ABSTRACT SUMMARY:
The risks of bacterial cross-contamination with reusable topical nasal and oropharyngeal anesthetic applicator devices.
Contents Bibliography:
Title:
Wolfe, T. R., T. A. Hillman, et al. (2002). "The comparative risks of bacterial contamination between a venturi atomizer and a positive displacement atomizer." Am J Rhinol 16(4): 181-6.
Coakley, J. F., G. J. Arthurs, et al. (1993). “The need for and development of a single use disposable nasal spray.” J Laryngol Otol 107(1): 20-3.
Spraggs, P. D., W. H. Hanekom, et al. (1994). “The assessment of the risk of cross-infection with a multi-use nasal atomizer.” J Hosp Infect 28(4): 315-21.
Williams, O. A., M. H. Wilcox, et al. (1993). “Lignocaine spray applicators are a potential source of cross-infection in the anaesthetic room.” Anaesthesia 48(1): 61-2.
Southwick, K. L., K. Hoffmann, et al. (2001). “Cluster of tuberculosis cases in North Carolina: possible association with atomizer reuse.” Am J Infect Control 29(1): 1-6.
Wolfe, T. R., T. A. Hillman, et al. (2002). "The
comparative risks of bacterial contamination between a Venturi atomizer and a
positive displacement atomizer." Am J Rhinol 16(4): 181-6.
INTRODUCTION: This laboratory study determined
the incidence of internal contamination of Venturi principle atomizers and
positive displacement atomizers exposed to high external concentrations of
Staphylococcal aureus (Staph). METHODS: Atomizer device nozzle tips were
immersed into a Staph solution and I ml of spray was atomized via compressed
wall air (Venturi) or hydraulic pump (positive displacement). The Venturi
nozzle was then wiped with 70% isopropyl alcohol while the disposable positive
displacement nozzle was replaced. After 30 minutes, 1 ml of atomized fluid was
collected and cultured and the process was repeated. After sixteen uses the
fluid remaining in the bottles was cultured. The Venturi atomizer also was
subjected to a single use trial to determine the location of device
contamination. RESULTS: Venturi atomizers sprays grew Staph in every case
(144/144), while positive displacement atomizer sprays never grew contaminants
(0/144; p < 0.0001). At the end of 16 uses, 7/9 of Venturi atomizers had
Staph within their medication reservoirs while none (0/9; p = 0.002) existed in
the positive displacement atomizers. After a single use of the Venturi
atomizer, the medication reservoir, the air lumen and the medication lumen of
the nozzle were all contaminated with Staph. CONCLUSIONS: External bacterial contamination
of the atomizer nozzle tip results in internal bacterial contamination of
Venturi devices in as little as one use but not of positive displacement
devices. These results warrant further investigation to determine whether a
risk of cross-contamination exists in a clinical setting.
Dubin, M. G., D. R. White, et al. (2004). "Multi-use venturi nasal atomizer contamination in a clinical rhinologic practice." Am J Rhinol 18(3): 151-6.
INTRODUCTION: Cross-contamination of Venturi atomizers has been reported. METHODS: In phase I, 16 atomizers were sterilized and refilled with either 1% lidocaine or 0.1% Tyzine (day 0). During phase II, atomizers were wiped with isopropyl alcohol wipes between uses. In both phases, on days 7, 14, 21, and 28, the contents of the atomizer were sprayed onto two culture media. If a culture was found positive, cultures from the nozzle, lumen, and solution were taken and cultured in depth. RESULTS: Twelve lidocaine bottles and three Tyzine bottles were initially positive. There were more positive cultures from lidocaine bottles than Tyzine bottles at 2 weeks (p = 0.02). After wiping with isopropyl alcohol, contamination was significantly reduced in the lidocaine bottles at 2 weeks (p = 0.02). CONCLUSION: Microbial contamination of questionable clinical significance may occur with nasal atomizers. Regardless of this significance, wiping the devices with isopropyl alcohol can eliminate microbial growth for a 2-week interval.
