hoapital acquired infection

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Blood Safety and Clinical TechnologyGuidelines on Prevention and Control of Hospital Associated Infections

Acknowledgements

The draft Guidelines on Prevention and Control of Hospital Associated Infections were finalized during a

Consultative Meeting on Prevention and Control of Hospital Associated Infections organized in Bangkok,Thailand, fro !" to !# $une !%%&'

The first draft was prepared () *r Geeta Mehta, Head of the Micro(iolog) *epartent, +ad) HardingeMedical College, ew *elhi, India and finalized in the Consultative Meeting' The valua(le contri(utionsof all the e-perts listed in the Anne- are gratefull) acknowledged

IntroductionInfections which arise in hospitals are tered .hospital associated infections. /HAI0' 1uch infections havealso (een called .noscoial infections. and soeties .hospital ac2uired infections.' As ore health careis now (eing provided in a(ulant patients, the ter .health care associated infections. is also used'

efinition

Hospital Associated Infections /HAI0 or noscoial infections are those infections that were neitherpresent nor incu(ating at the tie the patient was aditted to the health care facilit)'

The a3orit) of HAI (ecoe evident 45 hours or ore following adission' However, it a) not(ecoe clinicall) evident until after discharge'

There are various reasons wh) patients in hospital ac2uire infection'

Patients with infectious diseases are fre2uentl) aditted to hospital' 1oe of these patients are a(le

to spread their organiss to other patients and the) provide one source of infection in hospitalpatients aditted for other causes' 6-aples of such infections spreading in hospital include 7salonellosis, group A streptococcal infections, tu(erculosis, viral hepatitis and other infections' 8hensuch patients re2uire adission to hospital, the risk has to (e assessed for other patients andappropriate easures taken to contain the infection with isolation procedures of var)ing degrees ofstrictness depending on the infection'

The coonest fors of hospital9ac2uired infection are due to invasive procedures carried out onpatients such as surgical operations, intravenous therap), intu(ation and catheterization' A variet) of

easures is needed to control such infections'

Iuno9copetence of var)ing degrees is seen in an) of the patients aditted to hospital' These

include patients at the e-trees of age, those with dia(etes, receiving iunosuppressive drugs andthose with cancer, in particular those undergoing cheotherap)' These patients are prone to infectionwith (acteria which have little threat for health) persons'

Sources of infection in hospitalBacteria and viruses are natural inha(itants of the environent, (oth in the counit) and in thehospital' The a3orit) of these organiss are not pathogens and a) even have a (eneficial role topla) in huan (od)' The organiss in the natural environent a) provide a reservoir fro whichthe) a) (e passed to other patients and cause infections' However, there are ver) an) reservoirs:the one fro which infections arise is usuall) called the source' Identification of the correct source isessential to arrest the spread fro this source'

The sources of spread can (e classified along the sae lines as the t)pes of infection'

&'

1pread fro counit)9ac2uired infections to other patients in hospital can (e via;The respirator) tract as in tu(erculosis and respirator) viruses:Infected (lood as with viral hepatitis and HI9ra) departents and clinics'
http://www.searo.who.int/en/Section10/Section17/Section53/Section362.htm


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The organiss coe fro an) possi(le sources, such as;

The patients? own resident flora 7 the outh, gastrointestinal tract, vagina or the skin:The resident icro(ial flora of health care workers and fro other patients on the ward:Transient (acteria carried on the hands of health care workers fro one patient to another:Containated instruents, dressings, needles, etc' used for invasive procedures, andInfusions'

The wide variet) of opportunities for ac2uisition of hospital pathogens re2uires general standards ofhospital practice to protect all patients' At the sae tie, each risk group or procedure a) re2uirespecific easures related to reoving special sources of infection'

The general procedures include ites such as; 1uppl) of ade2uatel) sterilized instruents and dressings:

@perating theatre design, discipline and procedures:General application of aseptic techni2ues:Good environent cleaning, safe food, effective laundr) procedures and waste disposal, and

1pecific easures include ites such as;

1tandardized procedures for intu(ation, catheterization, venous access and investigativeprocedures andPeri9operative surgical cheoproph)la-is'

' The groups at high risk of ac2uisition of infection due to diinished defences re2uire additionalprotection including hospital areas where there are enhanced invasive procedures' The specificre2uireents of IC, special (a() units, oncolog) departents and long9sta) surgical wards need to(e docuented and ipleented' =or neutropenic patients, special isolation procedures providing aprotective environent rather than containent facilit) are necessar)'

8ith such a cople- series of events, it is necessar) to appl) a scientific approach to the assessentof risks in order to esta(lish priorities for infection control' All hospital staff re2uire inforation oncontrol of hospital infection and the particular role each group has to pla) in the process' Thepracticalities of the situation have to (e discussed with staff at all levels to ensure that the) arecapa(le of carr)ing out the recoended procedures' Instructions are ore readil) coplied with ifthe procedures have (een e-plained and are accepta(le to the surgeons, nurses, technicians anddoestic staff who have to ipleent the'

!agnitude of pro"lem

Hospital9associated infections are considered as a3or causes of ortalit), eotional stress andenhanced or(idit) in hospitalized patients' These also account for significant econoic loss andadditional (urden on health care institutions' In a stud) conducted () 8H@, the highest fre2uencies ofHAI were reported fro hospitals in the 6astern Mediterranean egion /&&'5D0 followed () 1outh96astAsia, where it was &%D' It has also (een estiated that at an) tie over &'4 illion people worldwide

suffer fro infectious coplications ac2uired in hospital' The infections ac2uired in the hospitals a)(e due to resistant organiss that further accentuate the pro(le' It has also (een estiated thatthese infections cost ore than 1E 4% illion ever) )ear in Thailand alone'

Infection Control Programme6ach hospital needs to develop a prograe for the ipleentation of good infection control practices

and to ensure the well (eing of (oth patients and staff () preventing and controlling HAI'

