Saline Syringes Research Articles

Preventing Outbreaks

Archives of Internal Medicine Multistate Outbreak of Serratia marcescens Bloodstream Infections Caused by Contamination of Prefilled Heparin and Isotonic Sodium Chloride Solution Syringes David Blossom, MD; Judith Noble-Wang, PhD; John Su, MD; Stacy Pur, RN, BSN; Roy Chemaly, MD, MPH; Alicia Shams; Bette Jensen, MMSc; Neil Pascoe, RN, CIC; Jessica Gullion, PhD; Eric Casey, BA; Mary Hayden, MD; Matthew Arduino, PhD; Daniel S. Budnitz, MD, MPH; Isaam Raad, MD; Gordon Trenholme, MD; Arjun Srinivasan, MD; for the Serratia in Prefilled Syringes Investigation Team Group Background To investigate clusters of Serratia marcescens (SM) bloodstream infections (BSIs) at health care facilities in several states and determine whether contaminated prefilled heparin and isotonic sodium chloride solution (hereinafter, saline) syringes from a single manufacturer (company X) were the likely cause, we performed an outbreak investigation of inpatient and outpatient health care facilities from October 2007 through February 2008. Methods Active case finding for clusters of SM BSIs. Information on SM BSIs was obtained, and SM blood isolates were sent to the Centers for Disease Control and Prevention (CDC). Culture specimens were taken from various lots of prefilled heparin and saline syringes by health care facilities and the CDC to test for the presence of SM. The SM isolates from syringes and blood were compared by pulsed-field gel electrophoresis. Results A total of 162 SM BSIs in 9 states were reported among patients at facilities using prefilled heparin and/or saline syringes made by company X. Cultures of unopened prefilled heparin and saline syringes manufactured by company X grew SM. Of 83 SM blood isolates submitted to the CDC from 7 states, 70 (84%) were genetically related to the SM strain isolated from prefilled syringes. A US Food and Drug Administration inspection revealed that company X was not in compliance with quality system regulations. Conclusions A multistate outbreak of SM BSIs was associated with intrinsic contamination of prefilled syringes. Our investigation highlights important issues in medication safety, including (1) the importance of pursuing possible product-associated outbreaks suggested by strong epidemiologic data even when initial cultures of the suspected product show no contamination and (2) the challenges of medical product recalls when production has been outsourced from one company to another.

Multistate Outbreak of Serratia marcescens Bloodstream Infections Caused by Contamination of Prefilled Heparin and Isotonic Sodium Chloride Solution Syringes

To investigate clusters of Serratia marcescens (SM) bloodstream infections (BSIs) at health care facilities in several states and determine whether contaminated prefilled heparin and isotonic sodium chloride solution (hereinafter, saline) syringes from a single manufacturer (company X) were the likely cause, we performed an outbreak investigation of inpatient and outpatient health care facilities from October 2007 through February 2008. Active case finding for clusters of SM BSIs. Information on SM BSIs was obtained, and SM blood isolates were sent to the Centers for Disease Control and Prevention (CDC). Culture specimens were taken from various lots of prefilled heparin and saline syringes by health care facilities and the CDC to test for the presence of SM. The SM isolates from syringes and blood were compared by pulsed-field gel electrophoresis. A total of 162 SM BSIs in 9 states were reported among patients at facilities using prefilled heparin and/or saline syringes made by company X. Cultures of unopened prefilled heparin and saline syringes manufactured by company X grew SM. Of 83 SM blood isolates submitted to the CDC from 7 states, 70 (84%) were genetically related to the SM strain isolated from prefilled syringes. A US Food and Drug Administration inspection revealed that company X was not in compliance with quality system regulations. A multistate outbreak of SM BSIs was associated with intrinsic contamination of prefilled syringes. Our investigation highlights important issues in medication safety, including (1) the importance of pursuing possible product-associated outbreaks suggested by strong epidemiologic data even when initial cultures of the suspected product show no contamination and (2) the challenges of medical product recalls when production has been outsourced from one company to another.

