Skin disinfection using hygiene swabs for self-injection of diabetes medications: an overview of the current best practices

Abstract

Injectable diabetes medications are widely available. Although self-injection techniques update with the release of new devices, current clinical practices in Japan consistently adhere to the standardized hygiene procedures for skin disinfection. On the other hand, the manual for disaster diabetes care does not require the victims to skin preparation using alcohol swabs before injection. The World Health Organization shows that skin disinfection with alcohol is not necessary for subcutaneous injections, and that hand hygiene and skin preparation with soap and water are important procedures. Skin preparation for self-injection remains controversial. Thus, this article overviewed current best practices and discussed future implementation of skin preparation for self-injection of diabetes medications. According to the latest published studies, there is a trade-off between standardized infection control and cost-saving. To address the practical debate, revision of the best practices for self-injection techniques stratified by healthcare setting, cost-effectiveness analysis based on patient-reported outcomes, and opt-in prescribing systems are needed.

New injectable diabetes medications are widely available across Japan. The better one from a variety of products, such as insulin analog and glucagon-like peptide-1 (GLP-1) receptor agonist, can be chosen for individual lifestyles [1]. New products will dramatically improve disease management and patient quality of life. Expecting its effectiveness, people living with diabetes learn the technique of self-injection and practice it in their daily lives.

Although self-injection techniques are updated with the release of injection devices, current clinical practices in Japan consistently adhere to the standardized hygiene procedures for skin disinfection. Patients undergoing injection therapy use disposable hygiene products prescribed by their health insurance. While the substantial costs of needles and syringes are accounted for in the national medical expenditure, those of hygiene swabs rely on copayment by medical facilities or patients.

Since Japan has experienced many times large-scale earthquakes and storms, if patients lose their supplies for self-injection during a disaster, skin disinfection with hygiene swabs is not required prior to injection [2]. Instead, patients are instructed to maintain skin hygiene by washing their hands and wiping the injection site with water.

The World Health Organization shows in the best practices for injections that skin disinfection using alcohol is not necessary for subcutaneous injections, and that hand hygiene and skin preparation with water and soap are recommended [3]. Although several countries are in accordance with this guideline, other countries, including Japan, generally apply standard hygiene procedures using alcohol-based solution due to insufficient national consensus [4, 5]. Skin preparation for self-injection is still controversial.

Given that diabetes is a costly disease, a trade-off between standardized precaution and cost-saving is posed. Here, this article discusses the risk and benefit of this issue. For the risk, healthcare providers must comply with medical standards and do infection control at the injection site. Individuals and environments with a high risk of infection, such as hospital care, require strict hygiene strategies. On the other hand, the case of home care may not need them [4]. One practical debate is the confusion between self-injection therapy by a patient and injection techniques by healthcare providers. The latter is a quite different matter from the skin preparation for self-injection. Hygiene procedures should be explicit in each case of self-injection or not. In addition, Japanese patients seem to master their own hygiene procedures by following trusted healthcare professionals. Therefore, it is necessary to carefully consider whether a hygiene regimen is beneficial for individual diabetes management [4].

For the benefit, self-injection technique can be simplified if disinfection with alcohol is not applied. Conducting multi-step procedures for self-injection in daily routines is challenging for patients, especially for children and older persons. Instead, cost-saving of hygiene swabs may contribute to appropriate distribution of medical resources. The COVID-19 pandemic has led to an overconsumption of medical resources worldwide. Now, the cost-effectiveness of skin disinfection for self-injection should be reconsidered.

According to the recent literature review including one randomized controlled trial, there is no found evidence of cost-effectiveness of skin disinfection [5]. Rather, experimental studies aimed at observing the occurrence of skin infections as a primary outcome are no longer feasible. For example, incremental cost-effectiveness ratio can be calculated to evaluate the trade-off between resource spent for skin disinfection and patient-reported outcomes [6].

As a patient-reported outcome, stigma is a reasonable outcome regarding the need for skin disinfection [7]. This is because cultural hesitancy toward self-injection therapy remains in Japanese society. The patients adhere to the treatment while experiencing psychosocial distress. Therefore, self-injection procedures should be refined based on patient-reported outcomes to be more universal for individuals.

Patients are consumers and should be able to make active decisions and choices about skin preparation methods for their own diabetes care. For them, diabetes self-management education and support need to be more accessible. Patients of all ages and at all stages of the disease want to obtain plain information. Otherwise, prescribing hygiene swabs may be better to apply opt-in claims rather than opt-out ones in the comprehensive payment system. Opt-in prescribing may help physicians avoid clinical inertia and optimize prescriptions for self-injection therapy.

This commentary overviewed current best practices for skin preparation in self-injection therapy of diabetes medications. There are gaps in the skin preparation procedures according to national and international consensus. Aside from research on skin infections by self-injection techniques with and without hygiene swabbing, updating best practices for self-injection procedures stratified by healthcare setting, cost-effectiveness analysis based on patient-reported outcomes, and opt-in prescribing systems are needed.

Funding

This study was supported by JSPS KAKENHI Grant Number JP19K10528.

Declarations

Conflict of interest

The authors declare no conflict of interest.

Human and animal rights statement

This article does not contain any studies with human or animal subjects performed by any of the authors.