Uniformes: uma revisão das evidências sobre a significância microbiológica dos uniformes, da política sobre o vestuário na prevenção e no controle de infecções associadas à assistência médica. Alerta ao Departamento de Saúde (Inglaterra)

REVISÃO

J.A. Wilson a,b,*, H.P. Loveday b, P.N. Hoffman c, R.J. Pratt b

a Department of Healthcare Associated Infection and Antimicrobial Resistance, Centre for Infections, Health Protection Agency, London, UK

b Richard Wells Research Centre, Thames Valley University, London, UK

c Laboratory of Healthcare Associated Infection, Centre for Infections, Health Protection Agency, London, UK

Disponível online em 28 de junho de 2007

Resumo:

Uma revisão sistemática baseada em literatura publicada de qualidade embasa o conhecimento atual sobre o papel da indumentária dos trabalhadores da saúde como veículo na transmissão de infecções associadas à assistência médica. Essa revisão compreende uma busca sistemática em guias nacionais e internacionais, em literatura já publicada sobre o assunto e em dados sobre os recentes avanços sobre tecnologia e processamento da roupas utilizadas na assistência à saúde humana. Encontramos somente um pequeno número de estudos relevantes e isso nos dá limitadas evidências diretamente relacionadas à descontaminação de roupas de serviços de saúde. Estudos sobre o processo de lavagem doméstica são, em última instância, puramente observacionais. A pratica atual e os guias para lavagem de roupas dos trabalhadores de serviços de saúde são extrapoladas de estudos sobre o processamento hospitalar desses insumos. As roupas dos trabalhadores da área da saúde, incluindo os jalecos brancos, se tornam progressivamente contaminados através do uso por bactérias de baixa patogenicidade ubíquas a pele humana que se misturam com outras bactérias de patogenicidade variada dentro do serviço de saúde e através do contato com pacientes. A hipótese que as indumentárias dos trabalhadores da área saúde podem ser o veículo na transmissão de infecções “ainda não possuía” o devido suporte literário quando publicado. (“veja o texto: Transmissão de patógenos nosocomiais pelo jaleco branco: um modelo in-vitro.”) Todos os componentes do processo de lavagem contribui para a remoção e para a morte dos micro-organismos no tecido. Não há evidencias fortes sobre a diferença na eficiência/eficácia da descontaminação desses uniformes/roupas quando comparamos os processos industriais e domésticos ou que a lavagem doméstica realiza uma descontaminação inadequada.

© 2007 The Hospital Infection Society. Publicado por Elsevier Ltda. Todos os direitos são reservados.

* Correspondência com o autor. Endereço: Department of Healthcare Associated Infection and Antimicrobial Resistance, Centre for Infections, Health Protection Agency, 61 Colindale Avenue, London NW9 5EQ, UK.

Tel.: +44 (0)208 3277338; fax: +44 (0)208 2059185.

E-mail: jennie.wilson@hpa.org.uk

REVIEW

Uniform: an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England)

J.A. Wilson a,b,*, H.P. Loveday b, P.N. Hoffman c, R.J. Pratt b

a Department of Healthcare Associated Infection and Antimicrobial Resistance, Centre for Infections, Health Protection Agency, London, UK

b Richard Wells Research Centre, Thames Valley University, London, UK

c Laboratory of Healthcare Associated Infection, Centre for Infections, Health Protection Agency, London, UK

Available online 28 June 2007

Summary A systematic search and quality assessment of published literature was conducted to establish current knowledge on the role of healthcare workers uniforms’ as vehicles for the transfer of healthcare associated infections. This review comprised a systematic search of national and international guidance, published literature and data on recent advances in laundry technology and processes. We found only a small number of relevant studies that provided limited evidence directly related to the decontamination of uniforms. Studies concerning domestic laundry processes are small scale and largely observational. Current practice and guidance for laundering uniforms is extrapolated from studies of industrial hospital linen processing. Healthcare workers’ uniforms, including white coats, become progressively contaminated in use with bacteria of low pathogenicity from the wearer and of mixed pathogenicity from the clinical environment and patients. The hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by existing evidence. All components of the laundering process contribute to the removal or killing of micro-organisms on fabric. There is no robust evidence of a difference in efficacy of decontamination of uniforms/clothing between industrial and domestic laundry processes, or that the home laundering of uniforms provides inadequate decontamination.

