Foreword

The International Federation of Infection Control (IFIC), founded in

1987, is an umbrella organisation of infection prevention and control
societies from more than 60 countries around the globe. The goal of IFIC
is to minimise the risk of infection within the healthcare setting world-
wide through development of a network of infection control
organisations for communication, consensus building, education and
sharing expertise.

The purpose of IFIC is to provide the essential tools, education

materials and communication that unite the existing infection
prevention and control societies and foster development of infection
prevention and control organisations where they are needed.

IFIC achieves its goals by:

promoting high quality educational opportunities, materials and
training programs across countries at low or no cost. Conferences
are held at least annually in different parts of the world;
numerous scholarships are made available to assist delegates,
especially those from low resource backgrounds, to attend and
present their work.
providing a communication network of support by members via
the International Journal of Infection Control, an on-line forum, a
regular electronic newsletter and especially its website
(www.theIFIC.org).
maintaining a liaison with the World Health Organisation and
other organisations that promote infection prevention including
prevention and management of occupational blood exposures
among health care workers.
drawing on the expertise of its member organizations to help
each other and to assist with formation of national societies in
countries that are in early stages of infection control
development.

IFIC Basic Concepts of Infection Control is a totally new basic infection

control manual that builds on the prior publication, Infection Control:
Basic Concepts and Training. The intent is to provide a foundation of
scientifically valid, basic infection control principles and requirements.
This handbook is the result of a co-operation between international

ix
experts on infection control. It is hoped that this booklet will serve as a
foundation on which local policies and procedures are developed. The
recommendations in this handbook are generally applicable to all
healthcare units, but should be particularly useful to hospitals where
resources are limited and/or whose infection control initiatives are still
beginning.

On behalf of the Board of Directors of the International Federation of

Infection Control, the corporate sponsors, and the authors of this text, I
hope that you will find it a useful resource in your daily practice.

Michael A. Borg
October 2007 IFIC Chair

x
 IFIC Basic Concepts of Infection Control
Working Group
Editors

Candace Friedman, MPH, CIC William Newsom, MD, FRCPath,

Ann Arbor, Michigan, USA DTM&H
Cambridge, England, UK

Authors

Michael A. Borg, MD, MSc (Lond), Shaheen Mehtar, MD, FRCPath

DLSHTM, MMCPath, DipHIC Tygerberg Hospital
St. Luke's Hospital Western Cape, South Africa
G'Mangia, Malta

Pola Brenner, RN, CIC, MSC Patricio Nercelles, MD, MSc

National Nosocomial Infection Chief of Epidemiology Unit
Program, Ministry of Health Hospital Carlos Van Buren
Santiago, Chile Valparaiso, Chile

Elizabeth Ann Bryce, MD, FRCP(C) Ulrika Ransj, MD, PhD, DTM&H
Vancouver Hospital/HSC Uppsala University Hospital
Vancouver, British Columbia, Uppsala,
Canada Sweden

Nizam Damani, MD, MBBS, MSc Ossama Shams El-Din Rasslan,

(Lond), FRCPI, FRCPath, CIC, DipHIC MD, PhD
Craigavon Area Hospital Nasr City, Cairo, Egypt
Portadown, N. Ireland, UK

T. Grace Emori, RN, MS Sanjay Saint, MD, MPH

Jacksonville, Oregon, USA University of Michigan Health
System
Ann Arbor, Michigan, USA

Gary French, MD, FRCPath Sydney L Scharf, RN, BA, CIC

St. Thomas Hospital Vancouver Hospital
London, England, UK Vancouver, British Columbia,
Canada

iv
Peter Heeg, MD Eva Thomas, MD, PhD, FRCP(C)
Eberhard Karls University Vancouver, British Columbia,
Tuebingen, Germany Canada

Smilja Kalenic, MD, PhD Gertie van Knippenberg-

Clinical Hospital Centre Zagreb Gordebeke, ICN
Zagreb, Croatia Consultant Infection Prevention
& Hygiene, Venlo-Boekend,
Netherlands

