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Phlebology OnlineFirst, published on December 15, 2014 as doi:10.1177/0268355514565194
Original Article
Air contamination in the sclerosing foam for the treatment of varicose veins
Phlebology 0(0) 1–5 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0268355514565194 phl.sagepub.com
S de Franciscis1,2, CGA Nobile3, E Larosa3, R Montemurro2 and R Serra1,2
Abstract Background: Fluids and drugs formulated for intravenous infusion may potentially promote the growth of microorganisms that can cause infections. The aim of this study is to test the sterility of sclerosing foam. Methods: Polidocanol was used for the production of the foam. The Tessari method was used in order to generate the foam. The preparation was carried out both in the operating theater and in an outpatient room. A validation test with microorganisms was also performed. Results: The measurements showed no evident growth of microorganisms and in the validation tests the foam appeared to even display bacteriostatic and/or bactericide properties. Conclusions: Sclerosing foam seems to be safe from a microbiological point of view.
Keywords Chronic venous disease, sclerotherapy, foam sclerotherapy, infectious disease, varicose veins
Introduction Sclerotherapy is the planned elimination of varicose veins or venous malformations by the injection of a sclerosing agent. The aim of sclerotherapy is to cause adequate vein wall injury converting the treated vessel into a sclerosed connective tissue cord. Sclerosing foam is produced by mixing a sclerosing agent with a gas and should provide a longer and more intensive contact with the endothelium, as it is displaced to a greater degree than liquid forms.1,2 Many authors have described methods of preparing foam, which may be used for sclerotherapy. The most widely used method (Tessari Method) is readily prepared using two syringes connected by a three-way tap. A mixture of sclerosant and air is drawn into one syringe at a ratio of one part of sclerosant to four parts of gas. The sclerosant can be sodium tetradecyl sulphate or polidocanol (POL).3,4 In comparison with surgery and other endovenous procedures for the treatment of varicose veins, very little is required in the way of equipment and facilities to treat varicose veins by foam sclerotherapy. The room used for this purpose (for preparing and injecting the foam) may be a consulting room or the operating theatre itself.4 These rooms may have different air
characteristics that could, theoretically, affect the sterility of the foam. In the current literature, only two cases of infection following foam sclerotherapy have been described,5 but none of the studies carried out so far have considered the issue of the sterility of the foam prepared in this way. The aim of this study is to test the sterility of the foam produced by the Tessari method, prepared in different clinical settings.
1 Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Græcia of Catanzaro, Catanzaro, Italy 2 Department of Surgical and Medical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy 3 Department of Health Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
Corresponding author: Raffaele Serra, Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Viale Europa, Localita` Germaneto, 88100 Catanzaro, Italy. Email: [email protected]
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Aethoxysclerol (Kreussler Pharma, Wiesbaden, Germany) was used for the production of the POL foam. Aethoxysclerol (Kreussler Pharma, Wiesbaden, Germany) contains water and POL, small amounts of pure (96%) ethanol, sodium monohydrogen phosphate dehydrate, and potassium dihydrogen phosphate. To generate the foam, the Tessari method was used.3,4 Two syringes are connected using a three-way stopcock (B. Braun, Melsungen AG, Germany): one syringe is filled with Aethoxysclerol (Kreussler Pharma, Wiesbaden, Germany) (1 ml) and the other ones with air (4 ml). The syringe containing air is emptied into the other syringe, and the contents of the second syringe are pushed back again (this is defined as one pump cycle) until a homogenous 5 ml foam is established.6 The liquid Aethoxysclerol and air were mixed by 20 pump movements and then the liquid Aethoxysclerol (Kreussler Pharma, Wiesbaden, Germany) became a dense foam. The foam was ejected into culture tubes after being mixed successfully.
