[Matthias Maiwald (KKH)]

Dear Wendy,

A very remote possibility — although nevertheless possible — are contaminated antiseptics and disinfectants, particularly weak antiseptics such as chlorhexidine, povidone-iodine, triclosan and benzalkonium chloride. Burkholderia cepacia is a very hardy organism that can survive and even grow in some of these.

See:

Weber DJ, Rutala WA, Sickbert-Bennett EE.
Outbreaks associated with contaminated antiseptics and disinfectants.
Antimicrob Agents Chemother. 2007 Dec;51(12):4217-24.
http://www.ncbi.nlm.nih.gov/pubmed/17908945

Chang CY, Furlong LA.
Microbial stowaways in topical antiseptic products.
N Engl J Med. 2012 Dec 6;367(23):2170-3. doi: 10.1056/NEJMp1212680
http://www.ncbi.nlm.nih.gov/pubmed/23215554

(There is certainly more literature available concerning contaminated antiseptics and disinfectants).

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

Good morning
Currently at The Canberra Hospital we have identified a small cluster of Burkholderia cepacia in blood cultures and vas cath tips in renal dialysis patients. To date we have conducted environmental surveillance but not identified a cause.
Our question is: is anyone else seeing this at this time and if so have you identified a cause?

Wendy Beckingham
CNC Infection Prevention and Control
ph. (02) 6244 3695 or mobile 0478408787 orpager 50390
e. wendy.beckingham@act.gov.au
Care Excellence Collaboration Integrity
GERMS CAN KILL…
[CH_Logo_ACT_Health_Lockup_CMYK_HR]

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[Matthias Maiwald (KKH)]

Dear Colleagues,

I just recalculated (with the help of a colleague whose maths is fresher than mine) the amount of alcohol that would be carried underneath the skin if an alcohol film were to remain on the skin after swabbing and before injecting the vaccine.

A 25 gauge needle (typically used in vaccinations) has an inner diameter of 0.26 mm; i.e. radius 0.13 mm.

If we assume an alcohol film remaining on skin of 0.1 mm thickness (that is probably an overestimate, because alcohol films are very thin), i.e. a cylinder height (h) of 0.1 mm.

Using the formula:

pi x r^2 x h

one obtains an alcohol amount carried within the needle bore of 5.3 nL (nanolitres).

Assuming an alcohol concentration of 70% (typical of skin antiseptics) and a typical volume of a vaccine of 0.5 mL, we arrive at an alcohol concentration of:

0.00074%

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

Dear Colleagues,

I have posted this several times on this forum before. I don’t think I should repeat myself in great detail again, so just short comments at this point.

The recommendation to do skin antisepsis only if skin is visibly dirty is baseless. Microorganisms are invisible, that is their very nature. Microorganism counts on skin — even visibly clean — vary dramatically between individuals and between different skin sites. There is absolutely no basis whatsoever for making a distinction — in the form of a “cutoff point” — between visibly clean and dirty skin in terms of swabbing or not swabbing. I should ask a question. You are sitting in front of a patient with darker skin colour wanting to give an injection: When would you decide that the skin is “visibly clean”?

It is correct that alcohol would inactivate vaccines if it would contaminate — in relevant concentrations — vaccines. However, (a) the alcohol is supposed to be dried before inserting the needle, and (b) even if it hasn’t dried, you can calculate this on the following grounds: (i) you take the needle gauge that you would be using (http://en.wikipedia.org/wiki/Needle_gauge_comparison_chart) and use the inner diameter, (ii) you use pi (that mathematical circle number from high school maths) and calculate the surface area of skin, (iii) then you assume a height of 0.1 mm as a thickness of an alcohol film that has not dried (that is probably an overestimate), and then you arrive at an alcohol amount that would be carried under the skin by the needle bore, and this would be in the nanolitre (nL) range (I calculated it once, but forgot exactly how many nanolitres). With an assumed 0.5 mL vaccine, the alcohol percentage would then be something like 0.0001% (if I am not mistaken). That alcohol concentration would never be able to affect any vaccine.

In conclusion, both the recommendations in the Australian Immunization Handbook and in the WHO document follow a severely defective logic.

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

Thank Marija – that would be great.

Christine Lawson | RN

Quality and Risk Manager | Caboolture Private Hospital
Caboolture Private Hospital
McKean Street, CABOOLTURE QLD 4510
t: 07 5495 9418
e: LawsonC@ramsayhealth.com.au | w: http://www.ramsayhealth.com.au

[http://www.ramsayhealth.com.au/images/email/RHC-email-2013.jpg]

Hi Christine,

I have an article from Ireland that I am happy to send you.

