Journal of Hospital Infection 80 (2012) 252e254

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Journal of Hospital Infection

journal homepage: www.elsevierhealth.com/journals/jhin

Short report

Prospective study on the effect of shirt sleeves and ties

on the transmission of bacteria to patients
R.L. Weber a, P.D. Khan a, R.C. Fader b, R.A. Weber a, *
a

Department of Surgery, Division of Plastic Surgery, Scott & White Healthcare, Texas A&M Health Science Center
College of Medicine, Temple, Texas, USA
b
Department of Pathology, Scott & White Healthcare, Texas A&M Health Science Center College of Medicine, Temple, Texas, USA

A R T I C L E

I N F O

Article history:
Received 9 September 2011
Accepted 20 December 2011
by J.A. Child
Available online 2 February
2012
Keywords:
Clothing
Hospital-acquired infection
Necktie
Policies
Sleeve
Transmission

S U M M A R Y

Costs associated with hospital-acquired infections lead to policies aimed at decreasing

their incidence. Clothing restrictions are often implemented in response, but they are
based on little scientific evidence. This study is a prospective, controlled investigation of
the effect of shirt sleeves and ties on the transmission of bacteria from doctors to
patients. Results show that wearing an unsecured tie results in greater transmission, but
that sleeve length does not affect transmission rate. The design is a possible model for
further controlled experiments to fill the evidence gap regarding the transmission of
micro-organisms from healthcare workers to patients.
2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Introduction

could lead to hospital-acquired infections.2 Unfortunately, like

many other studies, it fails to prove transmission. A literature
search revealed a relative lack of controlled trials to support
the various clothing restrictions that have been implemented
in healthcare delivery environments.
This study attempts to begin to fill the void and is a prospective, controlled investigation of the effect of various clothing
combinations on the transmission of micro-organisms from
doctors to patients. Specifically, this study investigates the extent
to which sleeve length and/or the wearing of a tie affects the rate
of transmission of bacteria from an examiner to a patient.

Hospital-acquired infections place large burdens on the

healthcare system. Their cost has led to policies aimed at
decreasing their incidence. During a recent outbreak of influenza A (H1N1), one Texas hospital asked its doctors not to wear
long sleeves or ties while seeing patients. This policy was based
on a British initiative, bare below the elbows e part of the
Heath Act of 2007 that had a goal of decreasing the spread of
organisms such as clostridia and staphylococcus.1
Debate has arisen regarding the evidence supporting these
policies. One frequently cited article reports the microbial
harbouring capacity of neck ties and long sleeves. It speculates
on the potential for spreading pathogenic bacteria, which

Methods

* Corresponding author. Address: Scott & White Healthcare, 2401

South 31st Street, Temple, TX 7508, USA. Tel.: 1 (254) 724 4263;
fax: 1 (254) 724 0315.
E-mail address: rweber@swmail.sw.org (R.A. Weber).

Institutional Review Board approval was obtained prior to

starting the study. Four clothing combinations were tested:
long sleeve shirt with unsecured tie, long sleeve without tie,
short sleeve with tie, and short sleeve without tie. To inoculate

0195-6701/$ e see front matter 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2011.12.012

