Universal Glove and Gown Use and Acquisition of Antibiotic-Resistant Bacteria in the ICU: A Randomized Trial | Critical Care Medicine | JAMA | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Talbot  GH, Bradley  J, Edwards  JE  Jr, Gilbert  D, Scheld  M, Bartlett  JG; Antimicrobial Availability Task Force of the Infectious Diseases Society of America.  Bad bugs need drugs: an update on the development pipeline from the Antimicrobial Availability Task Force of the Infectious Diseases Society of America.  Clin Infect Dis. 2006;42(5):657-668. doi:10.1086/499819.PubMedGoogle ScholarCrossref
Klevens  RM, Edwards  JR, Richards  CL  Jr,  et al.  Estimating health care–associated infections and deaths in US hospitals, 2002.  Public Health Rep. 2007;122(2):160-166.PubMedGoogle Scholar
Cosgrove  SE, Sakoulas  G, Perencevich  EN, Schwaber  MJ, Karchmer  AW, Carmeli  Y.  Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis.  Clin Infect Dis. 2003;36(1):53-59. doi:10.1086/345476.PubMedGoogle ScholarCrossref
DiazGranados  CA, Jernigan  JA.  Impact of vancomycin resistance on mortality among patients with neutropenia and enterococcal bloodstream infection.  J Infect Dis. 2005;191(4):588-595. doi:10.1086/427512.PubMedGoogle ScholarCrossref
Morgan  DJ, Rogawski  E, Thom  KA,  et al.  Transfer of multidrug-resistant bacteria to healthcare workers’ gloves and gowns after patient contact increases with environmental contamination.  Crit Care Med. 2012;40(4):1045-1051. doi:10.1097/CCM.0b013e31823bc7c8.PubMedGoogle ScholarCrossref
Hayden  MK, Blom  DW, Lyle  EA, Moore  CG, Weinstein  RA.  Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant Enterococcus or the colonized patients’ environment.  Infect Control Hosp Epidemiol. 2008;29(2):149-154. doi:10.1086/524331.PubMedGoogle ScholarCrossref
Boyce  JM, Pittet  D; Healthcare Infection Control Practices Advisory Committee: HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.  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.  MMWR Recomm Rep. 2002;51(RR-16):1-45. PubMedGoogle Scholar
Siegel  JD, Rhinehart  E, Jackson  M, Chiarello  L; Health Care Infection Control Practices Advisory Committee.  2007 guideline for isolation precautions: Preventing transmission of infectious agents in health care settings.  Am J Infect Control. 2007;35(10)(suppl 2):S65-S164. doi:10.1016/j.ajic.2007.10.007.PubMedGoogle ScholarCrossref
Wright  MO, Hebden  JN, Harris  AD,  et al.  Aggressive control measures for resistant Acinetobacter baumannii and the impact on acquisition of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus in a medical intensive care unit.  Infect Control Hosp Epidemiol. 2004;25(2):167-168. doi:10.1086/502370.PubMedGoogle ScholarCrossref
Klein  BS, Perloff  WH, Maki  DG.  Reduction of nosocomial infection during pediatric intensive care by protective isolation.  N Engl J Med. 1989;320(26):1714-1721.PubMedGoogle ScholarCrossref
Safdar  N, Marx  J, Meyer  NA, Maki  DG.  Effectiveness of preemptive barrier precautions in controlling nosocomial colonization and infection by methicillin-resistant Staphylococcus aureus in a burn unit.  Am J Infect Control. 2006;34(8):476-483. doi:10.1016/j.ajic.2006.01.011.PubMedGoogle ScholarCrossref
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):e1515-20. doi:10.1542/peds.2012-3389. PubMedGoogle ScholarCrossref
Morgan  DJ, Pineles  LL, Shardell  M,  et al.  The effect of contact precautions on healthcare worker activity in acute care hospitals.  Infect Control Hosp Epidemiol. 2013;34(1):69-73.PubMedGoogle ScholarCrossref
Morgan  DJ, Diekema  DJ, Sepkowitz  K, Perencevich  EN.  Adverse outcomes associated with Contact Precautions: a review of the literature.  Am J Infect Control. 2009;37(2):85-93. doi:10.1016/j.ajic.2008.04.257.PubMedGoogle ScholarCrossref
Stelfox  HT, Bates  DW, Redelmeier  DA.  Safety of patients isolated for infection control.  JAMA. 2003;290(14):1899-1905. doi:10.1001/jama.290.14.1899.PubMedGoogle ScholarCrossref
Donner  A, Klar  N.  Design and Analysis of Cluster Randomization Trials in Health Research. London, England: Arnold Publishing; 2000. 
Campbell  MK, Piaggio  G, Elbourne  DR, Altman  DG; CONSORT Group.  Consort 2010 statement: extension to cluster randomised trials.  BMJ. 2012;345:e5661. doi:10.1136/bmj.e5661.PubMedGoogle ScholarCrossref
Huskins  WC, Huckabee  CM, O’Grady  NP,  et al; STAR*ICU Trial Investigators.  Intervention to reduce transmission of resistant bacteria in intensive care.  N Engl J Med. 2011;364(15):1407-1418. doi:10.1056/NEJMoa1000373.PubMedGoogle ScholarCrossref
Climo  MW, Yokoe  DS, Warren  DK,  et al.  Effect of daily chlorhexidine bathing on hospital-acquired infection.  N Engl J Med. 2013;368(6):533-542. doi:10.1056/NEJMoa1113849.PubMedGoogle ScholarCrossref
Morgan  DJ, Meddings  J, Saint  S,  et al; SHEA Research Network.  Does nonpayment for hospital-acquired catheter-associated urinary tract infections lead to overtesting and increased antimicrobial prescribing?  Clin Infect Dis. 2012;55(7):923-929. doi:10.1093/cid/cis556.PubMedGoogle ScholarCrossref
Siegel  JD, Rhinehart  E, Jackson  M, Chiarello  L; Healthcare Infection Control Practices Advisory Committee.  Management of multidrug-resistant organisms in health care settings, 2006.  Am J Infect Control. 2007;35(10)(suppl 2):S165-S193. doi:10.1016/j.ajic.2007.10.006.PubMedGoogle ScholarCrossref
