DOI: 10.7860/JCDR/2012/4286.

2364
Original Article

White Coats as a Vehicle for

Infectious Diseases

Bacterial Dissemination
Section

Asima Banu, Mridu Anand, Nagarjun Nagi

ABSTRACT highly contaminated areas followed closely by the collar and

Introduction: White coats are known to be potential transmitt­ pockets. Staphylococcus aureus was the most common isolate
ing agents of multi-drug resistant organisms. This study followed by coagulase negative Staphylococci and Gram
was con­ducted to determine the level and type of microbial negative non fermenters. Most of the Gram positive cocci were
contamination present on the white coats of medical students resistant to Penicillin, Erythromycin and Clindamycin.
in order to assess the risk of transmission of pathogenic micro- Conclusion: White coats have been shown to harbor potential
organisms by this route in a hospital setting. contaminants and may have a role in the nosocomial transmission
Materials and Methods: A cross sectional survey of the bacterial of pathogenic microorganisms. Thus, a yearly purchase of white
contamination of white coats in a tertiary care hospital. 100 coats and the possession of two or more white coats at any point
medical students working in various specialties were included in time should be made compulsory. There is pressing need to
in the study. Swabs were taken from 4 different areas of the promote scrupulous hand washing before and after attending
white coat – collar, pocket, side and lapel and processed in the patients and alternatives to white coats, including universal use
Microbiology department according to standard procedures. of protective gowns, should be considered.
Results: Although most of the white coats had been washed
within the past 2 weeks, the sides of the coats were the most

Key Words: White coat, Bacterial contamination, Nosocomial infection

INTRODUCTION of our hospital. All the invited students were asked to read the
White coats are worn primarily for identification, but there has always questionnaire and to sign the consent forms.
been some concern that white coats, like nurses’ uniforms and
A brief, self-administered, structured questionnaire was used
other hospital garments, may play a part in transmitting pathogenic
to collect demographic data and information on the white coat
bacteria in a hospital setting, as white coats are known to be poten­
laundering habits of the participants. The demographic variables
tially contaminated with pathogenic drug resistant bacteria [1].
included gender, place of staying, the subject’s positions (student,
Since many medical colleges are closely attached to hospital
intern or post-graduate), their current work locations (paediatrics,
environments and as there is no changing area in the hospitals,
medicine, ophthalmology, ENT, skin and STD, microbiology,
students wear their white coats on the way to their colleges and
surgery, public health and obstetrics and gynaecology), the
even in the non-clinical and non-practical classes, library, cafeteria
reason for wearing the white coat (to cover clothing, to appear
and in the resting areas around their colleges. It is not uncommon
professional, dress code of the hospital, for the usage of pockets
to see white coats being left on chairs or being carried around
or other), length of the usage of the coat (<1 year, 1-2 years,
outside the hospital premises [2].
2-3 years or > 3 years), when the coat was last washed (<3
It was the interest of this study to find out the level and the type days, 1 wk, 2-4 weeks or >1 month), the frequency of washing
of microbial contamination which was present on the medical (<3 days, 1 week, 2-4 weeks or > 1 month), type of cleaning
student’s white coats in our college, in order to assess the risk (home or laundry), washing agents used (soaps, liquid wash
of transmission of the pathogenic organisms by this route in our or disinfectants), number of white coats possessed (1, 2, 3 or
hospital. The student’s way of handling the coats and cleaning >3), method of carrying the white coat (cover, bags, hands or
them, as well their perception towards white coat contamination shoulder), location of the use of the white coat (hospital only or
also were investigated. hospital and college), the wearer’s perception of whether the coat
was dirty or clean and whether they believed if their white coats
MATERIALS AND METHODS carried microbes and were the possible agents of the transmission
This cross sectional study was conducted in the Department of of pathogens.
Microbiology of a tertiary care hospital which was attached to a
Swabs were taken from four different areas of the white coat
medical college. Approval from the institutional ethical committee
(collar, pocket, sides and lapels). The swabs which were used
was duly taken for this study. 100 undergraduate and postgraduate
were plain, cotton-tipped and sterilized swabs. Normal saline
medical students and interns were randomly selected and they
was used to moisten the swabs before collecting the sample by
were included in this study, of which 65% were males and 35%
passing the swabs up and down twice on the desired areas and
were females. Of the 100, 83% were undergraduate students,
the swabs were sent immediately to the laboratory. The swabs
10% were interns and 7% were postgraduate students. All the
which were received by the Department of Microbiology were
students were working in the outpatient and the inpatient wards
Journal of Clinical and Diagnostic Research. 2012 October, Vol-6(8): 1381-1384 1381
 Asima Banu et al., White Coat Contamination www.jcdr.net