#"$ectives of the infection control programme

Monitoring of hospital9associated infections:Training of staff in prevention and control of HAI:

Investigation of out(reaks:Controlling the out(reak () rectification of technical lapses, if an):Monitoring of staff health to prevent staff to patient and patient to staff spread of infection:Advice on isolation procedures and infection control easures:Infection control audit including inspection of waste disposal, laundr) and kitchen, andMonitoring and advice on the safe use of anti(iotics'

%esponsi"ility of hospital administrator&head of health care facility


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The hospital adinistratorFhead of hospital should;

Provide the funds and resources for infection control prograe:6nsure a safe and clean environent:6nsure the availa(ilit) of safe food and drinking water:

6nsure the availa(ilit) of sterile supplies and aterial, and6sta(lish an infection control coittee and tea'

Infection control organi'ations in a hospital

Infection control organizations are essential features of an infection control prograe' These

organizations are;

() Infection Control Committee *ICC+epresentatives of edical, nursing, engineering, adinistrative, pharac), C11* and icro(iolog)departents are the e(ers' The coittee forulates the policies for the prevention and control ofinfection' @ne e(er of the coittee is elected chairperson and has direct access to the head of thehospital adinistration' The infection control officer is the e(er secretar)' The coittee eetsregularl) and not less than three ties a )ear',) Infection Control Team *ICT+Me(ers are the Infection undertake out the da) to da) easures for the control of infection'

-) Infection Control #fficer *IC#+The Infection Control @fficer is usuall) a edical icro(iologist or an) other ph)sician with an interest inhospital associated infections'.unctions&' 1ecretar) of Infection Control Coittee and responsi(le for recording inutes and arranging

eetings:!' Consultant e(er of ICC and leader of ICT:' Identification and reporting of pathogens and their anti(iotic sensitivit):4' egular anal)sis and disseination of anti(iotic resistance data, eerging pathogens and unusual

la(orator) findings:

' Initiating surveillance of hospital infections and detection of out(reaks:"' Investigation of out(reaks, and' Training and education in infection control procedures and practice'/) Infection Control 0urse *IC0+A senior nursing sister should (e appointed full9tie for this position' Ade2uate full9tie or part9tie

nursing staff should (e provided to support the prograe'

.unctions&' To liaise (etween icro(iolog) departent and clinical departents for detection and control of HAI:!' To colla(orate with the IC@ on surveillance of infection and detection of out(reaks:' To collect speciens and preliinar) processing: the ICs should (e trained in (asic icro(iologic

techni2ues:4' Training and education under the supervision of IC@, and' To increase awareness aong patients and visitors a(out infection control'1) Infection Control !anual*IC!+It is recoended that each hospital develops its own infection control anual (ased upon e-istingdocuents (ut odified, for local circustances and risks'

%ole of the micro"iology la"oratory

The icro(iolog) la(orator) has a pivotal role in the control of hospital associated infections' Theicro(iologist is usuall) the Infection Control @fficer' The role of the departent in the HAI control


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prograe includes;

Identification of pathogens 9 the la(orator) should (e capa(le of identif)ing the coon (acteria tothe species level:Provision of advice on antiicro(ial therap):Provision of advice on specien collection and transport:

Provision of inforation on antiicro(ial suscepti(ilit) of coon pathogens, andPeriodic reporting of hospital infection data and antiicro(ial resistance pattern 9 The periodic

reporting of such dates is an iportant service provided () the icro(iolog) departent' Thefre2uenc) of this should (e as deterined () the ICC'Identification of sources and ode of transission of infection 9 Culture of carriers, environent foridentif)ing the source of the organis causing infection /out(reak organis0' The selection of sites

for culture depends upon the known epideiolog) and survival characteristics of the organis:6pideiological t)ping of the isolates fro cases, carriers and environent:Micro(iological testing of hospital personnel or environent 9 Testing for potential carriers ofepideiologicall) significant organiss' As a part of the infection control prograe, theicro(iolog) la(orator) at ties a) need to culture potential environental and personnelsources of noscoial infections' suall) this is liited to out(reak situation when the source andethod of transission needs to (e identified' outine icro(iological sapling and testing is notrecoended:Provide support for sterilization and disinfection in the facilit) including (iological onitoring ofsterilization'Provide facilities for icro(iological testing of hospital aterials when considered necessar) 9 These

a) include; sapling of infant feeds: onitoring of (lood products and dial)sis fluids: 2ualit)control sapling of disinfected e2uipent: additional sterilit) testing of coerciall) sterilizede2uipent is not recoended:

Provide training for personnel involved in infection control 9This fors an iportant part of theInfection Control Prograe' 6ach hospital should develop an eplo)ee training prograe'*ifferent categories of staff should (e targeted through this prograe training relevant to theirfunctions' The Infection Control urse pla)s a a3or part in training and education' The ai of thetraining prograe is to thoroughl) orient all hospital personnel to the nature of HAI and to wa)sof prevention and treatent' As the various hospital eplo)ees have different functions and their

level of education is different, the training prograe needs to (e altered to suit the functionalre2uireents of each categor) of staff and should (e adapted accordingl)' Training should (epreceded () a needs assessent surve)' The training prograe should include the following;

Basic concepts of infection:Hazards associated with their particular categor) of work':Acceptance of their personal responsi(ilit) and role in the control of hospital infection:

Methods to prevent the transission of infection in the hospital, and1afe work practice'

Training should provide the inforation needed to odif) staff (ehaviour' Innovative techni2ues suchas role9pla), pro(le solving, 2uiz copetitions and poster aking etc should (e eplo)ed'

The ICC should agree to the level and fre2uenc) of training'

The Hospital 2nvironment and Hospital Associated Infections

2nvironment

The environent in the hospital pla)s an iportant role in the occurrence of hospital associatedinfections' The hospital environent consists of an) coponents' Man) have a direct (earing upon

