infection control; basic concepts and practices 2nd edition

8/10/2019 Infection Control; Basic Concepts and Practices 2nd Edition

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Introduction

Welcome to the 2nd Edition of Infection Control: Basic Concepts and Practices. The Board ofDirectorsof the International Federation of Infection Control (IFIC), the corporate sponsors and theathors of this te!t hope that "o find it sefl.

IFIC, fonded in #$%&, is a federation of infection pre'ention and control societies from more than contries arond the *lo+e. The prpose of IFIC is to help translate research findin*s intoinfection control practices sita+le for the particlar sitation in hich each mem+er or*anisation is

or-in*. Ths IFIC is an or*aniation for edcation and applied science related to pre'ention ofinfections related to health care. To accomplish this, the or*aniation pro'ides a commnicationnetor- to promote edcation, trainin* and e!chan*e of information amon* the mem+er societiesith particlar emphasis on assistin* those ith limited resorces. The *oals of the federation areto:

promote hi*h /alit" edcational opportnities, materials and trainin* pro*rams across

contries at lo cost. Conferences are held at least annall"0 in addition, IFIC pro'idesedcational infection control content and spea-ers for conferences or*anied +" otheror*aniations.

pro'ide a commnication netor- of spport +" mem+ers 'ia the nesletter, IFIC Blletin,

the e+site (.ific.narod.r), and email. maintain a liaison ith the World 1ealth r*anisation and other or*anisations that promote

infection pre'ention incldin* pre'ention and mana*ement of occpational +lood e!posresamon* health care or-ers.

dra on the e!pertise of mem+er or*aniationsto help each other and to assist ith

formation of national societies in contries that are in earl" sta*es of infection controlde'elopment.

The prpose of infection control is to redce ris- for patients and personnel for infections related tohealth care. 3an" of the essential methods to accomplish this in an" and all health care settin*s are

inclded in Basic Concepts and Practices. Three ne chapters are inclded: 4The costs of hospitalinfection5 +" 6ar" French, 3D0 4Economic e'alation in infection control5 +" 7an8a" 7aint, 3D,3P10 4Infection control information resorces5 +" 9iam Damani, 3BB7, 37c. eferences *idethe reader to information in more depth. ;dditionall", a series of mono*raphs that e!plore eachfndamental concept are +ein* de'eloped0 information ill +e posted to the e+site:.ific.narod.r

Members of the IFIC Infection Control: Basic ConceptsWorking Group:

6ar" French, 3D, FCPath, FCP; , "nch, 9, 3B; ,


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7an8a" 7aint, 3D, 3P1 ,


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1. Organisation of Infection ControlIntroduction

Infection control (IC) is a /alit" standard and is essential for the ell +ein* and safet" of patients,staff and 'isitors. It affects most departments of the hospital and in'ol'es isses of /alit", ris-mana*ement, clinical *o'ernance and health and safet".

;n infection control pro*ramme ith a firm strctre shold +e in e!istence in all instittions thatpro'ide health care in order to esta+lish a mana*ed en'ironment that

7ecres the loest possi+le rate of hospital ac/ired infection Protects staff and 'isitors from nnecessar" ris-s

The hospital mana*er or medical director is ltimatel" responsi+le for safet" and /alit" ithin thehospital. 1e or she mst ensre that appropriate arran*ements are in place for effecti'e infectioncontrol practices and that there is anInfection Control Team (ICT) and anInfection ControlCommittee (ICC). If the health care settin* is too small to spport sch an or*anisation, e!perts ininfection control shold +e a'aila+le for consltation at re*lar inter'als and hen needed in anacte sitation. Pro'iders of home care shold ensre that e!pertise in infection control is a'aila+lefor their staff.

Infection Control Team

The ICT shold ha'e a ran*e of e!pertise co'erin* -noled*e of infection control, medicalmicro+iolo*", infectios diseases and nrsin* procedres. The team shold ha'e a close liaison iththe micro+iolo*" la+orator" and ideall" a micro+iolo*ist shold +e a mem+er of the team.

The team shold consist of at least one ph"sician, the infection control officer (IC), and at leastone nrse, the infection control nurse (IC9). ne IC9 for 2A acte +eds on a fll@time +asis asrecommended in the


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Infection Control Officer - duties and responsibilities

The IC shold prefera+l" +e a senior mem+er of the hospital staff ith e!perience and trainin* ininfection control, sch as a medical micro+iolo*ist, epidemiolo*ist or infectios diseases ph"sician.In the a+sence of one of these, a sr*eon, paediatrician or other appropriate ph"sician ith specialinterest in the field cold +e appointed. Whiche'er person is appointed, the" mst +e *aranteed thee!tra time needed to flfil the responsi+ilit" of an Infection Control fficer. The IC is sall" thechairman of the Infection Control Committee and is responsi+le to the hospital mana*er or medicaldirector for infection control in the health care settin*.

Infection control nurse - duties and responsibilities

The IC9 shold +e a+le to fnction as a clinical nrse specialist. The dties of the IC9 areprimaril" associated ith IC practices ith special responsi+ilit" for nrsin* pro+lems andedcation.

In a lar*e hospital the IC9 can train lin- nrses. These indi'idals ha'e special responsi+ilit" formaintainin* *ood infection control practices and edcation ithin their clinical departments. This

person is the lin- +eteen the IC9 and the ard and helps identif" pro+lems, implement soltionsand maintain commnications.

Basic qualifications of the ICN

; re*istered nrse (or e/i'alent /alified person) ith clinical and administrati'e e!pertise. 6oodinterpersonal and edcational s-ills are important. eco*nised trainin* in IC is essential.

Infection control committee

The need for an ICC depends on the strctre of the health care settin*. In smaller hospitals, theICC ma" report directl" to the senior hospital mana*ement committee0 in lar*er ones it ma" +e as+committee of a ris- mana*ement or clinical *o'ernance committees. It shold +e made p ofrepresentati'es from 'arios hospital departments. ;ll the clinical departments shold +erepresented, to*ether ith mem+ers of other -e" departments, sch as occpational health, caterin*,

cleanin*, facilities+ildin*s and mana*ement. The committee shold act as a liaison +eteendepartments responsi+le for patient care and spporti'e departments (e.*., pharmac", maintenance).Its aim shold +e to impro'e hospital IC practice and recommend appropriate policies, hichshold +e s+8ect to fre/ent re'ie.

The committee shold +e responsi+le to the hospital mana*er or medical director and shold ha'e aph"sician, prefera+l" the infection control officer or hospital epidemiolo*ist as a chairman. Thehospital mana*er and the chief nrsin* officer, or their representati'es, shold attend meetin*s. Thesie of the committee ill 'ar" dependin* on the re/irements of the hospital. The departmentsshold nominate their representati'es and if not the departmental head, the representati'e shold +ein a position to ma-e decisions.

The committee shold hold re*lar minted meetin*s and the mintes shold *o to the 3edicalDirector and the 1ospital 3ana*ement Board as ell as to departments directl" in'ol'ed in the


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s+8ects discssed drin* the meetin*. It shold prodce an annal report and an annal +siness

plan for infection control.

The following are the most important activities to ensure adequate infection control practices

where health care is provided.

Pro'ide facilities and e/ipment that ma-e it possi+le for the staff to maintain *ood

infection control practices. Prodce standards (policies, *idelines) for procedres or s"stems sed ithin the health

care settin* Implement edcational pro*rammes for all personnel in the se of sch standards.

Esta+lish sr'eillance s"stems that identif" pro+lem areas.

Prodce a polic" for the prdent se of anti+iotics and or- to ensre adherence to thepolic".

Prodce *idelines for cleanin*, disinfection and decontamination and or- to ensre

adherence to those *idelines.

Infection control is the responsibility of every individual in the healthcare facility. However,

the hospital management and the infection control team can provide expertise, education and

support to help staff maintain proper standards and minimise the risks of infection.

Responsibilities of the health care provider

Ensre facilities are a'aila+le to the hospital staff to maintain *ood infection control

practices. Ensre an infection control team is a'aila+le.

7pport the acti'ities of the infection control team

Responsibilities of the infection control team

;d'ise staff on all aspects of infection control and maintain a safe en'ironment for patients

and staff Pro'ide edcational pro*rammes on the pre'ention of hospital infection for all hospital

personnel Pro'ide a +asic manal of policies and procedres and ensre that local ritten *idelines

+ased on these are in e!istence. Esta+lish s"stems of sr'eillance of hospital infection in order to identif" at@ris- patients

and pro+lem areas that need inter'ention. 3ethods for sr'eillance ma" inclde case findin*+" ard ronds and chart re'ies, re'ies of la+orator" reports, and tar*eted pre'alence orincidence sr'e"s.

;d'ise mana*ement of patients re/irin* special isolation and control measres.

In'esti*ate and control ot+rea-s of infection in colla+oration ith medical and nrsin*

staff. Ensre that an anti+iotic polic" is in e!istence.

>iaise ith the hospital doctors and administration (mana*erial and nrsin*), commnit"health doctors and nrses, and infection control staff in ad8acent hospitals.

Pro'ide rele'ant information on infection pro+lems to mana*ement and the ICC.


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Perform other dties as re/ired, e.*., -itchen inspections, pest control, aste disposal.

Examples

Topics of importance for a procedure manual

Patient care

1and h"*iene

Isolation practices

In'asi'e procedres (intra'asclar, rinar" catheterisation, mechanical 'entilation,tracheostom" care, and ond mana*ement).

ral alimentation

ard specific procedures

Isolation procedres for infectios patients

7r*ical and operatin* theatre techni/es

+stetrical, neonatal, and intensi'e care techni/es

Production of items of critical importance

7terilisation and disinfection 3edication and infsion preparation (incldin* +lood prodcts)

!taff health

Immniation

Post@e!posre mana*ement for emplo"ees, patients and others e!posed to infectios

diseases ithin the facilit"

Investigation and management of specific infections

3ethicillin resistant Staphylococcus aureus (37;) Diarrhoea

1I

T+erclosis

3ltiresistant 6ram@ne*ati'e +acteria

etails of components of safe environment for patients and staff

"esponsibility of the hospital manager

Ensre a safe, clean en'ironment.

Ensre the a'aila+ilit" of sterile ater for in'asi'e procedres.

Ensre the a'aila+ilit" of safe food.

Ensre the a'aila+ilit" of an air sppl" appropriate for the le'el of sr*er" pro'ided.


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"esponsibility of the infection control team

Pro'ide ad'ice on *eneral architectral featres (e.*. operatin* and isolation rooms).

