Gloves after hand washing linked with fewer NICU infections

1. Wearing nonsterile gloves after hand washing resulted in fewer instances of gram-positive bloodstream infections and possible central line associated bloodstream infections in neonatal intensive care unit (NICU) patients when compared to hand washing alone. 

2. Although there was a trend towards fewer instances of late-onset infections, which was the primary outcome, this failed to reach significance. There was no difference in the rate of necrotizing enterocolitis between the two groups.

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Advances in neonatal intensive care protocols have dramatically increased the survival rates of extremely premature infants. However, late-onset infections and necrotizing enterocolitis (NEC) continue to be an ever present threat in this patient population, causing significant morbidity and mortality. Previous studies of critically ill patients have demonstrated that gloves are effective in preventing Clostridium difficile and vancomycin-resistant Enterococcus transmission. This study sought to determine whether nonsterile glove use after standard hand hygiene was superior to standard hand hygiene alone to prevent late-onset infections and NEC in preterm infants.

This study demonstrated that nonsterile glove use in addition to standard hand hygiene resulted in fewer gram-positive bloodstream infections (BSIs) and fewer possible central line associated bloodstream infections (possible CLABSIs) than standard hand hygiene alone. However, there was no significant difference in the primary outcome, which was the rate of late-onset infections and NEC. Strengths of the study include the randomized design. Weaknesses include the small sample size, which may have caused the study to be underpowered to detect the primary outcome. Moreover, hand washing auditing conducted during the study found only 79% compliance. The authors also examined a large number of secondary outcomes, increasing the probability of committing a type 1 error. Lastly, this is a single center study, which may not be generalizable to other NICUs.

Click to read the study, published today in JAMA Pediatrics

Click to read an accompanying editorial in JAMA Pediatrics

Relevant Reading: Assessment of alternative hand hygiene regimens to improve skin health among neonatal intensive care unit nurses

In-Depth [randomized controlled trial]: This randomized controlled trial examined 124 preterm infants admitted to the University of Virginia NICU, who had birth weight less than 1000 grams or gestational age of less than 29 weeks. 124 infants were randomized to the intervention group (gloves and hand hygiene) or the control group (hand hygiene alone). Four patients (two from each group) were randomized but not enrolled due to methicillin-resistant Staphylcoccus aureus colonization, requiring contact insolation. Providers caring for patients in the intervention arm were required to wear nonsterile gloves after performing standard hand hygiene prior to all patient, bed, and catheter contact. The primary outcomes included late-onset invasive infection (>72 hours after birth), and/or NEC.

The rates of late-onset infection were 32% in the intervention group and 45% in the control group (p=0.13). The rate of NEC was 10% in the intervention group and 7% in the control group (p=0.38). The rate of CLABSIs was similar between both groups as well (p=0.88). The rate of possible CLABSIs, defined as the detection of 1 or more blood cultures of any organisms, including coagulase-negative Staphycoccus, was lower in the intervention group (p=0.01). There was also a lower rate of gram-positive bloodstream infections in the intervention group (p=0.03). Hand hygiene compliance, which was audited once monthly during the study, was 79%.

Image: PD/CDC

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