Use Of Multidose Vials Research Articles

Latent factors affecting safer injection practices that can reduce infections and how education can improve them.

The incidence of healthcare-associated infections, particularly injection-related infections, can increase patient comorbidities even in countries with adequate medical resources. Although there are clear guidelines for injection practices to prevent infections, their application in clinical settings is insufficient. Therefore, the objective of this study was to identify factors affecting injection practices associated with reduced infections by conducting surveys targeting practicing healthcare providers involved in administering injections at each healthcare organization and performing data analysis. We administered a survey to healthcare providers responsible for injection practices at each healthcare organization that included items related to infection-safe injection practice guidelines. All survey questions were reviewed by an expert panel of infectious disease and infection control nurses. Survey contents were subjected to exploratory factor analysis (EFA), confirmatory factor analysis, and multivariable robust regression tests to determine the impact of each factor and their correlations. A total of 842 questionnaires were analyzed. Each questionnaire was classified into four factors: reuse and contamination, compliance with aseptic technique, exchange of infusion set, and use of multidose vials. Nurses with higher careers showed more compliance. Education within one year and awareness of each item of the questionnaire had positive associations with proper injection practice. Education is thought to be the most important factor in good injection practices that could reduce infections. Relevant knowledge through timely training is expected to have a positive impact on performance and compliance related to safe injections.

Inundative, Dry-Powder, Inhaled Measles Vaccination to Prevent Deaths of Young Children in War-torn Regions.

Children living in war-torn and geographically remote regions often die from measles due to undervaccination. Protective community immunity could be safely improved through the comprehensive use of small, inexpensive, easy-to-use, dry-powder aerosolized measles vaccination inhalers. Influential local community members could be engaged to provide risk counseling and inform their peers of measles risks to inspire vaccine uptake. Vaccination by inhaled live attenuated measles vaccine has been shown to be safe and protective among several million research subjects and omits (1) needles, syringes, glass vials, and specialized disposal systems; (2) deadly vaccine reconstitution errors; (3) cold chain technology to protect temperature-sensitive vaccine; (4) vaccine wastage associated with suboptimal use of multidose vials; (5) trained vaccinators; (6) food, housing, and transportation costs associated with centralized vaccination campaigns; and (7) risk of violence to vaccinators and associated staff. All elements for inhaler-based measles vaccination are readily available. Dry-powder measles vaccine inhalers can be assembled and distributed to save lives.

Safe injection, infusion and medication-vial practices at a tertiary care centre: a quality improvement initiative.

There is a risk of transmission of viruses and microbial pathogens during routine health care procedures due to improper injection, infusion, and medication-vial practices. Unsafe practices lead to outbreaks of infection resulting in unacceptable and devastating events in patients. The present study was undertaken to assess the compliance of nurses with safe injection and infusion practices in our hospital and to identify staff education requirements in relation to the safe-injection and infusion practices policy. Baseline data were collected and high risk areas were identified on this basis, a quality improvement project was implemented by infection control team. FOCUS PDCA methodology was used to conduct the improvement process. The study was performed from March to September 2021. An audit checklist based on the CDC guidelines was used for monitoring compliance with safe injection and infusion practices. Poor compliance with safe injection and infusion practices in few clinical areas at baseline. During the pre-intervention period, non-compliance was mainly seen with the following elements: aseptic technique (79%), rubber septum disinfected with alcohol (66%), labelling of all IV lines and medications with date and time (83%), compliance with multidose-vial policy (77%), use of multidose vials for single patient (84%), safe disposal of sharps (84%), using trays instead of clothing/pockets to carry medications (81%). There was significant improvement in compliance with the following elements of safe injection and infusion practices in the post-intervention period: aseptic technique (94%), rubber septum disinfected with alcohol (83%), compliance with multidose-vial policy (96%), use of multidose vials for single patient only (98%), safe disposal of sharps (96%). Adherence to safe injection and infusion practices is very important to prevent outbreaks of infection in health care settings.

An outbreak of hepatitis C virus attributed to the use of multi-dose vials at a colonoscopy clinic, Waterloo Region, Ontario.

