Sterile gloves: do we really need them in wound
repair at the Emergency Department?
M. Been, pre-registration house officer, S.J.P.G. Aller MD, Emergency physician
St. Antonius Hospital Nieuwegein
ABSTRACT
Background – Sterile gloves are commonly used in wound management at the Emergency Department in
order to prevent transmission of microorganisms as well as to protect the operator. However, it remains
unclear whether sterile gloves provide an actual benefit compared to inexpensive non-sterile clean boxed
gloves in the prevention of wound infections.
Aim – To explore the best available evidence concerning the infection risk of wounds in the Emergency
Department with either the use of sterile or non-sterile surgical gloves.
Methods – A systematic search in Pubmed, Embase and Cochrane was performed. Based on title, abstract
and full text relevant articles were selected. Using predefined criteria selected articles were critically
appraised for relevance and validity.
Results – The study of Perelman et al. was considered the most relevant. They included and randomized
816 immunocompentent patients with uncomplicated lacerations and found no significant difference in
wound infection between sterile (6.1%) and non-sterile (4.1%) gloves (RR 1.37; 95%-CI 0.75-2.52).
Conclusion – The best available evidence suggests that sterile gloves do not reduce the risk of infection
when compared to non-sterile gloves in wound repair at the Emergency Department. However, further
research is needed to confirm the findings of Perelman et al. Until then, we advise clinicians to carefully
balance the risk factors that increase an individual’s risk.
Clinical scenario
.
A 22-year-old man visits the Emergency
Department after he fell off his bike. The fall
resulted in a superficial laceration on his arm
that requires suturing. Although it is common
practise to use sterile gloves for this procedure,
his doctor questions whether these costly sterile
gloves actually improve wound healing, i.e.
whether they reduce the risk of infection.
105 organisms/mL are needed to cause a wound
infection.3 Previous research has shown that,
although the bacterial load on clean gloves was
significantly greater than that of sterile ones, the
extent of this contamination was clinically
irrelevant when compared to the bacterial load
needed to cause an infection.4 In the case of
wound irrigation, several studies have revealed
that tap water instead of sterile saline can be
safely used for cleansing wounds in the
emergency setting.5,6,7 This evidence based case
report aims to explore the clinical evidence for
the benefit of sterile gloves in wound repair in
the Emergency Department.
Background
.
Current practise of using sterile techniques in
small surgical procedures is the result of a longterm development with gradually increased
knowledge
about
transmission
of
microorganisms and subsequent infections. The
use of sterile gloves as part of this approach,
motivated by the assumption that many bacteria
on our hands cannot be sufficiently removed by
soap or disinfectant, goes back to the nineteenth
century.1
However, as evidence based medical practise is
gaining ground against that of common sense,
the question arises whether these sterile and
costly gloves have actually proven their benefit
in the healing process of lacerations repaired at
the Emergency Department. Although current
guidelines still favour sterile gloves, Dutch
general practitioners are increasingly breaking
the habit of using the expensive ones en use the
inexpensive, non-sterile but clean gloves
instead.2 Besides the economic issue, using nonsterile gloves is likely to save time and requires
less assistance. It has been demonstrated that >
FIGURE 1. Flowchart
Clinical question
.
Does the use of sterile gloves in the treatment of
patients with wounds requiring small surgery at
the Emergency Department reduce the risk of
infection, compared to the use of non-sterile
gloves?
Methods
.
Search strategy
A systematic search in Pubmed, Embase and
Cochrane Library was performed. Synonyms for
the domain and determinant were combined
(see appendix 1). Duplicates were removed
using Refworks®. Title and abstract of all
identified publications were independently
screened by both reviewers, using in- and
exclusion criteria as presented in the flowchart
(figure 1). Subsequently, full texts of remaining
publications were screened using the same
1
criteria. Cross reference checking in Web of
Science was used to identify additional studies.
setting.11,12,13 Eventually, two studies were
excluded because sterile gloves were compared
to no gloves at all.8,9
Critical appraisal
Relevance and validity of the remaining studies
were appraised using predefined criteria (table
1). Consensus about applicability was reached
by all authors.
