Int.J.Curr.Microbiol.App.

Sci (2016) 5(7): 353-363

International Journal of Current Microbiology and Applied Sciences

ISSN: 2319-7706 Volume 5 Number 7 (2016) pp. 353-363
Journal homepage: http://www.ijcmas.com

Original Research Article http://dx.doi.org/10.20546/ijcmas.2016.507.038

Microbial Flora on Medical Students’ White Coat and an Analysis of its

Associated Factors: A Cross Sectional Study

Trupti B. Naik1*, Amruthkishan Upadhya2, Vijaykumar Mane3 and Asmabegaum Biradar4

1,2
Department of Microbiology, Subbaiah Institute of Medical Sciences,
Shivamogga, Karnataka, India
3
Department of Community Medicine, Koppal Institute of Medical Sciences,
Koppal, Karnataka, India
4
Department of Microbiology, Al-Ameen Medical College, Bijapur, Karnataka, India
*Corresponding author

ABSTRACT

Healthcare-associated infections (HAIs), also known as nosocomial infections,

constitute a significant hazard for patients and their families visiting a healthcare
Keywords facility. Transmission of these infections has been associated with transient
Bacterial harboring of pathogens in health care workers and students clothing including
contamination, white coats. 1) To study the bacteriological profile of medical students white coats.
Hospital acquired 2) To study the antibiotic susceptibility pattern of these microbial isolates. 3) To
infection, study the perception, usage and handling practices of white coats among medical
Medical students, students and their relationship with white-coat contamination. A cross sectional
White coats. study was conducted among 2nd year medical students, in the Department of
Microbiology at a tertiary care hospital in Shivamogga, Karnataka. A pretested and
Article Info semi structured questionnaire was administered to collect relevant data and swabs
were taken from the lower edge of the front of white coat and processed according
Accepted: to standard microbiological procedures. Out of 96 white coats, 61 (63.54%) were
12 June 2016
Available Online: contaminated. Maximum isolates were Coagulase negative Staphylococci 32
10 July 2016 (52.45%) followed by Micrococci 15 (24.59%). None of the handling/washing
practices of white coats were found to be significantly associated with
contamination in our study. Further research in this area is recommended to
identify factors responsible for contamination of white coats.

Introduction
Healthcare-associated infections (HAIs), present or was incubating at the time of
also known as nosocomial infections, admission. This includes infections acquired
constitute a significant hazard for patients in the hospital but appearing after discharge,
and their families visiting a healthcare and also occupational infections among staff
facility. The World Health Organization of the facility (Uneke et al., 2010).
(WHO) defines HAI as an infection
occurring in a patient in a Health care HAIs are a major public health problem in
facility in whom the infection was not both developed and developing countries.

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They cause a severe impact especially in the continued dissemination of bacteria. To

poor resource settings, where the rate of make matter worse, HAI have made lethal
infection is estimated to range from 25 to 40 combination with antibiotic resistance
%. Studies have shown that HAIs exert a (Treakle, et al., 2000). Potentially
tremendous toll on patients, their families pathogenic bacteria (including resistant
and health care systems, resulting in strains) have been isolated from different
increased morbidity and mortality, and sites of aprons of health care workers in
thereby increasing healthcare costs. An different studies and a study by Loh et al.
estimated 1.4 million people worldwide (2000) has found medical student’s aprons
suffer from infections acquired in hospitals being contaminated with bacteria, much
at any point of time (Uneke et al., 2010; more heavily than those of residents and
Mwamungule et al., 2015). attending physicians.

