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Glove Perforation And The Risk Of SSI

Tue, 01/05/2010 - 5:58am

Surgical glove perforation increases the risk for surgical site infection (SSI) unless antimicrobial prophylaxis is used, a prospective observational cohort study revealed in the June 2009 issue of the Archives of Surgery.

According to a review of the study by Medscape Medical News, the study was performed at University Hospital Basel, where approximately 28,000 surgical procedures are performed each year. The study involved 4,147 consecutive surgical procedures performed in the Visceral Surgery, Vascular Surgery and Traumatology divisions of the Department of General Surgery.

"All surgical staff members wear sterile gloves as a protective barrier to prevent hand-to-wound contamination during operations," write Heidi Misteli, MD, from University Hospital Basel in Basel, Switzerland, and colleagues. "When gloves are perforated, the barrier breaks down and germs are transferred. With the growing awareness among operating room staff of their risk of exposure to disease from patients, primarily human immunodeficiency virus and hepatitis B virus, gloves have begun to be regarded as a requirement for their own protection."

The main endpoint of the study was rate of SSI, as defined by the Centers for Disease Control and Prevention (CDC), and the main predictor variable was compromised asepsis because of glove perforation, Medscape summarizes.

Findings of the study include:

  • Of 4,147 procedures performed, 188 (4.5 percent) in all were associated with SSI.
  • Compared with procedures in which asepsis was maintained, procedures in which gloves were perforated had a higher likelihood of SSI, based on univariate logistic regression analysis (odds ratio [OR], 2.0; 95 percent confidence interval [CI], 1.4 - 2.8; P < .001).
  • The increase in the risk for SSI with glove perforation was different when surgical antimicrobial prophylaxis was or was not used (multivariate logistic regression analyses test for effect modification, P = .005). When antimicrobial prophylaxis was not used, the odds of SSI were significantly higher for glove perforation vs the group in which asepsis was maintained (adjusted OR, 4.2; 95 percent CI, 1.7 - 10.8; P = .003).
  • The likelihood of SSI was not significantly higher for procedures in which gloves were punctured when surgical antimicrobial prophylaxis was used (adjusted OR, 1.3; 95 percent CI, 0.9 - 1.9; P = .26).

"Without surgical antimicrobial prophylaxis, glove perforation increases the risk of SSI," the study authors write. "To our knowledge, this is the first study to explore the correlation between SSI and glove leakage in a large series of surgical procedures."

Limitations of this study include:

  • 22.1 percent missing data on glove perforation.
  • Prospective observational vs randomized controlled design.
  • Possible residual or unknown confounding.
  • Use of nonvalidated techniques to detect glove leakage.
  • Since this study was performed from 2000 to 2001, there have been significant changes in circulating relevant bacteria.

"Efforts to decrease the frequency of glove perforation, such as double gloving and the routine changing of gloves during lengthy surgical procedures, are therefore encouraged," the study authors conclude. "The present results support an extended indication of surgical antimicrobial prophylaxis to all clean procedures in the absence of strict precautions taken to prevent glove perforation. The advantages of this SSI prevention strategy, however, must be balanced against the costs and adverse effects of the prophylactic antimicrobials, such as drug reactions or increased bacterial resistance."

Critics of the study, however, note additional study limitations. According to the Medscape article, Edward E. Cornwell III, MD, from Howard University Hospital in Washington, DC, writes:

"I do not believe the recommendation to extend antibiotic prophylaxis guidelines is justified. Although the risk of SSI (with vs without glove perforation) among patients without antibiotic prophylaxis was significant on multivariate analysis, the data in this and other studies cited by the authors much more strongly support the measures suggested for lowering the risk of glove perforation. These measures would be substantially cheaper, more promising for efficacy, and less likely to produce allergies or adverse effects than giving prophylactic antibiotics to all patients."

The Department of General Surgery, University Hospital Basel, and the Freiwillige Akademische Gesellschaft Basel funded this study. The study authors and Dr. Cornwell have disclosed no relevant financial relationships.
Arch Surg. 2009;144:553-558.

Source: Medscape Medical News, article by Laurie Barclay, MD

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