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Figure 1.
Flow Diagram
Flow Diagram

The prospective single-arm observational study included in the systematic review was excluded from the meta-analysis.

Figure 2.
Meta-analysis
Meta-analysis

Meta-analysis includes findings of studies of surgical site infections with sterile vs nonsterile gloves after outpatient procedures. RR indicates relative risk. The size of the diamond represents the 95% CI of the overall assessment. If the diamond is wide, there is less confidence that it is accurate; however, if the diamond is narrow and small, then there is a higher confidence that the final analysis is accurately representing the truth.

Table.  
Quality Rating Scheme for Studiesa
Quality Rating Scheme for Studiesa
1.
Spirling  LI, Daniels  IR.  William Stewart Halsted—surgeon extraordinaire: a story of “drugs, gloves and romance”.  J R Soc Promot Health. 2002;122(2):122-124.PubMedGoogle ScholarCrossref
2.
Creamer  J, Davis  K, Rice  W.  Sterile gloves: do they make a difference?  Am J Surg. 2012;204(6):976-979.PubMedGoogle ScholarCrossref
3.
Lawson  C, Juliano  L, Ratliff  CR.  Does sterile or nonsterile technique make a difference in wounds healing by secondary intention?  Ostomy Wound Manage. 2003;49(4):56-58, 60.PubMedGoogle Scholar
4.
Adeyemo  WL, Ogunlewe  MO, Ladeinde  AL, Bamgbose  BO.  Are sterile gloves necessary in nonsurgical dental extractions?  J Oral Maxillofac Surg. 2005;63(7):936-940.PubMedGoogle ScholarCrossref
5.
Heal  C, Sriharan  S, Buttner  PG, Kimber  D.  Comparing non-sterile to sterile gloves for minor surgery: a prospective randomised controlled non-inferiority trial.  Med J Aust. 2015;202(1):27-31.PubMedGoogle ScholarCrossref
6.
Martin  JE, Speyer  LA, Schmults  CD.  Heightened infection-control practices are associated with significantly lower infection rates in office-based Mohs surgery.  Dermatol Surg. 2010;36(10):1529-1536.PubMedGoogle ScholarCrossref
7.
Mehta  D, Chambers  N, Adams  B, Gloster  H.  Comparison of the prevalence of surgical site infection with use of sterile versus nonsterile gloves for resection and reconstruction during Mohs surgery.  Dermatol Surg. 2014;40(3):234-239.PubMedGoogle ScholarCrossref
8.
Perelman  VS, Francis  GJ, Rutledge  T,  et al.  Non-sterile gloves were as safe as sterile gloves for repair of uncomplicated lacerations.  Evid Based Med. 2004;9(6):182. doi:10.1136/ebm.9.6.182.Google ScholarCrossref
9.
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(3):362-370.PubMedGoogle ScholarCrossref
10.
Rhinehart  MB, Murphy  MM, Farley  MF, Albertini  JG.  Sterile versus nonsterile gloves during Mohs micrographic surgery: infection rate is not affected.  Dermatol Surg. 2006;32(2):170-176.PubMedGoogle Scholar
11.
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(5):651-656.PubMedGoogle ScholarCrossref
12.
Cheung  LK, Chow  LK, Tsang  MH, Tung  LK.  An evaluation of complications following dental extractions using either sterile or clean gloves.  Int J Oral Maxillofac Surg. 2001;30(6):550-554.PubMedGoogle ScholarCrossref
13.
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(2):174-179.PubMedGoogle ScholarCrossref
14.
Ghafouri  HB, Zoofaghari  SJ, Kasnavieh  MH, Ramim  T, Modirian  E.  A pilot study on the repair of contaminated traumatic wounds in the emergency department using sterile versus non-sterile gloves.  Hong Kong J Emerg Med. 2014;21(3):148-152.Google Scholar
15.
Giglio  JA, Rowland  RW, Laskin  DM, Grenevicki  L, Roland  RW.  The use of sterile versus nonsterile gloves during out-patient exodontia.  Quintessence Int. 1993;24(8):543-545.PubMedGoogle Scholar
