Secondary Logo

Journal Logo

SYSTEMATIC REVIEWS

Glove utilization in the prevention of cross transmission: a systematic review

Picheansathian, Wilawan; Chotibang, Jutamas

Author Information
JBI Database of Systematic Reviews and Implementation Reports: April 2015 - Volume 13 - Issue 4 - p 188-230
  • Free

Abstract

Background

The hands of health care workers (HCWs) become contaminated by pathogens and the risk for contamination increases-linearly with time on hands during patient care.1 Therefore, cross transmission of microorganisms by the hands of HCWs is considered to be the most likely means of transmission of hospital-acquired infection.2,3 This risk can be minimized through thorough hand washing and the use of gloves. Gloves are worn to protect the hands from contamination with organic matter and microorganisms, and to reduce the risks of transmission of microorganisms from HCWs to patients and vice versa.4,5 Gloves should be worn for invasive procedures, any contact with sterile sites, non-intact skin, mucous membranes and exposure to blood, all other body fluids and sharp or contaminated instruments.6,7 Two prospective controlled trials provided evidence that wearing gloves can help reduce transmission of pathogens in healthcare settings.8,9 In addition, the efficacy of gloves in preventing contamination of HCWs' hands has been confirmed in several observational studies.10–12 However, gloves do not provide complete protection against hand contamination. Bacterial flora from patients was found on the hands of up to 30% of HCWs who had worn gloves during patient contact.1,10 Bacteria can gain access to the HCW's hands via small defects in gloves or by contamination of hands during glove removal.13–15 Gloves often leak during use and, in fact, may leak before use.16

Gloves must be worn as single-use items, and changed between different patients and between different care/treatment activities on the same patient to prevent cross-contamination of body sites.4,5,7,17 Nevertheless, inappropriate use of gloves is observed regularly worldwide. Three observational studies found that healthcare workers did not always remove gloves after previous care and gloves were not always changed between contact with each patient.18,20 Furthermore, one observational study demonstrated that gloves were overused in healthcare environments.20 The unnecessary and inappropriate use of gloves results in a waste of resources and may increase the risk of cross transmission. In addition, inappropriate use of gloves increases the wearer's exposure to the chemicals and accelerants in the glove material, which can result in skin sensitization or inability to work.5

Preventing cross contamination of hands by using gloves is considered important because hand washing or hand antisepsis may not remove all potential pathogens when hands are heavily contaminated.20,21 Although gloves offer protection, they do not provide complete protection against hand contamination, therefore, hands should always be decontaminated after glove removal.22 Hand hygiene following glove removal further ensures the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or that could contaminate the hands during glove removal.10,11,22 The impact of wearing gloves on adherence to hand hygiene policies has not been definitively established, since observational studies have yielded contradictory results.18,19,23–26 Furthermore, failure to remove gloves and to wash hands when moving between patients without change can result in the subsequent cross-transmission of nosocomial pathogens.10,27 Therefore, the influence of glove use on hand hygiene practice is unclear. Given the impact of glove usage on cross-transmission, this systematic review was conducted to contribute to the understanding of the efficacy of glove use in the prevention of cross transmission and identify specific areas for further research.

Before developing the protocol for this systematic review, the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports, Cochrane Library, MEDLINE, CINAHL, EMBASE, PubMed, EBSCO Host Research Databases, Thai Nursing Research Database, Thai Thesis Database, and Blackwell synergy were searched and no existing systematic reviews on this topic were identified. The objectives, inclusion criteria and methods of analysis for this review were specified in advance and documented in a protocol(systematic review protocol NO. 502).28

Review objectives

The objective of this review was to evaluate the evidence regarding clinical use of gloves in the prevention of cross transmission, the adherence to glove utilization among HCWs, the inappropriate uses of gloves among HCWs, and the impact of wearing gloves to hand hygiene among HCWs.

The following questions were addressed in this review:

1. Does glove usage prevent the contamination of HCWs' hands and reduce cross transmission?

2. What are the rates of adherence to glove utilization among HCWs?

3. How are gloves used inappropriately among HCWs?

4. How does the wearing of gloves impact on adherence to hand hygiene among HCWs?

Definitions of terms

Clinical use of glove or glove usage refers to the wearing of gloves to either prevent the hands from becoming contaminated with organic matter or microorganisms, or to prevent the transfer of microorganisms to both patients and healthcare workers. The choice of glove to be used should be based on an assessment of the task of transmission of microorganisms to the patient, and the risk of contamination to the healthcare worker by the patient's blood, body fluids, secretions and excretions.

Adherence to glove utilization is defined as wearing a pair of gloves when touching blood, body fluids, secretions, excretions, non-intact skin or mucous membranes.

Cross transmission is defined as the method by which any potentially infecting agent is spread

from the healthcare worker to the patient and vice versa, as well as from one patient to another.

Prevention of cross transmission refers to the management of those factors that could lead to the spread of microorganisms so as to prevent the occurrence of the disease.

Reduction of cross transmission refers to the act of decreasing the risk of germ dissemination to the environment and of transmission from the healthcare worker to the patient and vice versa, as well as from one patient to another.

Contamination of HCWs' hands refers to the presence of microorganisms on a surface of the

HCWs hands, and is therefore a potential source for transmission.

Inappropriate use of gloves among HCWs refers to the use of gloves when not indicated which represents a waste of resources and may increase the risk of cross-transmission. It also refers to HCWs failing to remove gloves between patients or failing to change gloves during the care of a single patient, thus facilitating the spread of microorganisms.

Adherence to hand hygiene among HCWs refers to readily acting in accordance with the

guideline for hand hygiene in the care of all patients. Adherence to the guideline is defined as either washing the hands with soap or antiseptic and water or rubbing the hands with alcohol-based solutions.

Inclusion criteria

Types of participants

This review considered studies that included healthcare workers.

Types of intervention

The review considered studies that evaluated glove utilization.

Types of outcome measures

The outcomes of interest included:

Contamination of HCWs' hands was measured for example as the number of bacterial colonies grown from the fingertips of the HCW's dominant hand at the end of the observation period.

