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Glove powder: implications for infection control
Journal of Hospital Infection (1999) 42: 283–285
INFECTION CONTROL IN PRACTICE
Glove powder: implications for infection control J. Dave, M. H.Wilcox and M. Kellett Departments of Microbiology, University of Leeds and Leeds Dental Institute,The Leeds Teaching Hospitals,The General Infirmary, Great George Street, Leeds LS1 3EX Summary: Gloves are increasingly promoted for use by healthcare workers, but this use is not without risk. Data associating powdered gloves with an increased risk of latex allergy is available and there is circumstantial evidence that the powder used may increase bacterial environmental contamination. In animal models, corn starch, the material used as glove powder, promotes wound infection. Infection control teams need to be aware of this evidence and should support switching from use of powdered to powder free gloves. Keywords: Powder free gloves; latex allergy; infection.
Introduction Gloves prevent the transmission of microorganisms between patients and healthcare workers. The Department of Health1 has issued revised guidance for protection of healthcare workers from blood-borne infections, with specific suggestions for glove use. Gloves should be worn when contact with blood is anticipated and changed between patients. Hands should be washed before donning and after removing gloves. Gloves are suggested while cleaning equipment before sterilisation or disinfection, handling chemical disinfectants and when cleaning up spillages. Recently there has been increasing concern Received 6 January 1999; manuscript accepted 2 April 1999 Corresponding author: Dr J Dave, Consultant Microbiologist, Department of Microbiology, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX Tel. 0113 392 4655 Fax. 0113 392 4654 E-mail [email protected]
0195–6701/99/080283 + 03 $12.00
about the use of powdered gloves and the evidence against their use will be examined.
Glove powder William Halsted2 introduced gloves at the turn of the century and originally, gloves were sterilized by boiling and worn over wet hands. Powder was introduced as a lubricant to facilitate the wearing of gloves. Talc (magnesium silicate) alone and with spores of Lycopodium clavatum3 were the first agents to be used, but foreign body granulomas, peritonitis, peritoneal adhesions, inflammatory reactions were associated with their use in clinical practice, and experimental studies confirmed these observations.4,5 In 1947 corn starch powder treated with epichlorhydrin,6 later mixed with 2% magnesium oxide (dessicating agent) was suggested as a suitable alternative and is in use today. Nevertheless, there have been numerous © 1999 The Hospital Infection Society
284
reports of starch induced peritonitis and intraperitoneal granulomas and adhesions4,7–9 and activation of T cell responses by glove powder products has been suggested as the mechanism.10
Allergy Glove powder has been linked to latex allergies with prevalence rates of 7–17% reported in healthcare workers.11,12 The incidence of latex allergy is especially high in dental personnel because of the high frequency with which gloves are changed.13 Latex sensitization in dental students reached 10% incidence early in the second year of glove use.14 Type 1 hypersensitivity is associated with natural proteins present in latex gloves.15 Symptoms varying from rashes, to anaphylaxis subside on removal of the allergen but the sensitivity is irreversible. Type 4 hypersensitivity is linked to the residues of accelerating chemicals present in gloves.15 Symptoms appear within hours typically as an itchy rash. Corn starch absorbs latex protein residues and accelerating chemicals present in gloves.15 Once airborne, the glove powder becomes an environmental contaminant, increasing the level of exposure. The Medical Device Agency15 has produced a guidance report recommending that hospitals use gloves with low levels of extractable latex proteins and where possible gloves should be powder free.
Infection Powdered gloves are used widely on wards and airborne starch powder can contaminate areas where they are used.16 A clear association between starch particles and bacterial colonies has been demonstrated by air sampling studies16 suggesting that starch dust may carry micro-organisms. Dust was found to be present in a variety of high dependency areas and was also present in the theatre air, where the scrub team were wearing powder free gloves, but
