Are sterile gloves necessary when repairing lacerations in the emergency department?

One of the first times I was really introduced to ‘dogma busting’ was when I was told early in residency that sterile gloves were absolutely not needed when repairing lacerations in the emergency department, and there were RCTs to prove it. I have lived by that anti-dogma dogma since, and so I expected this to be a very easy topic to review, with very solid research. 

I imagine that the reason I heard about this evidence so often in residency was that the largest emergency department study was published in Toronto, and the authors are now my friends and colleagues. (Perelman 2004) It was a multicentre RCT including emergency department patients over the age of 1 with uncomplicated lacerations. Patients at high risk for infection were excluded (diabetes, renal failure, immunosuppression, asplenia, cirrhosis). 816 patients were randomly assigned to have their physician wear sterile or just clean gloves. The primary outcome (wound infection) was assessed on a questionnaire provided to the patient to be filled out by their family doctor at the time of suture removal. If this wasn’t received they called the patient. Unsurprisingly, they received less than half of the questionnaires, but based on phone calls, they managed to reach 97% of all patients for follow-up. Infection occurred in 6.1% of the sterile glove group and 4.4% of the clean glove group, a nonsignificant difference (RR 1.37, 95% CI 0.75-2.25, p=0.3). For a study of emergency medicine wound repair, this is a big trial, but it cannot exclude small differences between the groups. (I am reassured that the sterile glove group actually had higher infection rates, as it makes it less likely that there is a real difference, and the trial is simply under-pwoered.) Out of approximately 9,000 eligible patients, they approached 1,110, and included 816, so selection bias is a big concern. They report that to do an equivalency trial, they would have needed 3,000 patients per group.

That is a good study, but there are obviously some weaknesses, such as the heavy reliance on telephone follow-up. More importantly, it is only a single study, and we all know that science requires replication. Given the certainty with which this fact was taught to me, I honestly expected more high quality data. 

We do have a few other trials to look at. Amazingly, there is an RCT comparing sterile gloves to no gloves at all. (Bodiwala 1982) In this study, from the early 1980s, lacerations were repaired by qualified nurses in the Accident and Emergency department of a single hospital in England, and they were randomized to gloves or no gloves (although the method of randomization is not great). There was no difference in infections, but it is a fair amount higher than other studies (13% had mild wound infections and 4% severe in both groups).  

In fact, this is not the only trial comparing sterile gloves to no gloves at all. Another RCT showed no difference in infection rates when lacerations were repaired with no gloves at all. (Maitra 1986) The infection rate was 7% in both groups in a study of 242 lacerations in the emergency department. Although the write up is somewhat vague, I think the key thing to know about this study is that they always performed a full surgical scrub before laceration repair, which would definitely limit generalizability. 

There is another trial done by a single doctor in his own family medicine practice in which he personally randomized 50 patients (by pulling coloured beads from a bag) to either have a full sterile laceration repair (picture OR sterility) versus no gloves at all (but he did wash his hands). (Worral 1989) He doesn’t present percentages, and only had follow-up on 43 patients (despite these being his own family practice patients). However, there was a reasonably big difference, with 10 of 22 patients in the sterile group with wound infections as compared to only 3 or 21 in the no glove group (p<0.05). That’s right: this study seems to conclude that sterile gloves cause infections. However, despite being infected, less than half of these patients needed antibiotics, and obviously this trial done in a single office, with significant loss to follow-up is far from perfect. 

Really – this doesn’t need to be studied any more. Don’t repair lacerations without gloves. That’s gross. But for our purposes, it is interesting to know that there isn’t even good evidence that sterile gloves are better than no gloves at all. 

As of mid-2022, that was the entirety of the emergency literature on sterile gloves.

However, there was some surgical literature to consider. It sort of makes sense that sterile gloves would be unnecessary with traumatic lacerations, as the implement making the laceration was not sterile. However, there is even evidence that sterile gloves aren’t necessary in outpatient dermal surgery, where the implements would all be sterile, and the skin would have been sterilized prior to starting. Brewer 2016 is a systematic review and meta-analysis that includes over 11,000 patients from 13 studies in dental clinicals and dermatology clinics undergoing procedures such as dental extractions and Mohs microsurgery. The rate of postoperative infection was the same in the sterile glove and clean glove groups (2% in both groups). Mixing dental and skin surgery seems strange, but they did run the analyses separately, and there was no difference.

