“What you wear is how you present yourself to the world, especially today, when human contacts are so quick.” Miuccia Prada.
We have a choice each day to look powerful, confident, elegant and chic through our clothing. The look we don’t want to present is “germy”; our clothing covered in bacteria. Especially true if we happen to be healthcare workers, or their patients. And even if our contact with patients is quick, it can be a problem.
A new finding from Dr. Deverick Anderson’s research team out of Duke University, showed that nurse’s scrubs are likely covered in pathogens! But wait, nurses care for sick people, that’s why they are in the hospital, but hospitals have hospital acquired infections. Nurses clothing may be covered in pathogens, and nurses go from room to room and interact with different patients and their environment. But what if the patient’s environment hasn’t been cleaned and disinfected properly from the last patient? This is the constant battle that goes on daily in hospitals and requires a holistic approach in terms of infection prevention and control. The most common way that pathogens are transmitted is through contact transmission. Therefore, proper hand hygiene is the best intervention to halt infection. Each pathway is important during an outbreak, as these are the routes that need to be disrupted. The methodology and practicality are a delicate balance to attain.
New research from Duke University, was presented at ID Week, a joint meeting of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society in New Orleans. The authors looked at Antiseptic Scrub Contamination and Transmission (ASCOT) in a randomized trial to see if antiseptic scrubs improved healthcare worker contamination. Healthcare workers’ clothes and uniforms routinely become contaminated through patient care. Some contaminants are obvious like blood, which prompts a worker to change as soon as they can. But what about all the contaminants that we can’t see? The authors were curious as well and sought to see if nurse’s scrubs that were made with antimicrobial fabrics would solve this problem. The authors noted that transmission of pathogens from patients and their environment is an important factor in putting in place infection control measures, but is not well studied or measured. This transmission from patient to nurse is not one that is usually well thought through when designing sophisticated infection control protocols. It is a vital piece of the triangle below and should be included when monitoring hand hygiene in the healthcare setting. Dr. Anderson wanted to focus his study primarily on the concept of the transmission triangle of disease transmission between the patient, nurse, and environment.
This is the Transmission Triangle used for this study:
The triangle is often used in infectious disease study to show simply the host, the environment, and the agent or disease to show how transmission can occur between them, and in which direction it can flow. When there is an outbreak or an unusually high number of cases of disease, the objective is to “break” one side of the triangle; or “break” a chain of transmission to halt the spread of disease. This is when infection control becomes important as a preventative measure, and as a mitigator during an outbreak. Infection control measures are in place to break as many links in the chain as possible. The chain of infection is also used as a conceptual framework to think of all possible transmissions of pathogens that may infect patients. Think of a chain with 6 links in a circle. The 6 links are Infectious agent, Reservoir, Portal of exit, Mode of transmission, Portal of entry, and Susceptible host. Again, the idea is to break a link in the chain. The intervention that can break each link is proper hand hygiene. This one action can have dramatic results in stopping transmission of pathogens if done properly and consistently.
The ASCOT trial was done to measure contamination transmission when nurses wore antimicrobial scrubs versus control scrubs. The study looked at whether the healthcare provider’s uniform or clothing can serve as a transmitter of pathogens, and whether uniforms that are made of antimicrobial material will be a sufficient barrier to spread of pathogens. The authors compared two types of antimicrobials, a silver-alloy and an organosilane quarternary ammonium compound that were applied to standard nurse’s scrubs versus a control group of regular scrubs. Forty nurses were randomly assigned to wear each type of scrub during 3 consecutive shifts in the ICU. Cultures were obtained from the nurse’s scrubs pre-and post-shift and the patient’s room such as bed rails, bed, etc. (which are high-touch areas for patients, healthcare workers, and visitors) and were cultured. These surfaces may or may not get the proper cleaning that they need daily. Again, hand hygiene is vital for the healthcare worker to prevent spread to other patients. A total of more than 2,000 cultures were obtained from scrubs, over 400 from the patients, and almost 3,000 from the patient’s room. A transmission was said to have occurred if the same pathogen was found on the scrubs, the patient, or the room. Confirmed transmission was done using pulsed field gel electrophoresis (PFGE). The results broke down like this:
10 patient to environment
6 patient to nurse
6 environment to nurse
What’s notable is that there were no transmissions from nurse to patient, but we know in real life this does occur. When looking at the nurse’s scrubs the area of contamination was at the midriff; the same level as the bedrail of a patient. The authors did demonstrate confirmed transmissions but also believed that transmission from nurses to patient and their environment is entirely possible, just not seen here. In terms of how effective the antimicrobial scrubs, they found that the antimicrobial scrubs were no better than the control scrubs. They did show that pathogens are passed continuously from nurses, patients, and environment. High touch surfaces like bed rails do transfer pathogens to nurse’s clothing. Keeping the chain of infection in mind, the best intervention that must be stressed and put in place is proper hand hygiene for the healthcare workers, visitors, and patients.
- The Antiseptic Scrub Contamination and Transmission (ASCOT) Trial: a 3-Arm Cluster-Randomized Controlled Crossover Trial to Determine the Impact of Antiseptic-Impregnated Scrubs on Healthcare Worker Contamination https://idsa.confex.com
- Break the Chain of Infection www.apic.org/professionals
- Keeping patients safe from infection is everyone’s responsibility. Remember these 10 ways to protect patients http://professionals.site.apic.org
- Molecular Analysis of Transmission Events in the Antimicrobial Scrub and Transmission (ASCOT) Trial https://idsa.confex.com
- Nurses’ Scrubs Carry Bad Bacteria http://www.medpagetoday.com/meetingcoverage/idweek
- Scrubs and Superbug Transmission in ICUs: What We Still Don’t Know Can Kill You http://forbes.com
If you like medicine and infections, this is one of the funniest videos on YouTube:
About the Author
Lisa A. Mack MS, MPH is an Epidemiologist and Communicable Disease Investigator. In addition, she is a certified HIV counselor and tester in a county sexually transmitted disease (STD) clinic. She received a Master of Science degree (Epidemiology) from the University of Massachusetts-Amherst, School of Public Health and a Master of Public Health degree (Epidemiology) from Columbia University, Mailman School of Public Health.
Her current research interest is investigating the antibacterial properties of essential oils to be used in treating multidrug resistant bacteria (MRSA, MSSA, Pseudomonas aeruginosa, etc.) in the healthcare setting. She loves germs, diseases, public health, educating & empowering people about their health and well-being. Public Health Rocks!