hospital infection control manual
TRANSCRIPT
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�CHAPTER 1. INTRODUCTION………………………………………… 2
CHAPTER 2. HOSPITAL INFECTION CONTROL COMMITTEE …… 4
CHAPTER 3 HOSPITAL HYGIENE……………………………………. 7
CHAPTER 4 OUTBREAK MANAGEMENT & ISOLATION…………. 20
CHAPTER 5 ANTIBIOTIC POLICY……………………………………. 25
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CHAPTER 1
INTRODUCTION
A hospital is a place where sick people congregate to avail of the services of
doctors in different specialties. The provision of an effective infection control programme is
a key to the quality and a reflection of the overall standard of care provided by that health
care institution. It is thus the primary responsibility of every hospital administrator to ensure
that adequate resources are allocated for hospital infection control. Employers also have a
responsibility to provide a safe working environment for the Health care Workers and the
employees are duty bound to comply with safety standards and procedures set by the
institution. The administration should include an infection control committee that monitors
the infections acquired within the hospital and goes about implementing measures to combat
this. Infection control specialists and the representatives from the various departments should
form a committee, designated the Hospital Infection Control Committee (HICC) to develop
the manual keeping the needs of all specialties in mind and to monitor the implementation
and effectiveness of the control programme.
In general, infections that occur more than 48-72 hrs after admission and
within 10 days after discharge are considered as nosocomial. Hospitalized patients are
generally more vulnerable to infection than any other healthy individual, since the host is
immunosuppressed, the environment is conducive to the growth of resistant bacteria and the
transmission of these bacteria is very much facilitated by the activities of the Health Care
Workers (HCW) and other patients. The epidemiological triad of host, environment and
agent work together with strong links of transmission. Sometimes there is a large increase in
the commonly occurring types of infection, or appearance of a new kind of infection e.g.
Salmonella infection in newborns. This is called an outbreak of nosocomial infection. Such
an infection is usually due to a single type of bacteria and the source can be traced e.g. a
solution contaminated with Pseudomonas causing wound infection in one ward.
The importance of hospital infection can be considered both in terms of morbidity
and of prolonged occupancy of the hospital bed. Approximately 10% of hospitalized patients
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develop infections every year .In developing countries, this may go up to 25%. One-third of
these are preventable. Diagnosing and treating these infections puts intense pressure on the
health services and health budget.
A Hospital Infection Control Manual is an essential part of any infection control
programme. It should establish standards in all aspects of infection control. In a large referral
hospital, doctors and nursing staff work in different specialties and super specialties. Each
specialty has evolved its own style of working and they have varied procedures which can be
performed only by skilled personnel. The procedures of infection control should thus be
adapted to suit the needs of all specialties and still maintain the basic principles needed for
effective control of infection. Over time all precautions tend to get diluted and recruitment of
new staff members without knowledge of infection control procedures followed will lead to
an increase in the hazard of spread of infection within the hospital. This can be overcome by
a standard manual which is updated yearly and is available to all staff for easy reference over
the hospital computer network system or in the wards/reading rooms.
The manual should include policy and procedures on:
1. Standard Precautions for HCWs
2. Isolation policies
3. Cleaning and decontamination of surfaces and equipment and management of spills
4. Antibiotic policy
5. Outbreak management.
6. Waste management and disposal of sharps. (Damani)
The Health Act 2006 Code of Practice for the Prevention and Control of Health Care Associated Infections, Dept. of Health, UK
“The term “Health Care Associated Infections” (HCAI) encompasses any infection by any infectious agent acquired as a consequence of a person’s treatment by the hospital or which is acquired by health care workers in the course of their duties. Effective prevention and control of HCAI has to be embedded into everyday practice and applied consistently by everyone. It is particularly important to have a high awareness of the possibility of HCAI in both patient and health care workers to ensure early and rapid diagnosis. This should result in effective treatment and containment of the infection. Effective action relies on an accumulating body of evidence that takes account of current clinical practices. This evidence base should be used to review and inform practice. All staff should demonstrate good infection control and hygiene practice. However, it is not possible to prevent all infections.”
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CHAPTER 2
HOSPITAL INFECTION CONTROL
COMMITTEE The Hospital Infection Control Committee (HICC) is an essential part of good
infection control practices and must function effectively. The Head of the Institution may be
nominated as the Chairperson. The Secretary should be a Senior Clinical Microbiologist,
Infectious disease specialist or Epidemiologist. Other members should include:
1. Heads of all clinical and paraclinical departments.
2. Administrator or his representative e.g. Medical Superintendent or Resident Medical
Officer (RMO).
3. Chief of Nursing staff e.g. Nursing Superintendent or Assistant
4. Engineer from the Public Works Dept. e.g. Asst. Engineer
5. Engineer from the Water supply Dept. e.g. AE, PHED
6. Head of Pharmacy services
7. Infection Control Team(ICT) including Infection Control Doctor(ICD) and
Nurse(ICN)
8. Chief technician of infection control lab or chief technician responsible for processing
of all outbreak and surveillance samples.
9. Chief Security Officer
10. Chief Biomedical Engineer(BM Engineer) responsible for the working of all the
Medical equipment in the hospital.
The committee should meet every 6 months. The ICT is responsible for the day-to- day
activities in infection control and monitoring their implementation and effectiveness.
AIMS OF THE HICC:
1. Recommend appropriate policies for the prevention of Hospital Acquired Infection
and ensure that they are implemented.
2. Maintain records on surveillance, outbreaks and needle stick injury incidents. These
are compiled by the Infection Control Team and come up for discussion during the
meetings.
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3. Formulate an antibiotic policy based on the needs of the different specialties and
prevalent susceptibility patterns.
4. Implement policies for the safety of health care workers.
5. Regulate and give recommendations on purchase of equipment needed for infection
control e.g. autoclaves in CSSD, steam sterilizers etc.
6. Regulate and give recommendations on any construction or renovation work in the
hospital. The plan should be approved by the committee.