1.2–1.5 m above the floor to simulate the breathing zone of healthcare workers. The doors of the operating theaters and locations surrounding the operating theater were always closed during the sampling period. The volumetric air sampler works by drawing measured volumes of air at a constant speed through the conical instrument that contains a Petri dish with standard culture media (Nutrient Agar, Liofilchem srl—Roseto degli Abruzzi TE, Italy). At the end of the sampling time of 5 min, the plate is removed and placed to incubate. Immediately after the collection of samples, the Petri dishes were taken to the laboratory and were incubated aerobically at 37 C for 24–48 h for bacteria and at 25 and 37 C up to seven days for yeasts. The number of colonies which appeared on the exposed plates was counted, and colony forming units (CFUs) were calculated (mean colonies on plates/sampling air volume) 1000.7 The sampling air volume used in this study was 500,000 cm3. Maximum acceptable levels were those determined by the Italian Institute for Occupational Safety and Prevention in 2009 for air microbial contamination in operating theatres with turbulent air flow and for outpatient rooms: 180 CFU/m3 in operational and 500 CFU/m3, respectively.8
Sclerotherapy with POL foam
Preparation of test suspensions
Sclerotherapy is carried out in a standard room approximately 16 m2 with a height of 2.50 m and a volume of approximately 40 m3, with four subjects: a patient, an attending physician, a resident, and a nurse. Immediately before injection, the physician creates the foam using the Tessari method. In order to investigate the quality of the air in the operating theatre and the outpatient room, the amount of bacteria in the air was measured using an impact air sample. The first measurement was taken on a typical day before the operating theatre or the outpatient room was used. The second measurement was taken at the end of the daily session. Air measurements were all performed wearing a mask, hairnet, and gloves.7
The test for sterility, applied to substances, preparations, or articles that are required to be sterile, is carried out under aseptic conditions. A satisfactory result only indicates that no contaminating microorganisms have been found in the sample examined. The POL foam was tested in accordance with a sterility test performed by European Pharmacopoeia guidelines9 and FDA regulatory requirements.10 Results of each examination were recorded and were expressed as growth or no growth.11
Material and methods Foam production
Air sampling To measure the amount of airborne microorganisms quantitatively, we used the Microflow a microbiological air sampler (Aquaria srl, Lacchiarella—Milan, Italy). This study evaluated the air quality in the operating theater and in the outpatient room in a teaching hospital in southern Italy. The air sampling instrument was placed approximately 1.5 m from the operating tables to avoid aseptic area contamination in the operating theaters during surgery or at the center of the outpatient room. The instrument was positioned
Validation test Two microorganisms, Staphylococcus aureus and Candida albicans, were used in the present study. These microorganisms were environmental isolates used for evaluating growth promotion qualities of test media used in sterility testing. A validation test as performed by European Pharmacopoeia guidelines9 was carried out. A growth promotion test was performed as a positive control. If the clearly visible growth of microorganisms is obtained after incubation in the presence of Aethoxysclerol foam, the product possesses no antimicrobial activity under the conditions of the test, and the sterility may be then achieved without further modification.12
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Results Between 3 April 2013 and 10 May 2013, hospital hygienists took 90 air measurements for 30 air samples in total, nine air measurements for three air samples daily, on 10 different days (Table 1). The hospital hygienists took 10 air samples in operation theatres while they were being prepared for use; the mean measurement was 56.35 CFU/ml (DS 41.41; range 2.7–106.7; n.v.180). They took 10 air samples in standard rooms at the beginning of the daily session; the mean measurement was 172.33 CFU/ml (DS 107.22; range 43.3–384.7; n.v.500). Finally, they took 10 air samples in standard rooms at the end of the daily session; the mean measurement was 174.46 CFU/ml (DS 155.47; range 27.3–552; n.v.500). Among all air measurements, findings revealed that only one was abnormal (552). At the end of the incubation period at the required temperature, all the tubes with the test solution (mixture of POL foam and culture medium) made in operating theatres were examined and no evidence of bacterial growth was noted. Analogous results arose in standard rooms at the beginning and at the end of the daily session (Table 2). At the end of the incubation period at the required temperature, the results of the validation test showed
that all tubes containing only culture medium demonstrated no evidence of bacterial growth; all tubes with the inoculum of 102 CFU of viable microorganisms in the culture medium showed a clearly visible growth of microorganisms, compared to the absence of growth in the control vessels without inoculum.9 The tubes containing the test solution (mixture of POL foam and culture medium) together with an inoculum of 102 CFU of viable microorganisms were then examined. This analysis showed that the S. aureus tested had not grown in 80% of tubes and the C. albicans tested had failed to grow in 20% of the tubes (Table 2).
