CLOTHING OF HEALTH CARE PROFESSIONAL AS POTENTIAL RESERVOIRS OF MICRO-ORGANISMS : AN INTEGRATIVE REVIEW

It has been aimed to determine, through an integrative review of the literature, reports about the occurrence of contamination by micro-organisms and isolation in their white coats, gowns, uniforms of the healthcare professionals, and the similarity to those related to Healthcare Associated Infections considering the profile of antimicrobial resistance. Articles were searched in the following databases MEDLINE, LILACS, and SCOPUS, published from 2000 to 2010. Nine articles were selected and analyzed. These studies considered and evidenced white coat, gown and uniform contamination. The analyzed studies there was the presence of mainly bacteria on pockets, cuff and waist area. As to the profile of sensitiveness the recuperation of Staphylococcus aureus meticiline resistant/MRSA, followed by Gram negative antimicrobial resistance. These were a similarity between the strains in the clothing of health workers and those related to the occurrence of infections. Thus, white coats, gowns, uniforms must be considered part of the dissemination chain of micro-organisms. DESCRIPTORS: Cross infection. Clothing. Health personnel. VESTUÁRIO DE PROFISSIONAIS DE SAÚDE COMO POTENCIAIS RESERVATÓRIOS DE MICRORGANISMOS: UMA REVISÃO INTEGRATIVA RESUMO: Objetivou-se identificar na literatura, artigos sobre a ocorrência de contaminação por microrganismos, em jalecos, aventais e uniformes dos profissionais de saúde, e a similaridade com aqueles associados às Infecções Relacionadas à Assistência à Saúde, considerando o perfil de resistência aos antimicrobianos. Realizou-se busca por artigos nas seguintes bases de dados: MEDLINE, LILACS e SCOPUS, publicados entre 2000 e 2010. Foram selecionados nove artigos. Os estudos evidenciaram a contaminação dos jalecos, aventais e uniformes. Nos estudos analisados, verificou-se a presença de bactérias, principalmente, nos bolsos, punhos e região abdominal. Quanto ao perfil de sensibilidade, verificou-se recuperação de Staphylococcus aureus meticilina resistente, seguidos dos Gram negativos resistentes aos antimicrobianos. Identificou-se semelhança entre as cepas isoladas no vestuário dos profissionais de saúde e aquelas relacionadas à ocorrência de infecções. Assim, jalecos, aventais e uniformes devem ser considerados na cadeia de disseminação de microrganismos resistentes. DESCRITORES: Infecção hospitalar. Vestuário. Pessoal de saúde. VESTUARIO DE LOS PROFISSIONALES SALUD COMO POSIBLES RESERVORIOS DE MICROORGANISMOS: UNA REVISIÓN INTEGRADORA RESUMEN: Se objetivó identificar, por revisión integrativa de la literatura, artículos sobre la ocurrencia de contaminación por microorganismos en gabachas, delantales y uniformes de profesionales de salud, y su relación con las Infecciones presentadas al realizar el Cuidado de Salud, teniendo en cuenta el perfil de resistencia a los antimicrobiano. Se realizó la búsqueda por artículos en los bancos de dados MEDLINE, LILACS y SCOPUS, publicados desde 2000 hasta 2010. Fueron seleccionados y analizados nueve artículos. Se destaco en los estudios la presencia de bacterias, principalmente en los bolsillos, los puños y en la región abdominal. Sobre el perfil de sensibilidad se destacó la recuperación de Staphylococcus aureus meticilino resistente/MRSA, seguidos por Gram negativos resistentes a los antimicrobianos. Se identificaron similitudes entre las cepas en el vestuario de los trabajadores de la salud y la aparición de infecciones. Por tanto las gabachas, delantales y uniformes de los profesionales en salud, deben ser considerados en la cadena de diseminación de microorganismos. DESCRIPTORES: Infección hospitalaria. Vestuario. Personal de salud. 684