Pro'ide ad'ice on clean ater and proper facilities for handashin* and drin-in*.

;rran*e for the separation of clean and dirt" materials and procedres (e.*., stora*e of

sterile spplies in a room separate from one sed for reprocessin* of dirt" e/ipment orstora*e of aste).

Pro'ide ritten policies for critical elements of infection control.

!inimal administrative re"uirements

; ph"sician and a nrse ith responsi+ilities for infection control.

; manal of critical infection control policies. ;n edcational pro*ramme for staff.

; clear line of responsi+ilit" to the senior mana*ement of the hospital.


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#. $urveillance for %osocomial InfectionsIntroduction

1ospital pro*rammes of infection control (IC) shold inclde sr'eillance to detect common sorceot+rea-s, identif" pro+lem areas, help set priorities for infection control acti'it", and meet nationalstandards. 7r'eillance can also pro'ide data to help con'ince clinicians and mana*ers of the needfor impro'ements in infection control practices. 7r'eillance mst +e performed in a s"stematica" ith the aim of redcin* rates of hospital infection. 7r'eillance reslts shold +e fed +ac- toclinical and mana*erial staff and shold lead to action.

7r'eillance folloed +" action for impro'ement can ha'e a si*nificant impact on rates of hospitalac/ired infection (1;I), called nosocomial infection or health care facilit"@associated infection insome contries. The 7td" on the Efficac" of 9osocomial Infection Control (7E9IC) G #H fond thathospitals that had a pro*ramme of sr'eillance and fed reslts +ac- to clinical staff hadconsidera+l" loer infection rates than others. French and collea*es ha'e demonstrated theeffecti'eness of repeated pre'alence sr'e"s G2H and the


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The definitions sed shold distin*ish +eteen 1;I and commnit"@ac/ired infection (C;I).

1ospital@ac/ired infections can +e defined as those that ere neither present nor inc+atin* at thetime the patient as admitted. Detailed definitions of specific infections ha'e +een p+lished +"se'eral or*anisations, incldin* the World 1ealth r*aniation GH, the


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Frthermore, care mst +e ta-en to a'oid the +ias prodced +" dplicates and screenin* cltres.

That is, hen trac-in* an or*anism it shold onl" +e conted once. 9e'ertheless, this is a seflmethod of sr'eillance for infection control prposes. It has the ad'anta*es of simplicit" and +ein*ine!pensi'e, and in compterised la+oratories the sr'eillance can +e atomated. In particlar, in a*i'en hospital it can sho trends in the isolation of specific or*anisms in different ards o'er time.

(revalence surve)s

In this method hospital in@patients are sr'e"ed o'er a short period of time, ideall" on a sin*le da".3an" hospitals and Infection Control Teams find pre'alence sr'e"s to +e more practical thanincidence sr'eillance since the" can +e performed +" 8st a fe people @ often temporaril"recrited from other tas-s @ once or tice a "ear. epeated pre'alence sr'e"s are not a complete

s+stitte for incidence sr'eillance, +t the" are sefl here resorces are limited.

Pre'alence sr'e"s are sefl to indicate the e!tent of nosocomial infection ithin a hospital orre*ion, to indicate specific pro+lems re/irin* more e!tensi'e in'esti*ation, and to define thechan*in* patterns of 1;Is in a sin*le hospital. If pre'alence sr'e"s are repeated at re*larinter'als and the reslts fed +ac- to medical and nrsin* staff the" can perform some of the samefnctions as continos sr'eillance.

In *eneral, pre'alence rates tend to +e loer than incidence rates since pre'alence stdies are lesseffecti'e in identif"in* acte or short@li'ed infections. epeated pre'alence sr'e"s ha'e shonthemsel'es to +e sefl for monitorin* trends in rates of +oth 1;I and C;I. The" are practical to

perform ith relati'el" limited resorces and the" prodce information on +oth infected andninfected patients that can +e sed to identif" independent ris- factors. When properl" applied,

pre'alence sr'e"s can also +e sed to anal"se the effecti'eness of inter'ention strate*ies.

Pre'alence stdies ha'e shon that, dependin* on the patient poplation, the pre'alence of 1;Ia'era*es arond $ @#AK. ;ltho*h most pre'alence stdies ha'e +een applied to the entire hospital,it is pro+a+l" more effecti'e to tar*et certain areas or ser'ices here infection rates are sspected or-non to +e hi*h.

Incidence surveillance

In this method, all patients are monitored o'er a period of time for the presence or a+sence of 1;I.This is the +est method for prodcin* accrate measres of infection rates, hoe'er as ith

pre'alence stdies, it re/ires strctred anal"sis, strict definitions and trained staff to 'isit allpatients repeatedl". Becase it is time consmin*, incidence sr'eillance sall" cannot +e donecontinosl"0 rather it is often tar*eted in areas here pro+lems are -non or sspected. It isdesira+le to *et sr*ical teams to do their on incidence sr'eillance of (sa") clean sr*ical ondinfection, sper'ised +" the Infection Control Team. This means the sr*ical teams ta-e onershipof the pro+lem and are more li-el" to ta-e action if rates are hi*h.

%umerator data

The patients name, identif"in* nm+er or code, ard or nit, medical ser'ice at the time theinfection +e*an to de'elop, and date of admission are the necessar" nmerator information to


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collect. The date of onset of the infection, precedin* ris- factors sch as respirator" therap" +efore

ne pnemonia, site of infection, si*nificant or*anisms cltred and their sensiti'it" patterns helpto descri+e the infection. ;dditional information ma" +e helpfl +t shold not +e collectedrotinel" nless it ill +e sed. (Patients primar" dia*nosis, a*e, se!, a measrement of se'erit" ofillness, ph"sicians name, antimicro+ial therap", indirect ris- factors sch as immnosppressi'ediseases or therapies are e!amples.)

enominator data *population at ris+,

ates are ala"s calclated ith the nmerator (nm+er of persons ith the infection or condition)di'ided +" the denominator (nm+er of persons at ris- for the infection). The more precisel" thedenominator captres the potentiall" pre'enta+le ris- elements the +etter. For e!ample, nosocomial

pnemonia cases amon* patients ho had respirator" therap" di'ided +" nm+er of patientsdischar*ed in a month or on a specific care nit pro'ides some estimate of ris-. 1oe'ernosocomial pnemonias amon* sch patients di'ided +" nm+er of patients recei'in* respirator"therap" "ields a mch +etter rate.

hat are the standards for rates of &'I

There are no p+lished standards of 1;I rates. The rate of 1;I ill 'ar" ith patient ris-, andtherefore, there ill +e different rates in different nits. ;"liffe has pointed ot that there is anirredci+le minimm rate of 1;I de to the inherent ris-s of nderl"in* disease and medicalinter'entions. ates ill also 'ar" dependin* on the le'el of facilities and staffin* a'aila+le indifferent hospitals of medical s"stems. In *eneral rates shold +e compared ith peer instittions.

Pre'alence sr'e"s sho a'era*e hole hospital rates of 1;I of &@#AK. It is tho*ht that a+otAK of these ma" +e pre'enta+le, dependin* on the patient poplation. 7r*ical site infection ratesin clean sr*er" shold pro+a+l" +e less than K, and e'en less than #K ma" +e achie'a+le.

/eedbac+

It is pointless to collect masses of data if it is onl" seen +" the Infection Control Team. It is essentialthat sr'eillance reslts are fed +ac- re*larl" to the front@line clinical staff in order to help them

choose actions to redce infection rates. It has +een shon on man" occasions that feed+ac- L ithedcational and practical help from the Infection Control Team L is one of the most effecti'e a"sof effectin* chan*e in h"*ienic practice.

!inimal Re"uirements for $urveillance

1 Monitor infection patterns !sites" pathogens" risk factors" location #ithin the facilit$%& 'etect changes in the patterns that ma$ indicate an infection problem( 'irect the rapid implementation of control measures) Monitor antibiotic use and resistance* +ro,ide the staff #ith e-actl$ the information the$ need in order to impro,e infection

pre,ention practices

References


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#. 1ale" W, Cl'er D1, White ?W, 3or*an W3, Emori T6, 3nn P. 1ooton T3. The

efficac" of infection sr'eillance and control pro*rams in pre'entin* nosocomial infectionsin . epeated pre'alence sr'e"s.Ballire's Clinical Infectious Diseases#$$J0:#&$@#$. Bac- to te!t

. eport. 3onitorin* 1ospital@;c/ired Infections to Promote Patient 7afet" @@ ippincott@a'en, #$$%.
http://www.ific.narod.ru/Manual/Surv.htm#b1%23b1http://www.ific.narod.ru/Manual/Surv.htm#b2%23b2http://www.ific.narod.ru/Manual/Surv.htm#b3%23b3http://www.who.int/emc-documents/antimicrobial_resistance/whocdscsreph200212.html#english%20contentshttp://www.who.int/emc-documents/antimicrobial_resistance/whocdscsreph200212.html#english%20contentshttp://www.ific.narod.ru/Manual/Surv.htm#b4%23b4http://www.ific.narod.ru/Manual/Surv.htm#b5%23b5http://www.ific.narod.ru/Manual/Surv.htm#b6%23b6http://www.ific.narod.ru/Manual/Surv.htm#b7%23b7http://www.ific.narod.ru/Manual/Surv.htm#b1%23b1http://www.ific.narod.ru/Manual/Surv.htm#b2%23b2http://www.ific.narod.ru/Manual/Surv.htm#b3%23b3http://www.who.int/emc-documents/antimicrobial_resistance/whocdscsreph200212.html#english%20contentshttp://www.ific.narod.ru/Manual/Surv.htm#b4%23b4http://www.ific.narod.ru/Manual/Surv.htm#b5%23b5http://www.ific.narod.ru/Manual/Surv.htm#b6%23b6http://www.ific.narod.ru/Manual/Surv.htm#b7%23b7


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. Cleaning2 disinfection2 and sterili3ation'econtamination of equipment and the en,ironment

Decontamination is a process hich remo'es or destro"s microor*anisms to render an o+8ect safefor se. It incldes cleanin*, disinfection and sterilisation.

efinitions

Cleaning

Cleanin* is a process that remo'es forei*n material (e.*. soil, or*anic material, micro@or*anisms)from an o+8ect.

Disinfection

Disinfection is a process that redces the nm+er of patho*enic microor*anisms, +t not necessaril"+acterial spores, from inanimate o+8ects or s-in, to a le'el hich is not harmfl to health.

(igh le$el disinfection

1i*h le'el disinfection is often sed for a process hich -illsyco)acterium tu)erculosis andentero'irses in addition to other 'e*atati'e +acteria, fn*i and more sensiti'e 'irses.