Hepatitis C virus (HCV) transmission has been epidemiologically linked to healthcare settings, particularly out-of-hospital settings such as endoscopy clinics and hemodialysis clinics. These have been largely attributed to lapses in infection prevention and control practices (IPAC). To describe the public health response to an outbreak of HCV that was detected among patients of a colonoscopy clinic in Ontario, and to highlight the risks of using multi-dose vials and the need for improved IPAC practices in out-of-hospital settings. Screening for HCV was conducted on patients and staff who attended or worked at the clinic within the same timeframe as the index case's procedure. Blood samples from positive cases underwent viral sequencing. Inspections of the clinic assessed IPAC practices, and a chart review was done to identify plausible mechanisms for transmission. A total of 38% of patients who underwent procedures at the clinic on the same day as the index case tested positive for HCV. Genetic sequencing showed a high degree of similarity in the HCV genetic sequence among the samples positive for HCV. Chart review and clinic inspection identified use of multi-dose vials of anesthesia medication across multiple patients as the plausible mechanism for transmission. Healthcare workers, especially those in out-of-hospital procedural/surgical premises, should be vigilant in following IPAC best practices, including those related to the use of multi-dose vials, to prevent the transmission of bloodborne infections in healthcare settings.

Increasing Medication Access by Promoting Appropriate Use of Multi-dose Vials.

Medication shortage is a problem that affects patients, providers, and institutions of all sizes and scope across the United States. The objective of this quality improvement project was to promote the appropriate use of multi-dose vials (MDVs) by anesthesia providers at an independent plastic surgery office. Multi-dose vials can be used to decrease waste and potentially cost, thus increasing access to necessary medications for the patients at this practice. A focus group was used to obtain an understanding of barriers to the use of MDVs at this practice. A focused E-learning module on safe use based on established guidelines was then created, and a simplified flow sheet was implemented and placed in medication preparation areas as a cognitive aid. The education and flow sheet focused on identification and preparation of the medication area, proper identification of MDVs versus single-use vials, hand hygiene, proper beyond-use labeling, septum cleaning, use of a new sterile syringe and needle, and administration time frames. Provider feedback included high levels of satisfaction with the E-learning module. Our comparison of the use of ketamine from MDVs during the pre- and postimplementation phases showed a 14% increase in the number of doses used per vial. This finding suggests that were similar practices implemented at a larger site with MDVs of medications other than ketamine, resources could be impacted to manage shortages and increase access to medications.

Increasing Medication Access by Promoting Appropriate Use of Multi-dose Vials.

Increasing Medication Access by Promoting Appropriate Use of Multi-dose Vials.

Use of a radiopharmaceutical multidose dispenser for positron emission tomography: Risk assessment and mitigation measures for infection prevention.

Positron emission tomography (PET) imaging necessitates the use of multidose vials for radiopharmaceutical delivery to patients. Conventional practices involve manual extraction of radiopharmaceuticals from a multidose vial prior to each PET procedure, which exposes the technologist to increasing levels of radiation and poses a potential infection risk to patients with frequent handling and access of the vial. New technologies for automated dosing and infusion delivery are available, however these incorporate both a multidose vial and a multi-patient infusion set. There is an absence of guidance for infection prevention (IP) units regarding the safety and acceptability of these devices. This paper describes the process of risk assessment and the mitigation measures for training, workflows, and documentation which led to the safe introduction of an automated PET infusion device in a large tertiary public healthcare facility.

Assessment of the infection prevention and control learning needs of Ottawa community-based healthcare providers