HAI including design of ward and operating theatre facilities, air 2ualit), water suppl), food andhandling of edical waste and laundr)'

() Premises&"uildingsAn infection control tea e(er should (e involved in the planning of an) new facilit) or renovation'The role of infection control in this process is to iniize hospital associated infections' These includeites such as;

6nsuring appropriate hand washing facilities:A safe water suppl):Ade2uate isolation facilities for the hospital:


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Ade2uate ventilation for isolation roos and high risk areas like operation theatres, transplant unitsand intensive care units:ecoending traffic flow to iniize e-posure of high risk patients and facilitate patienttransport:Preventing e-posure of patients to fungal spores during renovations, and@utlining precautions to (e taken to control rodents, pests and other vectors responsi(le for

transission of infection'

,) AirAir(orne droplet nuclei generated during coughing or sneezing are a potential source of transission ofinfection either () direct inhalation or indirectl) through containated edical devices' *ropletsgenerated fro infected respirator) tracts can reain air(orne for long periods of tie and transitinfections like tu(erculosis, respirator) viral illnesses and anti(iotic9resistant hospital (acteria'

1oe housekeeping activities /such as sweeping, using dr) ops or cloths or shaking linen0 canaerosolize dust particles that a) contain icro9organiss' Therefore, wet opping is preferred' Thenu(er of organiss present in roo air will depend on the nu(er of people occup)ing the roo, theaount of activit), and the rate of air e-change' 1kin s2uaae and lint are iportant sources ofcontaination'

3entilation4

1oe HAI are caused () air(orne pathogens and appropriate ventilation is necessar)' 1oe la(orator)onitoring a) (e needed in high9risk areas such as operation theatres for cardiac surger),

neurosurger) and transplant surger) after a3or (uilding works in the unit'

Circulation of fresh filtered air dilutes and reoves air(orne (acterial containation, in addition toreoving odour' All hospital areas and in particular the high9risk areas, should (e well ventilated as faras possi(le'


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container' 8ater should (e dispensed fro the storage container () an outlet fitted with a closuredevice or tap'1torage containers and water coolers should (e cleaned regularl)'

/) 6itchens and food handling6nsuring safe food is an iportant service in health care facilities 9 inappropriate food handling practicesperit containation, survival and growth of infecting (acteria'

The coon errors contri(uting to out(reaks of food poisoning include;

sing containated, uncooked food:

Advance preparation of food, i'e' ore than a half da), should (e avoidedndercooked food:Cross9containation of cooked food () raw food during preparation or storage:Containation () food handlers:1toring food at roo teperature or inade2uate refrigeration:Inade2uate reheating, andnh)gienic preparation of enteral or (a() feeds'

=ood containation should (e prevented () using relia(le supplies of food: providing ade2uate storagefacilities: separation of raw and cooked food to prevent cross9containation: preparation of food takingall h)gienic precautions: use of appropriate cooking ethods to prevent icro(ial growth in food, and

ade2uate refrigeration of uncooked and prepared food: kitchen staff should change work clothes at leastonce a da) and keep hair covered'

=ood handlers ust carefull) wash their hands (efore preparing food and aintain scrupulous personalh)giene'The) should avoid handling food when suffering fro an infectious disease /enteric, respirator) or skininfection0 and report all infections'

1) The 6itchen=ood(orne diseases are iportant, particularl) in iuno9coproised patients' As the counit)

incidence of enteric infections a) (e high in soe countries, it (ecoes all the ore iportant thatspecial attention is given to food preparation and handling in order to avoid containation'

The kitchen ust have ade2uate suppl) of clean and pota(le water' All work surfaces and foodstorage areas ust (e kept clean and sanitar)'

=ood should (e served as soon as possi(le after preparation'=ood storage refrigerators and freezers should (e properl) aintained and the teperaturechecked dail) () provided theroeters'+eft9over food should (e discarded'

In regions where enteric infections are coon, food handlers should undergo pre9eplo)entfaecal e-aination for the presence of 1higella, 1alonella and parasites such as 6ntaoe(a,Giardia, etc*ishwashing achines should (e prefera(l) used for crocker) and utensils'

7) Cleaning of the hospital environment

outine cleaning is iportant to ensure a clean and dust9free hospital environent'There are usuall) an) icro9organiss present in .visi(le dirt., and routine cleaning helps toeliinate this dirt' 1oap or detergents do not have antiicro(ial activit), and the cleaning processdepends essentiall) on echanical action'Methods ust (e appropriate for the likelihood of containation, and necessar) level of asepsis'This a) (e achieved () classif)ing areas into the following zones;

Adinistrative and office areas with no patient contact re2uire noral doestic cleaning'Most patient care areas are cleaned () wet opping' *r) sweeping is not recoended' Theuse of a detergent solution iproves the 2ualit) of cleaning' An) areas with visi(lecontaination with (lood or (od) fluids ust (e disinfected'High risk areas like the isolation roos and other areas with infected patients need cleaning witha detergentFdisinfectant solution'

All horizontal surfaces and all toilet areas should (e cleaned dail)'Hot water /5% C0 is a useful and effective environental cleaner'


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Bacteriological testing of the environent is not recoended unless indicated on epideiologicalgrounds when seeking a potential source of an out(reak'

8) 5aste

Hospital waste is a potential reservoir of pathogenic icro9organiss and re2uires appropriate handling'The coonest docuented transission of infection fro waste to health care workers is through

containated etallic wastes'

Principles of waste anageent

The .Cradle to grave. concept of waste anageent

Hospital waste re2uires anageent at ever) step fro generation, segregation, collection,transportation, storage, treatent to final disposal'1egregation of wastes into the prescri(ed categories ust (e done at the source i'e' at the point ofgeneration'Colour coded (ags as per international norsJ need to (e placed in appropriate containers with theappropriate la(elFlogo e'g' (iohazard s)(ol for infectious waste'Puncture proof containers ade of plastic or etal with a (iohazard s)(ol, in (lood collectionareas, in3ection trolle)s and nursing stations, and operation theatres should (e ade availa(le for

collecting etallic wastes'A collection s)ste for the transport of segregated wastes i'e' carts need to (e provided'A storage area for wastes prior to treatent needs to (e dearcated'

