Abstract & Commentary
Gloves Are Not Perfect
By Eric C. Walter, MD, MSc
Pulmonary and Critical Care Medicine, Northwest Permanente and Kaiser Sunnyside Medical Center, Portland
Dr. Walter reports no financial relationships relevant to this field of study.
This article originally appeared in the June 2014 issue of Critical Care Alert. It was edited by David J. Pierson, MD, and peer reviewed by William Thompson, MD. Dr. Pierson is Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
SYNOPSIS: After caring for patients with Clostridium difficile infection, nearly 25% of health care workers were found to have hand contamination with C. difficile spores.
SOURCE: Landelle C, et al. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol 2014;35:10-15.
Clostridium difficile is a prominent pathogen in intensive care units (ICUs) and frequently leads to nosocomial infections. One of the most common modes of transmission of C. difficile is via the hands of health care workers (HCWs). In this study, Landelle and colleagues aimed to determine how often HCWs’ hands became contaminated with C. difficile after caring for patients with C. difficile infection (CDI). They also identified risk factors for hand contamination.
In this prospective study, HCWs caring for patients with and without CDI were observed daily over an 8-week period. Patients were located in the ICU and medical and surgical hospital wards. Over the course of the study, HCWs caring for seven patients with CDI and 16 control patients without CDI were observed. Observations included patient contact time, level of risk of patient contact (high risk was defined by the possibility of HCWs’ hands to be highly contaminated with fecal material, such as with handling bedpans), use of gloves, hand hygiene compliance, etc. All patients with CDI were placed in contact precautions. For HCWs, these precautions included the use of dedicated equipment, donning a disposable gown with full-length sleeves and gloves prior to entering the room, hand hygiene with an alcohol-based solution before wearing gloves, and hand hygiene with soap and water followed by alcohol-based solution after glove removal. HCWs’ hands were sampled for C. difficile spores immediately after caring for patients, following glove removal, but before hand washing.
Amazingly, and also disturbing, C. difficile spores were found on the hands of nearly one out of every four HCWs who had cared for patients with CDI (16/66, 24%). C. difficile spores were not isolated from any HCWs caring for patients without CDI (0/44). Having more patient contacts or more contacts with a patient’s environment was associated with a higher risk of hand contamination. The number and length of high-risk contacts as well as lack of glove use were also risk factors for hand contamination. After controlling for multiple risk factors using logistic regression, the number of high-risk contacts (odds ratio for every additional high-risk contact, 2.78; 95% CI 1.42-5.45) and having at least 1 contact without the use of gloves (odds ratio 6.26; 95% CI 1.27-30.78) were associated with hand contamination with C. difficile spores.
In this study, Landelle and colleagues report a distressingly high proportion of HCWs found to have hand contamination with C. difficile. Remember this study the next time you go to shake the hand of a colleague caring for a patient with CDI. Even more worrisome, 24% may be a low estimate of the proportion of HCWs with hand contamination. In this study, all HCWs knew they were being observed. Despite knowing this, 7.8% of contacts occurred without the use of gloves. In unobserved settings, the lack of glove use is likely to be higher. Despite only 7.8% of contacts occurring without gloves, 24% of HCWs had contaminated hands. Some contamination can be explained by the lack of glove use but 56% of the HCWs with contaminated hands used gloves for all patient contacts. Gloves are not perfect.
There are some limitations to this study. The number of HCWs observed caring for patients with CDI was adequate but not large (n = 66) and there were only seven patients with CDI during the study. HCWs’ hands were not sampled for C. difficile spores prior to entering patient rooms, so it is possible that contamination was present prior to caring for patients with CDI. However, no spores were identified on the hands of HCWs caring for patients without CDI. It is presumed that hand contamination with spores is a risk for transmission of C. difficile but the degree of risk is not known, and this study does not address this question.
In summary, this study offers strong evidence that HCWs’ hands become contaminated with C. difficile spores during patient care and that glove use and contact precautions decrease the risk of contamination but are not perfect. The implied importance of washing your hands vigorously with soap and water after glove removal should not need repeating.