Discussion From the current literature foam sclerotherapy seems to be a safe and effective therapy for the treatment of venous disorders, although specific guidelines are needed for the effective use of this treatment.13 As an intravenous procedure the risk of infection has not been formally evaluated in studies.14 In fact, some fluids and drugs formulated for intravenous infusion can sustain the growth of microorganisms that may cause serious infectious complications.15–17 Although intrinsic (i.e. from the
Table 1. Results of 90 air measurements for 30 air samples totally, nine air measurements for three air samples daily and sterility test, in 10 different days. Surgery room Sampling 1 3/4/13 Sampling 2 10/4/13 Sampling 3 12/4/13 Sampling 4 15/4/13 Sampling 5 18/4/13 Sampling 6 22/4/13 Sampling 7 3/5/13 Sampling 8 7/5/13 Sampling 9 8/5/13 Sampling 10 10/5/13 Mean ( SD)
2.7
Outpatient room at beginning of morning session
Outpatient room at end of afternoon session
Surgery room
Outpatient room at beginning of morning session
Outpatient room at end of afternoon session
62.7
27.3
Negative
Negative
Negative
68
43.3
69.3
Negative
Negative
Negative
104.7
273.3
157.3
Negative
Negative
Negative
42.7
183.3
156
Negative
Negative
Negative
14.7
108.7
108.7
Negative
Negative
Negative
106.7
384.7
552
Negative
Negative
Negative
28.7
252.7
78.7
Negative
Negative
Negative
80
198
155.3
Negative
Negative
Negative
111.3
328.7
Negative
Negative
Negative
105.3
111.3
Negative
Negative
Negative
172.33 ( 107.22)
174.46 ( 155.47)
104 11.3 56.35 ( 41.41)
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Table 2. Results of validation test for sampling (tubes with only culture medium, tubes with with inoculum of 102 CFU, tubes with test solution (mixture of POL foam and culture medium) and inoculum of 102 CFU).
FTa FT þ 100 CFUb FT þ 100 CFU þ POLc
Staphylococcus aureus
Candida albicans
Total
Total
Negative
Positive
15 (100%) – 12 (80%)
– 15 (100%) 3 (20%)
SBCDd SBCD þ 100 CFUe SBCD þ 100 CFU þ POLf
Negative
Positive
15 (100%) – 3 (20%)
– 15 (100%) 12 (80%)
a
Fluid Thioglycollate. Fluid Thioglycollate þ 100 Colony Forming Unit. c Fluid Thioglycollate þ 100 Colony Forming Unit þ POL foam. d Soya-Bean Casein Digest. e Soya-Bean Casein Digest þ 100 Colony Forming Unit. f Soya-Bean Casein Digest þ 100 Colony Forming Unit þ POL foam. b
manufacturer) infusate contamination is rare, high rates of extrinsic contamination18 (i.e. occurring during the preparation of the infusate such as the sclerosing foam) may occur in daily practice. Infusate contamination may occur most frequently when physicians prepare admixtures for intravenous infusion.18 Methods used to guarantee air purity included foam production using a sterile disposable syringe kit including sterile air or even a special filter.19,20 It should be noted, however, that microorganisms that cause infections in healthcare facilities are commonly found in the patient’s own endogenous flora, such as the skin where the puncture needle is placed.21 Sclerotherapy is usually performed in the doctor’s office, and atmospheric air used for the preparation of the foam is not by itself a guarantee of sterility. In light of these considerations, the issue of the foam sterility is of primary relevance. In this study we evaluated the sterility of the foam prepared in two different settings (operating theatre and clinical room). The measurement showed almost no growth of microorganisms and in the validation test the foam appeared to possess some degree of bacteriostatic and/or bactericide properties. As reported in a previous study, it should be noted that the antimicrobial activity of foam is due to the agent itself and not to its foam state.22 Although further studies are required to validate these findings, sclerosing foam seems to be safe from a microbiological point of view. Acknowledgements We thank Mary Longrigg (Lecturer for English Language at L’Orientale University of Naples, Italy) and Heather Mandy Bond (Assistant Professor of Biochemistry at University Magna Graecia of Catanzaro, Italy) for their support in language editing and editorial assistance.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest None declared.
