Current practice in decontamination of nebulisers in ventilated patients, Johannesburg, South Africa

Abstract

Background: Jet nebulisers are one of the primary devices used in the nebulisation of ventilated patients. It has been observed that due to cost restraints devices marked as “single use” are inadvertently being used as “single-patient-use” devices. This has both ethical and medico legal implications for the ICU. Ventilator-associated pneumonia (VAP) in limited-resource countries carries a large burden of increased mortality, morbidity and cost. Ineffective or absent nebuliser decontamination in ventilated patients can increase the risk of the development of VAP as well as the risk of antibiotic resistance. Objectives: The aim of this study was to examine the current practice of nebuliser decontamination and the incidence of contamination of nebulisers after use within a ventilator circuit, in ICUs in Johannesburg, South Africa. The secondary objectives of the study were to assess the presence of and adherence to a decontamination protocol in intensive care units (ICU) in Johannesburg and to identify which practices were associated with lower or no bacterial growth. Methods: A cross-sectional study design was used which included an interview with the unit manager and an audit of current nebuliser practice in the ICU. Nebulisers that were identified in the interview were then swabbed and streaked on blood agar plates (BAPs). Blood agar plates were then incubated and assessed for bacterial colonisation, number of colony forming units (CFUs) and number of different species of CFUs that were formed. Results: Single-use jet nebulisers represented 93% of nebulisers used within a ventilator circuit. All of the single-use jet nebulisers were being re-used (n=42). None of the hospitals studied had a nebuliser decontamination protocol. The contamination rate for jet nebulisers that had been re-used within the ventilator circuit was 52%. In the group of nebulisers that had bacterial colonisation, the nebulisers that were stored in a sterile drape had a significantly higher concentration of bacterial growth, than those that were not stored in a sterile drape (p=0.03). Nebulisers are often used in the administration of bronchodilators in ICUs in Johannesburg, South Africa. Colonised nebulisers can create bacterial aerosol when used within a ventilator circuit. A change to single-patient-use devices, such as vibrating mesh nebulisers, may assist in reducing the problem of colonisation of jet nebulisers. Conclusion: The rate of colonisation of jet nebulisers that have been re-used is unacceptably high. ICUs need to develop nebuliser decontamination protocols. Physiotherapists should assist with creating awareness and driving the creation of these protocols. ICUs should be encouraged to change single-use devices to single-patient-use devices. Nebulisers should not be stored in sterile drapes after use in a ventilator circuit.