Practical Classification of Hospital 5aste

H#SPITA9 5AST2

Ha'ardous 0on:ha'ardous

Ha'ardous Infectious 6itchen %ecycla"les

/C)toto-ic drugs, /Biodegrada(le0 Card(oard (o-, to-ic cheicals, Glass (ottles' adioactive waste0

Sharps 0on:sharps

Patient contaminated 9a"oratory

Plastics 0on:plastics Specimens !icro : Anatomical parts

"iology Animal carcasses 9a" waste

*isposa(les Cotton Blood

1)ringes Gauze Bod) fluids

I< setsFcatheters *ressings Pus

Catheters 1ecretions

6T tu(es 6-cretions

Treatment of ha'ardous and infectious wastes

1harps

Alternatives availa(le include;

eedle (urners at the work station:Puncture proof containers which can (e autoclaved, shredded and land9filled or icrowaved,shredded and land9filled or treated () plasa p)rol)sis:

*eep (urial in a secure area, andCutting of needles which is a echanical ethod of disfigureent to avoid rec)cling (ut is not adisinfection odalit)'

8astes re2uiring incineration

Anatoical parts and anial carcasses, andC)toto-ic drugs /outdated0, to-ic la(orator) cheicals other than ercur)'Patient containated non9plastics and non9chlorinated plastics'


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8aste that cannot (e incinerated

Chlorinated plastics, volatile to-ic wastes such as ercur)'

Patient9containated plastics, non9plastics and infectious la(orator) wastes a) (e treated () steasterilization in autoclava(le (ags or icrowave treatent' 1hredding should follow (oth these ethods'In case of non9availa(ilit) of the a(ove, cheical treatent with &D h)pochlorite or a siilar disinfectantis recoended' However, e-cessive use of cheical disinfectants a) (e a health and environental

hazard'

adioactive wastes

These are dealt with according to local laws'

;) 9aundryTwo categories of used linen are recognized' 8here there is visi(le containation () (lood, faeces orother (iological fluids, it is tered .containated.' @ther linen is tered .soiled.' These two categoriesshould (e segregated and treated separatel)'

All linen should (e handled with iniu agitation to avoid aerosolization of pathogenic icro9organiss'Containated linen a) (e a source of infection to patients and staff and should (e placed inipervious (ags for transportation'*isinfection can (e achieved () using hot water and F or (leach, using heav)9dut) gloves, e)eprotection and asks to protect against splashes'Heav)9dut) washers F dr)ers are recoended for hospital laundr)'+aundered linen should (e autoclaved (efore (eing supplied to the operating roos F theatres andhigh risk areas e'g' (urns units and transplant units'

o linen should leave the hospital preises unless it has (een decontainated'

Prevention of Hospital Associated Infections

Standard&universal precautions

8ith the onset of the AI*1 pandeic, the concept of universal precautions has (een adopted i'e'precautions that should (e practised with all patients and la(orator) speciens regardless ofdiagnosis' It is presued that ever) patientFspecien could (e potentiall) infected with (lood (ornepathogens such as HI


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e2uipent or articles containated () these'

.or hand washing< the following facilities are re=uired4

unning water; large wash(asins with hands free controls, which re2uire little aintenance and withanti9splash devices'Products; dr) soap or li2uid antiseptic depending on the procedure'1uita(le aterial for dr)ing of hands; disposa(le towels, reusa(le sterile single use towels or roller

towels which are suita(l) aintained'

.or hand disinfection

The specific hand disinfectants 7 antiseptics recoended are; !94D chlorhe-idine, 9'D povidoneiodine, &D triclosan or alcoholic ru(s'Alcoholic handru(s are not a su(stitute for hand washing, e-cept for rapid hand decontaination(etween patient contacts'

.or surgical scru" *surgical care+

Training is needed in the current procedure for preparation of the hands prior to surgical procedures'1cru((ing of the hands for 9 inutes is sufficient' The recoended antiseptics are 4Dchlorhe-idine or 'D povidone iodine'

62uipent and products are not e2uall) accessi(le in all countries or health care facilities' =le-i(ilit) inproducts and procedures, and sensitivit) to local needs, will iprove copliance' In all cases, the (estprocedure possi(le should (e instituted'

Clothing

1taff can norall) wear clean street clothes' In special areas such as (urn or intensive care units,unifor trousers and a short9sleeved gown are re2uired for en and woen'

The working outfit ust (e ade of a aterial eas) to wash and decontainate' If possi(le, a cleanoutfit should (e worn each da)' An outfit ust (e changed after e-posure to (lood or if it (ecoes wetthrough e-cessive sweating or other fluid e-posure'

Shoes

In aseptic units and in operating roos, staff ust wear dedicated shoes, which ust (e eas) to clean'In other areas, change of footwear is unnecessar) for prevention of infection'

Caps

In aseptic units, operating roos, or perforing selected invasive procedures, staff ust wear caps or

hoods which copletel) cover the hair'

!asks

Masks of cotton wool, gauze, or paper asks are ineffective' Paper asks with s)nthetic aterial forfiltration are an effective (arrier against icro9organiss' Masks are used in various situations and theirre2uireents differ depending on the purposes for which the) are needed'

Patient protection41taff wear asks to work in the operating roo, to care for iuno9coproisedpatients, to puncture (od) cavities' A surgical deflector ask which directs aerosols awa) fro thesurgical site is sufficient'

Staff protection41taff ust wear asks when caring for patients with air(orne infections, or whenperforing (ronchoscopies or siilar e-aination' A high efficienc) filter ask is recoended' =ilter

asks reove organiss which ight (e inhaled'