References 1. Zimmet SE. Sclerotherapy treatment of telangiectasias and varicose veins. Tech Vasc Interv Radiol 2003; 6: 116–120. 2. Kendler M, Wetzig T and Simon JC. Foam sclerotherapy – a possible option in therapy of varicose veins. J Dtsch Dermatol Ges 2007; 5: 648–654. 3. Tessari L. Nouvelle technique d’obtention de la scle´romousse. Phlebologie 2000; 53: 129. 4. Coleridge Smith P. Foam and liquid sclerotherapy for varicose veins. Phlebology 2009; 24: 62–72. 5. Wilson G. Two cases of infection complicating foam ultrasound guided sclerotherapy (UGS). ANZ J Phlebol 2005; 9: 39–40. 6. Van Deurzen B, Ceulen RP, Tellings SS, et al. Polidocanol concentration and time affect the properties of foam used for sclerotherapy. Dermatol Surg 2011; 37: 1448–1455. 7. De Roos KP, Groen L and Leenders A. Foam sclerotherapy: investigating the need for sterile air. Dermatol Surg 2011; 37: 1119–1124. 8. ISPESL: Istituto Superiore per la Prevenzione e la Sicurezza del Lavoro. Linee guida per la definizione degli standard di sicurezza e di igiene ambientale dei reparti operatori, http://www.ispesl.it/documentazione/comp_sett.asp (2009, accessed January 2012). 9. European Pharmacopoeia 5.0, Biological test, §2.6.1 Sterility, 2005.
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10. Code of Federal Regulations. Title 21 Food and Drugs, Part 610.12 Sterility testing. Washington, DC: US Government Printing Office, 2012. 11. Angelillo IF, Bianco A, Nobile CGA, et al. Evaluation of the efficacy of glutaraldehyde and peroxygen for disinfection of dental instruments. Lett Appl Microbiol 1998; 27: 292–296. 12. Soncin S, Lo Cicero V, Astori G, et al. A practical approach for the validation of sterility, endotoxin and potency testing of bone marrow mononucleated cells used in cardiac regeneration in compliance with good manufacturing practice. J Transl Med 2009; 7: 78. 13. Rathbun S, Norris A and Stoner J. Efficacy and safety of endovenous foam sclerotherapy: meta-analysis for treatment of venous disorders. Phlebology 2012; 27: 105–117. 14. Rathbun S, Norris A, Morrison N, et al. Performance of endovenous foam sclerotherapy in the USA for the treatment of venous disorders: ACP/SVM/AVF/SIR quality improvement guidelines. Phlebology 2014; 29: 76–82. 15. Curran E. Intravenous drug preparation: the infection risks. Br J Nurs 2011; 20(S4): S6–8. 16. Rickard CM, Vannapraseuth B, McGrail MR, et al. The relationship between intravenous infusate colonisation and fluid container hang time. J Clin Nurs 2009; 18: 3022–3028. 17. Mercaldi CJ, Lanes S and Bradt J. Comparative risk of bloodstream infection in hospitalized patients receiving
18.
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22.
intravenous medication by open, point-of-care, or closed delivery systems. Am J Health Syst Pharm 2013; 70: 957–965. Macias AE, Huertas M, de Leon SP, et al. Contamination of intravenous fluids: a continuing cause of hospital bacteremia. Am J Infect Control 2010; 38: 217–221. Hamel-Desnos C, Ouvry P, Benigni JP, et al. Comparison of 1% and 3% polidocanol foam in ultrasound guided sclerotherapy of the great saphenous vein: a randomised, double-blind trial with 2 year-follow-up. ‘‘The 3/1 Study.’’ Eur J Vasc Endovasc Surg 2007; 34: 723–729. Gobin JP and Benigni JB. Sterivein: un nouveau proce´de´ de fabrication de mousse sclerosante. Phle´bologie 2006; 59: 73–76. Sehulster L and Chinn RY. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 2003; 52: 1–42. Dutch Working Party on Infection Prevention (WIP). Circumstances during (minor) surgical and invasive procedures, http://www.wip.nl/UK/free_content/Richtlijnen/ circumstances%20invasive%20procedures.pdf (2006, accesssed August 2014).
