To the Editor

Thank you for including my abstract “Quality Assurance in Infection Control” among those cited in the review of the 1990 American Society of Anesthesiologists’ Annual Meeting. (Winter 1990-91, Vol. 5, page 3 5.) Of primary concern in my abstract is prevention of transmission of AIDS, hepatitis, and other blood borne diseases.

A clarification is needed. I did not recommend abandoning use of multidose vials (MDVS) for more than one patient as long as proper aseptic technique is used and a new sterile syringe and needle are used each time medication is obtained. I did, however, question the continuing use of MDVs since 1) viral viability and transmission of disease has been documented if the vial becomes contaminated (ie. hepatitis B virus), 2) bacterial contamination of MDVs has resulted in nosocomial bacterial infections, and 3) health care workers’ (HCWs) compliance with aseptic technique and appropriate use of MDVs will likely continue to be less than the optimal 100 percent, despite continuing education programs and institution of department and hospital infection control standards.

Although use of MDVs for multiple patients is currently an accepted technique in medicine today if appropriate precautions are taken to avoid potential cross contamination (as described above), I question the risk-benefit analysis in which reuse risks potentially fatal blood borne infections from cross-contamination, whereas the only “benefits” of continued reuse of MDVs on multiple patients are perhaps a small cost savings.

This issue needs to be addressed not only by anesthesia personnel but by the entire health care field for adoption of uniform practice recommendations. At the present time it would be unrealistic to recommend anesthesia personnel abandon use of MDVs unless other HCWs also do so.

My study recommended continuing updates for HCWs on Universal Precautions and infection control, and utilization of quality assurance surveys to assess compliance and provide education and feedback to HCWs to further improve practice patterns. These practices include following all Universal Precautions including. obtaining hepatitis B vaccination, avoiding improper handing of contaminated needles, appropriate disinfection and/or sterilization for reused equipment, proper use of rnuitidose vials, and singe patient-use for all syringes, needles, intravascular tubing and fluids, drugs and other items where potential cross-contamination from one patient to another might occur. Also recommended was increased use of needleless systems for administration of intravenous drugs. Finally, I emphasized the need to use single-patient-use bacterial breathing filters on spirometers and inspiratory-force meters in the Post-Anesthesia Care Unit to prevent potential cross-infection via these items..

A goal to these ends is generation and promulgation of relevant national standards of practice.

Elliot S. Greene, M.D.

Assistant Professor of Anesthesiology

Albany (NY) Medical College

References

1. Longfield R, et al. Multidose medication vial sterility: an in-use study and a review of the literature. Infection Control 1984; 5:165-9.
2. Alter MJ et al. Hepatitis B virus transmission associated with a multiple-dose vial in a hemodialysis unit. Ann Intern Mod 1983; 99:330-2.
3. Oren I et al. A common-source outbreak of fulminant hepatitis B in a hospital. Ann Intern Med 1989; 110:691-8.
4. Greene E. Quality assurance in infection control. Anesthesiology; 73:A1061.
5. Greene E. Infection control in anesthesia and critical care medicine. Anesthesiobgy Report 1990; 3:280-90.