Antiseptic Swabsticks for Optimal Blood Donor Arm Disinfection
Blood transfusion-associated sepsis resulting from bacterially contaminated blood components remains a major concern for patient safety. The skin of blood donors harbors resident microflora that can lead to contamination if they are introduced into blood collection bags. Effective skin antisepsis at the phlebotomy site is thus critical for reducing this risk of contamination. This article summarizes learnings from three research studies that evaluated different antiseptic solutions and methods for donor arm disinfection.
A prospective randomized study by Ramirez-Arcos et al. compared the efficacy of 0.5% and 2% chlorhexidine gluconate (CHG) in alcohol to 10% povidone-iodine for preventing surgical site infections. They found both the 0.5% and 2% CHG alcohol preparations were significantly more effective than povidone-iodine. Patel et al. compared 4% CHG, 70% isopropyl alcohol, 10% povidone-iodine, and savlon (1.5% chlorhexidine + 3% cetrimide) for reducing bacteria on the venipuncture site. Again, CHG and isopropyl alcohol showed lower bacterial counts than povidone-iodine or savlon. Goldman et al. reported that a combination of isopropyl alcohol and povidone-iodine was the most effective method for reducing skin flora, compared to isopropyl alcohol or povidone-iodine alone.
Together, these findings demonstrate the superior efficacy of CHG-alcohol solutions over iodine-based preparations for skin antisepsis prior to blood collection. Both 0.5% and 2% CHG concentrations appear effective when combined with alcohol. Isopropyl alcohol alone is reasonably effective, but a combination with iodine may further enhance its activity. Solutions containing chlorhexidine were consistently shown to yield lower bacterial counts than iodine or cetrimide-based alternatives.
Multiple sequential scrubs with different antiseptic agents led to a gradual decline in bacterial colony counts in the studies by Patel et al. and Goldman et al. This indicates that a thorough multi-step disinfection process is advantageous. A sequence of isopropyl alcohol, povidone-iodine and repeat alcohol proposed by Patel et al. achieved complete disinfection with no colonies isolated afterwards. They further showed this process prevented contamination in collected blood bags, unlike savlon which led to contaminated units.
Common skin organisms identified across the studies included Staphylococcus epidermidis, Micrococcus spp., Streptococcus spp. and Bacillus spp. Some residual Staphylococcus, Micrococcus and Bacillus persisted after disinfection, emphasizing the need for diversion of the initial blood volume. As suggested by McDonald et al., this diversion coupled with proper skin antisepsis provides the best prevention of bacterial transmission by transfusion.
The studies assessed disinfection efficacy using skin cultures and bacterial colony counts. Clinical outcomes like surgical site infections were also examined by Ramirez-Arcos et al. These quantitative microbiological endpoints provide robust measures for comparing antiseptic effectiveness on skin flora. Additional clinical evidence on impacts like sepsis incidence would further substantiate the benefits of improved arm disinfection.
In summary, CHG-alcohol preparations offer superior antimicrobial activity over iodine or cetrimide solutions for donor arm disinfection prior to phlebotomy. Concentrations as low as 0.5% CHG retain good efficacy when combined with alcohol. Stepwise scrubbing with multiple agents can achieve progressive decontamination down to zero colonies. These improved disinfection practices, along with diversion of initial blood, help minimize the risk of bacterial transmission to recipients by transfusion of blood components.
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1. Patel TG, Shukla RV, Gupte SC. Impact of donor arm cleaning with different aseptic solutions for prevention of contamination in blood bags. Indian J Hematol Blood Transfus. 2013 Mar;29(1):17-20. doi: 10.1007/s12288-011-0138-3. Epub 2012 Jan 31. PMID: 24426327; PMCID: PMC3572260.
2. Hasegawa T, Tashiro S, Mihara T, Kon J, Sakurai K, Tanaka Y, Morita T, Enoki Y, Taguchi K, Matsumoto K, Nakajima K, Takesue Y. Efficacy of surgical skin preparation with chlorhexidine in alcohol according to the concentration required to prevent surgical site infection: meta-analysis. BJS Open. 2022 Sep 2;6(5):zrac111. doi: 10.1093/bjsopen/zrac111. PMID: 36124902; PMCID: PMC9487656.
3. Ramirez-Arcos, Sandra & Taha, Mariam & Kou, Yuntong & Goldman, Mindy. (2017). Alternative methods of blood donor skin disinfection.