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Phlebology OnlineFirst, published on December 15, 2014 as doi:10.1177/0268355514565194
Original Article
Air contamination in the sclerosing foam for the treatment of varicose veins
Phlebology 0(0) 1–5 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0268355514565194 phl.sagepub.com
S de Franciscis1,2, CGA Nobile3, E Larosa3, R Montemurro2 and R Serra1,2
Abstract Background: Fluids and drugs formulated for intravenous infusion may potentially promote the growth of microorganisms that can cause infections. The aim of this study is to test the sterility of sclerosing foam. Methods: Polidocanol was used for the production of the foam. The Tessari method was used in order to generate the foam. The preparation was carried out both in the operating theater and in an outpatient room. A validation test with microorganisms was also performed. Results: The measurements showed no evident growth of microorganisms and in the validation tests the foam appeared to even display bacteriostatic and/or bactericide properties. Conclusions: Sclerosing foam seems to be safe from a microbiological point of view.
Keywords Chronic venous disease, sclerotherapy, foam sclerotherapy, infectious disease, varicose veins
Introduction Sclerotherapy is the planned elimination of varicose veins or venous malformations by the injection of a sclerosing agent. The aim of sclerotherapy is to cause adequate vein wall injury converting the treated vessel into a sclerosed connective tissue cord. Sclerosing foam is produced by mixing a sclerosing agent with a gas and should provide a longer and more intensive contact with the endothelium, as it is displaced to a greater degree than liquid forms.1,2 Many authors have described methods of preparing foam, which may be used for sclerotherapy. The most widely used method (Tessari Method) is readily prepared using two syringes connected by a three-way tap. A mixture of sclerosant and air is drawn into one syringe at a ratio of one part of sclerosant to four parts of gas. The sclerosant can be sodium tetradecyl sulphate or polidocanol (POL).3,4 In comparison with surgery and other endovenous procedures for the treatment of varicose veins, very little is required in the way of equipment and facilities to treat varicose veins by foam sclerotherapy. The room used for this purpose (for preparing and injecting the foam) may be a consulting room or the operating theatre itself.4 These rooms may have different air
characteristics that could, theoretically, affect the sterility of the foam. In the current literature, only two cases of infection following foam sclerotherapy have been described,5 but none of the studies carried out so far have considered the issue of the sterility of the foam prepared in this way. The aim of this study is to test the sterility of the foam produced by the Tessari method, prepared in different clinical settings.
1 Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Græcia of Catanzaro, Catanzaro, Italy 2 Department of Surgical and Medical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy 3 Department of Health Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
Corresponding author: Raffaele Serra, Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Viale Europa, Localita` Germaneto, 88100 Catanzaro, Italy. Email: [email protected]
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Aethoxysclerol (Kreussler Pharma, Wiesbaden, Germany) was used for the production of the POL foam. Aethoxysclerol (Kreussler Pharma, Wiesbaden, Germany) contains water and POL, small amounts of pure (96%) ethanol, sodium monohydrogen phosphate dehydrate, and potassium dihydrogen phosphate. To generate the foam, the Tessari method was used.3,4 Two syringes are connected using a three-way stopcock (B. Braun, Melsungen AG, Germany): one syringe is filled with Aethoxysclerol (Kreussler Pharma, Wiesbaden, Germany) (1 ml) and the other ones with air (4 ml). The syringe containing air is emptied into the other syringe, and the contents of the second syringe are pushed back again (this is defined as one pump cycle) until a homogenous 5 ml foam is established.6 The liquid Aethoxysclerol and air were mixed by 20 pump movements and then the liquid Aethoxysclerol (Kreussler Pharma, Wiesbaden, Germany) became a dense foam. The foam was ejected into culture tubes after being mixed successfully.
