Br. 7. Anaesth. (1974), 46, 260
`
`INFECTION HAZARD FROM SYRINGES
`
`c. E. BLOGG, M. A. E. RAMS-AY AND J. D. JARVIS
`
`SUMMARY
`Bacterial contamination of the contents of disposable plastic syringes was demonstrated
`experimentally after repeated refilling. Supporting evidence for this mechanism as a
`potential source of bacteraemia was obtained by a spot check of syringes used for
`repeated injections. It is recommended that disposable syringes should be discarded
`after a single injection.
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`the syringe held with sterile rubber gloves. The
`syringes were filled and refilled using the common
`technique of withdrawing the plunger with one
`hand, whilst the other held the bottle from which
`the culture medium (I% peptone water) was aspi(cid:173)
`rated (fig. 1). The culture medium was withdrawn
`from capped bottles through a sterile rubber seal to
`the maximum calibration mark on the syringe and
`then re-injected into the bottle. The specimen was
`labelled "control".
`The gloved right hand was then dipped into a
`culture of Serratia marcescens, used as a marker
`organism. The syringe plunger was pulled back
`with the contaminated right hand, whilst the un(cid:173)
`contaminated
`left hand held only
`the bottle.
`Approximately 25 X 106 organisms per sq.cm were
`present on the glove. This represents a severe chal(cid:173)
`lenge. The procedure was repeated with the same
`syringe until five refills had been made. Separate
`culture bottles were used for each refill.
`
`(B) Investigation of syringes in prolonged use.
`Plastic syringes, which had been used throughout
`operative procedures for the repeated administration
`of drugs, were collected from anaesthetists in the
`operating theatres immediately after use and the
`needle and needle cover removed from the nozzle,
`which was then sealed with a sterile plastic cap
`(Braun). Care was taken not to contaminate the
`nozzle. The contents were then cultured. Similarly
`capped plastic syringes were collected from the ITU,
`where they had been used for the repeated flushing
`of intravascular cannulae.
`In all cases the culture medium was incubated at
`36°C for 48 hours. The bottles were then examined
`for bacterial contamination.
`
`C. E. BLOGG, F.F.A.R.c.s.; M. A. E. RAMSAY, F.F.A.R.c.s.;
`J. D . JARVIS, F.I.M.L.T.; Division of Anaesthesia and
`Department of Clinical Microbiology, The London
`Hospital, Whitechapel, London E.l.
`
`It is now standard practice to use disposable
`syringes for injection. Jn situations where repeated
`injections are required in the same patient-for
`example, by doctors and nurses in intensive therapy
`units (ITU) and by anaesthetists in operating
`theatres-it is common practice for these syringes
`to be refilled. Simple observation demonstrates that
`mishandling of the plunger may readily occur (fig.
`I), thus creating a potential source of contamination.
`This hypothesis has been investigated. In addi(cid:173)
`tion, syringes which had been used over a prolonged
`period in operating theatres and in an ITU were
`examined for bacterial contamination.
`
`FIG. 1. Common method of drawing up with a syr inge
`showing mishandling of che plunger shaft, that leads to
`bacterial contamination of the concems.
`
`METHOD
`(A) Investigation of syringes with a marker organism.
`A variety of sizes of sterile plastic and glass
`syringes were used.• Each syringe pack was opened
`in a sterile, filtered-air, positive-pressure room, and
`
`• P lastic syringes manufactured by Gillette, Beckton &
`Dickinson and D.H.S.S. Glass syringes manufactured by
`Smith & Nephew.
`
`Hospira, Exh. 2010, p. 1
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`INFECTION HAZARD FROM SYRINGES
`
`261
`
`RESULTS
`(A) From table I it can be seen that contamination
`never occurred at the first refill but by the second
`refill all of the glass syringes and at least 50% of
`the plastic syringes had their contents contaminated.
`Because the likelihood of transfer of bacteria from
`the plunger to the syringe contents was similar with
`all the makes of plastic syringe examined the results
`have been pooled.
`
`TABLE I. Concaminacion of syringe conrencs. Syringe
`plungers mishandled by a hand concaminaced wich a
`marker organism (Serracia marcescens).
`
`No. of syringe contents contaminated/No.
`of syringes tested
`Refills
`
`Syringes
`
`Control
`
`1st
`
`2nd
`
`5th
`
`Plastic
`1 ml
`2 ml
`5 ml
`10 ml
`20 ml
`Glass s ml
`10 ml
`20 ml
`
`0/10
`0/10
`0/15
`0/15
`0/15
`
`0/5
`0/5
`0/5
`
`0/10
`0/10
`0/15
`0/15
`0/15
`
`0/5
`O/S
`0/5
`
`6/10
`5/10
`7/15
`11/15
`6/15
`
`S/5
`5/S
`5/5
`
`10/10
`10/10
`15/15
`15/15
`15/15
`
`5/S
`5/S
`5/S
`
`(B) One hundred plastic syringes were collected
`from the ITU and the operating theatres (table II).
`The contents of eight syringes were contaminated.