Background: Under the Health Protection and Promotion Act and Infection Prevention and Control (IPAC) Complaint Protocol, Ontario public health units are mandated to respond to IPAC complaints about community-based clinical offices. From 2015 to 2018, Ottawa Public Health noted a seven-fold increase in IPAC complaints involving medical and dental settings. In response, we sought to assess the IPAC learning needs of our community-based healthcare providers. Specifically, our objectives were to assess: 1) clinical practice characteristics, 2) current IPAC practices, 3) IPAC knowledge, 4) barriers/facilitators to adherence to IPAC best practices, and 5) preferred IPAC professional development activities. Methods: An anonymous online survey targeting Ottawa community-based healthcare providers was disseminated through multiple methods including through Ottawa Public Health’s (OPH) subscription-based e-bulletin to physicians. The short survey questionnaire included Likert-scale, multiple choice, and open-ended questions. Data collection began in August 2018; a descriptive analysis was conducted using data extracted on January 19, 2019. Results: Our findings suggest that medical respondents may not be as aware of IPAC practices in their clinic as dental respondents were. Familiarity with IPAC best practice documents was also higher among dental respondents, as compared to medical respondents. IPAC knowledge-testing questions revealed that more medical than dental respondents knew the appropriate use of multi-dose vials, and that few medical respondents knew the IPAC best practices for point-of-care glucose monitoring equipment. Respondents recognized the importance of adhering to IPAC best practices to prevent healthcare-associated infections; however, lack of evidence and cost were selfreported barriers to adherence to IPAC best practices. Over half of all medical and dental respondents surveyed were interested in a voluntary audit of their IPAC practices to help meet their IPAC professional development needs. Conclusions: Findings from this needs assessment helped describe current IPAC practices and knowledge, identify barriers and facilitators to adherence to IPAC best practices, and understand the learning preferences of Ottawa community-based healthcare providers. This information will be instrumental in planning future IPAC capacity-building activities and tailoring these activities to specific professional groups in Ottawa and potentially beyond.

Barriers and Facilitators to Injection Safety in Ambulatory Care Settings.

OBJECTIVEIdentify factors referred to as barriers and facilitators that can prevent or assist safe injection practices in ambulatory care settings to guide quality improvement.DESIGNIn this mixed-methods study, we utilized observations and interviews.SETTINGThis study was conducted at ambulatory clinics at a midwestern academic medical center from May through August 2017. Sites included a variety of clinical settings that performed intramuscular, intradermal, intravenous, or intra-articular injections.PARTICIPANTS AND INTERVENTIONSDirect observations of injections and interviews of ambulatory care staff were conducted. An observation checklist was created, including standards of injection safety from nationally recognized guidelines. Interview questions were developed using the System Engineering Initiative for Patient Safety (SEIPS) model. Interviews were recorded, transcribed, and then coded by 2 investigators.RESULTSIn total, 106 observations and 36 interviews were completed at 21 clinics. Injection safety standards with the lowest adherence included using needleless access devices to prepare injections (33%) and the proper use of multidose vials (<80%). Of 819 coded interview segments, 461 (56.3%) were considered facilitators of safe injection practices. The most commonly identified barriers were patient movement during administration, feeling rushed, and inadequate staffing. The most commonly identified facilitators were availability of supplies, experience in the practice area, and availability of safety needles and prefilled syringes.CONCLUSIONSPerceived barriers and facilitators to infection control elements of injection safety are interconnected with SEIPS elements of persons, organizations, technologies, tasks, and environment. Direct observations demonstrated that knowledge of safety injection standards does not necessarily translate to best practices and may not match self-reported data.Infect Control Hosp Epidemiol 2018;39:841-848.

The impact of Bacille Calmette-Guérin shortage on immunisation practice and policies in Europe – A Paediatric Tuberculosis Network European Trials Group (ptbnet) survey

Recent reports indicate an ongoing BCG shortage that may influence immunisation practice. This study aimed to determine current availability of BCG vaccine across Europe, and implications on immunisation practices and policies in Europe. Web-based survey among Paediatric Tuberculosis Network European Trials Group (ptbnet) members, between May and October 2015. Twenty individuals from 13 European countries participated. Ongoing shortages were reported in eight countries routinely using BCG (8/11, 73%). As a consequence of the shortage, BCG was not given as completely unavailable in some countries (2/8, 25%), was given only whenever available (1/8, 13%), or only in certain regions of the country (1/8, 13%). Strategies reported to reduce loss of immunisation were administration to selected high-risk individuals (2/8, 25%), or cohorting vaccinees on specific days to maximise the use of multi-dose vials (3/8, 38%). Authorities in two countries each were considering a change of manufacturer/supplier (2/8, 25%). The BCG shortage in Europe leads to significant changes in immunisation policies including changes of BCG vaccine strain and manufacturer. In addition, infants and children eligible for immunisation are at risk of not receiving BCG. To ensure necessary BCG immunisations, collaboration between national health agencies and vaccine manufacturers is crucial.