Infection risk associated with a closed luer access device

The potential for microbial contamination associated with a recently developed needleless closed luer access device (CLAD) (Q-Syte; Becton Dickinson, Sandy, UT, USA) was evaluated in vitro. Compression seals of 50 multiply activated Q-Syte devices were inoculated with Staphylococcus epidermidis NCTC 9865 in 25% (v/v) human blood and then disinfected with 70% (v/v) isopropyl alcohol followed by flushing with 0.9% (w/v) sterile saline. Forty-eight of 50 (96%) saline flushes passed through devices that had been activated up to a maximum of 70 times remained sterile. A further 25 Q-Syte CLADs that had undergone multiple activations were challenged with prefilled 0.9% (w/v) sterile saline syringes, the external luer tips of which had been inoculated with S. epidermidis NCTC 9865 prior to accessing the devices. None of the devices that had been accessed up to 70 times allowed passage of micro-organisms, despite challenge micro-organisms being detected on both the syringe tip after activation and the compression seals before decontamination. These findings suggest that the Q-Syte CLAD may be activated up to 70 times with no increased risk of microbial contamination within the fluid pathway. The device may also offer protection from the external surface of syringe tips contaminated with micro-organisms.

Interventions To Control an Epidemic of Bloodstream Infections due to Mycobacterium

BACKGROUND: Rapid growing Mycobacterium species are commonly found in water environments but are rarely associated with bloodstream infections (BSIs). During February–June 2002, an outbreak of BSIs due to M. chelonae and M. fortuitum was documented. The objective of this study was to describe the outbreak investigation and the interventions implemented to control the epidemic. METHODS: Isolation of M. chelonae or M. fortuitum from one or more blood cultures in a patient with a central venous catheter (CVC) was the case definition. Five patients met the case definition. All patients had underlying malignancies. None of the patients have evidence of local CVC site infection. Prior to development of infection, all patients had the CVC accessed for flushing. No common medications or caregivers were identified. Pulsed-field gel electrophoresis identified as identical three of four M. fortuitum strains. All environmental cultures were repeatedly negative. We hypothesized that the epidemic was likely related to the CVC flushing procedure and the following interventions were implemented: 1) do not open packages containing profiled saline syringes until immediately prior to use, 2) do not remove the cap and put the needleless device on the syringe until immediately prior to use. The success of control measures was determined by monitoring for recurrence. RESULTS: No additional cases of M. chelonae or M. fortuitum were identified in blood cultures after implementation of control measures. This study indicates that an epidemic of M. chelonae or M. fortuitum may result from intermittent, extrinsic contamination of sterile, preservative-free intravenous flush solutions.

Injektionsautomaten in der Magnetresonanz- und Computertomographie: Pilotstudie zu hygienischen Aspekten

To evaluate hygienic conditions using automatic injectors in magnetic resonance imaging (MRI) and computed tomography (CT) during clinical routine. The surfaces of medical devices (e. g., control console) and the palms of the technical and medical staff were microbiologically analyzed by taking imprints before and after hygienic education. In addition, the injector syringes for contrast medium (CM) and saline were checked for microbiological contamination following multiple (MRI: 14 h; CT 8 h) and single use. Furthermore, the potential of retrograde contamination from the patient along the tube was analyzed. A bacterial contamination with typical dermal bacteria was documented for the surfaces of the medical devices, the palms of the technical and medical staff, and the injection syringes following multiple use (MRI: 10/10 CM syringes, 6/10 saline syringes; CT: 8/10 CM syringes, 5/10 saline syringes). Correct hand disinfection in combination with single use of syringes avoided bacterial colonization. Retrograde bacterial contamination from the patient was not observed. Regular hygienic teaching sessions for technical and medical staff in MRI and CT departments using automatic injectors should be mandatory. Furthermore, the multiple use of syringes should be avoided until investigations addressing the potential of bacterial contamination are performed.