(Editorial note – 69% of atomizers containing topical anesthetics were contaminated in both phases of this trial based on pre-defined study criteria. Only easily cultured organisms were detected. The rate of contamination by viruses or other pathogens is unknown. This editor believes the clinical significance of these results are not questionable but highly clinically significant. T. W.)
Coakley, J. F., G. J. Arthurs, et al. (1993). “The need for and development of a single use disposable nasal spray.” J Laryngol Otol 107(1): 20-3.
Nasal sprays, which work on the Venturi principle, have the disadvantage of suck-back which makes them unhygienic for use in more than one patient. In Wrexham we have developed a disposable nasal spray system, which is safe and would be of benefit to other ENT departments.
Spraggs, P. D., W. H. Hanekom, et al. (1994). “The assessment of the risk of cross-infection with a multi-use nasal atomizer.” J Hosp Infect 28(4): 315-21.
Atomizers working on the Venturi principle are used by otolaryngology departments in the UK to spray cocaine and other local anaesthetic and vasoconstricting solutions into the nasal cavities. These devices are rarely cleaned, nor is the cocaine in the reservoir changed between patients. This study aimed to assess the risk of cross-infection with such an atomizer of the Down's design. Nutrient broth from a sterile atomizer was sprayed into the nasal cavities of 12 healthy volunteers on three occasions, the tip of the nozzle was withdrawn between sprays into the right nostril, but not between sprays into the left. On each occasion the tip of the nozzle, a nutrient broth rinse of the inner tube of the nozzle and the residue of broth in the reservoir of the atomizer were cultured and the colonies compared with those from a nasal swab collected previously. The results show transmission of bacteria from the nasal vestibule on to the tip, into the nozzle and into the reservoir of the atomizer. Examination of the minimum inhibitory concentration values of 10% cocaine with and without Nipasept preservative indicated poor antibacterial properties. We conclude that the use of an atomizer on more than one patient poses a risk of cross-infection, and recommend their replacement with a single-use disposable nasal atomizer.
Williams, O. A., M. H. Wilcox, et al. (1993). “Lignocaine spray applicators are a potential source of cross-infection in the anaesthetic room.” Anaesthesia 48(1): 61-2.
Ten percent lignocaine spray is in widespread clinical use as a means of suppressing responses to tracheal intubation. It is sprayed from a multidose container into the glottis and on to the vocal cords through an applicator nozzle, which may be used on successive patients. We have investigated the likelihood of the contamination of these nozzles, with patients' mouth flora. Spray applicators from four of the 20 cases investigated showed contamination with potential bacterial pathogens. We therefore recommend that lignocaine spray should not be applied to successive patients using the same applicator nozzle.
Southwick, K. L., K. Hoffmann, et al. (2001). “Cluster of tuberculosis cases in North Carolina: possible association with atomizer reuse.” Am J Infect Control 29(1): 1-6.
BACKGROUND: Three patients with identical strains of M tuberculosis (TB) underwent bronchoscopy on the same day at hospital A. METHODS: We reviewed each patient's clinical history, hospital A's infection control practices for bronchoscopies, and specimen and isolate handling at each of 3 laboratories involved. We searched for possible community links between patients. Restriction fragment length polymorphism was performed on TB isolates. RESULTS: The first patient who underwent bronchoscopy had biopsy-confirmed granulomatous pulmonary TB. A sputum sample collected from the third patient 6 weeks after the bronchoscopy produced an isolate with an identical restriction fragment length polymorphism pattern to isolates collected during the bronchoscopies. No evidence existed for community transmission or laboratory contamination; the only common link was the bronchoscopy. Different bronchoscopes were used for each patient. Hospital ventilation and wall-suctioning were functioning well. Respiratory technicians reported sometimes reusing the nozzles of atomizers on more than one patient. A possible mechanism for transmission was contamination from the first patient of the atomizer if it was used to apply lidocaine to the pharynx and nasal passages of other patients. CONCLUSIONS: A contaminated atomizer may have caused TB transmission during bronchoscopy. Hospital A changed to single-use atomizers after this investigation.