Obviously, factories aren’t purposely contaminating our standard gloves with pathogens, so we can probably expect gloves to arrive at the hospital relatively sterile. I think the big concern is that as people grab gloves out of the larger box, they are contaminating the gloves they don’t use. There was an interesting ICU study that looked at this issue by culturing the first set of gloves removed from a brand new box, and then leaving the box to be used normally in the ICU setting, and then culturing gloves from about half way through the box, and then the final 2 gloves in the box. (Rossoff 1993) Despite being ‘unsterile gloves’, about half the gloves were found to be sterile across all time points. Obviously, that means that the other half had some bacteria on them, but the burden of contamination was very low, with bacteria considered to be of low pathologic potential. This provides a reasonably strong pathophysiologic support to the findings of the RCTs. (Sterile gloves can’t possibly reduce infections if they are being compared against other gloves that are also mostly sterile.) However, another study did find transfer of drug-resistant strains of Staph aureus to the box of gloves in the rooms of burn patients. (Sadowski 1988) I imagine the recurrent use of the same box for the same patient means that this data is not perfectly applicable to the emergency department. However, I think it reminds us to be cautious in our policies and extrapolation of this data. (And please, wash your hands between the time that you see a patient and go to get a new pair of gloves out of the communal glove box.)

Just after finishing my initial review in the summer of 2022, a very large mutli-centre non-inferiority RCT was published in the Emergency Medicine Journal. (Zwaans 2022) They included 1480 (of 2468 eligible) adult patients with lacerations requiring sutures in an emergency department, and randomized them to either have their wound closed by a doctor wearing sterile gloves or non-sterile gloves. All wounds were irrigated with tap water (which has been studied elsewhere, but if you are a believer in sterile gloves you might also be a believer in sterile irrigation). The primary outcome was wound infection, and was assessed by a physician blinded to the allocation group of the patient between 5 and 15 days later. They set a non-inferiority margin of 2% – meaning that they were OK with 2% more infections in the non-sterile group – but I am not sure this is a clinically appropriate margin. (This is always a problem with non-inferiority trials.) Unfortunately, the study was supposed to include 2140 patients, but they stopped early because apparently they weren’t seeing lacerations in the ED anymore (something about merging the ED with local GP offices). Mostly, the patients were young males without comorbidities (so low risk for wound infection). The wound infection rate in the sterile treatment group was 6.8% (95% CI 4.0% to 7.5%) vs 5.7% (95% CI 5.1% to 8.8%) in the non-sterile treatment group. The mean difference of the wound infection rate of the two groups was −1.1% (95% CI −3.7% to 1.5%). Despite being stopped early, this is the best evidence available on the topic, and is most consistent with no difference between using sterile gloves and not. It cannot completely exclude a small decrease in infections, but given the added costs and complexities of sterile laceration repair, I think non-sterile gloves are the way to go for almost all patients. Clinical judgment still applies though, and it might be reasonable to use sterile gloves in patients with much higher risk of infection.

Bottom line

The two biggest trials (Perelman and Zwaans) have very similar numbers, and although both have potential sources of bias, there is nothing that makes me think that bias would push the results in either direction. It is not possible to exclude a very small benefit, but I think we can be pretty comfortable that basic clean gloves are good enough for routine laceration repairs. 

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References

Bodiwala GG, George TK. Surgical gloves during wound repair in the accident-and-emergency department. Lancet. 1982 Jul 10;2(8289):91-2. doi: 10.1016/s0140-6736(82)91703-2. PMID: 6123821

Brewer JD, Gonzalez AB, Baum CL, Arpey CJ, Roenigk RK, Otley CC, Erwin PJ. Comparison of Sterile vs Nonsterile Gloves in Cutaneous Surgery and Common Outpatient Dental Procedures: A Systematic Review and Meta-analysis. JAMA Dermatol. 2016 Sep 1;152(9):1008-14. doi: 10.1001/jamadermatol.2016.1965. PMID: 27487033

Maitra AK, Adams JC. Use of sterile gloves in the management of sutured hand wounds in the A&E department. Injury. 1986 May;17(3):193-5. doi: 10.1016/0020-1383(86)90333-5. PMID: 3546125

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 Mar;43(3):362-70. doi: 10.1016/j.annemergmed.2003.09.008. PMID: 14985664

Rossoff LJ, Lam S, Hilton E, Borenstein M, Isenberg HD. Is the use of boxed gloves in an intensive care unit safe? Am J Med. 1993 Jun;94(6):602-7. doi: 10.1016/0002-9343(93)90211-7. PMID: 8506885

Worrall GJ. Repairing skin lacerations: does sterile technique matter? Can Fam Physician. 1989 Apr;35:790-1. PMID: 21249025

Zwaans JJM, Raven W, Rosendaal AV, Van Lieshout EMM, Van Woerden G, Patka P, Haagsma JA, Rood PPM. Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial. Emerg Med J. 2022 Jul 26:emermed-2021-211540. doi: 10.1136/emermed-2021-211540. Epub ahead of print. PMID: 35882525