Kind Regards

Marija Juraja |Clinical Service Coordinator (CICP) – Infection Prevention & Control Unit|
t: +61 8 8222 7588| p:47757| f: +61 8 8222 6461 | DX: 465432 |e:marija.juraja@health.sa.gov.au

Care Excellence Collaboration Integrity
GERMS CAN KILL…

Thanks guys – I do have this information for immunisations – I was thinking more of in hospital – S/C or IMI narcotics or clexane/heparin.

Christine Lawson | RN

Quality and Risk Manager | Caboolture Private Hospital
Caboolture Private Hospital
McKean Street, CABOOLTURE QLD 4510
t: 07 5495 9418
e: LawsonC@ramsayhealth.com.au | w: http://www.ramsayhealth.com.au

[http://www.ramsayhealth.com.au/images/email/RHC-email-2013.jpg]

Hi Christine

The Australian Immunisation Handbook states:

2.2.4 Preparation for vaccine administration
Skin cleaning
Provided the skin is visibly clean, there is no need to wipe it with an antiseptic (e.g. alcohol wipe).3,8 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 (to prevent inactivation of live vaccines and to reduce the likelihood of irritation at the injection site).9
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10-2-2

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
Please consider the environment before printing this email

Hi all,

Wondering if anyone can guide me to reference/ evidence base re swabbing skin before s/c or imi injection is or is not recommended.

Christine Lawson | RN

Quality and Risk Manager | Caboolture Private Hospital
Caboolture Private Hospital
McKean Street, CABOOLTURE QLD 4510
t: 07 5495 9418
e: LawsonC@ramsayhealth.com.au | w: http://www.ramsayhealth.com.au

[http://www.ramsayhealth.com.au/images/email/RHC-email-2013.jpg]
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[Matthias Maiwald (KKH)]

Dear Colleagues,

I have posted this several times on this forum before. I don’t think I should repeat myself in great detail again, so just short comments at this point.

The recommendation to do skin antisepsis only if skin is visibly dirty is baseless. Microorganisms are invisible, that is their very nature. Microorganism counts on skin — even visibly clean — vary dramatically between individuals and between different skin sites. There is absolutely no basis whatsoever for making a distinction — in the form of a “cutoff point” — between visibly clean and dirty skin in terms of swabbing or not swabbing. I should ask a question. You are sitting in front of a patient with darker skin colour wanting to give an injection: When would you decide that the skin is “visibly clean”?

It is correct that alcohol would inactivate vaccines if it would contaminate — in relevant concentrations — vaccines. However, (a) the alcohol is supposed to be dried before inserting the needle, and (b) even if it hasn’t dried, you can calculate this on the following grounds: (i) you take the needle gauge that you would be using (http://en.wikipedia.org/wiki/Needle_gauge_comparison_chart) and use the inner diameter, (ii) you use pi (that mathematical circle number from high school maths) and calculate the surface area of skin, (iii) then you assume a height of 0.1 mm as a thickness of an alcohol film that has not dried (that is probably an overestimate), and then you arrive at an alcohol amount that would be carried under the skin by the needle bore, and this would be in the nanolitre (nL) range (I calculated it once, but forgot exactly how many nanolitres). With an assumed 0.5 mL vaccine, the alcohol percentage would then be something like 0.0001% (if I am not mistaken). That alcohol concentration would never be able to affect any vaccine.

In conclusion, both the recommendations in the Australian Immunization Handbook and in the WHO document follow a severely defective logic.

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

Thank Marija – that would be great.

Christine Lawson | RN

Quality and Risk Manager | Caboolture Private Hospital
Caboolture Private Hospital
McKean Street, CABOOLTURE QLD 4510
t: 07 5495 9418
e: LawsonC@ramsayhealth.com.au | w: http://www.ramsayhealth.com.au

[http://www.ramsayhealth.com.au/images/email/RHC-email-2013.jpg]

Hi Christine,

I have an article from Ireland that I am happy to send you.

Kind Regards

Marija Juraja |Clinical Service Coordinator (CICP) – Infection Prevention & Control Unit|
t: +61 8 8222 7588| p:47757| f: +61 8 8222 6461 | DX: 465432 |e:marija.juraja@health.sa.gov.au

Care Excellence Collaboration Integrity
GERMS CAN KILL…

Thanks guys – I do have this information for immunisations – I was thinking more of in hospital – S/C or IMI narcotics or clexane/heparin.

Christine Lawson | RN

Quality and Risk Manager | Caboolture Private Hospital
Caboolture Private Hospital
McKean Street, CABOOLTURE QLD 4510
t: 07 5495 9418
e: LawsonC@ramsayhealth.com.au | w: http://www.ramsayhealth.com.au

[http://www.ramsayhealth.com.au/images/email/RHC-email-2013.jpg]

Hi Christine

The Australian Immunisation Handbook states:

2.2.4 Preparation for vaccine administration
Skin cleaning
Provided the skin is visibly clean, there is no need to wipe it with an antiseptic (e.g. alcohol wipe).3,8 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 (to prevent inactivation of live vaccines and to reduce the likelihood of irritation at the injection site).9
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10-2-2

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
Please consider the environment before printing this email

Hi all,

Wondering if anyone can guide me to reference/ evidence base re swabbing skin before s/c or imi injection is or is not recommended.