A white coat, apron or laboratory coat is a In 2005, WHO Patient Safety Initiative
knee-length overcoat or smock worn by launched the First Global Patient Safety
medical professionals or by those involved Challenge to galvanize international focus
in laboratory work to protect their street and action on the critical issue of HAIs. As
clothes. It is one of the personal protection per this initiative, any potential source of
equipments (PPE) to prevent contamination HAIs that could threaten the wellbeing of
of skin and clothing of a health care individuals within healthcare facilities
professional from direct contact with should be investigated and mitigated
infected saliva, blood, aerosols etc. which (Mwamungule et al., 2015).
are unavoidable in hospital environment
(Priya et al., 2009). Wearing white coats is With this background, the following study
an accepted practice in medical profession, was planned to find out the level and pattern
however when, where and how to wear and of microbial contamination present on the
wash them vary among individuals, their aprons of medical students along with their
specialties and even between different antibiotic susceptibility. Students’ way of
institutions. handling the coat and cleaning as well as
their perception towards white coat’s
Recently there has been a concern that contamination was also investigated.
aprons may play a big role in transmitting
infections within and outside hospital The main objectives of this study were to
settings. Patients-to-patients transmission of study the bacteriological profile of medical
infections within health care facilities has students white coats along with their
been associated with transient harboring of antibiotic susceptibility pattern and also to
pathogens in health care workers and study the perception, usage and handling
students clothing including white coats. It is practices of white coats among medical
very common to see health care workers and students and their association with white-
students wearing white coats outside clinical coat contamination.
areas such as canteen, supermarkets, library
etc. It is also very common to see people Materials and Methods
hanging them in their cars and offices or
carrying them frequently outside hospital Study site and design-
premises (Qaday et al., 2015; Saxena et al.,
2013; Banu et al., 2012). These A cross sectional study was conducted in the
contaminated coats may act as fomites for Department of Microbiology at a tertiary
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care hospital in Shivamogga, Karnataka (30µg), Gentamicin (10µg), Linezolid

after obtaining approval from the 310µg), Vancomycin (30µg), Teicoplanin
institutional ethical committee. (30µg), Tetracycline (30µg).

Study Population For Gram negative bacilli

96 medical students of 2nd year were Ampicillin (10µg), Amoxyclavulanic acid

included in the study. Those students who (30 µg), Cotrimoxazole (25 µg),
were absent on the day of data collection Tetracycline (30 µg), Chloramphenicol (30
were excluded from the study. The purpose µg), Gentamicin (10 µg), Amikacin (30 µg),
of the study was explained in detail to them Ciprofloxacin (5 µg), Cefoxitin (30 µg),
and an informed consent was taken. A Cefepime(30 µg), Ceftriaxone(30µg),
pretested and semi structured questionnaire Cephotaxime(30 µg), Ceftazidime(30 µg),
was used to collect socio demographic data Cefazoline (30 µg), Cefuroxime (30 µg),
and information relevant to perception, Aztreonam (30µg), Piperacillin (100 µg),
usage and handling of white coats among Meropenem (10 µg).
them.
Statistical Analysis
Sampling of coats
Statistical analysis was done using WHO
Lower edge of front of the white coat was Epi info 3.5.4 version software. Chi square
the site chosen to take samples. Sterile saline and p- value were calculated.
dipped cotton swabs were used to collect
samples and were collected by gently Results and Discussion
passing them up and down twice over the
site. Out of the 96 medical students who
participated in the study, 42 (43.75%) were
Culture and Drug Susceptibility testing males and 54 (56.25%) were females. Out of
96 white coats screened, majority i.e. 61
After collection, the swabs were replaced (63.54%) were found to be contaminated.
into the sterile test tubes and were
immediately streaked onto blood agar and The various microbial agents isolated from
MacConkey agar and the plates were white coat are shown in Figure no 1.
o
incubated overnight at 37 C. The colonies Maximum isolates were Coagulase negative
obtained were identified by using standard Staphylococci 32 (52.45%) followed by
techniques (Collee et al., 1996). Antibiotic Micrococci 15 (24.59%), Gram positive
sensitivity testing was done by using Kirby bacilli 9 (14.75%), Acinetobacter species 4
Bauer’s disc diffusion method as per CLSI (6.55%) and Staphylococcus aureus 1
guidelines 2015. The following antibiotics (1.63%). No case of mixed contamination
were used: was observed.

