1. Introduction
Hospital-associated methicillin-resistant
Staphylococcus aureus (MRSA) is the most common cause of nosocomial infections and multidrug-resistant healthcare-associated infection [
1]. Risk factors for MRSA mainly include immunosuppression, hemodialysis, extended hospital stays, and advanced age [
2]. MRSA is a Gram-positive Staphylococcus strain that is resistant to widely used antibiotics known as betalactams such as methicillin, oxacillin, and penicillin. Generally, MRSA can be divided according to its etiology, namely, healthcare-associated and community-associated MRSA.
MRSA is highly prevalent in hospitals worldwide with the highest rates (>50%) reported in North and South America, Asia, and Malta [
3]. The infection of MRSA in healthcare settings may lead to life-threatening conditions, which include meningitis, pneumonia, and infective endocarditis [
4]. Contributory factors include compromised immune systems among inpatients that may worsen the disease, which can be acquired via healthcare instruments or casual contact from visitors or healthcare workers themselves [
5]. MRSA has also been associated with surgical wound infections, urinary tract infections, bloodstream infections, and pneumonia [
5].
The national prevalence rate of MRSA among
S. aureus clinical isolates was 19.8% in 2017 [
6]. The contributing factors to MRSA spread include poor health care worker hygiene, inadequate barrier nursing, antibiotic resistance, and an increase of potential number carriers and their fomite use. Items that are in contact with skin may serve as a fomite in MRSA transmission, which includes attire such as white coats and ties as well as stationery items such as pens [
7]. With the rise in the sheer number of medical students in Malaysia, there appears to be a potential source of preventable threat to the spread of MRSA to patients. The medical students’ use of fomite and personal hygiene would need to be considered in prevention measures.
MRSA can be transmitted through direct hand contact with contaminated body fluid or contaminated stethoscopes [
8], identification badges [
9], neckties [
10], and white coats [
11], all worn by healthcare workers (mainly doctors and medical students) and it can also be transmitted through contaminated surfaces. Interestingly, a study on one of the medical universities showed that the presence of MRSA on neckties was only detected on doctors and not the medical students [
12].
The objective of the study is to detect the colonization of MRSA on neckties, headscarves, and identification (ID) badges among medical students and to determine the association of MRSA colonization with socio-demographic characteristics and knowledge score on hand hygiene. We would also like to explore the role of medical student’s fomites as a possible source of MRSA-spread in a local health care setting.
3. Discussion
The results show medical students in their clinical years who wear neckties and ID badges are more likely to be contaminated with S. aureus compared to those worn by preclinical medical students who have minimal exposure to hospital settings. The MRSA on clinical students’ neckties and ID badges might be because of exposure to hospital settings as opposed to preclinical students who are not yet exposed to hospitals.
MRSA colonization has a higher prevalence in the neckties worn by clinical students. Out of the 10 (25.0%) neckties worn by clinical students that were positive for
S. aureus (
p = 0.005), 1 (10.0%) had MRSA isolates. Furthermore, unrestrained neckties have the potential to make contact with patients easily because of their tendency to swing freely as the wearer leans forward, and it is not machine-washable [
13]. Studies have shown that 70% of doctors never cleaned their neckties, and the remainder reported their neckties are cleaned on average once in 20 weeks [
14]. Meanwhile, in our study, 48% admitted to never washing their neckties, while the remaining 52% admitted to washing their neckties at least once a month.
For ID badges, 3 (6.7%) came back positive with MRSA from 18 (45.0%) of those who were positive for
Staphylococcus aureus. The pendulous nature of ID badges that are attached to lanyards and hang around the front of the body may increase contact with patients and thus have higher chances of being colonized with MRSA [
13]. Interestingly, the poor hygiene of the ID badges worn by clinical medical students was postulated to increase measure taken the chances of ID badges being colonized with the nosocomial pathogen.
To our knowledge, this is the first study to report MRSA colonization in headscarves. One preclinical student tested positive for MRSA. Twelve cultures were positive for S. aureus (30.0%), and from those, 1 (8.33%) was positive for MRSA and was from a preclinical student. In our study, out of 63 preclinical students, 13 (20.0%) admitted to washing their headscarves at least once every fortnightly. In contrast, only 8.0% of clinical students washed their headscarves more frequently, which is every fortnight, weekly, or daily.
Medical students in their clinical years have a higher percentage of having good knowledge of hand hygiene practice compared to preclinical students [
15,
16]. The result shows 146 (57%) out of 256 medical students have a good knowledge score on hand hygiene practices. Out of 103 clinical students, 69 (67%) of them had good knowledge, which is slightly higher compared to preclinical students (50.3%). This is supported by previous studies that have indicated that 80–90% of clinical students show the right level of knowledge and awareness regarding hand hygiene practices and its importance as they have practiced it more while working in a clinical environment [
17,
18]. There is a significant association between knowledge scores on hand hygiene practices and the study phase of medical students.
Physician in formal attire (i.e., white coat, necktie) has been reported to portray a professional image to patients and may favorably influence trust and confidence-building [
19,
20]. However, contradicting results were observed in the Australian study that reported even without wearing a necktie, patients’ confidence or satisfaction in doctors did not diminish as long as they are neatly attired [
21]. Displaying ID badges are essential for healthcare as they serve as a secondary form of identification used to access controlled areas. Several studies have shown that cleaning or disinfecting ID badges is associated with the incidence of pathogen colonization [
22,
23]. The relevance of neckties and ID badges as a part of formal physician attire warrants further investigation as they have the potential to serve as a vector for nosocomial pathogen.
In retrospect, the number of clinical students as respondents should be increased to improve the validity of results. Further studies, including nasal carriage of
S. aureus, should be performed to determine the transmission of
S. aureus among medical students, patients, environment, and clothing. These strains should then be analyzed by molecular methods, e.g., Staphylococcal cassette chromosome mec (SCCmec) classification and typing methods, multilocus sequence typing (MLST), and pulsed-field gel electrophoresis (PFGE), which will further contribute to the determination of the transmission model of
S. aureus among medical students. Health authorities should take precautions on dress codes like wearing neckties, headscarves, and identification badges among medical students and health care workers to reduce the potential risk of harboring and transmitting life-threatening
S. aureus and MRSA. This is in line with the Malaysian Medical Association’s plea to discontinue the use of neckties as part of the hospital setup. Moreover, proper hand hygiene and attitude when in contact with patients should be adhered to in order to reduce the risk of transmitting
S. aureus to others, especially immunocompromised patients [
24].
This study was conducted at a single teaching center with 251 respondents. An increase in sample size may have yielded more statistically significant results. MRSA colonization was assessed in headscarves, neckties, and ID badges. It has been shown that MRSA colonization was also observed in other sites, such as whitecoats. Hence, this may lead to an underestimation of MRSA prevalence among clinical students that frequently use whitecoats compared to preclinical medical students.