7. Discuss and find solutions to problems related to infection control encountered by
different doctors in their specialties.(Damani)
INFECTION CONTROL TEAM (ICT)
Infection Control Team (ICT) – Consists of: - a) Infection Control Doctor (ICD). b) Infection Control Nurse (ICN)
a) ICD – Microbiologist / Infectious Disease Specialist / Epidemiologist
Should be a Registered Medical Practitioner. One for every 1000 beds
Experience in: -
1. Sterilization / Disinfection 2. Microbiology 3. Hospital Infection Epidemiology 4. Surveillance
Functions:
1. Draws up annual plans for prevention of hospital infection.
2. Implementation of agreed policies
3. Sets quality standards and coordinates surveillance activities.
4. Coordinates with administrator, PWD, PHED and BM engineer for proper
maintenance, or upgradation of existing facilities. Should be involved in the
design ,construction and commissioning of any new building.
5. Help the ICN to conduct continuing education programmes in infection
control practices for the staff members.
b) ICN – Senior Registered Nurse(BSc or MSc)
Training in Infection Control is preferred.
Full-time job. One for 250 beds.
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This includes: -
1. Assists ICD and ICC in drawing up annual plans for prevention of hospital infection
2. Monitor all infection control procedures, e.g. sterilization procedures in the CSSD,
use of disinfectants and adherence to universal precautions by all members of staff.
3. Surveillance of infection to prevent outbreaks. She will identify, investigate and
follow-up on infections acquired from the hospital which will help in prevention of
outbreaks.
4. Conduct continuing education programmes on infection control practices to all grades
of staff.
In a large hospital there will be a team of ICDs and ICNs, who make up the ICT. The
ICT is responsible for the day-to-day activities of the infection control programme. The ICT
conducts monthly meetings presided over by the seniormost ICD.(Damani)
Infection Control Lab
It is recommended that for surveillance and outbreak investigation activities, an
infection control lab may be set up under the Microbiology Department. This may be
supervised by the senior most ICD who is also a Microbiologist. The processing of
specimens in the lab is done by:
1. Senior lab technician/Scientist - Preferably BSc MLT /MSc. Microbiology and
preference given to person with PhD in any subject related to infection control.
Experience in typing of organisms will be an added advantage.
2. Junior Lab technician – BSc MLT or DMLT
3. Junior Lab assistant(JLA) – Passed Higher secondary with experience in lab work
4. Cleaner/Attender .
Functions of the Lab:
1. Participate in Surveillance activities and outbreak investigation as instructed by the
ICD.
2. Maintain in stock all the pathogens identified in outbreaks.
3. Typing of nosocomial pathogens – phage typing, biocin typing, molecular methods.
All the other bacteriology labs should send the multi-drug resistant nosocomial strains
identified in pus, blood samples etc. to this lab for full identification and typing.
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CHAPTER 3
HOSPITAL HYGIENE
In the chain of infection, the mode of transmission is the easiest link to break and is the
key to control of cross-infection in hospitals.
Based on the above, the 5 pillars of infection control are: -
1. Hand washing
2. Isolation of infected patients
3. Barrier nursing of immuno suppressed.
4. Prudent use of antibiotics
5. Decontamination and proper disinfection / sterilization of items and equipments
used in invasive procedures (Damani)
These guidelines are divided into two parts:
1. General policies to be followed uniformly all over the hospital.
2. Specific policies for special areas.
GENERAL POLICIES:
I STANDARD PRECAUTIONS : (CDC GUIDELINES 1987)
A set of precautions to protect health care worker from occupational exposure to blood-
borne infections.
1. BARRIER PROTECTION
2. HAND WASHING
3. SAFE TECHNIQUE
4. SAFE HANDLING OF SHARP
5. SAFE HANDLING OF SPECIMEN
6. SAFE HANDLING OF SPILLS
7. USE OF DISPOSABLES
8. IMMUNISATION WITH HEP-B VACCINE
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1. BARRIER PROTECTION: Materials that protect the HCW from infection.
Gloves Mask
Apron Eye wear
Foot wear
Gloves
� All skin defects must be covered with water proof dressing
� Use well fitting, disposable / autoclaved
� Change if visibly contaminated / breached
� Remove before handling telephones, performing office work, leaving workplace
Mask & Goggles
� Facial protection – When splashing or spraying of blood / blood fluids expected
Apron
� Gowns/Special uniforms – in high risk areas
Foot wear
· Feet should be well covered on all sides, especially while working in areas where
spillage of infectious material is common, like operation theatres, labour room,
laboratories. Soft shoes are preferred to sandals.
2. HAND WASHING: Protects both HCW and patients .The single measure that is
universally acknowledged and proved to reduce HCAI.
The main forms are:
a) Social handwashing – Done for simple cleaning of hands with soap and water. Reduces
the transient flora. A modification is careful handwashing which is done immediately
after touching a patient or after contamination. All areas of the hand upto the wrist are
cleaned by rubbing for at least 2 minutes. Fig 1 below shows the areas commonly missed
while washing, in red.
b) Hygienic hand disinfection – After social hand washing, to get a more sustained effect,
especially while caring for infected patients in special care units like ICUs and neonatal
units. 70% ethyl alcohol hand disinfectants may be rubbed thoroughly over the hands.
This effectively kills all transient flora, the action is fast and short-lived, hence has to be
repeated after touching each patient.
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c) Surgical hand disinfection – Preoperative washing hands by surgeon. Done with
antibacterial soap e.g containing chlorhexidine or an iodophore, followed by 70%alcohol
rub. Hands are scrubbed thoroughly for 5-10 minutes upto the elbows, taking care to
scrub nails and interdigital areas. (Hospital Hygiene and infection control, WHO 1999)
Fig.1 Areas missed (in red)
Running water is an essential pre-requisite for proper handwashing. In its absence, Fig 2
shows how hands can be washed using a container with a tap fitted (Model Injection
Practices Manual, IndiaClen Programme evaluation Network 2006)
Fig 2. Washing hands when running water is not available
3. SAFE TECHNIQUE & SAFE HANDLING OF SHARPS : These are techniques to
be followed while using sharp instruments like scalpel, scissors and needles.
a) Dispose your own sharps yourself.
b) Never pass used sharps to another person. e.g. give used scalpel to assistant in a kidney
tray, not directly
c) During exposure-prone procedures, minimize the risk of injury by ensuring that the
operator has the best possible visibility. E.g. by positioning the patient, adjusting good
light source and controlling bleeding. (CDC guidelines 1987)
d) Protect fingers from injury by using forceps instead of fingers for guiding suturing.
