American Journal of Infection Control 47 (2019) 994−1001

Contents lists available at ScienceDirect

American Journal of Infection Control

journal homepage: www.ajicjournal.org

State of the Science Review

Bacterial contamination of medical providers’ white coats and surgical

scrubs: A systematic review
Shreya Goyal BBA a,*, Sharwin C. Khot BS a, Vignesh Ramachandran BS a, Kevin P. Shah BBA a,
Daniel M. Musher MD b,c,d
a
Office of Undergraduate Medical Education, Baylor College of Medicine, Houston, TX
b
Department of Medicine, Baylor College of Medicine, Houston, TX
c
Medical Care Line (Infectious Disease Section), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
d
Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX

Key Words: Background: Horizontal transmission of bacteria, especially multidrug-resistant organisms (MDROs), remains
Infection an important concern in hospitals worldwide. Some studies have implicated provider attire in the transmission
Bacteria of organisms within hospitals, whereas others have suggested that evidence supporting this notion is limited.
Provider attire Methods: PubMed was searched for publications between 1990 and 2018 to identify studies of bacterial con-
Multi-drug resistant organisms
tamination of, or dissemination of, bacteria from physician, nursing, or trainee attire, with a specific focus on
Contaminants
white coats and surgical scrubs. A total of 214 articles were identified. Of these, 169 were excluded after
Antibiotic resistance
abstract review and 33 were excluded after in-depth full manuscript review.
Results: Twenty-two articles were included: 16 (73%) cross-sectional studies, 4 (18%) randomized controlled
trials, and 2 (9%) cohort studies. Results are organized by microbial contaminants, antibiotic resistance, types
of providers, fabric type, antimicrobial coating, and laundering practices. Provider attire was commonly colo-
nized by MDROs, with white coats laundered less frequently than scrubs. Studies revealed considerable dif-
ferences among fabrics used and laundering practices.
Conclusions: Findings suggest that provider attire is a potential source of pathogenic bacterial transmission
in health care settings. However, data confirming a direct link between provider attire and health care−asso-
ciated infections remain limited. Suggestions outlined in this article may serve as a guideline to reduce the
spread of bacterial pathogens, including MDROs, that have the potential to precipitate hospital-acquired
infections.
© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All
rights reserved.

Horizontal transmission of bacteria, especially multidrug-resistant white coats and long-sleeved clothing to decrease nosocomial infec-
organisms (MDROs), remains an important concern in hospitals tions.10 The United States, however, has yet to implement a broad-
worldwide.1,2 Bacteria can be harbored on provider attire, including based policy regarding physicians’ clothing.
white coats and surgical scrubs.3 Whether such apparel is responsible In the 1950s and 1960s, wearing of surgical scrubs was largely
for the spread of infection remains controversial. confined to hospitals; in fact, many hospitals forbade their wearing
Some studies have implicated provider attire in the transmission outside the surgical suite. As a logical consequence, all laundering
of organisms within hospitals,2,4,5 whereas others have suggested was done in hospital laundries. The same could be said for white
that evidence supporting this notion is limited.6-8 It is not surprising, coats (and white pants and skirts), which were provided to hospital
then, that there is no standard guideline concerning management of personnel daily and freshly laundered. In the 1970s, these standards
provider attire, with varying practices among countries, regions, facil- rapidly eroded. Scrubs were worn around the hospital and even out-
ities, and departments.4,9 Regions, such as the United Kingdom (UK), side the hospital, and ordinary street clothing was increasingly worn
have implemented guidelines that prohibit physicians from wearing by personnel. With increased wearing of white coats and scrubs out-
side the hospital, home-laundering has become routine but may be
less successful in eradicating microbial contamination.
* Address correspondence to Shreya Goyal, 1 Baylor Plaza, Houston, TX 77030. The white coat, symbolic of the practice of medicine, has long been
E-mail address: sgoyal@bcm.edu (S. Goyal). embedded within medical culture and tradition.11,12 Most, but not all,
Conflict of Interest: None to report.

