Microbial Flora on the White Coats of Dental staff, Karachi

Background: Wearing a white coat is recognized as a crucial part of medical practice. The definite use of white coats and how frequently they are reformed varies significantly among individual doctors and their specialties. There has always been some worry that white coats, like nurses’ uniforms and other hospital garments , may essentially play a part in spreading pathogenic bacteria. The aim of the present study was to evaluate the risk of transmission of pathogenic micro-organisms through the white coats of dental staff. Methodology: This cross-sectional study was conducted at Karachi Medical and Dental College (KMDC) from 4th August to 4th October 2019. 200 white coats samples were collected and sent to the KMDC laboratory. Samples were cultured on blood agar and MacConkeys' agar. SPSS version 17.0 was used to analyze the data and chi-square and Fisher exact test were applied for significance testing. Results: It was noted that most 150(75%) of the respondents washed their coats only once a week and 18(9%) had the habit of exchanging aprons. On the basis of self-grading, majority 158(79%) of the aprons were dirty, spillage was observed on 111(55.5%) aprons and 152(76%) of healthcare professionals did not remove lab coats while dining. Dental health professionals mostly kept their aprons on tables and about 53% of microorganisms were found in the upper region of aprons. The Gram-positive organisms were isolated as predominant ones from the samples obtained from the aprons. Conclusion: White coats and aprons serve as an important source of cross infection. Guidelines should be formulated for their effective cleaning, washing and appropriate handling.


Introduction
The nosocomial infections or healthcare associated infections are regarded as hazardous for patients and their families, who visit the healthcare facility 1 . Healthcare associated infections can be defined as, an infection taking place in a health care facility in an individual who was not infected before. It includes hospital acquired infections that become apparent after discharge. Moreover, occupational infections are also included that may occur among staff members of facility 2 .
In both the developing and developed countries, healthcare related infections are considered as a serious health problem. In poor resource setting, they may cause high impact. In such settings, the infection rate range is 25% to 40% 3 . Preceding research works have shown that nosocomial infections impart high financial strain on health care systems and patients. It results in increase in mortality, morbidity and high health care costs. According to an estimation, 1.4 million people suffer from nosocomial infections at any given time, throughout the world 4 .
Apron is a coat of dental as well as medical healthcare professionals which keeps their regular clothes safe from getting any kind of stains or contamination. Wearing apron is a sign of professionalism and it is a valued dress for doctors or healthcare professionals 5 . Wearing white coat brings credibility in medical profession and it is also used as a sign of authority and identification in medical profession. Wearing white coat have improved doctor-patient communication and build confidence to this relation 6 .
The color of coat is decisively selected as white because white color defines purity and cleanliness 7 . On the other hand, this may become contaminated with bacteria and play a role in dispersion of nosocomial infections to the patients. An important microorganism in this regard is methicillin-resistant Staphylococcus aureus (MRSA) which is antibiotic resistant and increases mortality 8 . In September 2007 the bare below the elbow policy brought about instatement in England. Contamination with pathogenic bacteria is commonly found on Aprons 6 . Hospitals are always concerned about the risk of transmission of pathogenic bacteria. Finding of many studies stated that transmission of pathogenic bacteria in hospital settings may have part role of white coats of doctors', nurses' uniform and other hospital garments 9 . White coats were banned and a new guideline was set regarding the dress code to control nosocomial infection in British hospitals. Hospitals are always concerned about the risk of transmission of pathogenic bacteria. Patients feel ease and show confident in doctors because of the white coat. Still, wearing white coat in non-clinical (rest room, cafeteria, libraries) area have marked question on the functionality of white coat 10 . Many hospitals do not have changing rooms so that medical student may be seen wearing white coat while traveling to and from hospital. It can also be a reason for contamination of coat.
Most of the times students kept wearing their aprons while eating their meals at canteen, library and also at nonclinical 11 . Also, sometimes healthcare professionals left their aprons on chairs or tables. In case of dental healthcare professionals, there is important risk factor for infection with various organisms due to the various contaminations found while doing dental care like splashes of blood, saliva and aerosols 1 Table 1 shows demographic data of the study participants. It was noted that 150(75%) healthcare professionals washed their coats only once a week and 18(9%) had habits of exchanging aprons. On the basis of selfgrading, 158(79%) of the aprons were dirty and spillage was observed on 111(55.5%) aprons. Aprons were used by 152(76%) health professionals while dining and 98(49%) had the habit of leaving their aprons on tables. No statistically significant association was found between microbial flora presence and factors such as place of keeping aprons (p=0.213), practice of exchanging (p=0.221), spillage (p=0.232), gender (p=0.112), frequency of washing (p=0.212) and use while eating (p=0.253).   (9) The microbial distribution for aprons is shown in the Table 2. About 53% of microorganisms were present on the chest region of aprons. The Gram-positive organisms were isolated as predominant ones from the aprons.