Edward Krisiunas, MT (ASCP), CIC Moira M Walker, RN, CIC

Burlington, Connecticut, USA Vancouver, British Columbia,
Canada

Patricia Lynch, RN, MBA

Seattle, Washington, USA

Reviewers

Mary Brachman, RN, MS, CIC Kathleen Petersen, MS, CIC

Long Lake, Minnesota, USA Ann Arbor, Michigan, USA

Carol Chenoweth, MD A Jeanne Pfeiffer, RN, MPH, CIC

Ann Arbor, Michigan, USA Golden Valley, Minnesota, USA

Janet Franck, RN, MBA, CIC Barbara Russell, RN, MPH, CIC, ACRN
Chicago, Illinois, USA Miami, Florida, USA

Gayle Gilmore, RN, MA, MIS, CIC Rachel L Stricof, MT, MPH
Duluth, Minnesota, USA Albany, New York, USA

Carol Goldman, RN, BScN, CIC Kristi Vander Hyde, RN, MSN, CIC
Toronto, Ontario, Canada Ann Arbor, Michigan, USA

Maryanne McGuckin, PhD

Philadelphia, Pennsylvania, USA

v
 Infection Prevention and Control Program Organizational Structure

Chapter 1
Infection Prevention
and Control Program
Organizational
Structure
Ossama Rasslan and Peter Heeg

Key points
Risk prevention for patients and staff is a concern of everyone
in the facility, and must be supported at the level of senior
administration.
An Infection Control Programme (ICP) has to develop an
appropriate, clear and firm organizational structure.
ICP in most countries is delivered through an Infection
Control Team.
A healthcare-associated infection manual compiling
recommended instructions and practices for patient care
is an important tool.

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IFIC Basic Concepts of Infection Control

Introduction

Infection prevention and control (IC) is a quality standard and is essential

for the well-being and safety of patients, staff and visitors. Provision of an
effective infection control program (ICP) is a key to the quality and a
reflection of the overall standard of care provided by the health care
institution. Each institution is unique and its specific needs must be
considered when developing or reorganizing an ICP. Because of these
differing needs, various groups, individuals, and functions within the
organization may be responsible for the IC program.

National Program

The responsible National Health Authority should develop a national

program to support hospitals in reducing the risk of
healthcare-associated infections. Such programs must:
Set relevant objectives consistent with other national health care
objectives.
Develop and continually update guidelines for health care
surveillance, prevention and practice.
Develop a national system to monitor selected infections and
assess the effectiveness of interventions.
Harmonize initial and continuing training programs for health care
professionals.
Facilitate access to products essential for hygiene and safety.
Encourage health care establishments to monitor healthcare-
associated infections, with feedback to the professionals concerned.

The Health Authority should designate an agency to oversee the program

(a ministerial department, institution or other body) and plan national
activities with the help of an expert committee. Professionals and
academic organizations must be involved.1

Hospital Programs

The major preventive effort should be focused in hospitals and other

health care facilities.2 Risk prevention for patients and staff is a concern of
everyone in the facility, and must be supported by the senior
administration. A yearly work plan to assess and promote good health

2
 Infection Prevention and Control Program Organizational Structure

care, appropriate isolation, sterilisation, and other practices, staff training,

and epidemiological surveillance should be developed. The hospital
manager or medical director is ultimately responsible for safety and
quality. He or she must ensure that appropriate arrangements are in place
for effective infection prevention and control (IC) practices and that there
is an Infection Control Committee (ICC) and an Infection Control Team
(ICT). If the health care setting is too small for such an organization,
experts in IC should be available for consultation at regular intervals and
in an acute situation. Providers of home care should ensure that expertise
in infection prevention and control is available for their staff.3

Infection Control Committee

An Infection Control Committee (ICC) provides a forum for

multidisciplinary input, cooperation, and information sharing. The ICC
is responsible for the planning, implementation, prioritisation, and
resource allocation of all matters relating to IC. The ICC must report
directly to either administration or the medical staff to promote
program visibility and effectiveness. The committee should act as a
liaison between departments responsible for patient care and support
departments (e.g., pharmacy, maintenance).

