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Hi Both,
I am far from an expert in this area, but wouldn’t one expect that blood, if it stagnates for a while, will coagulate, and one wouldn’t want to push the blood clot back into the patient?
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior Consultant in Microbiology
Head of Service, 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 Sonja
I can’t say that I am an expert in this area, but in our PICC policy it states this:
If the PICC has not been accessed for 7 days access the PICC with an empty 10ml syringe. Remove 5mls of blood and discard. Then flush with Normal saline 10mls.
Not sure exactly why that is in there, as our PICC policy is based on The Queensland Health PICC guidelines (https://www.health.qld.gov.au/__data/assets/pdf_file/0028/444493/icare-pcvc-guideline.pdf) and I cannot see this statement in there.
Not sure if this helps or not!
Cheers
MichaelMichael Wishart, CICP-E
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0] [cid:image002.png@01D42997.357FB770]
P Please consider the environment before printing this emailHello,
We are reviewing our central line management policies and we trying to find evidence related to the routine practice for aspiration of blood prior to accessing the central line (especially PICC).
Our ICU team states that this is routinely performed within oncology groups.I would be grateful for some specialist information.
Kind Regards
SonjaSonja Wegert | Infection Control Practitioner (ICP)
Infection Prevention and Control Unit | Central Australia Health Service
Northern Territory Government
Alice Springs Hospital, Gap Rd, Alice Springs
GPO Box 2234, Suburb, NT Postcode
p … 08 89517977
e … sonja.wegert@nt.gov.au http://www.nt.gov.au/health______________________________________________________________________
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[cid:imaged6dc6e.GIF@6460fad3.468f2d3b]shstagl1
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Dear Irene,
It is not necessarily the wrong way round. It looks to me as if there are simply different schools of thought. The ‘Vienna School’ is what I have ‘grown up with’ and what seems logical to me. Mind you, I have forgotten to mention that when hands are heavily soiled, it is taught to wipe off the soiling with a dry paper towel first, until very little residue remains (and disposing the paper towel in the infectious waste), to minimise the organic burden as much as possible. And this sequence only works when relatively large portions of alcohol are applied to hands.
Washing first, followed by alcohol, certainly depends on the hands being dried before applying the alcohol.
Mind you, I am NOT openly promoting to use alcohol on soiled hands, because it would clash with the WHO recommendations, and as I said, consistency is an important consideration. I was merely providing a perspective. Hope I have not opened a too big ‘can of worms’ here.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 1387Dear colleagues,
An interesting discussion. In SA we have always taught staff that if their hands are visibly soiled they should wash with soap and water, followed by alcohol-based hand rub. This has always seemed very logical to me, so I was surprised by Matthias’ comment that this may in fact be the wrong way around!
Irene
Irene Wilkinson BSc(Hons) MPH
Manager, Infection Control Service
Communicable Disease Control Branch
System Peformance and Service Delivery
SA Health
Government of South Australiahttp://www.sahealth.sa.gov.au/infectionprevention
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
This e-mail may contain confidential information, which also may be legally privileged. Only the intended recipient(s) may access, use, distribute or copy this e-mail. If this e-mail is received in error, please inform the sender by return e-mail and delete the original. If there are doubts about the validity of this message, please contact the sender by telephone. It is the recipient’s responsibility to check the e-mail and any attached files for viruses.Thanks for the feedback and background information Mathias.
Still leaves us with the question:
* Why in clinical areas of healthcare facilities do we recommend an antiseptic agent (i.e. alcohol-based hand rub) for hand hygiene for “visibly clean hands”, yet for “visibly soiled hands” an antiseptic agent is no necessarily required?
As mentioned I would be interested to know how infection control personnel/teams are overseeing, managing and monitoring this issue to ensure transient microbial flora are being reduced or removed from healthcare worker hands during handwashing (i.e. when hands are visibly soiled/dirty).
Regards
Glenys
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
E: infexion@ozemail.com.auDear Glenys,
You are touching upon two interesting questions:
(1) What is the role of plain versus antiseptic soap handwashing (as an alternative to alcohol-based hand rubs) in healthcare facilities?
(2) What is the best method to clean or disinfect hands when they are visibly soiled?
Re. (1). According to the literature (a bit too complex and convoluted to give references here, but I summarized some of it in a 2009 review for the then upcoming NHMRC guideline), the order of microbial elimination on hands is roughly: plain soap < antiseptic soap << alcohol-based hand rubs. Most antiseptic soaps/detergent are closer to plain soaps in terms of their microbial elimination capacity, meaning they are usually not that great. When I reviewed the literature on plain versus antiseptic soaps, it seemed to me that there was no clear benefit of antiseptic soaps over plain ones in general wards, but there seemed to be potential benefits of antiseptic soaps in critical care areas. Among the antiseptic ingredients in soaps, triclosan (mostly used in antiseptic household soaps) is very minimal in its antimicrobial activity, whereas chlorhexidine (CHX) is somewhat better. However, chlorhexidine is increasingly recognised as an agent of allergies and contact dermatitis, and so one has to weigh the minimal benefit of having an antiseptic ingredient with the potential downsides. We here are phasing out CHX-containing antiseptic soaps in general ward areas and are replacing CHX-containing ABHR with CHX-free ABHR (recent paper on CHX in ABHR: http://www.pubmed.gov/28924473).
Re. (2). When I moved to Australia in 2002, I initially propagated what was taught to me in medical school in the early 1980s, i.e. when hands are visibly soiled, use ABHR first and then wash off the “dead bacterial carcasses” (drastic wording used to teach us medical students so that it would stick) with soap and water in a second step. That was consistent with the “Vienna School” of hand hygiene (around Rotter) from the 1970s. However, in 2002 I quickly gave up on this, because (a) no one believed me, and (b) I realized that this was in contrast with what the then-upcoming CDC and WHO HH guidelines would propagate, and I did not want to be discordant with these, in order to avoid confusion and different teachings.
However, when examining things closely, it becomes clear that the recommendation to only wash hands with soap and water when they are visibly soiled is lacking a clear rationale and also data to support it. In contrast, the Vienna school recommendation makes a lot of sense: (a) it has been shown in earlier experiments in the 1960s and 70s that washing heavily contaminated hands under running water above a sink creates heavily contaminated splashes around the sink in about one metre plus diameter, and (b) alcohol actually retains its antimicrobial killing capacity in the presence of moderate organic soiling, i.e. the notion that alcohol does not work in the presence of soiling is incorrect (e.g. http://www.pubmed.gov/1629595). However, it must be emphasized that for this to work, relatively larger-than-usual quantities of ABHR must be used, meaning that a 1 ml or 2 ml portion of ABHR, as HCWs can often be observed to be using, does not work. Liberal application is the key here.
Please don’t misunderstand me, I am providing this mainly for clarification and background information. I do NOT want to counteract the WHO recommendation. Consistency (see statement above) is also an important consideration.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 1387Dear all,
Hand washing with plain soap versus hand washing with an antiseptic hand hygiene product in acute care facliity clinical areas
I understand some healthcare facilities have either replaced antiseptic hand hygiene products in clinical areas of acute care facilities with plain soap products or have added plain soap products as an option for handwashing (i.e. when hands are visibly soiled/dirty).
Plain soap has minimal antimicrobial activity but after 30 seconds can reduce counts by 1.8-2.8log10, however compliance with a 30sec hand wash is poor.
Several studies of handwashing with plain soap have shown that plain soap failed to remove pathogens from healthcare worker hands.
Standard handwashing with soap and water removes lipids and adhering dirt, soil and various organic substances from the hands and remains a sensible strategy for hand hygiene in non-healthcare settings.
Alcohol-based hand rubs are the most efficacious agents for reducing the number of bacteria on the hands of personnel, however, there will be times when healthcare worker hands are visibly soiled/dirty and they will need to wash their hands rather than use an alcohol-based hand rub.
What is the issues?
My understanding is that in clinical areas staff should use an antiseptic hand hygiene product when they need to wash their hands, not a plain soap products?
Semmelweis demonstrated that hand antisepsis (i.e. the use of chlorinated lime) was what stopped the infections in obstetric clinics not hand washing with soap and water.
He noted that physicians and medical student who went from performing autopsies to the delivery suite had a disagreeable odour on their hands despite hand washing with soap and water before entering the clinic.
Infection control concerns
My concerns include the following:
* In clinical areas of organisations where antiseptic hand hygiene products have been replaced with a plain soap product for hand washing (i.e. when hands are visibly soiled/dirty) transient microbial flora are not being reduced or removed from healthcare worker hands.
* In clinical areas of organisations where plain soap products have been added as an option for hand washing (i.e. when hands are visibly soiled/dirty), transient microbial flora are not being reduced or removed from healthcare worker hands when they are using a plain soap product.
* Hand washing products are generally sourced from one supplier, hence the dispensers (antiseptic & plain soap) are similar/same and usually located adjacent to one another in clinical areas at hand washing facilities/sinks.
o busy staff may not necessarily be aware of the difference in the products
o Staff generally select what they will use based on smell, consistency, feel and colour hence an antiseptic product may not be used at all when hand washing.
Summary
This raises the following question:
* Why in clinical areas of healthcare facilities do we recommend an antiseptic agent (i.e. alcohol-based hand rub) for hand hygiene for “visibly clean hands”, yet for “visibly soiled hands” an antiseptic agent is no necessarily required?