Christine Lawson | RN

Quality and Risk Manager | Caboolture Private Hospital
Caboolture Private Hospital
McKean Street, CABOOLTURE QLD 4510
t: 07 5495 9418
e: LawsonC@ramsayhealth.com.au | w: http://www.ramsayhealth.com.au

[http://www.ramsayhealth.com.au/images/email/RHC-email-2013.jpg]
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

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[Matthias Maiwald (KKH)]

Dear Liz,

From my reading, it seems like there is no right or wrong to your question, and I have seen both techniques described in the literature, although I don’t think this has been propertly (scientifically) investigated. It is more common to see the circles method described. One manufacturer of 2% CHX 70% IPA applicators seems to recommend back and forth with their applicators.

From a microbiological perspective, what is more important is (a) repeated applications with fresh antiseptic and (b) a sufficient contact time for the antiseptic to act and kill skin microorganisms. But there are no good published data on how many and how long. It seems that at least 2 subsequent applications are necessary, and at least 1 min overall contact time for blood cultures. (Note, at least). We are talking blood culture collection, which is biologically/physiologically different from other applications of skin antisepsis.

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,

We are working on a protocol for taking blood cultures. I had a question regarding technique for the skin prep. Should we be using concentric circles or a rubbing action backwards and forwards? We are using 2% chlorhexidine 70% alcohol for the skin prep. Does anyone have any references or evidence as to which option is best practice?

Regards,
Liz Orr
Infection Control Consultant
Monash Health
Monash Medical Centre Clayton
9594 2623
liz.orr@monashhealth.org

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[Matthias Maiwald (KKH)]

Dear Gerald,

The group from Petra Gastmeier from Germany has published some articles around this:

http://www.ncbi.nlm.nih.gov/pubmed/22011537

http://www.ncbi.nlm.nih.gov/pubmed/18948793

http://www.ncbi.nlm.nih.gov/pubmed/22579079

http://www.ncbi.nlm.nih.gov/pubmed/22828870

and also Nicholas Graves’ group from Queensland:

http://www.ncbi.nlm.nih.gov/pubmed/23434381

http://www.ncbi.nlm.nih.gov/pubmed/22999770

And it was also discussed at the recent ICPIC Infection Control meeting in Switzerland.

It now increasingly looks like laminar flow is probably not necessary in operating theatres, but of course, HEPA filtration continues to be.

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

Dear all,

There has been recent studies disputing the use of laminar air flow in theatres and some indicating its contribution to severe surgical site infections…

I’m interested to find out if anyone’s looked into this in further detail and if anyone’s implemented any changes to their current or future theatre designs?

I’m aware that current building guidelines recommend laminar flow systems but is this now due for a review based on what’s being published?

Keen to hear everyone’s comments.

Cheers,
Gerald

Gerald Chan
Coordinator Infection Control

St John of God Murdoch Hospital
100 Murdoch Drive
MURDOCH. WA 6150

P: 9366 1552
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[Matthias Maiwald (KKH)]

Dear Margaret,

For the facial superficial skin around the eyes, or for the mucous membranes of the eyes (i.e. the cornea etc.)?

For mucous membranes, the only good alternative that I can think of is aqueous octenidine, which unfortunately is not available in Australia. But let’s see what other suggestions come from the group.

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

Dear Colleagues

We are currently using half strength betadine as skin prep for our eye patients.

Our Theatre manager is looking for an alternative skin prep solution for those patients who have a sensitivity to iodine.

Would appreciate your input into alternatives available for this group.

Many thanks.

Regards,
Margaret Davidson I CNC Infection Control
Bentley Health Service I Infection Prevention and Management
18-56 Mills Street, Bentley I PO Box 158, Bentley WA 6982

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[Matthias Maiwald (KKH)]

Hi Cath, hi Michael,

I agree with Michael — not that Cath was fundamentally different on that issue — that (a) classical skin antisepsis before surgical incision (‘surgical skin prep’) and (b) antiseptic body washing or showering in the preoprerative phase (that includes preoperative antiseptic body wiping with cloths) are two fundamentally different processes, both biologically and clinically.