Transmission of infections was measured as hospital-acquired infection transferred from one patient to another via contaminated gloved hands. The potential for microbial transmission is defined as an instance where gloves contacted mucous membranes, patient skin, moist body substances or environments and gloves were not changed before performing a care necessitating strict aseptic precautions on the same patient or another patient.

Adherence to glove usage was measured as the number of observations of correct performance per number of observations of glove usage opportunities.

Inappropriate use of gloves was measured as the number of observations of gloving when not indicated or failure to remove gloves between patients and to change gloves during the care of a single patient.

Adherence to hand hygiene measured for example as the number of observations of correct performance per number of observations of hand hygiene opportunities.

Types of studies

This review considered any randomized clinical trial (RCT) that evaluated the use of gloves in the prevention of cross transmission. In the absence of RCTs, other research designs such as before and after studies, descriptive or observational studies were considered for inclusion in order to identify the best available evidence related to the rates of adherence to glove usage in caring for patients and the inappropriate use of gloves.

Search strategy

The comprehensive search strategy aimed to find both published and unpublished studies. The time period of the search covered articles published from 2000 to 2012 in English and Thai. A three-step search strategy was utilized in each component of this review. An initial phase limited search of MEDLINE and CINAHL was undertaken, followed by an analysis of textwords contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, reference lists or bibliographies of all identified reports and articles were searched for additional studies.

The following databases searched included:

MEDLINE

CINAHL

EMBASE,

The Cochrane Library

PubMed

EBSCO Host Research Databases

Thai Nursing Research Database

Thai Thesis Database

Blackwell synergy.

Individual search strategies were developed for each database, adopting the different terminology of the index if available.

Hand searching of the most recent issues of the following journals was conducted for additional references:

American Journal of Infection Control

Infection Control and Hospital Epidemiology

Hospital Infection

Journal of the Medical Association of Thailand

Nursing Newsletter

Bulletin of Nosocomial Infection Control Group of Thailand

Journal of Health Science.

The search was conducted to locate relevant unpublished materials, such as conference papers, research reports, digital-dissertations, World Health Organization (WHO) reports and Centre for Disease Prevention and Control (CDC) reports. Content experts were contacted in order to provide other alternatives for securing relevant literature.

All studies identified from the databases searched were first assessed for relevance to the review using a study eligibility tool developed by reviewers (Appendix I). Full reports were only retrieved for relevant studies that met the inclusion criteria as assessed independently by two reviewers. Any discrepancies in reviewer selections were resolved at a meeting between reviewers prior to selected articles being retrieved. Studies meeting the inclusion criteria were submitted to critical appraisal.

Initial keywords or terms included:

Gloves, transmission, infection, adherence, appropriate, inappropriate, hand hygiene

Search for grey literature

The grey literature search consisted of conducting an online search of databases and websites including:

  • Dissertation International
  • Conference Proceedings
  • Google.

Assessment of methodological quality

The retrieved articles were assessed by two independent reviewers for methodological validity using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II). Any discrepancies raised between the reviewers were resolved through discussion between the reviewers.

Data collection

Data were extracted from relevant studies using the data extraction tools developed by JBI-MASTARI (Appendix III).

The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review in question and specific objectives. Attempts were made to contact authors of primary studies to include any missing data or for clarification.

Data synthesis

Meta-analysis of quantitative data was not possible as all studies were heterogeneous in design and results. Therefore, the evidence is presented in narrative summary form and tables.

Review results

Description of studies

Study selection

The initial search on the basis of keywords yielded a total of 2243 papers. Of these, 2086 publications were excluded due to duplication of identified articles or were not research reports. A second stage elimination, based on closer scrutiny of the article title and abstract in relation to the inclusion criteria resulted in 35 studies deemed relevant for this review. Following reading of the full text articles and careful consideration of the inclusion criteria for this review, a third stage elimination resulted in the selection of 23 papers for retrieval. Twelve papers were excluded as they did not fulfil our criteria for inclusion and did not provide detailed results on glove usage. Of those that were eliminated at this stage, five measured glove usage and hand hygiene by self-report{Berthelot, 2006, Bacterial contamination of nonsterile disposable gloves before use;Cheng, 2005, Factors influencing the wearing of protective gloves in orthodontic practice;Ji, 2005, Prevalence of and risk factors for non-compliance with glove utilization and hand hygiene among obstetrics and gynaecology workers in rural China;Jeutissen, 2010, Dissemination of Bacillus cereus in the burn unit due to contaminated non-sterile gloves.;Jeutissen, 2010, Dissemination of Bacillus cereus in the burn unit due to contaminated non-sterile gloves.},16,29–32 three used inappropriate measurement outcomes,33–35 two were case reports36,37 and two provided inadequate data.38,39 Studies excluded from the review and reasons for their exclusion are detailed in Appendix IV. On final assessment, 23 studies were identified as fulfilling all criteria for inclusion and for methodological quality. Search results for the five major databases are included in Appendix V. A diagrammatic flow chart outlining the process of study inclusion for this review is presented in Figure 1.

Figure 1: Flowchart of the selection and exclusion of articles
Figure 1: Flowchart of the selection and exclusion of articles

Details of the 23 studies included are presented in Appendix VI. Eighteen studies were observational studies7,18,25,40–54 and five were quasi-experimental designs.10,55–58 Of all studies, 22 were published in English7,10,18,25,40–57 and one was published in Thai.58 The number of participants as reported in 11 studies ranged from 15 to 1478 HCWs. Twelve studies indicated the number of observational events which ranged from 164 to 7578 events. Nine of 23 studies were conducted in the USA,10,25,45,48–50,55–57 five were conducted in France,18,41,51,53–54 two each were conducted in the United Kingdom7,42 and Turkey,43–44 and one each were conducted in Hong Kong,40 Switzerland,46 Italy,47 Iran,52 and Thailand.58 All 23 papers addressed at least one or more of the review questions and thus the findings are presented in relation to each of the four questions of the review. Thirteen studies examined adherence to glove utilization among HCWs, eight studies investigated the wearing of gloves and the resulting impact on adherence to hand hygiene among HCWs, nine studies studied the link between glove usage in preventing the contamination of HCWs' hands and the reduction of cross transmission, and three studies examined the inappropriate use of gloves among HCWs.

