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Karthikeyan R, Agri H, Yadav A, Jayakumar V, Kiranmayee B, Karikalan M, Chandra M, Lyngdoh V, Ghatak S, Sinha DK, Singh BR. A study on the occurrence of Burkholderia cepacia complex in ultrasound gels used in different veterinary clinical settings in India. Vet Res Commun 2023; 47:1413-1425. [PMID: 36914918 DOI: 10.1007/s11259-023-10091-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/26/2023] [Indexed: 03/14/2023]
Abstract
Burkholderia cepacia complex (Bcc) organisms are emerging multidrug-resistant pathogens. They are opportunistic and cause severe diseases in humans that may result in fatal outcomes. They are mainly reported as nosocomial pathogens, and transmission often occurs through contaminated pharmaceutical products. From 1993 to 2019, 14 Bcc outbreaks caused by contaminated ultrasound gels (USGs) have been reported in several countries, including India. We screened a total of 63 samples of USGs from various veterinary and human clinical care centers across 17 states of India and isolated 32 Bcc strains of Burkholderia cenocepacia (46.8%), B. cepacia (31.3%), B. pseudomultivorans (18.8%) and B. contaminans (3.1%) species. Some isolates were co-existent in a single ultrasound gel sample. The isolation from unopened gel bottles revealed the intrinsic contamination from manufacturing sites. The MALDI-TOF analysis to identify the Bcc at the species level was supported by the partial sequencing of the recA gene for accurate species identification. The phylogenetic analysis revealed that isolates shared clades with human clinical isolates, which is an important situation because of the possible infections of Bcc by USGs both in humans and animals. The pulsed field gel electrophoresis (PFGE) typing identified the genetic variation among the Bcc isolates present in the USGs. The findings indicated USGs as the potential source of Bcc species.
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Affiliation(s)
- Ravichandran Karthikeyan
- Division of Epidemiology, ICAR-Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, India
| | - Himani Agri
- Division of Epidemiology, ICAR-Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, India
| | - Akanksha Yadav
- Division of Epidemiology, ICAR-Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, India
| | - Varsha Jayakumar
- Division of Epidemiology, ICAR-Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, India
| | - Bhimavarapu Kiranmayee
- Division of Epidemiology, ICAR-Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, India
| | - Mathesh Karikalan
- Center for wildlife Conservation Management and Disease Surveillance, ICAR-Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, India
| | - Mudit Chandra
- Department of Veterinary Microbiology, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana, Punjab, India
| | - Vanita Lyngdoh
- Division of Animal and Fisheries Sciences, ICAR Research Complex for NEH Region, Umiam, Meghalaya, India
| | - Sandeep Ghatak
- Division of Animal and Fisheries Sciences, ICAR Research Complex for NEH Region, Umiam, Meghalaya, India
| | - Dharmendra K Sinha
- Division of Epidemiology, ICAR-Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, India
| | - Bhoj R Singh
- Division of Epidemiology, ICAR-Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, India.
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Murata H, Vanegas C, Ogami-Takamura K. Ultrasound-guided regional anesthesia in COVID-19 and future pandemics: infection control. Curr Opin Anaesthesiol 2021; 34:648-653. [PMID: 34231548 PMCID: PMC8452256 DOI: 10.1097/aco.0000000000001034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Infection control is inherent in ultrasound-guided regional anesthesia practice, because ultrasound transducer and coupling gel can be vectors for pathogen transmission. We reviewed the current standards and recommendations of ultrasound transducer cleaning, disinfection, and safe handling of ultrasound equipment. Based on the available data, we propose a set of practical recommendations applicable to coronavirus disease 2019 (COVID-19) pandemic and future epidemics. RECENT FINDINGS Regional anesthesia is often preferred over general anesthesia for COVID-19 patients. Avoidance of general anesthesia reduces the need for aerosol generating procedures. Administration of ultrasound-guided regional anesthesia and surgery under regional anesthesia in COVID-19 patients requires careful infectious precautions to prevent the viral spread through the use equipment. SUMMARY Ultrasound machine, transducer and coupling gel can serve as a vector for transmission of pathogens. In the era of COVID-19 pandemic, standardized strategies are recommended to minimize the risk of spread of COVID-19 to both patients and the healthcare providers.