16.
Rogers  HD, Desciak  EB, Marcus  RP, Wang  S, MacKay-Wiggan  J, Eliezri  YD.  Prospective study of wound infections in Mohs micrographic surgery using clean surgical technique in the absence of prophylactic antibiotics.  J Am Acad Dermatol. 2010;63(5):842-851.PubMedGoogle ScholarCrossref
17.
Rogues  AM, Lasheras  A, Amici  JM,  et al.  Infection control practices and infectious complications in dermatological surgery.  J Hosp Infect. 2007;65(3):258-263.PubMedGoogle ScholarCrossref
18.
Lilly  E, Schmults  CD.  A comparison of high- and low-cost infection-control practices in dermatologic surgery.  Arch Dermatol. 2012;148(7):859-861.PubMedGoogle ScholarCrossref
19.
Burke  FJ.  The role of non-sterile gloves in clinical practice.  J Ir Dent Assoc. 1989;35(1):30-35.PubMedGoogle Scholar
20.
Burke  FJ, Wilson  NH.  Non-sterile glove use: a review.  Am J Dent. 1989;2(5):255-261.PubMedGoogle Scholar
21.
Checchi  L, Gatto  MR, Legnani  P, Pelliccioni  GA, Bisbini  P.  Use of gloves and prevalence of glove-related reactions in a sample of general dental practitioners in Italy.  Quintessence Int. 1999;30(9):633-636.PubMedGoogle Scholar
22.
Juraskova  ES, Matouskova  I.  Hand hygiene in dental practice: current situation.  Hygiena. 2014;59:71-73.Google ScholarCrossref
23.
Akagi  I, Furukawa  K, Miyashita  M,  et al.  Surgical wound management made easier and more cost-effective.  Oncol Lett. 2012;4(1):97-100.PubMedGoogle Scholar
24.
Cooper  JA.  The cost of keeping one’s hands clean.  Br Dent J. 1992;173(3):86.PubMedGoogle ScholarCrossref
25.
O’Grady  H, Baker  E.  Prevention of surgical site infections.  Surgery. 2011;29:513-517.Google Scholar
26.
Moher  D, Cook  DJ, Eastwood  S, Olkin  I, Rennie  D, Stroup  DF.  Improving the quality of reports of meta-analyses of randomized controlled trials: the QUOROM statement [in Spanish].  Rev Esp Salud Publica. 2000;74(2):107-118.PubMedGoogle ScholarCrossref
27.
Robinson  JK, Dellavalle  RP, Bigby  M, Callen  JP.  Systematic reviews: grading recommendations and evidence quality.  Arch Dermatol. 2008;144(1):97-99.PubMedGoogle ScholarCrossref
28.
Ho  B, Liebman  R, Hughes  CA.  The price of doing pediatric sinus procedures (a look at cost).  Int J Pediatr Otorhinolaryngol. 2013;77(10):1639-1642.PubMedGoogle ScholarCrossref
29.
Iwamoto  Y, Kato  M.  Should sterile gloves be used for outpatient cystoscopy?  J Endourol. 2014;28(suppl 1):A121.Google Scholar
30.
Odutoye  T, McGilligan  A, Robb  PJ.  Aseptic surgical technique and postgrommet otorrhoea.  Int J Pediatr Otorhinolaryngol. 2003;67(suppl 1):S233-S235.PubMedGoogle ScholarCrossref
31.
Zehtabchi  S, Tan  A, Yadav  K, Badawy  A, Lucchesi  M.  The impact of wound age on the infection rate of simple lacerations repaired in the emergency department.  Injury. 2012;43(11):1793-1798.PubMedGoogle ScholarCrossref
Original Investigation
September 2016

Comparison of Sterile vs Nonsterile Gloves in Cutaneous Surgery and Common Outpatient Dental ProceduresA Systematic Review and Meta-analysis

Author Affiliations
  • 1Division of Dermatologic Surgery, Mayo Clinic, Rochester, Minnesota
  • 2Center for Clinical and Translational Science, Mayo Graduate School, Rochester, Minnesota
  • 3Mayo Medical Library, Mayo Clinic, Rochester, Minnesota
JAMA Dermatol. 2016;152(9):1008-1014. doi:10.1001/jamadermatol.2016.1965
Abstract

Importance  Whether the use of sterile vs nonsterile gloves in outpatient cutaneous procedures affects the rate of postoperative wound infection is unknown.