Description of quasi-experimental studies

Five studies10,55–58 used a quasi-experimental design and took the form of pretest-posttest only one group designs. All studies were published between 2001 and 2008. These quasi-experimental studies involved health care workers and patients admitted in the studied units. The number of participants reported in four studies ranged from 15 to 156. One study indicated number of observational events which was 6948 events. The studies were conducted in the USA10,55–57 and Thailand.58 The interventions were the use of gloves. Three studies reported outcomes on contamination rates,10,55,57 one study reported outcomes on adherence to glove utilization,58 and one study reported outcomes on hand hygiene.56

Description of observational studies

Eighteen studies7,18,25,40–54 were observational studies. All participants were health care workers including physicians, nurses, assistant physicians, therapists, support workers and health care assistants. The number of participants reported in nine studies ranged from 42 to 1478. Nine studies indicated the number of observational events which ranged from 164 to 7578 events. The studies were conducted in hospitals in Hong Kong,40 France,18,41,51,53–54 United Kingdom,7,42 Turkey,43–44 USA,25,45,48–50 Switzerland,46 Iran41 and Italy.47 Twelve studies determined the impact of adherence to glove utilization among HCWs,7,18,25,40–42,44,47,51–54 while eight studies determined the wearing of gloves on adherence to hand hygiene among HCWs.7,18,25,40–43,47 Seven studies tried to determine the role of glove usage in preventing contamination of HCWs' hands and reducing cross transmission,10,18,45–46,48–50 and three studies documented inappropriate use of gloves among HCWs.7,18,52

Methodological quality

Methodological quality of quasi-experimental studies

All of the five quasi-experimental studies met five of the ten quality criteria (Table 1). Three studies used convenience sampling or purposive sampling depending on the availability of the healthcare workers who worked in the study units. None of the subjects withdrew from these studies. All studies did not blind to the treatment allocation from those assigning outcomes and did not conceal the allocation to treatment groups from the allocator. However, the outcomes were assessed using objective criteria and in a reliable manner in all of the studies. Appropriate statistical analysis was employed in all studies.

Table 1
Table 1:
Methodological quality summary (quasi-experimental designs)

Methodological quality of descriptive studies

All of the 18 descriptive studies met four of the nine criteria. All studies were cross-sectional studies with no participants withdrawing from the studies. In all studies, appropriate statistical analysis was used and outcomes appeared to be measured using objective criteria and in a reliable way. In five studies, attempts were made to control confounding factors and ensure that strategies to deal with them stated.

Systematic review findings

The study findings are presented according to the four objectives set out in this review. All findings are presented in a narrative summary in the order described under review objectives.

Glove usage prevents the contamination of HCWs' hands and reduces cross transmission

Meta-analysis was not possible as all nine studies were heterogeneous in design due to the wide range of outcome measures. Therefore, the evidence is presented in a narrative summary and table.

Table 2
Table 2:
Comparison of studies considered contamination of gloves with microorganisms
Table 2
Table 2:
Continued
Table 2
Table 2:
Continued
Table 2
Table 2:
Continued

A study by Pessoa-Silva et al.46 demonstrated that 90.5% of ungloved hands become progressively contaminated with commensal flora and potential pathogens during routine neonatal care. All care that did not include the use of gloves was associated with a significant increase in the bacterial contamination of HCWs' hands.

Nine studies10,18,45–46,48–50,55,57 consistently indicated that the gloves of HCWs frequently became contaminated with microorganisms during routine care and contaminants include A. baumanii, S. aureus, Enterobacteriacae, and MDR organisms such as VRE and MRSA. Of HCWs who wore gloves, 20 of 35 (57%) contaminated them after touching only the environment, and 43 of 61 (69%) contaminated their gloves after touching both the patient and the environment (p =.3).48 There was an increasing trend of hand or glove contamination among HCWs who touched both the patient and the environment (41of 59 [70%]), compared with HCWs who touched only the environment (23 of 44 [52%]), but the difference was not statistically significant.48 It was found that protective gloves reduced the incidence of transfer of MDR A. baumanii to the hands of HCWs eight-fold, from 36.2% to 4.5%.50

Three studies46,48,50 found that HCWs who wore gloves were significantly less likely to contaminate their hands. Hayden et al.48 demonstrated that 37% of HCWs who did not wear gloves contaminated their hands as compared to 5% of HCWs who wore gloves (an 86% difference). A study by Pessoa-Silva et al.46 also found that HCWs who did not wear gloves acquired 24.5 CFU/min (95% CI, 16.2 to 32.8 CFU/min; p < .001) as compared with -1.9 CFU/min (95% CI, -11.5 to 7.7 CFU/min; p =.690) among those who did. In addition, a study by Morgan et al.50 found that protective gloves reduced the incidence of transfer of MDR A. baumanii to the hands of HCWs eight-fold, from 36.2% to 4.5%. However, gloves were contaminated more frequently than gowns. The type and duration of care and the use of gloves significantly predicted bacterial hand contamination.46 Therefore, gloves reduced the risk of acquisition of bacteria on the HCWs' hands by 71%.10 However, the use of gloves did not fully protect HCWs' hands from bacterial contamination because three studies10,46,50 found that the hands of HCWs after glove removal were contaminated with microorganisms. In addition, a study by Girou et al.18 demonstrated that microbial transmission might have occurred in 18.3% of all contact because used gloves were not removed before performing care activities.

Three studies documented the risk factors associated with the acquisition of pathogenic organisms on gloves during patient care. Tenorio et al.10 found that duration of contact with a patient's body fluids, presence of diarrhea in a patient, mean VRE colony counts on a patient's skin, and the number of patient body sites colonized with VRE were associated with the acquisition of VRE on gloves. A study by Morgan et al.50 showed that risk factors for contamination with MDR A. baumannii were manipulation of wound dressing (OR, 25.9 [95% CI, 3.1–208.8]), manipulation of artificial airway (OR, 2.1 [95% CI, 1.1–4.0]), time in room longer than five minutes (OR, 4.3 [95% CI, 2.0–9.1]), being a physician or nurse practitioner (OR, 7.4 [95% CI, 1.6–35.2]), and being a nurse (OR, 7.4 [95% CI, 1.6–35.2]). Finally, a study by Hayden et al.48 demonstrated that the number of contacts was associated with gloved or ungloved hand contamination (OR, 1.1 [95%CI, 1.01–1.19] p = .02); each contact resulted in a 10% risk of hand contamination. The effect of the type of contact such as touching a patient and the environment or touching only the environment (OR, 1.65 [95% CI, 0.58–4.62]) were so closely related that they could not be distinguished. The VRE acquisition rate in patients was 1.80 cases per 100 days at risk in the gown and gloves period compared with 3.78 in the gloves only period (p = .04).57 In a proportional hazards model adjusted for length of stay, gloves-only precautions with a hazard ratio of 2.5 (p =.02; 95% CI, 1.2 to 5.3) were the only independence risk factor for VRE acquisition.57 This demonstrated that the risk of acquiring VRE was 2.5-fold higher when gloves alone were used as the barrier precautions.