Nosocomial outbreak of hepatitis B virus infection in a pediatric hematology and oncology unit in South Africa: Epidemiological investigation and measures to prevent further transmission.

Hospital-acquired hepatitis B virus (HBV) infection has been well described and continues to occur worldwide. Recent nosocomial outbreaks have been linked to unsafe injection practices, use of multi-dose vials, and poor staff compliance with standard precautions. This report describes a nosocomial outbreak that occurred in a pediatric hematology and oncology unit of a large academic hospital, the epidemiological investigation of the outbreak, and preventive measures implemented to limit further in-hospital transmission. Outbreak investigation including contact tracing and HBV screening were initially carried out on all patients seen by the unit during the same period as the first three cases. Routine screening for the entire patient population of the unit was initiated in February 2013 when it was realized that numerous patients may have been exposed. Forty-nine cases of HBV infection were confirmed in 408 patients tested between July 2011 and October 2013. Phylogenetic analysis of the HBV preC/C gene nucleotide sequences revealed that all tested outbreak strains clustered together. Most (67%) patients were HBeAg positive. The cause of transmission could not be established. Preventive measures targeted three proposed routes. HBV screening and vaccination protocols were started in the unit. The high number of HBeAg positive patients, together with suspected lapses in infection prevention and control measures, are believed to have played a major role in the transmission. Measures implemented to prevent further in-hospital transmission were successful. On-going HBV screening and vaccination programs in pediatric hematology and oncology units should become standard of care.

Critical evaluation of the off-label indication and of the risks associated to the use of multi-dose vials on the treatment of age-related macular degeneration

Age-related macular degeneration (AMD) is an ocular inflammatory diseases treated mainly by means of a bevacizumab (Avastin®) or ranibizumab (Lucentis®) intravitreal injection. Among these drugs, only ranibizumab has a specific therapeutic indication for AMD. Considering that, the off-label use on ophthalmic therapy seems to become a rule when it should be an exception. Furthermore, bevacizumab presentation consists of multi-dose vials although it does not contain preservatives in its formula. The current literature review aimed at assessing the risks for the patient related to the use of off-label indication and multi-dose vials on AMD treatment. Considering this, the proposal related to the Brazilian Public Consultation no.10, dated September 12, 2012, which proposes the Clinical Protocol and Therapeutic Guidelines for AMD treatment, was evaluated. This systematic review allowed to conclude that the bevacizumab off-label indication results in increased risks for the patient when compared to the product with specific therapeutic indication for AMD treatment (ranibizumab), especially referring to the significant raise in the adverse events. The risks for the patient related to the multi-dose vial use, referring to the microbiological stability and dose precision, were also made clear.

Pseudo-Outbreak ofKlebsiella oxytocaSpontaneous Bacterial Peritonitis Attributed to Contamination of Multidose Vials of Culture Medium Supplement

To determine the source of a cluster of Klebsiella oxytoca isolates cultured from peritoneal fluid of 3 patients with cirrhosis on a single day. Outbreak investigation and before-after study. A Veterans Affairs medical center. Epidemiologic investigation, analysis of antimicrobial susceptibility testing results and molecular typing of K. oxytoca isolates with repetitive sequence-based polymerase chain reaction (rep-PCR), review of microbiology laboratory procedures for processing peritoneal fluid cultures, and comparison of peritoneal fluid contamination rates 18 months before and after modification of laboratory procedures for culturing peritoneal fluid. Each of the peritoneal fluid samples that grew K. oxytoca was inoculated into blood culture bottles by different clinicians at different hospital locations. None of the patients had clinical findings suggestive of peritonitis or elevated polymorphonuclear cell counts in peritoneal fluid (range, 3-25 cells/μL). Molecular typing with rep-PCR demonstrated that the K. oxytoca isolates were genetically related (greater than 95% similarity). Laboratory procedures included the routine addition of a culture medium supplement of yeast extract and dextrose from a multidose vial into blood culture bottles with peritoneal fluid. After discontinuing use of the culture medium supplement, there was a marked reduction in the number of peritoneal fluid cultures deemed as contaminants (14.3% vs 0.9%; [Formula: see text]). A pseudo-outbreak of K. oxytoca peritonitis and high rates of contamination of peritoneal fluid were attributable to contamination of a multidose culture medium supplement. This article highlights the importance of discouraging the use of multidose vials in all clinical settings.