Objective  To explore rates of surgical site infection (SSI) with the use of sterile vs nonsterile gloves in outpatient cutaneous surgical procedures.

Data Sources  This systematic review and meta-analysis identified studies from Ovid MEDLINE (1946 to present), Ovid Cochrane Central Register of Controlled Trials (1991 to present), Ovid EMBASE (1988 to present), EBSCO Cumulative Index to Nursing and Allied Health Literature (1980 to present), Scopus (1996 to present), and Web of Science (1975 to present).

Study Selection  Studies with information on sterile vs nonsterile gloves in outpatient surgical procedures were retrieved. Only randomized clinical trials and comparative studies were included for final analysis.

Data Extraction  Data of trial design, surgery characteristics, and outcomes from published manuscripts and unpublished data were independently extracted.

Main Outcomes and Measures  Randomized clinical trials were considered high quality if randomization, allocation concealment, blinding, and follow-up completeness were appropriate. Relative risk and 95% CIs were derived for postoperative wound infections.

Results  Fourteen articles met eligibility and inclusion criteria for systematic review; they included 12 275 unique patients who had undergone 12 275 unique outpatient procedures with sterile or nonsterile gloves and had follow-up regarding SSI. With the exclusion of 1 single-arm observational study of 1204 patients, 11 071 patients from 13 studies remained in the meta-analysis. Of these, 228 patients were documented as having postoperative SSI (2.1%), including 107 of 5031 patients in the nonsterile glove group (2.1%) and 121 of 6040 patients in the sterile glove group (2.0%). Overall relative risk for SSI with nonsterile glove use was 1.06 (95% CI, 0.81-1.39).

Conclusions and Relevance  No difference was found in the rate of postoperative SSI between outpatient surgical procedures performed with sterile vs nonsterile gloves.

Introduction

Many health care specialties provide outpatient cutaneous surgical procedures. Gloves were first introduced to surgical practice more than a century ago, mostly for hygiene purposes. After that, gloves were mainly used for other reasons, including the prevention of hand dermatitis.1 During the past few decades, the use of surgical gloves has become standard practice to prevent postoperative wound infections or surgical site infection (SSI). However, whether the use of sterile vs nonsterile gloves makes a difference in the development of postoperative SSIs in the setting of cutaneous and minor outpatient surgical procedures remains unclear.2,3

Several studies2,418 have investigated nonsterile vs sterile gloves in the setting of Mohs micrographic surgery (MMS), outpatient dental procedures, and laceration repair. Studies of dental procedures4,12,13,15,1922 have not found a difference between sterile vs nonsterile gloves in adverse outcomes, including SSI. Other studies7,10,11,18 have found that sterile vs nonsterile gloves do not make a difference in SSI in the setting of MMS, but 1 study6 demonstrated that heightened infection control practices could decrease the occurrence of SSI from 2.5% to 0.9%. In another study of 3491 outpatient surgical procedures, those that were more complex and not considered simple excisions had an SSI rate of 14.7% with nonsterile gloves compared with 3.4% with sterile gloves (P = .001); no difference in SSI was noted in procedures categorized as simple excisions (1.7% and 1.6% with nonsterile and sterile gloves, respectively).17

Given the many outpatient minor and cutaneous surgical procedures that occur worldwide, and given the current heightened consciousness about appropriate management of health care resources, knowing the effect of nonsterile vs sterile gloves on postoperative SSI rates would be important.3,7,9,18,2325 We performed a systematic review and meta-analysis to examine this topic.

Box Section Ref ID

Key Points

  • Question What is the difference in rates of surgical site infection with the use of sterile vs nonsterile gloves during outpatient cutaneous surgical procedures?

  • Findings In this systematic review and meta-analysis that included 11 071 patients, no difference was found in the rate of postoperative surgical site infection between outpatient surgical procedures performed with sterile vs nonsterile gloves.

  • Meaning Considering the difference in cost and the increasing number of minor surgical procedures performed worldwide, use of nonsterile gloves is an acceptable option.