I would be interested to know how infection control personnel/teams are overseeing, managing and monitoring this issue to ensure transient microbial flora are being reduced or removed from healthcare worker hands during handwashing (i.e. when hands are visibly soiled/dirty).
Regards
Glenys
Definition of an Antiseptic agent
* An antimicrobial substance that inactivates microorganisms or inhibits their growth on living tissues.
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
E: infexion@ozemail.com.auMESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
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[cid:image7f3f1a.GIF@efae345d.41acad2b]shstagl1
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
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MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
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Dear Glenys,
You are touching upon two interesting questions:
(1) What is the role of plain versus antiseptic soap handwashing (as an alternative to alcohol-based hand rubs) in healthcare facilities?
(2) What is the best method to clean or disinfect hands when they are visibly soiled?
Re. (1). According to the literature (a bit too complex and convoluted to give references here, but I summarized some of it in a 2009 review for the then upcoming NHMRC guideline), the order of microbial elimination on hands is roughly: plain soap < antiseptic soap << alcohol-based hand rubs. Most antiseptic soaps/detergent are closer to plain soaps in terms of their microbial elimination capacity, meaning they are usually not that great. When I reviewed the literature on plain versus antiseptic soaps, it seemed to me that there was no clear benefit of antiseptic soaps over plain ones in general wards, but there seemed to be potential benefits of antiseptic soaps in critical care areas. Among the antiseptic ingredients in soaps, triclosan (mostly used in antiseptic household soaps) is very minimal in its antimicrobial activity, whereas chlorhexidine (CHX) is somewhat better. However, chlorhexidine is increasingly recognised as an agent of allergies and contact dermatitis, and so one has to weigh the minimal benefit of having an antiseptic ingredient with the potential downsides. We here are phasing out CHX-containing antiseptic soaps in general ward areas and are replacing CHX-containing ABHR with CHX-free ABHR (recent paper on CHX in ABHR: http://www.pubmed.gov/28924473).
Re. (2). When I moved to Australia in 2002, I initially propagated what was taught to me in medical school in the early 1980s, i.e. when hands are visibly soiled, use ABHR first and then wash off the "dead bacterial carcasses" (drastic wording used to teach us medical students so that it would stick) with soap and water in a second step. That was consistent with the "Vienna School" of hand hygiene (around Rotter) from the 1970s. However, in 2002 I quickly gave up on this, because (a) no one believed me, and (b) I realized that this was in contrast with what the then-upcoming CDC and WHO HH guidelines would propagate, and I did not want to be discordant with these, in order to avoid confusion and different teachings.
However, when examining things closely, it becomes clear that the recommendation to only wash hands with soap and water when they are visibly soiled is lacking a clear rationale and also data to support it. In contrast, the Vienna school recommendation makes a lot of sense: (a) it has been shown in earlier experiments in the 1960s and 70s that washing heavily contaminated hands under running water above a sink creates heavily contaminated splashes around the sink in about one metre plus diameter, and (b) alcohol actually retains its antimicrobial killing capacity in the presence of moderate organic soiling, i.e. the notion that alcohol does not work in the presence of soiling is incorrect (e.g. http://www.pubmed.gov/1629595). However, it must be emphasized that for this to work, relatively larger-than-usual quantities of ABHR must be used, meaning that a 1 ml or 2 ml portion of ABHR, as HCWs can often be observed to be using, does not work. Liberal application is the key here.
Please don't misunderstand me, I am providing this mainly for clarification and background information. I do NOT want to counteract the WHO recommendation. Consistency (see statement above) is also an important consideration.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 1387Dear all,
Hand washing with plain soap versus hand washing with an antiseptic hand hygiene product in acute care facliity clinical areas
I understand some healthcare facilities have either replaced antiseptic hand hygiene products in clinical areas of acute care facilities with plain soap products or have added plain soap products as an option for handwashing (i.e. when hands are visibly soiled/dirty).
Plain soap has minimal antimicrobial activity but after 30 seconds can reduce counts by 1.8-2.8log10, however compliance with a 30sec hand wash is poor.
Several studies of handwashing with plain soap have shown that plain soap failed to remove pathogens from healthcare worker hands.
Standard handwashing with soap and water removes lipids and adhering dirt, soil and various organic substances from the hands and remains a sensible strategy for hand hygiene in non-healthcare settings.
Alcohol-based hand rubs are the most efficacious agents for reducing the number of bacteria on the hands of personnel, however, there will be times when healthcare worker hands are visibly soiled/dirty and they will need to wash their hands rather than use an alcohol-based hand rub.
What is the issues?
My understanding is that in clinical areas staff should use an antiseptic hand hygiene product when they need to wash their hands, not a plain soap products?
Semmelweis demonstrated that hand antisepsis (i.e. the use of chlorinated lime) was what stopped the infections in obstetric clinics not hand washing with soap and water.
He noted that physicians and medical student who went from performing autopsies to the delivery suite had a disagreeable odour on their hands despite hand washing with soap and water before entering the clinic.
Infection control concerns
My concerns include the following:
* In clinical areas of organisations where antiseptic hand hygiene products have been replaced with a plain soap product for hand washing (i.e. when hands are visibly soiled/dirty) transient microbial flora are not being reduced or removed from healthcare worker hands.
* In clinical areas of organisations where plain soap products have been added as an option for hand washing (i.e. when hands are visibly soiled/dirty), transient microbial flora are not being reduced or removed from healthcare worker hands when they are using a plain soap product.
* Hand washing products are generally sourced from one supplier, hence the dispensers (antiseptic & plain soap) are similar/same and usually located adjacent to one another in clinical areas at hand washing facilities/sinks.
o busy staff may not necessarily be aware of the difference in the products
o Staff generally select what they will use based on smell, consistency, feel and colour hence an antiseptic product may not be used at all when hand washing.
Summary
This raises the following question:
* Why in clinical areas of healthcare facilities do we recommend an antiseptic agent (i.e. alcohol-based hand rub) for hand hygiene for "visibly clean hands", yet for "visibly soiled hands" an antiseptic agent is no necessarily required?
I would be interested to know how infection control personnel/teams are overseeing, managing and monitoring this issue to ensure transient microbial flora are being reduced or removed from healthcare worker hands during handwashing (i.e. when hands are visibly soiled/dirty).
Regards
Glenys
Definition of an Antiseptic agent
* An antimicrobial substance that inactivates microorganisms or inhibits their growth on living tissues.
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
E: infexion@ozemail.com.auMESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
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 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.
You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au
[cid:image7f3f1a.GIF@efae345d.41acad2b]shstagl1
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
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Hi Michael,
Exactly, if it causes a temporary 10-h (or so) drop in S. aureus numbers in the nose in the perioperative phase, and the nose is a seeding source for SSIs, then it would be useful for the purpose of SSI prevention. But let us see if this is confirmed/supported in further investigations.
In the Mullen et al. paper that Glenys sent, I do notice a 81% reduction in SSI incidence allegedly due mostly to the nasal treatment protocol, which is a big number, and this just seems a bit on the high side to be caused by nasal decolonisation alone.
A remaining concern clearly is the claim of sustained decolonization (see below). This is clearly an exaggerated claim, given that only 10 hours have been examined. Now, in my opinion, exaggerated claims of any kind, particularly associated with the impetus to sell/market products, should raise alarm bells in any of us from the medical/scientific community. Such matters should not be downplayed or taken as trivial offences.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 1387From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Monday, 23 October, 2017 1:40 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Nasal DecolonisationHi Matthias
In regard to an attempt to minimise self-inoculation with Staph aureus in the peri and early post-operative phase, would not 10 hours be a reasonable target?
I dont disagree with your terminology assessment, but, terminology aside, if we are attempting to prevent early-onset SSI with Staph aureus, would not this claim be reasonable in that context?
One of the posters cited on that website also suggested that peri-operative staff use of this product (voluntary, of course!) also could result in lower incidence of Staph aureus SSI. If there any biological plausibility in that concept?
Just wondering if this product does have a use, albeit not as a decoloniser.
Cheers
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0]
P Please consider the environment before printing this emailFrom: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Matthias Maiwald (SingHealth – PATH)
Sent: Monday, 23 October 2017 3:11 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Nasal DecolonisationHi Cath, hi Michael,
Thank you so much!
It was in fact exactly the Steed et al. 2014 paper and also the Infection Control Today White Paper that I had seen earlier (a while ago see my comment) and that I found unconvincing.
Similarly, what is written on the Nozin webpage is unconvincing.
Most of us, when we talk about, or read about decolonisation, we understand or imply that the effect is sustained for some time, e.g. weeks or months, or ideally permanently in the absence of external re-exposure. If I am not wrong, I think the historical origins of the modern S. aureus or MRSA decolonisation lie in the 1960s and 1970s in efforts to (a) reduce S. aureus infections affecting neonates in nurseries, and (b) to end the cycle of endogenous reinfection that is driving furunculosis.
The Steed paper is astonishing in its claims. It tests a reduction of S. aureus nasal bacterial counts up to 10 hours after application, but not any follow-up beyond these 10 hours. That is not what most of us in the profession would understand as decolonisation.
Neither the ICT White Paper nor the Website nor the Steed article seems to provide any data that go beyond these 10 hours, and yet, claims are made (e.g. page 5, White Paper) of sustained decolonization. The website describes it as long lasting and unlike the fleeting effect of hand sanitizers. Again, there is nothing to support this claim.
