Are sterile glove precautions necessary for joint injections or is a general aseptic process sufficient? A Clin-IQ

Abstract

Background:

Multiple studies have been conducted investigating the use of sterile vs non-sterile gloves. The aim of this Clin-IQ is to determine whether there is a clinically significant difference in the rate of infections in relation to the use of sterile vs non-sterile gloves for joint injections.

Conclusions:

Multiple studies have shown no appreciable difference in outcomes using sterile vs clean gloves for a variety of clinical applications including joint injections.

Answer: Sterile gloves are not necessary for joint injections.

Clinical Question:

Outpatient joint injections occur daily in busy clinics around the world. In many clinics it is common practice to use sterile gloves as a part of aseptic technique. Others may use non-sterile, clean gloves, otherwise known as gloves in a box. We seek to determine if a clinically significant difference occurs, examining mainly the occurrence of skin and intraarticular infections, between sterile glove use and clean glove use.

Methods:

We performed a PubMed search in September 2020 for randomized controlled trials using the key search terms of gloves (sterile, clean, and protective), joint injection and infection. Due to limited articles specific to the issue of joint injections and glove type, we expanded our inclusion criteria to articles addressing skin/soft tissue infections as well.

Discussion:

In one study (Creamer, et al)¹, the question was asked as to the actual number of bacteria present on clean vs sterile gloves. The chief reasoning for this question is derived from a previous study by Robson et al², who showed that > 10⁵ organisms/mL were required to cause infection in trauma wounds. Similar studies have also shown infections occurring near this bacterial load. In Creamer’s study, there were 3 separate arms. 25 volunteers self-donned clean gloves, self-donned sterile gloves, and were gloved with sterile gloves by a trained scrub technician. After each donning, cultures were obtained of the gloved hands. Results showed that there was, in fact, a statistically significant difference in bacterial load between clean gloves and self-donned sterile gloves (14.08 vs 1.28 CFUs/mL, P < 0.001) and clean gloves vs technician-assisted sterile gloves (14.08 vs. 0.32 CFUs/mL P < 0.001). However, they also found that the statistical significance may be clinically irrelevant. As mentioned previously, it has been shown that > 10⁵ organisms/mL are needed to cause a wound infection in most situations. This study showed that the amount of bacterial colonization was minimal for all glove types with the highest number of CFU’s cultured being 44 CFUs/mL.

In another study (Perelman, et al)³, a prospective multicenter trial involved 816 patients who were randomized into two groups. All had uncomplicated traumatic wounds requiring closure and were assigned into a clean glove group or a sterile glove group. Infection rate in the sterile glove group was 6.1% (95% CI 3.8%−8.4%) and 4.4% in the clean glove group (95% CI 2.4%−6.4%). The relative risk of infection was 1.37 (95% CI 0.75%−2.52%; p=0.295), which was statistically insignificant. The study concluded that there is no clinically important difference in infection rates between the two groups based on glove use.

Other studies have demonstrated similar results. A non-inferiority trial was conducted in 2015 by Heal et al⁴. This study was designed as a prospective single center randomized control non-inferiority trial enrolling 493 individuals who presented for minor skin lesion excisions. They were randomized into sterile or non-sterile glove groups and had their excisions performed under a standardized protocol. The incidence of infection in the non-sterile glove group (8.7%; 95% CI 4.9%−12.6%) was significantly non-inferior compared with the incidence in the control group (9.3%; 95% CI 7.4%−11.1%). Therefore, the study suggests that non-sterile clean boxed gloves are not inferior to sterile gloves for minor skin lesion excisions in general practice.

A 1999 study (Seror, J, et al.)⁵ examined the frequency of SALCSI (sepsis after local corticosteroid injection). In this study, 69 rheumatologists were surveyed about various items, including number of corticosteroid injections performed per year, number of SALCSI cases, bacteria identified, joint involved, whether the injected corticosteroid was pre-packaged in a sterile syringe, skin preparation, and type of gloves used. The study did not include specific statistics on sterile glove use as they found no relationship between sterile glove use and the incidence of SALCSI.

An article by Courtney (2013)⁶ describes an aseptic “no touch” technique as mandatory for all joint injections. Gloves are identified as a tool to protect the physician, but they do not need to be sterile for patient benefit provided a no touch approach is used for the administration of the injection.

A research article addressing intra-articular injections (Gray)⁷, lists several studies which were reviewed to determine the incidence of joint infections as a complication. These studies suggest the risk of infectious arthritis to be very uncommon. Incidence was noted to range from 2–7/100,000 injections. In all these studies, masks, drapes, and sterile gloves were not used as part of the injection procedure.

Finally, a review was conducted in 2007 examining clean versus sterile technique for common joint injections (Baima, J., Isaac, Z)⁸. The authors noted a significant cost difference between sterile and non-sterile gloves ($170 vs $3 per 100 pair, respectively).

Conclusion:

Our aim was to conduct a literature review to find evidence that helps to elucidate the necessity of using sterile gloves vs clean gloves while performing intraarticular joint injections. Though there were relatively few reference studies comparing the use of these two types of gloves specifically related to joint injections, the evidence found does support the appropriate use of clean gloves for office-based procedures, including joint injections. While there may be statistically significant differences in terms of bacterial count on different types of gloves, this does not correlate clinically with an increase in infections. Multiple studies show no appreciable difference in outcomes using sterile vs clean gloves. Procedures such as joint injections can safely be performed using non-sterile or clean gloves with no increased risk to patients and decreased costs to the practice.