Methods

This study was performed in accordance with a protocol that prespecified important criteria such as study selection, exclusion criteria, data extraction, and statistical analysis, as well as heterogeneity and measurements of inconsistencies. The methods used in this manuscript were in accordance with the Cochrane collaboration guidelines (http://www.cochrane.org), the Newcastle-Ottawa Scale for quality assessment (http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp), and the QUOROM statement.26

Search Strategy

The search strategy was initially designed in the expanded Ovid MEDLINE file, which includes in-process and nonindexed citations from 1946 to the present. Medical subject heading (MeSH) terms and text words were used to ensure that all relevant citations were included. MeSH terms are a controlled vocabulary used to minimize the number of synonyms necessary to describe each concept.

MeSH search terms used for this study included gloves, surgical; dermatologic surgical procedures; and surgical infections. Text words used for this study included: gloves, sterile, clean, and nonsterile. We used publication types and text words to filter for randomized clinical trials, cohort studies, follow-up studies, or comparative studies. The strategy was then translated into database-specific terms for the Ovid Cochrane Central Register of Controlled Trials (1991 to present), Ovid EMBASE (1988 to present), and EBSCO Cumulative Index to Nursing and Allied Health Literature (1980 to present). The databases Scopus (1996 to present) and Web of Science (1975 to present) were primarily searched with text words.

Study Selection

Studies included in this systematic review and meta-analysis were randomized clinical trials or prospective or retrospective observational comparative studies. The patients in the studies underwent an outpatient cutaneous or mucosal surgical procedure, including MMS, laceration repair, standard excisions, and tooth extractions. The procedures used sterile or nonsterile gloves, and documentation of postoperative SSI was present. Study eligibility criteria were assessed by 2 independent investigators (J.D.B. and A.B.G.J.).

Study Quality Assessment and Risk for Bias

All of the included trials and observational studies were reviewed in detail for methodologic features most pertinent to potential bias. The 2 independent reviewers (J.D.B. and A.B.G.J.) assessed features according to the Cochrane collaboration guidelines for the randomized clinical trials, which included randomization, intention-to-treat analysis, completeness of follow-up, and outcome assessment and attrition rates. Allocation of concealment, blinding, and masking of allocation were not evaluated as part of the assessment of quality given that, by the nature of these studies, all parties could tell whether the gloves used for the procedure were sterile or nonsterile. The Newcastle-Ottawa Scale was used to assess the quality of observational studies. All discrepancies in quality assessment were resolved by consensus-forming discussions between the 2 investigators (eTables 1 and 2 in the Supplement).

Data Abstraction and Management

The primary outcome variable in this study was postoperative wound SSI. Data from studies that included other postoperative complications such as dry socket or inflamed socket in the setting of dental procedures were not included. Assessment of the primary outcome was performed independently by the 2 investigators (J.D.B. and A.B.G.J.), and no discrepancies or disagreements existed.

After ensuring that each study included the correct primary outcome, we abstracted data regarding the use of sterile vs nonsterile gloves, in addition to the number of procedures in each arm of the study. Because this comparative study used dichotomous data measures for the primary outcome variable, the relative risk (RR) was the unit of analysis. No missing data were identified in any of the included studies. All data were abstracted and analyzed using Review Manager software (version 5.3; Cochrane). In the case of the study that included only data for 1 study arm—nonsterile gloves only and SSI—data regarding the primary outcome and number of procedures were abstracted.

Subgroup Analysis and Assessment of Heterogeneity

As a secondary meta-analysis, all studies pertaining to only cutaneous surgery (removing all dental procedure studies) and all studies pertaining to only dental procedures were analyzed separately. Finally, a subgroup meta-analysis was performed on studies pertaining to only MMS.

Results
Studies Included

A total of 512 publications were initially considered for inclusion after a comprehensive systematic review. From these, 463 were deemed irrelevant based on the abstract and content. The remaining 49 publications were reviewed in full. Of these, 14 met the inclusion criteria (Table, Figure 1, and eTable 3 in the Supplement).47,917 Among the 35 articles excluded after full-text review, 4 articles were in discordance between the 2 independent reviewers. Consensus was reached to ultimately exclude the 4 articles because of differences in study design and outcome.3,2830 One of these studies28 also had no clear evidence of the necessary data needed for inclusion. The authors of the study were contacted, and after multiple failed attempts, the study was excluded.

