Plastic culture bottles as an alternative to conventional glass

by Ron Stoker

Microbiology laboratory personnel are at increased risk for bloodborne pathogens because of their contact with blood and other body fluids. Most exposures are caused by percutaneous injuries with sharp objects, such as broken glass or needlesticks, that are contaminated with blood or body fluids (Romea et al., 1995; EPINet, 1998; NaSH, 1999; CCOHS, 2000; Puro et al., 2001). The most commonly transmitted pathogens include hepatitis B and C (HBV, HCV) and human immunodeficiency virus (HIV) (Sepkowitz, 1996a). Other pathogens also pose a significant risk to laboratory personnel.

The recovery of pathogens from blood culture for diagnosing bacteremia and fungemia remains one of the most important tests performed by microbiology laboratories today. Many laboratories still use glass culture bottles with growth media to grow microorganisms for further testing. Glass bottles can present a health risk to laboratory personnel who handle broken glass resulting from breakage when bottles are dropped, during removal of bottles that have broken in instruments, or ven from improperly disposed-of glass waste. Broken blood culture bottles are among the most dangerous sharps injuries in healthcare (Ernst, 2003). When a bottle breaks, it exposes laboratory personnel to infectious pathogens from bottle contents. Breakages also expose workers to aerosols and micro droplets that contain viruses and other pathogens if inhaled or splattered onto clothing.

In March of 2010, in order to determine the prevalence of glass bottle breakage, the International Sharps Injury Prevention Society (ISIPS) surveyed 276 hospital-based microbiology laboratories. The majority of the hospitals surveyed (69.41 percent) processed between 1,000 and 5,000 blood cultures sets per year. More than 60 percent of the respondents using glass bottles claimed that their laboratory had experienced a recent blood culture bottle breakage. Of this group, more than three quarters (75 percent) of respondents stated that the breakages resulted in as much as one hour of downtime. Sixty percent of the respondents added that breakage had resulted in an injury.

According to the survey results, 30 percent of laboratory workers improperly dispose of broken glass bottles in non-sharps containers such as standard garbage bags and waste cans. According to one survey respondent, an employee was cut when a shard of broken glass pierced through the waste bag where the broken glass had been discarded. Injuries associated with broken glass disposal put laboratory workers at an increased risk for lacerations and exposure to infectious materials, hazardous reagents and chemicals.

According to another survey respondent, her laboratory had at least one laceration per year from cleaning up broken culture bottles. An additional respondent commented that one of his laboratory workers was cut while attempting to remove a cracked bottle from an instrument. Many of the responding laboratories surveyed claimed that they experienced at least one laceration per year from cleaning up improperly disposed-of broken blood culture bottles.

One survey respondent commented that broken blood culture bottles make it very easy to become a “blood brother” with your patient. In one instance, the nurse-phlebotomist didn’t have space on his tray for the blood culture bottle, so he placed the inoculated bottle on the patient’s bed. When the patient moved to scratch his nose, the culture bottle rolled off the bed and shattered on the floor, splattering the contents of the blood culture bottle in the face and eyes of the attendant.

 The Occupational Safety and Health Administration (OSHA) estimates that 2,800 broken glass exposures occur each year in the United States (Jagger, 1998). According to EPINet, the exposure tracking system developed by the International Healthcare Worker Safety Center at the University of Virginia, sharps injuries are the most common cause of occupational infections among healthcare workers, causing an estimated 1,000 HIV, 66,000 hepatitis B, and 16,000 hepatitis C cases annually to health workers around the globe (World Health Organization 2003). A significant number of occupational infections are caused by direct blood contact.

OSHA published the Bloodborne Pathogen Standard (BPS, 29 CFR 1910.1030), which was aimed at preventing the more than 9,000 infections and 200 deaths per year that resulted from contact with bloodborne infections. Released in March 1992, the BPS primarily focused on hospitals, laboratories, and other institutions where there was a reasonable expectation for personnel to come in contact with potentially infectious blood or other bodily fluids that carry a high morbidity or mortality rate.

