Gowning FactFinder

Committed to providing helpful information to International Spine Intervention Society members about key patient safety issues, the Patient Safety Committee has developed a FactFinder series. FactFinders will explore and debunk myths surrounding patient safety issues. The intent of this FactFinder is to discuss the effectiveness of gowning in reducing the risk of infections following interventional spine procedures.

Myth: Gowns are necessary for performance of interventional spine procedures.

Fact: Currently there is insufficient evidence to make definitive recommendations with regard to routine use of gowns for interventional spine procedures.

Historical

The past century has seen an evolution in the use of surgical gowns.1 Oliver Wendall Holmes (1809-1894) was the first to suggest a relationship between infection and surgical attire, reporting his experience relative to puerperal fever. He encouraged physicians to mask themselves, put on clean clothes, and refrain from obstetric deliveries for 48 hours after contact with apatientwith puerperal fever. Polish surgeon Johannes Vonn Mikuliez-Radeek (1850-1905) was perhaps the first to use a face mask and William Halstead (1852-1922) became the first surgeon to use rubber gloves for operations.Joseph Lister (1822-1895) revolutionized surgery by developing the antiseptic approach and his student William MacEwan (1848-1924) was the first to introduce a sterilizable gown for surgeons to wear.2

Present Day

The Centers for Disease Control and Prevention (CDC) has developed recommendations for the application of standard precautions for the care of all patients in all health care settings.3 According to these recommendations, gowns are used during procedures and patient-care activities when contact of clothing or exposed skin with blood or bodily fluids, secretions, and excretions is anticipated.

Some have advocated for the use of gowns for neuraxial procedures based on data from the reduction incentral venous catheter infectionsand the use of gowns in the operating room to decrease bacterial contamination and lower surgical site infection rates. The infection rate is much higher for central venous catheter insertionswhen compared to neuraxial procedures. There are no similar infection control studies for neuraxial techniques, therefore, recommendations cannot be automatically applied.4-8 Without similar studies regarding neuraxial techniques, it may be useful to consider the reported infection rates for interventional spine procedures in weighing the benefit of wearing gowns.

In fact for most interventional spine procedures, infections are rare. Large series of patients undergoing spine procedures have failed to demonstrate any cases of infection9, yet clearly case reports exist.10 Large series of patients receiving epidural anesthesia have demonstrated low infection rates, with 95% confidence intervals demonstrating 0-10 infections per 100,000 cases.11 A review of post-dural puncture bacterial meningitis showed the dominant causative organism was various strains of viridans streptococcus (a mouth commensal).4 After institution of the use of face masks, 50% of infections following lumbar epidurals were linked to Staphyloccus aureus.12 While such large series do not exist for outpatient pain procedures, it is reasonable to consider that the infection rates for these procedures may be even lower due to the lack of indwelling catheter placement. The clear exception to this trend is discography, which has a reported infection rate of close to <1%13,14; but this high infection rate is essentially nullified with the use of routine prophylactic antibiotics.15 Other more invasive procedures, such as insertion of spinal cord stimulators, may also convey a higher risk, with reports of 2-8% of patients developing infections16 thus suggesting this type of procedure may warrant extra precautions.

Gowns may be a useful extra precaution for our more invasive interventional spine procedures. Gowns are used to prevent cross-contamination between patients by keeping infectious material from coming in contact with the clothes of health care providers.17 The evidence about effectiveness of gowns, however, is conflicting, with no studies specifically examining their utility in preventing infections for interventional spine procedures. Investigations have shown that the use of gowns did notreduce patient colonization, infection, or mortality rate in neonatal intensive care units.18,19 Other studieshavegenerated conflicting results. One study showedthatthe use of gloves and gowns wasnot superiorto the use of gloves alone in preventing colonization of vancomycin-resistantenterococci in medical intensive care units.20A similar study found that gowns were protective in reducing vancomycin-resistant enterococci acquisitions in a medical intensive care unitwhen colonization pressure washigh.21

At this time, there is insufficient data to make definitive recommendations with regard to the routine use of gowns forinterventional spine procedures.22 The treating physician must weigh the risk and severity of a neuraxial infection with the possible benefit of wearing a gown.