Health care-associated hepatitis C virus infection.

Hepatitis C virus (HCV) is a blood-borne pathogen that has a worldwide distribution and infects millions of people. Care-associated HCV infections represented a huge part of hepatitis C burden in the past via contaminated blood and unsafe injections and continue to be a serious problem of public health. The present review proposes a panorama of health care-associated HCV infections via the three mode of contamination that have been identified: (1) infected patient to non-infected patient; (2) infected patient to non-infected health care worker (HCW); and (3) infected HCW to non infected patient. For each condition, the circumstances of contamination are described together with the means to prevent them. As a whole, the more important risk is represented by unsafe practices regarding injections, notably with the improper use of multidose vials used for multiple patients. The questions of occupational exposures and infected HCWs are also discussed. In terms of prevention and surveillance, the main arm for combating care-associated HCV infections is the implementation of standard precautions in all the fields of cares, with training programs and audits to verify their good application. HCWs must be sensitized to the risk of blood-borne pathogens, notably by the use of safety devices for injections and good hygiene practices in the operating theatre and in all the invasive procedures. The providers performing exposed-prone procedures must monitor their HCV serology regularly in order to detect early any primary infection and to treat it without delay. With the need to stay vigilant because HCV infection is often a hidden risk, it can be hoped that the number of people infected by HCV via health care will decrease very significantly in the next years.

Remembering the importance of preventing blood‐borne infections in the critical care setting

Remembering the importance of preventing blood‐borne infections in the critical care setting

The use of multidose vials and fingerstick blood sampling devices in Korean emergency departments and intensive care units

This study was performed to compare compliance with standard precautions for the use of multidose vials (MDVs) and fingerstick devices in emergency departments (EDs) and intensive care units (ICUs). Between December 2007 and February 2008, 389 nurses from the EDs or ICUs of six university-affiliated hospitals in Korea were asked to complete the questionnaire. A total of 338 (86.9%) nurses completed the survey, corresponding to 159 of 184 ED and 179 of 205 ICU nurses. A comparison of MDV use in EDs and ICUs indicated a significant difference only in disinfection of the rubber septum of heparin vials; 88.1% of ED nurses and 96.6% of ICU nurses stated that they always disinfected the rubber septum of heparin vials whenever drawing medication (P = 0.003). The use of separate fingerstick devices for each patient (71.7% vs. 54.5%) and disinfection of these devices after each use (36.5% vs. 26.0%) were more common in ED nurses. The rate of good hand hygiene was lower in ED nurses, both before (43.7% vs. 74.3%) and after (64.6% vs. 91.6%) the use of fingerstick devices (P < 0.001 for both). There is a need to improve compliance with standard precautions, especially hand hygiene, in EDs.

Vaccination, consent and multidose vials

Multidose vials (MDVs) for injectable therapeutic agents, including vaccines, pose a risk of infection to injected patients as a result of contamination of the vials. The Australian Government Department of Health and Ageing (DoHA) distributed the vaccine against pandemic (H1N1) 2009 influenza in MDVs. The distribution was accompanied by consent forms. The consent forms provided an inadequate basis for a discussion with patients about the risks associated with the use of MDVs. The High Court of Australia has previously held that medical practitioners who fail to explain the material risks of medical procedures to their patients might be held liable in negligence for any adverse sequelae of the procedures, even if the risks are very low. Medical practitioners, nurses, medical indemnity insurers and the DoHA should prepare now for the probable future use of MDVs by developing a consent form that would provide a solid foundation for a discussion of material risks with patients seeking vaccination.