https://doi.org/10.1016/j.ajic.2019.01.012
0196-6553/© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
 S. Goyal et al. / American Journal of Infection Control 47 (2019) 994−1001 995

studies have found that patients associate white coats with higher lev- Quality assessment
els of confidence and overall quality of care.4,13-20 Dancer and Duerden8
suggested that the UK’s recently implemented ‘bare below the elbows’ Two investigators (S.G. and S.K.) independently reviewed all titles
(BBE) policy and near-disappearance of the white coat has marred the and abstracts for inclusion. Full texts of eligible studies were evalu-
physician-patient relationship, with less respect toward providers. ated for compliance with inclusion criteria. The information extracted
However, other findings suggest that patient comfort, satisfaction, included study design, statistical analysis, and, when available, types
trust, and confidence in physicians is unlikely to be affected by practi- of contaminating bacteria, antibiotic resistance of isolates, fabric type,
tioner’s attire.4,21 Patients appear to regard scrubs as being the most site of contamination, type of laundering facility, frequency of laun-
hygienic and to value white coats (or formal attire) for professionalism, dering, water temperature, types of HCW, and overall perception of
with BBE attire a lower preference. However, once informed of the provider attire cleanliness. Few publications contained all of this
potential risks associated with attire, patients were willing to change information.
their preferences, valuing hygiene over formal attire.7,22-24 Bond et al23
have suggested that an alternative policy supporting scrubs in inpatient RESULTS
settings and formal attire in outpatient settings be explored.
The literature on provider attire preference is not nearly as strong. Literature search
An overwhelming majority of health care workers (HCWs) believe
attire is an important factor in patient care.25 Most providers view Our search terms identified 604 citations. After we excluded articles
the white coat as a favorable part of their attire, but Garvin et al25 that did not align with the scope of our article and duplicates, 214
found that physicians were more likely than patients to be concerned articles were left for review. A total of 169 were initially excluded based
about their unhygienic nature.26 Moreover, attire preferences among on title and abstract review criteria, leaving 45 full-text articles to be
providers largely depend on the specialty and setting in which they reviewed. This in-depth screening led to exclusion of 33 additional
practice.4,23 articles, leaving 22 to be included in this systematic review (Fig 1).27
The purpose of this systematic review is to review and consolidate These articles are listed in Table 1.
findings of studies regarding bacterial contamination of white coats
and surgical scrubs worn by health care providers−including physi- Microbial contaminants
cians, nurses, and trainees−and their potential role in disseminating
infectious agents in the hospital setting. Eleven studies presented data on microbial contamination of
white coats (Table 2). The most common method of detecting these
contaminants was taking swabs of various areas of white coats and
METHODS
scrubs, including collars, pockets, sleeves, and sides. These swabs
were then plated and cultured in the microbiology departments of
Search strategy
each institution to determine individual isolates. Data on organisms
that are regarded as nonpathogens, such as Bacillus spp, were gener-
PubMed was searched from 1990 through 2018 to identify studies
ally not included. Staphylococcus aureus was the most commonly
of bacterial contamination or dissemination of bacteria from physician,
studied organism. Others included coagulase-negative staphylococci,