© 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Address: Department of Healthcare Associated Infection and Antimicrobial Resistance, Centre for Infections, Health Protection Agency, 61 Colindale Avenue, London NW9 5EQ, UK.

Tel.: +44 (0)208 3277338; fax: +44 (0)208 2059185.

E-mail address: jennie.wilson@hpa.org.uk

Introduction

Public perception that healthcare professionals wearing uniforms to travel to and from work might contribute to the spread of healthcare-associated infections (HCAI) has become the focus of professional and media concern. A survey by the Royal College of Nursing showed that staff have limited numbers of uniforms and that few hospitals have changing facilities.1 It is more common for healthcare staff to launder their uniforms at home than for Trusts to supply uniforms processed in an industrial laundry. However, evidence to support the perception that wearing uniforms in public spaces and home laundering pose an infection risk is rarely cited. Our review was commissioned and funded by the Department of Health (England) to inform policy development. We describe a systematic review of the literature related to healthcare workers’ uniforms as a vehicle of transmission and the efficacy of different laundry practices.

Discussion

The evidence directly related to the laundering of uniforms is limited and varies in method and design, making comparison difficult. Technological advances have resulted in changes in the fabrics used for the manufacture of uniforms and work clothing, the detergents used in domestic laundering and increased ownership of domestic washing machines. It is essential that the findings from these studies are considered within context and not overemphasized in the development of uniform policy.

There is a body of evidence from small-scale experimental and clinical studies that uniforms and white coats become progressively contaminated during clinical care and that this contamination reaches a level of saturation that then plateaus. Most microbial contamination originates from the wearer of the uniform rather than from the patient.2e9 This means that clean uniforms become contaminated by skin commensals from the wearer, and additional microorganisms from the environment and patients. Although it has been hypothesized that contaminated uniforms are a potential vehicle for the transmission of pathogens, no studies demonstrated the transfer of micro-organisms from uniforms to patients in the clinical situation.2e9 Only one study showed an epidemiological link between contaminated clothing and HCAI, but this occurred when clothing became highly contaminated in an industrial laundry rather than as a result of clinical care.10,11 There is evidence that where protective clothing, such as aprons, is used for direct contact with patients, exogenous contamination of uniforms from patients or their environment can be minimized. Uniforms should not be considered as a substitute for protective clothing and the use of plastic aprons as a component of standard principles is currently recommended in national infection prevention guidelines.32,33 It is unclear whether microbial adherence promotes or decreases the transmission potential of uniforms. Surfaces which more readily accumulate micro-organisms could be considered more likely to contribute to the transmission of HCAI. However, micro-organisms that have an enhanced ability to adhere to surfaces are less likely to be shed from fabric onto other surfaces and are thus less likely to contribute to transmission. In addition, the medium in which the microbe is suspended will affect both its adherence to surfaces and its ability to survive. The unpredictability of these effects means that the differences between fabrics in terms of microbial adherence and survival are unlikely to make a major contribution to the transmission of micro-organisms. Current advice relating to the laundering of uniforms is derived from recommendations related to laundering patient linen. National guidance on the standards required for hospital laundries is directed at processing hospital linen that has far greater patient contact than staff uniforms. It focuses on thermal disinfection rather than the complete laundry process in eliminating microbial contamination. Differences in both the level and type of contamination mean that the results of studies on patient linen may not be directly applicable to laundering healthcare uniforms. In addition, it is difficult to distinguish the effect that different components of the laundry process have on the reduction of soil because many studies use different machines; involve a wide range of process parameters; components cannot be tested in isolation from the whole process; and the methods used may not be comparable (see Box 4). Industrial laundries process most linen by batch continuous washing machines (‘tunnel washers’) where it is thermally disinfected. Healthcare workers’ uniforms tend to be washed industrially in washer-extractors and dried in tunnel driers (where hot air is blown at garments on hangers on a moving line as they travel through a semienclosed cabinet) rather than by batch continuous washing machine and tumble drying. Washerextractor cycles are thought to give a substantially greater dilution of contamination than batch continuous washing machines. Studies concerning the effectiveness of laundry processes focus on industrial laundries and patient linen rather than uniforms.14e23 They provide evidence that microorganisms are both removed and killed during the laundering process and dilution during washing and rinsing is important in removing micro-organisms. Significant reductions in micro-organisms occur at the lower wash temperatures more commonly used in domestic washing machines, e.g. 40ºC. The effect of the type of machine, size of load and level of soil is likely to have as much impact on the cleanliness of the item at the end of the process as the combination of detergent, water, dilution and wash temperature. Ensuring an optimal ratio between fabric load and water volume is important in both industrial and domestic settings to facilitate the effect of agitation and dilution on removing contamination. There is no strong scientific evidence to suggest that home laundering of uniforms is inferior to industrial processing as a means of decontaminating uniforms, or that laundering in domestic machines presents a hazard in terms of cross-contamination of other items in the wash-load with hospital pathogens. In normal circumstances staff uniforms are likely to be less contaminated with pathogens than other hospital linens that have more substantial contact with patients and their body fluids. Our review has demonstrated that common assumptions about the microbiological significance of healthcare workers’ uniforms and the inadequacy of domestic laundering are not supported by robust evidence. Current national guidance for the prevention of HCAI recommends that standard principles for infection control are key to protecting patients and staff from cross-contamination with pathogenic micro-organisms.32,33 Therefore, uniforms and other work clothing should not be regarded as personal protective clothing and plastic aprons or other personal protective clothing must be used to protect uniform/work clothing from contamination during patient care activities. Uniform/clothing that becomes obviously contaminated with organic soil, such as blood or other body substances, must be changed for a clean uniform as soon as practicable; and uniforms/work clothing should be washed/cleaned according to the manufacturer’s instructions. Where this is undertaken in a domestic washing machine, overloading should be avoided to ensure that adequate dilution is achieved during the washing process.