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Affiliation(s)
- Hiroaki Murata
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | | | - Keiko Ogami-Takamura
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Macroscopic Anatomy, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Mullins K, Burnham K, Henricson EK, Cohen S, Fair J, Ray JW. Identification and Analysis of Bacterial Contamination of Ultrasound Transducers and Multiuse Ultrasound Transmission Gel Bottle Tips Before and After the Aseptic Cleansing Technique. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1957-1963. [PMID: 32339352 DOI: 10.1002/jum.15300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 03/14/2020] [Accepted: 03/22/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To provide a descriptive analysis for species identification of culture and Gram stain results from ultrasound transducers and multiuse ultrasound transmission gel bottle tips in active clinical use and to compare bacterial cultures from ultrasound transducers before and after aseptic cleansing. METHODS A prospective blinded descriptive analytic study of 18 distinct clinical care sites within a single primary clinical institution was conducted. Before and after a disinfectant towel cleanse, transducers were pressed against tryptic soy agar contact plates. Plates were deidentified and submitted for blind incubation, Gram staining, and species identification with microsequencing. Results were classified as clinically relevant (CR) or non-clinically relevant. In total, 188 samples were analyzed: 80 from ultrasound transducers before and cleansing, 13 from multiuse gel bottle tips before and after cleansing, and 2 precleansing samples from the data collector's pen and badge. RESULTS Fifty-nine precleansing samples (73.8%) grew cultures with CR bacteria, and 21 samples (26.3%) did not. Staphylococcus simulans represented 31.0% of all positive culture samples. Thirteen postcleansing samples (16.3%) grew cultures with CR bacteria, equating to a 78.0% reduction of CR bacterial growth (likelihood ratio, 57.10; P < .001). CONCLUSIONS Ultrasound transducers have a notable CR bacterial burden and may serve as potential infective vectors. Aseptic cleansing effectively eliminates most of the bacterial load from ultrasound transducers, but some bacteria persist, presenting a risk of nosocomial infection with ultrasound-guided interventions. These findings support American Institute of Ultrasound in Medicine 2018 guidelines intended to ensure an appropriate level of transducer preparation based on the examination type while emphasizing rational infection control measures to minimize the risk of potential patient harm.
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Affiliation(s)
- Kevin Mullins
- Department of Physical Medicine and Rehabilitation, University of California, Davis, California, USA
| | - Kevin Burnham
- Department of Physical Medicine and Rehabilitation, University of California, Davis, California, USA
| | - Erik K Henricson
- Department of Physical Medicine and Rehabilitation, University of California, Davis, California, USA
| | - Stuart Cohen
- Department of Physical Medicine and Rehabilitation, University of California, Davis, California, USA
| | - James Fair
- Department of Surgery, Division of Emergency Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jeremiah W Ray
- Department of Physical Medicine and Rehabilitation, University of California, Davis, California, USA
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Genco M, Anderson-Shaw L, Sargis RM. Unwitting Accomplices: Endocrine Disruptors Confounding Clinical Care. J Clin Endocrinol Metab 2020; 105:5862419. [PMID: 32614432 PMCID: PMC7442273 DOI: 10.1210/clinem/dgaa358] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/05/2020] [Indexed: 01/05/2023]
Abstract
Burgeoning evidence over the last 25 years has identified myriad synthetic chemicals with the capacity to alter various aspects of hormone synthesis and action. These endocrine-disrupting chemicals (EDCs) have been linked to various diseases, including reproductive disorders, metabolic diseases, and developmental abnormalities, among others. Exposure to EDCs arises from industrial activity, use of personal and home care products, and consumption of contaminated food and water; however, the role of healthcare in exposing individuals to EDCs is grossly underappreciated. Indeed, through the use of medications as well as medical equipment and devices, healthcare providers are unknowing mediators of exposure to EDCs, chemicals that might not only promote disease but that may also antagonize the efficacy of treatments. The ethical implications of provider-dependent exposure are profound. A failure to disclose the endocrine-disrupting properties of medical interventions violates core principles of nonmaleficence, patient autonomy, and justice as well as the practice of informed consent. Furthermore, physicians' lack of knowledge regarding EDCs in medical practice artificially skews risk-benefit calculations that are fundamental to informed medical decision-making. To combat this underappreciated ethical challenge, urgent action is required. Healthcare providers must be educated about endocrine disruption. Known EDCs, defined by endocrinologists, should be clearly labeled on all medical products, and all medication components and devices should be screened for endocrine-disrupting properties. Finally, communication strategies must be devised to empower patients with knowledge about these risks. Providing ethically competent care requires an open acknowledgment of endocrine risks imposed by the medical community that have heretofore been ignored.
