Review Article

What’s Up Your Sleeve? A Scoping Review of

White Coat Contamination and Horizontal
Microbial Transmission
Ruba Sajdeya, MD, Akemi T. Wijayabahu, MS, Nichole E. Stetten, PhD, MPH,
Omar Sajdeya, MD, and Osama Dasa, MD, MPH
Objectives: White coats have been suggested to serve as fomites carry-
ing and transmitting pathogenic organisms and potentially increasing
the risk of healthcare-associated infections (HAIs). We aimed to exam-
ine the current evidence regarding white coat contamination and its role
in horizontal transmission and HAIs risk. We also examined handling
practices and policies associated with white coat contamination in the
reviewed literature.
Methods: We conducted a literature search through PubMed and Web of
Science Core Collection/Cited Reference Search, and manually searched
the bibliographies of the articles identified in electronic searches. Studies
published up to March 3, 2021 that were accessible in English-language
full-text format were included.
Results: Among 18 included studies, 15 (83%) had ≥100 participants,
16 (89%) were cross-sectional studies, and 13 (72%) originated outside of
the United States. All of the studies showed evidence of microbial col-
onization. Colonization with Staphylococcus aureus and Escherichia coli
was reported in 100% and 44% of the studies, respectively. Antibacterial-
resistant strains, including methicillin-resistant Staphylococcus aureus
and multidrug-resistant organisms were reported in 8 (44%) studies.
There was a lack of studies assessing the link between white coat con-
tamination and HAIs. The data regarding white coat handling and laun-
dering practices showed inconsistencies between healthcare facilities
and a lack of clear policies.
From the Department of Epidemiology, College of Public Health and Health Pro-
fessions, College of Medicine, and the Department of Occupational Therapy,
College of Public Health and Health Professions, College of Medicine, Uni-
versity of Florida, Gainesville, and the Department of Internal Medicine, Uni-
versity of Toledo Medical Centre, Toledo, Ohio.
Correspondence to Dr Ruba Sajdeya, Department of Epidemiology, College of
Public Health and Health Professions, College of Medicine, Emerging Path-
ogens Institute, 2055 Mowry Rd, PO Box 100009, Gainesville, FL 32610.
E-mail: rubasajdeya@ufl.edu. To purchase a single copy of this article, visit
sma.org/smj. To purchase larger reprint quantities, please contact
Reprintsolutions@wolterskluwer.com.
R.S. and A.T.W. contributed equally.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text, and links to the digital files are provided in the
HTML text of this article on the journal’s Web site (http://sma.org/smj).
The authors did not report any financial relationships or conflicts of interest.
Accepted November 23, 2021.
0038-4348/0–2000/115-360
Copyright © 2022 by The Southern Medical Association
DOI: 10.14423/SMJ.0000000000001405
Conclusions: There is robust evidence that white coats serve as fomites,
carrying dangerous pathogens, including multidrug-resistant organisms.
A knowledge gap exists, however, regarding the role of contaminated white
coats in HAI risk that warrants further research to generate the evidence
necessary to guide the current attire policies for healthcare workers.
Key Words: attire, contamination, healthcare-associated infections
(HAI), multidrug-resistant organisms, horizontal microbial
transmission, (MDRO), white coat
T he white coat, the symbol of purity and professionalism, has
been at the center of controversy around its potential role in
horizontal microbial transmission and healthcare-associated infec-
tions (HAIs). Current evidence suggests that white coats can serve
as fomites, carrying and transmitting pathogenic microorganisms,
including multidrug-resistant organisms (MDROs).1,2 Contami-
nation is believed to happen mainly when white coat sleeves come
in direct contact with patients’ bodies during physical examina-
tion.1,2 Previous data showed that up to 37% of HAIs in intensive
care units could be attributed to horizontal transmission,3 and
horizontal microbial transmission was associated with increased
morbidity, mortality, and patient care costs among hospitalized
patients.4,5 Horizontal transmission refers to the spread of infectious
agents from one individual to another through contact.6 Because
preventing HAIs has become a healthcare and public health prior-
ity,3,7 there have been calls to adopt policies to remove the white
coat from healthcare worker (HCW) dress codes. The white coat,
however, carries a symbolic significance of trust and professionalism
Key Points
• There is robust evidence that white coats worn by healthcare
workers can serve as fomites, carrying and transmitting danger-
ous pathogens, including multidrug-resistant organisms.
• There is evidence of inconsistent white coat handling and laun-
dering policies across healthcare settings in the United States
and around the globe.
• There is a knowledge gap regarding the role of contaminated
white coats in increasing the risk of healthcare-associated infec-
tions that warrant further research to generate the evidence neces-
sary for guiding the current attire policies of healthcare workers.