The ICC membership should reflect the spectrum of clinical services

and administrative arrangements of the hospital. It should include:

Chief Executive/Hospital Administrator or his or her nominated

representative.
Infection Control Doctor/Hospital Microbiologist who may act as
a chairperson.
Infection Control Nurse.
Infectious Disease Physician (if available).
Director of Nursing or his/her representative.
Occupational Health Physician (if available).
Representatives from the major clinical specialties.
Representatives of other departments (pharmacy, central supply,
maintenance, housekeeping, training services, etc.) may be
invited as necessary.

The committee should hold regular meetings with minutes. Minutes should

3
IFIC Basic Concepts of Infection Control

be sent to the Medical Director and the Hospital Management Board as well
as to departments directly involved in the subjects discussed during the
meeting. It should produce an annual report and an annual business plan for
infection prevention and control.

The ICC has the following tasks:

To review and approve the annual plan for IC for the facility.
To review and approve the IC policies.
To support the ICT and direct resources to address problems as
identified.
To ensure availability of appropriate supplies needed for IC.
To review epidemiological surveillance data and identify areas
for intervention.
To assess and promote improved practice at all levels of the
health facility.
To ensure staff training in IC and safety.
To review infectious risks associated with new technologies and
monitor risks of new devices and products, prior to their
approval for use.
To review and provide input into an outbreak investigation.
To review and approve infection prevention and control aspects
of construction/renovation projects.
To communicate and cooperate with other committees of the
hospital with common interests, such as Antibiotic Committee,
Occupational Health Committee, etc.

Infection Control Team (ICT)

The ICT should have a range of expertise covering IC, medical

microbiology, infectious diseases, and nursing procedures. The team
should have a close liaison with the microbiology laboratory and
ideally a microbiologist should be a member. The team should consist
of at least one physician, the Infection Control Officer (ICO), and at
least one nurse, the Infection Control Nurse (ICN). One ICN for 250
acute beds on a full-time basis was recommended in the US during the
1980s. However, the optimal number of ICNs cannot be calculated
simply on the basis of the number of acute care beds but depends on
the case mix and workload.3

4
 Infection Prevention and Control Program Organizational Structure

The ICT is responsible for the day-to-day running of ICPs.

All hospitals should have an ICT. If this is not practical, arrangements
for IC services should be made with a nearby hospital. The optimal
structure will vary with the type, needs, and resources of the facility.
The ICT must have appropriate authority to manage an effective ICP.
In large facilities, this usually means a direct reporting relationship
with senior administration.

The ICT must ensure that an effective ICP has been planned,
coordinate its implementation, and evaluate its impact. Twenty-four
hour access to the ICT for advice (both medical and nursing) on IC is
essential.

The team should meet regularly (several times a week or preferably

daily) to discuss relevant issues. A standing agenda may include
updates on surveillance, observations of IC practice, policy review,
revision of education and training, and follow-up on any identified
problem. Important decisions should be recorded in written minutes.
Any regulations, rules or recommendations should be widely
distributed throughout the facility. Feedback from the ward staff
should be encouraged.

The role of the ICT can be summarized as follows:

To develop an annual IC plan with clearly defined objectives.

To develop written policies and procedures, including regular
evaluation and updates.
To prepare an action plan for implementation of the ICP and to
get approval from the ICC.
To supervise and monitor daily practices of patient care
designed to prevent infection.
To identify problems in the implementation of IC activities
which need to be solved or addressed by the hospital ICC.
To organize epidemiological surveillance for healthcare-
associated infections (particularly in high risk areas to detect
outbreaks early).
To investigate outbreaks and provide data (and expert advice)
that should be evaluated to allow for any change in practice or
allocation of resources.
To educate all grades of staff in IC policy, practice and

5
IFIC Basic Concepts of Infection Control

procedures relevant to their own areas.