Sterilisation

7terilisation is a process that destro"s all microor*anisms incldin* +acterial spores. 7terilisationcannot +e pro'ed e!cept +" cltrin*, so normall" an o+8ect is said to ha'e +een sterilied if it has*one thro*h a controlled process of sterilisation.

The le'el of decontamination shold +e sch that there is no ris- for infection hen sin* thee/ipment. The choice of the method depends of a nm+er of factors, incldin* t"pe of material of

o+8ect, nm+er and t"pe of or*anisms in'ol'ed and ris- of infection to patients or staff.

Classification of infection ris+ from e"uipment or environment into three categoriesand suggested level of decontamination.

*o+ ris,

Items in contact ith normal and intact s-in, or the inanimate en'ironment not in contact ith thepatient (e.*. alls, floors, ceilin*s, frnitre, sin-s and drains). Cleanin* and dr"in* is sall"ade/ate.

Intermediate ris,


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E/ipment that does not penetrate the s-in or enter sterile areas of the +od" +t is in contact ith

intact mcos mem+ranes or non@intact s-in0 or other items contaminated ith 'irlent ortransmissi+le or*anisms e.*. respirator" e/ipment, *astrointestinal endoscopes, 'a*inalinstrments, thermometers. Cleanin* folloed +" disinfection is sall" ade/ate.

(igh ris,

Items that penetrate sterile tisses, incldin* +od" ca'ities and the 'asclar s"stem, e.*. sr*icalinstrments, intra@terine de'ices, 'asclar catheters. Cleanin* folloed +" sterilisation is re/ired.

Cleaning methods

Thoro*h cleanin* and dr"in* ill remo'e most or*anisms from a srface and shold ala"sprecede disinfection and sterilisation procedres. Cleanin* is normall" accomplished +" the se ofater, mechanical action and deter*ents. It ma" +e manal or mechanical, sin* ltrasonic cleanersor asherdisinfectors that ma" facilitate cleanin* and decontamination of some items and redcethe need for handlin*.

#anual $leaning

;ll items re/irin* disinfection or sterilisation shold +e dismantled +efore cleanin*. Cold ater ispreferred for cleanin* as it ill remo'e most of the protein materials (+lood, sptm, etc.) thatold +e coa*lated +" heat or disinfectants and old s+se/entl" +e difficlt to remo'e. Themost simple, cost effecti'e method is to thoro*hl" +rsh the item, -eepin* the +rsh +elo thesrface of the ater to pre'ent the release of aerosols. The +rsh shold +e decontaminated after seand dried.

inse items finall" in clean, arm ater and dr". Items are then read" for se or disinfection orsterilisation. Personnel handlin* contaminated items shold ear *ood /alit" *lo'es for personal

protection.

;dditional recommendations ha'e recentl" +een p+lished: ;ssociation for the ;d'ancement of3edical Instrmentation (;;3I) s**ests initial rinse in cold ater folloed +" arm

aterdeter*ent soltion and final rinse. ?1PIE6, an a*enc" that is sall" in'ol'ed in 'er"resorce@poor settin*s, s**ests soa-in* instrments and other soiled materials in cold ater ith+leach to A.K to decontaminate, folloed +" cold ater ash and rinse.

%nvironmental cleaning

Floors, srfaces, sin-s and drains shold +e cleaned ith ater and deter*ent. otine se ofdisinfectants is nnecessar".

If there is spilla*e, e.*. +lood, sptm, altho*h cleanin* is preferred, disinfection +efore cleanin* issometimes recommended. Cleanipe earin* *lo'es sin* A.@#K sodim h"pochlorite (,AAA@

#A,AAA ppm of Cl2 ) (hosehold +leach) or a disinfectant ith appropriate acti'it". 6lo'es shold+e orn. elease of chlorine *as from disinfection of lar*e spilla*e can +e haardos to staff.


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If spilla*e is immediatel" remo'ed, *eneral disinfection of the room is not necessar"0 thoro*h

cleanin* ill sffice.

isinfection

Disinfection can +e carried ot +" either thermal or chemical processes. Thermal disinfection ispreferred hene'er possi+le. It is *enerall" more relia+le than chemical processes, lea'es noresides, is more easil" controlled and is non@to!ic.

r*anic matter (serm, +lood, ps or faecal material) interferes ith the antimicro+ial efficienc" ofeither method. The lar*er the nm+ers of micro+es present the lon*er it ta-es to disinfect. Thsscrplos cleanin* +efore disinfection is of the *reatest importance.

Thermal methods

;ltho*h not necessar" for disinfection, atocla'in* or steam steriliation (or a pressre coo-er)ma" +e preferred if a'aila+le for the decontamination of certain items, e.*. 'a*inal speclae.

Moist heat at 70-100C

Boiling (#AANC) for at least mintes (holdin* time) is a simple and 'er" relia+le method for theinacti'ation of microor*anisms incldin* hepatitis B 'irs, hman immnodeficienc" 'irs andm"co+acteria. Pro'ided it is carefll" carried ot, it is a hi*h@le'el disinfection procedre.

The items shold +e thoro*hl" cleaned, placed in a container and co'ered ith ater. The ater isheated ntil it reaches +oilin* point. Disinfection shold +e timed (at least min) from hen

+oilin* commences. ;ddition of a 2K soltion of sodim +icar+onate helps to pre'ent corrosion ofthe instrments and tensils. If cheatle forceps are sed these shold +e +oiled (or atocla'ed) iththe holder at least dail" and stored dr". The +oiler shold +e emptied and dried dail".

Disinfection at lower temperatures is possi+le (e.*. %ANC for min) for items dama*ed +" +oilin*,if sita+le temperatre controllin* e/ipment is a'aila+le.

Disinfection by hot water can also +e performed in speciall" constrcted ashin* machines e.*. forlinen, +edpans, dishes and ctler", respirator" circits, la+orator" *lassare and sed sr*icalinstrments +efore atocla'in*. In these machines the process of cleanin*, hot ater disinfectionand dr"in* are com+ined in a 'er" effecti'e procedre, pro'idin* some items read" for se, e.*.respirator" circits, or safe to handle e.*. sr*ical instrments. The thoro*h initial rinsin* andashin* remo'es most of the microor*anisms and shorter disinfection times ma" +e appropriate,e.*. &ANC for min, %ANC for # minte. If machines are sed the" shold +e re*larl" maintainedand chec-ed for efficac". >o to hi*h le'el disinfection is achie'ed dependin* on t"pe of machineand comple!it" of the items.

$hemical #ethods

Before decidin* to se a disinfectant, consider hether a more appropriate method is a'aila+le. Themain se of chemical disinfection is for heat@la+ile e/ipment here sin*le se is not cost effecti'e.


16/72

7ome of these items (e.*. +ronchoscopes) re/ire hi*h@le'el disinfection. ; limited nm+er of

disinfectants (e.*. *ltaraldeh"de 2K, JK h"dro*en pero!ide, [email protected] peracetic acid) can +e sedfor this prpose. If a sporicidal action is re/ired, immersion in 2K *ltaraldeh"de for at least hors is re/ired.

Chemical disinfectants mst +e made p freshl" to the correct concentrations accordin* to themanfactres instrctions and discarded after the correct period of time or nm+er of ses. The"shold +e stored in clean +ottles ith plastic stoppers. When the +ottle is empt" it shold +ethoro*hl" cleaned +efore re@fillin*. Partiall" empt" +ottles shold not +e topped p since this illencora*e contamination ith and mltiplication of disinfectant resistant or*anisms.

The o+8ect mst +e thoro*hl" rinsed ith sterile ater after disinfection. If sterile ater is not

a'aila+le, freshl" +oiled ater can +e sed. ;fter rinsin*, items mst +e -ept dr" and ell protectedfrom +ein* recontaminated.

Disinfection of surfaces

7oiled srfaces ma" +e cleaned of 'isi+le soila*e and disinfected ith a chemical a*ent sita+le forthe tas-. n a clean srface alcohol is rapidl" +actericidal and rinsin* is not re/ired.

$terilisation

7terilisation is accomplished principall" +" steam nder pressre (atocla'in*), dr" heat, +"eth"lene o!ide *as or lo temperatre steam and formaldeh"de.

!team !terili&ation

7team sterilisation is the most common and preferred method emplo"ed for sterilisation of all itemsthat penetrate the s-in and mcosa, pro'idin* the" are not dama*ed +" heat and moistre. 7teamsterilisation is dependa+le, non to!ic, ine!pensi'e, sporicidal, ith rapid heatin* and *ood

penetration of fa+rics.

ethod

The steam mst +e applied for a specified time so that the items reach a specified temperatre.

#2#NC for 2A min for nrapped items, A mintes for pac-a*ed items at #.AJ Bar

(#.Apsi) a+o'e atmospheric pressre. #NC for min for nrapped items in a *ra'it" sterilier or rapped items in a 'acm

assisted steriliser at 2.A2J Bar (2$.# psi) a+o'e atmospheric pressre.

;s a possi+le alternati'e for nrapped instrments or tensils, a domestic pressre coo-er ma" +esed. 1oldin* time at least A min.

'ry heat

Dr" heat is preferred for resa+le *lass s"rin*es, and ointments, poders, oils etc.


17/72

ethod

; hot air o'en e/ipped ith fan or con'e"or, hich ill ensre e'en distri+tion of heat. Therecommended temperatre and time for sterilisation of medical e/ipment is as follos:

#&ANC for 2 hors

#%ANC for # hor

7terile items shold +e protected a*ainst recontamination.

%thylene oxide gas

This is sed for lo temperatre sterilisation of selected items in hospitals. Eth"lene o!ide *as isto!ic so the manfactrers instrctions for installation and se shold +e folloed. There are for

parameters that mst +e maintained to ensre E sterilisation: *as concentration, temperatre,hmidit", and e!posre time. 6as concentration shold +e A to #2AA m*>, temperatre ran*es2$N to JN C, hmidit" from K to %K, and e!posre times from to to fi'e hors. The processhas a lon* c"cle as aeration of the items is re/ired. 3icro+iolo*ical control of the process isrecommended.

Organisation of (h)sical /acilities in a $terile $ervice epartment

The ser'ice shold +e mana*ed +" a sita+l" /alified indi'idal. ;ll staff shold +e trained andnder*o continos professional de'elopment. Written protocols for all procedres shold +emaintained and there shold +e an adited pro*ramme of /alit" assrance.

The central processin* areas shold consist of decontamination, pac-a*in*, sterilisation and stora*eareas.

