Secondary Logo

Journal Logo

If One Is Good, Are Two Always Better?

Prielipp, Richard C. MD, MBA, FCCM*; Brull, Sorin J. MD, FCARCSI (Hon)

doi: 10.1213/ANE.0000000000000231
Editorials: Editorial

From the *Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota; and Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida.

Accepted for publication January 27, 2014.

Funding: Departmental support.

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Sorin J. Brull, MD, FCARCSI (Hon), Department of Anesthesiology, Mayo Clinic College of Medicine, 4500 San Pablo Rd., Jacksonville, FL 32224. Address e-mail to

Health care-associated infections are common and costly complications in hospitalized patients, especially the critically ill. The major nosocomial infections include surgical site infections (SSI), central line-associated bloodstream infections, ventilator-associated pneumonia, catheter-associated urinary tract infections, and Clostridium difficile-associated disease. Each infection accrues significant direct (e.g., additional medications and increased hospital length of stay), indirect (e.g., short- and long-term morbidity, lost income to the patient and family members), and intangible (e.g., pain and suffering, patient stress) costs. In addition to the increased risk of mortality, health care-associated infections increase attributable hospital costs by $10,000 to $40,000 per patient episode.1,2 A central question important to the pathogenesis and prevention of perioperative infections is how microorganisms are spread in the environment. The elegant investigation of Birnbach et al.3 reported in this issue of the journal provides important insight into this question by demonstrating that “we have met the enemy, and he is us” (Pogo).

Of course, the “pathogens” in this simulated study are nonexistent, but real patients are heavily populated with numerous microorganisms making up the oral flora4 and skin microbiome.5 Common oral microorganisms have been implicated in diseases such as bacterial endocarditis, aspiration pneumonia, necrotizing fasciitis, brain abscesses, osteomyelitis, cardiovascular disease, meningitis, and have been associated with preterm low birth weight babies.4 Moreover, of the 700 oral bacterial species (phylotypes), >60% have not yet been cultivated or fully identified.4 We do know, however, that the predominance of one bacterial species or another varies throughout individual sites inside the mouth; for instance, the dorsum of the tongue is populated differently than the lateral aspects of the tongue. The various microenvironments of the buccal epithelium, the hard and soft palate, the tonsils, and even tooth plaque all favor one bacterium over another. Overall, a total of 141 different bacterial taxa were cultivated from the oral cavity of 5 healthy volunteers, including species of Gemella, Granulicatella, Streptococcus, Veillonella, Actinomyces, Atopobium, Rothia, Neisseria, Eikenella, Campylobacter, Porphyromonas, Prevotella, Capnocytophaga, Fusobacterium and Leptotrichia.4 Organisms of the oral flora can be associated with specific diseases (Table 1). In the intensive care units or the institutionalized patient population, the aerobic and anaerobic Gram-negative bacilli often become transient and dominant opportunists, creating additional risk of secondary disease.6

Table 1

Table 1

During surgery, glove failure (e.g., perforation) defeats the protection of the surgeon from the patients’ blood-borne pathogens and exposes the surgical wound to microorganisms found on the surgeon’s hands. Since the incidence of inadvertent glove puncture is over 60%, double gloving or the use of gloves with puncture-indication systems that show a visible green color when damaged have been recommended.7 The use of double gloves also has been purported as an effective method of reducing surgical cross-infection and resulting in fewer SSI. In fact, double gloving (or even triple gloving, or the use of glove liners) results in significant reduction in perforations to the inner glove, but they do not appear to reduce the incidence of SSI.8 The practice that appears to decrease microbial contamination during orthopedic surgery is simply changing the outer glove after draping.9 Thus, in surgery, the use of double gloves has no defined benefit on SSI, but changing the outer glove after draping decreases bacterial cross-contamination.

For the anesthesiologist, then, the obvious questions are: how will the surgical lessons of double gloving be applied so that we (and our patients) might derive maximum benefit? What is the anesthesia practice equivalent of double gloving for surgical procedures? And, more importantly, what is the anesthesia practice equivalent of changing surgical gloves after patient draping, and when is our patient at greatest risk of contamination? Birnbach et al.3 give us a simple answer: 1 time of major contamination occurs immediately after airway management. Although this may seem intuitive, the study is brilliant not only in the fact that it addresses an important patient safety issue, but because it suggests some reasonable solutions that are readily and easily achievable.

There is ample precedent for implementation of new paradigms to reduce the risk of hospital-acquired infections. Education programs focusing on teaching doctors and nurses better sterile technique for the insertion and maintenance of catheters have been shown to significantly reduce the risk of catheter-related bloodstream infections.10 In particular, it has been possible to show that such programs can increase compliance with the use of maximum sterile barriers under “real world clinical conditions.”10 Thus, we believe anesthesiology teaching programs would do well to embed the simple step of double gloving for airway interventions into the first week of residency orientation.