nurse, or trainee attire, with a specific focus on white coats and surgical
gram-negative bacilli, and Clostridium difficile.2,28-30,34,41 Antibiotic-
scrubs. Search terms included: ‘white coat,’ ‘white coat AND infection,’
resistant organisms included methicillin-resistant S aureus (MRSA)
‘white coat infection risk,’ ‘white coat contamination,’ ‘white coat clean,’
and vancomycin-resistant Enterococcus (VRE).7,48 Our search failed to
‘white coat launder,’ ‘physician white coat,’ ‘physician AND infection
reveal articles addressing antibiotic-resistant gram-negative rods.
transmission,’ ‘doctor AND infection transmission,’ ‘nosocomial infec-
Treakle et al30 studied white coats from grand round attendees,
tion AND white coats,’ ‘physician attire AND infection,’ ‘trainee,’ ‘medi-
including attending physicians and surgeons, and trainees. Twenty-
cal students,’ ‘nurses,’ ‘nursing students,’ ‘nurse white coat,’ ‘nurse AND
three percent of white coats were contaminated with S aureus; 18% of
infection transmission,’ ‘nurse AND infection transmission,’ nursing
these isolates were methicillin-resistant. S aureus contamination was
attire AND infection,’ ‘bacterial contamination of white coats,’ ‘surgical
more common in residents working in inpatient settings. Surgeons’
scrubs,’ ‘scrubs,’ ‘scrubs AND infection,’ ‘surgical scrubs AND infection,’
white coats were more likely to contain S aureus than those of physi-
and ‘bacterial contamination of surgical scrubs.’ Articles referenced in
cians in medical specialties. The highest rate of MRSA colonization
works retrieved in this fashion were also reviewed.
was found on white coats of attending physicians.
Several studies presented data on microbial contamination of
Data extraction and selection criteria surgical scrubs (Table 3). In comparing precall and postcall scrubs,
Krueger et al35 found significant increases in contamination rates at
A systematic review of all relevant clinical studies was conducted. most sites. A total of 268 of 300 (89%) worn resident scrubs were col-
Studies were classified into categories based on scope of study onized with bacteria compared to 123 of 300 (41%) of unworn
(contamination analysis, laundering analysis, spread of bacteria, scrubs. These differences were statistically significant for S aureus,
and provider/patient perspective on attire of health care providers). coagulase-negative staphylococci and micrococci. All S aureus were
We excluded case reports, manuscripts not available in English, methicillin-susceptible S aureus (MSSA); no MDROs were identified.
systematic reviews, and editorials on initial review of titles and Similarly, Scott et al43 reported that 15 of 85 (17.6%) worn scrubs
abstracts. had MSSA-positive swabs, with no isolated MRSA. Thom et al47
On full-text review of eligible manuscripts, common reasons for found that 217 of 720 (30.1%) scrubs were colonized with potentially
exclusion of articles that passed initial screening included: (1) insuffi- pathogenic bacteria.
cient data collection or reporting, (2) studies of HCW uniforms other A few studies presented data on both white coats and scrubs.
than white coats or scrubs, or (3) focus on handwashing, equipment, Munoz-Price et al33 recovered 26 S aureus isolates from 119 scrubs
blood products, surgical site infections, or disposable gowns and and white coats, including 4 of 21 (19%) MRSA isolates specifically
equipment used in operating rooms. Articles with insufficient data from scrubs. Acinetobacter spp was isolated from 11 of 97 (11%)
collection or reporting generally did not report an objective (quanti- scrubs; all isolates were meropenem-susceptible. Wiener-Well et al32
tative) measure of colonization of organisms on the attire studied. found resistant pathogens in 3 of 32 (9%) cultures from scrubs versus
996 S. Goyal et al. / American Journal of Infection Control 47 (2019) 994−1001