To provide advice to all grades of staff on all aspects of infection
prevention and control on a day-to-day basis.
To develop an annual training plan for health care workers and
to get program approval from the ICC.
To implement IC training activities within the health care
facility.
To ensure availability of supplies and equipment needed for IC.
To have a scientific and technical support role in purchasing
and monitoring of equipment and supplies, and in evaluation
and checking the efficacy of sterilization and disinfection
measures.
To collaborate with the pharmacy and antibiotic committees in
developing a program for supervising antibiotic use.
To support and participate in research and assessment
programs.
To participate in audit activities.
To submit monthly reports on activities to the ICC.

Infection Control Officer: Duties and Responsibilities

The infection control officer (ICO) should be a medically qualified

senior staff member of the facility who spends most of his/her time
involved in hospital IC. The ICO could be a medical microbiologist, an
epidemiologist, or an infectious disease physician. If none of these are
available, then a surgeon, a paediatrician, or another appropriate
physician with a special interest in the field should be appointed.
Irrespective of professional background, the ICO should have interest,
knowledge and experience in different aspects of IC.

The role and responsibilities of the ICO are summarized as follows:

Serves as a specialist advisor and takes a leading role in the

effective functioning of the ICT.
Should be an active member of the hospital ICC and may act as its
Chair.
Assists the ICC in drawing up annual plans, policies and long-term
programs for the prevention and control of infection.
Advises the Chief Executive/Hospital Administrator directly on all

6
 Infection Prevention and Control Program Organizational Structure

aspects of IC in the hospital and on the implementation of agreed

policies and procedures.
Participates in the preparation of tender documents for support
services and advises on IC aspects.
Must be involved in setting quality standards, surveillance and
audit with regard to infection prevention.

Infection Control Nurse: Duties and Responsibilities

An Infection Control Nurse or Practitioner is a registered nurse with an

academic education (perhaps with a qualification) and practical training
which enables him or her to act as a specialist advisor in all aspects
relating to IC. The ICN is usually the only full-time practitioner on the
ICT and therefore takes the key role in day-to-day IC activities, with the
ICO providing the leading role.

The role and responsibilities of the ICN are summarized as follows:

Contributes to the development and implementation of policies and

procedures, participates in audits, and monitors tools related to IC
and infectious diseases.
Provides specialist-nursing input in the identification,
prevention, monitoring, and control of infection within the hospital.
Participates in surveillance, outbreak investigation, and control of
infection.
Identifies, investigates and monitors infections, hazardous
practice and procedures.
Participates in preparing documents relating to service specifications
and quality standards.
Participates in training and educational programs and in
membership on relevant committees where IC input is required.

Infection Control Link Nurse (ICLN)

An effective way to develop IC education and operational support can be

through a link system. In a large hospital the ICN can train link nurses. These
have special responsibility for maintaining good IC practices and education
within their own departments. The ICLN is the link between the ICN and
the ward and helps identify problems, implement solutions and maintain

7
IFIC Basic Concepts of Infection Control

communications. A competent ICLN can motivate ward staff by enabling

more effective practice. Sustained, consistent senior management backing
and interest are effective in supporting such link programs and essential in
ensuring their success.

The ICLN is responsible for:

Maintaining hygiene, consistent with hospital policies and good
nursing practice on the ward.
Monitoring aseptic techniques, including hand washing and use
of isolation.
Reporting promptly to the attending physician any evidence of
infection in patients.
Initiating patient isolation and ordering culture specimens from
any patient.
Identifying signs of a communicable disease when the physician
is not available.
Limiting patient exposure to infections from visitors, hospital
staff, other patients, or equipment used for diagnosis or
treatment.
Maintaining a safe and adequate supply of relevant ward
equipment, drugs and patient care supplies.

Infection Control Manual

A healthcare-associated infection manual, containing recommended

instructions and practices for patient care, is an important tool. The
manual should be developed by the ICT, with review and approval by
the ICC. It must be made readily available for patient care staff, and
updated regularly.