`Of these, five had been used in the ITU. The con(cid:173)
`tents grew Staphylococcus epidermidis 1 (3 syringes),
`Staphylococcus aureus2 (1 syringe) and Strepto(cid:173)
`coccus viridans3 (1 syringe).
`The remaining three syringes had been used for
`patients undergoing major surgery. The contents of
`two syringes used in two separate cases of resection
`of an aortic aneurysm grew Escherichia coli4 • The
`third syringe had been used for a patient undergoing
`mitral valve surgery and from its contents Staphylo(cid:173)
`coccus aureus was grown.
`No patients had clinical evidence of septicaemia.
`
`1. Staphylococcus epidermidis: gram positive, fermenta(cid:173)
`tive, catalase positive, slide coagulase negative, D.N.
`ase negative coccus.
`2. Staphylococcus aureus: gram positive fermentative,
`caralase positive, slide coagulase positive, D.N. ase
`positive coccus.
`3. Streptococcus viridans: gram positive, catalase nega(cid:173)
`tive, a-haemolytic (horse blood agar), coccus.
`4. Escherichia coli: gram negative, motile, citrate nega(cid:173)
`tive, K.C.N. negative, Eijkman positive rod.
`
`D
`
`TABLE II. Organisms culcured from che concenrs of 100
`syringes collecced afcer use in che operacing cheatres or
`che Intensive Care Unit.
`
`Organism
`
`From theatres
`Escherichia coli
`Staphylococcus aureus
`From ITU
`Staphylococcus epidermidis
`Staphylococcus aureus
`Streptococcus viridans
`
`No. of
`Syringes
`
`Total
`No. of
`Syringes
`
`2
`1
`
`3
`1
`1
`
`50
`
`so
`
`DISCUSSION
`that contamination of syringe
`It is undesirable
`contents should occur, although such contamination
`cannot necessarily be equated with clinical bacter(cid:173)
`aemia. Our results show that if the plunger of a
`syringe is contaminated by soiled hands, organisms
`can be transferred to the syringe contents.
`Anaesthetists and intensive care nurses frequently
`soil their fingers with tracheobronchial secretions
`and mucopus, and Lowbury and Lilly (1973)
`demonstrated that even a 2-min wash with ordinary
`bar soap does little to reduce the bacterial count on
`hands. Furthermore, it has been suggested (Teres
`et al., 1973) that in the intensive therapy unit, sinks
`provide reservoirs of Pseudomonas infection and
`that the bands of personnel are the vehicles of
`transmission.
`There have been many investigations into the
`sources of bacterial contamination of intravenous
`fluids and cannulae (Banks et al., 1970; Freeman
`and King, 1971; Colvin et al., 1972; Philips, Eykyn
`and Laker, 1972; Department of Health and Social
`Security, 1972; Committee of the Medicines Com(cid:173)
`mission, 1973; Lapage, Johnson and Holmes, 1973;
`Leading Articles, 1972, 1973a,b), but little has
`been reported on the possible introduction of bac(cid:173)
`teria into infusion systems, or directly into patients
`by the mishandling of syringes (Scurr and Edgar,
`1962).
`The reported incidence of bacteria in intravenous
`fluids to which drugs bad been added (D'Arcy and
`Woodside, 1973) may be accounted for by the use
`of contaminated syringes for the addition of the
`drugs. This is especially hazardous as intravenous
`nutrients are excellent culture media. In particular,
`the risk to patients undergoing cardiac and trans(cid:173)
`plant surgery may be considerable.
`The fact that patients are at risk is shown by our
`findings of organisms in the contents of 8 of 100
`
`Hospira, Exh. 2010, p. 2
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`262
`
`syringes collected at random. Pathogenic organisms
`were present in 4 of these 8 syringes. We have
`demonstrated that the use of disposable syringes for
`more than one injection is potentially hazardous.
`This study demonstrates that as well as taking the
`obvious precautions of avoiding manual contact
`with the needle or nozzle of the syringe, careless
`mishandling of the syringe plunger with repeated
`injections may allow bacteria to pass from the hands
`to the syringe contents via the plunger. Total avoid(cid:173)
`ance of handling the plunger shaft is difficult, especi(cid:173)
`ally when both hands cannot be employed, and
`therefore the only sensible precaution to be taken is
`to confine the use of the syringe to one injection.
`The seal formed between the washer of the syringe
`plunger and the barrel of the syringe cannot be
`considered as a barrier to bacteria.
`We recommend that syringes should not be used
`for more than one injection, and that a fresh sterile
`syringe should always be used whenever it is neces(cid:173)
`sary to draw up and inject a further supply of a drug
`into the same .Patient.
`
`ACKNOWLEDGEMENTS
`We thank Professor B. R. J. Simpson for his assistance
`and guidance in the preparation of this paper, Miss J.
`Tolhurst and Miss S. R. Liddell for secretarial work, and
`Mr R. Ruddick and Miss J. Abbott of the Departments
`of Photography and Medical Illustration for the figure.
