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      Bacterial migration through punctured surgical gloves under real surgical conditions

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          Abstract

          Background

          The aim of this study was to confirm recent results from a previous study focussing on the development of a method to measure the bacterial translocation through puncture holes in surgical gloves under real surgical conditions.

          Methods

          An established method was applied to detect bacterial migration from the operating site through the punctured glove. Biogel™ double-gloving surgical gloves were used during visceral surgeries over a 6-month period. A modified Gaschen-bag method was used to retrieve organisms from the inner glove, and thus-obtained bacteria were compared with micro-organisms detected by an intra-operative swab.

          Results

          In 20 consecutive procedures, 194 gloves (98 outer gloves, 96 inner gloves) were examined. The rate of micro-perforations of the outer surgical glove was 10% with a median wearing time of 100 minutes (range: 20-175 minutes). Perforations occurred in 81% on the non-dominant hand, with the index finger most frequently (25%) punctured. In six cases, bacterial migration could be demonstrated microbiologically. In 5% (5/98) of outer gloves and in 1% (1/96) of the inner gloves, bacterial migration through micro-perforations was observed. For gloves with detected micro-perforations (n = 10 outer layers), the calculated migration was 50% (n = 5). The minimum wearing time was 62 minutes, with a calculated median wearing time of 71 minutes.

          Conclusions

          This study confirms previous results that bacterial migration through unnoticed micro-perforations in surgical gloves does occur under real practical surgical conditions. Undetected perforation of surgical gloves occurs frequently. Bacterial migration from the patient through micro-perforations on the hand of surgeons was confirmed, limiting the protective barrier function of gloves if worn over longer periods.

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          Most cited references17

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          Surgical glove perforation and the risk of surgical site infection.

          Clinically apparent surgical glove perforation increases the risk of surgical site infection (SSI). Prospective observational cohort study. University Hospital Basel, with an average of 28,000 surgical interventions per year. Consecutive series of 4147 surgical procedures performed in the Visceral Surgery, Vascular Surgery, and Traumatology divisions of the Department of General Surgery. The outcome of interest was SSI occurrence as assessed pursuant to the Centers of Disease Control and Prevention standards. The primary predictor variable was compromised asepsis due to glove perforation. The overall SSI rate was 4.5% (188 of 4147 procedures). Univariate logistic regression analysis showed a higher likelihood of SSI in procedures in which gloves were perforated compared with interventions with maintained asepsis (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.4-2.8; P < .001). However, multivariate logistic regression analyses showed that the increase in SSI risk with perforated gloves was different for procedures with vs those without surgical antimicrobial prophylaxis (test for effect modification, P = .005). Without antimicrobial prophylaxis, glove perforation entailed significantly higher odds of SSI compared with the reference group with no breach of asepsis (adjusted OR, 4.2; 95% CI, 1.7-10.8; P = .003). On the contrary, when surgical antimicrobial prophylaxis was applied, the likelihood of SSI was not significantly higher for operations in which gloves were punctured (adjusted OR, 1.3; 95% CI, 0.9-1.9; P = .26). Without surgical antimicrobial prophylaxis, glove perforation increases the risk of SSI.
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            Incidence of microperforation for surgical gloves depends on duration of wear.

            The use of sterile gloves is part of general aseptic procedure, which aims to prevent surgical team members from transmitting infectious agents to patients during procedures performed in an operating room. In addition, surgical gloves also protect team members against patient-transmitted infectious agents. Adequate protection, however, requires that the glove material remain intact. The risk of perforations in surgical gloves is thought to correlate with the duration of wear, yet very few prospective studies have addressed this issue. We prospectively collected 898 consecutive pairs of used surgical gloves over a 9-month period in a single institution. After surgical team members wore the gloves during surgical procedures, the gloves were examined for microperforations using the watertight test described in European Norm 455, part 1. The gloves were analyzed as a pair; if 1 glove had a perforation, the pair was considered to be perforated. In addition, we evaluated the use of a hand cream that contained a suspension of cornstarch and ethanol to determine its potential influence on the rate of microperforation. Wearing gloves for 90 minutes or less resulted in microperforations in 46 (15.4%) of 299 pairs of gloves, whereas wearing gloves for 91-150 minutes resulted in perforation of 54 (18.1%) of 299 pairs, and 71 of (23.7%) of 300 pairs were perforated when the duration of wear was longer than 150 minutes (P = .05). Subgroup analysis revealed no significant difference in the rates of microperforation for surgeons (56 [23.0%] of 244 pairs of gloves perforated), first assistants (43 [19.0%] of 226 pairs perforated), and surgical nurses (53 [20.5%] of 259 pairs perforated). Of 171 microperforations, 114 (66.7%) were found on the left hand glove (ie, the glove on subjects' nondominant hand), predominantly on the left index finger (55 [32.3%]). The use of the hand cream had no influence on the rate of microperforation. Because of the increase in the rate of microperforation over time, it is recommended that surgeons, first assistants, and surgical nurses directly assisting in the operating field change gloves after 90 minutes of surgery.
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              Double gloving to reduce surgical cross-infection.

