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Title of Systematic Review Protocol:

Glove utilization in the prevention of cross transmission: A systematic review

Centre conducting review: The Thailand Centre for Evidence Based Nursing and
Midwifery

Primary reviewer: Associate Professor Dr. Wilawan Picheansathian

Telephone: 66-53-949007
Facsimile: 66-53-894171
Email: [email protected]

Secondary reviewer: Assistant Professor Dr. Jutamas Chotibang

Telephone: 66-53-949001
Facsimile: 66-53-894171
Email: [email protected]

Review Objective/Questions

The objective of this review is to evaluate the evidence regarding clinical use of gloves in the
prevention of cross transmission.
The following questions will be addressed in this review:
1. Does glove usage prevent the contamination of HCWs’hands and reduce cross
transmission?
2. What are the rates of adherence to glove utilization among HCWs?
3. What is the inappropriate use of gloves among HCWs?
4. How the wearing gloves impact on adherence to hand hygiene among HCWs?

Background:

Health care workers(HCWs)’hands become contaminated by pathogens and this increases

linearly with time on hands during patient care.(1) Therefore, cross transmission of
microorganisms by the hands of HCWs is considered the most likely means of transmission
of hospital-acquired infection.(2, 3) This risk can be minimized by thorough hand washing and
the use of gloves. Gloves are worn to protect the hands from contamination with organic
matter and microorganisms, and to reduce the risks of transmission of microorganisms from
HCWs to patients and vice versa. (4, 5) Gloves should be worn for invasive procedures, any
contact with sterile sites, non-intact skin, mucous membranes and exposure to blood, all other
body fluids and sharp or contaminated instruments. (6, 7) Two prospective controlled trials
provide evidence that wearing gloves can help reduce transmission of pathogens in health-
care settings.(8, 9) In addition, the efficacy of gloves in preventing contamination of
HCWs’hands has been confirmed in several observational studies.(10-12) However, gloves do
not provide complete protection against hand contamination. Bacterial flora from patients was
found on the hands of up to 30% of HCWs who had worn gloves during patient contact.(1, 10)
Bacterial can gain access to the caregivers’ hands via small defects in gloves or by
contamination of hands during glove removal.(13-15) Gloves often leak during use and, in fact,
may leak before use. (16)
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Gloves must be worn as single-use items, and changed between different patients and between
different care/treatment activities on the same patient to prevent cross-contamination of body
sites. (4, 5, 7) (4, 5, 7) Nevertheless, inappropriate use of gloves is observed regularly worldwide.
Three observational studies found that healthcare workers did not always remove gloves after
previous care and gloves were not always changed between each patient contact.(17-19)
Furthermore, one observational study demonstrated that gloves were overused in healthcare
environments.(19) The unnecessary and inappropriate use of gloves results in a waste of
resources and may increase the risk of cross transmission. In addition, inappropriate use of
gloves increases the wearer’s exposure to the chemicals and accelerants in the glove material,
which can result in skin sensitization or inability to work. (5)

Preventing cross contamination of hands by using gloves is considered important because

hand washing or hand antisepsis may not remove all potential pathogens when hands are
heavily contaminated. (19, 20) Although gloves offer protection, they do not provide complete
protection against hand contamination, therefore, hands should always be decontaminated
after glove removal.(21) Hand hygiene following glove removal further ensures that the hands
will not carry potentially infectious material that might have penetrated through unrecognized
tears or that could contaminate the hands during glove removal.(10, 11, 21) The impact of
wearing gloves on adherence to hand hygiene policies has not been definitely established,
since observational studies have yielded contradictory results. (17, 18, 22-25) Furthermore, failure
to remove gloves and to wash hands when moving between patients without change, can
result in the subsequent cross-transmission of nosocomial pathogens. (26, 27)Therefore, the
influence of glove use on hand hygiene practice is unclear. Given the impact of glove usage
on cross-transmission, we will conduct a systematic review to contribute to the understanding
of the efficacy of glove use in the prevention of cross transmission and identify specific areas
for further research.

A search of JBI Library of Systematic Reviews, Cochrane Library of Systematic Reviews,

DARE database, MEDLINE was performed and no existing systematic reviews on this topic.