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e) To collect blood a vacuum system is ideal
f) Never recap, bend or break disposable needles.
g) Place used needles and syringes in a rigid puncture resistant container or destroy using
needle destroyer.
Every institute should have a Sharps Policy to provide a safe working environment, the
basis of which should be:
A. Reduce use and Select the right devices.
B. Care in use - Handle used items with care for reuse or disposal.
C. Disposal - Dispose infected waste safely.
4. SAFE HANDLING OF SPECIMEN: These are to be followed while sending blood
or other body fluids to a laboratory for tests.
a) Wear gloves while collecting any specimen from a patient.
b) Keep all containers labeled and ready before collection
c) Use aseptic techniques
d) Keep all disinfectant containers ready before collection
e) Collect into a screw capped unbreakable container , screw it tight and dispatch safely
f) If it has to be sent to a distant lab follow packing instructions as for infectious material
and put a biohazard label on the package.
5. SAFE HANDLING OF SPILLS: Spilling of blood and body fluids is a common
hazard in the laboratory, theatres and wards. A uniform policy is necessary to
protect both HCWs and patients from spread of blood-borne infections by this
route.
Chemical Disinfectants effective in inactivating all blood-borne pathogens:
Disinfectant Concentration Period of contact
1. Hypochlorite 1% 30min
2. Formalin 4% 30min
3. Gluteraldehyde(Cidex) 2% 30min
4. Hydrogen peroxide 6% 30min
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The following steps should be followed if there is a spill:
Spill on floor/ work surface should be covered with paper towel / blotting paper /
newspaper / absorbent cotton. 1% (10,000 ppm) Hypochlorite solution should be poured
on the spill and covered with paper for 30 minutes. All the paper / cotton should be
removed with gloved hands.
0.1% or 0.5% Hypochlorite is used for general disinfection.
6. USE OF DISPOSABLES
It is impossible to avoid all contact with infected tissue or potentially contaminated body
fluids. Even when they are not touched with the bare hands, they come into contact with
instruments, containers, linen etc. All objects that come into contact with patients should
be considered as potentially contaminated. If an object that comes into such contact is
disposable it should be discarded as waste. If it is reusable transmission of infectious agents
should be prevented by cleaning, disinfection or sterilization.
7. IMMUNISATION WITH HEP-B VACCINE
Every Hospital should have facilities for immunization of all the HCWs against Hepatitis B.
II. CLEANING AND DECONTAMINATION
“The ‘environment’ means the totality of a patient’s surroundings which includes the fabric of the building and related fixtures, fittings and services such as air and water supplies. It is the duty of the administration to see to it that all parts of the premises in which it provides health care are suitable for the purpose, are kept clean and are maintained in good physical repair and condition.” The Health Act 2006 Code of Practice for the Prevention and Control of Health Care Associated Infections, Dept. of Health, UK.
The cleaning arrangements should
1. Detail the standards of cleanliness required in each part of the premises
2. Make available a schedule of cleaning frequencies
3. Include adequate provision of suitable hand wash facilities and antibacterial hand rubs.
4. Include effective arrangements for the appropriate decontamination of instruments and
other equipment.
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A. SURFACES: These are meant to be clean and not sterile. Cleanliness can be
ensured only if cleaning is repeated as often as contamination occurs.
The physical action of scrubbing with detergents and rinsing with water during
environmental cleaning effectively removes 90% of micro-organisms. Non-sporulating
bacteria are unlikely to survive on clean surfaces. It is essential that methods of cleaning do
not produce aerosols or dispersion of dust in patient care areas. Brooms should not be used in
intensive care facilities. Fresh cleaning solution should be made before each cleaning
procedure and discarded after use. There should be an area for cleaning and drying of used
mops.
1. Floors: Vacuum clean or dry mop twice daily.
Wet mop with detergent and phenol (1%) solution. Use 2% if there is obvious
contamination.
2. Furniture and ledges: Wet mopping daily with warm water and detergent.
3. Washbasin and sink: Clean with detergent. If contaminated use 0.5%Hypochlorite.
4. Mattresses and pillows: These should be enclosed in a waterproof cover. This should be
cleaned with a detergent after a patient is discharged and disinfected with 0.5%
hypochlorite, if contaminated.
5. Medicine trays: Keep all trays, with medicines and dressings inside a drawer or closed
cupboard. If kept exposed in a tray, keep covered and away from open windows.
6. Toilet seats: Wash daily with detergent and dry. Use 0.5% hypochlorite if soiling with
blood is likely as in Urology and Gynaecology units.
7. Beds, bed-frames: For normal cleaning use detergent and hot water. Perform cleaning
after discharge of patient and weekly in case of long stay patients. Use 0.5% hypochlorite
to disinfect if there is any contamination with blood or body fluids.
8. Cleaning of a room after source isolation of an infected patient: Fumigation of the
room or swabbing to monitor effectiveness of the cleaning procedure is NOT
needed.
a. Cleaner should wear apron and thick household gloves
b. Dust the high ledges window frames etc.
c. Wet mop all ledges, fixtures and fittings including taps and door handles
d. Vacuum clean the floor.
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e. Wash floor with detergent and 1% phenol solution.
f. Wipe mattresses with freshly prepared 0.5% hypochlorite solution.
B. EQUIPMENT: Disposables to be discarded after contamination and autoclavable
items to be autoclaved after use on one patient.
1. Fibre-optic endoscopes (and other heat sensitive instruments): Manufacturers instructions
for sterilization, if present should be followed.
i. All accessories should be disconnected as far as possible and immersed in a
detergent solution
ii. All channels should be flushed and brushed ,if accessible ,to remove all
organic materials
iii. External surfaces and accessories should be cleaned with a sponge or soft
cloth. Accessories that are reusable should be autoclaved
iv. Immerse the instrument in 2% Gluteraldehyde, so that all channels are
perfused, for 30 minutes. Discard the detergent after use.
v. If tuberculosis is suspected, the period of contact may be extended to 1 hr.
vi. After disinfection, endoscopes should be rinsed with with sterile water,
followed by a rinse with 70% alcohol.