Classical skin antisepsis is extremely well supported by evidence plus carries a clear scientific rationale:
(1) Historically, skin antisepsis before iatrogenic skin breaks has been used since the 1890s (e.g. a paper by Harrington & Walker 1903 stated it was in widespread use).
(2) There is a clear biological and microbiological theoretical framework supporting it, i.e. there is biological plausibility. This includes the fact that well-conducted skin antisepsis reduces microbe counts on skin by anywhere between 2 log and 4 log (a factor of 100-10,000) and that microorganisms from patients’ skin are known to cause surgical site infections.
(3) That based on microbiological testing — both in reagent tubes and on real skin — antiseptics can be categorised (that includes regulatory purposes by product approval agencies) into stronger and weaker ones, and some that pass standards and others that don’t.
(4) That outcomes from clinical trials, including very well conducted (i.e. high-level evidence) randomised clinical trials by and large reflect the outcomes from microbiological testing.
So, we have various angles of strong support here.

Preoperative antiseptic body washing is much less supported overall. This is also reflected by the statement in the draft text passage that Cath sent, saying that although showering or bathing should be done (note, no antiseptic stated here), it says “No recommendation can be made regarding the safety and effectiveness of specific body cleansing products, the optimal timing or number of product applications.” That means the draft does not necessarily imply that this should be done with antiseptics. The use of antiseptics for that purpose follows a reasonably good rationale and has biological plausibility, but support from high-quality randomised clinical trials is currently lacking. The latter also became clear in a recently-updated Cochrane review by Webster & Osborne (authors from QLD) in 2012. Microbiologically, antiseptic body washing achieves far lesser microbial reduction on skin than classical skin antisepsis. There are several other non-randomised (e.g. observational) clinical studies showing a benefit from antiseptic washing, and they should definitely not be discounted. These are still providing valuable evidence. But the evidence from the latter type of studies is not quite as clear-cut as one would wish, just as an example, by coincidence there were two almost back-to-back recently-appeared (but in different journals) papers, one by Kapadia et al. 2013, the other by Farber et al. 2013. One was antiseptic-industry-supported, the other not. The industry-supported paper showed a benefit, the other not. Just a few interesting observations here . . .

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

Michael

CDC does not typically drill down to the minutia level of applications. Under FDA and OSHA legislation I am sure that the assumptions rightly or wrongly are that manufacturers label as per their submission for registration and testing and that clinicians follow label instructions. Australia is no different.

Below is an interesting point about intraoperative skin prep and solution of choice.

There are also many in-press publications about CHG bathing pre-operatively as an additional measure.

We have to remain on top of all this research and public policy and it’s very time consuming and not easy without formal training in reading and understanding scientific papers. Our lot in life I guess.

JUNE 2013 UPDATED
8B. Perform intraoperative skin preparation with an appropriate antiseptic agent. (Category IA)
8B.1.a. Use chlorhexidine gluconate-alcohol in preference of aqueous iodophor skin preparation, unless contraindicated. (Category IA)
8B.1.b. No recommendation can be made regarding the safety and effectiveness of chlorhexidine gluconate-alcohol as compared to iodophor-alcohol skin preparation.(No recommendation/unresolved issue)

Cheers
Cath

Thanks Cath, very interesting. But this appears to be about pre-op antiseptic body wash rather than pre-op skin antisepsis. Is there any proposed change to the HICPAC guidelines about skin antisepsis? Presume they will at least have a statement about following antiseptic manufacturer’s instructions for application?

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
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Michael and all

In my research I am currently reviewing the draft US CDC Surgical Site Infection Guidelines which are due to be released in Nov 2013. They include comprehensive review of literature and rigorous grading of evidence for every recommendation. Guidance in this issue like many areas of infection prevention often becomes outdated due to new technologies and formulations. Misinterpretation, multi-resistant attitudes and holding onto sacred cows continue to plague effective clinical practice. The CDC draft statement regarding skin antisepsis suggests that multi applications may be one such sacred cow. The draft recommendation below is subject to normal HICPAC consultation processes.

Always interesting to see how public policy evolves, usually much slower and less responsive than technology and adoption of trends and fads. All of this keeps our role exciting and very necessary.

JUNE 2013 NEW

8A. Require patients to shower or bathe (full body-including scalp) on at least the night before the operative day (Category IB)
8A.1. No recommendation can be made regarding the safety and effectiveness of specific body cleansing products, the optimal timing or number of product applications. (No recommendation/unresolved issue)

Cath
Cathryn Murphy PhD
Executive Director
Infection Control Plus Pty Ltd
http://www.infectioncontrolplus.com.au
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Hi all

Can I ask a question which may seem naive to those with a recent theatre background? When applying antiseptic solution as part of a surgical skin preparation prior to a procedure, is it best practice to apply two ‘coats’ of antiseptic solution, one immediately on top of the other, using different swabs?

I can see not real benefit in doing this from an antiseptic action viewpoint (apart from mechanical friction) Can also not see this mentioned in a cursory review of any SSI prevention best practice guidelines.

Any comments? Any references to get me up-to-date if I need to be updated?

Thanks
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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[Matthias Maiwald (KKH)]

Dear James,

I am curious. What does it say?

