Wearing gloves: the worst enemy of hand hygiene?
2011; Future Medicine; Volume: 6; Issue: 8 Linguagem: Inglês
10.2217/fmb.11.77
ISSN1746-0921
Autores Tópico(s)Infection Control and Ventilation
ResumoFuture MicrobiologyVol. 6, No. 8 EditorialFree AccessWearing gloves: the worst enemy of hand hygiene?Matthieu EveillardMatthieu EveillardLaboratoire de Bactériologie-hygiène, Centre Hospitalier Universitaire d'Angers, et Groupe d'étude des interactions hôtes pathogènes (GEIHP, UPRES EA 3142), Faculté de médecine, Université d'Angers, 49000 Angers, France. Published Online:23 Aug 2011https://doi.org/10.2217/fmb.11.77AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail Keywords: glove removalhand hygiene complianceinfection controlmultiresistant bacteriastandard precautionsuniversal glovingAlthough healthcare worker (HCW) compliance with hand hygiene guidelines is considered the cornerstone of preventing pathogen cross-transmission, the overall proportion of adherence remains low, usually below 50% in most hospitals [1].Although a multimodal program designed to improve HCW adherence to hand hygiene has been shown to be effective [2], a sustained improvement of practice over time has been often difficult to obtain [3]. Other important efforts have been undertaken to increase hand hygiene compliance, particularly by improving our understanding of the determinants of hand hygiene behavior [4]. Some more coercive measures including violation letters and progressive disciplinary action for repeat offenders have also been proposed to act as an incentive for increased adherence [5].Hand hygiene and glove wearing are closely related practices in the clinical setting. Therefore, the usage of nonsterile disposable gloves must also be considered when investigating the reasons of poor compliance with hand hygiene and trying to improve it. According to standard precautions, gloves must be worn for contacts potentially exposed to body fluids in order to ensure the safety of HCWs. In addition, it is also recognized that gloves can be highly protective with respect to hand contamination [6]. The potential impact of this protective effect is particularly interesting for contact with multiresistant bacteria carriers or their environment [6]. However, wearing gloves is not completely free of risk in terms of microorganism cross-transmission.The frequent contamination of gloves after contact with patients and the risk of microorganism transmission in the absence of glove removal have been well established. In a study conducted in three intensive care units and two medical wards, Girou et al. demonstrated that failure to change or remove contaminated gloves was a major component in the poor compliance with hand hygiene [7]. In a more recent study, it has been shown that 36.2% of interactions between HCWs and patients colonized with multidrug-resistant Acinetobacter baumannii resulted in a contamination of the gloves worn by HCWs by the pathogen during these interactions [8]. It is also noticeable that 4.5% of these interactions resulted in contamination of HCW hands after glove removal. In another report, methicillin-resistant Staphylococcus aureus (MRSA) was isolated from HCW hands before washing in 13% of the cases in which HCWs had worn gloves during contact with an MRSA carrier [9].Therefore, several practices must occur around glove usage: hand hygiene before gloving, glove removal after each contact with the patient or environment and hand hygiene after glove removal. It must be admitted that poor practices are often recorded around glove usage. In a study conducted in a Turkish hospital, compliance with hand hygiene before gloving was 3% in physicians and 14% in nonphysicians [10]. The major risk associated with this lack of compliance is the contamination of glove boxes, making them an environmental reservoir of pathogens. The HCW behavior following a contact with gloves worn (i.e., glove removal and hand hygiene) is of major importance for the risk of microorganism cross-transmission. In a hemodialysis unit, a low compliance with hand hygiene (37%) and a lack of glove removal (performed in only 33% of cases) immediately after patient care have been reported [11]. Concurrently, the failure to change gloves between procedures on the same patient has been identified as a major problem in three hospitals in Hong Kong [12].Considering the risks generated by glove usage, another point of major interest is the extent of the indications for this practice. Certain authors consider that systematically donning gloves when caring for a multiresistant bacteria carrier can be questioned [7]. The recent national