`
`BRITISH JOURNAL OF ANAESTHESIA
`
`REFERENCES
`Banks, D. C., Yates, D. B., Cawdrey, H. M., Harries,
`M. G., and Kidner, P. H. (1970). Infection from intra(cid:173)
`venous catheters. Lancet, 1, 443.
`Colvin, M. P., Blogg, C. E., Savege, T. M., Jarvis, J. D.,
`and Strunin, L. (1972). A safe long-term infusion tech(cid:173)
`nique? Lancet, 2, 317.
`Committee of the Medicines Commission (1973). Report
`on the prevention of microbial contamination of medi(cid:173)
`cinal products. H.M. Stationery Office.
`D'Arcy, P. F., and Woodside, W. (1973). Drug additives:
`a potential source of bacterial contamination of infusion
`fluids. Lancet, 2, 96.
`Department of Health and Social Security (1972). Interim
`report on heat sterilised fluids for parenteral administra(cid:173)
`tion. H.M. Stationery Office.
`Freeman, R., and King, B. (1972). Infective complications
`of indwelling intravenous catheters and the monitoring
`of infections by the nitroblue-tetrazolium test. Lancet,
`1, 994.
`Lapage, S. P., Johnson, R., and Holmes, B. (1973). Bac(cid:173)
`teria from intravenous fluids. Lancet, 2, 284.
`Leading Article (1972). Contaminated infusion fluids. Br.
`Med. 1., 3, 190.
`- - (1973a). Particles in veins. Br. Med. 7., 1, 307.
`- - (1973b). Cleaner medicants. Br. Med. 7., 2, 6.
`Lowbury, E. J. L., and Lilley, H. A. (1973). Use of 4%
`chlorhexidine detergent solution (Hibiscrub) and other
`methods of skin disinfection. Br. Med. 1., 1, 510.
`Phillips, I., Eykyn, S., and Laker, M. (1972). Outbreak
`of hospital infection caused by contaminated autoclaved
`fluids. Lancet, 1, 1258.
`Scurr, C. F., and Edgar, W. M. (1962). A possible danger
`of all-glass syringes. Lancet, 1, 1303.
`Teres, D., Schweers, P., Bushnell, L. S., Hedley-Whyte,
`J., and Feingold, D. S. (1973). Sources of Pseudomonas
`aeruginosa infection in a respiratory /surgical I.T.U.
`Lancet, 1, 415.
`
`BOOK REVIEW
`
`Intractable Pain. By Mark Mehta. Published by W. B.
`Saunders Co. Ltd, London. Pp. 304, illustrated,
`indexed. Price £6.00.
`In opting to write a book about intractable pain Dr Mehta
`has chosen one of the most difficult subjects in medicine.
`He has also chosen one of the most misunderstood,
`despite the fact that most doctors encounter pain in one
`form or another almost every day of their lives. Concern
`has been expressed in the medical press with increasing
`frequency that this paradox, namely familiarity with pain
`in the clinical sense on the one hand and ignorance of its
`many physiological and psychological aspects on the other,
`should exist. Most medical undergraduates receive lectures
`concerning probable pathways for noxious impulses fol(cid:173)
`lowing stimuli in various parts of the body, and turgid
`accounts of the properties of hosts of analgesic agents
`with a limited review of indications for their administra(cid:173)
`tion. Few teachers are sufficiently inspired to explain the
`problems of those suffering from pain in the light of
`present-day knowledge of psychological, social, and
`physiological factors. Lack of knowledge of this kind is
`not confined to doctors alone, for others involved in the
`care of patients are often unaware both of their role in
`treating the severely ill, and of the effects of their atti(cid:173)
`tudes towards pain upon the manner in which they treat
`it. With these points in mind it is refreshing to find that
`Dr Mehta has taken steps to correcting some of the defi-
`
`ciencies. At the outset it should be said that his book is
`primarily concerned with methods of treatment for in(cid:173)
`tractable pain, but he does not neglect to refer to the
`nature of pain and to comment upon the importance of
`the knowledge of its psychological aspects. He gives a
`brief review of the current theories which attempt to
`explain how pain becomes a conscious experience, and
`proceeds to give an analysis of conditions which give rise
`to intractable pain. The third section of his book deals
`with methods of treatment. This includes familiar ap(cid:173)
`proaches to treatment with analgesic drugs and various
`forms of injection, both locally and at sites distant from
`the pain. He also considers less commonly used methods
`of
`treating pain,
`including neurosurgical procedures,
`hypnosis, psychotherapy and even acupuncture.
`For the student of pain, intractable or otherwise, Dr
`Mehta presents us with a fascinating description of this
`area of medicine. His writing is clear and there is an even
`quality about the work, which suggests that in most areas.
`particularly those concerning treatment, he has a good
`deal of personal experience. This is not the book, how(cid:173)
`ever, for those who seek detailed accounts of the theoreti(cid:173)
`cal, physical or psychological bases for pain, but it is
`heartily recommended both for undergraduates and post(cid:173)
`graduates, although the price of £6.00 may initially seem
`a little prohibitive.
`
`M. R. Bond
`
`Hospira, Exh. 2010, p. 3