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 Michael
Standard S18 of the ACORN standards covers this

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Hi all

Can I ask a question which may seem naive to those with a recent theatre background? When applying antiseptic solution as part of a surgical skin preparation prior to a procedure, is it best practice to apply two ‘coats’ of antiseptic solution, one immediately on top of the other, using different swabs?

I can see not real benefit in doing this from an antiseptic action viewpoint (apart from mechanical friction) Can also not see this mentioned in a cursory review of any SSI prevention best practice guidelines.

Any comments? Any references to get me up-to-date if I need to be updated?

Thanks
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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[Matthias Maiwald (KKH)]

Dear Michael,

There is not much literature or evidence available concerning this particular question, in terms of guiding you exactly how many coats or layers you should apply.

However, some basic information can be derived from the physicochemical properties of antiseptics and of antiseptic action.

Whether there are additional “coats” (in the sense of layers) on top of each other is of relatively little relevance.

All microbial killing by disinfection and sterilisation (including antisepsis) is a time-dependent action. You can see that from “time-kill-curves” of microorganisms when exposed to these processes. Figures are, for example, in the Gardner & Peel textbook, which is an Australian reference. The time-dependent nature of microbial killing is the conceptual reason for having contact times with any antisepsis or disinfection process.

Repeated applications of antiseptics for the purpose of skin antisepsis simply help to keep sufficient fresh antiseptic on the skin site in order for it to be antimicrobially effective for the duration of the contact time. It is a simple physical principle that if the site is not wet with the antiseptic (e.g. by evaporation), it cannot act.

The Australian College of Surgeons (RACS) has an earlier guideline on infection prevention in surgery (not sure if this has been updated) that says “at least 2, but preferably 5 minutes” of contact time of the antiseptic for surgical skin prep.

Clearly recognising that this is arbitrary, not guided by good evidence and up for debate, what I have recommended in the past is to have 3 repeated applications, providing an overall contact time, including evaporation at the end of the applications, of 5 minutes. The rationale for this recommendation is that this would be consistent with the RACS recommendation of 5 min (for major surgery you want to err on the side of greater caution) and consistent with the physicochemical properties.

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

Can I ask a question which may seem naive to those with a recent theatre background? When applying antiseptic solution as part of a surgical skin preparation prior to a procedure, is it best practice to apply two ‘coats’ of antiseptic solution, one immediately on top of the other, using different swabs?

I can see not real benefit in doing this from an antiseptic action viewpoint (apart from mechanical friction) Can also not see this mentioned in a cursory review of any SSI prevention best practice guidelines.

Any comments? Any references to get me up-to-date if I need to be updated?

Thanks
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
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[Matthias Maiwald (KKH)]

Dear Teresa,

This is unfortunate. While it is an important principle that everyone always should have the right to speak up and ask “where is the evidence”, I have long hypothesised that this right is often abused for the wrong reasons, particularly by people who consider adherence to good infection control practices as inconvenient. I have also long advocated that in instances where there is a strong biological (including microbiological) and scientific rationale, there should be an “evidence reversal”, i.e. a reversal of the onus to bring on evidence, such as “this is standard practice, supported by a good microbiological/scientific rationale, and now YOU show me the evidence that if this is not adhered to, this won’t lead to negative consequences for our patients”. (This also indirectly supports what I have advocated earlier, that understanding of the concepts and principles from teaching in medical schools would be important).

What would help, in my opinion, is if your institution would have an infection control committee (HICC) headed by a senior doctor (e.g. ID physician or microbiologist). For example, we here have HICC sessions once every three months, something like you describe (i.e. systematic practice breaches) would most likely be discussed there, and the chairperson of the HICC would then (most likely) issue a formal letter to the hospital CEO concerning adherence to practices.

I had a quick look at the ANTT website that Tim Spencer sent in his e-mail just before yours, and I do notice that it is very light on factual information and very heavy on management-speak (“weaselwords”).

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

I am working at a new, private small endoscopy centre.
I get to see the anaesthetists (which was not always easy when working at a busy hospital) and thought it would be great to have the discussion and look at the possibility of doing education etc. person to person.

Unfortunately, I have hit great resistance! They firmly believe that because our cannulas are in short-term – (being a day only endoscopy centre) this ANTT stuff does not apply to us.
They have asked for the evidence, which I gave them of course, but they keep saying it is not applicable to us. The other day I was talking to one of them about the importance of ANTT and that hand hygiene needs to be performed at the correct
time as per the 5 moments and I was shocked to hear….”so you expect me to perform hand hygiene each time before I administer an IV drug if I have touched the environment, my phone or another patient?”. So I think we still have a long way to go with education, especially of the practitioners who are out there in private practice (perhaps it’s just my doctors?)!!