Fig 1. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) diagram of study search strategy.

3 of 52 (6%) cultures from white coats. Similarly, Anderson et al46 caring for patients with wounds had more attire contamination than
found that 4 of 120 (3%) scrubs (including untreated scrubs and nurses caring for patients without wounds.
scrubs with antimicrobial coating) were contaminated with MRSA
and 1 of 120 (1%) scrubs became contaminated with VRE. Fabric type

Antibiotic resistance The most common fabrics used to make white coats are cotton,
polyester, or cotton/polyester blend.44,45 Data comparing contamina-
Banu et al2 and Uneke and Ijeoma31 determined antibiotic resis- tion rates of these fabrics are inconclusive. Gupta et al45 found that
tance of isolates found on white coats. Gram-positive cocci were bacterial counts on blend fabric were 60% and 36% higher than poly-
highly resistant to penicillin, erythromycin, and clindamycin. Multi- ester after a first and second shift, respectively (P < 0.05). However,
ple drug-resistant organisms, including MRSA and VRE, were Takashima et al50 reported that polyester, acrylic, and wool are all
reported in several studies, but microbial susceptibility data was not strong carriers of S aureus and P aeruginosa with high binding poten-
provided for gram-negative rods except for Uneke and Ijeoma,31 tial. Cotton was found to have a much lower ratio of binding to these
who determined Pseudomonas aeruginosa to be resistant to cipro- microbes.
floxacin. Neely and Maley51 and Chacko et al52 concluded that survival of
contaminants on polyester, cotton, or blend fabrics is largely variable
Types of providers based on the specific microbe. Chacko et al52 determined that bacteria
can survive from 10-98 days depending on the fabric, with polyester
No studies compared attire contamination among HCWs, such as alone having the shortest survival time compared to cotton and blend
nurses, medical students, interns, residents, fellows, faculty, and fabrics. Specifically, S aureus can survive from 10-26 days, P aerugi-
other care staff. Duroy and Le Coutour,49 however, found that white nosa from 18-98 days, Escherichia coli from 7-48 days, and Enterococ-
coats were over-sized for 50% of medical students, with a positive cus faecalis from 8-10 days. Gupta et al45 found that E coli was the
association between loose fitting clothing and contamination. most frequent (47.8%) organism isolated from polyester white coats,
Thom et al47 determined that specific care activities were associ- followed by staphylococci (19.1%). Streptococci were the least
ated with higher rates of scrub contamination. For example, nurses frequent (2%).
 S. Goyal et al. / American Journal of Infection Control 47 (2019) 994−1001 997

Table 1
Studies included in systematic review

Author, year Number of participants/samples Study design Type of health care worker description & setting (attire)
28
Wong et al, 1991 100 HCWs Cross-sectional Physicians at an urban general hospital (white coats)
Loh et al, 200029 100 HCWs Cross-sectional Medical students at an urban multidisciplinary medical school covering 3
hospitals (white coats)
Treakle et al, 200930 149 HCWs Cross-sectional Attending, fellows, residents, students, and other at medical/surgical
grand rounds in a large teaching hospital (white coats)
Uneke and Ijeoma, 201031 103 HCWs Cross-sectional Physicians in an acute care hospital (white coats)
Burden et al, 201110 100 HCWs Prospective randomized Residents and hospitalists at a university-affiliated public hospital (white
controlled trial coats)
Wiener-Well et al, 201132 135 HCWs; 238 samples Cross-sectional Physicians and nurses in a university-affiliated hospital (white coats/
scrubs)
Banu et al, 20122 100 HCWs Cross-sectional Medical students and interns at a tertiary care hospital (white coats)
Munoz-Price et al, 201233 119 HCWs Cross-sectional Physicians, nurses, technicians, therapists, and other ancillary staff at a
university-affiliated teaching hospital (white coats/scrubs)
~ o et al, 201234
Catan 159 HCWs Cross-sectional Health workers in an urban academic tertiary-level teaching hospital
(white coats)
35
Krueger et al, 2012 30 HCWs; 300 samples Cross-sectional Residents in a large medical center (scrubs)
Nordstrom et al, 201236 90 HCWs Cross-sectional Operating room personnel in a single hospital (scrubs)
Bearman et al, 201237 30 HCWs; 2,000 samples Randomized controlled Critical care team in university medical center (scrubs)
trial (crossover)
Munoz-Price et al, 201338 160 HCWs Cross-sectional Physicians at departmental weekly conferences in a hospital (white coats/
scrubs)
39
Burden et al, 2013 105 HCWs Randomized controlled trial Internal medicine hospital staff at a university-affiliated hospital (scrubs)
Boutin et al, 201440 90 HCWs; 720 samples Cohort (longitudinal) Nurses and patient care technicians in a large medical center (scrubs)
Qaday et al, 201541 180 HCWs Cross-sectional Physicians and medical students at a referral and teaching hospital (white
coats)
Mwamungule et al, 201542 107 HCWs Cross-sectional All health workers wearing white coats in a university teaching hospital
(white coats)
43
Scott et al, 2015 89 HCWs Cross-sectional Student nurses in an urban hospital setting (scrubs)
Gupta et al, 201644 10 HCWs Cross-sectional Nurses at a tertiary care government hospital (white coats)
Gupta et al, 201745 10 HCWs Cross-sectional Nurses at a tertiary care hospital (white coats)
Anderson et al, 201746 40 HCWs; 2,185 samples Randomized controlled Nursing staff in medical/surgical ICUs in tertiary care hospital (scrubs)
trial (crossover)
Thom et al, 201847 90 HCWs; 720 samples Cohort (longitudinal) Nurses and patient care technicians in a large medical center (scrubs)
HCWs, health care workers; ICU, intensive care unit.