For Gram positive cocci All the Acinetobacter species were sensitive
to all the antibiotics. All 33 of the Gram
Penicillin (10units), Erythromycin (15µg), positive cocci were sensitive to
Clindamycin (2µg), Ciprofloxacin (5µg), Vancomycin, linezolid and
Cotrimoxazole (25µg), Chloramphenicol chloramphenicol, whereas 20 (60.6%) were

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resistant to penicillin, 13 (39.39%) to those who had spillage on their aprons and
erythromycin and clindamycin each, 10 those who did not had. There was slightly
(31.25%) to cotrimoxazole and 3 (9.09%) to higher contamination rate among those who
Cefoxitin as depicted in table no.1. usually ate wearing their white coats than
those who do not. There was no significant
Perception of medical students with regard difference (p > 0.05) in the contamination
to white coat contamination is depicted in levels between those who wear white coats
table no. 2 which shows that 55 (57.29%) for more than 8 hours (63.15 %) compared
considered their white coat to be to those who wear for < 8 hours in a day
contaminated. 85 (88.54%) of students (64.1%). There was slightly higher
believed that their white coats carry germs contamination rate among the white coats
and 80 (83.33%) believed that white coat that was worn for 6 days and more in a week
can be a potential transmitting agent for than those which were worn for less than 6
pathogens. days. None of the above mentioned factors
were significantly associated with
White coats from males were slightly more contamination of the white coat (p > 0.05).
contaminated (64.28%) than those of their
female counterparts (62.96%). However, Table no. 5 depicts medical student’s
this difference was not statistically practice of washing white coat and its
significant (p > 0.05). Majority i.e. 74 association with contamination rate.
(77.08%) of the students in our study were Majority i.e.79 (82.29%) of students had
residents of the hostel and the contamination two white coats and contamination rate was
rate was higher i.e. 66.21% in them than found to be higher among students having
those who resided at home as shown in table three white coats. The degree of
no. 3 but it was not statistically significant contamination was similar irrespective
(p > 0.05). whether the white coat was washed by self
or in the laundry. 44 (45.83%) of medical
Table no. 4 depicts the relationship between students washed white coat weekly once and
white-coat usage/handling practices and they had slightly higher contamination rate
bacterial contamination of their white coats. i.e. 65.9%. Maximum 65 (67.70%) students
65 (67.7%) students wore the white coat as washed their white coats within 2 days.
it was the dress code of the hospital whereas Higher (68.18%) contamination rate was
58 (60.41%) wore them to look professional. observed among white coats that were
68 (70.83%) said they wear white coat all washed from 3-6 days. None of the above
the time and they had 61.76% of mentioned factors were significantly
contamination rate. White coats of students associated with contamination of the white
who used them only during hospital duties coat (p > 0.05).
4(4.16) had lower bacterial contamination
rate when compared with those who used From time immemorial, the white coat
during hospital, college and outside campus brings credibility and dignity to the medical
8 (8.33). Only 7 (7.29%) students in our profession (Muhadi SA et al., 2007).
study practiced exchanging white coats However, recently white coats have been
among themselves and they had the shown to harbour pathogenic organisms and
maximum (85.71%) contamination rate. so these may have a role in the transmission
There was no significant difference (p > of pathogenic microorganisms (Wong D et
0.05) between contamination rate among al., 1991). Our study revealed contamination

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rate of 63.54% in white coats of medical these were significantly lesser in number.
students. Other studies have found white- This is comparable to the finding reported
coat contamination rate ranging from 23% to from other studies (Muhadi et al., 2007,
95% (Uneke et al., 2010; Mwamungule et Moravvej et al., 2013; Zachary et al. 2001;
al., 2015; Qaday et al., 2015; Treakle et al., Grabsch et al. 2006). This difference might
2000; Wong et al., 1991; Pilonetto et al., be due to differences in the geographical
2004; Srinivasan et al., 2007). locations of the study. All these
microorganisms are frequently found in the
Coagulase negative Staphylococci were the hospital environment and are mainly skin
most commonly isolated organism followed commensals, but they have also been
by Micrococci and Gram positive bacilli in implicated as causative agents of
our study. This is consistent with the nosocomial infections. (Nester et al., 2004;
spectrum of bacterial agents isolated in the Loh et al., 2000). Coagulase negative
studies done by Priya et al., (2009); Wong et staphylococci which are used to be
al., (1991), Pilonetto et al., (2004); considered as harmless commensals or
Srinivasan et al., (2007); Moravvej et al., contaminants, have emerged as major
(2013) and Pydi et al., (2015). However few pathogens as medical technology has
other studies have found Staphylococcus advanced which cause endocarditis, otitis
aureus as the predominant organism media and infections of joint prosthesis,
contaminating white coats (Qaday et al., vascular grafts, and cardiac pacemakers
2015; Saxena et al., 2013; Banu et al., 2012; (Pydi et al., 2015). Thus, students white coat
Treakle et al., 2000; Muhadi et al., 2007). can be a potential source of contamination.
Gram negative bacilli were isolated but