A method of invaginating the facial vein for inferior alveolar nerve repair

Autogenous vein grafting has been previously described as a successful method of bridging defects in the inferior alveolar and peripheral nerves.1,2 Neuronal elements are able to grow along the lumen of the vein graft. However, animal studies have shown that the contact between the endothelial cells of the transplanted venous segment and nervous tissue initiates the development of connective tissue and may cause constriction of the nerve. This process may begin before axons can regenerate and compromise full regeneration of the nerve. Collagen and laminin have been shown to promote nerve regeneration. The vein wall consists of 3 layers: the endothelial layer containing a laminin-rich basal lamina, the media containing a thin muscle layer that is also rich in laminin, and the adventitia that is rich in collagen. Turning the vein inside-out such that the adventitia forms the lumen of the conduit has been shown in animal studies to expose the regenerating axons directly to the collagen-rich adventitia, allowing permeability of external factors and trophic and neurite-promoting factors that line the adventitia.3,4 Invaginated vein grafts have been reported to significantly increase regenerative axonal counts, with greater extent of early myelination and richer blood supply compared with conventional nerve grafting and standard vein grafts.4-6 In electromyographic studies on inside-out vein grafts, Wang et al5 showed faster conduction velocities compared with nerve grafting, the gold standard of peripheral nerve gap repair. Therefore, in theory, inverting the vein may release the full potential growth of the nerve fascicles anastomosed to the vessel. The following is a method for the inversion of small-caliber veins (eg, the facial vein) that we have successfully used. An 18-gauge angiocatheter with saline syringe is

Selective induction of c-Fos immunoreactivity in the prelimbic cortex during reinstatement of heroin seeking induced by acute food deprivation in rats

We previously reported that acute 1-day food deprivation reinstates heroin seeking in rats. The goal of the present study was to begin identifying brain sites potentially involved in this effect. For this purpose, we measured, by immunohistochemistry, the expression of c-Fos following a test for food deprivation-induced reinstatement. Groups of rats ( n=9–10 per group) were trained to lever-press for heroin (0.05–0.1 mg/kg/infusion) or saline for 10 days (9 h/day); each infusion was paired with a cue light. Rats were then given 10 days of extinction during which the heroin and saline syringes were removed. Next, a test for reinstatement was conducted after exposure to 0 (baseline) or 1-day food deprivation. During training, lever pressing for heroin increased over days, while responding for saline infusions paired with the cue light decreased over time. During extinction, responding on the heroin-paired lever decreased over time, while responding on the saline-paired lever remained low. In heroin-trained rats, food deprivation induced a large increase in responding on the lever associated with drug infusions. Surprisingly, food deprivation also modestly increased responding in the saline-trained rats. Food deprivation selectively increased c-Fos immunoreactivity (IR) in the prelimbic cortex of heroin-trained, but not saline-trained, rats ( n=4 per condition). Food deprivation also increased c-Fos IR in both heroin- and saline-trained rats in the basolateral amygdala and the ventrolateral bed nucleus of stria terminalis (BNST), but had no effect on c-Fos expression in the dorsolateral BNST, cingulate cortex, nucleus accumbens, and central amygdala. These results raise the possibility that the prelimbic cortex is involved in food deprivation-induced reinstatement of heroin seeking.

Nosocomial transmission of hepatitis C virus associated with the use of multidose saline vials.

To identify the source of an outbreak of acute hepatitis C virus (HCV) infection among 3 patients occurring within 8 weeks of hospitalization in the same ward of a Florida hospital during November 1998. A retrospective cohort study was conducted among 41 patients hospitalized between November 11 and 19, 1998. Patients' blood was tested for antibodies to HCV, and HCV RNA-positive samples were genotyped and sequenced. Of the 41 patients, 24 (59%) participated in the study. HCV genotype lb infections were found in 5 patients. Three of 4 patients who received saline flushes from a multidose saline vial on November 16 had acute HCV infection, whereas none of the 9 patients who did not receive saline flushes had HCV infection (P = .01). No other significant exposures were identified. The HCV sequence was available for 1 case of acute HCV and differed by a single nucleotide (0.3%) from that of the indeterminate case. This outbreak of HCV probably occurred when a multidose saline vial was contaminated with blood from an HCV-infected patient Hospitals should emphasize adherence to standard procedures to prevent blood-borne infections. In addition, the use of single-dose vials or prefilled saline syringes might further reduce the risk for nosocomial transmission of blood-borne pathogens.