Bacterial pathogens from bed linen used in secondary and tertiary health facilities in Benin city, Nigeria

Health Care Workers (HCW) are exposed to various occupational hazards that may threaten their health and safety.1 However, exposure to hazardous agents depends upon the job category and the work environment of the HCW.2 Healthcare textiles include bed sheets, blankets, towels, personal clothing, patient apparel, uniforms, gowns, and drapes for surgical procedures.3 The importance of a clean environment and linen for optimal patient care has been stressed upon since the very inception of hospitals. Clean bedding and clean clothes create a psychological confidence in the patients and public.4


Introduction
Health Care Workers (HCW) are exposed to various occupational hazards that may threaten their health and safety. 1 However, exposure to hazardous agents depends upon the job category and the work environment of the HCW. 2 Healthcare textiles include bed sheets, blankets, towels, personal clothing, patient apparel, uniforms, gowns, and drapes for surgical procedures. 3 The importance of a clean environment and linen for optimal patient care has been stressed upon since the very inception of hospitals. Clean bedding and clean clothes create a psychological confidence in the patients and public. 4 Exposure to blood borne pathogens occur if personnel come into contact with healthcare textiles that are contaminated with blood or other potentially infectious body fluids. 5 Individuals exposed to contaminated faecal material such as those whose work involves direct contact with fomites such as linen, bed-pans, etc are most at risk of acquiring hepatitis A in the course of their work. 6 Contaminated textiles and fabrics may harbour high numbers of microorganisms from the different body substances they are in contact with, such as, blood, skin, stool, urine, vomitus, sputum, and other body tissue and fluid. When contaminated with potentially infective body substances, linen can contain bacterial loads of 10 6 -10 8 CFU/100cm 3 .
Creamer et al. 7 found methicillin-resistant Staphylococcus aureus (MRSA), 8 Pseudomonas aeruginosa, 9 vancomycin-resistant Enterococci (VRE) 10 to have been associated with the spread of pathogens by bed linen as one of the possible environmental routes. Also, there have been reports on bacteria such as Salmonella and Bacillus cereus 11 viruses such as hepatitis B; fungi such as Microsporum canis; and parasites such as scabies, being transmitted from contaminated linen to healthcare workers via direct contact and aerosol droplets of lint, generated from sorting and handling linen. 3 A report of a short study on bacterial pathogens from bed linen used in secondary and tertiary health facilities in Benin City, Nigeria is herewith provided.

Geographical location of study area
Benin City, the capital of Edo State, has a land area of 1,219.626km 2 and is bounded by latitude 6°20'North and longitude 5°39' East. The study was conducted in hospitals with laundry departments.

Methodology
Health facilities were randomly selected to represent each of the hospital categories (private secondary, government secondary and government tertiary health facility). The tertiary care facility is a specialized consultative health care facility, usually for inpatients and on referral from a primary or secondary health professional with facility that has personnel and facilities for advanced medical investigation and treatment. Secondary Healthcare facility refers to a second tier of health care facility in Nigeria which patients from primary health care facility are referred to specialists in higher hospitals for treatment. Three designated hospital linen types (clean linen, Used linen but not soiled with blood, urine or faeces and linen soiled with blood, urine or faeces) were used. Culture was prepared using nutrient agar to isolate the bacteria. The culture was produced using 0.5% peptone, 0.3% yeast extract, 1.5% agar, 0.5% sodium chloride and distille water with pH adjusted to neutral (6.8) at 25 °C. Morphological characterization of bacterial isolates was carried out using Gram staining procedure. The stained and air-dried slides were examined under microscope using oil-immersion objective technique. Biochemical characterization of bacteria using solubilization index based on colony formation were used in differentiating and identifying the types of bacteria. 12 Following suggested procedure from Bacteriological Analytical Manual of US FDA, CFU/g=(average no. of colonies x total dilution factor)/ volume plated. 13

Occurrence and distribution of bacterial isolates among different samples
The percentage occurrence of identified bacterial isolates showed P. aeruginosa as the least occurring isolate (22.22%) and S. aureus as the most occurring isolate (77.78%). Serratia sp., C. freundii, S. epidermidis and Proteus sp. were observed to occur as 44.44% of sampled linen, while B. Subtilis and Klebsiella sp. were observed to occur in 55.56% of sampled linen. B. Cereus and E. coli however, were observed to occur in 66.67% of sampled linen (Table 3).

Discussion
The total bacterial count on contaminated laundry (dirty and soiled) was higher than on clean laundry. This finding supports a report by Sehulster et al., 3 who noted that contaminated textiles and fabrics may harbour high numbers of microorganisms as a result of contact with different body substances such as, blood, skin, stool, urine, vomitus, sputum, and other body tissue and Fluid. It should also be noted that clean (laundered) textile was also observed to contain some bacterial pathogens, but low in estimation. This calls for proper disinfection of linen used. Identified bacterial isolates include; Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Bacillus cereus, Bacillus subtilis, Serratia sp., Klebsiella sp., Citrobacter freundii, Staphylococcus epidermidis and Proteus sp. There have been reports of methicillin-resistant Staphylococcus aureus (MRSA), 8 Pseudomonas aeruginosa 9 and Bacillus cereus 11 to have been associated with hospital bed linens. Furthermore, a survey of bacterial contamination of hospital staff apparel in use in Anambra State, Nigeria, was carried out to determine the extent of contamination by clinically important bacteria. The potentially pathogenic bacteria isolated were Proteus spp., Pseudomonas aeruginosa and Staphylococcus aureus, 14 while a microbiological analysis of swabs taken from the cuffs and pocket mouths of physicians' white coats in an acute care hospital showed that 91.3% of the coats had bacterial contamination, specifically Staphylococcus aureus and gram-negative Bacilli which were resistant to nearly all of the antibiotics tested. 15

Conclusion and recommendation
Bacterial pathogens were found on hospital linen, which could pose danger to laundry workers responsible for washing them and other health workers using them. These pathogens can easily acquire antibiotic resistance and therefore calls for the need to establish an effective infection control policy that incorporates the welfare of hospital laundry workers and other healthcare workers in all healthcare facilities.