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Affiliation(s)
- Matthew Genco
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, US
| | - Lisa Anderson-Shaw
- Department of Medical Education, University of Illinois at Chicago, Chicago, IL, US
| | - Robert M Sargis
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, US
- Chicago Center for Health and Environment (CACHET); University of Illinois at Chicago, Chicago, IL, US
- Correspondence and Reprint Requests: Robert M. Sargis, MD, PhD, Division of Endocrinology, Diabetes, and Metabolism, University of Illinois at Chicago, 835 S. Wolcott Suite E625; M/C 640, Chicago, IL 60612.
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Hamm RF, Combs CA, Davidson CM, Davidson CM. Society for Maternal-Fetal Medicine Special Statement: Reducing the risk of transmitting infection by transvaginal ultrasound examination. Am J Obstet Gynecol 2020; 223:B2-B6. [PMID: 32470457 DOI: 10.1016/j.ajog.2020.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Recent surveys have shown widespread lapses in the procedures used to reduce the risk of transmitting infection via medical devices. Transvaginal ultrasound examination has the potential to transmit vaginal infections, including human papillomavirus. Areas of particular concern are the use of probe covers with high rates of leakage, disinfectants that are not effective against human papillomavirus, and coupling gel from multiple-use containers. We reviewed these issues, and we recommend 4 steps to reduce the risk of transmitting infection. First, during every transvaginal ultrasound exam, the probe should be covered with a sterile, single-use "viral barrier" cover or a condom. Second, sterile, single-use ultrasound gel packets should be used. Third, after every examination, the probe should be cleaned to remove any visible gel or debris. Finally, after cleaning, the probe should undergo high-level disinfection using an agent with proven efficacy against the human papillomavirus, including hydrogen peroxide, hypochlorite, or peracetic acid. Glutaraldehyde, orthophthalaldehyde, phenols, and isopropyl alcohol have virtually no efficacy against the human papillomavirus.
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Affiliation(s)
| | | | | | - Christina M Davidson
- Patient Safety and Quality Improvement Committee, Society for Maternal-Fetal Medicine, Washington, DC
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Ricci S, Pinette MG, Wax JR, Craig W, Forrest L, Dragoni C. The effect of temperature on bacterial growth in the presence of nonsterile ultrasound coupling gel. Am J Obstet Gynecol 2020; 222:188. [PMID: 31610151 DOI: 10.1016/j.ajog.2019.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/24/2019] [Accepted: 10/07/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Samantha Ricci
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Maine Medical Center, Portland, ME
| | - Michael G Pinette
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Maine Medical Center, Portland, ME
| | - Joseph R Wax
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Maine Medical Center, Portland, ME.