'econtamination

ecei'e materials, sort, clean and prefera+l" disinfect. Wear appropriate *lo'es and plastic aprons.6on slee'es that are flid@resistant are desira+le as are sr*ical face mas-s and e"e protection.

Packaging

;ssem+lin*. i.e. oilin* (mil-in*) and pac-a*in* clean +t nsterile materials prior to sterilisation.>a+el accratel" ith contents, date of processin* and e!pire date

!terili&ation Process

;tocla'in* is preferred.

;n" sterilisation procedre shold +e monitored rotinel" +" ph"sical (mechanical), chemical and

+iolo*ical techni/es. 3echanical techni/es inclde the dail" assessment of c"cle time,temperatre and pressre *a*e. ; lo* +oo- shold +e -ept.


18/72

Chan*e of color of chemical indicators placed on the otside of each pac- shos that the pac- has

+een e!posed to the sterilisation process. 7imilarl", chemical indicators shold +e sed inside thepac- to 'erif" steam penetration efficienc" in addition to ph"sical measrements. The BoieDic-test in #N C 'acm@assisted atocla'in* is recommended dail" +efore the sterilier is sed.

Biolo*ical indicators (BI) of -eo)acillus stearothermophilus spores are sed to monitor steam anddr" heat sterilisation processes in some contries, hileBacillus atrophaeus spores are sed formonitorin* eth"lene o!ide. Biolo*ical indicators shold +e placed in a process control de'ice or test

pac- that is representati'e of the load to +e sterilied. ;;3I recommends that steam atocla'es +etested ith BI at least ee-l" and ith e'er" load of implanta+le de'ices and that implanta+les +e/arantined ntil the BI is read. ;;3I recommends that e'er" eth"lene o!ide load +e monitoredith BI. ;;3I also recommends BIs sed hen steriliers are installed, after ma8or repairs,

malfnctions or sterilier failres.

!torage

Ensre stoc- rotation and store dr".

Sterile items should be protected against recontamination

.ousekeeping and laundr$

Transmission of micro+es ma" occr if the en'ironment immediatel" arond a patient +ecomescontaminated either +" soila*e of articles ith +od" secretions, or +" healthcare or-ers tochin*instrments or other srfaces and e/ipment ith contaminated hands. Increased infection ris- asreported hen patients ere admitted to rooms pre'iosl" occpied +" patients ith C difficilediarrhoea, G#H demonstratin* that it is necessar" to implement a schedle to clean patient care areasand pre'ent +ild@p of dst, soil, or other material that ma" har+or potential patho*ens andspport their *roth. 3oreo'er, a clean, ell@maintained healthcare en'ironment inspiresconfidence in patients, staff, and the p+lic of the facilit"s commitment to pro'idin* a safeen'ironment condci'e to achie'in* a hi*h standard of care.

Housekeeping

Cleanin* staff mst +e trained properl" and sper'ised. ;n on*oin* maintenance cleanin* schedlemst +e esta+lished. This schedle shold specif":

Who has responsi+ilit" and acconta+ilit" for specific 8o+s

Wor- procedres, incldin* special e/ipment, spplies, cleanin* and stora*e of e/ipment,

mop head chan*in* e/irements for t"pes of cleanin* soltions and fre/enc" of soltion chan*in*


19/72

7pecial cleanin* procedres ma" +e considered in certain circmstances, e.*., drin* an ot+rea- of

Clostridium difficile associated diarrhoea.

Walls do not accmlate dst and associated contaminants and do not need to +e cleaned fre/entl".1oriontal srfaces sch as floors, and simple de'ices sch as I poles and +ed frames, can +emaintained +" cleanin* ith ater and a deter*ent. 1oe'er, some de'ices or areas that arerepeatedl" toched ma" need more fre/ent and intensi'e cleanin*, incldin* disinfection.E!amples are +edrails, door handles, and areas li-el" to recei'e spatter.

4aundr) services

Carefl handlin* and reprocessin* of soiled linens pre'ents the transmission of infectios a*ents.

Pro'ision of fresh clean linen also enhances patient comfort.

!orting procedures(

;'oid contaminatin* hands ith soila*e

Place soiled linen in a landr" +a* or container

7ecre +a* hen O fll. If onl" cloth +a*s are a'aila+le, or-ers shold ear *lo'es and

handle +a*s ith care. Ba*s of soiled linen shold +e left in a secre place for pic-@p andtransport

Ba*s of soiled linen shold +e ta-en to an area dedicated for pre@ash sortin*

>andr" sorters mst recei'e edcation on procedres and the proper se of +arriers

>andr" sorters mst +e pro'ided ith ater resistant *lo'es and plastic aprons or ater

resistant *ons for protection.

ashing processes(

; preash rinse c"cle of # mintes ill remo'e *ross soila*e

If sin* a cold ater ash, chemicals sch as +leach mst +e added (2 ml of hosehold

+leach for e'er" litre of ater) ith deter*ent to facilitate disinfection ; hi*h temperatre ash mst +e done ( C) if cold ater deter*ents ith +leach are

not sed

Drin* the rinse c"cle, a sorin* a*ent shold +e added to the rinse c"cle to redceal-alinit". This decreases s-in irritation and frther redces the nm+er of +acteria present

1ot air dr"in* or dr"in* on a clothesline in snli*ht ill also redce the nm+ers of +acteria

present, as ill ironin* ith a hot iron Clean linen mst +e stored and transported in sch a manner that cross contamination is

a'oided >inen to +e sterilised mst +e appropriatel" rapped +efore +ein* sent to the sterile

processin* department

;ll staff mst +e made aare of the ris- to landr" or-ers if sharp o+8ects are left in soiled linen.>andr" or-ers shold ha'e immnisations crrent.

Waste management


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>andfill, +rial and incineration remain the most common means of hospital aste disposal. 7taff

responsi+le for cleanin* contaminated e/ipment re/ire ade/ate trainin*, shold ear appropriateprotecti'e apparel, sch as *lo'es, *ons or aprons, mas-s, protecti'e e"eear, and ha'e crrentimmnisations incldin* hepatitis B.

Clinical (potentiall" contaminated) aste can +e di'ided into la+orator" aste (incldin*anatomical and micro+iolo*ical materials), +lood and +od" flids, and other aste, incldin*contaminated dressin*s and sharps. In epidemic circmstances some potentiall" infectios materialma" re/ire special handlin* or disposal. Clinical aste *enerall" re/ires special disposal and can

+e distin*ished from other *eneral aste +" sin* color coded plastic +a*s.

Chemotherap" aste re/ires special handlin*, sch as incineration at hi*h temperatres. ther

chemical haards (e.*., formaldeh"de or sodim h"dro!ide) ma" need to +e disposed of +" specialmeans. efer to local *idelines.

Ta+le . illstrates recommendations for mana*ement of infectios aste.

Ta+le .#.;ntimicro+ial acti'it" of disinfectants

Ta+le .2.ther characteristics of disinfectants

Ta+le .. ecommendations for 3ana*ement of ondon, 7in*apore.

. ;ssociation for the ;d'ancement of 3edical Instrmentation. ;merican 9ational 7tandard:7afe handlin* and +iolo*ical decontamination of resa+le medical de'ices in health carefacilities and nonclinical settin*s. ;;3I P+lishers.( ###A 6le+e d., 7ite 22A, ;rlin*ton,;, 222A#, , Bosseme"er, D, 3cIntosh 9. Infection pre'ention: 6idelines for healthcarefacilities ith limited resorces. ?1PIE6. (?1PIE6 Corporation, Brons Wharf, #J#Thames 7treet, Baltimore, 3D , 2#2# ,


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5. &and &)gieneIntroduction

The natral flora of the moth and the +oel has +acterial concentrations p to #AR#A per ml andare si*nificant reser'oirs of nosocomial or hospital patho*ens. In hospitalised patients, the s-in ma"

+ecome colonised ith mltidr* resistant (3D) patho*ens, and infected onds and otherlesions are also potential sorces of cross@infectin* or*anisms. Patho*enic or*anisms fromcolonied and infected patients (and sometimes from the en'ironment) transientl" contaminate thehands of staff drin* normal clinical acti'ities and can then +e transferred to other patients. 1andtransmission is one of the most important methods of spread of infectios a*ents in health care

facilities. Proper hand h"*iene is an effecti'e method for pre'entin* the transfer of micro+es+eteen staff and patients.

The micro+ial flora of the s-in consists of resident and transient microor*anisms. esidentor*anisms (e.*., coa*lase ne*ati'e staph"lococci, diphtheroids) sr'i'e and mltipl" in thesperficial s-in la"ers. The transient micro+ial flora of the s-in consists of recent contaminants thatsr'i'e onl" for a limited period of time. These microor*anisms (e.*., S. aureus,E. coli,enterococci) ma" +e ac/ired +" contact ith the normal flora or colonised or infected sites of the

patient or from the inanimate hospital en'ironment. If the s-in of staff mem+ers hands is dama*ed,the +acterial cont on the s-in +ecomes hi*her. There is also a ris- for colonisation ith +acteria notnormall" +elon*in* to the hand flora.

Three le'els of decontamination of hands are reco*nied.

Social handwashing ith plain soap and ater remo'es most transient microor*anisms frommoderatel" soiled hands.

!ygienic handwashing or disinfection is a procedre here an antiseptic deter*ent preparation issed for ashin* or hands are disinfected ith alcohol (alcoholic r+). This is a more effecti'emethod to remo'e and -ill transient microor*anisms.

The distinction +eteen the need for social handashin* and h"*ienic hand ashin* ma" notala"s +e clear. ; thoro*h social hand ash ma" +e appropriate if disinfectants are not a'aila+le.

Surgical handwashing is performed ith the aim of remo'in* and -illin* the transient flora anddecreasin* the resident flora in order to redce the ris- of ond contamination if sr*ical *lo'es

+ecome dama*ed. ;*ents are the same as for the h"*ienic hand ash.

; defined techni/e for decontamination of hands is pro+a+l" of *reater importance than the a*entsed. The techni/e presented in Fi*re .#is recommended.

hen to 6ash hands

Social handwashing
http://www.ific.narod.ru/Manual/hands.gifhttp://www.ific.narod.ru/Manual/hands.gifhttp://www.ific.narod.ru/Manual/hands.gifhttp://www.ific.narod.ru/Manual/hands.gif


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+efore handlin* food, eatin*

+efore feedin* the patient after 'isitin* the toilet.