immediately streaked onto blood agar and McConkey’s agar and Do you perceive your white coat to be Number of
%
the plates were incubated overnight at 37oC. The colonies which clean if if it has no stains students
were obtained were identified by using standard techniques [3]. No 46 68.0
Antibiotic sensitivity testing was done by using Kirby Bauer’s disc Yes 32 32.0
diffusion method as has been described in the CLSI guidelines
Do you perceive your white coat to be clean if collar and pockets
2011 [4]. are clean
No 55 55.0
RESULTS Yes 45 45.0
Number of students Do you consider your white coat to be contaminated with or
Basic variables (n=100) % without stains
Gender No 77 77.0
Male 65 65.0 Yes 23 23.0
Female 35 35.0 Do you think your white coat carries germs
Staying No 8 8.0
Hostel 59 59.0 Yes 92 92.0
Home 41 41.0 Do you believe that white coats can be a potential transmitting
agent for pathogens:
Year of study
No 9 9.0
Student 83 83.0
Yes 91 91.0
Intern 10 10.0
[Table/Fig-4]: Knowledge with regards to white coat
PG 7 7.0
[Table/Fig-1]: Basic variables of subjects included in the study
Organism Collar Pocket Side Lapel Total
Staphylococcus 25 23 26 17 91
Number of
aureus
students (n=100) %
Coagulase negative 4 6 5 3 18
The reason to wear white coat
Staphylococci
To cover clothing 4 4.0
Pseudomonas 4 4 6 5 19
To keep warm 0 0.0 aeruginosa
To appear professional 67 67.0 Total 33 33 37 25 128
(25.8%) (25.8%) (28.9%) (19.5%)
Dress code of hospital 45 45.0
[Table/Fig-5]: Sites from which organisms were isolated
For usage of pockets 11 11.0
Any other 5 5.0
S. Organism(s) Number of Percentage
How do you carry your white coat No. isolates of isolates
Cover 16 16.0 1. Staphylococcus aureus 44 64.7%
Bag 80 80.0 2. Coagulase negative Staphylococci 7 10.3%
Hands 3 3.0 3. Pseudomonas aeruginosa 3 4.4%
Shoulder 1 1.0 4. Staphylococcus aureus + Coagulase 5 7.3%
Frequency of usage of white coats negative Staphylococci
Only hospital 82 82.0 5. Staphylococcus aureus + 5 7.3%
Pseudomonas aeruginosa
Hospital & college 18 18.0
6. Coagulase negative Staphylococci + 3 4.4%
[Table/Fig-2]: Attitude towards white coat
Pseudomonas aeruginosa
7. Staphylococcus aureus + 1 1.6%
When was your white coat last Number of Coagulase negative Staphylococci +
washed students % Pseudomonas aeruginosa
3 days or less 39 39.0 [Table/Fig-6]: Organism isolated from white coats
1 week 32 32.0
2-4 week 26 26.0 S. Percent- Percent-
No. Antibiotic Resistant age Sensitive age
1 month or more 3 3.0
1 Penicillin G 89 81.6% 20 18.4%
How often do you wash your white coat
2. Erythromycin 77 70.6% 32 29.4%
Once in 3 days 18 18.0
3. Clindamycin 64 58.7% 45 41.3%
Once in week 42 42.0
4. Amoxi-Clav 13 11.9% 96 88.1%
2-4 weeks 27 27.0
5. Ciprofloxacin 11 10.0% 98 90.0%
More than a month 13 13.0
6. Cefoxitin 5 4.6% 104 95.4%
Type of cleaning
7. Vancomycin 0 0% 109 100%
Laundry 11 11.0
[Table/Fig-7]: Sensitivity pattern of Gram positive cocci isolated from
Home wash 89 89.0
white coats
[Table/Fig-3]: Practice of washing lab coat

1382 Journal of Clinical and Diagnostic Research. 2012 October, Vol-6(8): 1381-1384
www.jcdr.net Asima Banu et al., White Coat Contamination