Patients

The 14 articles that met the inclusion criteria for systematic review included a total of 12 275 unique patients who had undergone 12 275 unique outpatient procedures with sterile or nonsterile gloves and had follow-up regarding SSI. Incidence of the primary outcome variable for these studies is shown in eFigure 1 in the Supplement. One study16 included 1204 patients who had undergone MMS with nonsterile gloves only. Thus, because the study was noncomparative, these patients could not be included in the meta-analysis. A total of 11 071 patients were included in the final meta-analysis, of whom 2741 were randomly assigned to sterile gloves (n = 1360) or nonsterile gloves (n = 1381) as the intervention in a clinical trial. The remaining 8330 patients were part of prospective and retrospective observational studies; these patients had undergone an outpatient cutaneous surgical procedure with sterile (n = 4680) or nonsterile (n = 3650) gloves.

Subgroup Analysis and Assessment of Heterogeneity

Low heterogeneity was identified among the studies included in the main meta-analysis as an I2 of 0% (P = .43) for the randomized clinical trials and an I2 of 0% (P = .94) for the observational studies. Between the 2 different study designs, the I2 was 0% (P = .43) with an overall I2 of 0% (P = .73). These statistics suggest that the 2 different study designs were not heterogeneous and that heterogeneity is not a problem across the included studies overall. All subgroup and sensitivity analyses also had an I2 of 0% except for the subgroup analysis for cutaneous reconstruction (I2 = 21.9%; P = .26) and the sensitivity analysis for Martin et al6 (excluding Lilly and Schmults18), which had an I2 of 7.9% (P = .30) for heterogeneity among the different study groups.

Postoperative SSI

Of the 11 071 patients included in the final meta-analysis, 228 were documented as having postoperative SSI (2.1%), including 107 of 5031 patients in the nonsterile glove group (2.1%) and 121 of 6040 patients in the sterile glove group (2.0%). In addition, the single-arm prospective study with only nonsterile gloves documented 11 of 1204 patients with a postoperative SSI after MMS (0.9%).16 When we included these patients in the nonsterile glove cohort, a total of 118 postoperative SSIs occurred in 6235 total patients (1.9%).

Data Synthesis

The combined analysis of all studies gave an overall RR of 1.06 (95% CI, 0.81-1.39). The 8 clinical trials had an RR of 0.95 (95% CI, 0.65-1.40), and the 5 observational studies had an RR of 1.19 (95% CI, 0.81-1.73). None of these RRs were significant (Figure 2).

Sensitivity Analysis

On contacting the authors of 1 study,6 we were made aware of a follow-up publication from the same institution.18 To maintain the assumption of independence, instead of including both studies separately, the data from the 2 studies were combined (Martin et al6 and Lilly and Schmults18) for the final analysis: a total of 1035 surgical procedures performed with nonsterile gloves and 585 with sterile gloves. A sensitivity analysis to determine whether the outcome was different if either one of the studies was excluded showed no difference: the RR including only Martin et al6 was 1.10 (95% CI, 0.84-1.44) and the RR including only Lilly and Schmults18 was 1.03 (95% CI, 0.78-1.34).

Risk for Bias

Quality assessment was concordant between the 2 reviewers, with no discrepancies. All studies were deemed to be high quality with minimal risk for bias (Table).27 The risk for publication bias is more of a factor with retrospective observational studies. Because all studies were believed to be of high quality and had no major discordances or outliers, especially among the observational studies, the risk for publication bias was believed to be minimal.

Additional Analyses

For the subgroup analyses, low heterogeneity was identified among the included studies in the MMS and dental procedures cohorts, with an I2 of 0% for both and P = .82 and P = .70, respectively. For the dental procedures, the overall RR for these studies was 3.36 (95% CI, 0.81-13.99) (eFigure 2A in the Supplement). The subgroup analysis for cutaneous reconstruction in the setting of MMS yielded an overall RR of 1.15 (95% CI, 0.68-1.97) for these studies (eFigure 2B in the Supplement). Finally, studies in the cutaneous surgery group included 4 randomized clinical trials and 5 observational studies. The subgroup analysis for these cutaneous reconstruction studies yielded an overall RR of 1.02 (95% CI, 0.78-1.34) (eFigure 2C in the Supplement).