Table.1 Antibiotic susceptibility pattern of Gram positive cocci (n=33)

Antibiotics Sensitive Resistant

No. % No. %
Penicillin 13 39.39 20 60.60
Erythromycin 20 60.60 13 39.39
Clindamycin 20 60.60 13 39.39
Tetracycline 29 87.87 4 12.12
Cefoxitin 30 90.90 3 9.09
Chloramphenicol 33 100 0 0
Ciprofloxacin 27 81.81 6 18.18
Cotrimoxazole 23 69.69 10 31.25
Gentamicin 29 87.87 4 12.12
Vancomycin 33 100 0 0
Linezolid 33 100 0 0
Teicoplanin 18 54.54 15 45.45

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Table.2 Distribution of study subjects according to their perception towards

white coat and its contamination.

No. of students %
(n=96)
Do u perceive your white coat to be clean if it has no stains?

Yes 21 21.87
No 75 78.12
Do u perceive your white coat to be clean if collar and pockets are clean?

Yes 20 20.83
No 76 82.29
Do you consider your white coat to be contaminated with or without stains?

Yes 55 57.29
No 41 42.7
Do you think your white coat carries germs?
Yes 85 88.54
No 11 11.45
Do you believe that the white coat can be a potential transmitting agent for
pathogens?
Yes 80 83.33
No 16 16.66

Table.3 Distribution of study subjects according to their white-coat usage/handling practices and
its association with bacterial contamination of their white coats.

Basic No. of students No. of white Contaminatio Chi square P value

variables white coats coats n rate (χ2)
examined contaminated (%) Value
n=96 (%)
Gender
Male 42 (43.75) 27 64.28
Female 54 (56.25) 34 62.96 0.018 0.894
Residence
Home 22 (22.91) 12 54.54
Hostel 74 (77.08) 49 66.21 0.997 0.318

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Table.4 Distribution of study subjects according to their white-coat usage/handling practices and
its association with bacterial contamination of their white coats.
Number of white No. of white Contamination Chi square P
coats examined coats rate (χ2) value
n=96 (%) contaminated (%) Value
The reason to wear white coat *

To cover clothing 8 (8.33)

To appear professional 58 (60.41)
Dress code of hospital 65 (67.7) - - - -
For usage of pockets 13 (13.54)
Any other 8 (8.33)
How do you carry white coat in and around campus

On the hands 2 (2.08) 2 100

Pack in isolated bag 0 (0) 0 0
Carry in bag 26 (27.08) 17 65.38 1.278 0.528
Wear it all the time 68 (70.83) 42 61.76
Frequency of usage of white coats

Only hospital 4 (4.16) 1 25

Hospital and college 84 (87.50) 51 60.71
Hospital , college and 8 (8.33) 6 75 3.038 0.219
outside campus
Practice of exchange of white coat

Yes 7 (7.29) 6 85.71

No 89 (92.7) 55 61.79 1.602 0.206
Does your white coat has any spillage on it

Yes 38 (39.58) 24 63.15

No 58 (60.41) 37 63.79 0.004 0.950
Use of white coat while eating

Yes 79 (81.25) 51 65.38

No 17 (17.7) 10 58.82 0.199 0.656
Length of time of white coat in use

< 8 hours 39 (40.62) 25 64.10

>=8 hours 57 (59.37) 36 63.15 0.009 0.925
How many days you wear white coat in week

< 6 Days 18 (18.75) 11 61.11

6 Days and more 78 (81.25) 50 64.10 0.056 0.812

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Table.5 Distribution of study subjects according to their white coat washing practices and its
association with contamination of their white coats

No. of white coats No. of white Contamination Chi square P value

examined coats rate (χ2)
n=96 (%) contaminated (%) value
No. of white coats do u have?

1 8 (8.33) 3 37.50
2 79 (82.29) 52 65.82 2.557 0.278
3 9 (9.37) 6 66.66
Type of cleaning

Laundry 10 (16.66) 10 62.50

Self wash 86 (83.33) 51 63.75 0.060 0.806
How often do you wash your white coat?