Study results
Results of the selected study can be found in
table 2. Details are discussed briefly. Perelman et
al.10 performed a multicenter randomized
controlled trial to evaluate infection risk when
using sterile or non-sterile gloves for the repair
of uncomplicated lacerations in the Emergency
Department.
They
included
816
immunocompetent patients with any type of
uncomplicated soft tissue lacerations. Open
fractures, vascular, nerve or tendon injury, bite
wounds and patients with delayed presentation
(>12 hours) were excluded. A wound infection
was considered to be significant if the follow-up
physician’s impression was that antibiotics or
referral for wound care was needed. They found
an absolute risk of wound infection of 6.1% in
the sterile glove group and 4.4% in the clean
glove group. This difference was not statistically
significant (RR 1.37; 95%-CI 0.75-2.52).
Data extraction
From all included studies absolute risks, relative
risks, risk differences and number needed to
treat or data to compute these outcomes were
extracted. Also, 95%-confidence intervals were
calculated.
Results
.
Search and selection
The search was performed on August 18th 2013.
The search retrieved 1267 unique articles. By
applying in- and exclusion criteria on title and
abstract, 13 articles remained. After full text
screening additionally seven articles were
excluded, because the article did not meet
inclusion criteria (see figure 1).
Discussion
.
It is commonplace to wear gloves in the
management of wound care, not only in order to
prevent transmission of microorganisms to the
patient, but also to protect the operator from
possible infections such as hepatitis. Although
current guidelines encourage the use of
Critical appraisal
An overview of the articles8,9,10,11,12,13 that were
critically appraised is presented in table 1. The
study of Perelman et al.10 was considered the
most relevant to answer our clinical question.
Three studies were excluded because their
domains were not applicable to the emergency
2
Rogues et al.12
(2007)
Xia et al.13
( 2011)
Analysis
Applicability
Chiu et al.11
(2005)
Blinding
Standardization of
treatment
Standardization of
outcome
Selection
Missing data
bias
Loss to follow up
Confounding Randomization
Baseline data
Concealed allocation
Intention to treat analysis
Perelman et al.10
(2004)
Validity
Domain
Determinant
Outcome
Study design
Information
bias
Maitra et al.9
(1986)
Relevance
Bodiwala et al.8
(1982)
TABEL 1. Critical appraisal
+
+
+
+
+
+
+
+
+
+
+
NS
NS
+
-
+
+
+
+
+
+
+
+
+
+
NS
NS
+
-
+
+
+
+
+
+
+
+
+
+
+
+
NS
+
+
+
+
+
+
+
+
+
+
+
+
NS
+
-
+
+
+
±
+
+
+
NS
+
-
+
+
+
+
+
+
+
+
+
+
+
NS
+
-
Domain: patients with traumatic skin injury requiring suturing: +, patients with elective non-traumatic surgery or
patients referred to operation room for complex surgery: -; determinant: comparison between sterile and nonsterile gloves: +, comparison between sterile gloves and no gloves -; outcome: risk of infection: yes +, no -; study
design: randomized controlled trial: yes +, no -; blinding: blinding of physician who evaluates outcome: yes +, no -;
standardization of treatment: clear description of standardized procedure: yes +, no -; standardization of
outcome: clear description of standardized outcome: yes +, no -; missing data: <10% or no risk of selection bias +,
10-20% with risk of selection bias ±, >20% with risk of selection bias -; loss to follow up: <10% or no risk of
selection bias +, 10-20% with risk of selection bias ±, >20% with risk of selection bias -; randomization: yes +, no -;
baseline data: available: yes +, no -; concealed allocation: yes +, no -; intention to treat analysis: yes +, no –;
analysis: AR, RR, RD, NNT and CI mentioned or extractable from data: yes +, no -; NS: not specified.
sterile gloves, this evidence based case report
questions their benefit in wound management in
the Emergency Department to prevent
infections.
gloves, the so-called Hawthorne effect.