2. Suction equipment: Following use the reservoir should be emptied (according to hospital
waste disposal policy) washed with hot water and detergent, rinsed and stored dry.
3. Anaesthetic or ventilator tubings: Wash and sterilize in CSSD. Never use Gluteraldehyde
to disinfect respiratory equipment. For patients with tuberculosis or AIDS, use disposable
tubing. For ventilator, follow manufacturer’s instructions. Use disposable filters or
autoclave between patients.
4. Humidifiers/Nebulizers: Clean and sterilize device between patients. Fill with sterile
distilled water which has to be changed every 24hrs, if not used up.
5. Infant incubators: Wash all removable parts, clean with detergent and dry. If
contaminated, wipe with 70% ethyl alcohol or isopropyl alcohol (if metallic) and with
0.5%hypochlorite (if plastic).
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Taken from the Guidelines for prevention of Nosocomial Pneumonia, CDC, Atlanta
C. INSTRUMENTS :
1. Speculums and rigid endoscopes: Clean and wash thoroughly. Rinse and dry. Send to
CSSD for autoclaving. An alternative is immersion in 2%Gluteraldehyde for 10 minutes after
disassembling any accessories. Rinse with sterile distilled water after disinfection.
2. Thermometers: Individual thermometers are recommended for each patient (at least in
ICUs). For multi-use, after each use wipe with 70%alcohol and store dry. Wash with
detergent at least twice daily. Alternatively, for individual thermometers, wash with detergent
and immerse in 70% alcohol for 10 minutes after the patient is discharged. Store dry.
3. Scissors: Surface disinfect with a 70% alcohol wipe.
4. Urinals and bedpans: Wash with detergent between each use. Store dry. Heat disinfect at
80oC between patients, clean and reuse.
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5. Cheatle forceps: Do not use. If necessary to use, autoclave daily and store dry in a closed
container.
6. Oxygen face mask: Wash with detergent and dry if contaminated. Before each use, wipe
with 70% ethyl or isopropyl alcohol.
SPECIFIC POLICIES
I. WARDS
1. Beds (centre) should be at least 3.6m away from each other.
2. There should be good ventilation.
3. Toilets and baths should be easy to clean and conveniently located.
4. Wash basins to be located within easy walking distance. One wash basin per 6 beds is
recommended.
5. Walls and ceilings should be kept in good repair, because micro organisms tend to
colonise only walls that are moist or sticky.
6. Pipe penetrations and plumbing fixtures should be smooth, and tightly sealed..
7. Overcrowding of wards should be avoided. Visiting hours should be fixed for 2 hours
daily and only one bystander allowed per patient.
8. It is recommended that food for the patient is provided by the hospital dietary
department based on recommendations by the attending doctor /dietician. This will
reduce the traffic in the wards during the day.
9. Cleaning schedule should be decided and followed. Brooms which raise dust are
NOT recommended. Instead, vacuum cleaning or dry mopping followed by wet
mopping may be done at least twice daily and after any contamination.
10. Detergent and 1% phenolic disinfectants may be used for floors. For non-metallic
surfaces 0.5% hypochlorite may also be used.
11. 70% ethyl or isopropyl alcohol may be used to wipe medicine trolleys and shelves
where instruments or medicines are kept, after thorough wet mopping.
Cleaning: Wet mopping with 1% phenol and detergent at least twice daily.
0.5% hypochlorite if there is visible contamination
1% hypochlorite for blood spills.
Clean ledges and window frames daily
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II. INTENSIVE TREATMENT UNITS
1. No bystanders allowed.
2. Restrict entry of visitors to 2hrs per day.
3. Floors and shelves to be cleaned as for wards.
4. Staff should wear masks and aprons while working in the unit.
5. Staff from the unit should not be sent outside for any purpose.
6. Staff from outside should not enter the unit.
7. Ventilators, nebulisers and humidifiers to be cleaned, sterilized/disinfected as
recommended above.
8. Environmental samples to be taken and Fumigation to be done only after any
renovation work and during outbreak investigation. Routine fumigation or swabbing
is not required.
III. OPERATION THEATRES
A. Environment:
1. Positive pressure ventilation, High Efficiency Particulate Air filtration (HEPA)
filtered air with at least 20 air exchanges per hour.
2. Temperature – 18-25oC, Humidity – 40 – 60%, Bacterial count of air(using slit
samplers) - < 30cfu/m3
3. Air-conditioning – Monitoring and servicing by accredited technicians.
4. Number of staff and movement inside the operating theater – to be minimum.
5. Proper cleaning of the floor, walls and the lights above the operating table is essential
B. STAFF & INSTRUMENTS
1. The surgeon, anesthetist and assisting nurse should scrub thoroughly before the
procedure.
2. All articles used for surgical procedures must be STERILE.
3. Staff working in the theatre should on no account be sent outside for any errand
during working hours.
4. All staff should change to theatre dress before entering. No other staff working in
other parts of the hospital should be allowed inside.
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C. PATIENT
1. Pre-existing skin lesion diabetes and other immunosuppressive condition - to be
corrected.
2. Pre-operative stay in hospital – to be kept to a minimum.
3. Pre-operative shaving using razors & brushes – to be avoided. Clip the hair or use
depilatory creams.
4. Antibiotic prophylaxis – not to exceed 24 hrs.
5. Operative site - to be disinfected properly. Use 0.5% Chlorhexidine / 10% Povidone
Iodine followed by 70% Ethyl alcohol/Iso propanol. First incision to be put only after
the alcohol has dried.
IV. NEONATAL UNITS
A. ENVIRONMENT:
1. Floors: Cleaning should be performed in the following order – patient areas, accessory
areas and then adjacent halls. Brooms are NOT recommended inside the unit. In the cleaning
procedure, dust should not be dispersed into the air. Wet mopping with detergent and 1%
phenol/0.5% Hypochlorite should be performed twice daily and at the time of any
contamination. Mop heads should be machine laundered and thoroughly dried daily.
