Aseptic Preparation
Ha-young Choi
A. Definitions
1. Aseptic technique: application of preventative measures used to minimize contamination by pathogens.
2. Antiseptic: relating to or denoting substances that prevent the growth of disease-causing microorganisms, usually refers to substances that may be applied to living tissues or cells.
3. Disinfectants: substances that are meant to destroy microorganisms on the surface of nonliving objects; are usually too strong or caustic to apply to living tissue.
B. Background
Adherence to proper aseptic technique and standard precautions are important in the health care setting, and especially so in the neonatal intensive care unit (NICU). These measures aim to protect patients and the health care workers and control the spread of infection. Patients in the NICU are particularly susceptible to nosocomial or hospital-acquired infection, with profound impacts on survival, outcomes, and costs of care.
Protocols and procedures for aseptic technique in NICUs are constantly being reevaluated and updated, and hand hygiene guidelines are routinely published by the U.S. Centers for Disease Control (CDC) (1, 2). Hospital managers should continuously develop and update strict policies and regulations as well as quality improvement projects aimed to promote adherence to aseptic technique and hand hygiene (3).
C. Indications
1. Preparation of patient’s skin and the hands of personnel prior to performing a procedure
a. To remove transient flora, which is sometimes pathogenic flora that are transiently found on the skin, usually less than 24 hours, for example, Escherichia coli
b. To decrease and temporarily suppress most resident skin flora, which is the usually low-virulence flora that survive and multiply on skin, for example, Staphylococcus epidermidis
2. Decontamination after a procedure
3. Maintenance of clean surgical sites
D. Standard Precautions
1. Universal precautions
a. All human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other blood-borne pathogens.
b. Universal precautions protect the caregiver and the patient, but remember it does not preclude the need for proper antisepsis, which is targeted at decreasing skin flora.
2. Core components (1)
a. Use gloves when touching blood, body fluids, mucous membranes, or nonintact skin, and when handling items or surfaces soiled with blood or body fluids.
b. Use a mask and eye protection during procedures that might generate splashing or droplets in the air.
c. Use a gown or a plastic apron when splashing of blood or body fluid is likely.
d. Wash hands carefully if they become contaminated with blood or body fluids.
e. Take extraordinary care when handling needles and other sharp objects, and dispose of them in puncture-resistant containers.
f. Exclude from patient care all personnel with exudative lesions or weeping dermatitis until these conditions have resolved.
3. Hand hygiene (1)
a. Alcohol-based hand rubs are the most effective products for reducing the number of pathogenic microorganisms on the hands of health care providers (1).
(1) In order to be effective, products should contain at least 60% to 95% alcohol.
(3) If hand disinfectants are not allowed to dry, alcohol-based disinfectant vapors can accumulate inside incubators (6).
b. Antiseptic soaps and detergents are the next most effective and nonantimicrobial soaps are the least effective. Soap and water are recommended in cases of:
(1) Visibly soiled hands
(2) Hospital outbreaks of contact with patients suspected to have Clostridium difficile, Norovirus, or Bacillus anthracis
(3) Before eating
(4) After using the restroom
c. Technique of hand hygiene:
(1) Remove all rings, watches, bracelets, etc.
(2) Roll up sleeves to the elbows.
(3) The CDC recommends at least 15 seconds of rubbing the solution on the hands, paying particular attention to the areas between the fingers, the thumb, and little finger.
d. In addition to hospital personnel, parents and visitors should also be taught to adhere to strict hand hygiene, as nosocomial infections can be spread by family members (7).
4. Gloves
a. Are not an alternative to hand hygiene.
b. The warm, wet skin surface under gloves offers an ideal environment for bacterial multiplication. Gloves are not completely impermeable to microorganisms.
c. Vinyl gloves may leak more readily than latex gloves (8).
d. Always clean hands before putting on and after removing gloves.
e. Change gloves during patient care if hands are moved from a contaminated body site (e.g., diaper area) to clean site (IV site or face).
f. Do not wear the same pair of gloves for the care of more than one patient.
a. Before performing any procedure where sterile gloves will be worn.
b. Remove rings, watches, and bracelets before beginning the surgical hand scrub.
c. Remove debris from underneath fingernails using a nail cleaner under running water.
d. Performing surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand sanitizer with persistent activity is recommended before donning sterile gloves when performing surgical procedures.
e. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 2 to 6 minutes. Rapid multiplication of bacteria occurs under surgical gloves if hands are washed with a nonantimicrobial soap.
f. Long scrub times (e.g., 10 minutes) are not necessary. A scrub brush is not recommended.
g. When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer’s instructions.
h. Before applying the alcohol solution, prewash hands and forearms with a nonantimicrobial soap and dry hands and forearms completely.
i. When rinsing hands with water, keep hands and wrists elevated above forearms.
j. When drying hands after washing, use sterile towel and dry hands first before drying forearms.
k. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves.
E. Proper Use of Antiseptics
No antiseptic is totally effective or without risk and there is no absolute consensus on the optimal antiseptic for use in neonates (9, 10, 11). The U.S. Food and Drug Administration (FDA) is awaiting further data on commonly used antiseptics (i.e., benzalkonium chloride, benzethonium chloride, chloroxylenol, ethyl alcohol, isopropyl alcohol, and povidone-iodine) so that the agency can make a safety and efficacy determination about these ingredients. While we await the data on these commonly used active ingredients, the FDA recommends that health care personnel continue to use currently available products, consistent with infection control guidelines (12).
1. Refer to Table 6.1 and Section G for advantages and complications associated with each antiseptic option.
2. Always allow antiseptics and disinfectants to dry before starting procedure.
a. A drying time of at least 30 seconds is required for optimal effect.
b. Avoid removal of antiseptic from skin prior to the procedure—removal negates the residual slow-release effect.
c. After the procedure, remove iodine-containing antiseptics from all but the immediate area of the procedure to prevent absorption.
d. Contamination of instruments or sample with antiseptic may invalidate specimens taken for culture.
3. Ensure that skin is not visibly soiled prior to application of antiseptic. However, overly vigorous scrubbing of the skin prior to, or with antiseptics application may lead to skin breakdown without conferring extra benefit regarding antisepsis (13). Antiseptic should
be applied gently but with some mild pressure, not enough to damage the fragile skin of the neonate.
be applied gently but with some mild pressure, not enough to damage the fragile skin of the neonate.
TABLE 6.1 A Comparison of Commonly Used Antiseptics | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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