Course Access
Hi Claire
I, too, agree with Matthias, but I do not think your comparison with IV access is correct. Giving a sub-cut or IM injection has a much lesser risk of infective complications than any direct access to the blood stream (such as IV access or phlebotomy, for example). In my own practice I currently still use alcohol swabs prior to IM vaccination as it is quick, cheap and not worth the potential infective risk (which is yet to be well quantified as pointed out by Matthias).
If patients are self-injecting (either sub-cut or IM), then the risk from auto-inoculation with their own flora may be even lower (viz self-catheterisation guidelines), so I would have no issues with teaching patients not to swab their own skin prior to a simple injection (as long as they were not directly injecting into a vein or device, though). The evidence supporting this is also pretty scant, though.
Cheers
Michael
Michael Wishart
CNC Infection Control
Holy Spirit Northside Private Hospital
627 Rode Road, Chermside, Qld 4032
t: (07) 3326 3068 | f: (07) 3607 2226
e: Michael.Wishart@hsn.org.au
w:www.holyspiritnorthside.org.au
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I completely agree with you Matthias.
With injections into IV ports we are now encouraged to “scrub the hub” for 30 seconds with either isopropyl alchol or alcoholic chlrohexidine etc!
Yet for the skin, which is nice and warm and moist – capable of supporting much higher microbe counts than a dry cool rubber bung, we use nothing…bizarre!!!
Best regards, Claire
Professor Claire Rickard RN PhD
c.rickard@griffith.edu.au | +61 7 3735 6460 | Skype: clairexm1 | Twitter: IVAD_Research | Intravascular Access Device Research Group | NHMRC Centre of Research Excellence in Nursing | Centre for Health Practice Innovation | Griffith Health Institute | Griffith University
Visiting Scholar: Royal Brisbane & Women’s Hospital | Princess Alexandra Hospital | The Prince Charles Hospital
P.S. Research frequently takes me off campus. Please contact Jenny Chan, School Secretary 3735 5406 or j.chan@griffith.edu.au with any urgent enquiries.
On 25 March 2013 11:29, Matthias Maiwald (KKH) <matthias.maiwald@kkh.com.sg> wrote:
Dear Franciska,
Not sure about clexane and insulin (s.c. injections), but I have looked in some detail into the current Australian recommendations concerning vaccinations. Most vaccinations are i.m. injections, which are biologically quite different from s.c. injections and also from venipuncture. The official recommendation by the Australian Immunisation Handbook is not to swab (so if you follow that, you are following official recommendations), and only to swab if the injection area is visibly dirty, but the problem is that these recommendation are severely misguided and intellectually flawed.
(1) Much of it is based on a short 2001 article in the MJA, examining a few hundred s.c. injections and venipunctures, and concluding that swabbing for ANY type of injection is not necessary, including i.m. injections. There are two fatal flaws with this assumption. (a) The article did not examine even a single i.m. injection and made conclusions pertaining to these (which is inconsistent with the principles of evidence-based medicine, which the article purported to adhere to), and (b) the natural infection rate after i.m. injections is very low, estimated to be in the range of 1:5000 to 1:10000 or less (which is reassuring), but if you study a smaller population than is needed to capture the natural incidence of an event, then you cannot make conclusions that the intervention has no effect on the occurrence of the event.
(2) The recommendation to swab only if visibly soiled is not justified either, because microorganisms are invisible, and implementing this as a cutoff between swabbing and non-swabbing is arbitrary without a scientific base or evidence base. Imagine you sit in front of a patient with a darker skin colour and want to give an injection. When would you be confident that the skin is NOT visibly dirty?
In summary, if you don’t swab, you are consistent with the guidelines, but the guidelines are seriously flawed (at least you won’t be responsible then). It is certainly reassuring that the natural infection rate is very low, and statistically you are unlikely (but it is possible) to see any adverse event. It is clear that i.m. injections and other types of injections are biologically and clinically different and bear a different infection risk. Also, the deeper an injection is, the more complicated infections can get (examples on the complicated end are joint injections, corticosteroid injections, or more complicated injections).
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387
Hi All,
There is still an ongoing debate whether we should use an alcohol swab before administering clexane, vaccines and insulin. Any ideas please?
I know the latest practice in regards administering clexane is to “not swab”.
I just want to advise my team from a infection control point of view with facts to stand on.
Kind Regards
Franciska Ferreira
INFECTION PREVENTION & CONTROL /WOUND MANAGEMENT CONSULTANT
Burnside War Memorial Hospital
120 Kensington Road, Toorak Gardens, SA 5056
t: 08 8202 7222 f: 08 8407 8573 e: fferreira@burnsidehospital.asn.au
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