Is Skin Preparation Necessary Before Needling?: A Review

Introduction

Physician–acupuncturists' concern about introducing infectious agents into patients' bodies through needling has perpetuated the preparation of skin with antiseptics such as 70% isopropyl alcohol. Are iatrogenic infections caused by needling a significant clinical problem? Woo et al. states that, since the 1970s, there have been 50 cases of infection attributed to acupuncture reported worldwide. ¹ This is an average of 1.25 cases per year. In the United States alone, there are 25,000 acupuncturists (LAcs) and 6000 physician–acupuncturists. If each acupuncturist saw 50 patients per week, this would equate to 1.55 million treatments per week, 80.6 million treatments per year. If all the infectious cases were from the United States, this would be an infection rate of 1.25/80.6 × 10⁶ = 0.0146 × 10^–6, or 1 case for every 68.5 million treatments. In an earlier article, Woo et al. described 16 anecdotal case reports of pyogenic bacterial infections complicating acupuncture in the English literature from 1996 to 2002. ² This would be a rate of 2.67 cases per year. Using a similar calculation as above, this yields an infection rate of 1 case per 30.2 million treatments. This compares with an incidence of 2% for cellulitis/abscess formation during venipuncture after isopropyl alcohol swabbing according to Sutton et al. ³

Yamashita and Tsukayama report that in Japan between the 1980s and 2002, 120 literature articles reported 150 adverse events regardless of causal relationship. ⁴ These included abscess formation, septicemia, spinal infections, erysipelas, streptococcal toxic shock–like syndrome, skull tuberculosis, infected atrial myxoma, acute hepatitis B, and local redness. No causal relationships between acupuncture and these infections were established. Between 1992 and 1998, 84 acupuncturists administered 65,482 treatment sessions with no serious adverse effects or infections reported. In another Japanese study by these same authors, a 4-month survey of less severe adverse events—1441 treatment sessions, 30,338 needle insertions, and 391 patients—reported no infections. The authors also refer to a study of physicians and physiotherapists in the United Kingdom^3,4 with 31,822 treatment sessions reporting only 1 infectious case, that of cellulitis of the leg.

The overall low incidence of infection in these studies—0%–0.0031%—does not minimize the seriousness of any adverse reaction such as abscess formation. This low incidence does, however, indicate the relative safety of acupuncture compared with venipuncture.

The Question

“Compared with no cleansing, does swabbing the skin with 70% isopropyl alcohol before puncture with a sterile needle reduce the risk of infection at the injection site?” This question has been asked of the authors in clinic and in lectures on medical acupuncture. The question is based on the longstanding practice of medical professionals—physicians, nurses, and phlebotomists—of treating the venipuncture or injection site with 70% isopropyl alcohol. A review of the literature reveals no greater risk of infection when no cleansing of normal skin is done.

Del Mar et al. ⁵ in a brief review article in 2001 found three controlled trials; two of the trails were randomized, examining the benefit of isopropyl alcohol swabbing before injection in preventing subsequent infection.

Skin Preparation

Although routine swabbing of the needle injection site of normal skin with 70% isopropyl alcohol is no better than no skin preparation as measured by clinical infection rates or microbiological culture, if the practitioner is determined to clean the skin or partially disinfect it, swabbing with 70% isopropyl alcohol and waiting between 30 seconds and 5 minutes (i.e., until dry) has been the standard ractice.^10–13 However, are there better ways to prepare skin before needle insertion if it is indicated, such as for immunocompromised patients?

Selwyn and Ellis compared the action of several popular surgical disinfectants on abdominal skin of cadavers and tested for bacteria by biopsy, cylinder-scrub, and tape sampling. ¹⁴ All disinfectants were rubbed briskly on the skin for 15 seconds and allowed to act for 30 seconds before sampling. Koivisto and Felig used the cylinder-scrub to measure abdominal skin bacteria after 5 seconds of skin cleaning with 70% isopropyl alcohol. ⁷ The researchers' results are summarized in Table 1.

