Making the World Safe from Drug-Resistant Bacteria, One Hospital Scrub at a Time

Dr. David C. Martin kicked off a widespread discussion about appropriate hospital and out-of-hospital attire when he wrote a series for Antidote earlier this year on why hospital scrubs and sandwiches should not mix. When a new study showed last week how infectious agents, including some superbugs, can live on scrubs and other uniforms, Antidote asked Martin for his thoughts.

He provided the great guest column below, which I am sure will give people even more to argue about.

Antibiotic-resistant pathogens are now a global health concern, though infection control practices vary among different countries and institutions within them. I applaud the authors from Shaare Zedek Medical Center for their recent study in the American Journal of Infection Control looking at the question of whether hospital scrubs contribute to the spread of infections.

As new studies emerge from the international community, we may have the opportunity to learn more about methods that are and are not effective in controlling the transmission of drug-resistant bacteria, including the role of scrubs.

It is conservatively estimated that there are 53 million carriers of MRSA (methicillin-resistant Staphylococcus Aureus) worldwide, and the incidence is rising. Genetic strains of these organisms continue to evolve into heartier and more virulent variants.

"If the new community-acquired MRSA clones are, however, sufficiently fit to sustain endemic levels by transmission in the community, the MRSA situation in hospitals, which still remains out of control in many countries, could potentially become explosive," wrote Dr. Hajo Grundmann of the National Institute of Public Health in The Netherlands, in 2006.

Conditions have only worsened in most countries since then. Antibiotic-resistant strains are especially prevalent in the United States, where an estimated 65% to 75% of all S. Aureus strains are drug resistant. They are increasingly common among many European countries. In Israel, where Shaare Zedek researchers undertook the study, resistance is estimated to be 44%.

In sharp contrast, Scandinavian countries have resistance rates at or below 1%, with most new carriers acquiring the organisms outside of Northern Europe. What are these northern countries doing differently and how does this inform our own "best practices" here in the United States?

The answers are not entirely clear, but enhanced environmental decontamination has been a priority in Scandinavia.  Denmark and the The Netherlands have contained MRSA in part through aggressive "search and destroy" policies, such as vigorous screening of patients and healthcare workers, followed by isolation, decontamination with topical agents and appropriate follow up.

American studies, in contrast, commonly show poor adherence to isolation precautions while decontamination and treatment of carriers (among healthcare workers) is a less common practice.

This is not proof that scrubs are a main source of infections, but it is worth noting that better dress code policies are in place in many northern European facilities.

A much bigger factor in the low resistance rates is the fact that European prescribers have curtailed inappropriate antibiotic use. Though largely as a cost-containment measure, this is perhaps the right decision for the second best reason. In southern Europe where MRSA rates are higher, practitioners have also adopted responsible prescribing habits, so this alone doesn't explain Scandinavia's control of resistant clones. American physicians continue to dole out antibiotics for mild, self-limited viral infections at the demand and expectation of consumers. This is a dangerous and antiquated practice that must stop, and probably a more serious infection-control issue than what we wear to and from work. But complex problems require multifactoral solutions.

In last week's Israeli study, the authors creatively examined several demographic and clinical risk variables among healthcare workers in seeking to identify appropriate infection-control interventions, among which only the frequency with which clothing was changed made a statistically significant difference in the carriage rate of dangerous pathogens. Notably unreliable, the investigators found, was the perception among workers that their own clothing was free of pathogens.

Denial? Changing clothes, as I have discussed previously, is safe, easy, and inexpensive and as the new study further suggests, effective.

The authors acknowledge that their study does not prove a causal link between clothing practices and hospital or clinic-acquired infection. Methodological limitations preclude such cut and dried results. These investigators do believe that there is ample data to support better dress code and contact precautions, along with the elimination of the traditional white coat. Short-sleeved attire is also encouraged.

In summary, the new well-crafted study from Israel adds further weight to a growing body of evidence that clothing and uniform practices should be modernized and that contaminated clothing may transfer dangerous pathogens from hospital to community. Many respondents to Antidote's previous columns on this and related issues cite lack of definitive proof that dress codes and laundry policy can reduce community colonization as reason to ignore clothing practices.  Such proof is not possible, nor is it necessary.

According to Dr. David Nash, Dean and Professor of Health Policy at the Jefferson School of Population Health, a firm evidentiary base supports only 20% of healthcare decisions. While we should strive to better that mark, we are often left with data that are incomplete and short of perfect, mandating that good judgment and common sense drive health choices. Such is the case with hospital attire.

Others who have been unswayed by my opinions, which are now supported by another well-respected, peer-reviewed study, suggest that our practical inability to repetitively sterilize cell phones, shoes, doorknobs, etc. are reason to trivialize the notion of contaminated clothing as a vehicle for transmission of dangerous pathogens. Indeed, we cannot decontaminate everything, nor can we sterilize ourselves. So we are left to abide reasonable practice, which now informs how healthcare workers dress.

We should not fail to do something about the issue of the spread of drug-resistant infectious agents because we cannot do everything. When one potential solution, with increasing scientific support, presents itself, we would be foolish not to pursue it.

For more coverage of hospital scrubs and drug-resistant infections, click here.