2. Surfaces: All ledges and fixtures should be cleaned by wet mopping with detergent once
daily. In addition, wipe surfaces where medicines and equipment are kept with 70% ethyl
alcohol. Cabinet counters, work surfaces, and similar horizontal areas should be cleaned
once a day and between patient use with a disinfectant/detergent and clean cloths, as they
may be subject to heavy contamination during routine use. Friction cleaning is important to
ensure physical removal of dirt and contaminating microorganisms.
3. Walls, windows, storage shelves and similar non-critical surfaces should be scrubbed
periodically with a disinfectant/detergent solution as part of the general housekeeping
program. Keep all medicines, vials and other minor equipment in closed shelves if not in use.
4. Sinks should be scrubbed clean at least daily with a detergent.
5. Always keep the doors closed with a self-closing device.
6. There should be a separate isolation room for babies with suspected sepsis, where source
isolation precautions are to be followed.
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B. EQUIPMENT:
1. Cradles / incubators/baby warmers: Surface clean once daily with detergent and 70% ethyl
alcohol. The mattresses may be cleaned between babies with detergent and wiped with
70%alcohol. Change sheets daily and use laundered linen from the hospital supply.
When the incubators / open care units are being cleaned and disinfected after the baby is
discharged, all detachable parts should be removed and scrubbed meticulously. If the
incubator has a fan, it should be cleaned and disinfected; the manufacturer’s instructions
should be followed to avoid equipment damage. The air filter should be maintained as
recommended by the manufacturer. Mattresses should be replaced when the surface covering
is broken, because such a break precludes effective disinfection or sterilization. Incubators
not in use should be thoroughly dried by running the incubator hot without water in the
reservoir for 24 hours after disinfection.
Infants who remain in the nursery for an extended period should be transferred
periodically to a different, disinfected unit so that the originally occupied unit can be
cleaned.
2. Suction catheters: Catheter tips should be sterile, disposable. Keep the bottles and rubber
tubes clean and dry when not in use. Wash the bottles with detergent and dry, daily and
between patients. Flush catheter with sterile distilled water after each use.
C. BABY CARE:
1. Hand washing: Medical and hospital personnel must follow careful hand-washing
techniques to minimize transmission of disease. The following steps are recommended by
the CDC, Atlanta:
I. Personnel should remove rings, watches, and bracelets before washing their hands and
entering the neonatal nursery. Fingernails should be trimmed short and no nail polish should
be permitted.
II. Before handling neonates for the first time, personnel should scrub their hands and arms to
a point above the elbow thoroughly with an antiseptic soap. After vigorous washing, the
hands should be rinsed thoroughly and dried. Antiseptic preparations (e.g. Chlorhexidine 4 %
or 70% alcohol ) should be used for scrubbing before entering the nursery, before providing
care for neonates, before performing invasive procedures, and after providing care for
neonates.
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III. A 10-second wash without a brush, but with soap and vigorous rubbing followed by
thorough rinsing under a stream of water, is required before and after handling each neonate
and after touching objects or surfaces likely to be contaminated with virulent microorganisms
or hospital pathogens.
Hand washing is necessary even when gloves have been worn in direct contact with
the infant. Hand washing should immediately follow removal of gloves, before touching
another infant. Alcohol-containing foams kill bacteria satisfactorily when applied to clean
hands and with sufficient contact. They can be used in areas where no sinks are available or
during emergency. But they are not sufficient in cleaning physically soiled hands, because
transient organisms are not removed.
2. Feeding of babies
Mother's milk is the best food for both normal and low birth weight babies. The
borderline term and growth retarded low birth weight babies can suckle fairly well at the
breast and should be given expressed breast milk in preference to formula feeds by
appropriate techniques such as clean cup and spoon or cleaned and sterilized ‘gokarnam’.
Milk should not be kept for long periods in open containers. The child should be put directly
to the breast as soon as possible. (IAP recommendation). The mother may be given
appropriate instructions regarding personal hygiene, which should include hand washing
techniques: a) Always wash your hands before expressing or handling your milk.
b) Be sure to use only clean containers to store expressed milk. Try to use screw-
cap bottles or hard plastic cups with tight caps. Do not use ordinary plastic bags or formula-
bottle bags. Do not store milk for more than 1 hr at room temperature. Use chilled milk (kept
at 0-4oC) within 24 hours.
3. Invasive procedures: For all invasive procedures, including lumbar puncture, introducing
a cannula or withdrawing blood for any investigation, ALL aseptic precautions have to be
taken. This includes STERILE gloves and wipe with povidone iodine and 70% alcohol, over
the area.
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CHAPTER 4
ISOLATION POLICY AND OUTBREAK
MANAGEMENT
1.ISOLATION STRATEGIES
In order to prevent the spread of infectious diseases the patients with communicable
diseases were often segregated. However as the knowledge about the different modes of
transmission increased the strategies involved have become more evidence based and
targeted. Though the Centres for Disease Control (CDC), Atlanta, USA, has published
guidelines regarding isolation practices in hospitals, each health care facility should devise its
own strategies based on the local needs. Though appropriate door signs may be necessary,
care must be taken to ensure no breach of confidentiality and not to stigmatise the patient.
Isolation procedures can be divided into two main categories:
Protective isolation — This is to prevent infection in immunocompromised patients
who are at increased risk of infection both from other patients and from the environment.
Isolation measures are usually maximal for those undergoing transplantation. A specialized
room with positive pressure ventilation and HEPA filtration is required.
Source isolation – A two- tier approach is recommended by the CDC. The Standard
precautions are for all patients admitted in the health care facility regardless of their disease
status. It reduces the risk of transmission of microbes from both known and unknown sources
of infection. These include: hand washing, gloves for body substances, gown if soiling is
likely, and mask if splash is likely. The additional precautions are dependent on the different
modes of transmission. Under this there are six categories of isolation or precaution:
1. Strict isolation - Spread is by contact or airborne. Single room with door shut.
Gloves, mask and gown for all those who enter. Diseases for which this is needed
are – Viral haemorrhagic fevers, pneumonic plague, pharyngeal diphtheria, primary
Varicella and disseminated zoster.