The rates of adherence to glove utilization among HCWs

Twelve studies described adherence to glove utilization among HCWs ranging from 26.2% to 92.3%, with an average of 61.2%.7,18,40–42,44,47,51–54,58 Nursing assistants donned gloves significantly more frequently than nurses.18,47 The compliance to glove use for doctors was significantly lower than that of nurses and healthcare assistants or nursing assistants.7,42,47,52 The rate of glove use was highest in the intensive care unit (65.2%) and lowest in pediatric wards (9.1%).47 In addition, gloves were used in 551 (16.7%) of 3292 low-risk contacts when there would not have been a clinical indication for using gloves. Conversely, gloves were not used in 141 (21.1%) of 669 high-risk contacts, when their use would have been indicated.42 Some HCWs did not wear gloves during procedures that exposed them to blood, body fluids, secretion, excretion, non-intact skin or mucous membranes such as venipuncture, removing dressing materials. Some HCWs did not wear gloves while examining or turning a patient or changing a dressing for a patient that required contact precautions.40

A study by Trick et al.55 demonstrated thatHCWs in the routine glove use section were significantly more likely to wear gloves than in the contact isolation precautions (61% vs. 44%, p=.03). In addition, a study by Trick et al.56 found that HCWs at the intervention hospital were more likely to protect themselves from microbial contamination by wearing gloves compared with HCWs at the control hospital. In the study the intervention at the hospital involved increasing the availability of alcohol-based hand rub, and the implementation of an interactive education program and a poster campaign.

The inappropriate use of gloves among HCWs

It was demonstrated that gloves were overused and often misused. The major break in compliance with glove use was failure to change gloves between procedures on the same patient (from contaminated to clean procedure).18,40,51–53 Three studies found that gloves were removed or changed immediately after contact in 64.4%-72.2 % of the time.18,51–53 Girou et al.18 found that 82.3% of contacts requiring strict aseptic precautions were performed with gloves that had not been removed after previous care. Some healthcare workers did not remove gloves before touching uncontaminated items and environmental surfaces. It was found that HCWs often remove gloves after a single contact or at the end of a series of successive contacts, but they are less likely to change gloves between procedures, particularly those conducted on the same patients.18,40–41,51,53 Furthermore, a study by Hitoto et al. (2008)53 also indicated that the type of ICU (OR: 2.03; p=0.01), the appropriateness of gloving (OR: 1.82; p=0.03), and the occurrence of a single contact (OR: 7.76; p<0.001) were significantly associated with glove removal by univariate analysis (p = 0.12) (adjusted OR: 8.592; p<0.001).

A study by Flores et al.7 found that gloves were overused. They were worn for tasks that were not recommended for use such as collecting equipment, talking to the patient, answering the phone and writing notes. However, nurses overused gloves significantly less than doctors and healthcare assistants.Furthermore, a study by Chau et al.40 demonstrated that HCWs were observed wearing three pairs of gloves at one time and removing one pair after each procedure. However, a study by Assawapalanggool et al.58 in Thailand demonstrated that after implementing a gloves usage promotional program, the proportion of correct practice on gloves usage among nurses increased significantly from 41.3% to 99.4% (p < .001).

The impact of wearing gloves on adherence to hand hygiene among HCWs

Three studies showed that glove use is positively associated with subsequent hand disinfection.25,47,56 In contrast, two other studies found that the adherence to hand hygiene after contact without gloves was significantly higher than after contacts with gloves worn.41–42 Meta-analysis was not possible as all five studies were heterogeneous in results.

Inappropriate glove use adversely affects adherence to hand hygiene protocols. Four studies found that the continued use of gloves without removal after contact resulted in performing procedures without adequate hand hygiene.7,18,25,40 Compliance with hand hygiene after gloving was significantly higher after a single contact or at the end of a series of successive contacts compared with inside series (92.5% vs. 32.5%, p< 10-7).51 It was found that compliance with hand hygiene before gloving was 16.1%,43 andafter removal of gloves was 51.5%18-80.0%.43 In addition, the proportion of missed hand hygiene opportunities associated with glove misuse was significantly higher for nursing assistants than for nurses (73.8%; 95%CI, 65.0–82.6% vs. 61.0%; 95% CI, 53.5–68.5%; p = 0.01, respectively).18

A study by Hitoto et al.53 demonstrated that appropriate glove usage was an independent significant predictor of hand hygiene compliance. However, this study did not separately analyse glove removal and hand hygiene after removal. A study by Girou et al.18 also indicated that poor compliance with glove change during patient care was identified as an independent factor for non-compliance in hand hygiene. In addition, Eveillard et al.41 demonstrated that compliance with hand hygiene could be improved by avoiding non-indicated glove usage in only 11.0% of contacts.

A study by Trick et al.56 found that implemenation of a multimodal intervention program resulted in a sustained increase in adherence to hand hygiene among HCWs. By multivariable analysis, hand hygiene performance was more likely after glove use (adjusted OR = 2.0; 95% CI, 1.7–2.2, p<.001).

Discussion

Gloves are the most common type of personal protection used in healthcare settings. The correct use of gloves in healthcare is part of standard precautions. The aim of wearing gloves is to reduce the risk of cross-transmission from healthcare workers to patients and vice versa, to reduce transient contamination of the hands by microorganisms that can be transmitted from one patient to another,6 and to protect users' hands from certain chemicals.7 Gloves appear to be a practical means of preventing transient hand contamination and cross-transmission,6,59–60 especially during control of outbreaks. Furthermore, the Centre for Disease Control and Prevention (CDC) recommends contact precautions, including the use of gloves in the care of hospitalized patients infected or colonized with MDR organisms.6 Gloves must be worn when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes or non-intact skin will occur. In addition, they must be worn when handling sharp or contaminated instruments.