Patients with air(orne infections ust use surgical deflector asks when outside their isolation roo'

Gloves

Gloves are used for;

Patient protection; 1taff should wear sterile gloves for surger), care for iuno9coproisedpatients and invasive procedures which enter (od) cavities' on9sterile gloves should (e worn for allpatient contacts where hands are likel) to (ecoe containated, or for an) ucous e(ranecontact' 8hen perforing ultiple procedures, the gloves should (e decontainated (etweenpatients' If visi(l) soiled with (lood, a fresh pair should (e used'1taff protection; 1taff should wear non9sterile e-aination gloves to care for patients withcounica(le disease transitted () contact'Hands ust (e washed when gloves are reoved or changed'


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*isposa(le gloves should not (e reused'The wearing of gloves, asks and other protective clothing is onl) necessar) for the tasks at hand andthese ites should (e reoved after the procedure'

,) Safe in$ection practices4

To prevent transission of infections (etween patients;

nnecessar) in3ections ust (e eliinated' Man) edicines can (e given orall) and this ispreferred to parenteral adinistration'1terile needle and s)ringe should alwa)s (e used' These should (e disposa(le, if possi(le'Containation of edications ust (e prevented () using single use vials'1afe disposal practices in respect of etallic waste should (e followed'

Additional precautions for prevention of transmission of infection

In addition to standard precautions which are re2uired for all patients in all situations, specialprecautions need to (e taken for patients suffering fro certain infections' These are (ased on theode of transission of these infections' The ICC should decide the polic) for the individual hospitaland procedures which are feasi(le in its situation'

() %outes of transmissionTransission of HAI can occur () one or ore of the following odes;

Air"orne

Through sall particles suspended in the air or large droplets e-pelled into the air () coughing, sneezing,talking /aerosols0, or () shedding of skin scales'

Contact

Through direct contact of hands or skin contact or indirectl) through environental surfaces and other

ites which coe in contact with the patient'

Inoculation or parenteral

Containated solutions, (lood and (od) fluids can enter either through a(rasions or other skin lesions,

through ucous e(ranes (ut not through intact skin'

.aeco:oral

Micro9organiss found in the intestines can (e transitted either directl) through containated food and

water following unh)gienic practices or indirectl)'

!ultiple routes

A disease a) (e transitted () ore than one ode e'g' respirator) viral infections can (e transittedthrough air(orne /droplet0 as well as () ph)sical contact'

Transmission:"ased precautionsare special precautions taken in addition to standard precautions forknown infections (ased on the ode of transission of the infection' 6ducation is ost iportant'Awareness prograes for staff, visitors and patients ust (e esta(lished' Posters outlining theprecautions should (e placed at appropriate locations' As the nae iplies, additional precautions should(e applied in addition to standardFuniversal precautions'

The following precautions are recoended;

() %espiratoryprecautions

=or infections transitted () the air(orne route through sall droplets less than icron in size whichcan (e dispersed over long distances e'g' tu(erculosis'

The patient should (e placed in a single roo that ideall) has good ventilation and sunlight,negative air pressure and "9&! air changes per hour' If single roo is not possi(le, patients should

(e in a cohort with other patients with sae infection' *oors should (e kept closed'=or additional respirator) protection, well9fitting filter asks should (e worn' 1uscepti(le personsshould not enter the roo of patients having easles or chickenpo- whereas persons iune to


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easles or chicken po- do not need to wear ask'Transportation of patient should (e done onl) when essential' Patient should wear a ask duringtransportation'

,) Contact precautions

These precautions should (e used in addition to standard precautions for patients who are infected or

colonized with iportant organiss that can (e transitted directl) () hand or skin contact or indirectl)through foites or environental surfaces in contact with the patient, such as gastrointestinal,respirator), con3unctival, skin and wound infections or colonization with ultiresistant (acteria'

The patient should prefera(l) (e placed in a single roo' If that is not possi(le, heFshe should (eplaced with a cohort of patients having infection with the identical icro9organis'Clean, non9sterile gloves should (e worn on entering the roo or patients environent' Glovesust (e reoved after leaving the patient?s environent and hands washed iediatel)'A clean non9sterile gown should (e worn on entering the patient?s roo and reoved on leaving

the roo'1haring of patient care e2uipent (etween patients should (e avoided' If sharing is necessar), thee2uipent should (e ade2uatel) cleaned and disinfected (efore using on another patient'Transportation of patient ust (e liited' If transport is necessar), precautions ust (e taken toavoid contact with other patients and containation of the environent'

-) Blood&inoculation precautions

In addition to standard precautions, diseases transitted through inoculation or parenteral route such ashepatitis B, HI


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The t)pe of operation andThe tie period (etween the operation and the developent of the infection'

=actors which influence the fre2uenc) of surgical site infections include;

1urgical techni2ue6-tent of endogenous containation of the wound at surger) /clean, clean9containated0*uration of operationnderl)ing patient status@perating roo environent

The nu(er of organiss shed fro the skin of the operating roo tea and fro the skin of thepatient

%isk factors for surgical site infections Prevention

Patient

Age

Avoid operating on ver) old or ver) )oung as the)are at higher risk for developing infections

utritional status Build a good nutritional status

*ia(etes Control and aintain (lood sugar levels

1oking Cessation of soking at least one onth prior tosurger)

@(esit) educe weight prior to surger)

Co9e-istent infections in a reote (od) site Treat ade2uatel) (efore operation

Colonization with icro9organiss 1creen and treat carriers: avoid pre9operative

shaving

Altered iune response Boost iunit) if possi(le

+ength of preoperative sta) Avoid long sta) in hospital

#perational procedures Guidelines

*uration of surgical scru( ! inutes as effective as &% inutes

1kin antisepsis se povidone9iodine F chlorhe-idine gluconate

Pre9operative shaving Avoid if possi(le or shave iediatel) prior tooperation

Preoperative skin preparation Allow dr)ing of antiseptic

*uration of operation Keep procedures as short as possi(le

General factors Guidelines

Antiicro(ial proph)la-is Give suita(le antiicro(ial cover

@perating roo ventilation Adhere to specifications (elow

Inade2uate sterilization of instruents Monitor C11* processes

=oreign aterial in the operative site Maintain high level of asepsis

1urgical drains Avoid unless reall) necessar)

