Public Health (PhD) / Δημόσια Υγεία (PhD)

Introduction: Several studies have reported the presence of multidrug-resistant bacteria on healthcare workers uniforms, implicating textiles in the acquisition and transmission of infection within healthcare settings. The healthcare environment is recognised as a source of infectious diseases, and textiles are a significant vector in the transmission. Aim: To analyze evidence of methicillin resistant Staphylococcus aureus on healthcare personnel attire through a systematic review and to determine the presence of multidrug resistant bacteria on the pockets of healthcare personnel uniforms in hospitals and long term care facilities in Nicosia, Cyprus. Furthermore, to evaluate the ability of multi-drug resistant bacteria to be transferred and to survive between textiles and skin, by using three isolated organisms to inoculate textiles from used uniforms onto pig skin. Methodology: We performed a systematic review in Pubmed and Scopus 2000-2020, according to the PRISMA guidelines to analyze evidence of methicillin resistant Staphylococcus aureus on healthcare personnel attire. Among 4425 titles, 23 studies were included which varied in the sampling technique, type of attire, culture methods and laundering practices. Our experimental study and sampling were performed based on the EN ISO 14698-1:2003 standard, in a cross-sectional manner, in 9 hospital wards and 7 long-term care facilities in Nicosia, Cyprus, between April-August 2019. Several characteristics and practices of consenting participants were recorded during personal interviews prior to sampling. Three multi-drug resistant bacteria were further used to demonstrate their viability on textiles and their transference onto pig skin. Results: From the analysis of data of the systematic review there was notable variation in the personnel surveyed, their attires, sampling techniques, culture methods and laundering practices. Using a standardised sampling technique in our experimental study, 140 healthcare personnel were sampled (69 from hospitals, 71 from long-term care facilities), a total of 37 multi-drug resistant bacteria from 280 samples (13.2%) were identified, including 16 vancomycin resistant Enterococci, 15 methicillin resistant Staph.aureus, 5 extended-spectrum b-lactamase-producing bacteria (including a carbapenem-resistant Klebsiella pneumonia), 1 carbapenem-resistant Acinetobacter baumannii. Presence of multi-drug resistant bacteria was notably higher in long-term care facilities compared to hospitals (p= 0.03). Higher prevalence of isolated organisms from uniforms were noted on healthcare personnel that had worked for less than a year (p= 0.45), in those that opted for home laundering (p=0.68) and among personnel that visited the toilet during their shifts (p=0.32). Methicillin resistant Staph.aureus was recovered from pig skins at all concentrations for the whole duration of six hours. Vancomycin- resistant Enterococcus faecium was recovered from the concentration of 108 cfu/ml for 6 hours, and from the concentration of 105 cfu/ml for up to 3 hours. Carbapenem-resistant K. pneumoniae was recovered from the 108 cfu/ml concentration for six hours and up to 30 mins from the concentration of 105 cfu/ml, and at 1-minute interval at concentration of 103 cfu/ml. Conclusions: Our results have shown that the 22.8% the participants in the study, harboured multi-drug resistant bacteria on their uniforms. We identified that long-term care facilities are an important reservoir of microorganisms, calling for targeted interventions to reduce transmission risk. Our study also suggests that multi-drug resistant bacteria can be sustained and transferred from textiles to skin, even at low concentrations over time, supporting the notion that textiles are fomites and can be implicated in the spread of infection. Key words: textiles; multi-drug resistant bacteria; pig skin; contact transmission; healthcare-associated infections; long-term care facilities.