Combined with the problems of applying alcohol to mucous membranes (see my earlier e-mail), I would say that biological plausibility of how this agent is supposed to provide sustained decolonisation in the sense of what we usually understand as decolonisation is not established.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 1387From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Monday, 23 October, 2017 12:24 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Nasal DecolonisationHi Cath
This product is not available in Australia, either. I would be surprised if there are any centres in Australia using formulations of ethanol or povidone iodine for nasal decolonisation currently, but would love to hear from anyone that can source appropriate nasal decolonisation products of this type in Australia.
Cheers
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0]
P Please consider the environment before printing this emailFrom: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Cathryn Murphy
Sent: Monday, 23 October 2017 1:59 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Nasal DecolonisationHi Matthias
I was loathe to use trade names on this site. However, I will to respond. There is a growing body of US evidence around a product called Nozin. More details are at nozinpro.com
When I was at APIC in June 2017 there was a lot of interest in the product in healthcare and other settings.
Thanks for your view on the existing literature Matthias, I always enjoy your responses.
Yours sincerely
Cath
Cathryn Murphy RN B. Photog MPH PhD CIC
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
QLD, AustraliaE: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.auFrom: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Matthias Maiwald (SingHealth – PATH)
Sent: Monday, 23 October 2017 12:50
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Nasal DecolonisationHi Cath, hi Michael,
I am curious about the remark below concerning ethanol for nasal decolonisation. The last time I looked (which is a while ago), the results achieved were not convincing.
From a physiological and/or conceptual point of view, while alcohol is a fantastic antiseptic/disinfectant for superficial skin, it is usually deemed unsuitable for mucous membranes (which the inside of the nose consists of), due to its more aggressive nature than aqueous antiseptics.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 1387From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Monday, 23 October, 2017 5:57 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Nasal DecolonisationHi Cath
Just a comment: the povidone iodine nasal cream commonly used pre-op in the US is not yet available in Australia, as far as I am aware. I wish it was, as getting traditional pre-admission nasal decolonisation (5 days of mupuricin or the like) done in a private hospital is not easy!
Cheers
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0]
P Please consider the environment before printing this emailFrom: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Cathryn Murphy
Sent: Monday, 23 October 2017 7:26 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Nasal DecolonisationDear All
I am interested in learning more about the adoption and use of nasal decolonisation in Australia and New Zealand. In the US this appears to be being used sometimes in place of Contact Precautions. There is a download from IC Today to that effect plus some recent papers. Happy to share if anyone wants it, please email me. So would any of you be able to comment on these questions and if and how you use nasal decolonisation in your organisations please. Thanks in advance.
a) other than ethanol and povidone iodine (e.g.: 3M and others) what else is used for nasal decolonisation right before surgery?
b) which are the most commonly used products?
c) what are the surgery profiles where these are used? (e.g.: ortho, open heart, hernia repair etc)
d) what is the adoption rate for using something like this? Is it universal or a % of surgeons opt to do it?Yours sincerely
Cath
Cathryn Murphy RN B. Photog MPH PhD CIC
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
QLD, AustraliaE: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.au______________________________________________________________________
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[cid:imagea25a23.GIF@7d3256b1.46ba7bdd]shstagl1
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The information contained in this e-mail and the attachments (if any) may be privileged and confidential and is intended solely for the named addressee. If you are not the intended recipient, please do not print, retain copy, disseminate, distribute, or use this e-mail or any part thereof. Please notify the sender immediately by replying to this e-mail and delete all copies of this e-mail and the attachments.MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
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Hi Cath, hi Michael,
Thank you so much!
It was in fact exactly the Steed et al. 2014 paper and also the Infection Control Today White Paper that I had seen earlier (a while ago see my comment) and that I found unconvincing.
Similarly, what is written on the Nozin webpage is unconvincing.
Most of us, when we talk about, or read about decolonisation, we understand or imply that the effect is sustained for some time, e.g. weeks or months, or ideally permanently in the absence of external re-exposure. If I am not wrong, I think the historical origins of the modern S. aureus or MRSA decolonisation lie in the 1960s and 1970s in efforts to (a) reduce S. aureus infections affecting neonates in nurseries, and (b) to end the cycle of endogenous reinfection that is driving furunculosis.
The Steed paper is astonishing in its claims. It tests a reduction of S. aureus nasal bacterial counts up to 10 hours after application, but not any follow-up beyond these 10 hours. That is not what most of us in the profession would understand as decolonisation.
Neither the ICT White Paper nor the Website nor the Steed article seems to provide any data that go beyond these 10 hours, and yet, claims are made (e.g. page 5, White Paper) of sustained decolonization. The website describes it as long lasting and unlike the fleeting effect of hand sanitizers. Again, there is nothing to support this claim.
Combined with the problems of applying alcohol to mucous membranes (see my earlier e-mail), I would say that biological plausibility of how this agent is supposed to provide sustained decolonisation in the sense of what we usually understand as decolonisation is not established.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 1387From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Monday, 23 October, 2017 12:24 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Nasal DecolonisationHi Cath
This product is not available in Australia, either. I would be surprised if there are any centres in Australia using formulations of ethanol or povidone iodine for nasal decolonisation currently, but would love to hear from anyone that can source appropriate nasal decolonisation products of this type in Australia.
Cheers
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0]
P Please consider the environment before printing this emailFrom: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Cathryn Murphy
Sent: Monday, 23 October 2017 1:59 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Nasal DecolonisationHi Matthias
I was loathe to use trade names on this site. However, I will to respond. There is a growing body of US evidence around a product called Nozin. More details are at nozinpro.com
When I was at APIC in June 2017 there was a lot of interest in the product in healthcare and other settings.
Thanks for your view on the existing literature Matthias, I always enjoy your responses.
Yours sincerely
Cath
Cathryn Murphy RN B. Photog MPH PhD CIC
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
QLD, AustraliaE: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.auFrom: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Matthias Maiwald (SingHealth – PATH)
Sent: Monday, 23 October 2017 12:50
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Nasal DecolonisationHi Cath, hi Michael,
I am curious about the remark below concerning ethanol for nasal decolonisation. The last time I looked (which is a while ago), the results achieved were not convincing.
From a physiological and/or conceptual point of view, while alcohol is a fantastic antiseptic/disinfectant for superficial skin, it is usually deemed unsuitable for mucous membranes (which the inside of the nose consists of), due to its more aggressive nature than aqueous antiseptics.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 1387From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Monday, 23 October, 2017 5:57 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Nasal DecolonisationHi Cath
Just a comment: the povidone iodine nasal cream commonly used pre-op in the US is not yet available in Australia, as far as I am aware. I wish it was, as getting traditional pre-admission nasal decolonisation (5 days of mupuricin or the like) done in a private hospital is not easy!
Cheers
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0]
P Please consider the environment before printing this emailFrom: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Cathryn Murphy
Sent: Monday, 23 October 2017 7:26 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Nasal DecolonisationDear All
I am interested in learning more about the adoption and use of nasal decolonisation in Australia and New Zealand. In the US this appears to be being used sometimes in place of Contact Precautions. There is a download from IC Today to that effect plus some recent papers. Happy to share if anyone wants it, please email me. So would any of you be able to comment on these questions and if and how you use nasal decolonisation in your organisations please. Thanks in advance.
a) other than ethanol and povidone iodine (e.g.: 3M and others) what else is used for nasal decolonisation right before surgery?
b) which are the most commonly used products?
c) what are the surgery profiles where these are used? (e.g.: ortho, open heart, hernia repair etc)
d) what is the adoption rate for using something like this? Is it universal or a % of surgeons opt to do it?Yours sincerely
Cath
Cathryn Murphy RN B. Photog MPH PhD CIC
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
QLD, AustraliaE: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.au______________________________________________________________________
This email and any attachments to it (the “Email”) 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. If you are not the intended recipient of the Email, please notify the sender immediately by return email, delete the Email, and do not copy, print, retransmit, store or act in reliance on the Email. St Vincent’s Health Australia (“SVHA”) does not guarantee that the Email is free from errors, viruses or interference. Emails to and from SVHA or its related entities may be scanned and filtered in locations outside Australia.
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
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This email and any attachments to it (the “Email”) 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. If you are not the intended recipient of the Email, please notify the sender immediately by return email, delete the Email, and do not copy, print, retransmit, store or act in reliance on the Email. St Vincent’s Health Australia (“SVHA”) does not guarantee that the Email is free from errors, viruses or interference. Emails to and from SVHA or its related entities may be scanned and filtered in locations outside Australia.
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
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[cid:imagea25a23.GIF@7d3256b1.46ba7bdd]shstagl1
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The information contained in this e-mail and the attachments (if any) may be privileged and confidential and is intended solely for the named addressee. If you are not the intended recipient, please do not print, retain copy, disseminate, distribute, or use this e-mail or any part thereof. Please notify the sender immediately by replying to this e-mail and delete all copies of this e-mail and the attachments.MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
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This email and any attachments to it (the “Email”) 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. If you are not the intended recipient of the Email, please notify the sender immediately by return email, delete the Email, and do not copy, print, retransmit, store or act in reliance on the Email. St Vincent’s Health Australia (“SVHA”) does not guarantee that the Email is free from errors, viruses or interference. Emails to and from SVHA or its related entities may be scanned and filtered in locations outside Australia.
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Hi Cath, hi Michael,
I am curious about the remark below concerning ethanol for nasal decolonisation. The last time I looked (which is a while ago), the results achieved were not convincing.
