Non-sterile gloves for abscess I&D?

The clinic nurse was setting up for an incision and drainage (I&D) of an abscess.  After opening the dressing pack and laying out the necessary equipment, she inquired about my glove size.  I replied “small”.  She said, “oh no, Doc, what size STERILE gloves?”

This made me question a very routine practice of mine…

Clinical question: Is there any evidence to support the use of sterile gloves over non-sterile gloves in the I&D of an abscess?

Interestingly, when I asked a couple of colleagues about this question, I received a mixed response.  Some had a similar practice to my own and others preferred sterile gloves, but not always for the reason of reducing infection.  Of those who preferred sterile gloves, some cited convention as their main driver, whilst others had a personal preference for the better fit and dexterity afforded by sterile gloves.  Most agreed that they would wear sterile gloves if there was any anticipation of deloculating the abscess with a gloved finger.

So what is the evidence?  Well, this appears to be an evidence-free zone and the best studies that I could find to answer my question relate to minor outpatient skin procedures rather than putting a knife into a collection of pus…

Findings 1: Systematic review & Meta-analysis, 2016

This review included 13 studies with over 11,000 patients who had cutaneous or mucosal outpatient procedures including Moh’s surgery, laceration repair & standard excision (NB: the authors recommended against generalising this evidence to more advanced/complex procedures).  Rates of surgical site infection were very similar in both groups (sterile gloves: 2.0% vs. non-sterile gloves 2.1%) with a relative risk of 1.06 (95% CI 0.81-1.39), which essentially means there was no difference! 

But is this generalisable to our population in far North Queensland?

Findings 2: Prospective RCT, North Queensland, 2015

This trial included 493 patients presenting to a private general practice in Mackay for a “minor skin excision”.  Rates of infection were a lot higher than that of other similar cohorts (approximately 8% vs 2%).  The reason for this is unclear but the authors suggest the humid, tropical environment may have something to do with it or perhaps patient behaviour in a rural setting.  Nonetheless, they found that non-sterile gloves were not inferior to sterile gloves for minor skin procedures in general practice (rates of infection with non-sterile gloves 8.7% vs non-sterile gloves 9.3%).  Strengths of this study included a standardised excision protocol, a uniform definition for a surgical site infection and intention-to-treat analysis.

Practical implications?

Non-sterile gloves do not increase the risk of surgical site infection in the setting of minor skin procedures and there is evidence to generalise these findings to our tropical North Queensland location.  It seems both reasonable and rational to apply these findings to the I&D of a simple abscess, so next time I’m asked for my glove size, I’ll be able to support my choice with a little more academic rigour.