!ygienic handwashing or alcoholic rub

+efore and after nrsin* the patient

+efore performin* in'asi'e procedres

+efore carin* for sscepti+le patients (sch as the immnocompromised)

+efore and after tochin* onds, rethral catheters, and other indellin* de'ices

+efore and after earin* *lo'es

after contact ith +lood secretions or else folloin* sitations in hich micro+ial

contamination is li-el" to ha'e occrred after contact ith a patient -non to +e colonised ith a si*nificant nosocomial patho*en

(sch as 37;, 3D1le)siella)

;n alcoholic hand r+, ideall" from a dispenser at the patients +edside is the most efficient andleast time consmin* procedre for hand decontamination.

Surgical handwashing

+efore all sr*ical procedres

!ethods

Watches and rin*s redce hand ashin*disinfection effecti'eness and shold +e remo'ed drin*hand h"*iene. 7ome s**est that the" not +e orn in patient care.

!ocial hand washing

In social hand ashin*, 'i*oros and mechanical friction is applied to all srfaces of lathered handssin* plain soap and ater for at least #A seconds sin* a defined techni/e (Fi*. .#). The handsare rinsed nder a stream of ater and dried ith paper toel. In the a+sence of rnnin* ater, a

clean +ol of ater shold +e sed. The +ol shold +e cleaned and ater chan*ed +eteen eachse. ;lternati'el", a drm ith a drain spot cold +e ele'ated to ser'e as rnnin* ater. 7imilarl",in the a+sence of paper toels, a small clean cloth cold +e sed, +t the toel shold not +e sedfor e!tended commnal se and shold +e discarded after each se into a +a* desi*nated forlanderin* and rese.

In places here there is fre/ent disrption of ater sppl", ater shold +e stored in lar*ereceptacles hene'er ater is a'aila+le. The ater shold +e free from infectios a*ents.

Recommended hand 6ash agents

Hygienic hand washing)disinfection

A&ueous
http://www.ific.narod.ru/Manual/hands.gifhttp://www.ific.narod.ru/Manual/hands.gif


23/72

K chlorhe!idine *lconatedeter*ent soltion

Po'idone @ iodinedeter*ent soltion containin* A.&K a'aila+le iodine

Wet hands ith clean (rnnin*) ater or, if not a'aila+le, from ater in a +ol. ;ppl" cleanser (@ml) dependin* on the prodct or thoro*hl" lather ith soap. Wash the hands for #A@# seconds,appl"in* friction o'er all hand srfaces, rinse and dr" as descri+ed a+o'e.

Alcoholic

A.K chlorhe!idine or po'idone@iodine in &AK isopropanol or ethanol

JAK isopropanol or &AK ethanol ithot antiseptic

;ppl" not less than ml of the preparation to the hands and r+ to dr"ness (appro!imatel" Aseconds). ;lcohol is more effecti'e than a/eos antiseptic soltions, +t a preliminar" ash ma"

+e needed for ph"sicall" soiled hands. ;lcohol is an effecti'e alternati'e hen there is no ater ortoels readil" a'aila+le and there is need for rapid hand disinfection. ;lcohol prodcts ithemollients added ill case less s-in irritation and dr"in* to hands (#@K *l"cerol).

!urgical hand washing)disinfection

;*ents for sr*ical hand ashin* are the same as for the h"*ienic hand ash. The difference is thetime of scr+ that is increased to 2@ min and shold inclde rists and forearms. If an alcoholic

preparation is sed, to applications of ml each r++ed to dr"ness are s**ested.

7terile disposa+le or atocla'a+le nail+rshes ma" +e sed to clean the fin*ernails onl", +t

not to scr+ the hands. ; +rsh shold onl" +e sed for the first scr+ of the da".

;fter hand ashin* ith soap and ater, a hand r+ ith an alcoholic +ase formlation

(&AK) shold +e sed if possi+le. This enhances the destrction or inhi+ition of resident s-inflora.

7terile toels shold +e sed to dr" the hands thoro*hl" after ashin* and +efore alcohol

is applied.

Important (oints to %ote

When +ar soap is in se, it shold +e -ept dr" to pre'ent contamination ith

microor*anisms that *ro in moist conditions. >i/id soap dispensers shold +e re*larl" cleaned and maintained.

6lo'es shold not +e re*arded as a s+stitte for hand h"*iene. ; *lo'e is not ala"s a

complete impermea+le +arrier (2A@AK of sr*ical *lo'es are pnctred drin* sr*er").1oe'er, *lo'es redce 'er" s+stantiall" the nm+er of microor*anisms +ein* transferredto the patient or to the 1CW ho is earin* the *lo'es. 6lo'es also pro'ide some

protection a*ainst the transmission of +lood@+orne 'irses. In an epidemic sitation, hand h"*iene and the se of *lo'es are important protecti'e

measres to pre'ent the transmission of infectios a*ents to sscepti+le patients or staff. Thesame *lo'e mst not +e orn from one patient to another patient, or +eteen clean and dirt"

procedres on the same patient.


24/72

;n alcoholic r+ or hand ash shold +e performed after remo'in* *lo'es and +efore sterile

*lo'es are orn.

In areas here *lo'es are not readil" a'aila+le, late! *lo'es can +e ashed ith soap and ater,dried, podered, sterilied or hi*h le'el disinfected and resed. 7terilisation is prefera+le forsr*ical procedres.

Minimal requirements

Watches and rin*s redce hand ashin* effecti'eness and shold +e remo'ed.

Wash hands ith soap and ater and dr" thoro*hl" ith a clean toel at the start of a

clinical shift or if hands +ecome *rossl" soiled. Decontaminate hands ith a hand disinfectant or alcoholic rinse or r+ +eteen each patient

contact. Perform a sr*ical scr+ +efore each operation.

Wear *lo'es as necessar" to redce transfer of or*anisms to patient and to redce

transmission of +lood +orne 'irses.

Bibliograph$

#. 7tandard principles for pre'entin* hospital@ac/ired infections.Journal of (ospitalInfection 2AA#0&(7ppl):72#@7&.

2. 6ideline for 1and 1"*iene in 1ealthcare 7ettin*s@ 2AA2.!" 2AA20#(@#J):#@.
http://www.cdc.gov/hand%20hygiene/http://www.cdc.gov/hand%20hygiene/


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7. Occupational &ealth Ris+s for &ealthCare or+ers

Introduction

1ealth care or-ers are at ris- of e!posre to a 'ariet" of infectios diseases hich ma" case themillness and hich ma" +e transmitted from them to other staff and patients. ccpational 1ealthDepartments (1D) that or- closel" ith the infection control department ma" minimie this ris-

+" maintainin* necessar" records, performin* immniations, edcatin* staff a+ot ris- andpre'ention, and condctin* e!posre mana*ement and in'esti*ations.

/e$ elements of 0. programs

;ssess infection ris-s to personnel and prioritise pre'enti'e measres.

Implement an on*oin* edcation pro*ramme a+ot safet" and infection pre'ention relatedto the specific ris-s of or- in the facilit".

Determine sscepti+ilit" to 'accine pre'enta+le diseases and implement an appropriate

immniation pro*ramme. Condct e!posre in'esti*ations, incldin* re'ie of post@e!posre mana*ement.

Implement sr'eillance of occpational +lood e!posres and de'elop pre'ention strate*ies

for hi*h@ris- practices or departments.

Ta+le .#presents a list of nosocomial infections in patients and emplo"ees in health care settin*s .It is important for local Infection Control Committees and 1Ds to re'ie this list and prioritisethe allocation of resorces for ris- redction strate*ies in their specific facilit". The rotes oftransmission of each microor*anism mst +e nderstood +efore appropriate pre'ention measrescan +e selected.

+re,ention of infection General measures

=eep accrate, easil" retrie'a+le occpational health records.

7creen ne emplo"ees for a histor" of commnica+le diseases. Immnie for 'accinepre'enta+le diseases.

ecord needlestic- and other in8ries in an accident lo*0 data on the epidemiolo*" of +loode!posres shold +e anal"sed periodicall" to adit practice and identif" pre'enta+le ris-s.

Pro'ide e'alation and *ide or- restrictions for staff ith infectios diseases or

e!posres. Ensre that all staff co'er lesions on e!posed s-in ith a aterproof dressin*.

'efinitions for modes of transmission

$ontact : Incldes direct person@to@person contact (e.*., +lood from a patient directl" into a health

care or-ers open ct) and indirect contact (transmission from one person to another 'ia anintermediate o+8ect sch as a health care or-ers hands or a de'ice sch as a needle).
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'roplet( Droplet spread ma" occr hen the infected person and the sscepti+le host are ithin

a+ot feet of each other. ral and respirator" secretions ma" +e transmitted into e"es or mcosmem+ranes +" co*hin*, either +" direct droplet spread or indirectl" +" contamination of srfacess+se/entl" toched +" another person.

*irborne( ccrs +" dissemination of air+orne droplet nclei (small@particles S microns in sie)that ma" remain sspended in the air for lon* periods of time.

$ommon vehicle transmission( 3icroor*anisms transmitted +" contaminated items sch as food,ater, medications, de'ices, and e/ipment.

+ectorborne transmission( e/ires 'ectors sch as mos/itoes, flies, rats, and other 'ermin to

transmit microor*anisms.

Minimal requirements for personnel and patient protection

Pre'entin* the spread of infection often re/ires s to +rea- the chain of infection, i.e., to interrptthe normal rotes of transmission.

$ontact( Wash hands hen the" are li-el" to ha'e +een soiled and +efore +e*innin* care for a nepatient. Waterless hand antiseptics are accepta+le nless the hands are 'isi+l" soiled. For contactith all mcos mem+ranes and non@intact s-in, ear *lo'es that are clean at the time of se.


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redce the fre/enc" of e!posres more than half +" chan*in* practices and increasin* +arrier

precations GH. Post@ e!posre mana*ement recommendations for hman immnodeficienc" 'irs(1I) chan*e fre/entl" and are +e"ond the scope of this chapter, +t the" are somehat sccessfland healthcare facilities shold ha'e appropriate policies in place.

The 7afe In8ection 6lo+al 9etor- GH estimates that appro!imatel" #J +illion in8ections are *i'enannall" in the orld. 3an" in8ections are sed nnecessaril" hen oral medication old +e

+etter. In addition, in settin*s ith limited resorces, more than half of all in8ections are *i'en iths"rin*es resed ithot steriliation or hi*h le'el disinfection. 7tdies in China, Pa-istan, India,3oldo'a, omania, E*"pt, ;frican nations and other contries ha'e reported an association

+eteen nsterile in8ections and s+se/ent 1B, hepatitis C 'irs (1C) and 1I infection to +e'er" hi*h. In 2AAA, contaminated in8ections cased an estimated 2# million 1B infections, to

million 1C infections and 2JA,AAA 1I infections, accontin* for 2K, AK and K respecti'el"of ne infections GH .