From a physiological and/or conceptual point of view, while alcohol is a fantastic antiseptic/disinfectant for superficial skin, it is usually deemed unsuitable for mucous membranes (which the inside of the nose consists of), due to its more aggressive nature than aqueous antiseptics.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 Cath
Just a comment: the povidone iodine nasal cream commonly used pre-op in the US is not yet available in Australia, as far as I am aware. I wish it was, as getting traditional pre-admission nasal decolonisation (5 days of mupuricin or the like) done in a private hospital is not easy!
Cheers
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0]
P Please consider the environment before printing this emailDear All
I am interested in learning more about the adoption and use of nasal decolonisation in Australia and New Zealand. In the US this appears to be being used sometimes in place of Contact Precautions. There is a download from IC Today to that effect plus some recent papers. Happy to share if anyone wants it, please email me. So would any of you be able to comment on these questions and if and how you use nasal decolonisation in your organisations please. Thanks in advance.
a) other than ethanol and povidone iodine (e.g.: 3M and others) what else is used for nasal decolonisation right before surgery?
b) which are the most commonly used products?
c) what are the surgery profiles where these are used? (e.g.: ortho, open heart, hernia repair etc)
d) what is the adoption rate for using something like this? Is it universal or a % of surgeons opt to do it?Yours sincerely
Cath
Cathryn Murphy RN B. Photog MPH PhD CIC
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
QLD, AustraliaE: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.au______________________________________________________________________
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Dear Colleagues,
The event(s) that led to cautionary measures concerning skin antisepsis for neuraxial blockade were the so-called “epidural tragedy” or “epidural tragedies” after applying chlorhexidine-alcohol (CHX-ALC) antiseptics. There were several cases of severe persistent neurological damage following the application of CHX-ALC skin antiseptics.
I have commented on the Infexion Connexion List before about this, so I will keep it short and refer to my previous post.
For one (or a few, can’t remember how many) of these cases it was reconstructed that the CHX-ALC was confused with the local anaesthetic because it was put in a “galley pot” and accidentally injected. In such an instance, there is a clear path set for damage. Both CHX and alcohol, when injected into live tissue (not talking about superficial keratinized skin), are very destructive substances. CHX is known to be neurotoxic, and alcohol will coagulate proteins and kill cells.
For several cases, it was apparently never fully clarified what caused the tragedy, and these cases remain a matter of speculation. It was speculated, for example, that the CHX-ALC mix could have been drawn in by capillary action along the needle track. But how the capillary action could draw such a substantial amount is unclear, and it is biologically plausible that this would not have happened if the antiseptic had dried before needle insertion, as it is supposed to do.
The CHX-ALC swabsticks certainly eliminate the problem of accidental injection, because they cannot be confused with the anaesthetic.
The replacement of 2% CHX plus alcohol with 0.5% CHX plus alcohol as suggested in the ANZCA (which I have not yet seen) and UK guidelines is based on pure assumption, and this may or may not eliminate or alleviate the problem, depending on how the CHX-ALC makes its way into the tissues.
It also needs to be pointed out again that contrary to what the UK guideline says, there is no documented evidence that CHX-ALC is superior to povidone-iodine combined with alcohol for this particular application. The only clinical application for which there is clear documented evidence of superiority of CHX-ALC over other antiseptics is vascular catheters. But this is a different application. The cited evidence in the UK guideline is either based on unequal comparisons (e.g. CHX-ALC versus povidone-iodine without ALC), or based on microbiological tests where there is insufficient documentation about whether neutralisers have been used (note, neutralisers are a prerequisite when assessing microbial counts after antisepsis).
So, for all intents and purposes, povidone-iodine-alcohol remains a suitable (and distinctly coloured) alternative.
There is also an interesting little paper here:
Sviggum HP et al. Neurologic complications after chlorhexidine antisepsis for spinal anesthesia. Reg Anesth Pain Med. 2012 Mar-Apr;37(2):139-44.
https://www.ncbi.nlm.nih.gov/pubmed/22286519The authors examined 12,465 spinal anaesthesias at Mayo Clinic and found no specific complications associated with CHX-containing skin antiseptics, i.e. the complication rate was small and within expected ranges. This is reassuring.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 Verily,
The 2015 Australian ANZCA guideline is similar to the 2014 UK safety guideline which is specific to central neuraxial blockade(CNB) and states the following:
* “Given the lack of convincing evidence of the antimicrobial superiority of a 2% solution of chlorhexidine in alcohol over a 0.5% solution, but the presence of clear evidence of the neurotoxicity of chlorhexidine, the Working Party has concluded that the use of a 0.5% solution should be preferred over a 2% solution for skin antisepsis before CNB”.
The UK document also includes and extensive review of chlorhexidine, alcohol and neurotoxicity and methods of application.
In terms of the type of applicator you mention the document states the following:
* “The applicators are manufactured with a reservoir containing 3 ml or 10.5 ml of antiseptic, and the solution may be dyed to allow identification of the area of prepared skin. Because the antiseptic solution is contained within the hollow of the handle, crossover errors are impossible and fluid spillage should be minimised. However, it has been observed that leakage of antiseptic solution over the operator’s gloves may occur via a hole at the end of the handle when the device is held upside down (the hole below the level of the antiseptic reservoir) to clean a patient’s back [19]”.
Hence it seems there are some risks with these types of applicators not just that the concentration of chlorhexidine is higher than recommended in the device you are currently utilising.
See attached and link below:
* Association of Anaesthetists of Great Britain & Ireland. Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia 2014, 69, 1279-1286
https://www.aagbi.org/sites/default/files/skin%20antisepsis%20for%20central%20neuraxial%20blockade_0.pdfregards
Glenys
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
E: infexion@ozemail.com.auHi Michael
Kindly forward this email to members for advise and comment, much appreciated.
Kind Regards
Verily Thomas
Clinical Nurse Consultant | Infection Prevention and Control
SWSLHD-Bankstown/Lidcombe Hospital
Eldridge Road, Bansktown.NSW 2200
Tel 02 97228000 pager 28230
Tel 02 9722 8633 | Fax 02 9722 7822 | verily.thomas@sswahs.nsw.gov.au
http://www.health.nsw.gov.au[Description: cid:image002.jpg@01CE8EA5.483A6E60]
LET’S KEEP OUR HOSPITAL ENVIRONMENT CLEAN
HAND HYGIENE SAVES LIVESHi Verily,
The chlorhexidine swabs sticks that were trialled for neuraxial blocks in perioperative services were 2% chlorhexidine in 70% Alcohol, the ANZCA guidelines on infection control in Anaesthesia PS28 state that 0.5% chlorhexidine in 70% Alcohol is to be used for neuraxial blocks, due to the neurotoxicity of chlorhexidine. We need to assess if the risk of using 2% chlorhexidine swab sticks mitigates the risk of using 0.5% Chlorhexidine liquid and gauze swabs for skin prep for neuraxial blocks. The swab sticks prevent any risk of chlorhexidine being injected into the epidural or subarachnoid space and splashing into other solutions on the sterile field. We also need to assess if the use of 2% has any benefit over 0.5% in terms of infection control and prevention.
Kind Regards,
Bridie
Bridie Treloar
Clinical Nurse Consultant Perioperative Services
Bankstown-Lidcombe Hospital
Monday Week 1 and 3, Tuesdays, Wednesdays_____________________________________________________________________
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________________________________
The information contained in this e-mail and the attachments (if any) may be privileged and confidential and is intended solely for the named addressee. If you are not the intended recipient, please do not print, retain copy, disseminate, distribute, or use this e-mail or any part thereof. Please notify the sender immediately by replying to this e-mail and delete all copies of this e-mail and the attachments.MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
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Dear Colleagues,
Indeed, some of these issues keep re-surfacing again and again. The problem here, as far as I can see, is an overly narrow definition of what constitutes evidence in many circles (e.g. the narrow focus on RCTs and systematic reviews as accepted evidence) and a common inability to analyze and view things from a rational, scientific perspective.
We need to accept the fact that there are many things and practices that (a) have been established historically, (b) have a reasonable scientific (and in this case microbiological) rationale behind it, and (c) have little or no evidence (in the narrow definition as stated above) supporting it, simply because it may be difficult to gather that evidence and/or medicine has moved beyond the point at which it is reasonable to focus evidence-gathering efforts at the question.
Some of the historical aspects are briefly but nicely explained in one of my favourite book chapters in the area:
Grschel DHM, Pruett TL. Surgical antisepsis. In: Block SS, ed. Disinfection, sterilisation and preservation. 4 ed. London: Lea & Febiger; 1991: 642-54.The authors basically say that many of these things have been established in the late 1800s and early 1900s as part of the post-Listerian system of aseptic surgery, and the practices are often based on what makes scientific and/or microbiologic sense, but are often not proven by evidence in the narrow definition above.
Another good example is surgical hand antisepsis (surgical scrubbing), which has never been tested in a controlled study.
Reasonable indirect evidence is coming from the investigations of Bischoff and/or Sherertz from the USA who show that Staph. aureus is readily dispersed in the air from carriers who have mild viral respiratory tract infections. Such dispersal seems patchy and originates from some people, but not from others.
