Keeping it clean

By Dr Mike Comins / 01 Jan 2014

Dr Mike Comins explains the vital importance of hygiene in your practice

Despite the glossy veneer of our industry, as healthcare professionals it is vital that we never lose sight of the fact that we are offering a medical service. In light of the Keogh report there has been a focus on the serious complications that can occur with injectables. These include skin necrosis, blindness and long-term granulomas. 

Certainly we should take these complications seriously, but we mustn’t also overlook the basics of our medical training, such as microbiology. More specifically in terms of injectables, blood-borne viruses such as HIV, Hepatitis B and Hepatitis C.

Over the years I have heard tales of people sharing syringes of fillers, believing it’s okay for friends to share; putting insulin needles back in a Botox vial; storing partially-used filler vials for another patient and so on. I’m sure many doctors and nurses have countless other examples and similar horror stories. This is not acceptable, and it serves to highlight the importance of self-regulation for our industry, and the ability to regulate those carrying out these kinds of treatments. I can’t overemphasise enough the need for stringent adherence to the Centre for Disease Control and Prevention, Infection Control and Safe Injection Practices. Whilst the public have become increasingly aware of HIV, healthcare professionals also need to remain focused on Hepatitis C and B (HCV and HBV). Unlike the HIV virus, which is very unlikely to survive outside the body for more then a few seconds, Hep B and C can. Hep C can survive for up to four days outside of the body, whilst Hep B can survive for at least seven days. Some clinicians believe by attaching a clean needle to a partially used syringe of filler or vial of botulinum toxin, they have protected their patients from viral contamination. However the risks do not stop with the needle. The smallest amount of negative pressure in the syringe can cause microscopic amounts of blood to travel up the needle and into the syringe. Even a swab of gauze used to mop a patients face post botox and discarded onto a counter may leave behind a potential reservoir of viruses that can then contaminate other gauzes or needles and transfer the virus from patient to patient.

“WHO estimate 300 million people in the world are infected with the Hepatitis B virus, of which the vast majority would be asymptomatic and may not know they are carriers and infectious,” says Graham Foster, Professor of Hepatology at Queen Mary University of London. “The average carrier may have many thousand viral particles per ml of blood and it is not unusual for someone in the Hepatitis B “e” antigen positive (HBeAg) phase to have millions of virions per ml. A small drop of blood would be enough to infect many thousands of people.”

According to Public Health England, the number of people living with HCV related Cirrhosis and/or Hepatocellular Carcinoma in the UK has risen by over 1000% in the last 20 years. Charles Core, Chief Executive of the Hepatitis C Trust explains that IV drug use is not the primary issue. “Of the 185 million people living with HCV worldwide ten million got it through IV drug use and almost all the rest through unsafe healthcare.” These facts are alarming. We need to ensure our industry is not going to be a part of this growing global problem. When we do hear of these unsafe practice stories we have a duty as healthcare professionals to ag them up to the relevant authorities. “The idea of sharing a vial of cosmetic filler between patients is, quite frankly, terrifying,” says Professor Foster. “It’s imperative that anyone using injectables fully understands the risks of blood-borne infections, and vigilantly adheres to infection control protocols.”

Cosmetic injectable treatments should only be performed by professionals with proper microbiology training. We also have a duty of care to use products from reputable manufacturers and ensure that we keep up to date with changes in microbiology.

Emma Davies, Chair of the British Association of Cosmetic Nurses concludes, “Nurses in the NHS undertake mandatory training in infection control, with updates as per local protocols. Those in Independent Practice must be mindful that such training remains mandatory outside the NHS, and must not be neglected as part of necessary CPD.” 



To ensure injection safety, healthcare workers should:

  • Use a sterile, single-use, disposable needle and syringe for each injection, and discard them intact in anappropriates harps container after use.

  • Use single-dose medication vials, prefilled syringes, and ampules when possible.

  • Avoid administering medications from single-dose vials to multiple patients or combining left over contents for later use.

  • Restrict multiple-dose vials (if used) to a centralised medication area or use only for a single patient. Never re-enter a vial with a needle or syringe used on one patient if that vial will be used to withdraw medication for another patient. Store vials in accordance with the manufacturer’s recommendations and discard if sterility is compromised.

  • Avoid using bags or bottles of intravenous solution as a common source of supply for multiple patients.

  • Use a septic technique to avoid contamination of sterile injection equipment and medications.


To ensure hand hygiene and proper use of gloves, healthcare workers should:

  • Wash their hands with soap and water, or use an alcohol-based hand rub before preparing and administering an injection; before and after donning gloves for obtaining blood samples; after inadvertent blood contamination; and between treating patients.

  • Wear gloves for procedures that might involve contact with blood, and change gloves and wash hands between patients.


    In maintaining a safe and sanitary work environment, healthcare workers should:

  • Dispose of used syringes and needles at the point of use in a sharps container that is puncture- resistant and leak- proof, and that can be sealed before completely full.

  • Maintain physical separation between clean and contaminated equipment and supplies.

  • Prepare medications in areas physically separated from those with potential blood contamination.

  • Use barriers to protect surfaces from blood contamination when blood samples are obtained.

  • Clean and disinfect blood-contaminated equipment and surfaces in accordance with recommended guidelines.


    When dealing with patient care equipment, healthcare workers should:

  • Handle equipment that might be contaminated with blood in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to themselves, other patients, and surfaces.

  • Evaluate equipment and devices for potential cross-contamination of blood. They should also establish procedures for the safe handling of such equipment during and after use, including cleaning and disinfecting or sterilising as indicated. 


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