. aureus

Enterococcus

7

7

Qaday J, 2015; n=132S. aureus

Ps. aeruginosa

91

7

Mwamungule M, 2015; n=107S. aureus

Gram negative bacilli

18

6

Berktold M, 2018; n=100S. aureus

Gram negative bacilli

3

6

The white coat is

20 square feet of a

microbiological zoo.Shivam Joshi, MD

3

5

6

7

18

18

19

23

23

29

32

79

91

0 20 40 60 80 100

Bertold M, 2018; n=100

Loh W, 2000; n=100

Pandey A, 2010; n=130

Williams C, 2015; n=44

Weiner-Well Y, 2011; n=60

Mwamungule M, 2015; n=107

Uneke CJ, 2010; n=103

Romano-Bertrand S, 2014; n=35

Treakle AM, 2008; n=149

Wong D, 1991; n=100

Munoz-Price LS, 2012; n=22

Osawa K, 2003; n=14

Qaday J, 2015; n=132

S. aureus contamination of white coats

%

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Occupational bacterial contamination

20

29

2

44

17 17

2

29

25

0

7

0

7

0

7

Clothing Shoes Hands Any site

Any pathogen MRSA CR-GNR C diff

Kanwar A et al. Am J Infection Control 2019;47:577-9.

• Cultures of hands, clothing & shoes of 41 physicians & nurses at the end of their work day

• Organisms assessed: MRSA, C difficile, carbapenem(R) gram-negative bacilli

%

Survival of pathogens on fabricLength of survival (days)

Organism Cotton Polyester

S. aureus (methicillin S) 4, 5, 19 10, 12, 56

S. aureus (methicillin R) 4, 5, 21 1, 16, 40

E. faecalis (vancomycin S) 11, 33 >90, >90

E. faecalis (vancomycin R) 18, 22 73, 80

E. faecium (vancomycin S) 22, 90 43, >90

E. faecium (vancomycin R) 62, >90 >80, >80

C. albicans 1, 3 1, 1

C. parapsilosis 9, 27 27, >30

A. fumigatus 1, 10, >30 1, 7, 30

Neely AN, Orloff MM. J Clin Microbiol 2001; 39:3360-3361.

Neely AN, Maley MP. J Clin Microbiol 2000;38:724-726.

White coats & scrubs:

Frequency of laundering

Mean frequency (days)

Munoz-Price LS et al. Am J Infect Control 2013;41:565-7.

N=160

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1% 2%

39% 40%

17%

Daily Everyother day

Weekly Monthly Never

0%

45%

40%

15%

Daily Weekly Monthly Never

Frequency of white coat laundering

Pellerin J, Edmond MB et al. Infect Control Hosp Epidemiol

2014;35:740-2.

Attending MDs, housestaff and

medical students (n=183)

Travers J et al. J Hospital Infect 2018;epub ahead of print.

Medical students (n=40)

Transfer of pathogens from white coat to skin

Time

(min)

Number of organisms inoculated onto lab coat

106 105 104 103 102

MRSA

1 + + – – –

5 + + – – –

30 + + – – –

VRE

1 + + – – –

5 + + – – –

30 + + – – –

PRA

1 + + – – –

5 + + – – –

30 + + + – –

+ = organism transferred from coat to skinButler D, Edmond M. J Hosp Infect 2010;75:137-138.

Experimental bacterial transmission

• Clothing was inoculated with Micrococcus (distal tie or

corresponding area on shirt, cuffs of long and short sleeves)

• Standardized 2.5 minute exam was performed on a mannequin

• Mannequin cultured

Mannequins contaminated

With tie Without tie

Long sleeve 4/5 1/5

Short sleeve 2/5 0/5

Tie vs. no tie: p = 0.036

Long sleeve vs short sleeve: p > 0.05

Weber RL et al. J Hosp Infection 2012:80:252-254.

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Experimental viral transmission• 34 HCWs randomized to long- or short-sleeved white coat while

performing a standardized 2-minute exam on a mannequin that was

inoculated with cauliflower mosaic virus DNA fluorescent marker

• Exam was then performed on a second (uncontaminated) mannequin

after glove removal, hand hygiene for 30 seconds, and donning new

gloves

Contamination

Cuffs/wrists 2nd mannequin

Long sleeve 5/20* 1/5

Short sleeve 0/20* NA

*p = 0.001

John AR et al. Infect Control Hosp Epidemiol 2018;39:233-4.