This review showed that HCWs were as likely to have contaminated their hands or gloves after touching the environment in a room occupied by a patient colonized by bacteria as they were after touching the colonized patient and the patient's environment. It was found that both commensal and pathogenic bacteria accumulate on gloves during the process of care. HCWs must be aware that contaminated gloves may facilitate cross-transmission when not appropriately removed,61 particularly following activities associated with high bacterial load. In addition, HCWs' hands became progressively more contaminated with potential pathogens during patient care and a longer duration of care was associated with greater levels of contamination.

This review demonstrated that wearing gloves was associated with a marked reduction in bacterial contamination of hands. Gloves were effective in protecting hands from contamination but the protection from gloves was incomplete. Gloves can have tiny perforations and bacteria can gain access to the caregiver's hands via small defects in gloves. Furthermore, the hands of HCWs might be contaminated with microorganisms after glove removal. This review found evidence that theuse of cover gowns, in addition to gloves, decreased nosocomial transmission of VRE. Thus, routine glove use should be implemented in long term care facilities as an alternative to contact-isolation precautions, even for care that involves contact with the intact skin of patients who may be colonized with VRE. However, glove use carried some disadvantages, including generating extra costs, which could pose a major problem for many settings, especially in countries with limited resources.

The correct use of gloves is vital in healthcare settings. However, compliance with glove use among healthcare workers was poor, with rates of 61.2% being reported.The percentage of occasions in which gloves were not worn when indicated underscores the significant risk of contamination of HCWs with pathogens from blood or other body fluids. Reasons for non-compliance with glove use were inconvenience, non-necessity and unavailability of gloves. In addition, it was reported that gloves were overused and often misused. Gloves were worn inappropriately for tasks that did not necessitate their use. HCWs often removed gloves after a single contact, but they were less likely to change gloves between procedures, particularly those conducted on the same patients. Failure to remove or change gloves after each patient contact or between dirty and clean body site care on the same patient was regarded as non-compliance with recommendations and facilitates the spread of microorganisms because glove contamination might occur during care activities.

Overuse of gloves might have been due to a belief that glove use obviated the need for hand hygiene. HCWs might wear gloves with the primary intention of protecting themselves and not the patient and might be unaware that contamination on gloves occurred just it did on hands. The unnecessary and inappropriate use of gloves resulted in a waste of resources and might increase the risk of cross-transmission. Furthermore, inappropriate use of gloves could increase the healthcare worker's risk of contracting skin problems on the hands, such as contact dermatitis. However, it was found that after implementation of a glove usage promotional program, the incidence of correct use of gloves usage among nurses increased significantly. Therefore, education and reinforcement of proper glove use among HCWs was needed.

Glove use is not a substitute for hand hygiene. Gloves should be changed between patient contacts and hands should be cleaned before putting on gloves and immediately after removing gloves.4–7 However, it was unclear if glove use modified compliance with hand hygiene among HCWs, as published studies yielded contradictory results. This might be a result of the difference among studies including the number of units studied or hospitals, definitions regarding the indications for glove use, and the assessment of hand hygiene in association with glove wearing. Most studies assessed hand hygiene compliance before or after patient contact only, with only one study assessing both. Therefore, a validated comprehensive assessment of glove use and its associated hand hygiene behaviors is needed and would be useful in helping with the development of interventions to improve the rate of hand hygiene compliance when gloves are worn. However, it was found that inappropriate glove use might be a contributing factor in poor hand hygiene compliance. HCWs might have felt that wearing gloves not only protected them from the pathogens on patients but also protected patients from the pathogens on healthcare workers' hands and that this obviated the need for hand disinfection. HCWs might erroneously believe that glove use alone was sufficient to limit the spread of micro-organisms. This demonstrated the importance of HCW conformity with guidance on use of gloves and hand hygiene.

Promoting alcohol hand rubs offer a unique opportunity to revise healthcare behavior towards gloves as hands can be immediately disinfected after use. However, the application of hand disinfectants to glove is not recommended as gloves are single-use medical devices. Cleansing of gloves could reduce the integrity of the material and this could reduce the protection normally afforded by the glove. Therefore, improving glove usage is not in itself an alternative strategy to improved hand hygiene compliance. It seems that hand hygiene and glove use may be governed by different behavioral determinants. Hand hygiene still remains the basic and most effective measure to prevent pathogen transmission and infection.

Limitations

A limitation of the present review was the heterogeneity of the care settings studies (ICU, LTCFs, nursing homes and acute care settings), methodological inconsistencies of the included studies, the wide range of outcome measures and the modest sample sizes. In addition, it should be noted that the presence of observers during the patient care activities in the studies may have compromised the validity of the conclusions about the hand hygiene and glove use compliance among healthcare workers.

Conclusions

HCWs performing routine clinical care readily contaminated their gloved or ungloved hands with microorganisms after touching both the patient and the environment. This review found evidence on the benefits of wearing gloves to protect hands from contamination by microorganisms, even for care that involves contact with the intact skin of patients who may be colonized with microorganism especially multidrug-resistant microorganisms such as VRE, MRSA. Gloves should be worn with the gown during care for patients with multidrug-resistant microorganisms. However, gloves were frequently contaminated with microorganisms and resulted in contamination of HCWs' hands after removal of gloves.

This review found a suboptimal rate of compliance with glove use among HCWs. Gloves were also overused and often misused. HCWs often failed to remove gloves between patients or between contacts with various sites on a single patient, therefore facilitating the spread the microorganisms. Failure to change or remove contaminated gloves was a major factor for the poor compliance with hand hygiene and could increase the risk of cross transmission via contaminated gloved hands. It was unclear if glove use modified compliance with hand hygiene among HCWs, as published studies yielded contradictory results.

