The use of hollow bore needles continues to be a regular practice for many. Injections are necessary to combat diabetes, to perform intravenous support, to aid in cancer therapy and at times, to bring about an addictive high. Whatever the use, there must always be the realization of the health risks associated with needle use. At the microbiological level, a needlestick represents a break in the dermal barrier leading to the potential for inoculation of bacteria or viruses and subsequent colonization leading to acute symptoms or, if subclinical, longer term health effects that will hinder quality of life and may shorten the lifespan. There is no doubt that mitigating these "Injection Infections” is a necessity for health.
The highest potential for an injection infection occurs in the community. While there is a greater use of hollow bore needles in healthcare facilities, healthcare workers are expected to adhere to standard precautions and perform their duties to the highest standard. Moreover, the incidence of a needlestick event requires specific reporting and follow up. Although, as will be seen below, this is not always the case, the fact is that in healthcare facilities, injections are for the most part microbiologically safer than those in the community.
Infection-based studies in the community have traditionally involved Injection Drug Users (IDU) and the primary foci have been the Hepatitis B and C viruses (HBV, HCV) and the Human Immunodeficiency Virus (HIV). One worldwide hotspot for such studies is Vancouver, Canada, where there exists a supervised safe injections facility. These studies have led to the understanding that IDU is a significant reason for the continued prevalence of both HIV and HCV. However, IDU are now showing a higher incidence of Methicillin-Resistant Staphylococcus aureus (MRSA). In a recent study of IDU in Vancouver (Lloyd-Smith et al. Epidemiol Infect 2010;138:713-720), of 218 participants, 42 showed signs of infected wounds. Of these, 14 were culture positive for MRSA. While this number only represents approximately 6% of individuals, the likelihood of spread through shared needles and other unsafe practices is apparent.
Other pathogens have also been found in IDU. Some, such as Pseudomonas aeruginosa and Streptococcus viridans would be expected, however IDU have presented with syphilis, dengue virus, Acinetobacter spp., Candida spp. and Corynebacterium spp. Another potential problem is the development of infective endocarditis, which may be mild and subclinical; however, this condition facilitates co-morbidities with more severe acute afflictions such as septic shock, respiratory failure and neurologic deterioration.
The information gained from IDU provides a perspective on how the development of safe injection practices can help reduce the potential for any infection. Whether these will take hold, however, is still up for debate. Regardless of how many guidelines and regulations are produced and no matter how much evidence-based information is available, there continues to be a sector of the population who choose to ignore or circumvent directives and assume that they can be safe on their own. Unfortunately, this is epitomized in the one environment where health is of the greatest concern - healthcare.
On an annual basis, there are approximately 385,000 reported healthcare related needlestick injuries in the U.S. each year, 54% of which are due to improper use of hollow bore needles. Based on the CDC, approximately 1 in 8 needlesticks involved exposure to infectious material. Over half of these incidents could be prevented through adherence to proper standard precautions and the proper use of safety devices. Yet even safety devices are not a guarantee; in almost 30% of cases where a safety feature was present, the injury occurred simply because the safety feature was not activated.
While these numbers appear disturbing, the picture is potentially grimmer as some estimates suggest that nearly half of all needlestick injuries go unreported. If this is the case, some 200,000 healthcare workers may encounter a needlestick each year and 25,000 are either exposed or infected without any reporting or further remedial action.
“Injection Infections” are a problem regardless of the setting and the process of safe injections requires greater attention. In particular, there needs to be an increased focus on adherence in healthcare to standard precautions and the fact that should a dermal break occur, that proper follow-up is conducted. For those in the community, any dermal break with a hollow bore needle should be accompanied by an understanding of the microbiological consequences both short term and long. Finally, regardless of the setting, whenever possible, needles with safety devices should be used properly and disposed in appropriate containers.
As for those who choose not to adhere or respect the consequences of unsafe injections, there needs to be a fail-proof mechanism to ensure that the safety features are activated as soon as the injection has completed. In addition, from a microbiological perspective, the use of a disinfectant within the mechanism to ensure the inactivation of any microbial agent would be optimal to ensure that the chance of infectious disease spread is minimized. The use of hydrogen peroxide, which has significant antimicrobial activity with no toxic effects to humans, may offer such a solution. While this advancement may not be important in healthcare, such a feature would be of particular importance in the event of accidental exposure such as individuals and children who come across discarded syringes. While these cases are rare, their impact on society is significant. After all, infection, morbidity and mortality should be the last expectation of anyone who comes into contact with a needle, regardless of how that contact occurred.
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