French recommendations regarding the prevention of resistant pathogen cross-transmission (excluding Clostridium difficile, vancomycin-resistant Enterococci and carbapenem-resistant Enterobacteriaceae, for which specific recommendations had been previously implemented) specify that glove usage should be limited to contacts presenting a potential risk of exposure to body fluids [13]. Nevertheless, these restrictions of gloving indications are poorly followed by HCWs. In a study conducted in eight healthcare settings for elderly people in western France, only 64.4% of contacts in which gloves had been worn were potentially exposed to body fluids [14]. A wide usage of gloves was also reported in other studies. For instance, in a Turkish university hospital, 35% of HCWs systematically wore gloves, whatever the kind of contact occurring with patients [15].Two recent studies conducted in French healthcare settings where glove usage is considered appropriate for contacts potentially exposing to body fluids and otherwise inappropriate, showed a close relationship between the appropriateness of glove usage and the adherence to practices following the contacts with gloves worn [16,17]. First, in four intensive care units located in a teaching hospital, an appropriate glove usage was reported as a factor significantly and independently associated with the compliance for glove removal immediately after contacts [16]. In addition, according to data recorded from an evaluation of practices conducted in 11 settings for the elderly, a significant negative correlation was identified between the proportion of glove usage in the absence of risk of exposure to body fluids and the compliance with hand hygiene [17]. Concurrently, it is noticeable that a significant positive correlation was identified between the overall proportion of contacts with glove using (with or without risk of exposure to body fluids) and the compliance with hand hygiene in the same study, showing that these practices are not contradictory [17]. Those results tend to demonstrate that glove usage should be limited to the indications corresponding to standard precautions.Recently, efforts have been made to incorporate additional components in gloves in order to facilitate and secure their usage and to extend their indications. Two objectives were followed: improving the skin tolerance to increase the hand hygiene compliance and adding antiseptic agents to prevent glove contamination by micro-organisms. The implementation of a strategy of universal gloving with emollient-impregnated gloves instead of contact precautions has been associated with improved hand hygiene compliance and skin health, while no statistically significant change in the rates of device-associated infections, C. difficile infections or acquisition of multidrug-resistant bacteria was observed [18]. Concurrently, gloves impregnated with an antiseptic dye showed a higher efficiency in preventing contamination of resistant pathogens on the outer membrane of gloves [19]. However, it seems difficult to generalize the results of this in vitro laboratory-based study to an in vivo clinical setting. In addition, the presence of an antiseptic agent in the gloves could encourage HCWs to wear them for prolonged periods of time with a false sense of security. Arguing from their results, Bearman et al. considered that universal gloving could be an alternative to contact precautions for controlling the spread of multidrug-resistant organisms [18]. However, the frequent misuse of gloves and its consequences on the lack of hand hygiene compliance and then on the occurrence of microbial transmission should lead us to carefully consider the impact of those new gloves in terms of effectiveness and safety in infection control. Moreover, a wide usage of these innovations could generate important extra costs that should be evaluated.While numerous studies have been undertaken to improve our understanding of the determinants of hand hygiene behavior, it seems urgent to improve our understanding of the determinants of glove usage behavior as well. One important reason for an excessive glove usage has already been identified, as some HCWs admitted to feeling safe while wearing gloves for prolonged periods of time, particularly in situations that they considered to be physically or 'emotionally' dirty [3].Finally, the most critical point in the interactions between glove usage and hand hygiene is probably the compliance with glove removal immediately after each contact with patients or environment. Therefore, an important question is to determine if a high compliance is an achievable goal or not. If