INTRODUCTION
Healthcare Associated Infections (HAIs) refer to those obtained during the provision of healthcare.] Despite significant progress in infection control, there is an increase in the frequency and severity of cases of HAI, which may be favored by the spread of drug resistant microorganisms. 37] However, the possible participation of environmental factors, such as surfaces, equipment and clothing (white coats, gowns and uniforms) used by the professionals, draws the attention of researchers, society, and the infection control agencies and associations. 8ith the emergence of resistant bacteria, the focus of the dissemination of these infections turned to some fomites that had been forgotten.][11][12] The spread of pathogens may occur in the hospital environment and also outside of this, i.e. in places in which the provision of direct care does not occur.The use by healthcare professionals, principally, of white coats outside the hospital environment has become common in areas close to the health institutions, on buses, in cafeterias and in other places. 12Given the importance of the subject, this study aimed to identify articles in the literature on the occurrence of contamination by microorganisms of white coats, gowns and uniforms of healthcare professionals, and to highlight the similarity of these microorganisms with those related to Healthcare Associated Infections.
The methodological approach adopted was that of Evidence-Based Practice (EBP), which is to organize the relevant information from the definition of a problem.This contributes to improving the quality and safety of patient care and encourages healthcare professionals to seek scientific knowledge already produced about the topic under investigation, providing the aggregation between the best available evidence, the clinical experience of the professional and the individuality of each patient assisted. 13

METHODOLOGY
The recent EBP initiatives have increased the need to evaluate the production of all the literature review methods.In this study, the integrative literature review was selected, which is one of the evidence-based practice resources. 13The development of this integrative review took the following steps: 1 st ) identification of the hypothesis, or the guiding question, for the development of the integrative review; 2 nd ) selection of the sample, from the establishment of the inclusion and exclusion criteria for the studies; 3 rd ) definition of the information to be extracted from the studies selected/ categorization of the studies; 4 th ) evaluation of the studies included; 5 th ) discussion and interpretation of the results, and 6 th ) presentation of the review and synthesis of the knowledge. 13The evidence is classified into seven levels: originating from I -a systematic review or meta-analysis of all the relevant randomized controlled clinical trials or from clinical guidelines based on systematic reviews of randomized controlled clinical trials; II -at least one well-designed randomized controlled trial; III -well designed clinical trials without randomization; IV -well designed cohort and case control studies; V -systematic reviews of descriptive and qualitative studies; VI -a single descriptive or qualitative study; and VII -the opinion of authorities and/or reports of expert committees. 14he development of the present review was defined using the following guiding question: what evidence is available in the literature regarding the recovery of microorganisms in white coats, gowns and uniforms of healthcare professionals and what is the similarity between these isolates and those related to HAI, considering the profile of antimicrobial resistance?For the selection of the articles three databases were used: MEDLINE (Medical Literature Analysis and Retrieval System online), LILACS (Latin American and Caribbean System on Health Sciences Information) and SCO-PUS (Database of research literature).The descriptors used in this study were controlled; i.e. they were used for the indexing of studies in databases, in order to facilitate access to the information.The following terms were defined for the search: a) in Portuguese: infecção hospitalar, pessoal de saúde and vestuário; b) in English: cross infection, health personnel and clothing; and c) in Spanish: infección hospitalaria, personal de salud and vestuário.The inclusion criteria for the studies selected for this integrative review were: those published in English, Spanish or Portuguese; primary articles which reflect the recovery of microorganisms in white coats, gowns and uniforms of healthcare professionals related to the occurrence of HAI and to bacterial resistance in healthcare institutions, with the application of laboratory (biochemical and/ or molecular) and statistical tests; and published between 2000 and 2010.It was chosen to consider works in this period because it is still a poorly studied subject, which is gradually attracting the attention of researchers.The exclusion criteria consisted of: articles repeated in the databases; articles of opinion; articles of reflection; editorials; articles that did not directly address the theme of this review; and articles published outside the previously defined period.
In the MEDLINE database 100 references were found.Of these, 60 were not primary articles, 20 were articles of opinion or reflection, five were editorials, and nine had been published before the established period.Therefore, 94 were excluded.In searching SCOPUS, 35 articles were obtained, of which 33 were excluded due to duplication in MEDLINE, as well as four articles in LILACS.Overall, a sample of 140 studies was obtained, with 131 being excluded.The data obtained were transcribed for the instrument proposed and validated in a previous study, 15 which considers the following items: identification of the original article, methodology of the study, and evaluation of the methodological rigor, the intervention measures and the results obtained.Critical reading of the articles was performed, highlighting the following aspects: authors, year of publication, journal, type of study design, evidence level and aim(s).

