Tampon alcool, études

Alcohol Swabs

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

SCIEH (2004) ICT Review of Skin Injection 080604 (http://www.documents.hps.scot.nhs.uk/hai/infection-control/publications/skin-disinfection-review.pd)

Tietjen L, Bossemeyer D, McIntosh N (2003) Infection Prevention Guidelines for Healthcare Facilities with Limited Resources. JHPIEGO, Baltimore. ISBN 0929817-80-X. http://www.nice.org.uk/nicemedia/pdf/cg2fullguidelineinfectioncontrol.pdf

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