360 © 2022 The Southern Medical Association

Copyright © 2022 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.

that is deemed irreplaceable for many patients and physicians,8,9
and also has served as a protective shield for HCWs from poten-
tially hazardous infectious agents, which has triggered opposi-
tion to white coat removal calls.10
The controversy also has been fueled by the inconsistent evi-
dence linking white coat contamination with HAIs.4,5 Some pre-
vious evidence has demonstrated that white coats can carry and
transmit dangerous pathogens, suggesting a potential role in
HAIs.11–13 Others, however, considered the available evidence insuf-
ficient to support an association between transmission and increasing
HAIs risk because carrying pathogens does not necessarily cause
infection.10 Nevertheless, organizations concerned with infection
control, such as the Society for Healthcare Epidemiology of
America, recommend taking cautious measures, including removing
white coats during patient examination or direct patient contact.14
As the potential risk of HAI transmission through white coats
needs to be further evaluated, there is no clear policy regarding
white coat wearing in most healthcare settings. The purpose of
this review was to critically examine the evidence on the poten-
tial role of white coat contamination in horizontal microbial
transmission and HAIs risk to help inform HCW attire policies.
We also aimed to evaluate current white coat handling practices
and discuss key findings of existing studies.
Methods
We conducted a scoping review to examine the level of evidence
on white coat contamination and its role in horizontal microbial
transmission.
Literature Search
Relevant articles were identified using PubMed (National
Institutes of Health) and Web of Science Core Collection/Cited
Reference Search. Two investigators searched for articles published
before March 3, 2021, with an English-language full-text format
that assessed evidence related to bacterial cross-contamination
of HCWs’ white coats and HAIs, while they excluded reviews,
editorials, and case reports/series. We used the following combi-
nation of search terms to identify relevant articles from PubMed:
“White Coat Contamination,” “Iatrogenic Disease” [MeSH] OR
“Cross Infection” [MeSH] AND “white coat” [tiab] OR “white
coats” [tiab] NOT “white coat effect” [tiab] OR “white coat hyper-
tension” [tiab]. Once eligible articles were identified from PubMed,
a second search was conducted on the Web of Science Core
Collection/Cited Reference Search to capture eligible research
articles that cited the original reports. We also searched the bib-
liography of selected articles to identify additional relevant ref-
erences. The literature search yielded a total of 586 results.
Article Selection
After duplicate removal, 349 eligible articles remained for
abstract and full-text screening. During the full-text screening,
we did not restrict articles based on the characteristics of the
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Review Article
healthcare setting (eg, teaching hospitals, primary-tertiary care
hospitals, clinical and experimental settings, number of beds),
HCW characteristics (rank/position, specialization), or geographic
location; however, we excluded studies within dental care set-
tings and those primarily evaluating other types of attire (eg, per-
sonal clothing, disposable gowns, uniforms, scrubs), medical
equipment/accessories (eg, stethoscope, identity badges, pens),
or fabric types. A total of 18 articles were included in the study
after applying inclusion and exclusion criteria (Fig.).
Data Extraction
Two investigators extracted information on study design,
sample size, characteristics of the study population and healthcare
setting, assessment of microbial contamination, including common
hospital-associated MDROs, and cleanliness of white coats (eg,
laundry habits).
Results
A total of 18 studies from 1991 to 2020 were included. Among
the 18 included studies, 15 (83%) had ≥100 participants, 16 (89%)
were cross-sectional studies, and 13 (72%) originated outside of the
United States. The key characteristics of the included studies are
summarized in Supplemental Digital Content Appendix Table 1
(http://links.lww.com/SMJ/A274).
Contamination
All of the studies showed evidence of white coat microbial
contamination. Although 17 (94%) studies assessed microbial
contamination by white coat sites (n = 1, unspecified sample
collection site), only five (28%) studies reported the amount of
contamination by site.15–19 Of the five studies that reported con-
tamination by site, three (17%) reported that sleeves/cuffs were
the most contaminated site.16,18,19 Pockets were identified as the
most contaminated site in two studies (11%),15,17 and the second
most contaminated site in three (17%) studies.16,18,19
Primary contamination findings are summarized in Supplemental
Digital Content Appendix Table 2 (http://links.lww.com/SMJ/
A274). All of the studies that evaluated microbial contamination
in white coats reported Staphylococcus aureus, and methicillin-resistant
S. aureus (MRSA) was reported in seven (39%) studies.11,13,19–23
The second most commonly reported pathogen was Escherichia
coli (n = 8 studies, 44%).20–22,24–27 Other Gram-negative bacte-
rial strains commonly observed in white coats were Acinetobacter
spp.,3,15,22,24,28,29 Pseudomonas spp.,11,17,18,20–25,28,29 and Klebsiella
spp.21,22,25–27 Antibiotic sensitivity testing for more than one type of
antibacterial compounds was not performed in all of the studies; how-
ever, multidrug-resistant bacteria were reported in two articles.27,28
Two studies assessed cross-contamination. In a unique ran-
domized controlled experiment by John et al, in which a cauli-
flower mosaic virus DNA marker was used, cross-contamination
between contaminants of white coats and mannequins in a simu-
lated study was evident.30 John et al initially seeded the marker
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Sajdeya et al • White Coat Contamination and Horizontal Microbial Transmission