1.2–1.5 m above the floor to simulate the breathing zone of healthcare workers. The doors of the operating theaters and locations surrounding the operating theater were always closed during the sampling period. The volumetric air sampler works by drawing measured volumes of air at a constant speed through the conical instrument that contains a Petri dish with standard culture media (Nutrient Agar, Liofilchem srl—Roseto degli Abruzzi TE, Italy). At the end of the sampling time of 5 min, the plate is removed and placed to incubate. Immediately after the collection of samples, the Petri dishes were taken to the laboratory and were incubated aerobically at 37 C for 24–48 h for bacteria and at 25 and 37 C up to seven days for yeasts. The number of colonies which appeared on the exposed plates was counted, and colony forming units (CFUs) were calculated (mean colonies on plates/sampling air volume) 1000.7 The sampling air volume used in this study was 500,000 cm3. Maximum acceptable levels were those determined by the Italian Institute for Occupational Safety and Prevention in 2009 for air microbial contamination in operating theatres with turbulent air flow and for outpatient rooms: 180 CFU/m3 in operational and 500 CFU/m3, respectively.8
Sclerotherapy with POL foam
Preparation of test suspensions
Sclerotherapy is carried out in a standard room approximately 16 m2 with a height of 2.50 m and a volume of approximately 40 m3, with four subjects: a patient, an attending physician, a resident, and a nurse. Immediately before injection, the physician creates the foam using the Tessari method. In order to investigate the quality of the air in the operating theatre and the outpatient room, the amount of bacteria in the air was measured using an impact air sample. The first measurement was taken on a typical day before the operating theatre or the outpatient room was used. The second measurement was taken at the end of the daily session. Air measurements were all performed wearing a mask, hairnet, and gloves.7
The test for sterility, applied to substances, preparations, or articles that are required to be sterile, is carried out under aseptic conditions. A satisfactory result only indicates that no contaminating microorganisms have been found in the sample examined. The POL foam was tested in accordance with a sterility test performed by European Pharmacopoeia guidelines9 and FDA regulatory requirements.10 Results of each examination were recorded and were expressed as growth or no growth.11
Material and methods Foam production
Air sampling To measure the amount of airborne microorganisms quantitatively, we used the Microflow a microbiological air sampler (Aquaria srl, Lacchiarella—Milan, Italy). This study evaluated the air quality in the operating theater and in the outpatient room in a teaching hospital in southern Italy. The air sampling instrument was placed approximately 1.5 m from the operating tables to avoid aseptic area contamination in the operating theaters during surgery or at the center of the outpatient room. The instrument was positioned
Validation test Two microorganisms, Staphylococcus aureus and Candida albicans, were used in the present study. These microorganisms were environmental isolates used for evaluating growth promotion qualities of test media used in sterility testing. A validation test as performed by European Pharmacopoeia guidelines9 was carried out. A growth promotion test was performed as a positive control. If the clearly visible growth of microorganisms is obtained after incubation in the presence of Aethoxysclerol foam, the product possesses no antimicrobial activity under the conditions of the test, and the sterility may be then achieved without further modification.12
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Results Between 3 April 2013 and 10 May 2013, hospital hygienists took 90 air measurements for 30 air samples in total, nine air measurements for three air samples daily, on 10 different days (Table 1). The hospital hygienists took 10 air samples in operation theatres while they were being prepared for use; the mean measurement was 56.35 CFU/ml (DS 41.41; range 2.7–106.7; n.v.180). They took 10 air samples in standard rooms at the beginning of the daily session; the mean measurement was 172.33 CFU/ml (DS 107.22; range 43.3–384.7; n.v.500). Finally, they took 10 air samples in standard rooms at the end of the daily session; the mean measurement was 174.46 CFU/ml (DS 155.47; range 27.3–552; n.v.500). Among all air measurements, findings revealed that only one was abnormal (552). At the end of the incubation period at the required temperature, all the tubes with the test solution (mixture of POL foam and culture medium) made in operating theatres were examined and no evidence of bacterial growth was noted. Analogous results arose in standard rooms at the beginning and at the end of the daily session (Table 2). At the end of the incubation period at the required temperature, the results of the validation test showed
that all tubes containing only culture medium demonstrated no evidence of bacterial growth; all tubes with the inoculum of 102 CFU of viable microorganisms in the culture medium showed a clearly visible growth of microorganisms, compared to the absence of growth in the control vessels without inoculum.9 The tubes containing the test solution (mixture of POL foam and culture medium) together with an inoculum of 102 CFU of viable microorganisms were then examined. This analysis showed that the S. aureus tested had not grown in 80% of tubes and the C. albicans tested had failed to grow in 20% of the tubes (Table 2).