1urgical techni2uePoor haeostasis=ailure to o(literate dead spaceTissue traua

Maintain good surgical techni2ue and ensureinial tissue traua'

A s)steatic prograe for prevention of surgical site infections includes the practice of optial surgicaltechni2ues, a clean operating roo environent with restricted staff entr) and appropriate staff attire,sterile e2uipent, ade2uate pre9operative preparation of the patient, appropriate use of peri9operativeantiicro(ial proph)la-is, and a surgical wound surveillance prograe' 1urgical site infection rates are


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decreased () continuous, standardized surveillance with reporting (ack of rates to individual surgeons'

Surveillance

%ole of Surveillance

1urveillance of hospital associated infections eans recording and counting of infections arising in thehospital' 1urveillance is done so that we know the e-tent of an) pro(les that e-ist'

There are various wa)s of recording and counting the nu(er of hospital infections' @ne is the clinicaloutcoe of the patient?s sta) in the hospital i'e' whether or not an infection arises in a patient as a

result of their sta)' Inforation as to the site and severit) of the infection and its relationship to an)operative, investigative or treatent carried out can (e recorded and related to the nu(er of patients(eing treated' There a) (e records of la(orator) cultures or (lood tests that would confir that aninfection is present'

Because there are an) patients passing through the hospital and so an) different t)pes of infectionwhich arise, one has to focus on specific readil) recognized infections such as surgical site infection asan inde- of infection rate' nless there are suita(le la(orator) facilities to identit) the infectionpathogen, little can (e done to deterine the possi(le organiss responsi(le and help in finding the

source of the infection' =or these reasons, ost surveillance s)stes depend on the use of la(orator)cultures to provide the aterial for 2uantification of the HAI rates' Accurac) in this case depends onthe cultures (eing ade fro ost clinical infections and a s)ste for recording the clinical data of the

infected patients'

In hospitals where little or no surveillance data e-ists and resources are liited, one has toconcentrate efforts on those parts of the hospital, and those procedures, which are coon sites forHAI' 1urgical site infection is clearl) one area, (ut others include intravenous infusion over a prolongedperiod leading to septicaeia: urinar) tract infection following indwelling urinar) catheters: hospital

associated respirator) infections particularl) in echanicall) ventilated patients, and episodes ofinfective gastroenteritis' Patients who are particularl) prone to ac2uiring infection in hospital includethe ost severel) ill, the aged, those coproised () dia(etes, use of steroids, cancer orhaeatological alignancies' Continuous surveillance is a tie9consuing activit) and re2uiresdetailed work over a period of tie to produce (eneficial results which can lead to a reduction in theac2uired infection rates' Man) different hospital staff are involved in onitoring the inial levels ofhospital infections and all ust (e aware of their role in surveillance' All ust (e alert to the possi(leoccurrence of an out(reak situation /see (elow0' Both clinical and icro(iological data are essential tocopile the necessar) inforation' The inforation gathered is 3ointl) the propert) of the clinical andla(orator) staff' The collection of inforation should (e ade as siple as is copati(le with o(taining

data of value in recognizing the e-tent and causation of the infections' nless one has soeinforation of the kind, finding the reasons for an infection is difficult and planning the avoidance ofthe infection less achieva(le'

Ke) factors to (e recorded clinicall) are;

The severit) and the e-tent of the infection in the patient:The t)pe of operation and the e-tent of (acteriological containation of the wound, and

The tie period (etween the procedure and appearance of the infection'

Ke) records icro(iologicall) needed are the organiss isolated and their antiicro(ial suscepti(ilit)'

Targeted surveillance

1ite9oriented surveillance; Priorities will (e to onitor fre2uent infections with significant ipact inortalit), or(idit), costs /e'g' e-tra9hospital da)s, treatent costs0, and which a) (e avoida(le'

Coon priorit) sites are;


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8hile surveillance is focused in high9risk sectors, soe surveillance activit) should occur for the rest ofthe hospital' This a) (e ost efficientl) perfored on a rotating (asis' Tie spent on surveillanceactivities ust not (e so long that other essential infection control easures, such as staff education,are neglected'

HAI surveillance includes data collection, anal)sis and interpretation, and feed(ack leading tointerventions for preventive action' The infection control tea ust (e trained for surveillance' Awritten protocol ust descri(e the ethods used, the data to (e collected and the anal)sis that can (ee-pected'

Prevalence rate4 The nu(er of infected patients /or the nu(er of infections0 at the tie of stud)as a percentage of the nu(er of patients o(served at the sae tie'

Incidence rate4The nu(er of new nosocoial infections ac2uired per &%%% patient da)s'

ata collection and analysis

Sources

*ata collection re2uires ultiple sources of inforation as no ethod, () itself, is sensitive enough toensure data 2ualit)' Trained data e-tractors /training should (e organized () the infection control

tea or the supervisor0 perforing active surveillance will increase the sensitivit) for identif)inginfections' Techni2ues for case9finding include;

5ard activity4 +ooking for clues such as;

The presence of devices or procedures known to (e a risk for infection /indwelling urinar) andintravascular catheters, echanical ventilation, surgical procedures0:ecord of fever or other clinical signs consistent with infection:Antiicro(ial therap):+a(orator) tests, andMedical and nursing chart review'

