Discussion

A significant reduction in risk of VPS infection was achieved with a change from single gloves to double gloves during VPS insertion. ^{Reference Kulkarni, Drake and Lamberti-Pasculli1,Reference Tulipan and Cleves2,Reference Kanev and Sheehan24} In our review of the literature, intraoperative outer-glove change or removal prior VPS insertion, particularly as part of an infection control bundle, appears to further reduce risk of VPS infections. Other strategies for preventing VPS infection have been proposed, ^{Reference Tulipan and Cleves2–Reference James, Hartley, Morgan and Ternier7,Reference Bashir and Sørensen9,Reference Omrani, O’Connor, Hartley and James10,Reference Okamura, Maruyama and Fukuda13–Reference Kalangu, Esene and Dzowa15,Reference Raygor, Oh and Hwang17,Reference Al-Shudifat, Alsabbagh and Al-Matour18} including use of intraventricular and topical vancomycin, ^{Reference Raygor, Oh and Hwang17} antibiotic-containing sutures, ^{Reference Sarmey, Kshettry and Shriver8,Reference Gruber, Riemer and Rozzelle23} and antimicrobial-impregnated shunts. ^{Reference James, Hartley, Morgan and Ternier7,Reference Mallucci, Jenkinson and Conroy14} Some of these strategies have demonstrated feasibility of systematic implementation with consistent and significant reductions in VPS infections. ^{Reference Sarmey, Kshettry and Shriver8,Reference Arts, Boogaarts and van Lindert16,Reference Liu, Dumville and Norman27} However, given the varying quality of evidence underlying these strategies, as well as provider preference, implementation is not standardized across US hospitals. ^{Reference Gruber, Riemer and Rozzelle23,Reference Kanev and Sheehan24,Reference Kraemer, Sandoval-Garcia, Bragg and Iskandar28} Use of antimicrobial-impregnated catheters has been shown to reduce VPS infections, ^{Reference Prusseit, Simon and von der Brelie4,Reference James, Hartley, Morgan and Ternier7,Reference Sarmey, Kshettry and Shriver8,Reference Erps, Roth and Constantini11,Reference Mallucci, Jenkinson and Conroy14,Reference Arts, Boogaarts and van Lindert16} but cost of implementation has been cited as a barrier to implementation, particularly in resource-limited environments. ^{Reference Erps, Roth and Constantini11,Reference Arts, Boogaarts and van Lindert16,Reference Kraemer, Sandoval-Garcia, Bragg and Iskandar28}

Glove change before handling vascular grafts and cardiac implantable electronic devices has been demonstrated to reduce glove contamination. ^{Reference Ward, Cooper and Lippert29,Reference Kozon, Riahi and Lundbye-Christensen30} Systematic intraoperative glove changes during orthopedic surgery reduces the frequency of occult perforations and bacterial loading of glove surfaces. ^{Reference Sørensen, Ejlertsen, Aaen and Poulsen31–Reference Al-Maiyah, Bajwa and Finn34} Substantial glove contamination has also been demonstrated intraoperatively before handling a VPS for insertion. ^{Reference Kulkarni, Drake and Lamberti-Pasculli1,Reference Makama, Okeme, Makama and Ameh35,Reference Dawson-Bowling, Smith and Butt36} Some authors have suggested frequent glove changes throughout surgical procedures, at least every 20–90 minutes and at critical points (eg, after draping, before handling of instrumentation, and prior to wound closure). ^{Reference Harnoss, Partecke, Heidecke, Hübner, Kramer and Assadian37,Reference Beldame, Lagrave and Lievain38} In 1 study, standardizing glove change 1 hour after initiating surgery resulted in a 10% absolute reduction in glove contamination. ^{Reference Makama, Okeme, Makama and Ameh35} During VPS insertion, one group of investigators found that contamination of sterile gloves occurred within 15 minutes of donning and recommended that ‘a simple measure would be to change the outer pairs of gloves before handling of the shunt material during surgery.’ ^{Reference Dawson-Bowling, Smith and Butt36} Unsurprisingly, outer-glove change prior to handling instrumentation during lumbar fusion led to an 86% reduction in postoperative infections. ^{Reference Rehman, Rehman, Rehman and Freeman39} Nevertheless, more data are needed with glove change alone to prove its utility as a standard of care for all procedures involving implantation of permanent devices.

Our review has a number of limitations. Publication bias is possible due to the small number of studies that met our inclusion criteria. Heterogeneity of the studies was high, and the studies were underpowered. One study assessed only intraoperative glove removal or change, ^{Reference Bashir and Sørensen9} whereas the 3 others assessed intraoperative glove change as part of an infection prevention bundle. ^{Reference Pirotte, Lubansu and Bruneau3,Reference Rehman, Rehman, Bashir and Gupta5,Reference Okamura, Maruyama and Fukuda13} In the lone study that assessed glove change alone, ^{Reference Bashir and Sørensen9} the reduction in VPS infection rate only reached statistical significance at a 6-month follow-up. As such, the attributable effect of outer-glove removal alone is likely contributory to lower infection rates, but further research is needed to unequivocally confirm the impact of this preventative strategy.

In conclusion, reducing risk of a VPS infection may be achieved through a low-cost protocol of standardizing outer-glove removal or change as part of an infection control bundle prior to handling of the shunt during intraoperative insertion. Replacing the outer glove may be preferable in the event that the inner glove was contaminated due to unsuspected outer-glove perforation during a surgical procedure or during outer-glove removal. This intervention does not require purchase of new equipment, is easy to implement, and can be utilized in resource limited and well-resourced settings.