The best way to avoid broken glass injuries and subsequent exposure to infectious blood and other body fluids is to eliminate glass whenever possible. According to the BPS, laboratories must use glass alternatives wherever possible (OSHA, 1991). Laboratories who continue to use glass culture bottles when plastic bottles are available may be subject to citations and fines in accordance with the most recent Compliance Directive. In the 2003 issue of Medical Laboratory Observer, OSHA’s Director of Enforcement Programs Richard Fairfax stated:

“Since Plastic can be easily substituted for glass in most all cases, we expect employers to use plastic where appropriate … Since plastic tubes are readily available that do not compromise specific clinical or diagnostic tests, a facility that is not using them would have to justify why they are not being used for each specific procedure or test and document that it is in their exposure control plan.”

One manufacturer of culture bottles, BioMérieux, has developed plastic culture bottles to reduce or eliminate the risks associated with glass culture bottles (Snyder, 2002). Snyder et al found that plastic standard aerobic (PSA) bottles, when used with the BacT/ALERT microbial detection system, was comparable to vented glass standard aerobic (VA) culture bottles for the recovery and speed of detection of pathogens in suspected cases of bacteremia or fungemia.

Since 1999, many hospital-based microbiology laboratories have adopted plastic tubes and bottles to reduce broken glass injuries; however, even one worker who is exposed to potentially contaminated blood due to glass breakage can expose a microbiology laboratory to potential liability. According to OSHA, healthcare facilities must consider all devices that are appropriate even if the facility is bound by a GPO contract.

Some microbiology laboratory managers may have been reluctant to use plastic culture bottles because they believe that aerobic plastic bottles do not perform as well as glass bottles for the detection of clinically significant microorganisms. Studies show, however, that the overall performance of plastic aerobic bottles is similar to that of glass for diagnosing bacteremia and fungemia (Petti, 2005), and many others.

One study found that plastic aerobic bottles exhibited similar detection times to glass bottles when samples were positive at 72 h. Plastic bottles offer comparable performance to glass bottles without the risk of exposure to potentially dangerous pathogens. Plastic eliminates sharps injuries that would otherwise occur when glass culture bottles break. One responding laboratory from the March 2010 ISIPS survey stated that plastic culture bottles decreased sharps injuries in its laboratories by more than 58 percent over a one-year period.

Plastic culture bottles offer several advantages over their glass counterparts while offering comparable rates of recovery and time to detection. By reducing sharps risks, plastic blood culture bottles can minimize laboratory personnel exposure to infectious agents.

In addition, although perception of glass may be that glass bottles are more environmentally friendly than plastic, as a medical waste neither glass nor plastic blood culture bottles may be recycled. In actual fact, plastic blood culture bottles introduce significant environmental and cost advantages over glass bottles due to reduced shipping weight and a more energy-efficient manufacturing process. The combination of reduced risk, environmental and cost factors make plastic culture bottles a preferable alternative to conventional glass bottles.