Finally, the question again highlights the problem of onus of evidence-gathering. It happens again and again that people question the evidence for measures that are inconvenient to them, in the sense of show me the evidence why we must do this. These questions are often very cynical (one may also say frivolous) because these people know very well (even before asking) that the inconvenient practice (to them) is not supported by RCTs or SRs, and they usually know that they will send infection control professionals and microbiologists scrambling and spending their work time and efforts to find evidence.
I think we need to reverse the onus for evidence in such cases. If an established measure, (a) when present, has the potential to enhance patient safety, and (b) when absent, has the potential to lead to lesser patient safety, then it becomes an ethical mandate to reverse this onus and say you show me the evidence that tells us that the practice can be safely omitted without leading to adverse outcomes. (And that evidence should withstand scientific scrutiny).
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 1387From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Glenys Harrington
Sent: Thursday, 10 August, 2017 9:55 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Wearing of Surgical masks in the Operating roomHi all,
A picture often helps to tell a story.
J Granville-Chapman and R L Dunne review the etiquette of sneezing in surgical masks. BMJ | 22-29 December 2007 | Volume 335
This surgical team looked at sneezing etiquette and the efficacy of masks in the operating theatre. The images on page 1293 of the attached article (and at the link below) will help demonstrate how a mask worn during an operating procedure can help protect the patient. i.e. Surgical masks are effective at containing a lot of droplets.
http://www.bmj.com/content/335/7633/1293
Regards
Glenys
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
E: infexion@ozemail.com.auFrom: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Lesley Alway
Sent: Thursday, 10 August 2017 11:28 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: [ACIPC_Infexion_Connexion] Wearing of Surgical masks in the Operating roomDear Cathryn and Michael, agree wholeheartedly have had to fit this fight for to many years, found it helpful ( and typical not to see the value to the patient) to focus on the wearer not the patient safety. I use the example would they do procedures without glove – of course not!!!!! Same applies to masks and eye protection.
Lesley Alway
Director
Strategic Health Resources.
Post Graduate Education Services.
0408 324 727
03 94390534Director Australian Health Design Council
[Logowithtxt_AHDC]From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Cathryn Murphy
Sent: Wednesday, 9 August 2017 4:17 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Wearing of Surgical masks in the Operating roomDear All
I agree with Michaels rationale and agree there are cases of occupational transmission of serious bloodborne illness from mucousal splashes reported in the literature. So from an OCH&S obligation the HCW should comply.
This is one of those frustrating issues that come up from time to time and they drive me crazy. They are like the ? of eating in theatres/ anaesthetists wearing masks/ OT staff changing attire etc. Why IC professionals continually have to fight these causes is exhausting and sad but back to the science.whilst Michael provides a meta-analysis it is a few years old and it is based on very few reports probably because the issue hasnt been well studied not that the issue isnt important.
I would also draw attention to the increasing use of air-purifying systems in the US and other countries. Some of the data related to validation studies are very compelling and show how CFU counts of bacteria rise (sometimes to extremes) when speaking (behind masks) happens. Obviously showing causation between high counts/ speaking and actual wound infection is difficult given to the many confounders (# of people in the room/ traffic/ movement/ +/- measures like laminar flow/ skin prep etc etc) but surely it just makes sense for people in the OR to wear masks for everyones sake.
Off track..but I recall being asked this exact question by a group of anaesthetists at a scientific meeting in the late 1990s and after responding seriously and scientifically I then added mask wearing depends on how good looking you are and in your case I wouldas you can imagine it went down like a lead balloon but it silenced the question asker.
I seriously wish you good luck in fighting these battles and I wish the people we served relaised the very serious and very real issues we fight daily and perhaps then they would stop creating distractions like this.
With respect
CathCathryn Murphy RN B. Photog MPH PhD CIC
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
QLD, AustraliaE: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.auFrom: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Wednesday, 9 August 2017 15:29
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Wearing of Surgical masks in the Operating roomHi Fran
This topic has received a fair bit of attention over the years, and yes, your doctors are correct: there is no compelling evidence to suggest surgical face masks reduce surgical site infection rates. See this meta-analysis conclusion: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0064347/
Having said that, my own rationale for staff wearing surgical face masks during procedures is for protection of their mucous membranes from splashing of potentially infectious material. In my view, the strike resistance for surgical face masks is of high importance, and has little to do with preventing contamination of the surgical wound.
To suggest staff in a room during a procedure dont wear masks would in my opinion be asking for trouble. From a occupational health and safety perspective, I would always recommend everyone in a room during a surgical procedure should be wearing a surgical face mask, and eye protection as well.
In my view, anyway.
Cheers
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0]
P Please consider the environment before printing this emailFrom: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Franciska Ferreira
Sent: Wednesday, 9 August 2017 3:03 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Wearing of Surgical masks in the Operating roomAfternoon All,
I require some assistance please.
Weve had interesting discussions amongst some of Visiting Medical Officers regarding the effectiveness of wearing surgical masks in the operating room to decrease the likelihood of postoperative surgical site infections. The practice of wearing masks is believed to minimize the transmission of oro-and nasopharyngeal bacteria from Theatre Operating staff to patients wounds. However a couple of individuals believe there is not enough evidence to support this and therefore dont think it is necessary to wear surgical masks while operating.
Im aware of the requirements as per the ACORN Standards and the National Infection Control Guidelines (2016 Draft version), which our Staff complies by, however I cannot find current best practice or evidence to provide to those two individuals.
Any suggestions please? And if youre willing to share, what is the Policy in regards this matter at your facilities?
Kind Regards
Franciska Ferreira
Infection Prevention & Control/Wound Management Consultant
Burnside War Memorial Hospital
120 Kensington Road, Toorak Gardens, SA 5056
t: 08 8202 7231 f: 08 8407 8573 e: fferreira@burnsidehospital.asn.au
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Dear Tim,
What does INS stand for, and what would be the bibliographical citation/reference for the text passage you cite?
If I read the text passage correctly, the notion is routinely, i.e. do not routinely culture. But it would seem indicated in cases of clinically suspected CR-BSI, in conjunction with blood cultures, and that seems consistent with what Claire writes and with the Mermel 2009 clinical definitions (as opposed to surveillance definitions) of CR-BSI that Claire attached.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 1387From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Tim Spencer
Sent: Thursday, 16 March, 2017 10:23 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: CVC Tip cultureHi Cate,
The current INS Standards of Practice (2016) recommendation not to culture the catheter tip. I have cut & pasted from the standards.
SHEA and APIC dont really address this issue clearly (or at all).
Other standards (IVNNZ, RNAO and RCN) follow the same recommendations as the INS SOP.Practice Criteria
A. Assess for signs and symptoms of a VAD-related infection which may include, but is not limited to, erythema; edema; any pain or tenderness or drain- age; fluid in the subcutaneous pocket of a totally implanted intravascular device or subcutaneous tunnel for any tunneled catheter; induration at the exit site or over the pocket; spontaneous rupture and drainage; necrosis of the overlying skin at the VAD insertion site; and/or body temperature elevation. Immediately notify the licensed independent practitioner (LIP) when signs and symptoms of a VAD- related infection are present, and implement planned interventions.1 (IV)
B. Consider site selection for VAD placement as a strategy to prevent infection. To minimize the risk of catheter-related infection with a nontunneled central vascular access device (CVAD), the subclavian vein is recommended in adult patients, rather than the jugular or femoral (refer to Standard 27, Site Selection).
C. Remove a peripheral venous catheter if the patient develops symptoms of infection (eg, erythema extending at least 1 cm from the insertion site, induration, exudate, fever with no other obvious source of infection) or the patient reports any pain or tenderness associated with the catheter.1-3 (IV)
D. Do not remove a functioning CVAD based solely on temperature elevation and the absence of confirmatory evidence of catheter-related infection. Use clinical judgment regarding the appropriateness of removing the catheter if an infection is evidenced elsewhere or if a noninfectious cause of fever is sus- pected.2,4 (IV)
E. Collaborate with the LIP and patient to collectively determine if the CVAD can be salvaged. For hemodynamically stable outpatients with catheter-related bloodstream infection (CR-BSI), catheter salvage may be a safe and appropriate strategy. Removal of the CVAD is required if there is clinical deterioration or persisting or relapsing bacteremia. The insertion of a new CVAD at a new site should be a collaborative decision based on the specific risks and benefits for each patient. Factors to consider in the decision to salvage a catheter include:
* The type of VAD (eg, percutaneous versus surgically inserted long-term catheter).
* Difficulty with inserting a new CVAD.
* Presence of bleeding disorders.
* The infecting organism(s) as confirmed by paired
* blood cultures.
* The presence of other complicating conditions
* including, but not limited to, severe sepsis, suppurative thrombophlebitis, endocarditis, or the presence of vascular or other hardware (eg, a pacemaker).1,5-8 (IV)F. Anticipate the removal of a short-term CVAD (in situ less than or equal to 14 days) in a pediatric patient with an uncomplicated CR-BSI and treat with systemic antibiotics for at least 7 to 14 days based on the pathogen. Infections with Staphylococcus aureus, gram-negative bacilli, or Candida require immediate removal of the infected CVAD and a defined course of systemic antibiotic therapy, except in rare circumstances when no alter- native venous access is available. Patients with a long-term CVAD and an uncomplicated CR-BSI because of coagulase-negative Staphylococcus or Enterococcus may retain the CVAD and complete a course of systemic antibiotics with the use of antibiotic lock therapy. Closely monitor and clinically evaluate pediatric patients treated without catheter removal, including additional blood cultures and the use of antibiotic lock therapy with systemic therapy for catheter salvage.8 (V)
G. Consider the use a prophylactic antimicrobial lock solution in a patient with a long-term CVAD who has a history of multiple CR-BSIs despite optimal maximal adherence to aseptic technique. Aspirate all antimicrobial locking solutions from the CVAD lumen at the end of the locking period (refer to Standard 40, Flushing and Locking).