R.L. Weber et al. / Journal of Hospital Infection 80 (2012) 252e254

the tie and sleeves, Micrococcus luteus (ATCC) was suspended
in sterile saline and adjusted turbidometrically to a concentration of w1.5  108 colony-forming units (cfu)/mL. A Dacron
swab was dipped into the bacterial suspension and was rubbed
over the terminal 6 cm of the tie for those tests involving the
tie and the corresponding location on the front of the shirt for
tests involving no tie. The terminal circumferential 2 cm of the
cuffed portion of long and short sleeve shirts were inoculated
in a similar manner. Cultures were obtained immediately after
inoculating the clothing prior to any interactions. The clothes
were cleaned and disinfected in between each combination
group.
Each of the four clothing combinations was worn by a
physician while he examined five simulated patients in each
combination group. The simulated patients were mannequins
dressed in hospital gowns lying in hospital beds in a simulation
center. Cultures were obtained from the mannequins cheek,
right hand, and abdomen before and after a standardized 2.5min history and physical examination. An area of w5 cm2 was
sampled with a Dacron swab moistened with sterile saline. The
swabs were inoculated on to Trypticase soy agar with 5% sheep
blood (BD Microbiology Systems, Sparks, MD, USA). Ties and
sleeves are sampled in a similar manner by rubbing a saline
moistened swab over the inoculated clothing surface. The
mannequins were cleaned and disinfected between each
encounter. After the last simulated patient encounter in
a group, the clothes were again cultured. In addition, after the
last simulated encounter, the tie was deliberately touched to
the mannequin, and this site was cultured.
The cultures were plated as above and incubated aerobically in an ambient air incubator at 35  C for 72 h. Colony counts
were then obtained from each plate, and the data were analysed using KruskaleWallis test, Fishers exact test, and Wilcoxon rank-sum test. Colony counts >300 cfu were statistically
analysed as 300 cfu.

Results
The control cultures of the physicians clothing inoculation
sites in each combination group both before the first simulated
patient interaction and after the last one demonstrated
>300 cfu of micrococcus on each. This confirmed the assumption that the bacteria were alive prior to and at the end of the
encounters. The culture of the deliberate contamination site
grew 44 colonies, demonstrating the ability of the mannequin
to be inoculated by an article of clothing.
Cultures taken from the abdomen, cheek, and hand sites of
the mannequin prior to encounter grew a total of five colonies
of contaminant bacteria. There was no growth of micrococcus
on any simulated patient prior to the history and physical
examination. Colony counts for the four combination groups on
all five mannequins are reported in Table I. The number of

Table I
Total colony counts of micrococcus cultured from the mannequins
after examination according to the four combinations of dress
Total colony counts
Long sleeve shirt
Short sleeve shirt

With tie

Without tie

24
2

1
0

253

simulated patients contaminated with micrococcus in each

combination group is reported in Table II.
Analysis of the data showed no significant difference in the
presence of micrococcus based on culture site (cheek, hand, or
abdomen). There was also no difference in total colony counts
or number of contaminated mannequins between any of the
four groups when analysed individually.
There were, however, important findings related to clothing
type. First, simulated patient encounters in which an unsecured
tie was worn had significantly more mannequins contaminated
with micrococcus compared with those encounters in which an
unsecured tie was not worn (P 0.036). Second, there was no
significant difference in colonization rates between long sleeve
and short sleeve patient encounters.

Discussion
Hand washing and basic infection control in regard to
clothing have been heralded for centuries as cornerstones in
the fight against pathogen transmission. In 1843, Oliver Wendell Holmes studies on puerperal fever urged physicians to
wash themselves and put on clean clothes.3 Four years later,
Ignaz Semmelweis implemented policies of hand washing upon
entering wards.4 Following the work of Louis Pasteur, Joseph
Lister established the principle that germs caused infections
and could be avoided with proper antiseptic practice, leading
to decreased mortality while lowering the burden on the
healthcare system.5
Recent increases in nosocomial infections have led to
additional precautions such as clothing restrictions to decrease
their incidence. Previous reports show that white coats and
sleeves, as well as equipment, such as pens and stethoscopes,
can harbour infectious agents.2,6e8 In 2007, the British medical
system adopted a bare below the elbows policy in an attempt
to decrease the transmission of infection from provider to
patient.3 This was based on two Thames Valley University
literature reviews, and the policy championed the idea of no
long sleeves, wristwatches, or neckties during clinical activity.
However, the articles in these reviews lacked controlled data
collection.
Previous studies have cited colonization to suggest that ties
and objects such as lanyards were likely to transmit bacteria to
patients.2,6 Dixon pointed out that ties may be sources of
transmission. Acknowledging that wearing barriers such as
aprons over the ties may lessen their potential as a source of
infection, the paper suggests the policy of (doing) without
neck ties all together in critical care areas.2 A cross-sectional
study by Kotsanas et al. showed that other items worn around
workers necks, such as lanyards, may be a potential source.6
Unfortunately, these reports lack appropriate controls and
fail to show actual transmission. In an era of evidence-based