Definitions of terms:

Clinical use of glove or glove usage refers to the wearing of gloves to either prevent the
hands becoming contaminated with organic matter or microorganisms, or to prevent the
transfer of microorganisms to both patients and healthcare workers. The choice of glove to be
use should be based on an assessment of the task of transmission of microorganisms to the
patient, and the risk of contamination to the healthcare worker by patients’ blood, body fluids,
secretions and excretions.

Cross transmission is defined as the method by which any potentially infecting agent is spread
from the healthcare worker to the patient and vice versa, as well as from one patient to
another.

Prevention of cross transmission refers to the management of those factors that could lead to
spread microorganisms so as to prevent the occurrence of the disease.

Reduction of cross transmission refers to the act of decreasing the risk of germ dissemination
to the environment and of transmission from the healthcare worker to the patient and vice
versa, as well as from one patient to another.
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Contamination of HCWs’hands refers to the presence of microorganisms on a surface of

HCW’s hands-therefore, a potential source for transmission.

Inappropriate use of gloves among HCWs is defined as the use of gloves when not indicated
which represents a waste of resources and may increase the risk of cross-transmission. It is
also refers to HCWs failing to remove gloves between patients or failing to change gloves
during the care of a single patient, thus facilitating the spread of microorganisms.

Adherence to hand hygiene among HCWs refers to readily acting in accordance with the
guideline for hand hygiene in the care of all patients. Adherence to the guideline is defined as
either washing the hands with soap or antiseptic and water or rubbing the hands with alcohol-
based solutions.

Inclusion Criteria

Types of studies
This review will consider any randomized clinical trails (RCTs) that evaluate the use of
gloves in the prevention of cross transmission. In the absence of RCTs, other research designs
such as before and after studies, descriptive or observational studies will be considered for
inclusion in order to identify the best available evidence related to the rates of adherence to
glove usage in caring for patient and the inappropriate use of gloves. .

Types of participants
This review will consider studies that include health care workers.

Types of intervention
The review will consider studies that evaluated glove utilization.

Types of outcome measures

The outcomes of interest include:

Contamination of HCWs’hands measured for example as the number of bacterial colonies

grown from the fingertips of the HCW’s dominant hand at the end of the observation period.

Transmission of infections measured for example as hospital-acquired infection transferred

from one patient to another via contaminated gloved hands. The potential for microbial
transmission is defined as an instance where gloves contacted mucous membranes, patient
skin, moist body substances or environment and gloves are not changed before performing a
care necessitating strict aseptic precautions on the same patient or another patient.

Adherence to glove usage measured for example as the number of observations of correct
performance per number of observations of glove usage opportunity.

Inappropriate uses of gloves measured for example as the number of observations of gloving
when not indicated or failure to remove gloves between patients and to change gloves during
the care of a single patient.
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Adherence to hand hygiene measured for example as the number of observations of correct
performance per number of observations of hand hygiene opportunity.

Search strategy
The comprehensive search strategy aims to find both published and unpublished studies. The
time period of the search cover articles published from 2000 to the present day in English and
Thai language. A three-step search strategy will be utilized in each component of this review.
An initial phase limited search of MEDLINE and CINAHL will be undertaken. A second
search using all identified keywords and index terms will then undertake across all included
databases. Thirdly, the reference lists or bibliographies of all identified reports and articles
will be hand searched for additional studies.

The following databases to be searched will include:

MEDLINE
CINAHL
EMBASE
The Cochrane Library
PubMed,
EBSCO Host Research Databases,
Blackwell synergy.
Individual search strategies will be developed for each database, adopting the different
terminology of index thesauri if available.

Hand searching of the most recent issues of the following journals will be conducted for
additional references:
American Journal of Infection Control
Infection Control and Hospital Epidemiology
Hospital Infection, Journal of the Medical Association of Thailand
Nursing Newsletter,
Bulletin of Nosocomial Infection Control Group of Thailand,
Nursing Journal,
Journal of Health Science.

The search will be conducted to locate relevant unpublished materials, such as conference
papers, research reports, Digital-dissertations, WHO (World Health Organization, CDC
(Centre for Disease Prevention and Control). Content experts will be contacted in order to
provide other alternatives for securing relevant literature.