Even though management were supportive initially, they have now said to just look at training our staff (not the doctors). This has come about since Advisory No: A13/05.
I am struggling with this, and will of course try to come up with some ideas to get around it sensitively.

While on the subject. Is Australia working on our own educational resources (I have worked hard to get rid of Lanyards and now I see them dangling in aseptic fields)?
Is everyone teaching glove use to draw up IV Medications? Is everyone sourcing a larger alcohol/chlorhexidine swab as per the educational videos?
It seems that although we all need to implement this standard, in talking to other practitioners everyone seems to be doing it a little differently, which then defeats the purpose.

Any feedback greatly accepted. Have a great week.

Teresa Lewis
Infection Control and Prevention CNC
Newcastle Endoscopy Centre

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[Matthias Maiwald (KKH)]

Dear Colleagues, dear Michael,

Since my post last week, I had another look at the numbers in this paper. I found the following:

The measured primary outcomes, according to the paper’s Methods section, were (a) any HAIs and (b) colonization with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE).

Reported in the Results section and in Table 2 were the total (i.e. combined for both trial arms) numbers of patients who had (a) HAI, (b) colonization, (c) both HAI and colonization (i.e. meaning only those patients who had both events occurring together), (d) HAI and/or colonization (i.e. the number of patients who had either HAI or colonization or both together, meaning any event), (e) HAI only but no colonization (i.e. number of patients who had HAI minus the ones who had both HAI and colonization), and (f) colonization only but no HAI (i.e. number of patients who had colonization minus the ones who had both HAI and colonization). I know this may be confusing, but these are the numbers that were reported. They didn’t call if (a)-(f), that is what I am writing here to make the figures more distinguishable.

Separate data for outcomes in each trial arm were only reported for (d), (e) and (f). For (d), the article reported what amounted to a 49% reduction in the copper rooms vs. non-copper rooms (21 vs. 41 patients; p.02), for (e) a 62% reduction in the copper rooms (10 vs. 26; p.013), and for (f), a 67% reduction (4 vs. 12; p.063, NS). What was missing were the numbers of patients with (a) HAI and (b) colonization, listed separately for each trial arm.

The article concluded — in the Discussion section — that copper surfaces in rooms reduced the risk of HAIs by more than half.

However, arguably, (a) any HAIs and (b) any colonization events, as listed in the Methods, would be biologically and clinically most relevant, and it may not be very informative to combine these two events (under d) in the same statistical calculation, because they are biologically and clinically different from each other.

What is listed in Table 2 as “HAI only” (figure e) is actually: “number of patients with HAI minus the number of patients who had both HAI and colonization together”. This — again arguably — is an artificially constructed number without clinical/biological relevance.

Similarly, what is listed in Table 2 as “Colonization only” (figure f) is actually: “number of patients with Colonization minus the number of patients who had both HAI and colonization together”.

I extracted the missing numbers from the other numbers presented and arrived at (a) HAIs 17 vs. 29, and (b) colonization, 11 vs. 15 events. Putting these into my statistics calculator, they were — non-significant.

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

—–Original Message—–

Hi Michael,

Very interesting study. Sometimes it is difficult to get one’s head around things and figure out whether one’s own thinking is correct. I have the following thoughts concerning the study, but do not know if my thoughts are correct:

I can think of the following three routes for transmission of HAIs:

– (i) Endogenously, from within the patient’s own flora (nosocomial UTIs would be typical)
– (ii) Exogenously via direct transfer, e.g. handborne transmission
– (iii) Exogenously via surfaces and secondary transmission from contaminated surfaces

The authors assessed two (actually three) things: (a) HAIs, independent of the organism, (b, c) colonisation with MRSA and VRE.

All three pathways can lead to (a), while only the exogenous pathways can lead to (b, c), because MRSA and VRE cannot arise spontaneously in a non-colonised patient.

The copper surfaces would only reduce the proportion of (a, b, c) due to the second exogenous pathway (iii), but not due to the others (they simply cannot).

If there is a 58% reduction of HAIs through copper surfaces, that would potentially mean that the overall proportion of transmission pathways (i) and (ii) among all HAIs would only be 42% (is that correct?).

My impression always used to be that the endogenous pathway and the exogenous pathway via direct transmission are important, but I have not seen recent estimates of the proportions of all three.

Other observations are that the overall number of HAIs is relatively small, that among the bloodstream infections in the non-copper rooms, there are 3 with coag.-neg. staphs, that among the HAIs in the non-copper rooms are 5 “other” undefined HAIs (among a total of only 26), and that the authors in the abstract combine both HAIs and colonisation events in the same statistics (one p value for both events). A friend who knows about statistics tells me that one should not combine things that are biologically different in the same statistical calculation, and HAIs and colonisations are biologically different.

Any additional thoughts? Again, not sure if my line of thinking is correct.