Fig. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram of the literature search and selection of
studies. *PubMed search term # 1: “white coat contamination”; PubMed search term # 2: “Iatrogenic Disease” [MeSH] OR “Cross Infec-
tion” [MeSH] AND “white coat” [tiab] OR “white coats” [tiab] NOT “white coat effect” [tiab] OR “white coat hypertension” [tiab].

on a first mannequin. Physicians were instructed to perform a sim-
ulated physical examination wearing long- or short-sleeved
white coats, followed by an examination on a second uncontam-
inated mannequin. Subsequently, swabs from the coats’ sleeves,
physicians’ wrists, second mannequins, and the surrounding
environment were taken. Compared with those wearing short-
sleeved white coats, participants who wore long-sleeved white
coats were found to have significantly higher contamination
with the DNA marker on their sleeves and wrists even after per-
forming proper hand hygiene practices.30 The viral DNA was
also recovered from the second mannequin as well as the sur-
rounding environment. They also found that the sleeves’ cuffs
of one or more physicians’ white coats came in direct contact
with patients and the surrounding environment (bed rails and
privacy curtains) during 44% of the physical examination simu-
lations.28 Contrarily, a cross-sectional study that compared the
contamination of S. aureus in white coats and owners’ nasal iso-
lates found no evidence of cross-infection.16
The Role of Laundry
The results of white coat contamination by laundering
behaviors of HCWs are summarized in Supplemental Digital Content
Appendix Table 3 (http://links.lww.com/SMJ/A274). There were
conflicting conclusions regarding the association between white
coat laundering and bacterial contamination. A majority of
studies found no association between white coat contamina-
tion and laundering habits.11,13,15–21,25,28 On the contrary,
one study, which assessed the contamination of any uniform
and laundering habits reported a positive correlation.27 Qaday
et al, who conducted a multivariable analysis of white coat
contamination by laundering habits, reported a null association