Considering the high occurrence of traumatic
wounds in the Emergency Department, the
authors suggest that implementing the use of
non-sterile gloves could be expected to have a
modest positive economic impact, as sterile
gloves can be up to ten times as expensive, and
in addition, may be timesaving as well.10
Our findings suggest that, when compared to
non-sterile gloves, the use of sterile gloves in
repairing wounds does not lead to reduced
infection risk and hence does not necessarily
contribute to a better healing of the wound. It
should be noted that Perelman et al. studied
immunocompetent patients with uncomplicated
lacerations, hence these results account only for
this population. Interestingly, they found even a
lower, although non-significant, infection rate in
the non-sterile group. The authors suggest this
might be the result of the operating physicians
(who were not blinded for the type of gloves)
being more careful when using non-sterile
A few limitations should be taken into account
when interpreting our findings. First, a
systematic search in three databases revealed
only one article that compared sterile to clean
gloves in the context of traumatic lacerations in
the Emergency Department. Nevertheless, noninferiority of clean gloves was also found in
studies of patients who underwent minor
procedures in both
general practices,
dermatology clinics and dental care.2,11,13
3
TABLE 2. Results
Perelman
et al.10
(2004)
Definition
of
infection
Intervention
Antibiotics
or referral
for wound
care was
required
Sterilized latexfree gloves
(Allegiance;
Cardinal Health
Co.; IL) vs.
standard cleanboxed nonsterile, latexfree gloves
Infection rate
Sterile
(%)
Control
(%)
RR
(95%-CI)
RD
NNT
24/396
(6.1)
17/384
(4.4)
1.37
(0.75-2.52)
-0.017*
(-0.046-0.017)
-61*
RR relative risk (%infectionssterile / %infectionscontrol); RD risk difference (%infectionssterile - %infectionscontrol); NNT number
needed to treat (1/RD); 95%-CI 95%-confidence interval.
* minus-symbol indicates that results favour the control group.
Furthermore, two older randomized studies that
compared sterile gloves to bare hands found no
overall difference in the incidence of
infections.8,9 Second, to estimate an individual’s
risk of infection other risk factors should be
taken into account. For example, the time
between trauma and treatment, immune status
of the patient and the complexity of the
procedure. The latter two have shown to be
independent risk factors that increase the risk of
infection.3
compared to non-sterile gloves in wound repair
at the Emergency Department.
Recommendations
.
We recommend that non-sterile boxed gloves
can be safely used at the Emergency Department
for the repair of lacerations. However, further
research is needed to confirm and extend the
findings of Perelman et al. Until then, we advise
clinicians to carefully balance the risk factors
that increase an individual’s risk such as
immunocompromised patients or a complex
procedure, as this case report is limited to
uncomplicated cases with immunocompetent
patients.
Conclusion
.
Although evidence on this topic is scarce, the
best available evidence suggests that sterile
gloves do not reduce the risk of infection when
4
References
1.
2.
3.
4.
5.
6.
7.
.
Broek van den, PJ. Steriele handschoenen wél
nodig bij kleine chirurgie. Ned Tijdschr Geneeskd.
2011;155:A2954.
Bruens ML, Keijman JMG, van den Berg PJ. Steriele
handschoenen zijn niet nodig bij kleine chirurgie.
Een kritische beschouwing van de NHG-Richtlijn
Infectiepreventie. Huisarts Wet 2008;51:444-6.
Raahave D, Friis-Møller A, Bjerre-Jepsen K, et al.
The infective dose of aerobic and anaerobic
bacteria in postoperative wound sepsis. Arch Surg.
1986;121:924 –9.
Creamer J, Davis K, Rice W. Sterile gloves: do they
make a difference? Am J Surg. 2012;204:976–980.
Angeras MH, Brandberg A, Falk A, et al.