+a(orator) reports; Isolation of icro9organiss potentiall) associated with infection, antiicro(ialresistance patterns and serological tests' @ne cannot rel) on la(orator) reports alone' Cultures are noto(tained for all infections: speciens a) not (e appropriate: soe pathogens such as viruses a)not (e isolated: isolation of a pathogen a) represent colonization rather than infection' +a(orator)reports are relia(le for urinar) tract infection, (loodstrea infections and, ultiple9drug resistant(acteria surveillance, (ecause the definitions for these are essentiall) icro(iological'

@ther sources of infection data include diagnostic iaging and autops) data'*iscussion of cases with the clinical staff during periodic ward visits is an essential source ofinforation'

Continuing colla(oration aong infection control staff, the la(orator), and clinical units will facilitate ane-change of inforation and iprove data 2ualit)' 1urveillance should also include the post9dischargeperiod' eduction of the average length of sta) increases the iportance of identif)ing late9onset

infections'

The inforation to (e collected should include;

Adinistrative data /hospital nu(er, adission dateL0Additional inforation descri(ing deographic risk factors /age, gender, severit) of underl)ingillness, priar) diagnosis, iunological status, and interventions /device e-posure, surgicalprocedure, treatents0 for infected and non9infected patients'*ate of onset and site of infection, icro9organiss isolated, and antiicro(ial suscepti(ilit)'

.eed"ack&dissemination

Infection data should (e disseinated to the people directl) involved in patient care: surgeons need toknow a(out these surgical site infections' *isseination of inforation should also (e organizedthrough the Infection Control Coittees to other units, anageent, and la(oratories'

eports should not identif) individual patients' Codes ust also (e assigned to units and responsi(leph)sicians, to ensure anon)it)'

Prevention and evaluation

An effective surveillance s)ste ust identif) priorities for preventive interventions and iproveent


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in 2ualit) of care'

B) providing 2ualit) indicators, surveillance ena(les the Infection Control Prograe, in colla(oration

with units, to iprove practice, and to define and onitor new prevention policies' The final ai ofsurveillance is the decrease of nosocoial infections with a reduction of costs'

1urveillance is a continuous process and needs to evaluate the ipact of changes in practices and tovalidate the prevention strateg), to see if initial o(3ectives are attained'

Investigation of an #ut"reak

Identification of an >out"reak>

The occurrence of two or ore siilar cases relating to place and tie is identified as a cluster or anout(reak and needs investigation to discover the route of transission of infection, and possi(lesources of infection in order to appl) easures to prevent further spread' If the cases occur in steadil)increasing nu(ers and are separated () an interval appro-iating the incu(ation period, the spreadof the disease is pro(a(l) due to person to person spread' @n the other hand if a large nu(er ofcases occur following a shared e-posure e'g' an operation, it is tered a coon source out(reak,ipl)ing a coon source for the occurrence of the disease'

2pidemiological methods

The investigation of an out(reak a) re2uire e-pert epideiological advice on procedures'=orulation of a h)pothesis regarding source and spread should (e ade (efore undertaking

icro(iological investigations in order that the ost appropriate speciens are collected'

Steps to "e taken to investigate an out"reak

Step (

ecognition of the out(reak' Is there an increase in the nu(er of cases of a particular infection ora rise in the prevalence of an organis 1uch findings indicate a possi(le out(reak'Preliinar) investigation ust (e (egun () developing a case definition, identif)ing the site,pathogen and effected population'*eterination of the agnitude of the pro(le and if iediate control easures are re2uired' Ifso general control easures such as isolation or cohorting of infected cases: strict hand washingand asepsis should (e iediatel) applied'


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1pecific control easures should (e ipleented as soon as the cause of out(reak is identified'Monitoring for further cases and effectiveness of control easures should (e done'A report should (e prepared for presentation to the ICC, departents involved in the out(reak,adinistration'

Immediate control measures

Control easures should (e initiated during the process of investigation' An intensive review ofinfection control easures should (e ade and general control easures initiated at once' General

easures include;

1trict hand washing:Intensification of environental cleaning and h)giene:Adherence to aseptic protocols, and1trengthening of disinfection and sterilization'

2pidemic curve

This is constructed to stud) the epideic pattern of the disease' An epideic curve is a graph/histogra0 in which the cases of disease that occurred during the out(reak are plotted according totie of onset of HAI of the cases'

The epideic curve is constructed to help deterine whether the source of infection is coon andcontinuing, and identif) the pro(a(le tie of e-posure of the cases to the source of infection and

pro(a(le incu(ation period'

!icro"iological study

Micro(iological stud) is planned depending upon the known epideiolog) of the infection pro(le' Thestud) is carried out to identif) possi(le sources and routes of transission' The investigation a)

include cultures fro other (od) sites of the patient, other patients, staff and environent' Carefulselection of speciens to (e cultured is essential to o(tain eaningful data'

2pidemiological studies

Case control stud);

A group of uninfected patients /the control group0 is copared with infected patients /the casegroup0'The differences in characteristics, suscepti(ilit) and e-posure factors are copared' These factorsinclude age, se-, tie, place, duration of sta), intervention, anti(iotic therap) and other therapies'

A statisticall) significant difference (etween the groups is identified and the pro(le can (edelineated'

Cohort stud);

*epending upon the infection pro(le, a defined high9risk population /cohort0 is identified andfollowed prospectivel)'This high9risk population is followed prospectivel) for the developent of infection'

After following these cases for soe tie, the differences in host factors (etween the patients thatdevelop the infection and those that do not (ecoes evident and will identif) the source of thepro(le'

Specific control measures

1pecific control easures are instituted on the (asis of nature of agent and characteristics of the high9risk group and the possi(le sources' These easures a) include;

Identification and eliination of the containated product:Modification of nursing procedures:Identification and treatent of carriers, andectification of lapse in techni2ue or procedure'

2valuation of efficacy of control measures

The efficac) of control easures should (e evaluated () a continued follow9up of cases after theout(reak clinicall) as well as icro(iologicall)' Control easures are effective if cases cease tooccur or return to the endeic level'