Discussion
White coat affiliates professionalism, credibility and purity with the health care professionals. However, they had been found to carry microorganisms that transmit infections 13 . This study was carried out to determine microbial flora on aprons of dental health care professionals in a dental college and hospital. Moreover, the factors related with contamination were aimed to be investigated along with usage and attitudes of doctors towards white aprons. The findings of present study show that white coats carry microorganisms because majority of the screened coats were contaminated. In one report contamination associated with white coats range from 28.46% to 95% 14 . This scenario imposes the question of place of white apron in the medical profession. Two reasons are responsible for this high bacterial load of white coats. One reason is that the doctors interact with patients, who shed microorganisms. Secondly, microorganisms can survive for 10 to 98 days on fabric material of white coats 15 .
The most common type of organisms found on aprons was Staphylococcus aureus (30%) these results are similar to what has been reported 7 . Bacillus species was the second most common organism found. Some forms of microbes including gram negative bacilli were regarded as environmental microorganisms having no clinical importance. MRSA was predominantly isolated S. aureus. MRSA is responsible for more than 60% hospital infections. Despite this fact, the dental health care professionals may carry them on aprons due to frequent dental contact 16 .
A study conducted by Srinivasan et al., 10 found that 95% of white coats of doctors and students were contaminated with Gram negative bacilli and aerobic spore bearers. Gram positive cocci and gram-negative bacilli were found to contaminate the white coats of 92% dental students in another study1. In the present study, an important isolated microorganism was diphtherias. These microorganisms are usually present as skin commensals, however; they result in nosocomial infections in immunocompromised individuals. Many other studies have reported diphtherias as an important isolate of white coats 12 . It was found that white coats of female doctors are more contaminated as compared to the male ones. However, there is no association between contamination and number of white coats possessed. This is because the frequency of washing a white coat is linked with contamination. In accordance with plateau effect, the maximum steady state is reached by contamination in first week and it does not alter in the following weeks. This is true as coats washed after a week were equally contaminated. To decrease contamination, white coats should be washed within a week with disinfectants 8 .
Future research works should be conducted by using unworn white coats as controls for comparison. Due to variation in predominant isolates in different studies, hospitals should attempt to find out predominant organism in their locality for comparison of nosocomial data. For pathogenic isolates, antibiotic sensitivity analysis should be conducted. The short sleeved white coats should be specially considered for evaluation in future studies. Moreover, association of doctor attire and patient preference should also be explored in Pakistan.

Conclusion
The findings of present study imply that white coat of doctors carry microorganisms, which can become means of spreading nosocomial infections and diseases. Thus, it is important to overcome contamination associated with white coats. This can be accomplished through regular hand wash before and after interaction with patients. Regular washing of aprons with disinfectants is also mandatory. To overcome bacterial contamination through coats, ban should be implemented on their use in nonclinical areas. Moreover, guidelines should also be formulated for better handling and washing of aprons.

Conflicts of Interest
None.