References

1. Nye KJ, Leggett VA, Watterson L. Provision and decontamination of uniforms in the NHS. Nurs Stand 2005;19:41e45.

2. Speers R, Shooter R, Gaya H, Patel N. Contamination of nurses’ uniforms with Staphylococcus aureus. Lancet 1969;2(7614):233e235.

3. Babb JR, Davies JG, Ayliffe GA. Contamination of protective clothing and nurses’ uniforms in an isolation ward. J Hosp Infect 1983;4:149e157.

4. Callaghan I. Bacterial contamination of nurses’ uniforms: a study. Nurs Stand 1998 Sept 23e29;13:37e42.

5. Perry C, Marshall R, Jones E. Bacterial contamination of uniforms. Short Report. J Hosp Infect 2001;48:238e241.

6. Boyce JM, Potter-Bynoe G, Chenevert C, King T. Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications. Infect Control Hosp Epidemiol 1997;18:622e627.

7. Wong D, Hollis P, Nye K. Microbial flora on doctors’ white coats. Br Med J 1991;303:21e28.

8. Loh W, Ng VV, Holton J. Bacterial flora on the white coats of medical students. J Hosp Infect 2000;45:65e68.

9. Hambraeus A. Transfer of Staphylococcus aureus via nurses’ uniforms. J Hyg 1973;71:799e814.

10. Barrie D, Wilson JA, Hoffman PN, Kramer JM. Bacillus cereus meningitis in two neurosurgical patients: an investigation into the source of the organism. J Infect 1992;25: 291e297.

11. Barrie D, Wilson J, Kramer J, Hoffman P. Contamination of hospital linen by Bacillus cereus. Epidemiol Infect 1994; 113:297e306.

12. Takashima M, Shirai F, Sageshima M, Ikeda N, Okamoto Y, Dohi Y. Distinctive bacteria-binding property of cloth materials. Am J Infect Control 2004;32:27e30.