;ltho*h health care personnel are also at ris- for e!posre to +lood+orne patho*ens, these fi*resinclde onl" the estimated ris- to patients.

7ome ris-s to health care or-ers can +e eliminated +" sin* de'ices that minimie pnctreopportnities0 man" others can +e redced +" infection pre'ention pro*rams that mandateappropriate se of +arrier precations and safe or- practices.

In the 7prin* of 2AA, a nel" emer*ed corona'irs as identified as the case of 7e'ere ;cteespirator" 7"ndrome (7;7). B" mid@smmer, more than %AA cases had +een identified ithmore than %AA fatalities, most in ;sian contries. ;ppro!imatel" JAK ere hospital ac/ired andman" occrred in health care personnel. Transmission to health care or-ers occrred mostfre/entl" after nprotected, close contact ith s"mptomatic indi'idals. Pre'ention strate*iesinclde a hi*h inde! of sspicion and immediate isolation for patients ith s"stemic 'irals"ndromes that prodce fe'er and co*h, especiall" amon* people ho ha'e tra'eled to re*ionsthat ere affected +" 7;7. Cleanin* and srface disinfection in care areas is also important.Personal protecti'e e/ipment for 7tandard Precations, and Contact and ;ir+orne Isolation incldehand h"*iene, *lo'es, *ons, and 9$ or e/i'alent respirator.

Information a+ot 7;7ith lin-s to crrent p+lications and recommendations is ala"sa'aila+le on the IFIC e+site(.ific.narod.r)

2eferences

#. 3ast 7T, Wooline ?D, 6er+erdin* ?>. Efficac" of *lo'es in redcin* +lood 'olmestransferred drin* simlated needlestic- in8r". ? Infect Dis #$$0#J%:#%$@$2. Bac- to te!t

2. >"nch P, White 3C. Perioperati'e +lood contact and e!posres: ; comparison of incidentreports and focsed stdies. ;m ? Infec Control #$$0 2#:&@J. Bac- to te!t

. White 3C, >"nch P. Blood contacts in the after hospital@specific data anal"sis andaction. ;m ? Infect Control#$$&02:2A$@2#. Bac- to te!t

. 1ari ;3, ;rmstron* 6>, 1tin Q?F. The 6lo+al Brden of Disease ;ttri+ta+le toContaminated In8ections 6i'en in 1ealth Care 7ettin*s. Int ? 7TD and ;ID7. 2AA. (In

press) Bac- to te!t
http://www.ific.narod.ru/Manual/Occuh.htm#3%233http://www.ific.narod.ru/Manual/Occuh.htm#4%234http://www.ific.narod.ru/Manual/Occuh.htm#4%234http://www.ific.narod.ru/SARS/sars.htmhttp://www.ific.narod.ru/http://www.ific.narod.ru/Manual/Occuh.htm#b1%23b1http://www.ific.narod.ru/Manual/Occuh.htm#b2%23b2http://www.ific.narod.ru/Manual/Occuh.htm#b3%23b3http://www.ific.narod.ru/Manual/Occuh.htm#b4%23b4http://www.ific.narod.ru/Manual/Occuh.htm#3%233http://www.ific.narod.ru/Manual/Occuh.htm#4%234http://www.ific.narod.ru/Manual/Occuh.htm#4%234http://www.ific.narod.ru/SARS/sars.htmhttp://www.ific.narod.ru/http://www.ific.narod.ru/Manual/Occuh.htm#b1%23b1http://www.ific.narod.ru/Manual/Occuh.htm#b2%23b2http://www.ific.narod.ru/Manual/Occuh.htm#b3%23b3http://www.ific.narod.ru/Manual/Occuh.htm#b4%23b4


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The following references describe occupational health programs :

Dec-er 3D, 7chaffner W. Chapter J: 9osocomial diseases of health care or-ers spread

+" the air+orne or contact rotes (other than t+erclosis). I9: 3a"hall C6 (editor).(ospital Epidemiology and Infection Control . Baltimore : Williams M Wil-ins, #$$J:%$@%%.

Fal-, P. Chapter %: Infection control and the emplo"ee health ser'ice. I9: 3a"hall C6

(editor).(ospital Epidemiology and Infection Control . Baltimore : Williams M Wil-ins,#$$J:#A$@#A$$.

>"nch P. 3ana*in* emplo"ee and patient e!posres in health care settin*s. I9: >"nch P,

?ac-son 33, Preston 6; , 7ole B3.Infection pre$ention +ith limited resources2 Ahand)oo, for infection committees . Chica*o : Etna P+lications0 #$$&.

7heret ?, 3aroso- D, 7treed 7;. Chapter #: Infection control aspects of hospitalemplo"ee health. I9: Wenel P (ed).#re$ention and Control of osocomial Infections ,2nd edition. Baltimore : Williams M Wil-ins, #$$:2$@2.


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8. Isolation (recautionsIntroduction

r*anisms casin* hospital@ac/ired infections can +e transmitted from infected and colonisedpatients +oth to other patients and to staff. ;ppropriate isolation precations for all patients,incldin* those ho are infected and colonised redce the ris- of transmission.

Transmission of infection

r*anisms can +e spread +" se'eral rotes hich are listed in the chapter on occpational health.

These rotes inclde direct person@to@person contact, indirect contact 'ia an intermediate o+8ect,and air+orne transmission. Patient@to@patient transmission 'ia staff hands is re*arded as the mostimportant rote0 therefore proper hand h"*iene is an important means of pre'entin* spread ofinfection in the hospital. (7ee additional information in the chapter on hand h"*iene).

$tandard (recautions for 'll (atients

In all patient care, transfer of potentiall" harmfl microor*anisms +eteen patients and staff mst+e a'oided. For this reason, the folloin* *eneral precations are sed:

e*ard all patient +lood, e!cretions and secretions as potentiall" infectios and institte

appropriate precations to minimise ris-s of transmission. Wear *lo'es that are clean at the time of se for contact ith mcos mem+ranes and

nonintact s-in of all patients. Decontaminate hands +eteen each patient contact.

Decontaminate hands promptl" after tochin* infecti'e material (e.*., +lood, +od" flids,

secretions, or e!cretions), infected patients or their immediate en'ironment, andcontaminated articles sed for patient care. Waterless hand antiseptics are efficient nlessthe hands are 'isi+l" soiled in hich case the" shold +e ashed first. (7ee the chapter onhand h"*iene)


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D"senter" incldin* cholera ith nmana*ea+le diarrhoea

3ethicillin@resistant S. aureusparticlarl" if there is li-el" to +e considera+lecontamination of articles in the room

T+erclosis

Infected lar*e +rns

In hi*h ris- areas, patients infected or colonised ith mltidr* resistant patho*ens

7;7

(recautions for /amil) !embers (roviding Care to (atients in &ospitals

It is 'er" important that famil" mem+ers pro'idin* care to patients in hospitals +e edcated +" thestaff to se *ood h"*iene and appropriate precations to pre'ent spread of infections to themsel'es

and to other patients. The precations for famil" mem+ers ma" need to +e the same as those sed +"staff.

!inimal Re"uirements

1and h"*iene after handlin* secretions, e!cretions or contaminated items from an" patient.

Isolation in a sin*le room, if a'aila+le, for air+orne or particlarl" haardos infections, and

for sitations in hich a patients soil the room en'ironment ith secretions or e!cretions.

0ibliograph)

7tandard Principles for pre'entin* hospital@ac/ired infections.Journal (ospital Infection

2AA#0&(7ppl):72#@7&. 1ICP;C. 6ideline for Isolation Precations in 1ospitals.American Journal Infection

Control #$$J02:2@2.


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. (revention of (ost-operative oundInfections

Introduction

Post@operati'e ond infections or sr*ical site infections (77Is) dela" reco'er", increase len*th ofsta" and are associated ith increased mor+idit" and mortalit". The" increase healthcare costs +"dela"in* dischar*e and increasin* the need for in'esti*ation, treatment and nrsin* care. Pre'entionor redction of 77Is is ths an essential part of /alit" patient care. >o rates of 77Is are directl"related to edcation, aareness of the cases of infection, and the introdction of practices that

redce ris-. G#H Pre'ention is *reatl" aided +" sr'eillance for ond infections ith re*larreportin* of the reslts +ac- to indi'idal sr*eons in sfficient detail to allo them to identif" andeliminate ris- factors for infection. G2H

2isk Factors

3ltiple ris- factors for 77I ha'e +een identified. 7r*ical procedres ma" +e di'ided into thefolloin* cate*ories:

clean, hen no inflammation is encontered and no colonied +od" s"stem is entered0

clean contaminated, hen a colonied s"stem (e.*., *astrointestinal or respirator" tract), is

entered, +t there is no si*nificant spilla*e0 contaminated, hen inflammation, +t not ps, is encontered or spilla*e from a 'iscs

occrs0 and dirt", hen a perforated 'iscs or ps is encontered.

The incidence of infection shold +e less than K for clean operations, +t rises to more than AKin dirt" operations. 7ome other ris- factors are shon in Ta+le &.#.

Table -.( "isk factors for surgical site infection

"is, factors related to patient condition

a*e (elderl" and neonates)

concrrent diseases, e.*., dia+etes

malntrition or o+esit"

s-in diseases, particlarl" infections

Surgical categories

Contaminated or dirt" sr*ical procedres

transplant or implant operations

Surgical procedure
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lon* dration of operation (ma" +e a pro!" for difficlt procedres)

haemorrha*e and haematomas tisse trama, dr"in*, or de'italiation

location and t"pes of drains

#erioperati$e patient care

inappropriate anti+iotic proph"la!is

inade/ate s-in preparation or care

inade/ate staffin* le'els and theatre desi*n

staff ith s-in infections in the theatre

e!cessi'e mo'ement of staff

inade/ate operatin* theatre 'entilation

simltaneos operations in the same room

E&uipment

inade/ate sterilisationdisinfection

re@se of inade/atel" processed in'asi'e de'ices

The surgical +ard

prolon*ed preoperati'e sta" inappropriate dressin* techni/es

+re,enti,e Measures

Patient factors

In case of concrrent disease, dela" operation and treat an" infections.

