Should We Use Alcohol Swabs Before Injections? A Look At The Arguments

At the beginning of November 2024, it was reported in the news that 77-year-old, Patricia Hines, had sadly died shortly after receiving a Vitamin B12 injection the year before, in October 2023. On the day following the injection, she had become unwell and was admitted to hospital with a confirmed Group A Streptococcus infection. She unfortunately died 6 days later. Most national media outlets have since started reporting on it. See an example here. This is because the coroner ruled the likely cause of the introduction of the bacteria was down to the B12 injection and took the case to a jury which concluded on the 22nd October 2024. 

The medical cause of death was noted in the report as: 

I a Septicaemic Shock
I b Necrotising Fasciitis, Right Shoulder
I c Invasive Group A Streptococcus Pyogenes Infection
II Type 2 Diabetes Mellitus; Ischaemic, Hypertensive and Valvular Heart Disease

The coroner asserted that the nurse was to blame for not using an alcohol swab to cleanse the skin of the bacteria that caused the death, before giving the injection. This has resulted in lively discussions amongst medical professionals and the public about whether this was indeed the ‘nurse’s fault’.

Examining the evidence: Does using an alcohol swab prior to injection really reduce infection risk?

Studies and observational data challenge the effectiveness of alcohol swabbing in reducing infection risk for routine injections. The WHO guidance on best practices describes that, even without alcohol swabs, infection rates remain consistently low in various healthcare settings. For instance, they cite studies in vaccination clinics showing negligible differences in infection rates between those who used alcohol swabs and those who did not.​

The nurse was therefore following the current UK guidance that is stated in the Green Book which is; “If the skin is clean, no further cleaning is necessary. Only visibly dirty skin needs to be washed with soap and water. It is not necessary to disinfect the skin.” (P29, Ch 4)

Unfortunately, the news headlines of November 2024 were very unforgiving towards the nurse who administered the injection without first wiping the skin with alcohol. The coroner claimed she did not use ‘common sense’. 

She states: “Common sense would seem to suggest that reducing the bacterial count would reduce the risk of bacteria being inadvertently introduced into the deeper tissues during an injection.”

Common sense or clinical recommendation? What should she have done?

Now, we don’t know at this point if Patricia’s skin was indeed ‘visibly dirty’ at the time although it was reported by the nurse that it was not. However, if it was, then even so, alcohol wipes were still not indicated – with soap and water being the cleansing preference. Therefore she likely still would not have used an alcohol swab in this circumstance if following the guidance. 

As the coroner suggests, it seems like it might be ‘common sense’ to clean skin with alcohol first. Cleaner the better right? By killing bacteria on the skin, the idea is to lower the chances of bacterial infections from injections. Many healthcare protocols include this step, especially for procedures where sterility is critical. And Phlebotomy Guidelines, for instance, DO advise this important step (blood samples do not have an adaptive immune system like a human so it makes sense to reduce bacterial count in there).

But the Green Book also states this: “Studies have shown that cleaning the skin with isopropyl alcohol reduces the bacterial count, but there is evidence that disinfecting makes no difference to the incidence of bacterial complications of injections (Del Mar et al., 2001; Sutton et al., 1999).” (P29, Ch 4).”

This is an important point 

We can’t really go on bacterial count on the skin alone to be a determining factor. After all, we have immune systems that challenge bacterial contamination all the time. And we use sterile needles and other infection control methods to reduce environmental bacteria. So, any tiny amounts of rogue bacteria inadvertently administered at the same time will usually be sorted out by the body. Our mouths have huge amounts of bacteria in them and dentists give injections there all the time without using alcohol first. We rarely hear in the news or the literature about people dying of sepsis because of dental injections (nor do most of us worry too much about eating in restaurants with knives and forks that have been washed in soap and water and not been decontaminated with alcohol). 

Therefore, to know the true impact of skin swabbing, we need to know the incidence of infections reported post-injection that can be directly attributed to the injections. The authors referenced by the Green Book have suggested the study size would have to be so large to detect any sort of difference that this would be quite difficult to do. It’s hard to ‘prove a negative’.  Large-scale studies isolating the effect of alcohol swabbing on injection infections are therefore limited, partly due to ethical and logistical challenges.

What about the risks of using alcohol swabs before injections? 

One thing that struck me about the coroner report to the UKHSA is that she only focuses on the (clearly very rare) risks of NOT alcohol swabbing. And has not considered (well, mentioned) the perhaps relatively higher risks of using alcohol swabs. 

She states in section 6 of the report:

“In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action.” 

As she focuses on ‘death’ it’s worth looking at this from both perspectives. Everything in the field of evidence-based medicine has to be weighed up for risk versus benefit. And I feel that the coroner has perhaps only presented one side of the argument. There are risks of using alcohol swabs, as well as risks of not doing so when it comes to medicines.