Comparison between sterile saline and tap water
for the cleaning of acute traumatic soft tissue
wounds. Eur J Surg.1992;158:347-350.
Valente JH, Forti RJ, Freundlich LF, et al. Wound
irrigation: tap water or saline? [abstract] Acad
Emerg Med. 8:539.
Riyat MS, Quinton DN. Tap water as a wound
cleansing agent in accident and emergency. J Accid
Emerg Med. 1997;14:165-166.
8.
9.
10.
11.
12.
13.
5
Bodiwala GG, George TK. Surgical gloves during
wound repair in the accident-and-emergency
department. The Lancet. 1982;10:91-92.
Maitra AK, Adams JC. Use of sterile gloves in the
management of sutured hand wounds in the A&E
department. Injury. 1986;17:193-195.
Perelman VS, Francis GJ, Rutledge T, Foote J,
Martino F, Dranitsaris G. Sterile versus nonsterile
gloves for repair of uncomplicated lacerations in
the emergency department: a randomized
controlled trial. Ann Emerg Med. 2004;43:362-70.
Chiu WK, Cheung LK, Chan HC, Chow LK. A
comparison of post-operative complications
following wisdom tooth surgery performed with
sterile or clean gloves. Int J Oral Maxillofac Surg.
2006;35:174-179.
Rogues AM, Lasheras A, Amici JM, et al. Infection
control practices and infectious complications in
dermatological surgery. J Hosp Infect.
2007;65:258-63.
Xia Y, Cho S, Greenway HT, Zelac DE, Kelley B.
Infection rates of wound repairs during mohs
micrographic surgery using sterile versus
nonsterile gloves: a prospective randomized pilot
study. Dermatol Surg. 2011;37:651-656.
APPENDIX 1. Search strategy performed on August 18th 2013
Pubmed
Embase
Cochrane
Domain*
(stitching[tiab] OR stitch[tiab]
OR stitches[tiab] OR
suturing[tiab] OR suture[tiab]
OR sutures[tiab] OR
wound[tiab] OR wounds[tiab]
OR laceration[tiab] OR
lacerations[tiab] OR cut[tiab]
OR trauma[tiab])
(stitching:ab,ti OR stitch:ab,ti OR
stitches:ab,ti OR suturing:ab,ti OR
suture:ab,ti OR sutures:ab,ti OR
wound:ab,ti OR wounds:ab,ti OR
laceration:ab,ti OR
lacerations:ab,ti OR cut:ab,ti OR
trauma:ab,ti)
(stitching OR stitch OR
stitches OR suturing OR
suture OR sutures OR
wound OR wounds OR
laceration OR lacerations
OR cut OR trauma)
Determinant
(sterile[tiab] OR sterility[tiab]
OR sterilized[tiab] OR nonsterile[tiab] OR nonsterility[tiab] OR nonsterilized[tiab] OR aseptic[tiab]
OR antibacterial[tiab] OR antibacterial[tiab] OR
antiseptic[tiab] OR clean[tiab])
AND
(glove[tiab] OR gloves[tiab] OR
equipment[tiab] OR
material[tiab])
(sterile:ab,ti OR sterility:ab,ti OR
sterilized:ab,ti OR non-sterile:ab,ti
OR non-sterility:ab,ti OR nonsterilized:ab,ti OR aseptic:ab,ti OR
antibacterial:ab,ti OR antibacterial:ab,ti OR antiseptic:ab,ti
OR clean:ab,ti)
AND
(glove:ab,ti OR gloves:ab,ti OR
equipment:ab,ti OR material:ab,ti)
(sterile OR sterility OR
sterilized OR non-sterile
OR non-sterility OR nonsterilized OR aseptic OR
antibacterial OR antibacterial OR antiseptic OR
clean)
AND
(glove OR gloves OR
equipment OR material)
Total hits
619
894
183
Note: domain and determinant were combined by using “AND”.
* For domain synonyms for suturing as well as for wound were used as we expected studies could either describe their domain as
patients who need suturing or patients having wounds.
6