J. Dave et al.
other staff were wearing powdered gloves.16 There is also a potential for corn starch to act as a food source for bacteria (including MRSA and VRE) and to act as a vector for their spread e.g., during phlebotomy, catherization or radiocogica procedures. Epidural catheters have also been demonstrated by electron microscopy to be contaminated by starch powder.17 Other catheters and invasive devices may also become contaminated with glove powder, acting as a vector for micro-organisms. In animal models corn starch promotes the development of wound infection,18 and delays wound healing.19 In the presence of powder, the number of organisms required to induce infection is reduced tenfold.18 Starch contaminated wounds also contained multiple granulomata.19
Conclusion The wide range of usage of powdered gloves by surgeons20 emphasizes their uncertain value and in other healthcare settings such as laboratory procedures,21 they are positively disadvantageous. Moreover, it should be emphasized that switching from powdered to powder-free gloves has little cost implication. Commonly used powdered and powder-free gloves both cost about 10 pence per pair. Cost calculations should include the potential savings occurring from the reduction in post-operative adhesions, allergic reactions and possibly litigation. At a European Surgical Conference in 1997,22 it was considered that there was sufficient evidence for the banning of glove powder. We believe that Infection control doctors should support this view.
References 1. Department of Health. Guidance for Clinical Health Care workers: protection against infection with blood-borne viruses. 1998. London: DOH, 1998. 2. Miller JM. William Stewart Halsted and the use of the surgical rubber glove. Surgery 1982; 92: 541–543.
Glove powder: implications for infection control
3. Antopol W. Lycopodium granuloma. Archives of Pathology 1933; 16: 326–331. 4. Ellis H. The hazards of surgical glove dusting powders. Surg Gynaecol Obstet 1990; 171: 521–527. 5. German WM. Dusting powder granulomas following surgery. Surg Gynaecol Obstet 1943; 76: 501–502. 6. Lee CM, Lehman EP. Experiments with nonirritating glove powder. Surg Gynae Obstet 1947; 84: 689–695. 7. Corless DJ, Holland J, Wastell C. Effect of starch containing glove powder on wound healing in a rat. Br J Surg 1985; 82: 368–370. 8. Giercksky KE. Misdiagnosis of cancer due to multiple glove powder granulomas. Eur J Surg 1997; Suppl 579: 11–14. 9. Duron J-J, Ellian N, Oliver O. Post-operative peritoneal adhesions and foreign bodies. Eur J Surg 1997; Suppl 579: 15–16. 10. Renz H, Gemsa D. Effects of powder on infection risks and associated mechanisms. Eur J Surg 1997; Suppl 579: 35–38. 11. Turjanmaa K. Incidence of immediate allergy to latex gloves in hospital personnel. Contact Dermatitis 1987; 17: 270–275. 12. Yassin MS, Lierl MB, Fischer JL, O’Brien K, Cross J, Steinmetz C. Latex allergies in hospital employees. Ann Allergy 1994; 72: 245–249. 13. Feild EA. The use of powdered gloves in dental practice: A cause for concern? J Dent 1997; 25: 299–214.
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14. Hanmann CP, Turjanmaa K, Rietschel R, et al. Natural rubber latex hypersensitivity incidence and prevalence of type 1 allergy in the dental profession. J Am Den Assoc 1998 129 (1): 43–45. 15. Department of Health, Latex sensitization in the health care setting: use of latex gloves. Medical Devices Agency. London: DOH, 1996. 16. Newsom SWB, Shaw P. Airborne particles from latex gloves in the hospital environment. Eur J Surg 1997; Suppl 579: 31–34. 17. Green M. Powder contamination of epidural catheters and implication for infection risk. Eur J Surg 1997; Suppl 579: 35–38. 18. Jaffray DC Nade S. Does surgical glove powder decrease the inoculum of bacteria required to produce an abscess? J R C Surg 1983; 28: 219–222. 19. Holmdahl L. Mechanisms of adhesion development and effects on wound healing. Eur J Surg 1997; Suppl 579: 7–9. 20. Davis PA, Corless DJ, Wastell C. Hazards of powdered surgical gloves. Lancet 1997; 350: 1783. 21. De Lomas JG, Sunzeri FJ, Busch MP. False negative results by polymerase chain reaction due to contamination by glove powder. Transfusion 1992; 32: 83–85. 22. Emmerson M. Chairman’s conclusions. Eur J Surg 1997; Suppl 579: 41.