Implications for practice

This review supports recommendations for HCWs to wear gloves when participating in patient care activities in order to prevent contamination of HCWs' hands and to reduce transmission of micro-organisms. Gloves should be worn with the gown during care of patients with multidrug-resistant microorganisms and touching an inanimate surface in the patient's room as these pose a high risk of hand contamination. In the absence of a program to screen and isolate residents, long-term care facility residents should be treated as if they were colonized with an antimicrobial-resistant organisms and glove use for HCW contact with residents must be stipulated as an alternative to contact-isolation precautions. Nevertheless, the glove surface itself can become heavily contaminated during patient care, and pathogens can be transferred from the gloves of health care workers to patients and/or environmental surfaces. Therefore, gloves should not be reused between patients. Healthcare workers should be reminded that failure to remove gloves between patients or when moving between different body sites of the same patient may contribute to the transmission of organisms. Careful attention should be paid to the use of medical gloves according to indications for donning, but also for their removal.

This review strengthens recent suggestions to promote hand hygiene action immediately after glove removal and to change gloves between care of different body sites for the same patients. Interventions to improve the use of gloves in healthcare settings should be included in staff education and training, emphasizing the appropriate use of gloves and the importance of adherence to hand hygiene guidelines. It is important that all HCWs have a clear understanding of which gloves are to be used in which situations and which procedures do not require the use of gloves.

Implications for research

The following priorities for further research have been identified:

  1. There is a need for further studies with consideration for the behavioral determinants of glove use to elucidate those attitudes toward glove use and removal that have a considerable impact on appropriate glove use.
  2. Promoting strategies to reduce misuse and overuse of gloves among HCWs who are poor compliers to glove use could be evaluated.
  3. Large randomized controlled trials are required to better assess the effect of glove use on adherence with hand hygiene among HCWs.
  4. Further study evaluating the causal association between the dynamics of gloved-hand contamination and the risk of healthcare-associated infection among patients need to be undertaken.

Conflict of interest

The authors declare that there were no conflicts of interest.

Acknowledgements

The authors sincerely thank the Joanna Briggs Institute and the Thailand Centre for Evidence Based Nursing, Midwifery and Health Science at the Faculty of Nursing, Chiang Mai University, Thailand, for supporting this review. The review received financial support from Faculty of Nursing, Chiang Mai University, Thailand.

