Does double gloving prevent cerebrospinal fluid shunt infection?

Abstract

Drs. Tulipan and Cleves address a very important question of whether a change in surgical technique, namely the use of double gloving, can decrease the incidence of cerebrospinal fluid (CSF) shunt infection. In their study “Effect of an intraoperative double-gloving strategy on the incidence of cerebrospinal fluid shunt infection,” they report that the use of double gloving reduced the incidence of the CSF shunt infection rate in 863 patients from 15.2 to 6.7%. They also assert that the infection rate was higher in younger children (, 11.3 years compared with . 11.3 years of age). Their change in practice was apparently prompted by a study conducted at my institution; 4 the latter was an observational study in which investigators examined risk factors for CSF shunt infection in a prospective cohort of children undergoing CSF shunt surgery. In the aforementioned study we found that holes in the gloves worn by any member of the operative team (present in 30%) was a risk factor for CSF shunt infection, and we recommended, “Surgeons should minimize manual contact with the shunt system and consider the use of double gloves.” Tulipan and Cleves have taken what would be regarded as the next logical step—an interventional study in which staff wore either single or double gloves while patients underwent surgery, and the intergroup CSF shunt infection rates were compared. Their study, however, exhibits enough methodological problems, including an extremely broad definition of infection, that the effect of double gloving on shunt infection remains uncertain. What are the methodological limitations of their study? The study is retrospective, uses historical controls, blinding or independent adjudication was absent, and the results are derived from a single center and from a single surgeon reporting his own results. There are many sources of bias in