References

1. Belkin NL. Barrier surgical gowns and drapes: Just how necessary are they? Textile Rental. 2002 July;66-73.

2. Jones A. Bare below the elbows: A brief history of surgeon attire and infection. BJU International. 2008 September;102(6):665-666.

3. CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

4. Baer ET. Post-dural puncture bacterial meningitis. Anesthesiology 2006; 105:381-93.

5. Ruppen W, Derry S, McQuay H, Moore RA. Incidence of epidural hematoma, infection, and neurologic injury in obstetric patients with epidural analgesia/anesthesia: Meta-analysis. Anesthesiology 2006;105:394-399.

6. Raad II, Hohn DC, Gilbreath BJ, Suleiman N, Hill LA, Bruso PA, Marts K, Mansfield PF, Bodey GP. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 1994;15:231-238.

7. Hepner Dl. Gloved and masked - will gowns be next? The role of asepsis during neuraxial instrumentation. Anesthesiology 2006;105:241-243.

8. Lambert DH. Gloved and masked - will gowns be next? Let the data (not logic) decide this issue. Anesthesiology 2006; 106:877-878.

9. Derby R, Lee S, Kim B, Chen Y, and Seo K. Complications following cervical epidural steroid injections by expert interventionalists in 2003. Pain Physician 2004;7:445–449.

10. Hooten W, Mizerak A, Carns P, Huntoon M. Discitis after lumbar epidural corticosteroid injection: A case report and analysis of the case report literature. Pain 2006;7:46–51. doi:10.1111/j.1526-4637.2006.00088.x.

11. Auroy Y, Benhamou D, Bargues L, Ecoffey C, Falissard B, Mercier F, Bouaziz H, Samii K, Mercier F. Major complications of regional anesthesia in France: The SOS regional anesthesia hotline service. Anesthesiology 2002;97:1274–1280.

12. Goodman B, Posecion L, Mallempati S, Bayazitoglu M. Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections. Current Reviews in Musculoskeletal Medicine 2008;1:212–222. doi:10.1007/s12178-008-9035-2.

13. Willems P, Jacobs W, Duinkerke E, and De Kleuver M. Lumbar discography: Should we use prophylactic antibiotics? A study of 435 consecutive discograms and a systematic review of the literature. Journal of Spinal Disorders & Techniques 2004;17:243–247.

14. Pobiel R, Schellhas K, Pollei S, Johnson B, Golden B, Eklund J. Diskography: Infectious complications from a series of 12,634 cases. AJNR. American Journal of Neuroradiology 2006;27:1930–1932.

15. Osti O, Fraser R, Vernon-Roberts B. Discitis after discography. The role of prophylactic antibiotics. The Journal of Bone and Joint Surgery. British Volume 1990;72:271–274.

16. Engle M, Vinh B, Harun N, Koyyalagunta D. Infectious complications related to intrathecal drug delivery system and spinal cord stimulator system implantations at a comprehensive cancer pain center. Pain Physician 2013;16:251–257.

17. McHugh SM, Corrigan MA, Hill AD, Humphreys H. Surgical attire, practices and their perception in the prevention of surgical site infection. 2013 November;S1479-666X(Epub ahead of print).

18. Pelke S, Ching D, Esaa D, Melish ME. Gowning does not affect colonization or infection rates in a neonatal intensive care unit. Arch Pediatr Adolesc Med 1994;148:1016-1020.

19. Tan SG, Lim SH, Malathi I. Does routine gowning reduce nosocomial infection and mortality rates in a neonatal nursery? A Singapore experience. Int J Nurs Pract 1995;1;52-58.

20. Slaughter S, Hayden MK, Nathan C, Hu TC, Rice T, Van Voorhis J, Matushekm ,Franklin C, Weinstein RA. 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;125:448-456.

21. Puzniak LA, Leet T, Mayfield J, Kollef M, Mundy LM. To gown or not to gown: The effect on acquisition of vancomycin-resistant enterococci. Clin Infect Dis 2002;35:18-25.

22. Hebl JR. The Importance and Implications of aseptic techniques during regional anesthesia. Reg Anesth Pain Med 2006; 31:311-323.

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