Transmission via contaminated clothing

• 50 patients in LTC or hospital colonized with

MRSA but no open wounds or active infection

– Cultures of clothing at neck, chest waistline, sleeve

cuffs, over pockets

– Gloved hands applied to contaminated clothing to

assess transfer

– Patients w/ contaminated clothing sat in wheelchair

for 20 seconds, then wheelchair seat cultured

Kanwar A et al. Am J Infect Control 2018; 46:1414-6.

Transmission via contaminated clothing

• 74% of carriers had

MRSA cultured from

clothing

• Of those with

contaminated clothing:

– 62% transferred MRSA to

gloved hands

– 50% transferred MRSA to

wheelchair seat

50

90

Daily (n=20) Less than daily (n=30)Frequency of clothing change

% MRSA+

Kanwar A et al. Am J Infect Control 2018; 46:1414-6.

P=.002

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Summary of evidence:

Clothing & the cycle of transmission

Component Strength of evidence

Pathogens contaminate patients’skin

& the environmentConclusive

HCW clothing become contaminated with pathogens Conclusive

Clothing can transmit pathogens In vitro evidence

Removal of white coats/ties reduces infection rates No evidence to date

Biologic plausibility

When is biologic plausibility enough to

support a change in practice?

• Potential for benefit

• No risk for harm

• Minimal cost

But without strong evidence for benefit, we

should recommend, not mandate, the new

practiceBraithwaite RS. JAMA 2013;310:2149-50.

There is no evidence

to suggest that….

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Pellerin J, Edmond MB et al. Infect Control Hosp Epidemiol 2014;35:740-2.

Percentage of

respondents who

believe the white

coat can transmit

pathogens

White coat

as vector?Bare below the elbows

White coats:

• HCWs should possess >2 white coats and have access to a convenient and economical means for

laundry

• Hospitals should provide coat hooks that allow removal of white coats prior to contact with patients or

the patient’s immediate environment

Neckties: If worn, they should be secured to prevent them from coming into direct contact with the

patient or near-patient environment.

Laundering: Optimally, any apparel worn at the bedside that comes into contact with the patient or

patient environment should be laundered after daily use. White coats worn during patient care should be

laundered no less frequently than once a week and when visibly soiled. If laundered at home, a hot-water

wash cycle (ideally with bleach) followed by a cycle in the dryer is preferable.

SHEA expert guidance on HCW attireApproaches for facilities to consider

Bearman G. Infect Control Hosp Epidemiol 2014;35:107-121.

Some experts may argue that we should

focus on proven infection control practices,

such as hand hygiene. Yet it's hard to see

how voluntarily giving up your white coat

would distract from that.

The risks of doing nothing seem much

greater than of making the change.

Peter Pronovost, MDFormer Director, Armstrong

Institute for Patient Safety

and Quality, Johns Hopkins

Hospital

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Given what we know,

how do we move forward?

Conventional wisdom:

The paradox

• On the basis of the same evidence and assumptions:

– We are willing to wrap ourselves in plastic & restrict patients to their hospital rooms (contact precautions)

– We are not willing to eliminate white coats & ties

VCU Medical Center

Infection Control

Committee

recommended (but did

not mandate) a bare

below the elbow

approach in the

inpatient setting, 1/09

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Seasonal Variation in BBE Compliance

0

10

20

30

40

50

60

70

80

0%

10%

20%

30%

40%

50%

60%

70%

80%

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

2014 2015

Avera

ge T

em

pera

ture

(○

F)

BB

E C

om

plia

nce

BBE Compliance

Average Temperaturer = 0.89

Masroor N, Edmond M et al. Infect Control Hosp Epidemiol 2017;38:504-6..

BBE Compliance VCU Medical Center 2017

67

80

87

93

85

86

86

90

84

0 10 20 30 40 50 60 70 80 90 100

MD

Med Student

RN

RN Student

Physcial Therapist

Respiratory Therapist

Radiologic Tech

Nursing Asst

ALL

Goudbout EJ, Masroor N, Doll M, Edmond MB et al. Am J Infect Control 2019. Epub ahead of print.

33,277 patient encounters

%

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Personal Infection Prevention Bundle

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