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2. Contact isolation – Spread is by contact. Single room. May cohort with patients with
same infection. Gloves and gown if there is likelihood of contact. Diseases include:
Scabies, infection of wounds or burns with multiply resistant organisms(e.g.
MRSA), rabies and rubella.
3. Droplet precautions – Spread is by large droplets. Requires close contact with the
person and occurs when the particles come into contact with eyes or mucous
membranes of a susceptible person. Single room. May cohort with similar patients,
but at least 1 m separation between patients. Gloves and gown if soiling is likely.
Masks only for those in close contact. Diseases are: Meningococcal meningitis,
measles, mumps, pertussis, H.influenzae epiglottitis.
4. Airborne precautions – Spread is by small droplets, e.g. pulmonary tuberculosis,
where patient is sputum positive. Small droplets remain suspended for longer
periods and travel farther. Single room with a negative pressure .At least six changes
of air / hour .The air has to be exhausted well away from any air intakes. Masks used
should be particulate respirator type with filter. The patient is kept here till at least
three consecutive sputum samples become negative for AFB. One month for
severely ill patients and those with multi-drug resistant tuberculosis. This is also
recommended for HIV infected patients with undiagnosed respiratory infection. Not
needed for atypical mycobacterial infection.
5. Enteric precautions – Diseases spread by faeco oral route. No need of separate room.
Toilet facilities may be shared if patient is hygienic.
2. SURVEILLANCE & OUTBREAK MANAGEMENT
Surveillance of nosocomial infection is the foundation for organizing and maintaining
an infection control programme. This information obtained should reach those who may
influence practice, implement change or provide financial resources necessary to improve
outcome. The data also provides a baseline to compare after certain new infection control
measures are implemented. When there is an ongoing surveillance programme, any sudden
change in the infection rates i.e. outbreak situation, can be noted and infection control action
implemented, before the actual outbreak occurs. The process of surveillance incorporates
four key stages: Data collection, analysis, interpretation and dissemination.
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Collection: Methods 1. Continuing Surveillance (CS) of all patients: All records, i.e. clinical, laboratory, nursing
etc. are continuously surveyed. This is time-consuming and some specialties may not have
any infection. This requires staff, IT resources, and a well organized reporting system.
2. Ward liaison (WL): Twice weekly visits to wards and review records.
3. Laboratory based: Laboratory records only. Depends wholly on the kind of investigation
done
4. Laboratory based Ward Surveillance (LBWS): Follow up lab records in the ward. This is
more accurate.
5. LBWS + WL: Time consuming but more accurate.
6. Targeted surveillance: Only high risk areas, e.g. ICUs, newborn units etc.
A minimum data set for surveillance includes:
Surveillance methods should be flexible enough to accommodate technological changes,
shortening lengths of stay and to include procedures carried out after discharge in the
community.
Analysis: A simple comparison of actual number of cases with the expected number is routinely
carried out��Validity of data - Incidence increases when there is awareness of a problem,
Name/Hospital no.
Date of birth
Sex
Ward/Unit
Name of consultant
Date of admission
Date of onset of infection
Site of infection
Organism isolated/suspected
Antibiotic sensitivity
Treatment given
Other risk factors
Outcome
Date of discharge/death
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improved diagnostic methods, ongoing screening programmes and higher reporting
propensity.�
Interpretation
The data generated should be appropriately risk adjusted, for meaningful infection
rates. Clearly defined surveillance objectives can overcome problems of data interpretation.
Dissemination � Active participation by all those who are engaged in filling forms and updating data is
ensured only when the final information from the various parts of the hospital is analyzed
and sent back to them as useful information that helps in their day-to-day clinical work.
The main objectives of surveillance should be:
1. Establishing endemic infection rates
2. Comparing infection rates between health care establishments
3. Evaluating control measures
4. Identifying outbreaks
5. General reduction of nosocomial infection rate.
Lab personnel or clinicians cannot be expected to conduct a surveillance programme.
This can be assigned to the Infection Control Lab and the ICD with the help of the ICN can
coordinate the data collection. Analysis and interpretation can be done by an Epidemiologist
who is part of the ICT.
An outbreak situation is detected and can be immediately brought under control if their
activities are well coordinated by the ICD. In the absence of an outbreak, the data may be
used by the administrators to convince the media and general public about the effective
infection control precautions taken by the administration. The ICD and ICN use the data to
monitor infection rates in wards and ICUs and post-operative infection rates. This helps in
targeting continuing education programmes and evaluating any gaps in implementation of the
hygiene policies of the hospital.
OUTBREAKS AND THEIR MANAGEMENT
Outbreaks within hospitals can involve the whole hospital, one theatre, one ward ,one
unit or one wing of the hospital The exact measures taken depends on the kind of infection
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and its mode of spread. The ICT with the help of the hospital management has to plan the
steps to be taken and implement it on a day-day basis. The basic steps of outbreak control
alone are discussed here:
1. Surveillance data indicate an outbreak situation.
2. Confirm the existence of an outbreak by comparison with previous data. An
outbreak is the occurrence of an infection at a rate greater than that expected
within a defined area (unit or ICU or theatre or ward) over a defined period
of time e.g. one month or one week.
3. Create a case definition, i.e. the cases that come under the label ‘outbreak
case’, should be similar clinically / laboratory wise or both.
4. Identify the index case and construct an epidemic curve in time. This will help
in narrowing down the source and mode of transmission.
5. Screen the staff (for carrier state) and environment, if necessary.
6. Take immediate control measures e.g. close down the ICU or source
ward/theatre, any major defects like a break in the chain of waste disposal or
sudden shortage of cleaning staff in that ward will have to be addressed on an
urgent basis.
7. Summarise the investigation and report on steps taken and disseminate the
information to the appropriate authorities. Communicate this information to
the personnel involved, in the hospital.
