BUGGing Out: Gowns, Gloves, and Methods for Reducing Microbial Burden

Can health care workers reduce the risk of bacterial contamination through employing universal glove and gown measures? The uniforms of health care workers are at high risk for becoming contaminated by bacteria. Unless isolation precautions are required, gowns are infrequently used and one’s attire is likely to become bogged down by bioburden throughout the day.

Investigators at the University of Maryland School of Medicine and VA Maryland Health Care System sought to evaluate the use and benefits of universal gloves and gown (BUGG) in an intensive care unit against gram-negative bacteria, especially those resistant to antibiotics. The team performed a study that was published in Clinical Infectious Diseases.

Antibiotic-resistant infections are estimated to cost the United States more than $4 billion per year and impact millions of patients. Previously, the research team performed a cluster-randomized trial regarding the BUGG approach and found that it offered no significant impact on methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) acquisition. For this effort though, they sought to assess whether the BUGG intervention could help reduce the acquisition of antibiotic-resistant gram-negative bacteria.

In this approach, the investigators hoped to focus on a larger scope of bacteria and evaluate 20 hospital intensive care units. By utilizing a randomized trial, the team had health care workers wear gloves and gowns when entering a non-isolated patient’s room (ie they did not require a gown for isolation precautions).

Across nearly 41,000 admission and discharge perianal swabs from over 20,000 patient admissions, they found that interventions did decrease the acquisition of antibiotic-resistant gram-negative bacteria. While the results weren’t statistically significant, the study team did note that any reduction in acquisition is helpful.

The authors note that “the primary outcome rate ratio was 0.90 indicating a 10% decrease in acquisition rate in intervention units compared to control units. The question as to what an individual hospital should do with these results is also challenging. One key data point for hospitals to consider is to address the question about how many patients would not acquire antibiotic-resistant gram-negative bacteria in in a typical ICU with a universal glove and gown policy.”

While this study failed to find statistically significant results with the BUGG approach to reducing antibiotic-resistant gram-negative bacteria, it sheds light on some questions we should be asking.

As drug-resistant infections are usually undetected for several days and thus staff are unknowingly exposed, should health care workers be utilizing gown and gloves for everyone?

Perhaps just high-risk patients like those with recent antibiotic usage or coming from long-term care facilities?

It can be easy to make the broad statement that everyone should get the equivalent of contact precautions, but this may not benefit the patients or staff.

First, these are burdensome and take time for health care workers, which often leads to less time with the patient. Second, they are costly. Third, they might provide a false sense of security, which could encourage people to employ less hand hygiene after glove removal. Last, patient and visitor perception are important. Why utilize these measures if we’re being diligent in hand hygiene and environmental disinfection?

This study raises several helpful questions about the utility of the BUGG approach and if sweeping isolation precautions can be helpful. Additional analysis is needed though, and we should continue to look at more effective barriers to drug-resistant infections being transmitted throughout hospitals.