RESULTS
In this integrative review, the nine articles that met the previously established inclusion criteria were analyzed (Table 1).Regarding the year of publication, the majority of the studies occurred between 2000 and 2004 (4), followed by 2010 (2), 2009 (2) and 2008 (1).Regarding the origin of the journals, eight are International and one is Brazilian.In relation to the target populations of the studies, the following were identified: multidisciplinary team -five articles; nursing staff -one; physicians of different specialties -one; medical students -one, and physicians and nurses -one article.Of these, three were performed in the Intensive Care Units (ICU) of hospitals; five in inpatient units; and one study in a geriatric clinic.Concerning the type of research design of the articles analyzed, one study was descriptive and eight cross-sectional.Thus, regarding the strength of evidence obtained in the articles, it was found that the nine studies were of level VI; i.e. not presenting strong evidence for clinical application.In addition, the cross-sectional type studies, which represent the majority of the articles analyzed, may present greater vulnerability to bias (mainly selection bias).
[19][21][22] Direct contact of the areas analyzed with the agar plates was used in two articles for obtaining the microbiological samples. 12,19The bacterial species were identified by biochemical tests; and the antimicrobial susceptibility through the disc diffusion technique or by the identification of the Minimum Inhibitory Concentration (MIC). 11- 12,16-22 ] Of the microbial samples isolated from the white coats, gowns and uniforms of the healthcare professionals, the following were identified: Diphtheroids, Vancomycin Resistant Enterococcus (VRE), gram-negative bacteria (Acinetobacter baumannii, Klebsiela pneumoniae and Serratia rubidae) and methicillin-resistant Staphylococcus aureus (MRSA), which was most frequently isolated, including in outbreak situations.17][18][19][20][21][22] A higher level of contamination of clothing by VRE was observed during the care of patients with tracheostomy, gastrostomy, jejunostomy and ileostomy. 11,20] Among the studies included in the integrative review, there was consensus that white coats, gowns or uniforms of the healthcare professionals can be contaminated during patient care, becoming potential vehicles for the dissemination of microorganisms associated with HAIs.The main locations of contamination were: pockets, cuffs and the waist region.7][18][19][20][21][22] The use of white coats restricted to only areas of direct patient care was considered a important factor for lower levels of contamination of the coat (p<0.05),compared to coats used in non-care areas, such as cafeterias and libraries. 18