Antimicrobial coating 44% tested positive for coliform bacteria, compared to 0% of those
laundered in the hospital.
Some fabrics are impregnated with antimicrobial substances such Limited literature exists regarding the details of laundering practi-
as organosilane-based quaternary ammonium, fluoroacrylate copoly- ces.45 Bearman et al4 found the greatest degree of eradication of
mer emulsion, complex compounds with a silver alloy, and chitosan. gram-positive and gram-negative bacteria when washing at high
Three of 4 studies found no significant difference in isolates between temperatures was followed by tumble drying and ironing. Students
antimicrobial scrubs and control scrubs.37,39,40,46 For example, Burden reported using variable water temperatures when washing scrubs
et al39 found no significant difference in colony counts at the end of a and only 5.6% use bleach. Scott et al43 concluded that 35.7% of scrubs
work day when comparing standard scrubs with those impregnated remained MSSA positive after home laundering. Finally, Munoz-Price
with proprietary antimicrobial chemicals with or without silver et al33,38 found a higher percentage of white coats to be contaminated
embedded in the fabric. Similarly, Boutin et al40 found no difference in than scrubs (45.4% vs 28.8%). White coats were also laundered less
overall pathogenic bacteria, S aureus, Enterococcus spp, or gram-nega- frequently than scrubs (12.4 § 1.1 days vs 1.7 § 0.1 days).
tive rods in scrubs treated with chitosan. However, 4.4% of antimicro-
bial-treated scrubs had MRSA, VRE, or multidrug resistant gram- DISCUSSION
negative rods compared to 7.8% of nontreated scrubs (P = 0.06). Bear-
man et al37 discovered a significant 4-7 mean log reduction in MRSA The focus on reducing the spread of bacteria in US hospitals during
with antimicrobial scrubs (organosilane-based quaternary ammonium the past several decades has been centered on handwashing and ster-
and fluoroacrylate copolymer emulsion) versus control scrubs. This dif- ilization of medical equipment.53,54 Less attention has been directed
ference was not observable for VRE and gram-negative rods. toward the potential for spread of pathogens from HCW attire. Even
with an increasingly negative public perception of health care profes-
Laundering sionals wearing uniforms outside of the workplace, providers and
trainees continue to do so, posing a health risk of potentially spread-
Four studies revealed variability in average laundering frequency, ing bacteria, especially MDROs.6
with estimates ranging from 5%-65% of HCWs laundering their white Data suggests that white coats have a higher degree of contamina-
coat ≤1 time every 2 weeks.2,30,41,49 Surveys have shown students tion than scrubs; uncoincidentally, they are laundered less frequently
only launder white coats once every 3.5 weeks and even wear the and at home rather than in the hospital.33,38 A return to earlier practi-
same pair of scrubs over multiple days.43,49 ces, namely confining the wearing and laundering of scrubs to hospi-
Data show that providers launder white coats at home 64%-89% of tals, would clearly reduce bacterial contamination. Hospital laundering
the time.2,30 Nordstrom et al36 found higher bacterial contamination of white coats is less commonly done, but similar arguments favor this
on home-laundered scrubs and unwashed scrubs compared with hos- practice.45 The variation in microbial eradication by home laundering
pital-laundered and disposable scrubs. Of home-laundered scrubs, techniques can be linked to a lack of education and formal guidelines
 998
Table 2
Microbial contamination of white coats

Manuscript Banu et al, Qaday et al, Treakle et al, Wong et al, Uneke and Loh et al, ~ o et al,
Catan Gupta et al, Gupta et al, Munoz-Price et al, Wiener-Well et al,

