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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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Hi Franciska,
The Australian Immunisation Handbook 9th states 1.4.4 page 43 “provided the skin is visibly clean” no swabbing is required. If need be using an alcohol wipe is to be used, allow drying time before administering vaccination.
I am not aware of any other recommendations for skin preparation for IM / SC route.
Regards,
Rebecca O’Donnell | Infection Prevention and Control Co-ordinator
St Vincent’s Hospital Toowoomba | 22-36 Scott Street TOOWOOMBA 4350
T 07 4690 4042 | F 07 46904400
E rebecca.o’donnell@stvincents.org.au | W http://www.stvincents.org.auP Please consider the environment before printing this email.
This e-mail and any attachments to it (the “Communication”) is confidential and is for the use only of the intended recipient, and may not be duplicated or used by any other party without the express consent of the sender. The Communication may contain copyright material of St Vincent’s Health & Aged Care (“SVHAC”), or any of its related entities or of third parties. If you are not the intended recipient of the Communication, please notify the sender immediately by return e-mail, delete the Communication, and do not read, copy, print, retransmit, store or act in reliance on the Communication. Any views expressed in the Communication are those of the individual sender only, unless expressly stated to be those of SVHAC. SVHAC does not guarantee the integrity of the Communication, or that it is free from errors, viruses or interference.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________________________________
This email is intended only for the use of the individual or entity named above and may contain information that is confidential and privileged. If you are not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this email is strictly prohibited. If you receive this email in error, could you please notify us by return email and delete it and any attachments from your system. Even though this message is scanned no representation is made that this email or any attachments are free of viruses or other defects. Virus scanning is recommended and is the responsibility of the recipient.______________________________________________________________________
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Hi Franciska
The immunization guidleines reflect that swabbing of skin is not
recommended for vaccines unless the injectable area is dirty – see link
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Conte
nt/Handbook-home
Section 1.4.4 – Provided the skin is visibly clean, there is no need to
wipe it with an antiseptic (eg. alcohol wipe).3,4 If the immunisation
service provider decides to clean the skin, or if the skin is visibly
not clean, alcohol and other disinfecting agents must be allowed to dry
before vaccine injection (otherwise there may be some increased
injection pain).Hope that helps
Thanks Cassie
Cassie Pethrick
OSH Consultant
Moore House, Brockway Road
Mt Claremont WA 6010________________________________
Behalf Of Franciska Ferreira
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
________________________________
This email is intended only for the use of the individual or entity
named above and may contain information that is confidential and
privileged. If you are not the intended recipient, you are hereby
notified that any dissemination, distribution or copying of this email
is strictly prohibited. If you receive this email in error, could you
please notify us by return email and delete it and any attachments from
your system. Even though this message is scanned no representation is
made that this email or any attachments are free of viruses or other
defects. Virus scanning is recommended and is the responsibility of the
recipient.______________________________________________________________________
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service.
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do not represent the opinion of ACIPC.Archive of all messages are available at http://aicalist.org.au/archives
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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 1387Hi 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________________________________
This email is intended only for the use of the individual or entity named above and may contain information that is confidential and privileged. If you are not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this email is strictly prohibited. If you receive this email in error, could you please notify us by return email and delete it and any attachments from your system. Even though this message is scanned no representation is made that this email or any attachments are free of viruses or other defects. Virus scanning is recommended and is the responsibility of the recipient.______________________________________________________________________
This email has been scanned by the Symantec Email Security.cloud service.
For more information please visit http://www.symanteccloud.com
______________________________________________________________________
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[cid:kkh2ebe.gif]kkh
________________________________
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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 UniversityVisiting Scholar: Royal Brisbane & Women’s Hospital | Princess Alexandra
Hospital | The Prince Charles HospitalP.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)
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****
>
> ** **
>
> *From:* ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] *On
> Behalf Of *Franciska Ferreira
> *Sent:* Monday, 25 March, 2013 8:54 AM
> *To:* AICALIST@AICALIST.ORG.AU
> *Subject:* RE; Alcohol swab before injections****
>
> ** **
>
> 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****
>
> ** **
>
> ** **
> ——————————
>
> This email is intended only for the use of the individual or entity named
> above and may contain information that is confidential and privileged. If
> you are not the intended recipient, you are hereby notified that any
> dissemination, distribution or copying of this email is strictly
> prohibited. If you receive this email in error, could you please notify us
> by return email and delete it and any attachments from your system. Even
> though this message is scanned no representation is made that this email or
> any attachments are free of viruses or other defects. Virus scanning is
> recommended and is the responsibility of the recipient.