References

1. Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med. 1999;159(8):821-6.
2. Reybrouck G. Role of the hands in the spread of nosocomial infections. 1. J hospit infect. 1983;4(2):103-10.
3. Casewell M, Phillips I. Hands as route of transmission for Klebsiella species. BMJ. 1977;2(6098):1315-7.
4. Pittet D, Allegranzi B, Boyce J, World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core Group of E. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infect Control Hosp Epidemiol. 2009;30(7):611-22.
5. Boyce J, Pittet D, Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task F. 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. Infect Control Hosp Epidemiol. 2002;23(12 Suppl):S3-40.
6. Siegel J, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory C. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. 2007;35(10 Suppl 2):S65-164.
7. Flores AaPD. Appropriate glove use in the prevention of cross-infection. Nurs Stand. 2007;21(35):45-8.
8. Johnson S, Gerding DN, Olson MM, Weiler MD, Hughes RA, Clabots CR, et al. Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. Am J Med. 1990;88(2):137-40.
9. Hartstein A, Denny M, Morthland V, LeMonte A, Pfaller M. Control of methicillin-resistant Staphylococcus aureus in a hospital and an intensive care unit. Infect Control Hosp Epidemiol. 1995;16(7):405-11.
10. Tenorio A, Badri S, Sahgal N, Hota B, Matushek M, Hayden M, et al. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care. Clin Infect Dis. 2001;32(5):826-9.
11. Olsen R, Lynch P, Coyle M, Cummings J, Bokete T, Stamm W. Examination gloves as barriers to hand contamination in clinical practice. JAMA. 1993;270(3):350-3.
12. McFarland L, Mulligan M, Kwok R, Stamm W. Nosocomial acquisition of Clostridium difficile infection.[see comment]. New Eng J Med. 1989;320(4):204-10.
13. HR. K, Brinker JP, Avato JL, NM G. Latex and vinyl examination gloves: Quality control procedures and implications for health care workers. Arch Intern Med. 1989;149(12):2749-53.
14. Korniewicz D, Laughon B, Butz A, Larson E. Integrity of vinyl and latex procedure gloves. Nurs Res. 1989;38(3):144-6.
15. Doebbeling B, Pfaller M, Houston A, Wenzel R. Removal of nosocomial pathogens from the contaminated glove. Implications for glove reuse and handwashing. Ann Intern Med. 1988;109(5):394-8.
16. Berthelot P, Dietemann J, Fascia P, Ros A, Mallaval FO, Lucht F, et al. Bacterial contamination of nonsterile disposable gloves before use. Am J Infect Control. 2006;34(3):128-30.
17. Thompson B, Dwyer D, Ussery X, Denman S, Vacek P, Schwartz B. Handwashing and glove use in a long-term-care facility. Infect Control Hosp Epidemiol 1997;18(2):97-103.
18. Girou E, Chai SHT, Oppein F, Legrand P, Ducellier D, Cizeau F, et al. Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission? J Hosp Infect. 2004;57(2):162-9.
19. Ehrenkranz N, Alfonso B. Failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters. Infect Control Hosp Epidemiol. 1991;12(11):654-62.
20. Kjolen H, Andersen BM. Handwashing and disinfection of heavily contaminated hands—effective or ineffective? J Hosp Infect. 1992;21(1):61-71.
21. Bearman G, Marra A, Sessler C, Smith W, Rosato A, Laplante J, et al. A controlled trial of universal gloving versus contact precautions for preventing the transmission of multidrug-resistant organisms. Am J Infect Control. 2007;35(10):650-5.
22. Zimakoff J, Stormark M, Larsen SO. Use of gloves and handwashing behaviour among health care workers in intensive care units. A multicentre investigation in four hospitals in Denmark and Norway. J Hosp Infect. 1993;24(1):63-7.
23. Meengs M, Giles B, Chisholm C, Cordell W, Nelson D. Hand washing frequency in an emergency department. J Emerg Nurs. 1994;20(3):183-8.
24. Larson E. Compliance with isolation technique. Am J Infect Control. 1983;11(6):221-5.
25. Kim P, Roghmann M-C, Perencevich E, Harris A. Rates of hand disinfection associated with glove use, patient isolation, and changes between exposure to various body sites. Am J Infect Control. 2003;31(2):97-103.
26. Yap F, Gomeall C, Fung K, Ho P-L, Ho O-M, Lam P, et al. Increase in methicillin-resistant Staphylococcus aureus acquisition rate and change in pathogen pattern associated with an outbreak of severe acute respiratory syndrome. Clin Infect Dis 2004;39(4):511-6.
27. Poutanen SM, Vearncombe M, McGeer AJ, Gardam M, Large G, Simor AE. Nasocomial acquisition of methicillin-resistant Staphylococcus aureus during an outbreak of severe acute respiratory syndrome. Infect Control Hosp Epidemiol 2005;26(2):134-7.
28. Picheansathian W, Chotibang J. Glove utilization in the prevention of cross transmission: A systematic review. JBI LIBRARY OF SYSTEMATIC REVIEWS 2011;9(16):S260-S271.
29. Ji G, Yin H, Chen Y. Prevalence of and risk factors for non-compliance with glove utilization and hand hygiene among obstetrics and gynaecology workers in rural China. J Hosp Infect. 2005;59(3):235-41.
30. Jeurissen A, Weyers L, Cossey V, Muller J, Schuermans A. Dissemination of Bacillus cereus in the burn unit due to contaminated non-sterile gloves. J Hosp Infect. 76. England2010. p. 92-3.
31. Lai JYF, Guo YP, Or PPL, Li Y. Comparison of hand contamination rates and environmental contamination levels between two different glove removal methods and distances. Am J Infect Control. 2011;39(2):104-11.
32. Cheng H-C.,Lee S-Y.,Chou H-Y. Factors influencing the wearing of protective gloves in orthodontic practice. Eur J Orthod. 2005;27(1):64-71.
33. Moongtui W, DK. G, JG. T. Using peer feedback to improve handwashing and glove usage among Thai health care workers. Am J Infect Control. 2000;28(5):365-9.
34. Piro S, Sammud M, Badi S, Al Ssabi L. Hospital-acquired malaria transmitted by contaminated gloves. J Hosp Infect. 2001;47(2):156-8.
35. Kanjirath P, Coplen A, Chapman J, Peters M, Inglehart M. Effectiveness of gloves and infection control in dentistry: student and provider perspectives. J Dent Educ. 2009;73(5):571-80.
36. Stock C, Veyrier M, Raberin H, Fascia P, Rayet I, Lavocat MP, et al. Severe cutaneous aspergillosis in a premature neonate linked to nonsterile disposable glove contamination? Am J Infect Control. 2012;40(5):465-7.
37. Sacar S, Turgut H, Kaleli I, Cevahir N, Asan A, Sacar M, et al. Poor hospital infection control practice in hand hygiene, glove utilization, and usage of tourniquets. Am J Infect Control. 2006;34(9):606-9.
38. Takahashi I, Osaki Y, Okamoto M, Tahara A, Kishimoto T.The current status of hand washing and glove use among care staff in Japan: its association with the education, knowledge, and attitudes of staff, and infection control by facilities. Env Health Prev Med. 2009;14:336-44.
39. Taukamoto Y, Haseynma M. Association between adherence to hand hygiene practice and glove use. Am J Infect Control 2011;39(5): E176-E177.
40. Chau J, Thompson D, Twinn S, Lee D, Pang S. An evaluation of hospital hand hygiene practice and glove use in Hong Kong. J Clin Nurs. 2011;20(9-10):1319-28.
41. Eveillard M, Guilloteau V, Kempf M, Lefrancq B, Pradelle MT, Raymond F, et al. Impact of improving glove usage on the hand hygiene compliance. Am J Infect Control. 2011;39(7):608-10.
42. Fuller C, Savage J, Besser S, Hayward A, Cookson B, Cooper B, et al. “The dirty hand in the latex glove”: a study of hand hygiene compliance when gloves are worn. Infect Control Hosp Epidemiol. 2011;32(12):1194-9.
43. Hakko E, Rasa K, Karaman ID, Enunlu T, Cakmakci M. Low rate of compliance with hand hygiene before glove use. Am J Infect Control. 39. United States2011. p. 82-3.
44. Kuzu N, Ozer F, Aydemir S, Yalcin AN, Zencir M. Compliance with hand hygiene and glove use in a university-affiliated hospital. Infect Control Hosp Epidemiol. 2005;26(3):312-5.
45. Zachary K, Bayne P, Morrison V, Ford D, Silver L, Hooper D. Contamination of gowns, gloves, and stethoscopes with vancomycin-resistant enterococci. Infect Control Hosp Epidemiol. 2001;22(9):560-4.
46. Pessoa-Silva C, Dharan S, Hugonnet S, Touveneau S, Posfay-Barbe K, Pfister R, et al. Dynamics of bacterial hand contamination during routine neonatal care. Infect Control Hosp Epidemiol. 2004;25(3):192-7.
47. Pan A, Mondello P, Posfay-Barbe K, Catenazzi P, Grandi A, Lorenzotti S, et al. Hand hygiene and glove use behavior in an Italian hospital. Infect Control Hosp Epidemiol. 2007;28(9):1099-102.
48. Hayden M, Blom D, Lyle E, Moore C, Weinstein R. 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):149-54.
49. Snyder G, Thom K, Furuno J, Perencevich E, Roghmann M, Strauss S, et al. Detection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on the gowns and gloves of healthcare workers. Infect Control Hosp Epidemiol. 2008;29(7):583-9.
50. Morgan D, Liang S, Smith C, Johnson J, Harris A, Furuno J, et al. Frequent multidrug-resistant Acinetobacter baumannii contamination of gloves, gowns, and hands of healthcare workers. Infect Control Hosp Epidemiol. 2010;31(7):716-21.
51. Eveillard M, Pradelle M-T, Lefrancq B, Guilloteau V, Rabjeau A, Kempf M, et al. Measurement of hand hygiene compliance and gloving practices in different settings for the elderly considering the location of hand hygiene opportunities during patient care. Am J Infect Control. 2011;39:339-41.
52. Naderi H, Sheybani F, Mostafavi I, Khosravi N. Compliance with hand hygiene and glove change in a general hospital, Mashhad, Iran: an observational study. Am J Infect Control. 2012;40(6):e221-3.
53. Hitoto H, Kouatchet A, Dube L, Lemarie C, Mercat A, Joly-Guillou ML, et al. Factors affecting compliance with glove removal after contact with a patient or environment in four intensive care units. J Hosp Infect. 2009;71:186-8.
54. Eveillard M, Joly-Guillou ML, Brunel P. Correlation between glove use practices and compliance with hand hygiene in a multicenter study with elderly patients. Am J Infect Control. 2012;40(4):387-8.
55. Trick W, Weinstein R, DeMarais P, Tomaska W, Nathan C, McAllister S, et al. Comparison of routine glove use and contact-isolation precautions to prevent transmission of multidrug-resistant bacteria in a long-term care facility. J Am Geriatr Soc. 2004;52(12):2003-9.
56. Trick W, Vernon M, Welbel S, Demarais P, Hayden M, Weinstein R. Multicenter intervention program to increase adherence to hand hygiene recommendations and glove use and to reduce the incidence of antimicrobial resistance. Infect Control Hosp Epidemiol. 2007;28(1):42-9.
57. Srinivasan A, Song X, Ross T, Merz W, Brower R, Perl TM. A prospective study to determine whether cover gowns in addition to gloves decrease nosocomial transmission of vancomycin-resistant enterococci in an intensive care unit. Infect Control Hosp Epidemiol. 2002;23(8):424-8.
58. Assawapalangool S, Picheansathian W, Kasatpibal N. Effect of gloves usage promotional program on knowledge andpractice among nurse in a general hospital (in Thai). Nurs J 2009; 35(4):12-22.
59. Slaughther S, Hayden M, Nathan C, Ann Acoteouuogagwtoguaoaov-reiamicu, 125:448-456. A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Ann Intern Med. 1996;125:448-56.
60. Moore G, Dunnill CW, Wilson AP. The effect of glove material upon the transfer of methicillin-resistant Staphylococcus aureus to and from a gloved hand. Am J Infect Control. 2013;41(1):19-23.
61. Patterson J, Vecchio J, Pantelick E, Farrel P, Mazon D, Zervos M, et al. Association of contaminated gloves with transmission of Acinetobacter calcoaceticus var. anitratus in an intensive care unit. Am J Med. 1991;91(5):479-83.