              The invasive nature of surgery, with its increased exposure to blood, means that during surgery there is a high risk of transfer of pathogens. Pathogens can be transferred through contact between surgical patients and the surgical team, resulting in post-operative or blood borne infections in patients or blood borne infections in the surgical team. Both patients and the surgical team need to be protected from this risk. This risk can be reduced by implementing protective barriers such as wearing surgical gloves. Wearing two pairs of surgical gloves, triple gloves, glove liners or cloth outer gloves, as opposed to one pair, is considered to provide an additional barrier and further reduce the risk of contamination. The primary objective of this review was to determine if additional glove protection reduces the number of surgical site or blood borne infections in patients or the surgical team. The secondary objective was to determine if additional glove protection reduces the number of perforations to the innermost pair of surgical gloves. The innermost gloves (next to skin) compared with the outermost gloves are considered to be the last barrier between the patient and the surgical team. We searched the Cochrane Wounds Group Specialised Register (January 2006), and the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library Issue 4, 2005). We also contacted glove manufacturing companies and professional organisations. Randomised controlled trials involving: single gloving, double gloving, triple gloving, glove liners, knitted outer gloves, steel weave outer gloves and perforation indicator systems. Both authors independently assessed the relevance and quality of each trial. Data was extracted by one author and cross checked for accuracy by the second author. Two trials were found which addressed the primary outcome, namely, surgical site infections in patients. Both trials reported no infections. Thirty one randomised controlled trials measuring glove perforations were identified and included in the review. Fourteen trials of double gloving (wearing two pairs of surgical latex gloves) were pooled and showed that there were significantly more perforations to the single glove than the innermost of the double gloves (OR 4.10, 95% CI 3.30 to 5.09). Eight trials of indicator gloves (coloured latex gloves worn underneath latex gloves to more rapidly alert the team to perforations) showed that significantly fewer perforations were detected with single gloves compared with indicator gloves (OR 0.10, 95% CI 0.06 to 0.16) or with standard double glove compared with indicator gloves (OR 0.08, 95% CI 0.04 to 0.17). Two trials of glove liners (a glove knitted with cloth or polymers worn between two pairs of latex gloves)(OR 26.36, 95% CI 7.91 to 87.82), three trials of knitted gloves (knitted glove worn on top of latex surgical gloves)(OR 5.76, 95% CI 3.25 to 10.20) and one trial of triple gloving (three pairs of latex surgical gloves)(OR 69.41, 95% CI 3.89 to 1239.18) all compared with standard double gloves, showed there were significantly more perforations to the innermost glove of a standard double glove in all comparisons. There is no direct evidence that additional glove protection worn by the surgical team reduces surgical site infections in patients, however the review has insufficient power for this outcome. The addition of a second pair of surgical gloves significantly reduces perforations to innermost gloves. Triple gloving, knitted outer gloves and glove liners also significantly reduce perforations to the innermost glove. Perforation indicator systems results in significantly more innermost glove perforations being detected during surgery.
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                Author and article information

                Journal
                BMC Infect Dis
                BMC Infectious Diseases
                BioMed Central
                1471-2334
                2010
                1 July 2010
                : 10
                : 192
                Affiliations
                [1 ]Institute of Hygiene and Environmental Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany
                [2 ]Department of Surgery, Clinic of General, Visceral, Vascular and Thoracic Surgery, Ernst-Moritz-Arndt University, Greifswald, Germany
                [3 ]Department of Hygiene and Medical Microbiology, Medical University of Vienna, Vienna, Austria
                Article
                1471-2334-10-192
                10.1186/1471-2334-10-192
                2909237
                20594293
                03d5b3ae-dfca-438f-b752-c937352ee96a
                Copyright ©2010 Hübner et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 13 November 2009
                : 1 July 2010
                Categories
                Research Article

                Infectious disease & Microbiology
                Infectious disease & Microbiology

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