All studies identified during the databases search will be assessed for relevance to the review
using a study eligibility tool developed by reviewers (see Appendix I). Full reports will be
retrieved for all studies that meet the inclusion criteria as assessed independently by two
reviewers. Any discrepancies in reviewer selections will be resolved at a meeting between
reviewers prior to selected articles being retrieved. Those studies meeting the inclusion
criteria will be submitted to critical appraisal.

Initial keywords or term:

include: gloves, transmission, infection, adherence, hand hygiene.
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Search for Grey Literature

The grey literature search will consist of conducting an online search of databases and
websites including:
 MEDNAR
 Dissertation International
 Conference Proceedings
 Google

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independently reviewers for methodology
quality prior to inclusion in the review using standardized critical appraisal instruments from
the Joanna Briggs institution (JBI) Meta Analysis of Statistics Assessment and Review
Instrument (JBI-MAStARI) (see Appendix II). Any discrepancies arise between the reviewers
will be resolved through discussion between the reviewers.

Data extraction

Data will be extracted from papers included in the review using the Joanna Briggs Institute
Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MASTARI) (see
Appendix III).

The data extraction will include specific details about the interventions, populations, study
methods and outcomes of significance to the review question and specific objective.

Data synthesis

Where possible, study results will be pooled in statistical meta-analysis using the Joanna
Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-
MASTARI). All results will be subject to double data entry. Heterogeneity between combined
studies will be tested using chi-square test. Odds ratio (for categorical outcome data) or
weighted mean differences (for continuous) and their 95% confidence intervals will be
calculated for analysis. Where statistical pooling is not possible the findings will be
summarized in a narrative form.

Conflict of interest
No conflicts of interest.

References:

1. Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. Bacterial contamination of the hands of
hospital staff during routine patient care. Archives of Internal Medicine. 1999 Apr 26;159(8):821-6.
2. Reybrouck G. Role of the hands in the spread of nosocomial infections. 1. J Hosp Infect. 1983
Jun;4(2):103-10.
3. Casewell M, Phillips I. Hands as route of transmission for Klebsiella species. Br Med J (Clin Res Ed).
1977 Nov 19;2(6098):1315-7.
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4. Pittet D, Allegranzi B, Boyce J, World Health Organization World Alliance for Patient Safety First
Global Patient Safety Challenge Core Group of E. The World Health Organization Guidelines on Hand Hygiene
in Health Care and their consensus recommendations. Infection Control & Hospital Epidemiology. 2009
Jul;30(7):611-22.
5. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee. Society for Healthcare
Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of
America. Hand Hygiene Task F. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene
Task Force. Infection Control & Hospital Epidemiology. 2002 Dec;23(12 Suppl):S3-40.
6. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory C.
2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings.
American Journal of Infection Control. 2007 Dec;35(10 Suppl 2):S65-164.
7. Flores A. Appropriate glove use in the prevention of cross-infection. Nursing Standard. 2007 May 9-
15;21(35):45-8.
8. Johnson S, Gerding DN, Olson MM, Weiler MD, Hughes RA, Clabots CR, et al. Prospective,
controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. American Journal
of Medicine. 1990 Feb;88(2):137-40.
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Staphylococcus aureus in a hospital and an intensive care unit. Infection Control & Hospital Epidemiology.
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10. Tenorio AR, Badri SM, Sahgal NB, Hota B, Matushek M, Hayden MK, et al. Effectiveness of gloves in
the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after
patient care. Clinical Infectious Diseases. 2001 Mar 1;32(5):826-9.
11. Olsen RJ, Lynch P, Coyle MB, Cummings J, Bokete T, Stamm WE. Examination gloves as barriers to
hand contamination in clinical practice. JAMA. 1993 Jul 21;270(3):350-3.
12. McFarland LV, Mulligan ME, Kwok RY, Stamm WE. Nosocomial acquisition of Clostridium difficile
infection.[see comment]. New England Journal of Medicine. 1989 Jan 26;320(4):204-10.
13. Kotilainen HR, Brinker JP, Avato JL, Gantz NM. Latex and vinyl examination gloves. Quality control
procedures and implications for health care workers. Archives of Internal Medicine. 1989 Dec;149(12):2749-
53.
14. Korniewicz DM, Laughon BE, Butz A, Larson E. Integrity of vinyl and latex procedure gloves.[see
comment]. Nursing Research. 1989 May-Jun;38(3):144-6.
15. Doebbeling BN, Pfaller MA, Houston AK, Wenzel RP. Removal of nosocomial pathogens from the
contaminated glove. Implications for glove reuse and handwashing. Annals of Internal Medicine. 1988 Sep
1;109(5):394-8.
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16. Berthelot P, Dietemann J, Fascia P, Ros A, Mallaval FO, Lucht F, et al. Bacterial contamination of
nonsterile disposable gloves before use. American Journal of Infection Control. 2006;34(3):128-30.
17. Thompson BL, Dwyer DM, Ussery XT, Denman S, Vacek P, Schwartz B. Handwashing and glove use
in a long-term-care facility. Infection Control & Hospital Epidemiology. 1997 Feb;18(2):97-103.
18. Girou E, Chai SHT, Oppein F, Legrand P, Ducellier D, Cizeau F, et al. Misuse of gloves: the
foundation for poor compliance with hand hygiene and potential for microbial transmission? Journal of
Hospital Infection. 2004 Jun;57(2):162-9.
19. Ehrenkranz NJ, Alfonso BC. Failure of bland soap handwash to prevent hand transfer of patient
bacteria to urethral catheters. Infection Control & Hospital Epidemiology. 1991 Nov;12(11):654-62.
20. Kjolen H, Andersen BM. Handwashing and disinfection of heavily contaminated hands--effective or
ineffective? Journal of Hospital Infection. 1992 May;21(1):61-71.
21. Bearman GML, Marra AR, Sessler CN, Smith WR, Rosato A, Laplante JK, et al. A controlled trial of
universal gloving versus contact precautions for preventing the transmission of multidrug-resistant organisms.
American Journal of Infection Control. 2007 Dec;35(10):650-5.
22. Zimakoff J, Stormark M, Larsen SO. Use of gloves and handwashing behaviour among health care
workers in intensive care units. A multicentre investigation in four hospitals in Denmark and Norway. Journal of
Hospital Infection. 1993 May;24(1):63-7.
23. Meengs MR, Giles BK, Chisholm CD, Cordell WH, Nelson DR. Hand washing frequency in an
emergency department. Journal of Emergency Nursing. 1994 Jun;20(3):183-8.
24. Larson E. Compliance with isolation technique. American Journal of Infection Control. 1983
Dec;11(6):221-5.
25. Kim PW, Roghmann M-C, Perencevich EN, Harris AD. Rates of hand disinfection associated with
glove use, patient isolation, and changes between exposure to various body sites. American Journal of
Infection Control. 2003 Apr;31(2):97-103.
26. Yap FHY, Gomersall CD, Fung KSC, Ho P-L, Ho O-M, Lam PKN, et al. Increase in methicillin-resistant
Staphylococcus aureus acquisition rate and change in pathogen pattern associated with an outbreak of
severe acute respiratory syndrome.[see comment]. Clinical Infectious Diseases. 2004 Aug 15;39(4):511-6.
27. Poutanen SM, Vearncombe M, McGeer AJ, Gardam M, Large G, Simor AE. Nosocomial acquisition of
methicillin-resistant Staphylococcus aureus during an outbreak of severe acute respiratory syndrome.[see
comment]. Infection Control & Hospital Epidemiology. 2005 Feb;26(2):134-7.
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Appendix I: Study eligibility checklist

Glove utilization in the prevention of cross infection

Author…………………………………….Year……………..Record No……

Types of participants

Health care workers 

Types of interventions

Glove use 

Types of outcome measures

Cross transmission 
Contamination 
Adherence to glove usage 
Adherence to hand hygiene 
Inappropriate uses of gloves 

Types of studies

Randomized Controlled Trials 

Quasi-experimental design 
Observational study 

.
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Appendix II: Critical appraisal instruments

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Appendix III: Data extraction instrument

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