Tourniquets conceal superbugs

REUSABLE venesection tourniquets are frequently colonised with “superbugs” and should be replaced by disposable alternatives, according to infectious diseases experts.

Researchers from Concord Repatriation General Hospital in Sydney cultured 100 tourniquets that were in use throughout the hospital and found that 25 were colonised with multiresistant organisms (MROs). Sixty-one reusable tourniquets were colonised with bacterial species that would not be considered normal upper-limb skin flora.

The research, published in the MJA, found that the intensive care unit had a higher rate of MRO colonisation (67% [6 out of 9 tourniquets]) compared with the wards (23% [15/64]) and ambulatory care areas (13% [3/23]). (1)

Dr Thomas Gottlieb, an infectious diseases physician from Concord Hospital and an author of the MJA paper, told MJA InSight that he was surprised how many tourniquets were colonised with MROs, saying it was probably a reflection of rising MRO levels in hospitals generally.

He said there was a need for improved cleaning processes, as well as improved antibiotic stewardship and vigilant hand hygiene to reduce MROs in hospitals.

Dr John Ferguson, area director of infection prevention and control at Hunter New England Health in NSW, agreed that the results reflected the poor hygienic state of most hospitals, particularly larger hospitals.

He called for more stringent cleaning techniques, such as using vapour, steam or ultraviolet light as an adjunct to disinfectant, to ensure adequate environmental hygiene.

“It’s about ensuring absence of pathogens from the environment, and in general I think that’s an area that’s neglected. In NSW, audits of cleanliness are done on the basis of visible cleanliness: if there’s an absence of dust, then it’s considered clean … but you can’t see bugs.”

Dr Gottlieb said it was time to rethink the use of reusable tourniquets.

“In a setting of significant MRO rates, as we are seeing, ongoing use of reusable tourniquets may not be viable and we should be looking at alternatives”, he said.

The authors said tourniquets might have higher potential for MRO transmission than other fomites, as they were applied with high pressure on bare skin near vascular access sites. However, the research did not specifically address transmission.

“It is untenable that patients are exposed to potentially virulent pathogens on reused equipment”, the authors wrote.

The MJA paper said that disposable tourniquets were a viable alternative to reusable tourniquets, but they needed to be introduced as part of a bundle of infection control measures.

The authors said that although there were some perceived difficulties with using disposable tourniquets, recent research showed that 95% of doctors found them easy to use.

Dr Ferguson, who is also analysing rates of MROs on tourniquets at John Hunter Hospital, said he believed used tourniquets should either be sterilised and re-bagged, or disposed of after use.

He said tourniquets were just one of several fomites at hospitals that needed to be considered. Others included stethoscopes, sphygmomanometer cuffs and adhesive tape used on drips.

There was a need to “look very critically” at the practice of reusing certain equipment within the hospital, he said.

“Perhaps we need to have allocated devices for each patient. Perhaps we should go back to the old days, where there was a sphygmo machine at each bed and a tourniquet for each patient until they leave.”

However, in the hospital involved in the MJA research, tourniquets used in the intensive care unit were allocated for single patient use.

Dr Ferguson agreed that single use of various devices was a secondary concern to ensuring hospital environmental hygiene. “The environment is the elephant in the room.”

In another hospital study, published last week in the American Journal of Infection Control, researchers found that up to 60% of hospital staff uniforms were colonised with potentially pathogenic bacteria. However, they said it was yet to be determined if these could be transferred to patients and cause infection. (2)

- Sophie McNamara

1. MJA 2011; 195: 276-279

2. Am J Infect Control 2011; 39: 555-559

Posted 5 September 2011