;nti+iotic proph"la!is for dirt" or contaminated operations

Proph"la!is is sall" *i'en for clean operations here an infection old +e a catastrophe for thepatient, e.*., insertion of 8oint or cardiac prostheses, h"sterectom", or Caesarean section ithprolon*ed rptre of mem+ranes. ecommendations for sr*ical proph"la!is are chan*edfre/entl" in response to research and ne antimicro+ial a*ents.

!urgical procedure

;de/ate sr*ical trainin* and e!perience is important to pre'ent 77Is.

ound drains

Wond drains pro'ide access for +acterial entr" and shold not +e sed as an alternati'e to *oodhaemostasis. The closed s"stem of ond draina*e is preferred here draina*e is essential. pen


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ond drains ma" lead to an increase in 77I and shold +e placed thro*h a separate sta+ ond

rather than +ein* +ro*ht thro*h the operati'e incision.

Perioperative patient care

Correct timin* of anti+iotic proph"la!is

;n anti+iotic that pro'ides co'era*e for the t"pes of or*anisms li-el" to +e encontered shold +e*i'en at the correct time, i.e. at indction of anaesthesia, ithin # hor of incision. It shold not +e*i'en for more than 2 hors, prefera+l" one or to doses shold +e pro'ided.

!having

7ha'in* is no lon*er recommended +ecase it a+rades the s-in and increases the ris- of micro+ialcolonisation and infection. Where necessar", remo'e hair ith clippers or depilator" cream.

!kin disinfection

It is essential that the operatin* site +e ell disinfected +efore incision. ; rapid redction of s-inflora is re/ired. &AK ethanol or isopropanol are effecti'e disinfectants. 1oe'er, alcoholicsoltions that contain lon*@actin* s-in disinfectants, sch as chlorhe!idine or po'idone iodine, are

preferred. The antiseptic shold +e applied ith friction ell +e"ond the operation site for @mintes. The area mst +e alloed to dr" +efore operatin*.


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Ideall", operatin* theatre air shold +e filtered to redce the concentration of air+orne +acteria

(especiall" S. aureus ) *enerated +" staff. If indos ha'e to +e left open, the" shold +e co'eredith fl" or insect@proof nettin*.

;ir conditionin* s"stems shold ensre that a minimm of # air chan*es per hor of filtered air isdeli'ered. GH With correct desi*n and *ood control of staff mo'ement, the le'el of air+ornecontamination old then +e +elo #AA cf (colon" formin* nit) per mR drin* operations.

, et al. 6ideline for pre'ention of sr*ical siteinfection, #$$$.Infect Control (osp Epidemiology 2A0 2&@&%. Bac- to te!t

2. 1ale" W, Cl'er D1, et al. The efficac" of infection sr'eillance and control pro*rams inpre'entin* nosocomial infections in


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;. (revention of Intravascular evice'ssociated Infection

Introduction

Intra'enos infsions are amon*st the most common in'asi'e procedres performed in hospitalsand are administered either +" the peripheral or central rotes. Infections associated ith thesede'ices are common, and in man" contries intra'enos catheters are the most common sorce ofnosocomial or hospital ac/ired +acteraemia. The principles sed for pre'ention of infection aresimilar for +oth central and peripheral catheters.

;n intra'enos catheter is a forei*n +od" that prodces a reaction in the host resltin* in theformation of a film of fi+rinos material on the inner and oter srfaces of the catheter. This +iofilmma" +ecome colonised +" micro@or*anisms hich are protected from host defence mechanisms andthe effect of anti+iotics. 3icro+ial contamination ma" case local sepsis, or septicthrom+ophle+itis, or +acteraemiasepticaemia G#H .

Infection control measres are desi*ned to pre'ent micro@or*anisms from enterin* the e/ipment,the catheter insertion site, or the +loodstream (Fi*re %.#).

Becase of the dan*ers of infection, catheters shold not +e inserted nnecessaril", and indicationsfor insertion of catheters shold +e strict (e.*., se'ere deh"dration, +lood transfsion, and parenteral
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feedin*).


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o Wipe diaphra*m ith &AK

alcohol +efore insertin* a cannla.

o


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Infection rates are loest ith small needles. Teflon catheters are also associated

ith lo rates, hoe'er are not necessar" for short periods of infsion. Well trained staff shold set p and maintain infsions. 3as-s, caps and *ons

are not necessar" for insertion of peripheral lines. The se of non@sterile *lo'esand an apron or *on ill protect the operator if profse +leedin* is li-el".

(rotocol for peripheral infusions

Place arm on clean toel. perator shold se an alcohol r+ or antiseptic deter*ent to disinfect hands. If

antiseptic is not a'aila+le, ash hands thoro*hl" for 2A seconds. Dr" hands thoro*hl" on a paper toel or clean linen toel, nless alcohol is

sed. ;'oid sha'in* s-in site0 clip hair instead, if necessar". Disinfect s-in site ith A.K alcoholic chlorhe!idine, 2K tinctre of iodine, #AK

alcoholic po'idone@iodine, or &AK alcohol. ;ppl" ith r++in* for A secondsand allo to dr" +efore insertin* cannla.

Insert cannla into 'ein, prefera+l" of pper lim+, sin* no toch techni/e. ;ppl" sterile dressin* (*ae or e/i'alent, or clear semi@permea+le) and secre.

7emi@permea+le adhesi'e dressin*s are more e!pensi'e, +t ha'e the ad'anta*e

of alloin* inspection of the site ithot remo'al of the dressin* G%H. 7ecre cannla to a'oid mo'ement and la+el ith insertion date. ;ssess the need for continin* catheterisation e'er" 2 hors. Inspect catheter dail" and remo'e at first si*n of infection. ;'oid ct dons, especiall" in the le*. Cannlae and *i'in* sets shold +e sterilised +efore se and prefera+l"

disposa+le.o If rese is necessar", clean thoro*hl" and atocla'e if possi+le.o If this is not possi+le, se +oilin* ater (see Cleanin*disinfection section)o Chemical disinfection is ndesira+le +t if resa+le items are heat@la+ile,

immerse in A.K sodim h"pochlorite or other chlorine@releasin* soltionfor # mintes after thoro*h cleanin*.


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!inimal re"uirements

Do not insert catheters nnecessaril" and minimise maniplations. The operator shold disinfect his or her hands +efore insertion of catheter and

drin* maintenance procedres. Thoro*hl" disinfect the s-in site +efore insertion.


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%. 3adeo 3, 3artin C, 9o++s ; (#$$&) ; randomied std" comparin* I AAA

(transparent pol"rethane dressin*) to a dr" *ae dressin* for peripheralintra'enos catheter sites. ? Intra'en 9rs 2A: 2 L 2J Bac- to te!t

$. Poell C, Traeto 3?, Fa+ri P?, =ds- =;, +er* > (#$%) p@7itedressin* std": a prospecti'e randomied std" e'alatin* po'idone iodineointment and e!tension set chan*es ith & da" p@7ite dressin*s applied to total

parenteral ntrition s+cla'ian sites. ? Parenter Enteral 9tr $: @ J Bac- tote!t

3uggestions for further reading

3ermel >;, Farr B3, 7herert ?, aad II et al (2AA#) 6idelines for themana*ement of intra'asclar catheter@related infections. Clin Infect Dis 2: #2$@ #2&2.

7eifert 1, ?ansen B, Farr B3, eds (#$$&) Catheter@related infections. 3arcelDe--er , 9e Qor- .

6idelines for pre'entin* infections associated ith the insertion andmaintenance of central 'enos catheters.Journal of (ospital Infection 2AA#0&(7ppl):7&@7J&.
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T and case infection. This *rop of patients has sall" had

prolon*ed hospitalisation and recei'ed (sometimes se'eral corses of) anti+iotics. Becase of this,the or*anisms in'ol'ed are often mltidr* resistant (3D) opportnistic patho*ens. Thesemicro+es ma" +e introdced into the respirator" tract 'ia contaminated e/ipment or staff hands,

+t often the" are or*anisms that ha'e first colonised the patients +oel.

efinition and diagnosis

9osocomial or hospital ac/ired pnemonia is a loer respirator" tract infection that appearsdrin* or after hospitalisation in a patient ho as not inc+atin* the infection on admission. It isdia*nosed +" the folloin*: clinical si*ns, p"re!ia, sall" prlent sptm, rele'ant U@ra" chan*esand prefera+l" micro+iolo*ical dia*nosis from +ronchial la'a*e, transtracheal aspirate or protected

+rsh cltre.

0igure 1. #ode of acquisition of hospital acquired pneumonia


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2isk factors for nosocomial pneumonia

$ondition of patientTherapy

7e'erel" ill, e.*. septic shoc-

;*e (elderl" or neonate)

7r*ical operation

(ChestYa+domen) 3a8or in8ries

Coronar" +"pass sr*er"

E!istin* cardioplmonar"

disease Cere+ro'asclar accidents

Coma

1ea'" smo-er

7edation

6eneral anaesthesia

Tracheal int+ation

Tracheostom", artificial'entilation, enteral feedin* >en*th of time of 'entilation

;nti+iotic therap", 1@2

+loc-ers

Immnosppressi'e and

c"toto!ic dr*s

Etiologic agents of nosocomial pneumonia

Streptococcus pneumoniae and(aemophilus influen/ae can case post@operati'e pnemonia,particlarl" in patients ith e!istin* plmonar" disease.

6ram@ne*ati'e +acilli, e.*.,1le)siella pneumoniae Escherichia coli #seudomonas aeruginosaSerratia marcesens Entero)acter species, andAcineto)acter species.

*egionella infection ma" +e ac/ired from the hospital air conditionin* s"stem or from aterspplies, particlarl" in immnocompromised patients.

ther or*anisms, e.*., respirator" s"nc"tial and other respirator" 'irses, Candida al)icans , and,rarel",Aspergillus fumigatus.


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#neumocystis carinii cases pnemonia in immnosppressed patients, particlarl" if 1I positi'e,

+t this is sall" a commnit"@ac/ired infection. pportnistic plmonar" diseases cased +"different m"co+acteria, incldin*yco)acterium tu)erculosis can occr and can +e transmitted toother patients.

0asic methods of prevention

"isk Prevention

7r*ical operation Identif"in* patients at hi*h ris-.

Deep +reathin* and co*hin* e!ercises

+efore and after operation. Percssion and postral draina*e to

stimlate co*hin*.

3o+ilise earl" after operation.

Cardioplmonar"illnesses

Clearin* aira"s.

ral ca'it" care at least J times a da".

espirator" failre andartificial 'entilation

Decontamination of respirator" e/ipment

after % to &2 hors. The fre/enc" ofdecontamination depends on its se.

Protection of mechanical 'entilation ith

filters redces the need to disinfect aftereach patient.