References

• Atlanta, GA, USA, Centers for Disease Control and Prevention, The National Surveillance System for Hospital Care Workers (Internet communication of EPINet (1998).
• Uniform needlestick and sharp object injury report. University of Virginia, USA, International Health-care worker Safety Center, Exposure Prevention http://www.med.virginia.edu/medcntr/centers/epinet/soi98.html.
• CCOHS (2000) Needlestick injuries. Hamilton, Ontario, Canada, Canadian Center for Occupational Health and Safety (Internet communication of October 2001 at web site http://www.ccohs.ca/oshanswers/diseases/needlestick_injuries.html.
• EPINet (Exposure Prevention Information Network) Data Reports. International Health Care Worker Safety Center, University of Virginia. 2000. Accessed on: May 17, 2010. Available at: http://hsc.virginia.edu/medcntr/centers/epinet/estimates.html.
• EPINet. International Healthcare Worker Safety Center. EPINet™ Exposure Prevention Information Network. Access on: May 18, 2010. Available at: http://www.healthsystem.virginia.edu/internet/epinet/about_epinet.cfm.
• Ernst, D.J. The Other OSHA Mandate: Plastic Blood Collection Tubes and Blood Culture Bottles. Center for Phlebotomy Education. 2003. 2 Pp.
• Global Initiative in Healthcare Worker. Protecting healthcare workers worldwide from occupational exposures to bloodborne pathogens: Defining the problem. Accessed on May 18, 2010. Available at: http://www.healthsystem.virginia.edu/internet/safetycenter/internetsafetycenterwebpages/DefiningtheProblem.cfm.
• Jagger, J., Bentley, M., and Perry, J.: Glass capillary tubes: eliminating an unnecessary risk to healthcare workers. Adv Exp Prev 3(5):49-55, 1998.
• NaSH (1999) Summary report for data collected from June 1995 through July 1999. Information Network (Internet communication of October 2001 at web site November 2001 at web site http://www.cdc.gov/ncidod/hip/NASH/report99.PDF).
• OSHA. 35-Year Milestones (2007). Accessed on: May 16, 2010. Available at: http://www.osha.gov/as/opa/osha35yearmilestones.html.
• Pettie C.A.; Mirrett, S.; Woods, C.W., Reller, L.B. Controlled Clinical Comparison of plastic and Glass Bottles of BactT/ALERT FA Medium for Culturing Organisms from Blood of Adult Patients. Journal of Clinical Microbiology. 2005. 43(4):1960-1962.
• Puro V, De Carli G, Petrosillo N, Ippolito G.(2001) Risk of exposure to bloodborne infection for Italian healthcare workers, by job category and work area. Infection Control and Hospital Epidemiology, 22(4):206–210.
• Rogues AM, Verdun-Esquer C., Buisson-Valles I. et al. Impact of safety devices for preventing percutaneous injuries related to phlebotomy procedures in health care workers. Am J Infect Control 2004; 32(8):441-444.
• Romea S, Alkiza ME, Ramon JM, Oromi J. (1995) Risk of occupational transmission of HIV infection among health-care workers. Study in a Spanish Hospital. European Journal of Epidemiology, 11:225–229.
• Sepkowitz KA. (1996a) Occupationally acquired infections in health-care workers. Part II. Annals of Internal Medicine, 125(11):917–928.
• Snyder, J.W.; Munier, G.K.; Bostic, G.D.; Bozigar, P.S.; Hanna, R. Evaluation of a plastic nonvented aerobic blood culture bottle for Use with the BacT/ALERT Microbial Detection System. Journal of Clinical Microbiology. 2002. 40(12):4657-4759.
• Stoker, R.Sharps Safety Matters: Where to find safety products? Accessed on: May 17, 2010. Available at: http://www.isips.org/reports/Articles/mic0208w56.pdf.
• U.S. Department of Labor and Occupational Safety and Health Administration (OSHA).
• Occupational exposure to bloodborne pathogens; final rule (29 CFR 1910.1030 Federal Register. 1991: December 6:64004-64182.

Ron Stoker, MS, is the executive director of the International Sharps Injury Prevention Society (ISIPS). He has 29 years experience in the medical device industry as a researcher, marketer, educator, consultant and healthcare worker advocate. He has written more than 200 medical journal articles, primarily on sharps injury prevention, infection control, and hand hygiene. Mr. Stoker has his BS in Pre-Medical Zoology from Brigham Young University, an MS in Bioengineering from the University of Utah and an “honorary doctorate” from the school of hard-knocks. As a result of a surgical mishap he was rendered a quadriplegic in December 2006. Informed that he would never walk again, with tenacity and a “supportive and mean wife,” Mr. Stoker taught himself how to walk again. He says that he walks like an “alcoholic” but is really just a recovering quadriplegic!

            Mr. Stoker has conducted workshops and Congresses on sharps safety at national and international meetings for the last 10 years. He is a founder and lecturer for the Infection Preventionist Boot Camp Series. For more information contact Mr. Stoker at info@isips.org.