Should we all be wearing gloves? Every time we touch a baby?

Two new articles over the summer suggest that the answer to that question may well be yes. The first is the best quality of the studies, an RCT in a single center in the USA. Kaufman DA, Blackman A, Conaway MR, Sinkin RA: Nonsterile glove use in addition to hand hygiene to prevent late-onset infection in preterm infants: Randomized clinical trial. JAMA Pediatrics 2014. 124 babies less than 1kg or less than 29 were randomized. There was a sign placed on a stand next to the incubator informing the caregivers that the baby was in a study; also on the stand was a box of non-sterile gloves for the babies randomized to the gloving group. There was a bottle of alcohol hand rub within arms length of the baby’s bed for babies in both groups.

In the usual care group caregivers were told to use the rub before touching the baby, in the gloving group they also were supposed to clean their hands in the same way, and then put on the gloves. I say ‘supposed to’ because of course we know how lousy hospital staff are at washing their hands.

In the gloving group there were fewer Gram Positive infections, and fewer catheter related infections (at least when using a pragmatic definition, rather than the more stringent CDC definition). As a modestly sized study the authors did not find other differences that you might hope for, such as decreased mortality, decreased length of stay, or decrease in costs, but those things are all driven by multiple factors, and would need a much larger study to prove.

I think this is the only neonatal RCT of this intervention, but it is consistent with 2 before/after studies, one of which was also published during the summer (Janota J, Šebková S, Višňovská M, Kudláčková J, Hamplová D, Zach J: Hand hygiene with alcohol hand rub and gloves reduces the incidence of late onset sepsis in preterm neonates. Acta Paediatrica 2014) This study was restricted to larger preterm infants from 32 weeks gestation onward. Their rationale for excluding the smaller babies was that the CDC already recommends routine glove use for very preterm infants. I do not actually think this is true, the reference they give is to the 3rd article (which ic not from the CDC) that I will refer to briefly, and a search of the CDC website did not turn up any recommendation for universal gloving for care of the very preterm infant; rather gloves are recommended whenever there may be contact with any body fluid. If anyone knows of such a guideline perhaps they would let me know. In this study the authors introduced universal glove use prior to touching any preterm baby in that gestational age range. They compared 7 months before introducing gloves and 7 months after, and found 5 of the 111 babies in the first group developed late-onset sepsis, and none of the 89 in the second group.

The third neonatal study I am aware of was published in 2004 (Ng PC, Wong HL, Lyon DJ, So KW, Liu F, Lam RKY, Wong E, Cheng AFB, Fok TF: Combined use of alcohol hand rub and gloves reduces the incidence of late onset infection in very low birthweight infants. Archives of Disease in Childhood – Fetal and Neonatal Edition 2004, 89(4):F336-F340.). With about 160 VLBW babies per group, they saw a reduction the proportion of babies who had at least 1 infection, from 53% to 31% after they introduced universal glove use.

Readers of this blog will all know that before and after studies are a less reliable source of data than an RCT, and that we should be thoughtful about introducing changes in the care of the very preterm infant. It is also interesting that the 2 observational studies required the caregivers to re-apply the alcohol antiseptic wash after putting on the gloves, and then wait another 15 seconds for the alcohol to dry. In Dr Kaufman’s study they did not do that. In their publicaiton they do not describe all pf the things they did not do (!) so I wrote him to sepcifically ask him about that point, he kindly replied immediately to tell me that they did not require alcohol re-application after putting on the gloves.

Are there other data supporting the universal use of gloves for patient care? An observational study from a pediatric hospital (which included an NICU, Haem/Onc, PICU, and bone marrow transplant unit) compared their infections during RSV season, when the hospital had a policy of universal gloving for all patient contact, to non-RSV season when selective glove use was the norm. Their rates of invasive bacterial infections were lower over the 9 year period whenever universal gloving was the policy, in the NICU, the PICU and the transplant unit. Their overall conclusion was :

Universal gloving is a simple, practical, and feasible prevention strategy that requires minimal time and economic resources. In our study, the routine use of gloves to prevent spread of RSV in pediatric units also prevented other HAIs, such as BSIs and CLABSIs. These secondary benefits support the continuation of universal gloving throughout the year in high-acuity PICUs.

I am not sure why they only state that for the PICU, the data seem just as strong for the NICU and the Bone Marrow Transplant unit.

So are there enough data to start doing this right away? There are a few reasons to be cautious I think, the main one being that there are observational data showing that people are even worse at washing their hands when they are required to wear gloves. Gloves easily get contaminated when you put them on, so you still have to wash your hands properly before putting on the gloves (and when you take them off!). During a clinical trial the results might be different to what would happen over a long time in routine practice, would the benefits decrease as caregivers became blasé about hand-washing, because ‘I am going to wear gloves anyway’?

I think this requires some more thought and some more study, but it may be the way to go.

About keithbarrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
This entry was posted in Neonatal Research and tagged , , . Bookmark the permalink.

2 Responses to Should we all be wearing gloves? Every time we touch a baby?

  1. Jan Janota says:

    From Jan Janota:
    Re: Our article about handwashing in Acta Paediatrica
    Professor Kaufman (article about hand washing in JAMA Pediatrics) asked me the same question regarding CDC criteria for hand washing and gloves for very preterm neonates.
    There is an answer:
    I think our formulation was probably not appropriate in the Introduction of the article. There was a misunderstanding of our sentences. In the first part of the study we followed CDC criteria for hand washing. CDC generally recommends only washing and hand rub. Than we switched to criteria NOT recommended by CDC, but published by Wu et al. – hand washing, hand rub and gloves. So, gloves were added to the CDC protocol in the study of Wu et al., and then used in our study.
    Best regards and thank you for your comments :-)!
    Jan Janota

    • Thanks for the information. I think that using gloves universally for the tiny babies may well be a good idea, so I hope I did not sound critical. I appreciated your study, I think it will be helpful to have that information as we go forward.

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