Selwyn and Ellis remarked that disinfecting normal skin might create opportunities for pathogenic infections, because the normal flora, which produce antipathogenic bacterial effects, are disrupted. Their case for minimal disinfection of skin runs thus:

Other studies compared the effectiveness of chlorhexidine-alcohol versus povidone-iodine in skin antisepsis. Darouiche et al. compared the effects of chlorhexidine-alcohol scrub and povidone-iodine scrub and paint. ¹⁵ The rate of infection at the surgical sites was significantly lower with chlorhexidine-alcohol than with povidone-iodine (9.5% versus 16.1%; P = 0.004). Choi evaluated chlorhexidine gluconate-ethanol scrub and povidone-iodine for antimicrobial efficacy. ¹⁶ The results are shown in Table 2.

Clearly, chlorhexidine gluconate-ethanol is more effective immediately than povidone-iodine and has a stronger residual effect.

What About Touching the Needle Before Insertion?

Several schools of acupuncture training use gloveless or tubeless needle insertion techniques, such as the Helms Medical Institute's “Push that Finger” technique, in which the middle finger touches the needle shaft but not the tip. The medical literature is bereft of studies on needling with or without touching the needle. For venipuncture and catheter insertions, the standards exclude needle touching, but no studies are offered to prove or disprove this practice. Until such studies with acupuncture needles are forthcoming we can indirectly justify touching the needle shaft. Our argument follows these lines:

What Role Does Hand Washing Play in Best Needling Practices?

In addition to Choi's study above, Bulus and Kaleli compared the antibacterial effects of different antiseptics after hand washing. ¹⁷ Eighteen volunteers washed their hands with 7.5% povidone-iodine, 4% chlorhexidine-gluconate, or liquid soap by applying a standard hygienic handwashing technique. Bacterial counts of the hands were taken just after handwashing, after 3 hours (residual effects), and after 5 days with daily handwashings (cumulative effects). The immediate results showed chlorhexidine-gluconate was superior to povidone-iodine, which was superior to liquid soap. There was no difference between chlorhexidine-gluconate and povidone-iodine at 3 hours, while both chlorhexidine-gluconate and povidone-iodine showed cumulative effects. Garcia et al. presented evidence that a single chlorhexidine preparation—2% chlorhexidine-gluconate—a 70% isopropyl alcohol formulation—maintained antimicrobial activity for at least 48 hours. ¹⁸ Proper handwashing needs to include proper handdrying. Patrick et al. concluded that careful handdrying is a critical factor in determining touch-contact–associated bacterial transfer after hand washing. ¹⁹ Bacterial counts decreased progressively as drying with an air or cloth towel removed residual moisture from the hands. Snelling et al. also concluded that effective hand drying is important for reducing transfer of commensals or remaining contaminants to surfaces (including skin). ²⁰ These researchers also noted that rubbing hands during warm air drying can counteract the reduction in bacterial numbers acquired during handwashing.

Universal Precautions

Practitioners must remember the context of contacting and treating patients with an invasive technique, although mildly invasive, such as acupuncture. All patients should be treated as though they are infected. Universal precautions (universal blood and body fluid precautions) should be used in the care and treatment of all patients, especially in the emergency care setting where the risk of exposure to blood is increased and patients' infection status is usually unknown. The salient points of universal precautions ²¹ are: (1) All health care workers (HCWs) should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with patients blood or other body fluids is anticipated. Gloves should be worn for touching blood or body fluids, and for performing venipuncture or other vascular access procedures. During normal acupuncture procedures needles are inserted into intact skin and withdrawn without bleeding. A simple sterile cotton ball can act as an appropriate barrier to prevent contact with patients' blood or body fluids. (2) All HCWs should strive to avoid injury when disposing of or handling sharps after procedures. This is implicit in best needling practices for physician acupuncturists. (3) HCWs with exudative lesions should refrain from direct patient care and should not handle patient equipment until the condition resolves.

In summary, for a medical acupuncturist's normal patient population with intact, clean skin, preparation with 70% isopropyl alcohol is unnecessary and, if Selwin and Ellis are correct, can potentially increase the risk of infection. If antisepsis is indicated, chlorhexidine-alcohol preparations are the superior agents. Hand washing between patients with chlorhexidine-alcohol or providone-iodine scrubs will further reduce the risk of introducing pathogens into the patient. Universal blood and body fluid precautions (universal precautions) should be followed.

Recommendations

Disclosure Statement

No competing financial conflicts exist.