H. Remove a CVAD from a patient with CR-BSI associated with any of the following conditions: severe sepsis; suppurative thrombophlebitis; endocarditis; bloodstream infection that continues despite greater than 72 hours of antimicrobial therapy to which the infecting microbes are susceptible; or infections due to S. aureus, P. aeruginosa, fungi, or mycobacteria following collaboration with the LIP.1,4 (IV)
I. Do not use a guidewire exchange to replace a non-tunneled catheter suspected of infection.2 (V)
J. Consider a catheter exchange procedure when other vascular access sites are limited and/or bleeding dis- orders are present. Consider an antimicrobial- impregnated catheter with an anti-infective intraluminal surface for catheter exchange.1 (IV)
K. Collect a specimen of purulent exudates from a peripheral or CVAD exit site for culture and gram staining to determine the presence of gram-negative or gram-positive bacteria as ordered by an LIP.1 (IV)
L. Do not routinely culture the CVAD tip upon removal unless the patient has a suspected CR-BSI. Catheter colonization may be detected but does not indicate the presence of a bloodstream infection. This practice results in inappropriate use of anti-infective medications, thus increasing the risk of emergence of antimicrobial resistance. Recognize that the catheter tip culture will identify microorganisms on the external catheter and not microorganisms located on the intraluminal surface.1 (IV)
M. Culture the tip of short-term central vascular and arterial catheters suspected of being the cause of a CR-BSI using a semiquantitative (roll-plate) method or quantitative (sonication) method upon removal. Culture the introducer/sheath tip from a pulmonary artery catheter when a CR-BSI is suspected.1 (IV)
N. Culture the reservoir contents of a port body of an implanted port and the catheter tip when it is removed for suspected CR-BSI.1 (IV)
O. Consider contamination of the infusate (such as par- enteral solution, intravenous medications, or blood products) as a source of infection. This is a rare event, but an infusate can become contaminated during the manufacturing process (intrinsic contamination) or during its preparation or administration in the patient care setting (extrinsic contamination). An infusate-related bloodstream infection is the isolation of the same organism from the infusate and from separate percutaneous blood cultures, with no other identifiable source of infection.2,7-9 (IV) (see Standard 43, Phlebotomy).P. For a suspected CR-BSI, obtain paired blood samples for culture, drawn from the catheter and a peripheral vein, before the initiation of antimicrobial therapy. Blood cultures from both the catheter and venipuncture must be positive for the same organism with clinical signs and symptoms and no other recognized source. Consider quantitative blood cultures or the differential period of central line culture versus peripheral blood culture positivity >2 hours for the diagnosis of CR-BSI (see Standard 43, Phlebotomy).1,6,10,11 (IV)
REFERENCES
Note: All electronic references in this section were accessed October 5, 2015.1. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter- related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49(1):1-45. Erratum in: Clin Infect Dis. 2010;50(3):457; Clin Infect Dis. 2010;50(7):1079.
2. OGrady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. http:// http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html. Published April 2011.
3. Rickard CM, Webster J, Wallis MC, et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet. 2012;380(9847):1066-1074.
4. Chopra V, Flanders SA, Saint S, et al. The Michigan appropriate- ness guide for intravenous catheters (MAGIC): results from an international panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(suppl 6):S1-S39.
5. Caroff D, Norris A, Keller S, et al. Catheter salvage in home infusion patients with central line-associated bloodstream infection. Am J Infect Control. 2014;42(12):1331-1333.
6. Chopra V, Anand S, Krein SL, Chenoweth C, Saint S. Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med. 2012;125(8): 733-741.
7. Kumar A, Kethireddy S, Darovic GO. Catheter-related and infusion-related sepsis. Crit Care Clin. 2013;29(4):989-1015.
8. Huang EY, Chen C, Abdullah F, et al. Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg. 2011;46(10):2000-2011.
9. The Joint Commission. Preventing central line-associated blood- stream infections: a global challenge, a global perspective. http:// http://www.jointcommission.org/preventing_clabsi. Published May 2012.
10. Septimus E. Clinician guide for collecting cultures. http://www.cdc.gov/getsmart/healthcare/implementation/clinicianguide.html. Published April 7, 2015.
11. Garcia RA, Spitzer DE, Beaudry J, et al. Multidisciplinary team review of best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremias, reducing contamination, and eliminating false-positive central line-associated bloodstream infections. Am J Infect Control. 2015;43(11):1222-1237.
APIC Guide 2009 – ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Guide to the Elimination of Catheter-Related Bloodstream Infections1. A CLABSI as defined by CDC, is a primary (i.e., no apparent infection at another site) BSI in a patient that had a central line within the 48-hour period before the development of the BSI. BSI is defined using either laboratory- confirmed bloodstream infection (LCBI) or clinical sepsis (CSEP) definitions (see Definition of Terms). In the CDC/NHSN definition of CLABSI, there is no minimum period of time that the central line must be in place in order for the BSI to be considered central lineassociated. The culture of the catheter tip is not a criterion for CLABSI.
Timothy R. Spencer, RN, APN, DipAppSci, BHealth, ICCert, VA-BC
Vascular Access Consultant
E: tim.spencer68@icloud.com
M: +1 (623) 326 8889 (USA)
M: +61 (0)409 463 428 (AU)
ABN: 51606547370
http://orcid.org/0000-0002-3128-2034On Mar 15, 2017, at 10:42 PM, Cate Coffey <Cate.Coffey@NT.GOV.AU> wrote:
Hi everyone
We are updating our policies and I notice that our CVC and Vascath polices recommend culturing the tip of CVC. Could you tell me if there is evidence to support this practice Wouldnt a blood culture be more appropriate to diagnose infection? Can there be a CVC tip infection without bloodstream infection and what is the relevance if there is?
We do not have 24 hour pathology service so it means that tip cultures could only be sent during lab hours?
Can you let me know your thoughts?
Cate Coffey | Clinical Nurse Consultant
Infection Prevention and Control Unit | Central Australia Health Service
Northern Territory Government
Alice Springs Hopsital, Gap Rd, Alice Springs
GPO Box 2234, Suburb, NT Postcode
p … 08 89517737
e … cate.coffey@nt.gov.au http://www.nt.gov.au/healthOur Vision: Better health outcomes for all Central Australians
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Dear Amanda, dear Julie,
I refer to a few prior postings that I made on this forum on this topic. I don’t want to repeat this in detail (but certainly can do so if this is required), but the evidence assessments (both in the Immunisation Handbook and of the WHO – have not seen the Joanna Briggs one) leading to the recommendation to NOT swab before ANY type of infections (including deep intramuscular, intraarticular, etc., etc.) are seriously flawed. Just as a small example, there is no factual or evidence-based or microbiological basis for the distinction between visibly clean and dirty skin. Visibly clean skin can harbour very high microorganism numbers.
What needs to be recognised is that the physiology of (and pathophysiology of infections caused by) the different types of injections is fundamentally different. The decision to not swab before very superficial (subcutaneous or intracutaneous) infections may be justifiable on the basis that these are anatomically very superficial and any infections easily treatable, but this cannot be generalized to any types of injections.
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior 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 Amanda
We don’t clean with an alcohol wipe prior to any injections, including immunisations unless the area of skin is visibly dirty. You could have a look at The Australian Immunisation Handbook which confirms this for vaccinations. You might also want to look at the WHO Best Practices for Injections policy & the Joanna Briggs Institute website.
Kind regards
Julie
Julie Baile I Clinical Nurse Infection Prevention & Management
South Metropolitan Health Service Fiona Stanley Hospital
Level Ground, Block B, 11 Robin Warren Drive, MURDOCH WA 6150
Postal Address: Locked Bag 100, PALMYRA DC WA 6961
T: 6152 8915
E: julie.baile@health.wa.gov.au
http://www.southmetropolitan.health.wa.gov.au
http://www.fsh.health.wa.gov.auHi All,
I am just looking at what everybody’s current practice is when giving insulin or clexane injections.
Do you swab prior to injection or not? And does anybody have any of the latest evidence regarding this?
Thanks
Amanda
Amanda Hill
Staff Development Nurse – Palliative Care
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Dear Colleagues,
A few remarks. I have seen it stated occasionally that the first surgical hand preparation of the day should be done water and (antiseptic) detergent-based, and alcohol-based preparation only for subsequent procedures (but not for the first). This is INCORRECT. You may refer to the WHO 2009 hand hygiene guideline, pages 54-60, where surgical hand preparation is described. Detergent and water-based wash is necessary (followed by towel drying before applying the alcohol) when the hands are visibly dirty, but the first hand preparation of the day can still be done with alcohol.
Alcohol-based preparation has a few advantages over detergent and water-based:
(1) It achieves much greater microbial reduction factors on arms/hands than detergent-based scrubbing, thus providing an advantage in terms of residual germs on hands/arms.
(2) It requires much shorter application times than detergent-based scrubbing, saving time for the surgeons and the surgical teams.
(3) If adequate preparations with good emollients are used, it leads to substantially less damage/irritation on hands/skin.