Patient-to-patient transmission of hepatitis C virus (HCV) during colonoscopy diagnosis

BackgroundNo recognized risk factors can be identified in 10-40% of hepatitis C virus (HCV)-infected patients suggesting that the modes of transmission involved could be underestimated or unidentified. Invasive diagnostic procedures, such as endoscopy, have been considered as a potential HCV transmission route; although the actual extent of transmission in endoscopy procedures remains controversial. Most reported HCV outbreaks related to nosocomial acquisition have been attributed to unsafe injection practices and use of multi-dose vials. Only a few cases of likely patient-to-patient HCV transmission via a contaminated colonoscope have been reported to date. Nosocomial HCV infection may have important medical and legal implications and, therefore, possible transmission routes should be investigated. In this study, a case of nosocomial transmission of HCV from a common source to two patients who underwent colonoscopy in an endoscopy unit is reported.ResultsA retrospective epidemiological search after detection of index cases revealed several potentially infective procedures: sample blood collection, use of a peripheral catheter, anesthesia and colonoscopy procedures. The epidemiological investigation showed breaches in colonoscope reprocessing and deficiencies in the recording of valuable tracing data. Direct sequences from the NS5B region were obtained to determine the extent of the outbreak and cloned sequences from the E1-E2 region were used to establish the relationships among intrapatient viral populations. Phylogenetic analyses of individual sequences from viral populations infecting the three patients involved in the outbreak confirmed the patient pointed out by the epidemiological search as the source of the outbreak. Furthermore, the sequential order in which the patients underwent colonoscopy correlates with viral genetic variability estimates.ConclusionsPatient-to-patient transmission of HCV could be demonstrated although the precise route of transmission remained unclear. Viral genetic variability is proposed as a useful tool for tracing HCV transmission, especially in recent transmissions.

Sharp injuries and their determinants among health care workers at first-level care facilities in Sindh Province, Pakistan

To assess the rate and determinants of sharp injuries during the previous 6 months among health care workers at first-level care facilities in two districts of Pakistan. Cross-sectional survey at public, general practitioners and non-licensed private practitioners selected through stratified random sampling. At each facility, we interviewed a prescriber and a dispenser/injection provider about knowledge of bloodborne pathogens transmission and preventive practices, risk perception, and use of precautions and sharp injuries received during the previous 6 months. Multivariable Poisson regression was used to assess the factors associated with the number of sharp injuries. Fifty-four percentage of the 233 workers had at least one injury during the previous 6 months. The overall rate of sharp injuries per person per year was 3.7; among non-physician prescribers (9%), it was 4.3; among dispensers (69%), it was 3.7, and among physicians (18%), it was 2.1. In the multivariable model, work experience, risk perception and type of health care worker were significantly associated with receiving sharp injuries during the previous 6 months. In the model including dispensers only, a higher knowledge score was associated with fewer sharp injuries, while perceived severity of disease and lack of professional qualification were associated with more. Sharp injuries are common in Pakistan. Better knowledge about modes of bloodborne pathogen transmission and professional qualification may reduce their incidence.

Healthcare-associated hepatitis C virus transmission among patients in an abdominal organ transplant center.

De novo hepatitis C virus (HCV) infection among transplant patients is rarely recognized but can have severe consequences. We investigated the scope, source, and mode of HCV transmission within a transplant center after incident HCV infection was identified in 2 patients who had liver transplantation in late 2006. Patients were interviewed, and transplant logs, medical records, and staff practices were reviewed to identify opportunities for HCV transmission. Infection via receipt of blood or organs was evaluated. Molecular epidemiology was used to determine the relatedness between persons with incident and chronic HCV infection. HCV from infected blood or organ donors was ruled out. Among the 308 patients who underwent transplant in 2006, no additional incident HCV infections were identified. Eighty-five (28%) had pre-transplant chronic HCV infection; 13 were considered possible HCV source patients based upon shared days on the inpatient unit, nursing assignment, or invasive procedures in common with incident HCV case-patients. Viral isolates from 1 HCV source patient and 1 incident case-patient were found to be highly related by quasispecies analysis, confirming patient-to-patient HCV transmission. Possible modes of transmission identified were the improper use of multidose vials, sharing of blood-contaminated glucometers, and touch contamination. Sporadic transmission or endemic levels of HCV transmission might be overlooked in a setting with high HCV prevalence, such as liver transplant units, where multiple, repeated opportunities for patient-to-patient HCV transmission can occur. Surveillance through pre- and post-transplant screening is necessary to identify incident HCV infection in this setting. Constant, meticulous attention must be paid to maintaining aseptic technique and good infection control practices to eliminate HCV transmission opportunities.