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

—–Original Message—–

I would be interested in other infection control and prevention professionals’ thoughts about the article below. I must admit a healthy dose of scepticism to any study mainly funded by a lobby group (Copper Development Foundation), but the science and methods seems reasonable to me. What is the considered role of the ICU environment in HAI’s? More studies of these effects seem warranted. Are there any similar studies being conducted in Australia currently?

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
Please consider the environment before printing this email

US Study Shows Copper Cuts Hospital Infections by 58%

A 4-year study in the U.S. has shown that using Antimicrobial Copper surfaces in hospital rooms reduced the number of Healthcare Acquired Infections (HAIs) by 58% compared to rooms without Antimicrobial Copper.

The U.S. Department of Defense funded study compared rooms with and without Antimicrobial Copper objects in Intensive Care Units at three major hospitals-The Medical University of South Carolina, Memorial Sloan-Kettering Cancer Center in New York City and the Ralph H. Johnson Veterans Affairs Medical Center in Charleston, South Carolina.

The results, which have been published online in the Infection Control and Hospital Epidemiology (ICHE) Journal, compared copper to equivalent non-copper touch surfaces during active patient care between routine cleaning and sanitizing.

The study confirmed that Antimicrobial Copper surfaces can continuously kill 83% of bacteria that cause HAIs within 2 hours, including drug resistant strains that are often called ‘superbugs’.

“Because the antimicrobial effect is a continuous property of copper, the re-growth of deadly bacteria is significantly less on these surfaces, making a safer environment for hospital patients, “said Dr. Michael Schmidt, Vice Chairman of Microbiology and Immunology at the Medical University of South Carolina and one of the authors of the study.

HAI’s are a major and growing problem worldwide. Here in Australia around 9,000 people die as a result of picking one up in hospital.

“We’ve known for a while that copper and copper alloy surfaces can kill off bacteria and viruses within hours of contact, but we now have proof that they also cut the risk of picking up an infection and that will save lives and cut health care costs,” John Fennell from the International Copper Association said.

“Antimicrobial Copper surfaces and products are now being manufactured worldwide, and there’s been a growing number of hospital, medical clinics, aged care facilities and even kindergartens that have installed them as part of their infection control strategies.”

The [full] study can be found at: http://www.jstor.org/stable/10.1086/670207
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[Matthias Maiwald (KKH)]

Hi Michael,

Very interesting study. Sometimes it is difficult to get one’s head around things and figure out whether one’s own thinking is correct. I have the following thoughts concerning the study, but do not know if my thoughts are correct:

I can think of the following three routes for transmission of HAIs:

– (i) Endogenously, from within the patient’s own flora (nosocomial UTIs would be typical)
– (ii) Exogenously via direct transfer, e.g. handborne transmission
– (iii) Exogenously via surfaces and secondary transmission from contaminated surfaces

The authors assessed two (actually three) things: (a) HAIs, independent of the organism, (b, c) colonisation with MRSA and VRE.

All three pathways can lead to (a), while only the exogenous pathways can lead to (b, c), because MRSA and VRE cannot arise spontaneously in a non-colonised patient.

The copper surfaces would only reduce the proportion of (a, b, c) due to the second exogenous pathway (iii), but not due to the others (they simply cannot).

If there is a 58% reduction of HAIs through copper surfaces, that would potentially mean that the overall proportion of transmission pathways (i) and (ii) among all HAIs would only be 42% (is that correct?).

My impression always used to be that the endogenous pathway and the exogenous pathway via direct transmission are important, but I have not seen recent estimates of the proportions of all three.

Other observations are that the overall number of HAIs is relatively small, that among the bloodstream infections in the non-copper rooms, there are 3 with coag.-neg. staphs, that among the HAIs in the non-copper rooms are 5 “other” undefined HAIs (among a total of only 26), and that the authors in the abstract combine both HAIs and colonisation events in the same statistics (one p value for both events). A friend who knows about statistics tells me that one should not combine things that are biologically different in the same statistical calculation, and HAIs and colonisations are biologically different.

Any additional thoughts? Again, not sure if my line of thinking is correct.

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

—–Original Message—–

I would be interested in other infection control and prevention professionals’ thoughts about the article below. I must admit a healthy dose of scepticism to any study mainly funded by a lobby group (Copper Development Foundation), but the science and methods seems reasonable to me. What is the considered role of the ICU environment in HAI’s? More studies of these effects seem warranted. Are there any similar studies being conducted in Australia currently?

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
Please consider the environment before printing this email

US Study Shows Copper Cuts Hospital Infections by 58%

A 4-year study in the U.S. has shown that using Antimicrobial Copper surfaces in hospital rooms reduced the number of Healthcare Acquired Infections (HAIs) by 58% compared to rooms without Antimicrobial Copper.