Weekly once 44 (45.83) 29 65.9

Weekly twice 41 (42.7) 26 63.41 0.000 1.00
Weekly thrice 11 (11.45) 6 60
When your white coat was last washed?

1- 2 days 65 (67.70) 29 44.61

3-6 days 22 (22.91) 15 68.18 0.458 0.795
1 week or more 9 (9.37) 5 55.55

Fig.1 Distribution of organisms isolated from contaminated white coats (n=61)

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All the Acinetobacter species were sensitive rate of their white coat. Studies done by
to all the antibiotics tested in our study. All Qaday et al. (2015) and Treakle et al. (2000)
33 of the Gram positive cocci were sensitive have found no significant association
to Vancomycin, linezolid and between contamination of white coat with
chloramphenicol, whereas 20 (60.6%) any of the factors similar to the findings of
isolates were resistant to penicillin, 13 our study.
(39.39%) to erythromycin and clindamycin
each, 10 (31.25%) to cotrimoxazole, similar On the contrary, Uneke, et al., (2010)
to the findings of study done by Priya et al. reported that white coats of physicians who
(2009). The high level of antibiotic used them only during clinical duties had a
resistance exhibited by the bacterial isolates significantly lower rate of bacterial
from the coats is of public health contamination compared with those used
significance and has gained importance during both clinical and nonclinical duties.
because they are capable of initiating severe Also study conducted by Wong et al. (1991)
nosocomiasis in a hospital environment and found that coats that were more frequently
often require contact isolation and used had significantly greater bacterial
aggressive treatment to prevent their spread contamination than those which were less
(Uneke et al., 2010). frequently used. This difference in findings
may be due to geographical variation in
More than half of the students considered study location, difference in site of white
their white coat to be contaminated in our coat selected for sampling and differences in
study. More than 85% of students knew that profile of the study participants.
their white coats may carry germs and more
than 80% of them believed that the white The level of contamination found on white
coat can be a potential transmitting agent for coats of medical students was very high in
pathogens. Similar finding was observed by our study. Majority of the isolates were
Banu et al. (2012) and Muhadi et.al. (2007). Coagulase negative Staphylococci followed
by Micrococci and Gram positive bacilli.
Neither there was significant association The level of resistance exhibited by these
between contamination of white coat of isolates to various antibiotics used in our
medical students with their gender nor with study is slightly higher and raises concern.
their residential status in our study.
Comparable findings were reported by Perception/ Knowledge of students towards
Uneke et al. (2010) and Qaday et al. (2015). cleanliness of their white coat was good in
our study. None of the handling or washing
practices by the students was found to be
In our study, the handling and washing associated with contamination rate of their
practices like carrying white coat in and white coats. Further research is
around the campus, frequency of its usage, recommended in this area to identify factors
practice of exchanging among themselves, responsible for contamination of white coats
use of white coats while eating, any spillage so that effective steps can be taken to
on it, length of time in use, number of days prevent it and thereby to prevent
per week in use, number of white coats transmission of Hospital acquired infections.
possessed by the students, type of cleaning Acknowledgement
and the frequency of washing the white
coats by the students were not found to be The authors thank the Management of the
significantly associated with contamination Subbaiah institute of medical sciences,

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Shivamogga for providing an opportunity to of the medical student’s white coats.

conduct the study. The authors also thank Malayasian J. Microbiol., 3(1): 35-38.
the participants for their cooperation and Mwamungule, S., Chimana, H.M., Malama,
also the technical personnel in the S., Mainda, G., Kwenda, G. and
Microbiology laboratory Mr. Santhosh for Muma, J.B. 2015. Contamination of
the assistance rendered during the study health care workers’ coats at the
period. University Teaching Hospital in
Lusaka, Zambia: the nosocomial risk.
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How to cite this article:

Trupti B. Naik, Amruthkishan Upadhya, Vijaykumar Mane and Asmabegaum Biradar. 2016.
Microbial Flora on Medical Students’ White Coat and an Analysis of its Associated Factors: A
Cross Sectional Study. Int.J.Curr.Microbiol.App.Sci. 5(7): 353-363.
doi: http://dx.doi.org/10.20546/ijcmas.2016.507.038

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