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Handling Infection Control [Aug 2012]

From the operating theatre to the intensive care unit, Dr Seamus McHugh and Dr Mark Corrigan look at the current controversies and novel technologies surrounding gloves and hand hygiene. 

Healthcare associated infection (HCAI) causes considerable morbidity and mortality. The total number of patients acquiring HCAIs in the European Union every year is estimated at three million, and results in more than 50,000 deaths.

A recent Hospital Infection Society Prevalence Survey (HISPS) of HCAI noted an overall prevalence of 4.9%, with the figure increasing to 6% in tertiary referral centres. In North America, financial assessments calculate the costs of HCAIs to be $4.5 to $5.7 billion per year. In an individual patient context this translates into a minimum of $4,644 per case.

Factors associated with surgical site infection (SSI) can be either intrinsic or extrinsic. Intrinsic patient factors are those which are not reversible, such as diabetes mellitus. Extrinsic factors are those in which adherence to best practise can decrease infection rates.

Glove use is part of the standard operating procedure for the prevention of HCAI which further includes sterile procedural techniques, appropriate prophylactic antibiotics and optimal post procedural care.

Specifically in surgery the use of gloves has evolved over time, with early initial studies showing significant decreases in infection rates, particularly in SSI.

The use of gloves in HCAI prevention is a subject attracting much research and debate in the current literature, not only in the operating theatre but also in an intensive care unit (ICU) setting.

Double gloving

A number of current controversies exist regarding glove use in the healthcare setting, such as whether glove perforation intra-operatively results in increased SSI rates, therefore posing the question: can double gloving reduce the risk of surgical site infection?

A Cochrane review of 14 randomised controlled trials comparing double gloving versus single gloving was published in 2006. It found significantly more perforations in the single glove group than the inner gloves of the double glove group. The review also found that the addition of a second pair of surgical gloves significantly reduced perforations to innermost gloves.

Double gloving is also recommended to decrease the risk of occupational acquisition of a bloodborne virus such as hepatitis B. This is of particular importance when the operation involves a bloody field and there is glove perforation, with or without an injury to theoperator. A study involving 195 scrubbed operating theatre personnel noted a decreased relative risk of injury (relative risk 0.20 W[95% CI, 0.10-0.42]) where double gloving rather than single gloving was performed.

It has been traditional teaching that gloves should be changed promptly if punctured; however, there has been a paucity of research noting a definitive increased risk of SSI associated with glove punctures intra-operatively.

Several studies have demonstrated no increase in bacterial contamination of the surgeons’ hands or the outside of the surgical gloves in operations where gloves were shown to be punctured. One such study involving patients undergoing bilary surgery noted no transfer of skin bacteria from the operating team through perforated gloves. 

Similarly, both Ritter et al and McCue et al demonstrated that areas of contamination on surgical gloves examined after the procedure did not correspond with glove puncture locations in operators’ gloves that had been perforated.

Despite these findings a team of Swiss researchers linked glove perforation with increased SSI rates. This was a prospective cohort study involving 4,147 surgical procedures. Multivariate analysis showed an increased risk of SSI in procedures where there was glove perforation, and when antibiotic prophylaxis had not been given, odds ratio 4.2 p=0.003.

When antibiotic prophylaxis was given, the incidence of SSI was not significantly increased in those procedures where gloves were punctured. This raises the potential importance of double gloving only in cases where antibiotic prophylaxis is not routinely administered; for example, clean procedures or when it is inadvertently omitted.

Sterile versus non-sterile

A further debate in the literature centres upon the appropriate use of sterile versus clean, non-sterile gloves in a variety of healthcare settings. A study assessing superficial lacerations sutured in an emergency department setting looked into whether the use of sterile gloves improved patient outcome. This multicentre prospective randomised controlled trial (RCT) assessed 816 patients. It reported a decreased infection rate in the sterile gloves group of 6.1% compared to 4.4% in the non-sterile gloves group. 

A recent study assessing patients undergoing dermatological surgery supported the use of non-sterile gloves as a safe alternative to sterile gloves at a significant cost saving. This study assessed 60 patients undergoing Mohs micrographic surgery, specifically with regard to the dermatological procedures performed.

With regard to post-operative wound care there are a number of publications assessing whether the use of sterile gloves confers a benefit over non-sterile gloves. Traditional teaching would suggest that post-operative care of the surgical site is carried out using sterile gloves.

A previous study of 963 patients assessing whether SSI rates increase if clean, non-sterile gloves were used for wound care post-procedure noted no significant increase in SSI rates over a three month period. This study also noted significant cost savings with regard to decreased sterile glove use.
In contrast, recent publications have commented upon insufficient evidence to justify a universal practise change to non-sterile gloves in post-operative wound care management.

In the field of catheter related bloodstream infection (CRBSI) prevention, the use of sterile gloves is a source of debate in current literature. Undoubtedly best practise guidelines recommend that for insertion of central venous catheters (CVC), sterile gloves should be worn following hand hygiene consisting of a full surgical scrub.

