Re: Frequency of sepsis after local corticosteroid injection

B. Pal

Rheumatology Department, Withington Hospital, Nell Lane, West Didsbury, Manchester M20 2LR, UK

SIR, I was interested to read the paper by Seror et al. [1] on the frequency of sepsis after local corticosteroid injections. As the authors apparently were unaware of and did not refer to our article on the topic published recently [2], I would like to draw your readers’ attention to this. We conducted a questionnaire survey of rheumatologists in the UK for recall of post-injection sepsis in their own experience. Although the sample was relatively small (32 out of 40 returned questionnaires; 80% response) our findings of an estimated risk of 4.6 episodes of post-injection infection per 100 000 injections appear higher compared with Seror et al.'s estimated risk of 1/77 300 injections. To the best of my knowledge and experience in the UK, very few centres routinely use sterile syringes prepackaged with corticosteroids, as apparently is the case in France, as reported by Seror et al. It is likely, therefore, that such prepackaged injection materials may help to reduce the risk of post-injection sepsis. I would agree with the conclusion reached by the authors that we should encourage and advise NHS Trusts as well as pharmaceutical companies to provide prepackaged corticosteroid syringes to minimize the risks.

Seror et al. did not report on the use of local anaesthetics (LA) whether the anaesthetic is mixed with the corticosteroid whilst corticosteroid injections are given, or LA given before as a separate injection or not at all, which seems the least likely option. Most rheumatologists in the UK would use LA when injecting corticosteroids. This raises the question whether LA preparations should also be available in prepackaged sterilized syringes.

Accepted 24 February 2000

References

  1. Seror P, Pluvinage P, Lecoq d'Andre F, Benamour P, Attuil G. Frequency of sepsis after local corticosteroid injection (an inquiry on 1 160 000 injections in rheumatological private practice in France). Rheumatology1999;38:1272–4.[Abstract/Free Full Text]
  2. Pal B, Morris J. Perceived risks of joint infection following intra-articular corticosteroid injections: a survey of rheumatologists. Clin Rheumatol1999;18:264–5.[ISI][Medline]

 

Reply

P. Seror

146 Avenue Ledru Rollin, 75011 Paris, France

I was very interested in Dr Pal's letter. This is certainly an additional argument for the prepackaging of corticosteroids in sterile syringes for local injection.

The rate of 4.6 cases of sepsis per 100 000 injections (1/21 700) is similar to our own experience, which is 1/21 000 for corticosteroid injection without prepackaging in a sterile syringe. In France the use of a local anaesthetic is rare, as in private practice the practitioners avoid the use in injections of additional drugs that could lead to an anaphylactic reaction. Of course, we use a local anaesthetic for pusillanimous patients or for special or painful procedures. A corticosteroid prepackaged in a sterile syringe provides a rate of sepsis of 1/162 000, seven-fold less than with corticosteroids not prepackaged in a sterile syringe.

Can the use of a local anaesthetic explain some of the difference between 1/21 000 and 1/162 000? I do not think so. Local anaesthetics are usually applied to the skin and soft tissue surrounding the joint, but never inside the joint or very close to the site of corticosteroid injection for tendinitis or bursitis. The use of local anaesthetics could explain superficial sepsis but certainly not joint sepsis.

Accepted 24 February 2000





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