Bestinfectioncontrolpracticesforintradermal,subcutaneous ...

1 Best infection control practices for intradermal, subcutaneous,and intramuscular needle injectionsYvan Hutin,1 Anja Hauri,2 Linda Chiarello,3 Mary Catlin,4 Barbara Stilwell,2 Tesfamicael Ghebrehiwet,5 Julia Garner,2& the Members of the Injection Safety Best Practices Development GroupObjectiveTo draw up evidence-based guidelines to make injections development group summarized evidence-based best practices for preventing injection-associated infections in resource-limited settings. The development process included a breakdown of the WHO reference definition of a safe injection into a list ofpotentially critical steps, a review of the literature for each of these steps, the formulation of best practices, and the submission of thedraft document to peer unnecessary injections is the highest priority in preventing injection-associated infections.

2 However, whenintradermal, subcutaneous, or intramuscular injections are medically indicated, best infection control practices include the use of sterileinjection equipment, the prevention of contamination of injection equipment and medication, the prevention of needle-stick injuries tothe provider, and the prevention of access to used availability of best infection control practices for intradermal, subcutaneous, and intramuscular injections will providea reference for global efforts to achieve the goal of safe and appropriate use of injections. WHO will revise the best practices five yearsafter initial development, in , Intradermal/adverse effects/standards; Injections, Subcutaneous/adverse effects/standards; Injections,Intramuscular/adverse effects/standards; Needles; Infection control/methods/standards; Benchmarking; Evidence-based medicine(source: MeSH, NLM).

3 Mots cle sInjection intradermique/effets inde sirables/normes; Injection sous-cutane e/effets inde sirables/normes; Injectionintramusculaire/effets inde sirables/normes; Aiguille; Lutte contre infection/me thodes/normes; Banc mesure performance; Me decinefactuelle (source: MeSH, INSERM).Palabras claveInyecciones intrade rmicas/efectos adversos/normas; Inyecciones subcuta neas/efectos adversos/normas; Inyeccionesintramusculares/efectos adversos/normas; Agujas; Control de infecciones/normas; Benchmarking; Medicina basada en evidencia(fuente: DeCS, BIREME).Bulletin of the World Health Organization 2003;81 page 498 le re sume en franc ais.

4 En la pa gina 498 figura un resumen en espan transitional and developing countries where unnecessaryinjections are common, the average number of health careinjections per person was estimated to be per year (thisincludes all health care injections, including those given todiabetics for administering insulin) (1). Many injections, as wellas being unnecessary, are also unsafe. Each year, the reuse ofinjection equipment may cause 20 million infections withhepatitis B virus (HBV), 2 million infections with hepatitis Cvirus (HCV), and 250 000 infections with human immunode-ficiency virus (HIV) worldwide (1). These chronic infectionslead to a high burden of morbidity and mortality (1).

5 No evidence-based guidelines are available to guideinjection providers through the steps they should follow toprevent injection-associated infections. Thus, WHO asked adevelopment group and a steering group to develop bestpractices for the use of safe injections (Box 1) using WHO-recommended processes to formulate evidence-based guide-lines, as outlined usersThe primary audience for the guidelines on best practice forsafe injections includes public health professionals, clinicians,1 Medical Officer, Department of Blood Safety and Clinical Technology, Health Technology and Pharmaceuticals, World Health Organization, 1211 Geneva 27, Switzerland(email.)

6 Correspondence should be addressed to this of Blood Safety and Clinical Technology, Health Technology and Pharmaceuticals, World Health Organization, Geneva, for Disease Control and Prevention, Atlanta, GA, of Arizona Cancer Center, Tucson, AZ, Council of Nurses, Geneva, of the World Health Organization 2003, 81 (7)and infection control practitioners. The secondary audienceincludes injection providers reached through training orcommunications material developed on the basis of these development group defined an injection as aprocedure that introduces a substance into the body bypiercing the skin or a mucosal membrane.

7 Injections maybe administered with a needleor with needleless devices,such as jet injectors. However, for the purpose of thesebest practices, only needle injections were defines a safe injection as one that does not harmthe recipient, does not expose the provider to anyavoidable risk, and does not result in waste that isdangerous to other of the reference definitionThe steering group separated this reference definition into24 potentially critical issues (Table 1).Review of evidenceThe steering group searched the English language literatureusing MEDLINE. The search terms included injection(s),infection, sterilization, disinfection, vial, ampoule, medication,skin (preparation, cleaning, disinfection), hand hygiene,antisepsis, needle-stick(s), recapping, and sharps (container,collection, disposal).

8 Identified articles were used to selectadditional key and MeSH terms for further searches. Relevantreferences in identified articles and additional studies madeavailable by members of the development group were best infection control practices for intradermal, subcutaneous, and intramuscular needle injectionsEliminating unnecessary injections is the highest priority in preventing injection-associated infections. When injections are medically indicated, theyshould be administered safely. These best practices are measures that have been determined through scientific evidence or expert consensus mosteffectively to protect patients, providers, and Use sterile injection equipmentUse a sterile syringe and needle for each injection and to reconstitute each unit of , use a new, single-use syringe and packaging for breaches in barrier integrity.

9 Discard a needle or syringe if the package hasbeen punctured, torn, or single-use syringes and needles are not available, use equipment designed for steam sterilization. Sterilize equipment according to WHOrecommendations and document the quality of the sterilization process using time, steam, temperature (TST) spot Prevent contamination of injection equipment and each injection in a clean designated area, where contamination from blood or body fluid is single-dose vials rather than multi-dose multi-dose vials must be used, always pierce the septum with a sterile leaving aneedle in place in the stopper of the pop-open ampoules rather than ampoules that need to be opened by using a metal file.

10 If an ampoule that requires a metal file is used, protectfingers with a clean barrier ( small gauze pad) when opening the for and discard medications with visible contamination or breaches of integrity ( cracks, leaks).bFollow product-specificrecommendations for use, storage, and a needle that has touched any non-sterile Prevent needle-stick injuries to the and take measures to prevent sudden movement of patient during and after recapping of needles and other hand manipulations of needles. If recapping is necessary, use a single-handed scoop used syringes and needles at the point of use in an enclosed sharps container that is puncture-proof and leak-proof and that is sealed before itis completely Prevent access to used sharps containers for transport to a secure area in preparation for disposal.