Discussion

Our meta-analysis found no difference in the rates of postoperative SSIs when comparing sterile vs nonsterile gloves in the setting of outpatient minor surgery. This finding that simple cutaneous surgical procedures can be safely performed with clean, nonsterile gloves was similar in separate subgroup analyses of dental procedures, cutaneous surgery, and MMS (grade of recommendation, 1; strength of evidence, A to B).

This systematic review and meta-analysis provide important insight into an area of medical practice that is large in scope and far reaching. Many health care specialties are involved in outpatient cutaneous minor surgery on a regular basis. Given the current interest in a more mindful approach to the use of medical resources and cost containment, understanding whether the use of sterile vs nonsterile gloves affects SSIs in outpatient minor surgery is important because of the large cost difference between these different glove types.7,28

The strengths of this systematic review and meta-analysis include the pooling of a large number of patients (n = 11 071) and the quality of the studies and trials that were pooled, all being deemed as high-quality research with minimal heterogeneity and risk for bias. Thus, the evidence from the analyses performed as part of this systematic review and meta-analysis would also be considered of high quality. Subtle differences may have existed among the studies analyzed that were not reported, including details of surgical site antisepsis measures, draping, use of topical or systemic antibiotics, or details of hand scrubbing or washing. However, given the large number of patients summarized and the low heterogeneity found in the included studies, we do not believe that these possible differences affect the outcomes of this review or the power of the overall assessment.

Because several of the studies used for this meta-analysis were observational studies, the possibility of publication bias remains. This bias seems unlikely, however, given the number of randomized clinical trials that demonstrate similar results and the relatively similar outcomes noted across all observational studies.

Given the thoroughness of the original search strategy and systematic review, the data in this study would be considered complete. Some studies that compared sterile vs nonsterile gloves were excluded because they had a different study design and outcome measure. One of these excluded studies evaluated the effects on open wounds after surgery3 and another determined the chances of urinary tract infection in the setting of cystoscopy.29 Although cystoscopy is an outpatient procedure, for the purposes of inclusion, it was not considered similar enough to an outpatient surgery to meet inclusion criteria. Specifically, no cutaneous or mucous membrane was cut or breached as part of the cystoscopy procedure.3,29

We should consider some previous findings that are in disagreement with the findings of our study. In 1 study6 that included heightened infection control—multiple sterile precautions, including gloves—the postoperative SSI rates were 2.5% vs 0.9% in the nonsterile and sterile glove categories, respectively. A follow-up study from this same institution18 demonstrated that decreasing the costs of infection control protocols, such as eliminating sterile gloves during the tumor removal stage of MMS and removing sterile gowns and half-sheet drapes during reconstruction, did not affect infection risk in an office-based MMS practice. In contrast, in a study separating outpatient surgical procedures by complexity, procedures that were more complex than simple excision had a postoperative SSI rate of 14.7% using nonsterile gloves, compared with 3.4% when sterile gloves were used.17 Thus, more extensive surgery or complicated repairs may have a higher risk for SSI, which should be taken into consideration. This information should be considered carefully when deciding surgical practice guidelines, because this systematic review may not be generalizable to more complex surgical procedures. Of interest, however, some evidence shows that having an open wound for a long duration in the setting of a complex surgery or repair may not affect the risk for postoperative SSI as much as once was thought.31 In contrast to these disagreements, ample evidence suggests that, in general, nonsterile gloves do not influence the chances of postoperative SSI in outpatient surgical procedures.