| | - Wendy Craig
- Maine Medical Center Research Institute, Scarborough, ME
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Milton SC, Cronin AJ, Monti JD. Evaluation of Glucomannan Powder as an Ultrasound Transmission Gel Alternative for Resource-Constrained Environments: A Prospective, Comparative Study. Wilderness Environ Med 2018; 29:446-452. [PMID: 30290983 DOI: 10.1016/j.wem.2018.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 06/15/2018] [Accepted: 06/15/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Resource and logistical constraints may limit the availability of commercial ultrasound (US) transmission gel (USTG) in austere environments. Glucomannan powder, a dietary fiber supplement, can be mixed with tap water to form a gel that may be a field-expedient substitute for USTG. We compared glucomannan gel with a commercial USTG for US image adequacy and quality. METHODS A single clinician obtained 193 US video clips from 14 different examinations on live-tissue and simulation training models using both commercial and glucomannan USTGs. Four US fellowship-trained providers, blinded to type of gel used, independently reviewed the randomized US video clips. The primary outcome of US image adequacy was scored as "yes" or "no" and analyzed using Pearson χ2 analysis. The secondary outcome of image quality was rated on a 0 to 5 Likert scale and analyzed with the independent t test. RESULTS For US image adequacy, commercial USTG was superior to glucomannan gel (P=0.042, 95% CI: 96.5-96.6%), with commercial USTG adequate in 96.6% of images (375 of 388 "yes"), whereas glucomannan USTG was adequate in 93.5% (359 of 384 "yes") of images. For US image quality there was no statistically significant difference between the 2 USTGs (P=0.176, 95% CI: 93.4-93.5%), with commercial USTG rated at 3.4±1.0 and glucomannan gel at 3.3±1.1. CONCLUSION Despite a high image adequacy rate, glucomannan gel proved inferior to commercial USTG for US image adequacy but produced equivalent image quality. Glucomannan USTG may be a reasonable substitute when commercial USTG is unavailable.
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Affiliation(s)
- Sandra C Milton
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA
| | - Aaron J Cronin
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA
| | - Jonathan D Monti
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA.
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Westerway SC, Basseal JM. The ultrasound unit and infection control - Are we on the right track? ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2017; 25:53-57. [PMID: 28228825 DOI: 10.1177/1742271x16688720] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 12/13/2016] [Indexed: 11/15/2022]
Abstract
Best practice guidelines for the disinfection of ultrasound transducers and infection prevention in ultrasound departments are generally recommended by either government health groups or the ultrasound societies of individual countries. The literature shows a wide variance in not only transducer cleaning methods but basic hygiene practices in the ultrasound workplace. This paper describes results from a UK survey of disinfection of ultrasound transducers and hygiene practice in the workplace. The survey revealed that some ultrasound practitioners did not follow current guidelines with regard to the correct disinfection method of transducers, cords or ultrasound machine keyboards. Furthermore, the survey exposed the lack of training from the product manufacturers on how to use the disinfection product appropriately. These inconsistencies may be responsible for compliance issues and highlight the need for an awareness campaign and a unified approach to infection control by ultrasound practitioners.
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Affiliation(s)
- Susan C Westerway
- Faculty of Dentistry & Health Sciences, Charles Sturt University, NSW, Australia; Australasian Society for Ultrasound in Medicine (ASUM), Sydney, NSW, Australia
| | - Jocelyne M Basseal
- Australasian Society for Ultrasound in Medicine (ASUM), Sydney, NSW, Australia
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Dietrich CF, Horn R, Morf S, Chiorean L, Dong Y, Cui XW, Atkinson NSS, Jenssen C. Ultrasound-guided central vascular interventions, comments on the European Federation of Societies for Ultrasound in Medicine and Biology guidelines on interventional ultrasound. J Thorac Dis 2016; 8:E851-E868. [PMID: 27747022 DOI: 10.21037/jtd.2016.08.49] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Central venous access has traditionally been performed on the basis of designated anatomical landmarks. However, due to patients' individual anatomy and vessel pathology and depending on individual operators' skill, this landmark approach is associated with a significant failure rate and complication risk. There is substantial evidence demonstrating significant improvement in effectiveness and safety of vascular access by realtime ultrasound (US)-guidance, as compared to the anatomical landmark-guided approach. This review comments on the evidence-based recommendations on US-guided vascular access which have been published recently within the framework of Guidelines on Interventional Ultrasound (InVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) from a clinical practice point of view.