7ction +ottles chan*ed dail", atocla'ed

or disposa+le.

Other important measures

1and h"*iene +efore and after contact ith patients, hether or not *lo'es are orn.

Clean disposa+le or reprocessed *lo'es and catheters for tracheal aspiration and tracheostom" care.

Disposa+le or reprocessed *lo'es hen handlin* respirator" secretions.

Edcation of staff in patient care practices and cleanin* and disinfection of respirator" e/ipment.

Cleaning and isinfection of Respirator) E"uipment

1midifiers Cleanin*, dr"in* and fillin* ith steriledistilled or freshl" +oiled ater e'er" % to 2

hors. 9e+liers ;tocla'in* or thermal disinfection preferred

after cleanin*0 sterile ne+lier flids as


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aerosols are *enerated.

Endotracheal aira"t+es, face mas-s,t+in*, am+@+a*s

;tocla'in* or thermal disinfection

Disposa+le items are safe +t e!pensi'e

Chemical disinfection ma" +e re/ired

ral ca'it" cleanin*soltion

7terile or freshl" +oiled ater for each se

7pirometr" 3othpiece for each patient shold +e sterile,disinfected or disposa+le

Endotracheal aira"

maniplations

7terile, disposa+le, for each procedre e!cept

hen sed for the same patient for 2 hors0flshed for each aspiration ith sterile orfreshl" +oiled ater

7ction +ottles and

t+in*

Washin* in deter*ent and dried, or disinfectedith soltion of chlorine@releasin* a*ent,rinsed and dried. Prefera+l" disinfected inashin* machine or atocla'ed or disinfectedin hot ater and dried. Disposa+les a'aila+le

+t e!pensi'e

!inimal re"uirements

;de/atel" decontaminated e/ipment.

1and h"*iene +efore and after patient contact

6lo'es (non@sterile) and disposa+le sction catheters for tracheal aspiration, if a'aila+le.

Chan*e *lo'es +eteen patients and procedres

Dispose of or decontaminate sction catheters +eteen patients

0ibliograph)

6ideline for Pre'ention of 9osocomial Pnemonia.Amer J Infect Control #$$022:2&@

2$2. hame F7, 7treifel ;, 3cCom+ C, Bo"le 3. B++lin* hmidifiers prodce microaerosols

hich can carr" +acteria. Infection Control #$%J0&:A@&.


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1=. (revention of urinar) tract infection*>TI,

Introduction

The *reat ma8orit" of


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Fi*re #A.# Bac- to te!t

Other precautions

The spot from the tap shold +e completel" emptied to pre'ent a +ild@p of or*anisms insta*nant rine.

The +a* shold not +e alloed to stand on the floor or to rise a+o'e the le'el of the +ladder.

Disinfectants in the +a* are not cost@effecti'e nless the infection rate is hi*h and cannot +e

controlled +" other means. Catheters shold not +e chan*ed rotinel" as this e!poses the patient to increased ris- of

+ladder and rethral trama. The" shold +e chan*ed if associated ith anti+iotic treatment

or if there is an o+strction.


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remo'ed at first si*n of penile irritation or s-in +rea-don. Condom se for 2@hor periods

shold also +e a'oided and other methods, sch as nap-ins or a+sor+ent pads, sed at ni*ht.

!inimal Re"uirements

Decontamination of staff hands and cleanin* of perirethral area +efore insertion of sterile

(or ade/atel" decontaminated) catheter. 3aintenance of closed draina*e s"stem.

1and h"*iene +efore and after empt"in* drainin* +a*s.

Bibliograph$

6idelines for pre'entin* infections associated ith the insertion and maintenance of short@term indellin* rethral catheters in acte care.Journal (ospital Infection2AA#0&(7ppl):7$@7J.


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11. (rinciples of antibiotic polic)Introduction

In contries here there is nrestricted sale 4o'er the conter of anti+iotics, ncontrolled misse ofanti+iotics is responsi+le for a *eneral pool of resistant strains in the micro+ial poplation. 7ales ofanti+iotics shold +e restricted to medical prescription onl".

Within hospitals, the nnecessar" se or o'erse of anti+iotics encora*es the selection andproliferation of resistant and mltipl" resistant strains of +acteria. nce selected, resistant strainsare fa'ored +" anti+iotic sa*e and spread +" cross@infection. Where resistance is encoded on

transmissi+le plasmids, resistance can also spread +eteen +acterial species.

There is ths a lin- +eteen anti+iotic se (or a+se) and the emer*ence of anti+iotic resistant+acteria casin* hospital@ac/ired infections. It is not possi+le to completel" eliminate thise'oltionar" phenomenon, +t it can +e sloed or modified +" prdent anti+iotic se. This re/iresthe inclsion of an anti+iotic polic" in the infection control pro*ramme.

h) is an antibiotic polic) necessar)

$n antibiotic policy will%

impro'e patient care +" promotin* the +est practice in anti+iotic proph"la!is and therap",

ma-e +etter se of resorces +" sin* cheaper dr*s here possi+le

retard the emer*ence and spread of mltiple anti+iotic@resistant +acteria.

impro'e edcation of 8nior doctors +" pro'idin* *idelines for appropriate therap"

eliminate the se of nnecessar" or ineffecti'e anti+iotics and restrict the se of e!pensi'e

or nnecessaril" poerfl ones

/ormation of a &ospital 'ntibiotic Committee

The medical director andor hospital mana*er shold ensre that the hospital plan for pre'ention

and control of nosocomial infection incldes an official committee that has responsi+ilit" for theformlation and sper'ision of an anti+iotic polic". This mi*ht +e a s+committee of the hospitalDr*s and Therapetics Committee or of the Infection Control Committee. The ;nti+ioticCommittee shold ha'e the spport of the 3edical Director and the athorit" to ensre that its

policies are implemented thro*hot the hospital.

/unction of the antibiotic committee

The main tas-s of an anti+iotic committee are the folloin*:

to conslt idel" ith the clinical staff to *et a*reement on anti+iotic sa*e in different

specialities to then esta+lish an anti+iotic formlar", hich ma" pre'ent the se of some dr*s and

restrict the se of others


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to formlate *idelines for anti+iotic prescri+in*, incldin* indications for proph"la!is and

therap" of infection, the optimm dosa*es, timin*s and dration of therap" and policies forminimisin* the ris-s of to!icit"

to re'ie the appropriateness of anti+iotic se and the emer*ence of antimicro+ial resistance

and pro'ide feed+ac- on this to clinicians to +e responsi+le for edcation and dissemination of information

to or- closel" ith the Infection Control Team and the 3icro+iolo*" Department

The ?e) !embers of the 'ntibiotic Committee

3em+ership of an anti+iotic committee ma" 'ar" accordin* to local conditions and needs. Thecommittee shold +e responsi+le for prodcin* *eneral *idelines and policies for the health care

areas after ide consltation ith the sers.

&f possible' the following (ey persons should be included in the committee%

The #harmacist ho ill report +ac- to the ;nti+iotic Committee at each meetin* on dr*

tilisation and cost. The icro)iologist ho ill report on anti+iotic sscepti+ilit" patterns of +acteria isolated

from ma8or infections. Clinical doctors and nurses responsi+le for direct patient care ho pro'ide a lin- +eteen

clinical practice and the ;nti+iotic Committee.

anger3s4 ho ill ensre the resorces are a'aila+le for implementation of the anti+ioticpolic". "eciprocal em)ership+eteen the Infection Control Committee and the Dr*s Committee

shold +e ensred.

ther mem+ers can +e co@opted as necessar".

The anti+iotic committee ill ha'e to ma-e rational choices amon*st e/i'alent dr*s and classesof dr*s in order to select the least e!pensi'e, most effecti'e a*ents. Cost shold determine theselection, hen micro+iolo*ical, pharmacolo*ical, and other rele'ant properties are similar.

9uidelines

; ma8or tas- of the ;nti+iotic Committee ill +e to esta+lish *idelines for anti+iotic se. This illlead to prodction of a formlar" that restricts a*ents a'aila+le to the minimm nm+er needed formost effecti'e therap".

)he guidelines should

+e dran p after ide consltation and a*reement in the hospital

+e simple, clear and short, and ideall" p+lished in a +oo-let small eno*h to +e carried in a

poc-et +e pro'ided to all nel" appointed doctors and nrses and readil" a'aila+le in the hospital,

for e!ample, a'aila+le on ards


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contain *idance on anti+iotic proph"la!is (e.*. in sr*er" ith details of timin*, rote,

dosa*e and fre/enc") contain *idance on the choice of anti+iotics for empirical and tar*eted therap" of ma8or

infections indicate first and second line therap" for common infections (mi*ht limit the se of certain

second line dr*s to consltant prescription onl")

Good +ractices

Consider hether or not the patient actall" re/ires an anti+iotic.

;'oid treatin* colonised patients ho are not actall" infected.

In *eneral do not chan*e anti+iotic therap" if the clinical condition is impro'in*.

If there is no clinical response ithin &2 hors, the clinical dia*nosis, the choice ofanti+iotic andor the possi+ilit" of a secondar" infection shold +e reconsidered.

6i'e the anti+iotic for the minimm len*th of time that is effecti'e.

e'ie the dration of anti+iotic therap" after da"s.

Consider the se of pharmac" stop policies, here dr*s are ritten p for a specified

period and are then onl" contined if a ne prescription is issed. For sr*ical proph"la!is start the anti+iotic ith the indction of anaesthesia and contine

for a ma!imm of 2 hors onl".

Contribution from the !icrobiolog) 4aborator)

The micro+iolo*" la+orator" contri+tes in se'eral a"s toards the dail" clinical mana*ement ofinfection.

The clinician shold recei'e reports of anti+iotic sscepti+ilit" +ased on the dr*s a'aila+le in thea*reed formlar". The testin* shold +e performed ith a limited nm+er of anti+iotics selected tooptimise patient care and cost effecti'eness. The nm+er of anti+iotics reported mi*ht +e limited inorder to encora*e +etter prescri+in* (e.*. a*mentin need not +e reported if the or*anism issensiti'e to ampicillin). The report shold also indicate here or*anisms are in'aria+l" resistant(e.*., methicillin@resistant S. aureus are resistant to all +eta@lactams).

The ;nti+iotic Committee and the Infection Control Committee shold recei'e re*lar pdates onanti+iotic sscepti+ilit" of +acterial isolates from the local area. This ill assist the Committees in

prodcin* effecti'e *idance for the local patient poplation. The la+orator" shold also alert t

infection control; basic concepts and practices 2nd edition

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