>
> ______________________________________________________________________
> This email has been scanned by the Symantec Email Security.cloud service.
> For more information please visit http://www.symanteccloud.com
> ______________________________________________________________________****
>
> Messages posted to this list are solely the opinion of the authors, and do
> not represent the opinion of ACIPC. ****
>
> Archive of all messages are available at http://aicalist.org.au/archives- registration and login required.
> ****
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> Replies to this message will be directed back to the list. To create a new
> message send an email to aicalist@aicalist.org.au ****
>
> To send a message to the list administrator send an email to
> aicalist-request@aicalist.org.au. ****
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> You can unsubscribe from this list be sending ‘signoff aicalist’ (without
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>
>
>
> kkh
>
> ——————————
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Thanks for a very informed and well-structured reply Mathias.
I totally agree.
Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert.
Clinical Nurse Consultant, Central Venous Access & Parenteral Nutrition
ServiceConjoint Lecturer, South West Sydney Clinical School | Faculty of
Medicine | University of NSW
Dept of Intensive Care, Level 2, Clinical Building, Liverpool Hospital,
Elizabeth Street, Liverpool, 2170, NSW, Australia
Tel (+61) 2 8738 3603 | Fax (+61) 2 8738 3551 | Mob +61 (0)409 463 428 |
Tim.Spencer@sswahs.nsw.gov.au | Timothy.Spencer@unsw.edu.auBehalf Of Matthias Maiwald (KKH)
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
Behalf Of Franciska Ferreira
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
________________________________
This email is intended only for the use of the individual or entity
named above and may contain information that is confidential and
privileged. If you are not the intended recipient, you are hereby
notified that any dissemination, distribution or copying of this email
is strictly prohibited. If you receive this email in error, could you
please notify us by return email and delete it and any attachments from
your system. Even though this message is scanned no representation is
made that this email or any attachments are free of viruses or other
defects. Virus scanning is recommended and is the responsibility of the
recipient.______________________________________________________________________
This email has been scanned by the Symantec Email Security.cloud
service.
For more information please visit http://www.symanteccloud.com
______________________________________________________________________Messages posted to this list are solely the opinion of the authors, and
do not represent the opinion of ACIPC.Archive of all messages are available at http://aicalist.org.au/archives
– registration and login required.Replies to this message will be directed back to the list. To create a
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(without the quotes) to listserv@aicalist.org.aukkh
________________________________
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Actually, although this is strictly unproven (only anecdotal), direct access to a blood vessel and then removing the needle, such as in venipuncture or i.v. injection, presumably has a lower risk of infection than injecting into tissue, because in tissue it takes a while for defense cells to reach it. What makes vascular catheters and i.v. cannulas (that stay in) more problematic than clean, one-off access into blood vessels is that you have (a) hardware that stays in place, and (b) a continuing skin breach over several days, from which the organisms can enter.
From the 1999 CDC surgical site infection guideline, the conceptual framework for the risk of surgical site infections is:
Dose of bacterial contamination x virulence
——————————————————- risk of surgical site infection
resistance of the host patient(Hope the display of the equation comes across OK).
This would similarly apply to injections, although all the parameters involved are different from those in surgery.
If you look at a recent article from MJA:
http://www.ncbi.nlm.nih.gov/pubmed/23496408
even though the inoculum in the injection and the virulence was probably very (!) low, there were two factors that decreased the host resistance, (a) prosthetic joint (hardware) in place, and (b) a large volume (8 mL) of injected fluid, which makes drainage of the fluid from the injected site difficult, and therefore a very small inoculum can cause an infection.
M.