INFECTION CONTROL IN PRACTICE
Glove powder: implications for infection control J. Dave, M. H.Wilcox and M. Kellett Departments of Microbiology, University of Leeds and Leeds Dental Institute,The Leeds Teaching Hospitals,The General Infirmary, Great George Street, Leeds LS1 3EX Summary: Gloves are increasingly promoted for use by healthcare workers, but this use is not without risk. Data associating powdered gloves with an increased risk of latex allergy is available and there is circumstantial evidence that the powder used may increase bacterial environmental contamination. In animal models, corn starch, the material used as glove powder, promotes wound infection. Infection control teams need to be aware of this evidence and should support switching from use of powdered to powder free gloves. Keywords: Powder free gloves; latex allergy; infection.
Introduction Gloves prevent the transmission of microorganisms between patients and healthcare workers. The Department of Health1 has issued revised guidance for protection of healthcare workers from blood-borne infections, with specific suggestions for glove use. Gloves should be worn when contact with blood is anticipated and changed between patients. Hands should be washed before donning and after removing gloves. Gloves are suggested while cleaning equipment before sterilisation or disinfection, handling chemical disinfectants and when cleaning up spillages. Recently there has been increasing concern Received 6 January 1999; manuscript accepted 2 April 1999 Corresponding author: Dr J Dave, Consultant Microbiologist, Department of Microbiology, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX Tel. 0113 392 4655 Fax. 0113 392 4654 E-mail [email protected]
0195–6701/99/080283 + 03 $12.00
about the use of powdered gloves and the evidence against their use will be examined.
Glove powder William Halsted2 introduced gloves at the turn of the century and originally, gloves were sterilized by boiling and worn over wet hands. Powder was introduced as a lubricant to facilitate the wearing of gloves. Talc (magnesium silicate) alone and with spores of Lycopodium clavatum3 were the first agents to be used, but foreign body granulomas, peritonitis, peritoneal adhesions, inflammatory reactions were associated with their use in clinical practice, and experimental studies confirmed these observations.4,5 In 1947 corn starch powder treated with epichlorhydrin,6 later mixed with 2% magnesium oxide (dessicating agent) was suggested as a suitable alternative and is in use today. Nevertheless, there have been numerous © 1999 The Hospital Infection Society
284
reports of starch induced peritonitis and intraperitoneal granulomas and adhesions4,7–9 and activation of T cell responses by glove powder products has been suggested as the mechanism.10
Allergy Glove powder has been linked to latex allergies with prevalence rates of 7–17% reported in healthcare workers.11,12 The incidence of latex allergy is especially high in dental personnel because of the high frequency with which gloves are changed.13 Latex sensitization in dental students reached 10% incidence early in the second year of glove use.14 Type 1 hypersensitivity is associated with natural proteins present in latex gloves.15 Symptoms varying from rashes, to anaphylaxis subside on removal of the allergen but the sensitivity is irreversible. Type 4 hypersensitivity is linked to the residues of accelerating chemicals present in gloves.15 Symptoms appear within hours typically as an itchy rash. Corn starch absorbs latex protein residues and accelerating chemicals present in gloves.15 Once airborne, the glove powder becomes an environmental contaminant, increasing the level of exposure. The Medical Device Agency15 has produced a guidance report recommending that hospitals use gloves with low levels of extractable latex proteins and where possible gloves should be powder free.
Infection Powdered gloves are used widely on wards and airborne starch powder can contaminate areas where they are used.16 A clear association between starch particles and bacterial colonies has been demonstrated by air sampling studies16 suggesting that starch dust may carry micro-organisms. Dust was found to be present in a variety of high dependency areas and was also present in the theatre air, where the scrub team were wearing powder free gloves, but