Topics of importance for a procedure manual

Patient care
Hand hygiene
Isolation practices
Invasive procedures (intravascular and urinary catheterisation,
mechanical ventilation, tracheostomy care, and wound
management)
Oral alimentation

8
 Infection Prevention and Control Program Organizational Structure

Ward specific procedures

Isolation procedures for infectious patients
Surgical and operating theatre techniques
Obstetrical, neonatal, and intensive care techniques

Production of items of critical importance

Cleaning, sterilisation and disinfection
Medication and infusion preparation (including blood
products)

Staff health
Immunisation
Post-exposure management for employees, patients and others
exposed to infectious diseases within the facility

Investigation and management of specific infections

Methicillin resistant Staphylococcus aureus (MRSA)
Diarrhoea
HIV
Tuberculosis
Multiresistant Gram-negative bacteria

Minimal Requirements
A physician and a nurse with responsibilities for IC.
A manual of critical IC policies.
An educational program for staff.
A clear line of responsibility to the senior management of the
hospital.

References and Further Reading

1. Ducel G, Fabry J, Nicolle L. Prevention of hospital-acquired

infections; A practical guide. 2nd ed. Geneva, Switzerland: World
Health Organization; 2002.
2. Scheckler WE, Brimhall D, Buck AS, et al. Requirements for
infrastructure and essential activities of infection control and
epidemiology in hospitals: a consensus panel report. Infect Control
Hospital Epidemiol 1998;19: 114-24.

9
IFIC Basic Concepts of Infection Control

3. Friedman C. Infection Control Program: Structure, Administrative

Reporting In: APIC Text of Infection Control and Applied
Epidemiology: Principles and Practice (CD-ROM version).
Washington, D.C.: Association for Professionals in Infection
Control and Epidemiology, Inc.; 2002. p. 1-11-9.

10
 Epidemiology of Healthcare-Associated Infections

Chapter 2
Epidemiology of
Healthcare-Associated
Infections
T. Grace Emori

Key points
Healthcare-associated infections (HAI) occur in all types of
healthcare facilities.
Understanding the risk factors associated with specific types
of HAI is important in developing effective and efficient
prevention and control measures.
HAI risk is high when invasive medical devices are used on
patients.
Antimicrobial resistance among hospital pathogens is
increasing.

11
IFIC Basic Concepts of Infection Control

Introduction

Hospitalized patients are at high risk of developing infections they did

not have before admission. In the United States, more than one out of
every 20 patients develops a healthcare-associated infection (HAI), so
about 2 million patients become infected every year.1 Most HAIs occur
at four sitesblood, respiratory tract, surgical site, and urinary tract.
HAIs occur in all types of hospitals, from small ones to large university
hospitals and in countries with sophisticated health care systems and
those that are newly organized. Regardless of size or location all
hospitals are places where the infection risk is high. Risk factors fall into
three groups:

1. intrinsic factors which mean the patients susceptibility to

infection;
2. extrinsic factors such as the hospital environment and devices
used on the patients; and
3. the microorganisms involved.

The importance of the risk factors may differ in hospitals, but we can
understand their potential role by examining the epidemiology of HAIs
to see how often they occur, where, and why.

The Centers for Disease Control and Prevention (CDC) has been
collecting epidemiologic data on HAIs in the U.S. since the late 1960s.
Researchers and public health officials realized that HAIs were
increasing in number and becoming more serious, leading to disability
and death, pain and suffering, and high extra cost.

Other countries and regions have since begun surveillance and

published epidemiologic data on HAIs. These areas include:

Europe: Improving Patient Safety in Europe

http://helics.univ-lyon1.fr
England: Nosocomial Infection National Surveillance Scheme
http://www.hpa.org.uk/infections/topics_az/hai/default.htm
Australia: Victorian Nosocomial Infection Surveillance System
http://www.vicniss.org.au
Canada: Canadian Nosocomial Infection Surveillance Program
http://www.phac-aspc.gc.ca/nois-sinp/cnisp_e.html

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 Epidemiology of Healthcare-Associated Infections

Most hospitals collect some data on HAIs. Comparing rates of HAI is

difficult because of differences in surveillance methods and ongoing
changes in how and where patients receive care. The purpose of this
chapter is to use data from surveillance systems and studies to show the
most important risk factors associated with HAIs and to describe how
this information can be used to reduce the infection rate.