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after accounting for sex, HCW specialty, and working location
within the hospital (odds ratio 0.6, 95% confidence interval
0.2–1.3).25
Eight studies evaluated the relation between the duration of
white coat use and overall microbial/pathogen contamination but
using different time intervals. The association between contam-
ination and length of duration for which the coats were used was
not consistent (n = 4 null association/plateaued effect11,18,20,25;
4 = positive association16,22). Burden et al found that contamina-
tion happened within a few hours of wearing, with no difference
in contamination between nonlaundered and newly laundered
white coats, or between long- and short-sleeved white coats,
after wearing the coats for 8 hours.19 One study reported that
the percentage of contamination was higher among HCWs who
used white coats for >2 hours compared with <2 hours (76% vs
33%)21; another reported no difference between 30 min and
1 hour of use and > 1 hour of use (47% vs 48%).20 Two studies
reported that the level of bacterial contamination reached a pla-
teau within days to weeks.11,21
In addition, there were inconsistent laundry habits among
HCWs across the studies. Muhadi et al found that the frequen-
cies of washing white coats among medical students varied from
once a week to once every 2 months.17 There was no specific
policy for white coat laundering in any of the facilities, and there
were varying percentages of HCWs who washed their white
coats at home versus those who used hospital laundering facili-
ties. Treakle et al found that 67% of the white coats contami-
nated with MRSA were washed in the hospital laundering facil-
ity, compared with white coats that were washed at home,13 in
contrast to other studies that found higher contamination levels
in white coats that were washed at home.20
Other Findings
None of the studies were designed to compare different HCW
groups; nevertheless, some studies found differences among dif-
ferent HCW groups based on HCW types, department types, and
patient settings (Supplemental Digital Content Appendix Table 4,
http://links.lww.com/SMJ/A274). There was no significant correla-
tion between white coat contamination and demographic factors
of HCWs (sex17,18,20,21,25,26 and race17). There was a mixed evi-
dence contamination level by the position/grade of HCWs and
work location (eg, department/ward). There is, however, evi-
dence of a high degree of pathogen contamination, including
S. aureus in high-contact wards such as gynecological and inten-
sive care/accident wards and surgical and preoperative wards.
Discussion
The evidence regarding the potential role of white coat con-
tamination in horizontal microbial transmission and the risk
of HAIs remains limited. We reviewed 18 publications that
evaluated white coat contamination in HCWs. Differences in
study designs, including the characteristics of the clinical set-
ting (eg, number of beds, location, type of hospital) and the
Southern Medical Journal • Volume 115, Number 6, June 2022
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Review Article
variability of measurements make a direct comparison of the
results across the studies difficult. Below, we discuss key
findings, knowledge gaps, and potential implications for attire
policy development.
What Is Bugging the Coat? White Coats Harbor
Potentially Dangerous Pathogens
This article shows consistent evidence that white coats can
harbor potentially dangerous pathogens with antibacterial resis-
tance (eg, meropenem-resistant Gram-negative bacilli, MRSA,
and MDROs). The data suggest a possible role of white coats in
transmitting pathogenic microbes and increasing the risk of HAIs,
specifically when HCWs come in direct contact with patients dur-
ing physical examination. John et al illustrated the role of direct
contact with patients during examination in white coat contamina-
tion.30 Pathogens such as S. aureus and Enterococcus spp. can be
transmitted through direct contact or fomites.1 Even though this
trial studies the transmission of a DNA marker in an experimental
simulation rather than pathogens in clinical settings, disseminat-
ing the marker was analogous to live virus MS2 and nontoxigenic
Clostridioides difficile spores dissemination.
Even as the current evidence suggests that white coats serve
as fomites that can carry and transmit pathogens across hospital-
ized patients from the hospital environment to the community
and vice versa,4 there is no current HCW-attire infection control
policy in place in the United States. This is possibly the result of
the complex criteria of HAIs diagnoses and the limited evidence
linking the attire of HCWs as a risk factor for HAIs31,32 and the
controversy over whether white coats should be considered uni-
forms or personal protective equipment.14 Further experimental
studies are needed to evaluate a causal relation between white
coat contamination and HAIs risk.
To Use or Not to Use? That Is the Question
Most of the reviewed studies provided recommendations to
reduce white coat microbial transmission; these recommenda-
tions ranged from implementing infection control and laundry
guidelines to completely discarding white coats. Some recom-
mended restricting white coat wearing in nonclinical areas, includ-
ing cafeterias and dorms. Both Wong et al16 and Burden et al19
argued that there is not enough evidence to support the exclusion
of white coats from the hospital’s nonclinical areas, and echoed
others’ concerns about the repercussions of such exclusion for
patient–physician relationships.8
Meanwhile, no white coat laundering policies existed in any
of the hospitals included; some did not even have laundering-
facility services, and others did not offer laundering services
to all employees, leaving laundering responsibilities depen-
dent entirely on the habits of HCWs. Several studies found
higher contamination levels in white coats that were washed
at home, presumably because of differences in washing parame-
ters between the industrial laundry wash cycles (eg, water qual-
ity, water temperature, industry wash chemicals) and home wash
363
Sajdeya et al • White Coat Contamination and Horizontal Microbial Transmission
cycles, where low water temperatures and probable lack of dis-
infectant usage is expected in the home.26 In older studies, how-
ever, washing processes were less likely to match the cleaning