The out(reak should (e docuented'


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Health Care Staff

Transmission of infection from health care workers to the patients

Health care workers with infections should report their illnesses to the staff clinics when the) are atrisk of transitting infection to patients' The closer the contact the) have with the patients, the ore

likel) the) are to transit the infection' The list of counica(le diseases /Chapter 50 indicates which

infections a) (e transissi(le (ut organiss of special concern in hospitals are as follows;

&' Staph) aureus4A(out %D of noral persons carr) staph)lococci in their nose, (ut norall) thereis no transission to patients fro this site' 1oe persons e'g' with eczea, heavil) colonized withstaph)lococci, a) (e shedding staph)lococci in a ward environent' If there is an) evidenceindicating spread of 1taph' aureus, the shedder status should (e investigated () collecting swa(sfro the nose, skin, hair and perineu' If heavil) colonized, the) should (e treated with upirocinointent &D and given dail) (athFshapoo with triclosan &D or chlorhe-idine !D for da)s, and

status checked (efore their return to noral work' Theatre and ward staff with purulent skin lesionsdue to staph)lococci should reain awa) fro dut) until the lesions have healed'

!' !ulti:resistant Staph aureus4asal carriers of M1A a) (e found aong health care staffduring investigation of out(reaks' The su(3ect should (e swa((ed to deterine the e-tent ofcolonization and su(se2uentl) treated with upirocin F triclosan F chlorhe-idine to reove carriage'

' !ulti:resistant Staph epidermidis41taff colonized with M16 do not re2uire an) intervention'4' iarrhoeal disease41taff with diarrhoea should report this to the staff health departent' 1oe

staff e'g' food handlers a) need to (e e-cluded fro dut) during this period' =or other staff,

careful application of enteric precautions is essential'

Preventing infection in health care personnel

+arge hospitals generall) have a clinic for resident and non9resident staff' Aong the tasks of suchclinics is the onitoring of infection risks (oth to staff who are at risk of ac2uiring infection fropatients and to patients who a) have an infection that a) (e transferred to patients'

Hepatitis B

Hepatitis B virus can (e transferred fro patients to staff and vice9versa () inute 2uantities of

(lood' The ain wa) of preventing this transission is () iunization of health care staff' All staffwho a) coe into direct contact with patients or their secretions, should have their hepatitis Bstatus deterined () easureent of (lood arkers for hepatitis B' on9iune staff need to (e

iunized' 1taff who have hepatitis B antigen present in (lood, particularl) the envelope antigen, arecapa(le of spreading hepatitis B to patients and a) (e e-cluded fro high risk duties in the hospitalto prevent transission'

Sharps in$uries

Minor in3uries to the hands of health care workers coonl) occur while perforing invasiveprocedures on patients' The coonest are needle9stick in3uries during phle(oto) or while givingin3ections' 1oeties sharp instruents containated with (lood a) also (e involved'

1uch in3uries should (e iediatel) treated () encouraging (leeding and washing thoroughl) withrunning water and an antiseptic solution' The infection control tea should (e consulted for furthereasures in use locall)' The risk of hepatitis B, hepatitis C and HI< infection should (e assessed andappropriate iunization or cheoproph)lactic steps taken if necessar)'

Tu"erculosis

Tu(erculosis a) (e a high risk for soe staff e'g' icro(iolog) la(orator) workers and soe clinicalstaff' 1oe onitoring s)ste e'g' onitoring at entr) to the occupation or during eplo)ent isneeded depending on the degree of risk involved'

!eningococcal meningitis

Transission of eningococci to health care staff is ost likel) within !4 hours of adission of the


18/21

patient' Health care workers in close contact with such cases should receive cheoproph)la-is withciproflo-acin or an effective alternative agent

Containment of Community Ac=uired InfectionsPatients with infectious disease are fre2uentl) aditted to hospitals' 1uch patients need to (e assessedand appropriate easures taken to contain the infection' The following ta(le highlights the said

precautions' However, standard precautions should (e applied when handling (lood and (od) fluids'

Infection & Pathogen Isolation & infection control precautions?

ActinomycosisActinomyces israelii

one

Adenovirus espirator) precautions

Anthra@Bacillus anthracis

Transfer to isolation unit

Ac=uired immune deficiency virusHuan iunodeficienc) virus /HI


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2nteric fever

Salmonella typhiSalmonella paratyphi1alonellae sp e'g' S.typhimurium

1tool precautions

Gas gangreneClostridium perfringens

Cl.oedematiensCl.septicum

one

GiardiasisGiardia lamblia

1tool precautions

Glandular fever6pstein9Barr virus /6B


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Plague 8ound and skin precautions' espirator)precautions

PleurodyniaCo-sackie virus B

1tool precautions

Pneumocystis carinii one

PoliomyelitisPolio virus 1tool precautions

PsittacosisChlamydia psittaci

espirator) precautions

fever espirator) precautions

%a"ies&habdovirusgroup

Contact precautions

%elapsing feverBorrelia recurrentis

Blood precautions

%espiratory syncytial virus /1


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'richuris trichura/8hipwor0 Contact precautions

5hooping coughBordetella pertussis

espirator) precautions

J 1ee chapter 4 for details

Suggested .urther %eading&' International =ederation of Infection Control' 6ducation Prograe for Infection Control' Basic

Concepts and Training' 6ditors; A)eliffe GA, Ha(raeus A and Mehtar 1' #'!' 8enzel P' Prevention and Control of osocoial Infections' Third 6d' Baltiore, M*' 8illias and

8ilkins' #' C*C Guidelines for Infection Control in Hospital Personnel' 1 *epartent of Health and Huan

1ervices Centres for *isease Control and Prevention' Atlanta, Georgia'4' C*C Guideline for Isolation Precautions in Hospitals' Aerican $ournal of Infection Control, !4; !49

!' #"'' Guidelines for preventing HI

hoapital acquired infection

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