Table II
Number of contaminated mannequins after examination according
to the four combinations of dress
No. of colonized mannequins
Long sleeve shirt
Short sleeve shirt

With tie

Without tie

4 of 5
2 of 5

1 of 5
0 of 5

254

R.L. Weber et al. / Journal of Hospital Infection 80 (2012) 252e254

medicine, restrictions are implemented regarding clothing

without adequate supporting evidence.
This small study begins to fill this gap by reporting a
controlled experiment documenting the transmission of
bacteria, or lack thereof, from an article of clothing to a
simulated patient. First, the results demonstrate that wearing
an unsecured tie did result in transmission of bacteria from the
physician to the patient. Neck ties most often end at the waist,
swing, and are not readily machine washable. In patient
interactions, unsecured ties may swing across an infected field
either to transmit bacteria to the patient, or to the cleansed
hands of the provider which are then transferred to the
patient.6 Our report provides evidence for a policy suggesting
that physicians should not wear unsecured ties when seeing
patients.
Second, the data did not show any significant difference in
the transmission of bacteria based on sleeve length. Sleeve
length and possible routes of transmission have been written
about in the past.9 One can understand how long sleeves make
contact with various objects and then the patient. Some feel
that long sleeves may actually decrease the adequacy of hand
washing, increasing transmission of bacteria. Recent studies
show that most doctorepatient contacts come from direct
touch between fingers or palms of the hands.10 Our study
showed that long sleeves were no more likely than short
sleeves to transmit bacteria during a history and physical
examination, such that policies prohibiting long sleeves may be
unwarranted. It should be noted that this is a small study of one
individual who knew he was being observed, therefore his
behaviour may not have been normal. Observational or larger
studies using this model are required to further define best
practice recommendations.
Decreasing the incidence of nosocomial infections is
a necessary task. Identifying possible vectors of bacterial
transmission from healthcare worker to patient is important,
and, as this paper demonstrates, hypotheses can be tested.
Appropriate healthcare policies can then be developed based

on evidence. In this study, wearing an unsecured tie significantly increased the risk of bacterial transmission during
a history and physical examination, whereas long sleeves did
not significantly increase the risk of bacterial transmission
compared with short sleeves.
Conflict of interest statement
None declared.
Funding sources
None.

References
1. Anonymous. Uniforms and workware. An evidence base for
developing local policy. London: Department of Health; 2007.
2. Dixon M. Neck ties as vectors for nosocomial infection. Intensive
Care Med 2000;26:250.
3. Jones A. Bare below the elbows: a brief history of surgeon attire
and infection. Br J Urol Int 2008;102:665e666.
4. Lister J. On a new method of treating compound fracture, abscess,
etc. Lancet 1867;89:387e389.
5. De Moulin D. A history of surgery. Amsterdam: Martinus-Nijhoff;
1988.
6. Kotsansas D, Scott C, Gillespie EE, Kroman T, Stuart R. Whats
hanging around your neck? Pathogenic bacteria on identity badges
and lanyards. Med J Aust 2008;188:3e4.
7. Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD,
Perencevich EN. Bacterial contamination of health care workers
white coats. Am J Infect Control 2009;37:101e105.
8. Wong D, Nye K, Hollis P. Microbial flora on doctors white coats.
BMJ Int 1991;303:1602.
9. Farrington RM, Rabindran J, Crocker G, Ali R, Polard N, Dalton HR.
Bare below the elbows and quality of hand washing: a randomized comparison study. J Hosp Infect 2010;74:86e88.
10. Pittet D, Allegranzi B, Sax H, et al. WHO Global Patient Safety
Challenge, World Alliance for Patient Safety. Evidence-based
model for hand transmission during patient care and the role of
improved practices. Lancet Infect Dis 2006;6:641e652.