Intrinsic risks

The normal human body has many defences against infection. These
defences may be compromised by very old age, underlying disease or
injury. These are called intrinsic risks. Table 2.1 shows the association
between the most common HAIs and some intrinsic risks. Although we
may not be able to remedy these conditions, caregivers can take special
precautions to protect patients who are highly susceptible to infections.
Furthermore, when infections occur in low risk patients, infection
prevention and control (IC) staff should be alert to new problems that
may be preventable.

Extrinsic risks in the hospital environment or from

treatments

The hospital is a busy place where peoplepatients, caregivers, and

visitorsare in constant contact, where all types of equipment and
supplies are used, and high risk procedures are performed. The hospital
and those who work there maintain a safe environment for patients and
caregivers by ensuring clean food, water and air, adequate sanitation,
practicing IC, and using antibiotics wisely. IC should be focused on
these factors. (See Table 2.1)

Caregivers must also be protected from becoming infected while

working in hospital. Serious infections of concern to caregivers are
human immunodeficiency virus/acquired immunodeficiency syndrome,
viral hepatitis, tuberculosis, and (in some countries) viral hemorrhagic
infections.

High-risk medical devices

Many HAIs are related to the use of a medical device, especially
invasive devices that by-pass the normal barriers to entry of
microorganisms into the body. HAI rates of urinary tract infections

13
IFIC Basic Concepts of Infection Control

Table 2.1. Intrinsic and extrinsic risk factors associated with hospital-associated
infections

Site of
Intrinsic risk factors Extrinsic risk factors
infection

ICU
Vascular access:
Arterial pressure monitor
Immunosuppressive therapy
Haemodialysis
Bloodstream Loss of skin integrity Intravenous line, especially
infection central and umbilical line
Severe underlying disease
Receipt of large volume of
Very young or very old
parenteral fluids or blood
products
Systemic antimicrobial therapy

Chronic lung disease

Immunosuppressive therapy
Long duration of surgical Enteral feeding
operation Intubation with nasogastric tube
Pneumonia Surgical operation Respiratory therapy equipment
(especially high abdominal
or thoracic Tracheal suctioning
and long duration)
Very old

Loss of skin integrity

OR asepsis
Obesity or malnutrition
OR equipment and supplies
Presence of infection at
another site Skin antisepsis
Surgical site
Severe underlying disease Surgeons skill and experience
infection
(e.g., high American Society Tissue perfusion
for Anesthesiologists score, Type of operation
diabetes mellitus)
Length of operation
Trauma

Female Indwelling urinary catheter

Urinary tract Severe underlying disease, Other urinary tract
infection e.g., diabetes mellitus instrumentation, especially
Very old cystoscopy

ICU = Intensive Care unit; OR = Operating Room (theatre)

Adapted from Emori TG, Gaynes RP. An overview of nosocomial infections,
including the role of the microbiology laboratory. Clin Micro Rev 1993;6:428-42.

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 Epidemiology of Healthcare-Associated Infections

(UTI), bloodstream infections, and pneumonia are significantly greater

among patients when a medical device is used.2 Almost 65% of
healthcare-associated bloodstream infections (BSI) relate to an invasive
device in the bloodstream and nearly all UTIs occur in patients with
indwelling urinary catheters.3,4

Use of invasive devices is especially high in the intensive care unit

(ICU) where the risk of infection is increased because the patients are
more severely ill or injured. About one-fourth of the HAIs in the U.S.
are in ICUs,5 where the infection rate is 5-10 times greater than on the
general wards.6 ICUs in hospitals worldwide had bloodstream infection
rates associated with central venous catheters similar to those in US
hospitals (5.02 vs. 3.82 BSI/1000 line days).7

As medical technology advances and new devices are introduced

careful thought must be given to how they can be safely used on
patients. Must they be sterile or clean? If re-used, how are they
reprocessed? Patients should be examined for any evidence of infection
related to the devices. Deciding against using an invasive device in
favour of a non-invasive approach can be an effective infection
prevention measure.

