Reusable sharps bins – are they spreading gut infections?

A remarkable taster of research data soon to be presented at an upcoming APIC meeting,  identifies higher rates of Clostridium difficile infection among hospitals that use reusable sharps containers.

These data, from a new and independent study of acute care hospitals have been supported by medical technology company BD Medical, a segment of Becton, Dickinson and Company.  The study showed hospitals that used single-use containers had significantly lower rates of C difficile (C diff) as compared to those using reusable containers, with a nearly 15% difference in the prevalence of infection rates. The study, based on completed surveys from more than 600 U.S. hospitals, showed hospitals with single-use sharps disposal containers had significantly lower rates of C diff infections versus hospitals with reusable containers after controlling for several hospital characteristics. “The use of containers to properly dispose of sharps in the health care setting is a critical component of most occupational safety programs in health care settings,” said Dr Monika Pogorzelska-Maziarz, Assistant Professor at the Jefferson School of Nursing.

“These findings, while they do not confirm a direct correlation between protocols for sharps disposal and risk of health care associated infection, do raise important questions about the potential role that reusable sharps containers may play in pathogen transmission.”

The company said the burden associated with C diff infections is at a historic high, with an attributable mortality of more than 29,000 deaths in 2011, citing the Center for Disease Control and an estimated annual cost to the US health care system of $4.8 billion. Dr. Pogorzelska-Maziarz will make a presentation on the results at the 42nd Annual Conference of the Association for Professionals in Infection Control and Epidemiology at the Music City Center in Nashville, Tennessee.

The first and most obvious concern is that BD is a major manufacturer of single-use sharps bins, though that is no reason to cast a shadow over the independence of this research. We eagerly await the detail and look forward to early publication of the results. Research independence and integrity is crucial, and it is regrettable that in recent years a leading proponent, and ex-Sharpsmart employee, has travelled the world, sitting of committees, lecturing, supporting collaborative research studies and publications through trials of the Sharpsmart product, and proposing their value with sometimes missionary zeal. Never answering questions regarding current links to Sharpsmart, which are resolutely denied, but refusing questions about funding of his busy international travails in support of Sharpsmart reusable sharps containers, their remains a deep dark cloud over the integrity of this research that is always, and quite implausibly, presented as being independent.

But set that matter aside for a moment.

Clostridium difficile infection is an infection of the large bowel, an often severe and potentially fatal gastro-intestinal infection. How therefore it may be linked with the use of one type of sharps bin, reusable or not, seems rather strange if not implausible. Some may latch onto these new data suggesting higher C diff infection rates in hospitals using reusable sharps bins. It certainly looks like Becton Dickinson do, and as noted above they too have an axe to grind and product line to support. Wherever the truth may be in regard to other matters, the link between reusable sharps bins and C diff gastro-intestinal infection is hard, almost impossible, to grasp. Publication of the results may shed some light and until then we should avoid speculation since there are many potential confounders that might be responsible for this apparent link, that may be more apparent than real.

Epidemiologists, Infection Control practitioners and microbiologists will together be looking at these data with close scrutiny, and seeking to explore the arrant ling in ever-greater detail. Immediate thoughts may be directed toward the standards of recycling and decontamination processes, that would be of yet greater concern if found inadequate when reprocessing reusable containers intended for soft wastes than reusable sharps containers since there would be greater probability for contamination of the former.

Detail concerning biocide additives to the detergent products used during reprocessing of Sharpsmart and similar products is presently scant. Biocides may interact with and accelerate the deterioration of painted metal surfaces and many plastics, especially if used frequently and not rinsed and dried carefully after exposure.

In many cart washers, detergent concentrations are kept intentionally low and biocide use often substituted with deodorisers. Cost concerns and disposal concerns – wash water and additives are often reused time and again – would suggest that their efficacy must be low and may deteriorate still further over time. If biocide is added to reusable sharps bin wash waters, the probability of it being tested against the highly resistant spores of Clostridium difficile must be low; in all probability, these tests have not been done, either by the biocide producers or end users.

The possibility for cross-contamination of equipment items must increase. Since products are not dedicated to a single hospital or Trust, wide spread of potential pathogens could happen, as proposed for Eurocarts used to hold clinical and other waste sacks.

Rigorous testing of biocide additives for all waste container washing, evaluated under typical in use conditions of soiling, contact times, and aging through recycling and reuse must now include tests with all major hospital pathogens, including Clostridium difficile.





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