JAMA Pediatrics Journal Club Slides: Glove Use to Prevent Infections in Preterm Infants

1. JAMA Pediatrics Journal Club Slides:Glove Use to Prevent Infections inPreterm Infants 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 Pediatr. Published online August 11, 2014. doi:10.1001/jamapediatrics.2014.953.

2. Introduction • Background • Late-onset infections commonly occur in extremely preterm infants and are associated with high rates of mortality and neurodevelopmental impairment. • Hand hygiene alone does not always achieve the desired clean hands, as microorganisms are still present >50% of the time. • Remaining colony-forming units on hands after hand hygiene may be a significant exposure to preterm infants. • Some retrospective studies have shown that glove use after hand hygiene may further decrease infections compared with hand hygiene alone. • Study Objective • To determine if nonsterile glove use after hand hygiene before all patient and intravenous catheter contact, compared with hand hygiene alone, prevents late-onset infections in preterm infants.

3. Methods • Study Design • Prospective, single-center, randomized clinical trial. • Duration of ≥4 weeks until patient no longer has venous access (central or peripheral). • Setting • Neonatal intensive care unit. • Participants • Birth weight <1000 g and/or gestational age <29 weeks. • <8 days old. • 175 eligible infants, of whom 120 were enrolled.

4. Methods • Outcomes • Primary: ≥1 episode of late-onset (>72 hours of age) infection in the bloodstream, urinary tract, or cerebrospinal fluid or necrotizing enterocolitis. • Secondary: Infection-related data, mortality, other neonatal morbidities.

5. Methods • Limitations • Single-center study and may be affected by local infection control practices. • Sample size was based on a higher incidence of infections than were observed in the control group, so it was underpowered for the primary outcome. • Aim of study was to have >90% compliance with hand hygiene rates. • Parents had the choice to use gloves or not use gloves if their child was randomized to group A (group with nonsterile glove use after hand hygiene). • There is a possibility that if hand hygiene, glove use by parents, and study protocol compliance were higher, infection rates may have been lower in 1 or both groups.

6. Results Primary and Secondary Infection-Related Outcomes

7. Results Difference in Proportions Between Groups With 95% CIs

8. Comment • Nonsterile glove use after hand hygiene prior to patient and catheter contact is associated with fewer gram-positive bloodstream infections (BSIs) and central line–associated bloodstream infections (CLABSIs) in this group of preterm infants. • Number needed to treat: • To prevent 1 gram-positive BSI is 6. • To prevent 1 possible CLABSI is 7.

9. Comment • In addition to the Centers for Disease Control and Prevention definition of CLABSI, we also evaluated possible CLABSIs defined as detection of growth from ≥1 blood culture of any organism, including coagulase-negative Staphylococcus, and the presence of a central catheter in the absence of another source. • We included this definition because asymptomatic BSIs, defined as growth in ≥1 blood culture and treated, even when caused by coagulase-negative Staphylococcus organisms, are associated with increased neurodevelopmental impairment and white matter injury in preterm infants.

10. Comment • Retrospective studies have demonstrated an association with the addition of glove use after hand hygiene in preterm infants and other patient populations. • Very low-birth weight infants: Decreased BSIs and necrotizing enterocolitis in preterm infants with birth weight <1500 g; this study had an additional step of applying alcohol hand rub to the gloves.1 • Intensive Care Units: Glove use after hand hygiene during respiratory syncytial virus season compared with the other months during an 8-year period in a children’s hospital was associated with fewer BSIs and CLABSIs in the neonatal intensive care unit, pediatric intensive care unit, and pediatric bone marrow transplant unit.2 • Ng PC, Wong HL, Lyon DJ, et al. Combined use of alcohol hand rub and gloves reduces the incidence of late onset infection in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 2004;89(4):F336-F340. • Yin J, Schweizer ML, Herwaldt LA. Pottinger JM, Perencevich EN. Benefits of universal gloving on hospital-acquired infections in acute care pediatric units. Pediatrics. 2013;131(5):e1515-e1520.

11. Comment • This readily implementable infection control measure may result in decreased infections in high-risk preterm infants.

12. Contact Information • If you have questions, please contact the corresponding author: • David A. Kaufman, MD, Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, 3768 OMS Hospital Dr, Charlottesville, VA 22908 (dak4r@virginia.edu). Funding/Support • The study was funded in part by grants from the University of Virginia Institute of Quality and Patient Safety, Cardinal Health Foundation, and University of Virginia Children’s Hospital Grant’s Program (Dr Kaufman). Conflict of Interest Disclosures • None reported.