The U.S. Department of Defense funded study compared rooms with and without Antimicrobial Copper objects in Intensive Care Units at three major hospitals-The Medical University of South Carolina, Memorial Sloan-Kettering Cancer Center in New York City and the Ralph H. Johnson Veterans Affairs Medical Center in Charleston, South Carolina.

The results, which have been published online in the Infection Control and Hospital Epidemiology (ICHE) Journal, compared copper to equivalent non-copper touch surfaces during active patient care between routine cleaning and sanitizing.

The study confirmed that Antimicrobial Copper surfaces can continuously kill 83% of bacteria that cause HAIs within 2 hours, including drug resistant strains that are often called ‘superbugs’.

“Because the antimicrobial effect is a continuous property of copper, the re-growth of deadly bacteria is significantly less on these surfaces, making a safer environment for hospital patients, “said Dr. Michael Schmidt, Vice Chairman of Microbiology and Immunology at the Medical University of South Carolina and one of the authors of the study.

HAI’s are a major and growing problem worldwide. Here in Australia around 9,000 people die as a result of picking one up in hospital.

“We’ve known for a while that copper and copper alloy surfaces can kill off bacteria and viruses within hours of contact, but we now have proof that they also cut the risk of picking up an infection and that will save lives and cut health care costs,” John Fennell from the International Copper Association said.

“Antimicrobial Copper surfaces and products are now being manufactured worldwide, and there’s been a growing number of hospital, medical clinics, aged care facilities and even kindergartens that have installed them as part of their infection control strategies.”

The [full] study can be found at: http://www.jstor.org/stable/10.1086/670207
—
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[Matthias Maiwald (KKH)]

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 <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 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
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) <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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[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

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.
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[cid:kkh2ebe.gif]kkh

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[Matthias Maiwald (KKH)]

Dear Michael,

Interesting aspects. I have been arguing for many years that what is missing are (a) the theoretical and conceptual underpinnings, and (b) actually putting a value on proper, intact scientific and/or logical reasoning.

Take medical school teaching, for example. Many people argue that it is enough to put medical students and junior doctor in practice situation (e.g. on clinical rotations), tell them to “adhere to proper practices” and watch them absorb infection control in a passive, osmosis-like process. While I agree that learning through practising is probably the most important component, I have also long argued that this is simply not enough. What is needed is teaching of the theoretical and conceptual underpinnings, e.g. disease pathogenesis, transmission of infectious diseases and how transmission can be effectively prevented.

I have called the first approach the “parrot” approach to infection control. Parrots can be taught to speak but don’t understand it. (I can probably still find my earlier e-mails to OzBug/AICAlist calling this the “parrot” approach). If you look critically at the e-mail below and the report in the weblink, it looks like that’s exactly what’s happening here. I quote: “People were wearing them to protect themselves and not around actually anything to do with patient safety”.

For these reasons, I also vigorously disagree with the statement that it has to do with a “lack of clear guidelines”. How many guidelines for how many different clinical situations can healthcare workers be expected to memorise? It is a lack of understanding, not a lack of guidelines. If someone knows WHY something is necessary and/or makes sense, this is an important step towards doing it.

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

—–Original Message—–
From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Friday, 22 March, 2013 5:43 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Masks, gloves a ‘waste of time’: study

This article may be worth debating or at least commenting on here

‘Doctors and nurses are confused about when and how to wear face masks and respirators, with some doing it just for show, an Australian study finds.

In-depth interviews at a major Sydney hospital found several staff held negative attitudes towards infection control measures, with one even complaining respirators made them sound like the Cookie Monster.

Speaking Tuesday at the Australasian Society for Infectious Diseases annual conference in Canberra, researcher Dr Holly Seale highlighted a quote from a senior ward director suggesting masks, handwashing, gloves and gowns were a waste of time.

They actually said its all a show and there may not be any value in using those products, she said.

Meanwhile, face mask and respirator use among health workers was inconsistent, with staff unsure about when, how and why to wear them, Dr Searle said. Some complained they interfered with communication and rapport.

People were wearing them to protect themselves and not around actually anything to do with patient safety, said Dr Searle, blaming the lack of clear guidelines.

One participant even went on to call the respirator a Cookie Monster muffler quite out-there language in terms of a product that should be commonly used in these settings.

The interviews were conducted last year with 18 staff. The hospital has not been named.

Dr Seale, from the University of NSWs school of public health and community medicine, called for a review of current recommendations on infection control measures, citing studies showing low levels of compliance among hospitals worldwide.

My concern is that hospital staff dont know how to properly don and doff, nor are there any clear guidelines as to how long a mask can be worn for and whether masks can be used between patients, she said.’

Link: http://www.6minutes.com.au/news/latest-news/masks-gloves-a-waste-of-time-study (free registration by AHPRA registration number required).

Cheers
Michael Wishart
ACIPC Infexion Connexion Administrator
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 email

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