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Affiliation(s)
- Christoph F Dietrich
- Medical Department, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany;; Sino-German Research Center of Ultrasound in Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Rudolf Horn
- Notfallstation, Kantonsspital Glarus, Glarus, Switzerland
| | - Susanne Morf
- Intensivmedizin Kantonsspital Graubünden, Chur, Switzerland
| | - Liliana Chiorean
- Department of Medical Imaging, des Cévennes Clinic, Annonay, France
| | - Yi Dong
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Xin-Wu Cui
- Medical Department, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany;; Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430074, China
| | - Nathan S S Atkinson
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Märkisch Oderland Strausberg, Wriezen, Germany
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Abstract
BACKGROUND Sterile and clean working conditions are one of the keystones of medical practice and this is also true for ultrasound-guided regional anesthesia. The routine clinical practice in ultrasound-guided regional anesthesia does not always comply with the principles of sterile and clean working conditions in medicine: therefore, patients are exposed to potential hazards regarding the transmission of pathogens via the ultrasound equipment. OBJECTIVE This article deals with the question of whether sterile working conditions in ultrasound-guided regional anesthesia are a relevant topic with medical and economic implications. Is it possible to implement the general recommendations for sterile working conditions in ultrasonography for the specific application of ultrasound-guided regional anesthesia? MATERIAL AND METHODS A search of the available literature and published guidelines in the field of sterile working conditions with ultrasound was carried out. RESULTS The association between cross-infections and ultrasound equipment is undeniable. Many methods for cleansing and disinfection of ultrasound equipment have been published. All these methods are associated with advantages and disadvantages. The direct sterilization of ultrasound probes with high-percentage alcohol can damage ultrasound probes (especially linear). The use of self-adhesive sterile ultrasound probe covers is a practical method to achieve sterile working conditions in ultrasound-guided regional anesthesia. CONCLUSION The use of sterile ultrasound probe covers and sterile ultrasound contact media is an important prerequisite to avoid cross-infection between patients. An appropriate scientific evaluation should serve as evidence in this field.
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Shokoohi H, Armstrong P, Tansek R. Emergency department ultrasound probe infection control: challenges and solutions. Open Access Emerg Med 2015; 7:1-9. [PMID: 27147883 PMCID: PMC4806800 DOI: 10.2147/oaem.s50360] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Point-of-care ultrasound (US) has become a cornerstone in the diagnosis and treatment of patients in the emergency department (ED). Despite the beneficial impact on patient care, concern exists over repeat use of probes and the role as a vector for pathogen transmission. US probes are used for various applications, with the level of infection risk, based on the Spaulding Classification, ranging from noncritical with common practice to semicritical with endocavitary probes. To date, the most closely studied organisms are Staphylococcus aureus and human papilloma virus. Current evidence does confirm probe colonization but has not established a causative role in human infection. Based on current literature, US use during invasive procedures remains an infection control concern, but routine use on intact skin does not appear to cause significant risk to patients. Various barrier methods are available, each with indications based on extent of procedure and likelihood of contact with mucosal surfaces. Additionally, chemical cleansing methods have been shown to be effective in limiting probe contamination after use. New technologies utilizing ultraviolet light are available and effective but not widely used in the ED setting. As our understanding of the critical factors in US probe cleaning and disinfection improves, it is important to assess the challenges found in our current practice and to identify potential solutions to improve practices and procedures in infection control across the spectrum of US probe use in various applications in the ED. This article serves as a summary of the current literature available on infection control topics with the utilization of point-of-care US, and discusses challenges and potential solutions to improve the current practice of probe-related infection control.
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Affiliation(s)
- Hamid Shokoohi
- Department of Emergency Medicine, George Washington University Medical Center, Washington DC, USA
| | - Paige Armstrong
- Department of Emergency Medicine, George Washington University Medical Center, Washington DC, USA
| | - Ryan Tansek
- Department of Emergency Medicine, George Washington University Medical Center, Washington DC, USA
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Morillas-Sendin P, Ortega-Romero A, del-Olmo C. Basic considerations before injections and scanning techniques. ACTA ACUST UNITED AC 2013. [DOI: 10.1053/j.trap.2014.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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