S. Goyal et al. / American Journal of Infection Control 47 (2019) 994−1001

20122 201541 200930 199128 Ijeoma, 201031 200029 201234 2017 45; 1st Shift 2017 45; 2nd Shift 201233 201132

Total # of culturesa, positive culturesb, white 128b 180c 149c 100c 103c 100c 52b 1222.5d 2322.5d 22c 52a
coatsc, or colony forming units (CFUs)d
S aureus 91 (71%) 120 (67%) 34 (23%) 29 (29%) 18 (17%) 5 (5%) - - - 7 (32%) 10 (19%)
MRSA 4 (4%)* - 6 (4%) 0 - 0 - - - 0 -
MSSS - - - - - - 30 (58%) - - - -
MRSS - - - - - - 5 (10%) - - - -
Staphylococcus spp - - - - - 100 (100%) - 276 (23%) 444 (19%) - -
Enterobacteriaceae - 3 (2%) - - 18 (17%) - - 553 (45%) 1109.5 (48%) - 4 (8%)
Salmonella - - - - - - - 40.5 (3%) 51.5 (2%) - -
Klebsiella - - - - - - - 136.5 (11%) 173.5 (7%) - -
Acinetobacter spp - - - - - 7 (7%) - - - 7 (32%) 17 (33%)
Pseudomonas aeruginosa 19 (15%) 9 (5%) - - 9 (9%) - - 185 (15%) 428 (18%) - 1 (2%)
Enterococcus - - - - - - - - - 1 (5%) -
VRE - - 0 - - - - 12 (1%) 70.5 (3%) 0 -
Skin flora 18 (14%) - - - - - - - - 14 (64%) -
Diphtheroids - - - - 49 (48%) 12 (12%) - - - - -
Streptococcus spp - - - - - - - 19.5 (2%) 45.5 (2%) - -
Bacillus - - - - - - 13 (25%) - - - -
Gram-negative - - - - - 3 (3%) - - - - -
Gram-negative rods - - - - - - 4 (8%) - - - -
MDROs - - - - - - - - - - 3 (6%)
NOTE: All percentages are based on the total for each specific column. A hyphen indicates not reported.
CFU, colony forming units; MDRO, multidrug-resistant organism; MRSA, methicillin-resistant Staphylococcus aureus; MRSS, methicillin-resistant staphylococcal spp; MSSS, methicillin-sensitive staphylococcal spp; VRE, vancomycin-resis-
tant enterococci.
*Denotes number of white coats as n (% of total white coats).
 S. Goyal et al. / American Journal of Infection Control 47 (2019) 994−1001 999

Table 3
Microbial contamination of surgical scrubs

Manuscript Krueger et al, Krueger et al, Scott et al, Thom et al, Munoz-Price et al, Wiener-Well et al,
201235; Precall scrubs 201235; Postcall scrubs 201543 201847 201233 201132

Total number of culturesa or scrubsb 300a 300a 85a 720a 97b 32a
S aureus 0 33 (11%) 15 (18%) 116 (16%) 11 (11%) 4 (13%)
Coagulase-negative staphylococci 94 (31%) 271 (90%) - - - -
MRSA 0 0 0 - - -
Enterobacteriaceae - - - - - 1 (3%)
Enterobacter cloacae - - - 12 (2%) - -
Enterobacter aerogenes - - - 2 (0.3%) - -
Escherichia coli - - - 3 (0.4%) - -
Serratia marcescens - - - 7 (1%) - -
Proteus mirabilis - - - 3 (0.4%) - -
Klebsiella spp - - - 27 (4%) - -
Acinetobacter spp - - - 52 (7%) 11 (11%) 14 (43%)
Pseudomonas aeruginosa - - - 13 (2%) - 2 (6%)
Enterococcus - - - 21 (3%) 3 (3%) -
VRE - - - - 0 -
Skin flora - - - - 66 (68%) -
Micrococci - 51 (17%) - - - -
Viridans streptococci 8 (3%) - - - - -
Gram-positive rods 34 (11%) 28 (9%) - - - -
Gram-negative - - - 113 (16%) - -
MDROs 0 0 0 44 (6%) - 3 (9%)
NOTE: All percentages are based on the total for each specific column. A hyphen indicates not reported.
MDRO, multidrug-resistant organism; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant enterococci.