13. Neely AN, Maley MP. Survival of Enterococci and Staphylococci on hospital fabrics and plastic. J Clin Microbiol 2000;38:724e726.

14. Smith J, Neil K, Davidson C, Davidson R. Effect of water temperature on bacterial killing in laundry. Infect Control 1987;8:204e209.

15. Blaser MJ, Smith PF, Cody HJ, Wang WL, LaForce FM. Killing of fabric-associated bacteria in hospital laundry by lowtemperature washing. J Infect Dis 1984;149:48e57.

16. Walter G, Schillinger J. Bacterial survival in laundered fabrics. Appl Microbiol 1975;29:368e373.

17. Jerram P. An investigation into the ability of laundry processes to kill pathogenic bacteria in soiled articles. Mon Bull Minist Health Public Health Lab Serv 1958;17:170e176.

18. Crone PB. Survival of Staphylococci during experimental laundering. Mon Bull Minist Health Public Health Lab Serv 1958;17:167e170.

19. Orr KE, Holliday MG, Jones AL, Robson I, Perry JD. Survival of Enterococci during hospital laundry processing. J Hosp Infect 2002;50:133e139.

20. Wilcox MH, Jones BL. Enterococci and hospital laundry. Lancet 1995;345:594.

21. Bradley CR, Fraise AP. Heat and chemical resistance of Enterococci. J Hosp Infect 1996;34:191e196.

22. Christian RR, Manchester JT, Mellor MT. Bacteriological quality of fabrics washed at lower-than-standard temperatures in a hospital laundry facility. Appl Environ Microbiol 1983;45:591e597.

23. Tompkins DS, Johnson P, Fittall BR. Low-temperature washing of patients’ clothing: effects of detergent with disinfectant and a tunnel drier on bacterial survival. J Hosp Infect 1988;12:51e58.

24. Ridenour GM. A bacteriological study of automatic clothes washing. The National Sanitation Foundation, Ann Arbor, MI, USA, as cited by: battles DR, Vesley D. Wash water temperature and sanitation in the hospital laundry. J Environ Health 1981;43:244e250.

25. Jurkovich P. Home versus hospital-laundered scrubs; a pilot study. Am J Matern Nurs 2004;29:106e210.

26. Patel SN, Murray-Leonard J, Wilson APR. Laundering of hospital staff uniforms at home. J Hosp Infect 2006;62: 89e93.

27. National Health Service Executive. Hospital Arrangements for Used and Infected Linen. Health Service Guidelines HSG(95)18. Heywood, Lancashire: Health Publications Unit. 28. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for environmental infection control in healthcare premises. RR-10. Morb Mortal Wkly Rep 2003;52.

29. Australian Government Department of Health and Ageing. Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting. Commun Dis Intell January 2004;28:59.

30. AS/NZS 4146(2000) Laundry practice. Strathfield New South Wales and Wellington New Zealand. Standards Australia International and Standards New Zealand. p. 59.

31. National Audit Office. A Comparison of International Practices in the Management and Control of Healthcare associated Infections. A Component of the VFM Follow-up Study of the National Audit Office Report:the Management and Control of Hospital Acquired Infections in Acute NHS Hospitals in England. The Stationary Office; 2004. p. 60.

32. Pratt RJ, Pellowe CM, Wilson JA, et al. epic2eNational evidence-based guidelines for preventing healthcare associated infections in NHS hospitals. J Hosp Infect 2007; 65(Suppl. 1), S1eS4.

33. Pellowe CM, Pratt RJ, Harper P, et al. Infection control: prevention of healthcare-associated infection in primary and community care. J Hosp Infect 2003;55(Suppl. 2):1e127.


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One Response to Uniformes: uma revisão das evidências sobre a significância microbiológica dos uniformes, da política sobre o vestuário na prevenção e no controle de infecções associadas à assistência médica. Alerta ao Departamento de Saúde (Inglaterra)

  1. Sharing health was good in your hand. More expect friends ..

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