(4) It is ecologically more friendly, because it saves a lot of running water.A large French clinical trial of alcohol-based versus antiseptic detergent-based surgical hand preparation has shown equivalence in terms of surgical site infection (SSI) rates:
Parienti JJ, Thibon P, Heller R, Le Roux Y, von Theobald P, Bensadoun H, et al. Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site
infection rates: a randomized equivalence study. JAMA 2002; 288: 722-7. doi:10.1001/jama.288.6.722
http://www.ncbi.nlm.nih.gov/pubmed/12169076On one past occasion, I have taken the liberty to publish a small letter to the editor that emphasizes the need for proper technique:
Maiwald M. Technique is important for alcohol-based surgical hand antisepsis. Healthcare Infection 17(3) 106-107.
http://www.publish.csiro.au/paper/HI12028.htmIn my personal opinion, human learning is better when following an example or when something is personally shown/taught than when something has to be learnt from reading manuals or policy and procedure documents (there are so many around already). So, I think it would be a good choice for an organization to have a senior person (e.g. scrub nurse or surgeon) who is familiar with the technique and is able to show this, by personal example, to every newcomer to the facility (or to established staff when the technique is newly introduced) as part of operating theatre introduction/orientation.
And to confirm what Michael has stated, in some settings alcohol-based surgical hand preparation has been done for a long time. When I did my surgical internship in 1986 (this shows my age), it was already the established standard of care.
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 Fran
Not sure if you are referring to use of alcohol hand gels/rubs in procedural areas for social handwashing, or use of waterless alcohol as a scrub agent.
We have been doing both here for a number of years. There are some surgical disciplines where the use of waterless alcohol based scrub agents has been embraced with a gusto. And some surgical disciplines where waterless alcohol based scrub agents are still frowned upon.
I would say 70% of all of our surgical scrubbing is now down with waterless alcohol based products. It has generally been well received. My only reservations are bout the professional societies not having good guidance on their use. ACORN has recently released some better guidance, but none of the surgical colleges have any specific guidance about how to use waterless agents, when you need to wash with soap and water, or anything. This to me makes to hard to enforce good practice across all disciplines. But then again, I have recently discovered that RACS doesn’t even have a procedure on how to do a water based surgical scrub!
Europeans have been using waterless based alcohol scrubbing for some time, and there has been no reported changes in SSI rates there.
So, I would give surgeons and theatre nurses the option of using these products, setting some simple ground rules for their use (like soap and water wash before the first waterless scrub of each list).
Good luck.
Cheers
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
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P Please consider the environment before printing this emailDear all,
How many of you out there are currently using an alcohol-based surgical hand rub in the Perioperative Suites? Some Visiting Medical Officers states that they’ve never heard of it and others can’t go without it.
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[user] [bHand Hygiene day 16]
“Share the fun not the germs, clean your hands”
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Dear Jo-Anne,
Forgot to add three more aspects, partially in response to your questions:
A large French clinical trial of alcohol-based versus antiseptic detergent-based surgical hand preparation has shown equivalence in terms of surgical site infection (SSI) rates:
Parienti JJ, Thibon P, Heller R, Le Roux Y, von Theobald P, Bensadoun H, et al. Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site
infection rates: a randomized equivalence study. JAMA 2002; 288: 722-7. doi:10.1001/jama.288.6.722
http://www.ncbi.nlm.nih.gov/pubmed/12169076The conclusion was: “Hand-rubbing with aqueous alcoholic solution, preceded by a 1-minute nonantiseptic hand wash before each surgeon’s first procedure of the day and before any other procedure if the hands were soiled, was as effective as traditional hand-scrubbing with antiseptic soap in preventing surgical site infections. The hand-rubbing protocol was better tolerated by the surgical teams and improved compliance with hygiene guidelines.”
In terms of dispensers, I would discourage hand-driven dispensers as commonly used at the bedside for the 5 Moments (due to the possibility of hand recontamination). In Europe, elbow-driven dispensers are in common use, as depicted here (not specific product endorsement intended, result from googling):
https://www.asport.nl/eurodispenser-1-plus-met-elleboog-bediening.html
With elbow-driven dispensers, autoclaving is not necessary, provided surgeons follow good technique (i.e. each rubbing act starts at the hands and ends at the elbows). Touch-free dispensers would be an option, but are not necessary with elbow-driven dispensers (simpler mechanics), and the concern with touch-free dispensers would be appropriate volumes dispensed (much larger volumes are required for surgical hand antisepsis than for ward-based hand hygiene as in the 5 Moments); see my little letter to the editor that I sent earlier.
Lastly, alcohol-based surgical hand preparation saves a lot of water (estimated 20 L required per surgical scrub) and is cheaper in cost.
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 1387Dear Jo-Anne,
I am not sure how widespread alcohol-based surgical hand preparation is now in Australia (I am now based in Singapore), but it is certainly now state of the art according to all major hand hygiene guidelines, and it has been the standard of care (and has supplanted detergent-based surgical hand preparation) since the 1980s in continental Europe.
The WHO 2009 Hand Hygiene Guideline (I assume you have that) has a section on it from page 54 to page 60, and that should have all the information you require.
A published version (in a journal) of essentially that same section has appeared here:
Widmer AF, Rotter M, Voss A, Nthumba P, Allegranzi B, Boyce J, Pittet D. Surgical hand preparation: state-of-the-art. J Hosp Infect. 2010 Feb;74(2):112-22. doi: 10.1016/j.jhin.2009.06.020. Epub 2009 Aug 28.
http://www.ncbi.nlm.nih.gov/pubmed/19716627Essentially, alcohol-based surgical hand preparation has three major advantages over antiseptic detergent-based:
(1) It achieves much greater microbial reduction factors on arms/hands than detergent-based scrubbing.
(2) It requires much shorter application times than detergent-based scrubbing, saving time for the surgeons and the surgical teams.
(3) If adequate preparations with good emollients are used, it is gentler on hands/skin.
There are some highly active preparations around. While the standard time to fulfill the stringent European standard EN 12791 is 3 min, some of the better preparations fulfill EN 12791 in as short as 60 seconds (which is a phenomenally short time), but even with those preparations it is usually recommended to go slightly beyond that time (e.g. 2 min) for added safety. For most products, 3 min is appropriate.
It can be used for any type of surgery.
I have heard the notion before that alcohol-based hand/arm preparation cannot be used for the first scrub of the day (which is what you seem to indicate). But this is incorrect. It definitely can be used for the first and for subsequent scrubs, see WHO.
I have also published a small letter to the editor, highlighting the need for proper technique and providing some additional info, here:
Maiwald M. Technique is important for alcohol-based surgical hand antisepsis. Healthcare Infection 17(3) 106-107.
http://www.publish.csiro.au/paper/HI12028.htmBest 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
Is anyone using these alcohol-based hand rub products after the first surgical scrub?
Do you have specific criteria for specialities that do use it?
Is it better to install the touch free design or autoclavable dispenser?
Any significant outcomes for patients?
What is your staff satisfaction rate?
Has it improved the efficiency in the operating theatre?
Thank you
Joe-Anne Bendall
Joe-Anne Bendall
Clinical Nurse Consultant Infection Prevention and Control
(Including vaccination and screening)
Monday – Friday 0800 – 1630
Sydney Hospital and Sydney Eye Hospital
8 Macquarie St
SYDNEY NSW 2000
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Dear Jo-Anne,
I am not sure how widespread alcohol-based surgical hand preparation is now in Australia (I am now based in Singapore), but it is certainly now state of the art according to all major hand hygiene guidelines, and it has been the standard of care (and has supplanted detergent-based surgical hand preparation) since the 1980s in continental Europe.
The WHO 2009 Hand Hygiene Guideline (I assume you have that) has a section on it from page 54 to page 60, and that should have all the information you require.
A published version (in a journal) of essentially that same section has appeared here:
Widmer AF, Rotter M, Voss A, Nthumba P, Allegranzi B, Boyce J, Pittet D. Surgical hand preparation: state-of-the-art. J Hosp Infect. 2010 Feb;74(2):112-22. doi: 10.1016/j.jhin.2009.06.020. Epub 2009 Aug 28.
http://www.ncbi.nlm.nih.gov/pubmed/19716627Essentially, alcohol-based surgical hand preparation has three major advantages over antiseptic detergent-based:
(1) It achieves much greater microbial reduction factors on arms/hands than detergent-based scrubbing.
(2) It requires much shorter application times than detergent-based scrubbing, saving time for the surgeons and the surgical teams.
(3) If adequate preparations with good emollients are used, it is gentler on hands/skin.
There are some highly active preparations around. While the standard time to fulfill the stringent European standard EN 12791 is 3 min, some of the better preparations fulfill EN 12791 in as short as 60 seconds (which is a phenomenally short time), but even with those preparations it is usually recommended to go slightly beyond that time (e.g. 2 min) for added safety. For most products, 3 min is appropriate.
It can be used for any type of surgery.
I have heard the notion before that alcohol-based hand/arm preparation cannot be used for the first scrub of the day (which is what you seem to indicate). But this is incorrect. It definitely can be used for the first and for subsequent scrubs, see WHO.
I have also published a small letter to the editor, highlighting the need for proper technique and providing some additional info, here:
Maiwald M. Technique is important for alcohol-based surgical hand antisepsis. Healthcare Infection 17(3) 106-107.
http://www.publish.csiro.au/paper/HI12028.htmBest 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
Is anyone using these alcohol-based hand rub products after the first surgical scrub?