DISCUSSION In the present study, Staphylococcus aureus was the major

pathogen which was isolated (64.7%), which is similar to that which
Traditionally, the white coat is thought to bring credibility and dignity
was found in the studies of Muhadi et al., [2], Treakle et al., [9] and
to the medical profession [2]. However, white coats have been
Wong et al., [1] and different from the findings of a study which
shown to harbour potential contaminants [1,2, 5,6] and so these
was done by Uneke et al., [7], in which diphtheroids were the
may have a role in the nosocomial transmission of pathogenic
most common organisms which were isolated. The antimicrobial
microorganisms. The high rates of the bacterial contamination of
susceptibility pattern of the gram positive cocci revealed that most
white coats may be associated with the following 2 facts: Firstly,
of them were resistant to Penicillin (81.6%), Erythromycin (70.6%)
patients continuously shed infectious microorganisms in the
and Clindmycin (58.7%). This is consistent with the susceptibility
hospital environment, and the health care providers are in constant
pattern of similar organisms which were isolated from suspected
contact with these patients. Secondly, it has been demonstrated
nosocomial infections in our hospital and this indicated a possible
that microorganisms can survive between 10 and 98 days on
link between the contamination of the white coats and the
fabrics which are used to make white coats, which include cotton,
transmission of infections to the susceptible patients. In our study,
cotton and polyester, or polyester materials [7,8].
MRSA was isolated from 4 white coats, which was significantly
Our hospitals were tertiary care hospitals which were attached to lower than that which was reported Uneke et al., [7] but similar to
a medical college and a research institute, where the incidence the findings of a study which was done by Treakle et al., [9], who
of the nosocomial infections was approximately 10%. All the reported no MRSA isolation from the white coats.
medical students worked in the clinical wards from the 2nd phase
Coagulase negative Staphylococci were also isolated (10.3%),
and examined patients. These students indiscriminately used the
which are skin commensals and these can be potentially infectious
white coats even outside the hospital premises. Since white coats
to the patients who are admitted in the hospital. Gram negative
are implicated as major fomites in the transmission of nosocomial
bacilli were isolated from the white coats, but these were also
infections, we studied 100 medical students who were working in
significantly lesser in number but were also potentially infectious, as
various specialities. Most of them i.e., 83 were undergraduates, 10
was reported by Zachary, 2001 and Grabsch 2006 [2, 5, 10,11].
were interns and the remaining 7 were postgraduate students. Of
the 65 white coats which belonged to the male subjects, 47(74.3%) Our study has several limitations. Firstly, the sample size was
were contaminated, while of the 35 white coats which belonged to small and statistically significant differences between the colonized
the female subjects, 22(62.8%) were contaminated. This was in and the uncolonized coats could not be brought out. Secondly,
contrast to the findings of a study which was conducted by Muhadi the use of swabs for obtaining the samples may have been less
et al., [2] who found in their study, that the coats of females tended effective than using the sweep plate method, as was done in
to be more contaminated. some previous studies. Also, since the swabbing was done by the
participant himself/herself, the sufficiency of the time of contact
The medical students who were residing at home tended to have
could not be established. Lastly, our study did not include a control
white coats that were more contaminated (72.9%), whereas
group of non-worn white coats and thus the possibility of the
those who were residing in the hostel had less contaminated
coats being contaminated prior to their use could not be ruled out.
coats (63.1%), which was a worrying prospect, as the hospital
However, that would have no bearing on the fact that the coats
organisms were likely to spread in the community. Most of the
were contaminated with potentially pathogenic organisms and that
students were of the opinion that white coats were worn to appear
they could function as fomites for the transmission of pathogenic
professional (67%) and because it was the dress code of the
organisms [9].
hospital (45%). However, 82 of the subjects used their white coats
only in the hospital premises, while the other 18 used it outside The following suggestions may be made on the basis of the findings
the hospital premises too. Although both the clinical and the of this investigation. Firstly, a yearly purchase of white coats and
non-clinical students had a high level of awareness regarding the the possession of 2 or more white coats at any point of time should
contamination of the white coats, they still wore it in different areas be made compulsory. The wearers of the white coats should be
of the college such as the library, reading rooms, canteen, classes encouraged to wash their white coats weekly. This study provides
and even outside the hospital premises when it was not necessary. microbiological evidence to support the exclusion of white coats
Providing students with changing areas in at the hospital site may from the nonclinical areas of the hospital such as the libraries and
reduce their frequency of using the white coats in the college and the dining rooms. A number of earlier studies had demonstrated
in the non-clinical areas [2]. that the compliance with the hand-hygiene protocols among all
the healthcare workers, including the physicians, was poor [7]. A
Even though the subjects perceived their white coats to be clean,
lack of hand hygiene undoubtedly enhances the contamination of
even without stains, 91 were aware that the coats could act as
the white coats, since they are often touched by the physicians
a mode of transmission of the hospital’s pathogenic organisms.
in the course of their work. As a result, there is a pressing need
The data from the washing practices of the students revealed
to promote a scrupulous hand washing among the physicians
that most of the students had washed their white coats within the
before and after they attended to patients and also to promote
past 1 week (71%). In spite of this, the contamination was high
alternatives to the white coats, which includes the universal use of
(62%-78%), irrespective of the time gap since the last wash. This
protective gowns.
was similar to the findings of a study which was done by Wong
et al., [1], who found that the microbial counts did not vary with
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AUTHOR(S): NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING
1. Dr Asima Banu AUTHOR:
2. Dr Mridu Anand Dr. Asima Banu
3. Mr. Nagarjun Nagi Associate Professor, Department of Microbiology,
Bowring and Lady Curzon Hospital.
PARTICULARS OF CONTRIBUTORS:
Phone: 9845720258
1. Associate Professor, Department of Microbiology,
E mail: [email protected]
Bangalore Medical College and Research Institute, India.
2. Post Graduate Student, Department of Microbiology, Financial OR OTHER COMPETING INTERESTS:
Bangalore Medical College and Research Institute, India. None.
3. Undergraduate Student, MBBS, Bangalore Medical Date of Submission: Mar 16, 2012
College and Research Institute, India. Date of Peer Review: May 30, 2012
Date of Acceptance: Jun 11, 2012
Date of Publishing: Oct 10, 2012

1384 Journal of Clinical and Diagnostic Research. 2012 October, Vol-6(8): 1381-1384