Abby S. Van Voorhees, MD, January 03, 2011
In this month’s Acta Eruditorum column, Physician Editor Abby S. Van Voorhees, MD, talks with Daniel B. Eisen, MD, about his recent JAAD article, “Surgeon’s garb and infection control: What’s the evidence?” Latin for “reports/acts of the scholars,” Acta Eruditorum will highlight a journal article each month and discuss how readers can apply the findings in their practices.
Dr. Van Voorhees: We all wear gloves, but what can you tell us about the potential advantages as well as the shortcomings of surgical glove use?
Dr. Eisen: The advantages of using surgical gloves are two-fold. One is to prevent the transfer of bacteria from the surgeon or operating staff to the surgery site and thus to reduce potential surgical site infections (SSIs). The other advantage is to prevent the contraction of contagious diseases from the patient and to prevent the patient from getting contagious diseases from the surgeon — hepatitis, HIV, or something of that nature.
Dr. Van Voorhees: Is there a reductionin SSIs when using either sterile ornon-sterile gloves?
Dr. Eisen: The use of surgical gloves in preventing SSIs really hasn’t been proven.
Many dermatologic surgeons practice surgery using the so-called clean technique, using clean but not sterile boxed gloves. Other people will do a full-on sterile garb and face mask and cap and sterile gloves. There haven’t been many studies comparing sterile gloves to clean boxed gloves, but those that have been done haven’t shown a difference between the two types of gloves in terms of infection rates.
This is probably because clean boxed gloves contain very few bacteria on them to begin with. One study looked at the incidence of bacterial contamination on open boxed gloves in the ICU; they cultured the gloves without telling people and found that over half the gloves were sterile to begin with and the rest had three colony-forming units or less, which is very low and not likely to be a relevant source of infection. That’s probably the most likely explanation.
Dr. Van Voorhees: You reference a Mohs study in your paper looking at sterile vs. clean boxed gloves how do infection rates compare in that setting?
Dr. Eisen: That was a retrospective study with two surgeons. One surgeon performed procedures using non-sterile gloves and the other one with sterile gloves; they traded off halfway through. Sterile gloves were used for all of the closures. There was no difference in infection between the two surgeons; their conclusion was that sterile gloves didn’t reduce infections. The problem is that it was a retrospective study, but if they didn’t see a difference with 1000-something procedures, it probably isn’t clinically relevant.
Dr. Van Voorhees: Is this strong enough data to encourage practitioners to consider whether sterile glovesare necessary?
Dr. Eisen: My personal feeling is that they’re not necessary. The evidence so far hasn’t supported their use. There’s a study coming out in JAAD looking at infection rates using the clean technique and their infection rate was 0.9 percent — very low. For me the use of sterile gloves is probably an unnecessary expense.
Dr. Van Voorhees: What about double gloving?
Dr. Eisen: Double gloving, the use of glove liners, or triple gloving all of those things have been studied in terms of puncture rates. There is a significantly reduced puncture rate of the inner glove when multiple layers are used, but that hasn’t necessarily translated into lower infection rates. I think it’s sensible to wear liners or multiple layers when you have a patient with a known communicable disease like hepatitis C or HIV, but otherwise it’s probably not necessary.
Some of these studies have looked at contamination of the gloves after puncture and interestingly, the contamination of the gloves wasn’t related to where the puncture sites were, which suggests there isn’t a lot of bacteria escaping from these puncture sites when they occur. Gloves most likely to be contaminated were those used to drape the patient, which indicates the primary source of contamination was most likely the surgical field.
Dr. Van Voorhees: Does wearing masks reduce the risk of skin infections?
Dr. Eisen: Surgical masks were the last part of the surgeon’s garb to be adopted. Their use was mainly designed to prevent dispersion of respiratory droplets from the surgeon’s mouth to the surgery site. But many people will be surprised to learn that masks haven’t been shown to reduce SSIs. Air flows around the mask rather than through it, taking the path of least resistance. There have been studies done with tracer particles about the same size as bacteria and the studies have demonstrated that the particles make it out whether you’re wearing a mask or not.
Dr. Van Voorhees: What aboutthe presence of long hair or facialhair does that increase the riskof bacterial contamination?
Dr. Eisen: It doesn’t seem to make a difference.
Dr. Van Voorhees: What about protective clothing? Gowns? Shoe covers?
Dr. Eisen: Gowns have two potential advantages. One is to prevent the direct transfer of bacteria from the surgeon’s clothing or skin directly to the site; the other is to contain bacterial fallout from skin scales that we all release on a continual basis. We don’t know whether gowns help, but it doesn’t seem likely.
Shoe covers were never meant to prevent bacteria transfer but to reduce static electricity when surgery was done with ether, which is explosive. No one has shown a reduction in SSI from shoe coverings. It’s not likely they make much difference.
Dr. Van Voorhees: Are there any other factors that contribute to SSIs? Steps we can take to prevent them?
Dr. Eisen: The number-one factor in terms of reducing the number of airborne bacteria is the number of people present in the operating room. People shed thousands of skin scales; the more people you have, the more skin scales. If you’re really serious about reducing the number of bacteria in the air, you probably need to reduce the number of people in your operating room. That’s difficult in academic centers because students, residents, and fellows want to participate.
I think direct physical contact is the most likely and biggest source of bacterial contamination for most surgical sites; good sterile technique is the most important means we have of preventing SSIs. I don’t think that we can make a good argument for the use of most items of the surgeon’s garb in terms of SSI reduction, except for the use of gloves (clean or sterile).
Dr. Eisen is associate professor of clinical dermatology, director of aesthetic dermatology, and co-director of dermatologic surgery in the department of dermatology at the University of California-Davis. His article was published online by the Journal of the American Academy of Dermatology on Sept. 16, 2010. doi: 10.1016/j.jaad.2010.04.037.