Griffin F, Resar R. IHI Global Trigger Tool for Measuring Adverse Events. Second ed. Institute for Healthcare Improvement Innovation Series White Paper; 2009. http://www.ihi.org/knowledge/pages/IHIWhitePapers/IHIGlobalTriggerToolWhitePaper.aspx. Updated August 13, 2013; Accessed September 12, 2013.
Wright  M, Hebden  JN, Allen-Bridson  K, Morrell  GC, Horan  T.  Health care–associated infections studies project: case 4.  Am J Infect Control. 2011;39(1):64-65. doi:10.1016/j.ajic.2010.12.001.Google ScholarCrossref
Wright  MO, Hebden  JN, Allen-Bridson  K, Morrell  GC, Horan  T.  Health care–associated infections studies project: case 3.  Am J Infect Control. 2010;38(8):642-643. doi:10.1016/j.ajic.2010.07.001.PubMedGoogle ScholarCrossref
Wright  MO, Hebden  JN, Allen-Bridson  K, Morrell  GC, Horan  T.  Healthcare–associated infections studies project: an American Journal of Infection Control and National Healthcare Safety Network data quality collaboration.  Am J Infect Control. 2010;38(5):416-418.PubMedGoogle ScholarCrossref
Wright  MO, Hebden  JN, Allen-Bridson  K, Morrell  GC, Horan  T.  Health care-associated infections studies project: case 2.  Am J Infect Control. 2010;38(7):557-558. doi:10.1016/j.ajic.2010.06.003.PubMedGoogle ScholarCrossref
Robinson  GL, Harris  AD, Morgan  DJ, Pineles  L, Belton  BM, Johnson  JK; Benefits of Universal Gloving and Gowning (BUGG) Study Group.  Survival of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus spp for an extended period of transport.  J Clin Microbiol. 2012;50(7):2466-2468. doi:10.1128/JCM.00911-12.PubMedGoogle ScholarCrossref
Richter  SS, Heilmann  KP, Dohrn  CL,  et al.  Activity of ceftaroline and epidemiologic trends in Staphylococcus aureus isolates collected from 43 medical centers in the United States in 2009.  Antimicrob Agents Chemother. 2011;55(9):4154-4160. doi:10.1128/AAC.00315-11.PubMedGoogle ScholarCrossref
Bell  JM, Paton  JC, Turnidge  J.  Emergence of vancomycin-resistant enterococci in Australia: phenotypic and genotypic characteristics of isolates.  J Clin Microbiol. 1998;36(8):2187-2190.PubMedGoogle Scholar
Horan  TC, Andrus  M, Dudeck  MA.  CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting.  Am J Infect Control. 2008;36(5):309-332. doi:10.1016/j.ajic.2008.03.002.PubMedGoogle ScholarCrossref
Landrigan  CP, Parry  GJ, Bones  CB, Hackbarth  AD, Goldmann  DA, Sharek  PJ.  Temporal trends in rates of patient harm resulting from medical care.  N Engl J Med. 2010;363(22):2124-2134. doi:10.1056/NEJMsa1004404.PubMedGoogle ScholarCrossref
Institute for Healthcare Improvement. How-to guide: Improving hand hygiene. http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingHandHygiene.aspx. Updated July 8, 2011. Accessed September 12, 2013.
Thompson  SG, Pyke  SD, Hardy  RJ.  The design and analysis of paired cluster randomized trials: an application of meta-analysis techniques.  Stat Med. 1997;16(18):2063-2079.PubMedGoogle ScholarCrossref
Brookmeyer  R, Chen  YQ.  Person-time analysis of paired community intervention trials when the number of communities is small.  Stat Med. 1998;17(18):2121-2132.PubMedGoogle ScholarCrossref
Ho  J, Tambyah  PA, Paterson  DL.  Multiresistant gram-negative infections: a global perspective.  Curr Opin Infect Dis. 2010;23(6):546-553. doi:10.1097/QCO.0b013e32833f0d3e.PubMedGoogle ScholarCrossref
Yokoe  DS, Mermel  LA, Anderson  DJ,  et al.  A compendium of strategies to prevent healthcare-associated infections in acute care hospitals.  Infect Control Hosp Epidemiol. 2008;29(S1)(suppl 1):S12-S21. PubMedGoogle ScholarCrossref
Harris  AD, Furuno  JP, Roghmann  MC,  et al.  Targeted surveillance of methicillin-resistant Staphylococcus aureus and its potential use to guide empiric antibiotic therapy.  Antimicrob Agents Chemother. 2010;54(8):3143-3148. doi:10.1128/AAC.01590-09.PubMedGoogle ScholarCrossref
Huang  SS, Septimus  E, Kleinman  K,  et al; CDC Prevention Epicenters Program; AHRQ DECIDE Network and Healthcare-Associated Infections Program.  Targeted versus universal decolonization to prevent ICU infection.  N Engl J Med. 2013;368(24):2255-2265. doi:10.1056/NEJMoa1207290.PubMedGoogle ScholarCrossref
McGann  P, Kwak  YI, Summers  A, Cummings  JF, Waterman  PE, Lesho  EP.  Detection of qacA/B in clinical isolates of methicillin-resistant Staphylococcus aureus from a regional healthcare network in the eastern United States.  Infect Control Hosp Epidemiol. 2011;32(11):1116-1119. doi:10.1086/662380.PubMedGoogle ScholarCrossref
Lee  AS, Macedo-Vinas  M, François  P,  et al.  Impact of combined low-level mupirocin and genotypic chlorhexidine resistance on persistent methicillin-resistant Staphylococcus aureus carriage after decolonization therapy: a case-control study.  Clin Infect Dis. 2011;52(12):1422-1430. doi:10.1093/cid/cir233.PubMedGoogle ScholarCrossref
Feng  PJ, Kallen  AJ, Ellingson  K, Muder  R, Jain  R, Jernigan  JA.  Clinical incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection as a proxy measure for MRSA transmission in acute care hospitals.  Infect Control Hosp Epidemiol. 2011;32(1):20-25. doi:10.1086/657668.PubMedGoogle ScholarCrossref
Original Investigation
October 16, 2013