J. Dave et al.
other staff were wearing powdered gloves.16 There is also a potential for corn starch to act as a food source for bacteria (including MRSA and VRE) and to act as a vector for their spread e.g., during phlebotomy, catherization or radiocogica procedures. Epidural catheters have also been demonstrated by electron microscopy to be contaminated by starch powder.17 Other catheters and invasive devices may also become contaminated with glove powder, acting as a vector for micro-organisms. In animal models corn starch promotes the development of wound infection,18 and delays wound healing.19 In the presence of powder, the number of organisms required to induce infection is reduced tenfold.18 Starch contaminated wounds also contained multiple granulomata.19
Conclusion The wide range of usage of powdered gloves by surgeons20 emphasizes their uncertain value and in other healthcare settings such as laboratory procedures,21 they are positively disadvantageous. Moreover, it should be emphasized that switching from powdered to powder-free gloves has little cost implication. Commonly used powdered and powder-free gloves both cost about 10 pence per pair. Cost calculations should include the potential savings occurring from the reduction in post-operative adhesions, allergic reactions and possibly litigation. At a European Surgical Conference in 1997,22 it was considered that there was sufficient evidence for the banning of glove powder. We believe that Infection control doctors should support this view.
References 1. Department of Health. Guidance for Clinical Health Care workers: protection against infection with blood-borne viruses. 1998. London: DOH, 1998. 2. Miller JM. William Stewart Halsted and the use of the surgical rubber glove. Surgery 1982; 92: 541–543.
Glove powder: implications for infection control
3. Antopol W. Lycopodium granuloma. Archives of Pathology 1933; 16: 326–331. 4. Ellis H. The hazards of surgical glove dusting powders. Surg Gynaecol Obstet 1990; 171: 521–527. 5. German WM. Dusting powder granulomas following surgery. Surg Gynaecol Obstet 1943; 76: 501–502. 6. Lee CM, Lehman EP. Experiments with nonirritating glove powder. Surg Gynae Obstet 1947; 84: 689–695. 7. Corless DJ, Holland J, Wastell C. Effect of starch containing glove powder on wound healing in a rat. Br J Surg 1985; 82: 368–370. 8. Giercksky KE. Misdiagnosis of cancer due to multiple glove powder granulomas. Eur J Surg 1997; Suppl 579: 11–14. 9. Duron J-J, Ellian N, Oliver O. Post-operative peritoneal adhesions and foreign bodies. Eur J Surg 1997; Suppl 579: 15–16. 10. Renz H, Gemsa D. Effects of powder on infection risks and associated mechanisms. Eur J Surg 1997; Suppl 579: 35–38. 11. Turjanmaa K. Incidence of immediate allergy to latex gloves in hospital personnel. Contact Dermatitis 1987; 17: 270–275. 12. Yassin MS, Lierl MB, Fischer JL, O’Brien K, Cross J, Steinmetz C. Latex allergies in hospital employees. Ann Allergy 1994; 72: 245–249. 13. Feild EA. The use of powdered gloves in dental practice: A cause for concern? J Dent 1997; 25: 299–214.
285
14. Hanmann CP, Turjanmaa K, Rietschel R, et al. Natural rubber latex hypersensitivity incidence and prevalence of type 1 allergy in the dental profession. J Am Den Assoc 1998 129 (1): 43–45. 15. Department of Health, Latex sensitization in the health care setting: use of latex gloves. Medical Devices Agency. London: DOH, 1996. 16. Newsom SWB, Shaw P. Airborne particles from latex gloves in the hospital environment. Eur J Surg 1997; Suppl 579: 31–34. 17. Green M. Powder contamination of epidural catheters and implication for infection risk. Eur J Surg 1997; Suppl 579: 35–38. 18. Jaffray DC Nade S. Does surgical glove powder decrease the inoculum of bacteria required to produce an abscess? J R C Surg 1983; 28: 219–222. 19. Holmdahl L. Mechanisms of adhesion development and effects on wound healing. Eur J Surg 1997; Suppl 579: 7–9. 20. Davis PA, Corless DJ, Wastell C. Hazards of powdered surgical gloves. Lancet 1997; 350: 1783. 21. De Lomas JG, Sunzeri FJ, Busch MP. False negative results by polymerase chain reaction due to contamination by glove powder. Transfusion 1992; 32: 83–85. 22. Emmerson M. Chairman’s conclusions. Eur J Surg 1997; Suppl 579: 41.