Research shows that up to 25% of healthcare practitioners re-enter vials with needles just injected into patients.¹ There has been at least one report in PA-PSRS documenting this behavior, and similar actions may not have been reported because practitioners may be unaware that routinely re-entering vials with used needles and reusing syringes is placing patients at risk for infection from contamination.

The consequence of sharing multidose vials was dramatically illustrated by an occurrence elsewhere that made national news. In February 2008, the Southern Nevada Health District reported findings from an investigation arising from a cluster of hepatitis C virus (HCV) infections in their area. The health district’s investigation uncovered that six patients infected with the HCV had undergone procedures at the Endoscopy Center of Southern Nevada. Genetic testing on five of the cases identified a common source, although the sixth patient did not share the same source.² As a result of these infections, 40,000 patients are being informed they should be tested for HCV, as well as for hepatitis B and HIV. As of May 2008, results show 77 individuals were likely exposed to HCV from a procedure performed at the clinic. These numbers are expected to rise since another 10,000 patients have yet to be tested for the virus.³

A full on-site investigation conducted by the Centers for Disease Control and Infection, the Nevada State Health Division, and the Southern Nevada Health District confirmed that during the past four years, syringes were reused by practitioners to withdraw additional doses of medication for the same patient; these findings substantiated that this practice was not a one-time occurrence.⁴ This technique most likely contaminated the medication vial, and when used for subsequent patients, the bloodborne pathogens in the vial were inadvertently transmitted even though a clean needle and syringe were used. Since the 1970s, reports of iatrogenic patient-to-patient transmission of microbes due to contamination of multidose vials have been well documented.⁵ Even when the multidose vials are bacteriostatic, the vials still support microbial growth; previously entered multidose vials exhibit viable organisms, and debris such as red blood cells, epithelia cells, and lint fibers can be detected.⁶

While goal 7 of the Joint Commission National Patient Safety Goals is intended to reduce the risk of healthcare-acquired infections, it does not address poor aseptic technique associated with multidose vials. Healthcare organizations must recognize that through either lack of knowledge or poor technique, some practitioners routinely re-enter vials with used needles, without any realization they are likely contaminating the contents of the vial.

Although the potential for time and cost savings is apparent, multidose vial use in any patient care area is risky, with an ever-present danger for iatrogenic cross-contamination. The safest practice is to use patient-specific vials and discard them immediately after use. If multidose vials must be used, provide frequent staff education and monitor for proper infection control techniques. When a multidose vial is used for an infected patient, transmission can be prevented by isolating the vial and using it exclusively for that patient.⁷

Notes

1. Prott RT, Wagner RF, Tyring SK. Iatrogenic contamination of multi-dose vials in simulated use. Arch Dermatol 1990 Nov;126(11):1441-4.
2. Centers for Disease Control and Prevention. Epi-Aid Trip Report (2008-019): investigation of acute hepatitis C among patient who underwent procedures at clinic A: Nevada 2007 [online]. [cited 2008 May 23]. Available from Internet: http://health.nv.gov/docs/FinalEpi2_20080515.pdf.  
3. Steinhauer J. 77 New cases of hepatitis are identified in Las Vegas. N Y Times [online]. 2008 May 9 [cited 2008 May 23]. Available from Internet: http://www.nytimes.com/2008/05/09/us/09vegas.html.
4. Vegas clinic may have exposed 40k to hepatitis, HIV [online]. CNN.com 2008 Feb 28 [cited 2008 May 5]. Available from Internet: http://www.cnn.com/2008/HEALTH/02/28/vegas.hepatitis.ap/index.html.
5. Highsmith AK, Greenhood GP, Allen JR. Growth of nosocomial pathogens in multiple-dose parenteral medication vials. J Clin Microbiol 1982 Jun;15(6):1024-8.
6. Infectious Disease Branch, State of California Health and Welfare Agency. Multi-dose vials of Xylocaine-doses re-use predispose to HBV or HIV transmission? California Morbidity 1988 Nov 11.
7. Smetzer JL, Cohen MR. Preventing drug administration errors. Chapter 11. In: Cohen MR, ed. Medication errors 2nd edition, American Pharmacological Association; 2007:261.