Appendix I: Study eligibility checklist

Figure
Figure

Appendix II: Appraisal instruments - MAStARI appraisal instrument

Figure
Figure
Figure
Figure

Appendix III: Data extraction instruments

MAStARI data extraction instrument

Figure
Figure
Figure
Figure
Figure
Figure

Appendix IV: Excluded studies

Berthrlot P, Dietemann J, Fascia P, Ros A, Mallaval FO, Lucht F, Pozzetto B,

Grattard F. Bacterial contamination of nonsterile disposable gloves before use. Am J Infect Control 2006; 34(3):128–13016

Reason for exclusion: Inappropriate outcome measure (measure contamination of

gloves before use).

Cheng H-C, Lee S-Y, Chou H-Y. Factors influencing the wearing of protective gloves in orthodontic practice. Eur J Orthodontics 2005; 27(1):64–71.32

Reason for exclusion: Self-report.

Ji G, Yin H, Chen Y. Prevalence of and risk factors for non-compliance with glove utilization and hand hygiene among obstetrics and gynaecology workers in rural China. J Hosp Infect 2005; 59:235–241.29

Reason for exclusion: Self-report.

Jeutissen A, Weyers L, Cassey V, Muller J. Dissemination of Bacillus cereus in the burn unit due to contaminated non-sterile gloves. J Hosp Infect 2010; 76(S1):84–85.30

Reason for exclusion: Inappropriate outcome measure (measure contamination of gloves before use).

Joanna YF, Guo YP, Peggy PL, Yi L. Comparison of hand contamination rates and environmental contamination levels between two different glove removal methods and distance. Am J Infect Control 2011; 39(2):104–111.61

Reason for exclusion: Inappropriate outcome measure (test contamination levels between two different glove removal method and distances).

Kanjirath PP, Coplen AE, Chapman JC, Peters MC, Inglehart MR. Effectiveness of gloves and infection control in dentistry: student and provider perspective. J Dent Edu 2009; 73(5):571–580.35

Reason for exclusion: Self-report.

Moongtui W, Gauthier DK, Turner JG. Using peer feedback to improve handwashing and glove usage among Thai health care workers. Am J Infect Control 2000; 28(5): 365–370.33

Reason for exclusion: No detailed results on glove usage were provided.

Piro S, Sammud M, Badi S, Al Ssabi L. Hospital-acquired malaria transmitted by contaminated gloves. J Hosp Infect 2001; 47:156–158.34

Reason for exclusion: Case report.

Sacar S, Turgut H, Kaaleli I, Cevahir N, Asan A, Sacar M, Tekin K. Poor hospital infection control practice in hand hygiene, glove utilization, and usage of tourniquets. Am J Infect Control 2006; 34(9): 606–609.37

Reason for exclusion: Self-report.

Stock C, Veyrier M, Raberin H, Fascia P, Rayet I, Lavocat MP, et al. Severe cutaneous aspergillosis in a premature neonate linked to nonsterile disposable glove contamination?. Am J Infect Control 2012; 40:465–467.36

Reason for exclusion: Case report.

Taukamoto Y, Haseynma M. Association between adherence to hand hygiene practice and glove use. Am J Infect Control 2011; 39(5): E176-E177.39

Reason for exclusion: No detailed results on glove usage were provided.

Takahashi I, Osaki Y, Okamoto M, Tahara A, Kishimoto T. The current status of hand washing and glove use among care staff in Japan: its association with the education, knowledge, and attitudes of staff, and infection control by facilities. Env Health Prev Med 2009; 14:336–344.38

Reason for exclusion: Self-report.

Appendix V: Search strategy of five major databases and results

Table
Table
Table
Table
Table
Table

Appendix VI: Included studies

Table
Table
Table
Table
Table
Table
Table
Table
Table
Table
Table
Table
Table
Table
Keywords:

Gloves; utilization; infection prevention; cross transmission

© 2015 by Lippincott williams & Wilkins, Inc.