Do you have specific criteria for specialities that do use it?
Is it better to install the touch free design or autoclavable dispenser?
Any significant outcomes for patients?
What is your staff satisfaction rate?
Has it improved the efficiency in the operating theatre?
Thank you
Joe-Anne Bendall
Joe-Anne Bendall
Clinical Nurse Consultant Infection Prevention and Control
(Including vaccination and screening)
Monday – Friday 0800 – 1630
Sydney Hospital and Sydney Eye Hospital
8 Macquarie St
SYDNEY NSW 2000
|* ph +61 2 9382 7199 |page 22070 via switch 9382 7111| 7 Fax 93827510 |
Mobile 0418984255 | * Joe-Anne.Bendall@HEALTH.NSW.GOV.AUThis message is intended for the addressee named and may contain confidential information. If you are not the intended recipient, please delete it and notify the sender.
Views expressed in this message are those of the individual sender, and are not necessarily the views of NSW Health or any of its entities.
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Dear Michael, dear All,
I have commented upon this issue several times in the past in this list, and I will keep it short this time.
The recommendation to NOT swab before injections is based on scientifically inappropriate interpretation of the available evidence by some evidence-focused groups and people who neither understand the underlying microbiology of skin colonization and of disinfection, nor the physiology of injections or the pathophysiology of injection-site infections.
A key paper in this aspect is a short “EBM in Action” article published by Del Mar and coauthors in the MJA in 2001. In this article, the authors examined the evidence from 3 studies, one with 13 patients (only) with insulin injections (s.c.) and two trials of a few hundred patients (only) with venipuncture (note, venipuncture is into a highly vascularized site and therefore has a very low risk of infection). The infection/contamination rate in patients who had no skin disinfection done was not significantly different from patients who received skin disinfection. The authors (inappropriately) concluded that skin antisepsis was generally NOT necessary before ANY kind of injections, including IM injections, despite the fact that not even a single IM injection had been reviewed as part of the evidence review. In addition, the estimated natural incidence of injection-site infections is about 1:5000 to 1:10000 or less, meaning that (a) it is a rare – albeit sometimes life-threatening – event, and (b) that if you study a few hundred patients when the natural event frequency is about 1:10000, you will not be able to make meaningful conclusions.
Nevertheless, the Australian Immunisation Handbook took this (inappropriate) evidence assessment and says that no skin disinfection is generally necessary before IM injections.
Another common misconception is that alcohol swabbing is contraindicated before live vaccines, because it would inactivate the live vaccines. If one calculates the amount of alcohol that would be introduced that way, one arrives in the nanolitre range (1 nL is 0.000000001 L), and there is absolutely NO WAY that this could inactivate a live vaccine.
An alcohol swab costs about 1 cent, and swabbing is easy.
The physiology of injections differs according to injection mode and injection site (bradytrophic tissue is more prone to infections than well vascularized). Heparin injection often creates small haematomas, which constitute locally-confined bradytrophic areas. That potentially makes them more prone to infections, but the extent to which it does this is probably unknown.
While it is NOT possible to say with absolute certainty whether or not swabbing is necessary and in what kind of injections it is (because the evidence is lacking), it is clear that the common recommendations to NOT swab are based on shoddy and scientifically inaccurate interpretation of the facts. Injection-site infections are very, very rare, but when they occur, they can be serious. Alcohol swabbing is cheap and easy, and it follows the “primum non nocere” (first, do no harm) principle in that it errs on the side of caution and on the side of avoiding harm.
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 1387Do we think this has come about with the small study that was done around vaccination of children in the community? This issue always raises its head about now with staff flu vaccination as well. ICP discussion usually leans towards swabbing recognising the increased risk factors in the health care environment. The cost of a swab is negligible so cost should not be the issue. Nurse immunisers are being taught not to swab (live vaccines are a foregone conclusion) so we often find some conflict with practices.
I would love to see more research on this if anyone is aware of any.
Regards
Robyn
Robyn Birch
CNC Infection Control
Redland Hospital
Department of Health | Queensland Government
PO Box 585, ClevelandQLD 4163
t. (07) 3488 3518
m. 0412 585 099
Robyn.Birch@health.qld.gov.au | http://www.health.qld.gov.au________________________________
As an aside to this conversation, there appears to be a difference in risk between subcutaneous injections and IM injections. There is a definite rare but documented risk of sepsis following IM injection (see http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769353/ as an example).
The risk of sepsis from subcutaneous injections seems to be much lower, and possibly more to do with incorrect technique than anything.
I am not sure if universities are taking a blanket approach to injecting and teaching students not to use alcohol disinfection of the skin for all injections. Do we have any academics on the list that can answer this question?Thanks
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0]
P Please consider the environment before printing this emailHi Lyn,
I’ve found the following information on the NPS website for Fragmin Single dose injections – Consumer medication information leaflet
Before you inject, make sure that the injection site is clean by wiping the area with an antiseptic swab, or by washing it with soap and water and patting it dry with a clean towel
http://www.nps.org.au/medicines/heart-blood-and-blood-vessels/anti-clotting-medicines/for-individuals/anticoagulant-medicines/for-individuals/active-ingredients/dalteparin-sodium/fragmin-single-dose-syringe-solution-for-injectionFor Clexane it didn’t specify cleaning of the skin
http://www.nps.org.au/medicines/heart-blood-and-blood-vessels/anti-clotting-medicines/for-individuals/anticoagulant-medicines/for-individuals/active-ingredients/enoxaparin-sodium/clexane-solution-for-injectionWhen administering vaccines, provided the skin is visibly clean, there is no need to wipe it with an antiseptic.
Regards
MarlizeMarlize Senekal
Infection Prevent & Control CNC – Education and ResearchT (07) 3621 4545 | M 0418 866 816
E m.senekal@wmb.org.au | http://www.wmb.org.au
Central Offices – Wheller Gardens: 930 Gympie Road, Chermside QLD 4032[cid:image001.gif@01D19C8E.47C30FB0]
[cid:image002.gif@01D19C8E.47C30FB0] [cid:image003.gif@01D19C8E.47C30FB0] [cid:image004.gif@01D19C8E.47C30FB0] [cid:image005.gif@01D19C8E.47C30FB0] [cid:image006.gif@01D19C8E.47C30FB0] [cid:image007.gif@01D19C8E.47C30FB0]Morning,
I was just wondering what the general consensus is with regards to the use of alcohol wipe swabbing prior to giving Clexane/Fragmin/Heparin etc.
Some of the students we are seeing come through the hospital are educated not to.
With kind regards,
Lynette Cribb
Infection Control Coordinator | St Andrew’s War Memorial Hospital457 Wickham Terrace, Spring Hill, QLD, 4001
GPO Box 764, Brisbane, QLD, 4001
P: +61 7 3834 4328 F: +61 7 3834 4599
M: 0427 141 223
E: sawmh.icc@uchealth.com.au
W: http://www.uchealth.com.au
[Bugs-and-tear LR]Remember to protect your patients, family and yourself by getting the Influenza vaccination
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Dear Colleagues,
Just for clarification — if this is required — that microbiologically, an antiseptic hand wash is in between a plain soap hand wash and an alcohol-based hand rub, in the order of reduction factors:
Plain soap hand wash < antiseptic hand wash << alcohol-based hand rub.
The usual achieved reduction factors of antiseptic hand washes are in fact closer to plain soaps than they are to alcohol-based hand rubs. That also depends on the individual product and/or preparation used (not all are equal).
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 Tim
Interestingly, the US HICPAC BSI guidelines has this:
Hand Hygiene and Aseptic Technique
1. Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained [12, 77-79]. Category IB
This recommendation seems to be generic for all intravascular devices from what I can see. No specific recommendation for hand cleaning with an antiseptic solution prior to CVC insertion.
Cheers
MichaelMichael Wishart
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
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P Please consider the environment before printing this emailHi Michelle,
Have you asked them for what reasons they have changed their current practice?
Maybe they can supply you with the evidence they used to stop using antiseptic hand wash.
This is currently NOT the recommendations of both a number of Australian and international guidelines and recommendations.
Currently CDC, SHEA, APIC, EPIC, ACI, INS , CNSA and NSW MoH CVAD guidelines support the use of antiseptic handwashing in all aspects of vascular access.
Tim..Timothy R. Spencer, RN, APN, DipAppSci, Bach.Health, ICCert, VA-BC.
Independent Vascular Access Consultant
Conjoint Lecturer, South West Sydney Clinical School | Faculty of Medicine | University of NSW
Director-at-Large, Vascular Access Certification Corporation (VACC)
M: +1 (623) 326 8889 (USA)
M: +61 (0)409 463 428 (AU)
E: tim.spencer68@icloud.com
“Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected.” – Steve JobsMorning All, I recently found our PICC team no longer use antiseptic hand wash pre PICC insertion and use neutral soap. Can anyone tell me where to find evidence of using antiseptic hand wash prior to invasive procedures?
Thank you
Michelle KennedyCNC | Infection Prevention Service
John Hunter Hospital Campus
Lookout rd, New Lambton
Tel 02 4921 3129 | michelle.kennedy@hnehealth.nsw.gov.au
http://www.health.nsw.gov.au[http://www.health.nsw.gov.au/images/communications/e-signatures/images/NSW-Health-Master.jpg]
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