8. Implement long-term measures so that such an outbreak does not occur in the
future.
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CHAPER 5
ANTIBIOTIC POLICY
An antibiotic policy is not a restriction on the independence to prescribe antibiotics,
but a sensible guide to the practicing doctor on how to manage infections in the most
effective manner. The policy will help the doctor solve the most important problems of
rapidity of action, cost and availability, best route of administration, the most effective dose
and duration of therapy. Generally the microbiologist insists that the antibiotic should be
given according to the pattern of sensitivity obtained after the organism is grown and
identified. This takes a minimum of 24- 48 hrs. Many of the infections can be diagnosed
clinically, e.g. meningitis, lobar pneumonia, infective endocarditis, enteric fever etc. and
need early treatment. The antibiotic policy will help in the following ways:
1. Giving the correct advice to the clinician regarding the antibiotic to be started, after
appropriate cultures have been taken. The sensitivity report will then confirm
whether the same antibiotics may be continued. If the policy is good, there will be
almost no change in the antibiotics started.
2. Another important bonus to the administration is that the number of multi drug
resistant strains that typically cause nosocomial outbreaks will also dramatically
decrease.
3. The pharmacy can order the needed antibiotics in greater quantities rather than
spreading out the resources over drugs that are rarely needed.
The ICT cannot make this policy on its own. The HICC has a big role here. Since all
the specialists are members, the policy may be made by the Microbiologist or Infectious
disease specialist, after receiving suggestions from all of them. The policy can be
reviewed by the committee every year and updated. It should be available for easy
reference in tabular form in all the wards, ICUs and casualty services. If the hospital has
a computer networking system, this will help in easy dissemination to all the medical
officers.
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The following policy is based on one followed by the National Health Services
(NHS), UK. These guidelines were developed by a multi-disciplinary working group to
ensure balanced input. It has considered the antimicrobial choice for specific conditions, and
the existing policies for specific agents. By following the guidelines it will be possible to
maintain a high standard of patient care, delivered in a consistent way, by all the doctors in
the hospital. It may be modified appropriately based on cost and availability.
INDICATIONS FOR ANTIMICROBIAL THERAPY
The use of antimicrobials has adverse consequences which compromise the efficacy of
therapy for individual patients and the hospital as a whole. These include:
1. Adverse drug-related effects for patients
2. Alteration of normal flora leading to superinfection with organisms such as
Pseudomonas aeruginosa, Candida spp. and Clostridium difficile.
3. Selection of drug-resistant strains
4. Increased rates of cross infection
5. Unnecessary cost
The decision to use antimicrobial agents must take these effects into account and is always a
balance of risk against benefit.
Directed Therapy
Antimicrobial treatment should normally be directed by the results of microbiological
investigations confirming the presence of a true infection which is amenable to antimicrobial
therapy.
Empiric Therapy
Where delay in initiating therapy to await microbiological results would be life threatening or
risk serious morbidity antimicrobial therapy based on a clinically defined infection is
justified. Where empiric therapy is used the accuracy of diagnosis should be reviewed
regularly and treatment altered/stopped when microbiological results become available.
Microbiological samples must always be sent prior to initiating antimicrobial therapy.
Rapid tests, such as Gram films, can help determine therapeutic choices when empiric
therapy is required.
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CHOICE OF ANTIMICROBIAL
The sections in this policy indicate the suggested approach to treating the most
common forms of infection encountered in a hospital setting. The use of a restricted range of
antimicrobial agents provides greater familiarity with their efficacy and potential side effects.
It also allows the Microbiology services to provide appropriate sensitivity data to guide
therapy.
However this general guidance is not applicable to all patients. The choice of antimicrobial
may need to be modified in the following situations:
1. Hypersensitivity to first choice antimicrobial (see guidance on hypersensitivity)
2. Recent antimicrobial therapy or preceding cultures indicating presence of resistant
organisms
3. In pregnant or lactating patients
4. In renal or hepatic failure
MONITORING TREATMENT
The continued need for antimicrobial therapy should be reviewed at least daily. For
most types of infection treatment should continue until the clinical signs and symptoms of
infection have resolved – exceptions to this are indicated in the relevant sections. Parenteral
therapy is normally used in seriously ill patients and those with gastrointestinal upset. Oral
therapy can often be substituted as the patient improves. Where treatment is apparently
failing, advice from a clinical microbiologist should normally be sought rather than
blindly changing to an alternative choice of antimicrobial agent.
ANTIBIOTIC POLICY
1. SPECIFIC GASTROINTESTINAL INFECTIONS
As most cases of gastroenteritis are self-limiting, antimicrobials are not indicated and
management should focus on fluid and electrolyte replacement. Furthermore, many cases
have a viral aetiology and current antimicrobials are ineffective. Moreover, in some
situations, antimicrobial therapy may be associated with an adverse clinical outcome.
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Shigellosis and Salmonellosis: First choice: Ciprofloxacin 500mg po bd for 5 days.
Although this can be commenced empirically, it should be noted that resistance to
ciprofloxacin is increasing and therapy may have to be modified according to in-vitro
susceptibility testing. Second choice: III gen. Cephalosporins, especially for children.
Giardiasis and amoebiasis: First choice: Metronidazole 2g daily for 3 days (if tolerated) or
400mg tds for 5 days. Second choice: single dose Tinidazole 2g
2. COMMUNITY ACQUIRED PNEUMONIA Pneumonia is defined as 'community acquired' if it presents within the first three days of
hospital admission.
Mild - moderate infection
Amoxicillin 500mg TDS PO
Penicillin allergy - Erythromycin 500mg QDS PO/Azithromycin
Severe infection
Crystalline penicillin IV
Penicillin allergy - Cefuroxime 1.5g TDS IV
Continue IV therapy for at least 24 hours. Severe CAP - 10 to 14 days treatment
Staphylococcus suspected (eg post influenza during epidemics and cavitation seen on CXR)
add Cloxacillin 1g 6th hrly IV.
3. COMMUNITY ACQUIRED MENINGITIS
If meningitis is suspected, take blood samples and then give antibiotics before LP or CT
scan. LP may be done within one hour of starting antibiotics.