Discussion From the current literature foam sclerotherapy seems to be a safe and effective therapy for the treatment of venous disorders, although specific guidelines are needed for the effective use of this treatment.13 As an intravenous procedure the risk of infection has not been formally evaluated in studies.14 In fact, some fluids and drugs formulated for intravenous infusion can sustain the growth of microorganisms that may cause serious infectious complications.15–17 Although intrinsic (i.e. from the
Table 1. Results of 90 air measurements for 30 air samples totally, nine air measurements for three air samples daily and sterility test, in 10 different days. Surgery room Sampling 1 3/4/13 Sampling 2 10/4/13 Sampling 3 12/4/13 Sampling 4 15/4/13 Sampling 5 18/4/13 Sampling 6 22/4/13 Sampling 7 3/5/13 Sampling 8 7/5/13 Sampling 9 8/5/13 Sampling 10 10/5/13 Mean ( SD)
2.7
Outpatient room at beginning of morning session
Outpatient room at end of afternoon session
Surgery room
Outpatient room at beginning of morning session
Outpatient room at end of afternoon session
62.7
27.3
Negative
Negative
Negative
68
43.3
69.3
Negative
Negative
Negative
104.7
273.3
157.3
Negative
Negative
Negative
42.7
183.3
156
Negative
Negative
Negative
14.7
108.7
108.7
Negative
Negative
Negative
106.7
384.7
552
Negative
Negative
Negative
28.7
252.7
78.7
Negative
Negative
Negative
80
198
155.3
Negative
Negative
Negative
111.3
328.7
Negative
Negative
Negative
105.3
111.3
Negative
Negative
Negative
172.33 ( 107.22)
174.46 ( 155.47)
104 11.3 56.35 ( 41.41)
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Table 2. Results of validation test for sampling (tubes with only culture medium, tubes with with inoculum of 102 CFU, tubes with test solution (mixture of POL foam and culture medium) and inoculum of 102 CFU).
FTa FT þ 100 CFUb FT þ 100 CFU þ POLc
Staphylococcus aureus
Candida albicans
Total
Total
Negative
Positive
15 (100%) – 12 (80%)
– 15 (100%) 3 (20%)
SBCDd SBCD þ 100 CFUe SBCD þ 100 CFU þ POLf
Negative
Positive
15 (100%) – 3 (20%)
– 15 (100%) 12 (80%)
a
Fluid Thioglycollate. Fluid Thioglycollate þ 100 Colony Forming Unit. c Fluid Thioglycollate þ 100 Colony Forming Unit þ POL foam. d Soya-Bean Casein Digest. e Soya-Bean Casein Digest þ 100 Colony Forming Unit. f Soya-Bean Casein Digest þ 100 Colony Forming Unit þ POL foam. b
manufacturer) infusate contamination is rare, high rates of extrinsic contamination18 (i.e. occurring during the preparation of the infusate such as the sclerosing foam) may occur in daily practice. Infusate contamination may occur most frequently when physicians prepare admixtures for intravenous infusion.18 Methods used to guarantee air purity included foam production using a sterile disposable syringe kit including sterile air or even a special filter.19,20 It should be noted, however, that microorganisms that cause infections in healthcare facilities are commonly found in the patient’s own endogenous flora, such as the skin where the puncture needle is placed.21 Sclerotherapy is usually performed in the doctor’s office, and atmospheric air used for the preparation of the foam is not by itself a guarantee of sterility. In light of these considerations, the issue of the foam sterility is of primary relevance. In this study we evaluated the sterility of the foam prepared in two different settings (operating theatre and clinical room). The measurement showed almost no growth of microorganisms and in the validation test the foam appeared to possess some degree of bacteriostatic and/or bactericide properties. As reported in a previous study, it should be noted that the antimicrobial activity of foam is due to the agent itself and not to its foam state.22 Although further studies are required to validate these findings, sclerosing foam seems to be safe from a microbiological point of view. Acknowledgements We thank Mary Longrigg (Lecturer for English Language at L’Orientale University of Naples, Italy) and Heather Mandy Bond (Assistant Professor of Biochemistry at University Magna Graecia of Catanzaro, Italy) for their support in language editing and editorial assistance.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest None declared.
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