Addition of Nonsterile Glove Use to Hand Hygiene May Reduce Gram-Positive and Central Line-Associated Blood Stream Infections in Premature Infants in the Neonatal Intensive Care Unit

EBM Focus - Volume, 9 Issue 48

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Reference: JAMA Pediatr 2014 Oct 1;168(10):909 (level 2 [mid-level] evidence)

Preterm birth is estimated to occur in 11.1% of all live births worldwide and is the most frequent cause of infant death in the United States (Lancet 2012 Jun 9;379(9832):2162, Pediatrics 2006 Oct;118(4):1566). Infection is a major cause of morbidity and mortality in preterm neonates and infection prevention measures are therefore extremely important when treating patients in neonatal intensive care units. Hand hygiene and glove use are simple measures that have been shown to reduce infections in cohort studies of preterm neonates and other pediatric populations (Arch Dis Child Fetal Neonatal Ed 2004 Jul;89(4):F336, Pediatrics 2013 May;131(5):e1515). A recent randomized trial compared nonsterile glove use plus hand hygiene vs. hand hygiene alone for all patient, bed, or catheter contact with 124 premature neonates < 8 days old in the neonatal intensive care unit. All included neonates had a birth weight < 1,000 grams or were born before 29 weeks gestation.

The trial defined hand hygiene as the use of alcohol hand sanitizer or handwashing with antimicrobial soap. Late onset infection was defined as ≥ 1 episode of bloodstream infection, urinary tract infection, meningitis, or necrotizing enterocolitis with clinical signs and symptoms at > 72 hours after birth. Hand hygiene compliance was 79%. Nonsterile glove use was associated with significantly fewer gram-positive blood stream infections (15% vs. 32%, p = 0.03 NNT 6) and a decreased rate of possible central line-associated blood stream infections (3.4 per 1,000 line days vs. 9.4 per 1,000 line days, p = 0.01), but there was no significant difference in late-onset infections overall (32% vs. 45%, p = 0.13). There were also no significant differences gram-positive urinary tract infections, gram-negative blood stream or urinary tract infections, coagulase-negative Staphylococcus blood stream infection, antibiotic treatment, length of hospital stay, or death.

The results of this trial suggest that some late-onset infections may be prevented by using nonsterile gloves in addition to hand hygiene when contacting the patient, bed, or catheter of extremely low birth weight and very preterm neonates. Although there was no significant difference in the rate of overall late-onset infections between groups, the rate of late-onset infections was lower than expected resulting in the trial being underpowered to detect differences between groups for this outcome. Nonsterile glove use was optional for parents and extending glove use to include parent contact may further decrease the rate of infection. Hand hygiene compliance was also lower than expected, however, and increasing compliance may impact the rate of infection in all preterm neonates.

For more information, see the Prematurity topic in DynaMed.

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