If confident that patient has typical meningococcal rash and no allergy - Benzyl penicillin
2.4g IV every 4 hours. If adult without a typical meningococcal rash - Cefotaxime IV 2g
QDS. If patient > 50 years, or immuno-compromised, or pregnant, and no typical
meningococcal rash - consider adding Amoxicillin 2g IV every 4 hours (to cover listeriosis)
For suspected meningococcal contacts(Prophylaxis):
Adults - Rifampicin 600mg PO every 12 hours for 2 days
Children over 1 year - Rifampicin 10mg/kg PO every 12 hours for 2 days
Children under 1 year - Rifampicin 5mg/kg PO every 12 hours for 2 days
Pregnant females - Ceftriaxone 250mg IM stat
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4. UNCOMPLICATED URINARY TRACT INFECTION (UTI)
Clinical signs:
� Dysuria, frequency, nocturia � Lower abdominal pain or discomfort � Asymptomatic bacteriuria is common in elderly patients, suggest treating bacteriuria in
elderly patients if symptomatic NB Mild symptoms may not require antibiotic treatment.
Mild clinical signs –
Consider non drug treatment until MSU available - > 2L oral fluids per day
Trimethoprim 200mg BD for 3 days
Or Nitrofurantoin 50mg QDS for 7 days
If there is no response, send urine for culture and treat accordingly.
Pregnancy – III gen. Cephalosporin,oral/IV(asymptomatic bacteriuria is common and should
be treated.
5. PYELONEPHRITIS Clinical signs:
Pyrexia, rigors, loin pain +/- urinary tract symptoms and renal colic
Initial antimicrobial therapy is almost always given intravenously.
Cefuroxime IV 750mg TDS for at least 5 days.
> 2L oral fluids per day.
Culture negative MSU with pyuria and/or persistent symptoms - consider urethritis including
Chlamydia or TB. Refer to Urologist after first time in males and second UTI in females.
5. PELVIC INFLAMMATORY DISEASE (PID) Empirical treatment of PID should be initiated in sexually active young women and others at
risk of sexually transmitted diseases if all the following minimum criteria are present, and no
other cause for illness can be identified:
� Lower abdominal tenderness
� Adnexal tenderness
� Cervical motion tenderness ('cervical excitation')
All patients should have a negative pregnancy test and ectopic pregnancy, appendicitis and
ovarian cysts excluded before a diagnosis of PID is made.
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Delay in diagnosis and effective treatment for PID can increase the risk of tubal damage.
Therefore, treatment should start immediately, without waiting for the results of the swabs.
The patient's sexual partner must have antibiotic therapy to prevent possible re-
infection. She should be advised to abstain from sexual intercourse until both she and her
partner have completed the antibiotics.
Outpatient
Doxycycline 100mg PO BD for 14 days and Metronidazole 400mg BD for 14 days
Or Ceftriaxone 250mg IM stat
Inpatient
Cefuroxime 750mg IV TDS and Metronidazole 500mg IV TDS
Or Metronidazole 1g PR TDS and Doxycycline 100mg PO BD
IV therapy should continue for a minimum of 24 - 48 hours, then:
Doxycycline 100mg PO BD for 14 days and Metronidazole 400mg BD for 14 days
6. OTITIS MEDIA Inflammation of the middle ear which may be followed by profuse purulent discharge as the ear-drum perforates. Discharge usually settles after a few days. Continuing discharge may indicate mastoiditis. It may be associated with an obstruction of the eustachian tube.
Non antibiotic treatment:
� Drain pus through acute perforation, clean debris � Analgesics such as paracetamol, NSAIDS and dihydrocodeine � Decongestants may be of some benefit.
Amoxicillin PO 500mg TDS for 5 days
Treatment failure
Cefaclor PO 500mg TDS for 5 days
7.TONSILLO PHARYNGITIS Inflammation of the part of the throat behind the soft palate and/or tonsils due to bacterial or viral infection causing a sore throat, fever and dysphagia.
There is little evidence that antibiotics are beneficial unless quinsy or necrosis are suspected.
Non antibiotic treatment:
� Warm saline throat irrigations � Throat lozenges containing local anaesthetics � Analgesics such as paracetamol, NSAIDS and dihydrocodeine. Penicillin V PO 500mg QDS for 10 days
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Treatment failure / Penicillin allergic
Erythromycin PO 250mg QDS for 10 days
Severe infection
Parenteral treatment may be required
Benzylpenicillin IV 1.2g QDS
Treatment failure / Penicillin allergic
Clarithromycin IV 500mg BD
8.CELLULITIS / ERYSIPELAS Intravenous antibiotics are required if patient meets one of the following criteria:
� Systemically unwell � Rapidly spreading or extensive disease � Immuno-compromised Cloxacillin IV 1 - 2g QID and Benzylpenicillin IV 1.2 - 2.4g every 4 to 6 hours
If confident of diagnosis of erysipelas, omit Cloxacillin IV
Add Metronidazole 500mg TDS in diabetic patients
After 48 - 72 hours if appropriate oral therapy can replace Parenteral :
Cloxacillin 1g QID and Amoxicillin 1g TDS
9. ENTERIC FEVER
Oral antibiotics are best to tackle the infection in the Peyer’s patches. Though oral
route is recommended for uncomplicated cases, parenteral Ciprofloxacin is recommended in
the presence of complications, with switch over to oral route after the symptoms have
resolved. Ciprofloxacin resistance is coming up due to the continued misuse of quinolones in
wound infections and common respiratory infections. In such cases, parenteral third gen.
cephalosporin followed by oral Cefixime is recommended.
Ciprofloxacin 250mg TDS IV or 750mg BD orally for 10 – 14 days is the drug of
choice.
These are only the common infections. A comprehensive list can be made after
discussion with specialists. The basic principle is that simpler antibiotics are used first to
preserve the efficiency of higher ones. If this is followed by all the doctors in a hospital and
then the peripheral hospitals and dispensaries are also made aware, spread of multi drug
resistant strains in the hospitals can be reduced, In addition the total cost of treatment of
infections is reduced significantly.