DISCUSSION
Regarding the aims of this review -to identify evidence in the literature concerning the recovery of microorganisms from white coats, gowns and uniforms of healthcare professionals; and to show the similarity of these with those related to HAI, considering the profile of antimicrobial resistance -it was observed in the articles that the clothing of healthcare workers can become contaminated with microorganisms of epidemiological relevance, contributing to the potential spread of pathogens between different patients and environments.
The results of the studies reviewed demonstrated the recovery of Staphylococcus aureus, Acinetobacter baumannii, Klebsiela pneumoniae, Pseudomonas aureuginosa, MRSA and VRE from white coats, gowns and uniforms.It should be highlighted that these constitute additional concerns for healthcare institutions worldwide, due to the high pathogenicity, the ease of cross transmission and the reduced profile of sensitivity to different antimicrobials. 23he relevance of the contamination of the clothing of healthcare professionals is evident, due to the fact that many of the microorganisms recovered are resistant to antimicrobial agents, and are thus capable of causing serious infections in hospitalized patients, as well as in the community.] The contamination of clothes may vary according to the type of hospitalization unit.It is higher in those that care for patients in critical health conditions, such as in the ICU, where normally there is a greater possibility of direct contact between the professional and the patient, with risk factors for infection of the patient, and also large amounts of equipment, which helps to promote greater environmental contamination. 8,20n this context of the discussion, the scarcity of studies with strong evidences for clinical application is highlighted.] To prevent the cross transmission of HAI between patients and healthcare professionals is an indispensable issue for the safe care of the patient, which constitutes a great challenge.According to the Association for Professionals in Infection Control and Epidemiology (APIC), unsafe practices and behavior that put the health, and even the lives, of patients and professionals at risk are unacceptable.Therefore, it is indispensable that healthcare professionals perform measures to control the spread of microorganisms. 18,26t appears, however, that the adherence of professionals to such measures is not taking place as required, citing as an example the use of the white coat outside the hospital environment, an increasingly common habit among healthcare professionals.Such behavior is repeated among students, who, without thinking critically, reproduce the same behavior without analyzing the possible repercussions in the chain of dissemination of microorganisms. 27n relation to the areas of recovery of pathogens in the white coats, gowns and uniforms, the studies indicate the pockets, the cuffs and the waist region as those with greater contamination, due to the frequency of contact with the hands of the professionals when putting belongings in the pocket and when the waist and wrists come into contact with patients and the inanimate environment. 11,20he use of plastic and/or disposable aprons as protection for the clothes of the professional must be encouraged during the practices with greater risk of exposure to humidity and secretions. 16 point rarely discussed in the studies analyzed, which can be directly related to the contamination and maintenance of microorganisms in the clothing, is the type of fabric and fiber.In the fabrics composed of cotton fibers, pathogens may survive for longer periods in contrast to fabrics composed of synthetic fibers.] Another aspect to be considered is the pos-sibility of reducing contamination of the clothing through the professionals cleaning their hands before and after patient care.The hands constitute the main route of the spread of microorganisms between patients and the clothing of the healthcare professionals. Another issue associated with the contamination of the clothes of healthcare professionals is the frequency of changing and of laundering them and the use of the same white coat, gown or uniform while providing care to patients in different clinical and epidemiological conditions. 8,17he white coats of medical students presented significant amounts of pathogens when considered dirty by the students themselves, however, the laundering of the clothes still only occurred ocasionally. 12he restricted use of the white coat in patient care units contributed to the reduction in the contamination of the coat.The use of this clothing in related areas as well presented higher contamination by microorganisms. 19Faced with the need to promote safe care for patients and healthcare professionals, the following recommendations should be considered regarding the handling and storage of clothing used in healthcare institutions: to provide enough coats, gowns and uniforms to the healthcare professionals, thus favoring an increased frequency of changing them; to recommend the washing of such clothing at least once a week, and to prohibit the use of white coats in non-care areas i.e. outside the inpatient units. 12,16ther recommendations should be observed, such as: to promote the involvement and participation of the health institution managers in the compliance with the actions of preventing the spread of microorganisms, foreseeing the establishment of the monitoring of the compliance with this measure; and to promote guidance regarding the cleaning of clothes and the adequation of the models, to facilitate hand washing. 12,16,18he clarification regarding the role of clothes in the dissemination of pathogens can contribute to a change in attitude and to improve the adherence of healthcare professionals to the measures of control of the spread of microorganisms, including those with profiles of antimicrobial multiresistance.
It was possible to detect gaps in the studies analyzed with regard to the occurrence of infec-tions related to the contamination of the clothing of the healthcare professionals.This results in the need to promote studies with greater methodological rigor, such as studies with evidence levels I and II, i.e. meta-analysis and randomized controlled clinical trials, which are able to present recommendations for use in the clinical practice.

FINAL CONSIDERATIONS
In total, nine articles were analyzed, one being descriptive and eight being cross-sectional.Regarding the strength of evidence obtained in the articles, it was found that the nine studies were of level VI; i.e. not presenting strong evidence for clinical application.
Even faced with this limitation and the small number of studies on the contamination of the clothing of healthcare professionals, there was agreement among them regarding the recovery of microorganisms, including strains resistant to antimicrobial agents, from the clothing of the healthcare professionals.In two studies, a similarity was observed between strains found in patients and in the occurrence of an outbreak and those isolated from white coats and gowns.
Considering the studies analyzed in this integrative review, it is suggested to revise and implement measures to guide healthcare professionals in care related to the storage and washing of clothes and their availability in sufficient numbers, favoring an increased frequency of changing and conscientization regarding their use in patient care areas.
Even though the contamination of clothes, especially of white coats, can seem obvious, the analysis and the registration of the presence of multiresistant bacteria can constitute a clear strategy concerning the importance of the role of each person in combating the dissemination of bacterial resistance.
In relation to EBP, the importance of developing new studies with strong levels of evidence in relation to the contamination of white coats, gowns and uniforms is emphasized, which could possibly contribute to the prevention and control of HAIs.

Table 1 -Description of the studies included in the integrative review, showing the authors, year of publication, journal, type of study design, evidence level and aim(s)
To evaluate the rate and risk factors for the detection of MRSA and VRE in gowns and gloves of healthcare professionals.