One must be careful with some of the extrapolations of the findings made by Birnbach et al.,3 since several questions remain. Do the conditions and findings in the simulation laboratory room translate to the clinical operating room (OR)? Can anesthesia professionals be convinced to adhere to a “simple” change in practice like double gloving, or will providers stubbornly maintain old habits? For instance, we have ample evidence that hospital programs to implement universal hand-washing protocols may achieve compliance rates of only 26% despite a plethora of science, safety, and quality motivators.11 In addition, airway management at the start of the anesthetic is not the only time when the provider’s hands could become contaminated with oral microflora; similar contamination of the OR environment likely occurs after insertion of nasogastric tubes (which is unfortunately “routine” practice after tracheal intubation in some institutions), placement of oral airways, use of Yankauer and other oral or tracheal suction catheters, introduction and manipulation of esophageal bougies during surgical procedures such as Nissen fundoplication, and placement of bite-blocks to prevent bite injuries in neurosurgical cases requiring transcranial motor-evoked potential monitoring. More work is needed in these settings to better delineate the potential for bacterial contamination of the OR environment by the providers’ hands. Nevertheless, the study by Birnbach et al.3 should serve as the quintessential model for further investigations in this area.

The future will likely see the development of better educational tools, standardized protocols, and technological interventions to assist in our battle against nosocomial infections. One intervention might be introduction of standardized anesthesia protocols for reducing infection risk. We already have protocols for hand-washing and central line insertion. We envision the use of double gloves as part of standardized anesthesia infection reduction protocols. Such protocols might also include placing hand-washing gels on the anesthesia workstation, providing clearly demarcated areas for clean and contaminated items, defining work areas for “next case” preparation to minimize comingling current and future case supplies on the anesthesia machine, addressing the problem of keyboard/knob/drawer contamination, and defining policies on when unused items should be returned to storage even though they have been lying exposed on the anesthesia workstation for many hours. The work of Birnbach et al.3 improves our understanding of the invisible contamination occurring daily during the first 6 minutes of our routine work process. It also emphasizes the need to create “best practices” infection reduction protocols that codify and facilitate interventions to minimize the risk of health care-acquired infections to our surgical patients.

Back to Top | Article Outline


Dr. Sorin J. Brull is the Section Editor for Patient Safety for the Journal. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Brull was not involved in any way with the editorial process or decision.

Back to Top | Article Outline


Name: Richard C. Prielipp, MD, MBA, FCCM.

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Richard C. Prielipp approved the final manuscript.

Conflicts of Interest: The author has no conflicts of interest to declare.

Name: Sorin J. Brull, MD, FCARCSI (Hon).

Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.

Attestation: Sorin J. Brull approved the final manuscript.

Conflicts of Interest: Sorin J. Brull consulted for Merck.

Back to Top | Article Outline


1. Nair GB, Niederman MS. Nosocomial pneumonia: lessons learned. Crit Care Clin. 2013;29:521–46
2. Scott RD II. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. National Center for Preparedness, Detection, and Control of Infectious Diseases. Centers for Disease Control and Prevention. Available at: Accessed November 30, 2013
3. Birnbach DJ, Rosen LF, Fitzpatrick M, Carling P, Arheart KL, Munoz-Price S. Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. Anesth Analg. 2015;120:848–52
4. Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defining the normal bacterial flora of the oral cavity. J Clin Microbiol. 2005;43:5721–32
5. Schommer NN, Gallo RL. Structure and function of the human skin microbiome. Trends Microbiol. 2013;21:660–8
6. Lam OL, McGrath C, Li LS, Samaranayake LP. Effectiveness of oral hygiene interventions against oral and oropharyngeal reservoirs of aerobic and facultatively anaerobic Gram-negative bacilli. Am J Infect Control. 2012;40:175–82
7. Laine T, Aarnio P. How often does glove perforation occur in surgery? Comparison between single gloves and a double-gloving system. Am J Surg. 2001;181:564–6
8. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev. 2006(3):CD003087
9. McCue SF, Berg EW, Saunders EA. Efficacy of double-gloving as a barrier to microbial contamination during total joint arthroplasty. J Bone Joint Surg Am. 1981;63:811–3
10. Sherertz RJ, Ely EW, Westbrook DM, Gledhill KS, Streed SA, Kiger B, Flynn L, Hayes S, Strong S, Cruz J, Bowton DL, Hulgan T, Haponik EF. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med. 2000;132:641–8
11. Garus-Pakowska A, Sobala W, Szatko F. Observance of hand-washing procedures performed by the medical personnel after the patient contact. Part II. Int J Occup Med Environ Health. 2013;26:257–64
12. Scannapieco FA, Stewart EM, Mylotte JM. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med. 1992;20:740–5
© 2015 International Anesthesia Research Society