Arguments against using alcohol swabs before injections

1. Minimal effect on infections rates

As mentioned, the WHO and UKHSA guidelines indicate that for healthy individuals with intact skin, alcohol swabs do not significantly lower infection risks in routine injections​. It is so awfully sad about poor Patricia- not taking away from that- but how often do we see reports like this? It’s thankfully incredibly rare. It’s hard to say how many people receive B12 injections in the UK as some are privately given and there is not a large amount of surveillance data that I can find. But I imagine it’s easily in the thousands. And when we add other injectable medicines into the mix, we are probably talking millions who have non-pre-swabbed injections every day to SAVE their lives– and don’t get sepsis afterwards.

2. Cost, time, and waste reduction

For high-frequency injections, such as insulin or routine vaccinations, NOT swabbing can save time and reduce waste without sacrificing patient safety. Let’s imagine that we started routinely swabbing everyone who had an injection. If alcohol is allowed to dry properly (30 – 180 seconds depending on which literature you are looking at) and a proper (30 second contact) cleanse is done, this could add up to an extra two and a half minutes to an appointment. In a busy flu vaccine clinic where appointments can be as little as two minutes each in themselves, swabbing routinely could mean a 50% reduction in people vaccinated that day. Flu is a killer and maimer too. Leaving people unvaccinated or delayed in getting vaccinated is also a risk to life. 

3. Skin irritation

Repeated use of alcohol, especially on sensitive or frequently injected areas, can lead to skin irritation and drying, which may be counterproductive for patients with ongoing injection needs. Sore, broken skin can also be a source of the harbouring of deadly bacteria and opens up routes to infection. Also, alcohol that has not been allowed to dry and is consequently tracked into the skin is not pleasant and can cause further pain and irritation. 

4. Potential risks for interactions with injectable medicines

How does medicinal vitamin B12 interact with alcohol? Do we know? Have the manufacturers tested this? Live vaccines, such as the MMR vaccine, contain attenuated viruses that must replicate in the body to build immunity. Alcohol swabs, if not allowed to dry fully, could theoretically inactivate these vaccines by damaging the live virus before injection. This risk is why in countries that do recommend an alcohol swab on occasion (such as New Zealand) official guidelines recommend waiting at least two minutes for alcohol to dry completely before administering a live vaccine or, when possible, using soap and water as an alternative for visibly soiled skin​. The WHO state specifically “DO NOT use alcohol for skin decontamination for administration of vaccinations” (p7). If MMR vaccine was routinely deactivated, I think we can all foresee the suffering and deaths that would ensue from measles cases, and we can infer that this would be at a far greater rate that any sepsis cases in the absence of wipes… 

Not to mention the even more specific risks for putting all this in the national media.

Unfortunately, now this incident is public knowledge and the media have gone to town on the nurse:

• Patients all over the place will be concerned, asking their health professionals to swab them first, and worrying when they don’t. 
• Health professionals themselves will be confused and looking to the guidance again, questioning their practice. Do they risk potentially compromising efficacy for the sake of satisfying patient concerns? Maybe they will be swayed into using wipes on request and therefore be feeling pressured to go against the current guidance, leaving them vulnerable either way. 
• Maybe they will be worrying now about all the un-swabbed injections they have spent their lives giving and wondering if they ever caused harm? … I can’t even imagine how that nurse who did the ‘fatal injection’ is feeling right now. And I want her to know that there are many fellow nurses out there (myself included) that support her and do not feel that she failed to perform good care for Patricia based on what we have heard so far. 
• As B12 has been referred to incorrectly by newspapers multiple times as a ‘vaccine’, I wonder how many people are once again prompted to worry about vaccines and decide against vaccination: The best life-saving medicines we have?
• Will the public also have their confidence knocked in health professionals in general and therefore lose trust in other medical interventions? 

Has this very public enquiry caused more risk of harm to the public than it could possibly ever prevent? 

Final thoughts

It’s always stimulating and important to reflect on current practice when an abnormal or rare event happens that seemingly contradicts the guidance we follow. And it will be interesting to see the UKHSA / JCVI response when it arrives (they have been given until 20th Dec 2024 to respond). 

There are clearly arguments for and against using alcohol swabs prior to injections. While alcohol swabs have long been part of the infection control process in many clinical areas, evidence suggests they may not be necessary for every injection, and even detrimental on occasion too, especially when the skin is clean and the patient is healthy. For some medicines, drying time is crucial, as alcohol could compromise the medicine’s efficacy. 

But the coroner also mentions the evidence is old. It is also quite sparse. So perhaps it is indeed right to put some focus back on it after this terribly unfortunate event and review the evidence again to better inform clinical judgement. ‘Clinical judgement’ is of course preferential to the ‘common sense’ approach that the coroner argues for. As a good friend and nurse colleague of mine (Jasmin Amoroso) pointed out: 

“As nurses, we have salted, vinegared, bleached and egg-washed wounds on the basis of ‘common sense’ before the evidence revealed we are neither fish, chips or salads”. 

Before the days of evidence-based practice we might well have relied upon misplaced thoughts about ‘what seems the right thing to do’. Nursing now goes way beyond being a ‘common sense’ profession. But do we have to deal with this so publicly? Common sense is not always what it might seem if one doesn’t have all the different perspectives to compare and contrast with.

Training at Health Academy