efficiency of more modern washing techniques, chemicals,
and equipment.
It is noteworthy that maximum contamination was achieved
within 8 hours of wearing the white coats in the study by Burden
et al, a duration that is similar to the shift duration of an HCW,
suggesting that using a new white coat at the beginning of each
shift would help minimize colonization, in contrast to only increas-
ing laundry frequency within a certain amount of time.19 Mishra
et al also reported increased pathogen contamination in white
coats from day-one shift to day-two shift.22 This finding may
give policymakers a clue as to whether white coats should be
considered uniforms or personal protective equipment. Never-
theless, a significant association between washing frequency
and contamination was found in other studies supporting imple-
menting laundry policies.
In 2007, the British Department of Health implemented the
“bare below the elbow” (BBE) dress code, which requires HCWs
to wear short-/ rolled-up sleeves to reduce the contamination on
sleeves/cuffs, and consequently, potentially reducing horizontal
transmission.33 The presence of potentially dangerous pathogens
known to cause HAI in white coats supports the logic behind the
BBE dress code and prompts us to consider adopting similar pol-
icies in the United States. Nevertheless, the studies that compared
contamination levels between long-sleeved white coats and short-
sleeved uniforms did not report strong evidence supporting the
use of short-sleeved uniforms. Another barrier to removing white
coats from the attire of HCWs is the patient–physician relationship
consequences. A large survey conducted in the United Kingdom
showed that the public did not consider the new physicians’ attire
to be any less of an infection risk and considered it to be the least
professional appearance for a male physician compared with a
long-sleeved shirt and tie or hospital scrubs.33 Zahrina et al found
that most patients changed their perception after being educated
about the infection risk associated with long-sleeve attire9; how-
ever, a survey conducted in the United Kingdom showed that
there was a significant decrease in HAIs within 5 years after im-
plementing the BBE.34
Is It the Culprit or the Bystander?
Although most of the studies reported cross-sectional evi-
dence on white coat contamination, a minimal number of studies
explored cross-contamination. The presence of pathogens on
white coats or evidence of cross-contamination may imply the
role of white coats as a risk factor for HAI; however, correlation
alone does not provide evidence for a causal link between white
coat contamination and HAI. As such, epidemiological studies
designed to account for potential confounders and temporal rela-
tionships are needed.
Wong et al found no evidence of cross-contamination between
white coats and hospitalized patients with HAIs, with only 34%
364
Copyright © 2022 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.
of S. aureus strains from white coats matching the owner’s nasal
swab strains.16 The cross-sectional nature of the study, evaluating
cross-contamination of only S. aureus, and the use of methods
(antibiograms and phage type) with limited comparative potential
to identify specific strains makes it difficult to rule out cross-
infection, however.35 Nevertheless, the phage-typing methods
could provide evidence of hospital-acquired strains of S. aureus
compared with community-acquired strains.36 The randomized
controlled trial conducted by John et al30 demonstrated the like-
lihood of pathogen cross-contamination between hospitalized
individuals and white coats of HCWs using a simulation study.
The study did not, however, provide evidence regarding the risk
of HAIs in real-life settings. Moreover, both studies did not con-
sider a wide range of factors that may affect the transmission of
organisms from fabrics to patients (eg, patient density, patient–
HCW contact duration) or the chain of infection and its relation-
ship to microbial transmission.
Our review is subject to other limitations and consider-
ations, which include the following: most of the included studies
were cross-sectional, hindering the ability to assess temporal or
causal associations; most of the studies had relatively small sam-
ple sizes, which may have affected power and led to insignificant
findings; no study evaluated fungus/viruses; studies were con-
ducted in different geographic locations, and the variability of
infection control practices, policies, pathogen distribution, and
microorganism screening methods make the findings hard to
compare; and most of the studies were not designed to compare
HCW groups and limited the study population to fewer groups
(eg, physicians, medical students), which affects the generaliz-
ability of the findings. Despite these limitations, there seems to
be some consensus in the literature on considering white coats
as a potential risk factor for HAI and taking precautionary mea-
sures to limit the level of contamination in white coats.
Can We Presume Innocence Until Proven Guilty?
Given the serious ramifications of HAIs on stakeholders
(patients, HCWs, and community) and considering the reports
of MDROs on white coats, a more sensible approach to minimize
contaminant load on white coats is needed. Strategies to reduce
contaminants on white coats include increasing the frequency
of laundering, home washing guidelines, encouraging HCWs to
own more than one white coat, emphasizing hand hygiene prac-
tices, offering storage spaces for residents and students, and using
short-sleeved white coats (or rolled-up sleeves) during direct con-
tact with patients and physical examination.2,4 Although these
recommendations may help, the decision to follow them is left to
individuals, and there are no active programs to implement such
guidelines or track compliance among HCWs. As such, reeval-
uation of white coat-wearing policies is needed.
Conclusions
There remains limited evidence of an association between HAIs
and white coat contamination. There is consistent evidence that
© 2022 The Southern Medical Association

white coats can serve as fomites for dangerous microorganisms,
including MDROs, suggesting a potential role of HAIs through
horizontal transmission. Further clinical and experimental studies
assessing a possible causal association between white coat con-
tamination and HAIs are warranted to provide reliable evidence.
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