—
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 1387in fact, I have quite a nice bruise the size of a 5c piece after my flu needle, which bears out my theory that supposed IM injections can be exposed directly to the bloodstream quite nicely! (although I would rather they didn’t)
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 12:48, Claire Rickard <c.rickard@griffith.edu.au> wrote:
True enough Michael…although all sorts of tiny vessels lie within the subcutaneous and muscle tissue…who’s to say we are not injecting directly into some of these when we gve an IM/SC?As you say, better to err on the side of caution since the consequences are so catastrophic…as your cost-benefit analysis bears out 🙂
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 12:17, Michael Wishart <Michael.Wishart@hsn.org.au> wrote:
Hi ClaireI, 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
MichaelMichael 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
Please consider the environment before printing this emailI 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 1387Hi 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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I cared for a patient who developed extensive cellulitis at IMI injection site and then went on to develop a spinal abscess.
No doubt the rarest of rare complications, however, I continue to swab !
Rebecca McCann Program Manager
Healthcare Associated Infection Unit (HAIU)
Communicable Disease Control Directorate Department of Health
Grace Vaughan House
227 Stubbs Terrace
SHENTON PARK WA 6008
T:08 9388 4859 M:0439 920 819 F:08 9388 4888
E:rebecca.mccann@health.wa.gov.auThe contents of this e-mail transmission are intended for the named recipients only and may contain confidential and/or privileged information. If you received this message in error, you must not copy, duplicate, forward, print or otherwise distribute any information contained herein, but must ensure that this e-mail is permanently deleted and advise the sender immediately.
Actually, although this is strictly unproven (only anecdotal), direct access to a blood vessel and then removing the needle, such as in venipuncture or i.v. injection, presumably has a lower risk of infection than injecting into tissue, because in tissue it takes a while for defense cells to reach it. What makes vascular catheters and i.v. cannulas (that stay in) more problematic than clean, one-off access into blood vessels is that you have (a) hardware that stays in place, and (b) a continuing skin breach over several days, from which the organisms can enter.
From the 1999 CDC surgical site infection guideline, the conceptual framework for the risk of surgical site infections is:
Dose of bacterial contamination x virulence
——————————————————- risk of surgical site infection
resistance of the host patient
(Hope the display of the equation comes across OK).
This would similarly apply to injections, although all the parameters involved are different from those in surgery.
If you look at a recent article from MJA:
http://www.ncbi.nlm.nih.gov/pubmed/23496408
even though the inoculum in the injection and the virulence was probably very (!) low, there were two factors that decreased the host resistance, (a) prosthetic joint (hardware) in place, and (b) a large volume (8 mL) of injected fluid, which makes drainage of the fluid from the injected site difficult, and therefore a very small inoculum can cause an infection.
M.
—
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
in fact, I have quite a nice bruise the size of a 5c piece after my flu needle, which bears out my theory that supposed IM injections can be exposed directly to the bloodstream quite nicely! (although I would rather they didn’t)
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 12:48, Claire Rickard wrote:
True enough Michael…although all sorts of tiny vessels lie within the subcutaneous and muscle tissue…who’s to say we are not injecting directly into some of these when we gve an IM/SC?
As you say, better to err on the side of caution since the consequences are so catastrophic…as your cost-benefit analysis bears out 🙂
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 12:17, Michael Wishart wrote:
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
w:www.holyspiritnorthside.org.au
Please consider the environment before printing this email
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) 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
________________________________
This email is intended only for the use of the individual or entity named above and may contain information that is confidential and privileged. If you are not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this email is strictly prohibited. If you receive this email in error, could you please notify us by return email and delete it and any attachments from your system. Even though this message is scanned no representation is made that this email or any attachments are free of viruses or other defects. Virus scanning is recommended and is the responsibility of the recipient.
______________________________________________________________________
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______________________________________________________________________Messages posted to this list are solely the opinion of the authors, and do not represent the opinion of ACIPC.
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kkh
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WARNING : This email contains information, which is CONFIDENTIAL, and that maybe subject to LEGAL PRIVILEGE. This e-mail and any attachments to it (the “Communication”) is confidential and is for the use only of the intended recipient, and may not duplicated or used by any other party without the express consent of the sender. The Communication may contain copyright material of St Vincent’s Health & Aged Care(“SVHAC”), or any of its related entities or of third parties. If you are not the intended recipient of the Communication, please notify the sender immediately by return e-mail, delete the Communication, and do not read, copy, print, retransmit, store or act in reliance on the Communication. Any views expressed in the Communication are those of the individual sender only, unless expressly stated to be those of SVHAC. SVHAC does not guarantee the integrity of the Communication, or that it is free from errors, viruses or interference. Thank-you.
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