With regard to CVC access, a study carried out in a paediatric oncology intensive care setting assessed whether using sterile gloves decreased CRBSI rates. Over a three year period routine use of sterile gloves for accessing CVCs was suspended. Sterile gloves were used only when obtaining blood samples from the line, or when injecting substances that required direct entry into the lumen. They noted no statistically significant difference in the incidence of exogenous septicaemia when comparing the control and study patients.

Gloves and hand hygiene compliance

Hand hygiene is the cornerstone of infection prevention and it is imperative that the wearing of gloves does not diminish hand hygiene compliance rates. A recent study aptly titled ‘The dirty hand in the latex glove’, reported that glove use was strongly associated with lower levels of hand hygiene (adjusted odds ratio, 0.65 [95% confidence interval (CI), 0.54-0.79]; P < .0001).

Improper glove use including sub-optimal hand hygiene compliance has been reported to be a significant HCAI risk. A previous study from a French university hospital noted potential microbial transmission in 18.3% (95% CI, 17.8%-18.8%) of patient contacts, because used gloves were not removed before performing care activities that necessitated strict aseptic precautions. They also noted that failure to change contaminated gloves contributed to poor compliance with hand hygiene.

A publication from the USA assessed 589 opportunities for hand disinfection. In contrast to previous studies they reported a significant positive association between glove use and subsequent hand disinfection (relative risk 3.9 [95% CI, 2.5-6.0]; P <.0001); however, this was an observational study in a single centre where initial hand hygiene compliance rates were noted to be quite low at 22.1%.

Novel technologies

There are a number of novel approaches seeking to optimise the protection afforded to both patients and healthcare professionals in infection prevention. Knitted outer gloves and glove liners significantly reduce perforations to the innermost glove. Perforation indicator systems such as the wearing of coloured inner gloves have also been seen to result in significantly more innermost glove perforations being detected during surgery.

One such study assessed the ability of participants to locate 30-micron laser holes in surgical gloves while performing simulated surgery. In participants using an indicator glove system up to 84% of the holes were identified, compared to as few as 8% in those gloves not using an indicator system.

Gloves impregnated with antimicrobials represent a novel approach to decreasing contamination after glove perforation. A recent study assessed microbial passage between glove layers in those wearing single gloves, double gloves and antimicrobial trilayer gloves in a theatre setting. A significant reduction in microbial passage was noted in those wearing trilayer antimicrobial gloves.

Wearing a third layer of sterile gloves itself has been previously reported to decrease glove perforation rates. While double gloving has been reported to have no substantial impact on function or tactile sensitivity in surgeons, wearing a third layer of gloves may compromise dexterity when performing delicate procedures.

A recent study assessed the use of universal gloving with emollient-impregnated gloves to determine if they resulted in improved hand hygiene compliance rates, as well as lower device associated infection rates in an intensive care setting. Although no statistically significant decrease was noted in CRBSI, urinary infection or ventilator associated pneumonia (VAP), there was a significant improvement in hand hygiene compliance.

Summary

In an operating theatre setting there exists ongoing debate about the efficacy of different aspects of surgical attire, such as double gloving to decrease SSI rates. Double gloving decreases the glove perforation rate, which may impact on SSI rates in cases where antibiotic prophylaxis is not given.

The use of indicator systems may lead to increased detection of glove perforations in a shorter time period, which may also confer increased protection to the operating team from bloodborne contamination.

The dexterity of those operating must be considered; however, it has been suggested that wearing a third layer of gloves, including those impregnated with antimicrobials, decreases glove perforation rates and further lowers levels of contamination within the operative field.

In an ICU setting, sterile glove use is a vital part of decreasing infection rates from indwelling devices, such as CVCs and urinary catheters. Best practise recommendations include the use of sterile gloves during their insertion. There have been recent studies questioning their widespread use in the daily accessing of CVCs where clean, non-sterile gloves have been suggested in particular instances at decreased cost, and without increased risk to patient care.

It is important to continue to maintain high levels of hand hygiene compliance throughout, irrespective of glove use or types of gloves used. The use of emollient-impregnated gloves presents a novel method of potentially increasing hand hygiene levels in healthcare workers wearing gloves.

Several studies have noted decreasing hand hygiene compliance rates where the wearing of gloves is erroneously considered an alternative. This presents a risk to patient safety and is a challenge that healthcare workers must be both vigilant towards, and active against. 

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Author


Dr Seamus McHugh and Dr Mark Corrigan


Dr Seamus McHugh is a specialist registrar in general surgery with The Royal College of Surgeons in Ireland.

T: +353 61 482219
E: seamusmchugh@rcsi.ie

Dr Mark Corrigan is a consultant breast surgeon at Cork University Hospital. He is also the lead author of the medical teaching book ‘Make a Decision: Surgery’, which provides a new approach to case based teaching.

T: +353 87 94 11 555
E: markcorrigan@rcsi.ie 

Dr Seamus McHugh and Dr Mark Corrigan are authors of the medical educational websites Surginfection and Pilgrims Hospital.

Surginfection is a targeted e-learning programme for surgical trainees to enhance patient safety in preventing surgical infection.

Pilgrims Hospital, which incorporates the interactive teaching resource Surgent, offers a platform of student e-learning using the application of interactive visual images to assist problem based learning in undergraduate surgery.

W: www.surginfection.com
W: www.pilgrimshospital.com 



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