it is not, glove usage should be restricted to contacts that are potentially exposing to body fluids.Financial & competing interests disclosureThe author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.Bibliography1 Sax H, Allegranzi B, Uçjay I, Larson E, Boyce J, Pittet D. 'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene. J. Hosp. Infect.67,9–21 (2007).Crossref, Medline, CAS, Google Scholar2 Pittet D, Hugonnet S, Harbarth S et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet356,1307–1312 (2000).Crossref, Medline, CAS, Google Scholar3 Jang JH, Wu S, Kirzner D, et al. Focus group study of hand hygiene practiceamong healthcare workers in a teaching hospital in Toronto, Canada. Infect.Control. Hosp. Epidemiol.31,144–150 (2010).Crossref, Medline, Google Scholar4 Whitby M, Pessoa-Silva CL, McLaws ML et al. Behavioural considerations for hand hygiene practices: the basic building blocks. J. Hosp. Infect.65,1–8 (2007).Crossref, Medline, CAS, Google Scholar5 Chou T, Kerridge J, Kulkarni M, Wickman K, Malow J. Changing the culture of hand hygiene compliance using a bundle that includes a violation letter. Am. J. Infect. Control38,575–578 (2010).Crossref, Medline, Google Scholar6 Hayden MK, Blom DW, Lyle EA, Moore CG, Weinstein RA. Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant Enterococcus or the colonized patients' environment. Infect. Control. Hosp. Epidemiol.29,149–154 (2008).Crossref, Medline, Google Scholar7 Girou E, Chai SHT, Oppein F et al. Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission. J. Hosp. Infect.57,162–169 (2004).Crossref, Medline, CAS, Google Scholar8 Morgan DJ, Liang SY, Smith CL et al. Frequent multidrug-resistant Acinetobacter baumannii contamination of gloves, gowns, and hands of healthcare workers. Infect. Control. Hosp. Epidemiol.31,716–721 (2010).Crossref, Medline, Google Scholar9 McBryde ES, Bradley LC, Whitby M, McElwain DLS. An investigation of contact transmission of methicillin-resistant Staphylococcus aureus.J. Hosp. Infect.58,104–108 (2004).Crossref, Medline, CAS, Google Scholar10 Hakko E, Rasa K, Karaman IP, Enunlu T, Cakmakci M. Low rate of compliance with hand hygiene before glove use. Am. J. Infect. Control39,82–83 (2011).Crossref, Medline, Google Scholar11 Girou E, Chevaliez S, Challine D et al. Determinant roles of environmental contamination and non-compliance with standard precautions in the risk of hepatitis C virus transmission in a haemodialysis unit. Clin. Infect. Dis.47,627–633 (2008).Crossref, Medline, Google Scholar12 Chau JP, Thompson DR, Twinn S, Lee DT, Pang SW. An evaluation of hospital hand hygiene practice and glove use in Hong Kong. J. Clin. Nurs.20,1319–1328 (2011).Crossref, Medline, Google Scholar13 Société française d'hygiène hospitalière. Recommandations nationales. Prévention de la transmission croisée: précautions complémentaires contact. Consensus formalisé d'experts, avril 2009. Hygienes17,81–138 (2009).Google Scholar14 Eveillard M, Pradelle MT, Lefrancq B et al. Measurement of hand hygiene compliance and gloving practices in different settings for the elderly considering the location of hand hygiene opportunities during patient care. Am. J. Infect. Control39,339–341 (2011).Crossref, Medline, Google Scholar15 Sacar S, Tugurt H, Kaleli I et al. Poor hospital infection control practice in hand hygiene, glove utilization, and usage of tourniquets. Am. J. Infect. Control34,606–609 (2006).Crossref, Medline, Google Scholar16 Hitoto H, Kouatchet A, Dubé L et al. Factors affecting compliance with glove removal after contact with a patient or environment in four intensive care units. J. Hosp. Infect.71,186–188 (2009).Crossref, Medline, CAS, Google Scholar17 Eveillard M, Joly-Guillou ML, Brunel P. Correlation between the practices of glove usage and the compliance with hand hygiene according to a multicenter study conducted in 11 settings for the elderly. Am. J. Infect. Control (2011) (In Press).Google Scholar18 Bearman G, Rosato AE, Duane TM, et al. Trial of universal gloving with emollient-impregnated gloves to promote skin health and prevent the transmission of multidrug-resistant organisms in a surgical intensive care unit. Infect. Control. Hosp. Epidemiol.31,491–497 (2010).Crossref, Medline, Google Scholar19 Reitzel RA, Dvorak LT, Hadrem RY, Fang X, Jiang Y, Raad I. Efficacy of novel antimicrobial gloves impregnated with antiseptic dyes in preventing the adherence of multidrug-resistant nosocomial pathogens. Am. J. Infect. 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This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.PDF download
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