Universal Glove and Gown Use and Acquisition of Antibiotic-Resistant Bacteria in the ICU: A Randomized Trial

Author Affiliations
  • 1University of Maryland School of Medicine, Baltimore
  • 2Yale New Haven Health System Center for Healthcare Solutions, New Haven, Connecticut
  • 3McMaster University, Hamilton, Ontario, Canada
  • 4University of Maryland School of Nursing, Baltimore
  • 5The Joint Commission, Oakbrook Terrace, Illinois
  • 6University of Iowa Health Care, Iowa City, Iowa
  • 7Agency for Healthcare Research and Quality, Rockville, Maryland
  • 8VA Maryland Health Care System, Baltimore
JAMA. 2013;310(15):1571-1580. doi:10.1001/jama.2013.277815

Importance  Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria.

Objective  To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care.

Design, Setting, and Participants  Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012.

Interventions  In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room.

Main Outcomes and Measures  The primary outcome was acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care–associated infections, and adverse events.

Results  From the 26 180 patients included, 92 241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, −1.71 acquisitions per 1000 person-days, 95% CI, −6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference,  0.89 acquisitions per 1000 person-days; 95% CI, −4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, −2.98 acquisitions per 1000 person-days; 95% CI, −5.58 to −0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, −0.96; 95% CI, −1.71 to −0.21, P = .02), increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference, 15.4%; 95% CI, 8.99% to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, −15.7; 95% CI, −40.7 to 9.2, P = .24).

Conclusions and Relevance  The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions.

Trial Registration  clinicaltrials.gov Identifier: NCT0131821