on how to properly clean HCW attire. Improved training could be pro- Strategies to reduce bacterial contamination of white coats
vided on best practices. Additionally, an ideal fabric that minimizes include sanitizing sleeves and pockets regularly in addition to altering
bacterial colonization has not been identified; in fact, studies to date the coat itself by shortening the overall length and sleeves.9 In 2007,
present conflicting results. More robust research, preferably controlled the UK Department of Health implemented BBE, a dress code requir-
trials, needs to be conducted to determine the binding potential and ing HCWs to wear attire with short sleeves or rolled up sleeves, and
length of survival of microbes on various fabrics. no white coats, jewelry, ties, watches, or rings when seeing patients
Our study shows that many investigators have documented bacte- at the bedside, to decrease nosocomial infections. This initiative was
rial colonization of hospital attire. It is important to note, however, associated with a decrease in HAIs over a 5-year period, from 8.2% in
that a direct relationship between bacterial contamination of HCW’s 2006 to 6.4% in 2011. The policy is also now reflected in UK legisla-
clothing and hospital-acquired infection has, to our knowledge, not tion.57 Presumably, BBE allows for maintenance of proper hand
been demonstrated.2,28-35,41-43,45,47 In fact, some experts argue that hygiene, which has proven to be cost-effective in the reduction of
there is little to implicate an association between the 2.6-8 Ham- nosocomial infections.58 Bearman et al4 reviewed hospital policies
braeus5 has demonstrated that bacteria can be transferred from nurs- regarding HCW attire of 7 US institutions, finding that each outlined
ing gowns to both patients and bed linens. However, there is no generic dress code requirements specifying professional attire, but
definitive evidence that has linked bacterial colonization of attire did not address specifics aside from operating room attire (scrubs,
with health care−associated infections (HAIs). One sole exception to masks, head covers, and footwear). Only 1 institution provided rec-
this is a case series conducted by Barrie et al,55 in which 2 patients ommendations for physicians, and that was the BBE policy. Wide-
were diagnosed with Bacillus cereus meningitis status postneurosur- spread adoption of similar provider attire policies may be beneficial
gery. An investigation concluded that lint from bed linens contami- for countries such as the United States
nated with B cereus spores likely served as the transmission source, The use of proprietary antimicrobial coating on scrubs has
eventually resulting in wound infection.56 increased in the last decade to combat colonization of bacteria on

Table 4
Suggestions for ways to reduce bacterial colonization of health care worker attire

 Actively increase frequency of laundering white coats−at least weekly and when visibly soiled.4,28 Appropriate guidelines should be established for providers within each
specialty based on type and frequency of patient-physician encounters.
 Scrubs should be changed each workday. Providers are encouraged to wear clean scrubs when exiting and returning to a hospital setting, even within a single shift.59
 If laundering a white coat or surgical scrubs at home, use a hot-water wash cycle and bleach to eliminate a greater percentage of bacterial contamination. Washing should be
followed by heated drying.4
 HCWs should own multiple sets of clothing to assure appropriate laundering.2,4
 Wash or gel hands appropriately.
 Consider formal adoption of United Kingdom guidelines (no neck ties, bare below the elbows).57
Suggestions for hospitals and health care systems to reduce bacterial colonization of health care worker attire
 Determine whether provider attire should be laundered at home or within the institution—if within the hospital, complimentary or reduced-cost laundering services should
be offered. Employees should be provided with recommendations for laundering attire outside of the hospital.4,29
 Recommend that each department provide multiple white coats and surgical scrubs for HCWs to encourage safe laundering practices.4
 Implement guidelines regarding laundering of provider attire outside the hospital.57
 Lead an orientation teaching best practices of provider attire maintenance.49
 Provide white coat hooks in residents’ offices, conference rooms, and throughout hallways within clinical settings.4

HCWs, health care workers.

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