When considering surgical practices and guidelines, multiple factors should be considered, including the potential consequences of deviating from accepted sterile glove use and the potential challenges this could cause from a medicolegal standpoint. Patient perception of the sterile technique used should also be considered, in addition to the dexterity that comes from wearing a surgical glove that fits snugly, as opposed to a clean glove that gives the surgeon a different feel. Although the broad use of nonsterile clean gloves may be justified, caution is advised in generalizing this justification to more advanced outpatient surgical procedures that may not pertain to the information summarized in this review and meta-analysis. Future study could include whether duration of surgery and complexity of the repair influence postoperative SSI development in the setting of sterile vs nonsterile gloves.

Conclusions

This systematic review and meta-analysis found no difference in the rates of postoperative SSI in outpatient surgical procedures performed with nonsterile vs sterile gloves. Given the cost difference between these gloves and the multitude of outpatient surgical procedures performed worldwide, these findings could have a significant effect on and implications for current practice standards.

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Article Information

Corresponding Author: Jerry D. Brewer, MD, Division of Dermatologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (brewer.jerry@mayo.edu).

Accepted for Publication: May 5, 2016.

Published Online: August 3, 2016. doi:10.1001/jamadermatol.2016.1965.

Author Contributions: Drs Brewer and Gonzalez had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Brewer, Roenigk, Otley, Erwin.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Brewer, Erwin.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Gonzalez.

Administrative, technical, or material support: Gonzalez, Erwin.

Study supervision: Brewer, Arpey, Roenigk, Otley.

Conflict of Interest Disclosures: None reported.

References
1.
Spirling  LI, Daniels  IR.  William Stewart Halsted—surgeon extraordinaire: a story of “drugs, gloves and romance”.  J R Soc Promot Health. 2002;122(2):122-124.PubMedGoogle ScholarCrossref
2.
Creamer  J, Davis  K, Rice  W.  Sterile gloves: do they make a difference?  Am J Surg. 2012;204(6):976-979.PubMedGoogle ScholarCrossref
3.
Lawson  C, Juliano  L, Ratliff  CR.  Does sterile or nonsterile technique make a difference in wounds healing by secondary intention?  Ostomy Wound Manage. 2003;49(4):56-58, 60.PubMedGoogle Scholar
4.
Adeyemo  WL, Ogunlewe  MO, Ladeinde  AL, Bamgbose  BO.  Are sterile gloves necessary in nonsurgical dental extractions?  J Oral Maxillofac Surg. 2005;63(7):936-940.PubMedGoogle ScholarCrossref
5.
Heal  C, Sriharan  S, Buttner  PG, Kimber  D.  Comparing non-sterile to sterile gloves for minor surgery: a prospective randomised controlled non-inferiority trial.  Med J Aust. 2015;202(1):27-31.PubMedGoogle ScholarCrossref
6.
Martin  JE, Speyer  LA, Schmults  CD.  Heightened infection-control practices are associated with significantly lower infection rates in office-based Mohs surgery.  Dermatol Surg. 2010;36(10):1529-1536.PubMedGoogle ScholarCrossref
7.
Mehta  D, Chambers  N, Adams  B, Gloster  H.  Comparison of the prevalence of surgical site infection with use of sterile versus nonsterile gloves for resection and reconstruction during Mohs surgery.  Dermatol Surg. 2014;40(3):234-239.PubMedGoogle ScholarCrossref
8.
Perelman  VS, Francis  GJ, Rutledge  T,  et al.  Non-sterile gloves were as safe as sterile gloves for repair of uncomplicated lacerations.  Evid Based Med. 2004;9(6):182. doi:10.1136/ebm.9.6.182.Google ScholarCrossref
9.
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(3):362-370.PubMedGoogle ScholarCrossref
10.
Rhinehart  MB, Murphy  MM, Farley  MF, Albertini  JG.  Sterile versus nonsterile gloves during Mohs micrographic surgery: infection rate is not affected.  Dermatol Surg. 2006;32(2):170-176.PubMedGoogle Scholar
11.
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(5):651-656.PubMedGoogle ScholarCrossref
12.
Cheung  LK, Chow  LK, Tsang  MH, Tung  LK.  An evaluation of complications following dental extractions using either sterile or clean gloves.  Int J Oral Maxillofac Surg. 2001;30(6):550-554.PubMedGoogle ScholarCrossref
13.
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(2):174-179.PubMedGoogle ScholarCrossref
14.
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