Though several
types of disinfectants can be used, most needle exchange programs distribute
alcohol swabs that serve to disinfect the injection site before injection.
Reuse and sharing
Alcohol
swabs seem to be shared less often than other paraphernalia. 23% of the
interviewed PWID in Scotland had shared alcohol swabs (Scottish Drug Forum and
Glasgow Involvement Group, 2004).
Type of disinfectant used
Different
types of disinfectants can be used; however if an alternative to alcohol is
used, this is usually Chlorhexidine. We hereby briefly describe the
characteristics of these two products.
Table 1.
Antimicrobial activity of antiseptics used in hand hygiene, adapted from WHO
(2007)
Alcohol
is an excellent antiseptic that is commonly available and inexpensive (Mangram
et al., 1999; Tietjen et al., 2003); the use of an alcohol swab on the
injection site prior to injection is advised by the world health organisation
(WHO, 2010). Solutions of 60-80% are more effective than 100% alcohol[1]. Its rapid killing
action makes it very effective in reducing the number of microorganisms on
skin. Alcohol is effective against Gram positive and Gram negative bacteria and
a variety of fungi. Additionally, alcohol has an antiviral activity against all
hepatitis viruses and HIV (WHO, 2006). Alcohol is amongst the safest known
antiseptics. Although it has no persistent killing effect; the rapid reduction
of microorganisms on skin protects against their regrowth for several hours
(WHO, 2006; Tietjen et al., 2003). However, alcohol is easily inactivated by
organic materials and should not be used on visibly soiled skin (WHO, 2010).
Chlorhexidine
is a very good antiseptic too. Its immediate antimicrobial activity is weaker
than that of alcohol, but its action lasts longer (WHO, 2006). It has a good
activity against Gram positive bacteria, but it is less effective against Gram
negative bacteria and fungi (Tietjen et al., 2003; WHO, 2006) and not effective
against tubercle bacillus (Tietjen et al., 2003). Chlorhexidine is also active
against HIV (WHO, 2006). Alcohol based Chlorhexidine solutions are more efficient
than water based solutions or wipes (Lemani et al., 2009).
The
action of Chlorhexidine is minimally affected by organic material, but natural
soaps, substances present in hard tap water and some hand creams reduce or even
neutralise its action (WHO, 2006; Tietjen et al., 2003).
Both
alcohol and Chlorhexidine are inactive against bacterial spores.
Efficacy of Alcohol Swabs
In a study that did not concern intravenous injection
and that was conducted in a hospital setting, skin disinfection has not been
proven to reduce injection site infections (SCIEH, 2004). The
authors recommended washing the injection site with soap and water.
Nevertheless, as stated, this review did not concern intravenous (IV)
injection; furthermore the environmental hygiene in a hospital setting differs
from the hygiene of some of the places where people inject drugs; soap and
running water are always available in a hospital.
In the context of drug injection, PWID do not always
have access to soap and water. Furthermore, in a study described by Scott (2008), only one
person had washed his hands prior to preparation, even though 83% (n=50) of the
injections were prepared in a building considered likely to have access to
washing facilities.
In a population of PWID, Vlahov et
al (1992) found that people who always cleaned their skin had a lower
prevalence of abscesses than others. Murphy et al. (2001) found that skin
disinfection with alcohol before injection was the only independent protective
factor (RR of 0.48). Binswanger et al. (2010) found a difference
too, though it was not statistically significant.
Viral contaminations due to the reuse and sharing
of alcohol swabs
Crofts et al. (1999) found HCV RNA on 67% of the used alcohol swabs tested.
Thibault et
al. (2011) also found HCV RNA on swabs (on up to 80%- 83% of them), however, it
is unclear whether they tested dry post injection swabs or alcohol swabs[2].
Furthermore,
Thibault et al. (2011) state that alcohol swabs can be visibly contaminated by
blood. This probably reflects inappropriate use of alcohol swabs which are
supposed to be used before injection.
These
studies detected viral RNA, it is unclear whether the virus was still
infectious. Alcohol has viriscidal properties, additional research should be
carried out to study whether the viral load is high enough to cause infection.
Other infections and overall risks associated with alcohol swab use,
reuse and sharing.
Alcohol swabs are sometimes used to clean hands and fingers, as well as some
surfaces. Though effective on skin, alcohol is not the best disinfectant for
surfaces or harm reduction tools (bleach will do better). Furthermore, alcohol
swabs are conceived to disinfect a small surface of skin.
Care should
be taken not to use the same swab to disinfect various body parts; the risk
exists to move bacteria to the injection site.
Recommendations
People
should be advised to wash their hands prior to injection; hands can be washed
with soap and water, an alcohol hand rub or wipes.
The
injection site should subsequently be disinfected with an alcohol swab.
Separate
swabs should be used for the disinfection of several body parts or for the
cleaning of considerable skin surfaces.
The
alcohol swab should be used to disinfect the injection site only. A small
surface should be disinfected. The swab should be drawn across the
injection site once only, and in one direction to avoid spreading bacteria from
another part of the skin to the injection site. The skin should then be allowed
to dry naturally prior to injection.
A
small alcohol swab is sufficient, if programs prefer to give out large ones,
they should inform their clients that these should not be used for the hands,
arm and injection site.
References
Binswanger,
IA, Kral, AH, Bluthenthal, RN, Rybold, DJ,Edlin, BR (2000) High Prevalence of
Abscesses and Cellulitis Among Community-Recruited Injection Drug Users in San Francisco Clin Infect Dis.30 (3):579-581
Mangram AJ, Horan TC, Pearson ML; Silver LC, Jarvis WR
(1999) Guideline for Prevention of Surgical Site Infection, 1999 Infection
Control and Hospital Epidemiology. 20 (4): 250-280
Murphy
EL, DeVita D, Liu H, Vittinghoff E, Leung P, Ciccarone DH, Edlin BR.(2001) Risk
Factors for Skin and Soft-Tissue Abscesses among Injection Drug Users: A
Case-Control Study Clin Infect Dis. (2001) 33 (1): 35-40
Vlahov D, Sullivan M, Astemborski J, Nelson KE (1992) Bacterial Infections and Skin Cleaning Prior to Injection Among
Intravenous Drug Users. Public Health Rep 107(5):595-598
WHO
(2006). WHO Guidelines on hand hygiene in Health Care. (Advanced Draft)
WHO (2009) WHO Guidelines on Hand Hygiene in
Health Care : a Summary.
WHO (2010) WHO best practices for injections and related
procedures toolkit. ISBN 978 92 4 159925 2
[1] The action of alcohol results from
its ability to denature proteins and proteins are not easily denatured in the
absence of water.
[2]In the articles text, it is
outlined that alcohol swabs and dry post injection swabs have been pooled,
however in the article’s table, they state that this concerns cotton swabs