Surgical procedures
Surgical site infection (SSI) is often a serious event that, on average,
prolongs hospital stay by eight days, doubles the risk of death, increases
re-admissions to hospital 5-fold and imposes a huge extra cost of care.8
Because the risk of developing a SSI is strongly associated with bacterial
contamination of the wound during the operation, SSI rates have been
grouped by wound classclean, clean-contaminated, contaminated and
dirty. Recent SSI studies have grouped patients according to the
operation performed, the length of the operation, and the general
condition of the patient. Using more precise risk groups allows
comparison of infections rates between patients with similar risks.

Infectious agents
Microorganisms are everywhere in hospitals and some of them will
become resistant to antibiotics if these are over-prescribed.

Overall, about half of all HAIs are caused by four pathogens E. coli,
enterococci, P. aeruginosa, and S. aureus. However, the microbes are

15
IFIC Basic Concepts of Infection Control

different for each kind of infection. For example, E. coli is commonly

found in UTIs, but less frequently found at other infection sites.
S. aureus is rarely found in UTIs but is common in wounds, pneumonia
and bloodstream infections.

The growing problem of antimicrobial-resistant microorganisms is one

of the greatest challenges facing infection prevention and control. The
trend of selected pathogens from ICUs in the U.S. that are antibiotic-
resistant is shown in Figure 2.1. Inappropriate use of antibiotics, (un-
necessary use, prescribing the wrong drug, dosage, or duration) is an
important factor in promoting antimicrobial resistance. Patients need to
be trained not to expect an antibiotic for every possible infection, and to
follow the instructions on taking an antibiotic when one is ordered.

Rates of Resistance Among Nosocomial Infections Reported in

Intensive Care Unit Patients
Comparison of January through December 2003 with Historical Data
Vancomycin/enterococci 28.5%
Methicillin/S. aureus 59.5%
Methicillin/CNS 89.1%
3rd Ceph/E. coli** 5.8%
3rd Ceph/K. pneumoniae** 20.6%
Imipenem/P. aeruginosa 21.1%
Quinolone/P. aeruginosa 29.5%
3rd Ceph/P. aeruginosa 31.9%

3rd Ceph/Enterobacter spp. 31.1%

0 10 20 30 40 50 60 70 80 90
% Resistance
January through December 2003
1998 through 2002 (+/- standard deviation)*

Figure 2.1. Selected antimicrobial-resistant pathogens associated with

nosocomial infections in ICU patients, comparison of resistance rates from
January through December 2003 with 1998 through 2002, NNIS System.

3rd Ceph = 3rd generation cephalosporin such as ceftazidime

(From the NNIS System. National Nosocomial Infections Surveillance (NNIS)

system report, data summary from January 1992 through June 2004, issued
October 2004. Am J Infect Control 2004; 32:470-85)

16
 Epidemiology of Healthcare-Associated Infections

Using epidemiologic data to reduce the infection rate

Data collected in surveillance systems are being used successfully by IC

staff to identify high risk areas in their hospital, to provide objective
data to the patient care staff, including physicians, to assist in
developing prevention plans and to measure the programs
effectiveness.

Conclusion

If hospitals are to be successful in reducing HAIs and using their

resources most effectively, they should pay careful attention to factors
that increase infection risk in their patients and institute specific
prevention and control measures. The infection risk is highest when
patients are treated with invasive medical devices, undergo surgical
operations and are placed in the ICU. Pathogens resistant to
antimicrobial drugs are continuing to increase.

References and Further Reading

1. CDC. Public health focus: surveillance, prevention and control of

nosocomial infections. MMWR 1992;41:783-7.
2. Jarvis WR, Edwards JR, Culver DH, et al. Nosocomial infection
rates in adult and pediatric intensive care units in the United
States. Am J Med 1991;91 Suppl 3B:185S-91S.
3. Maki DG. Nosocomial bacteremia: An epidemiologic overview.
Am J Med 1981;70:719-32.
4. Stamm WE. Catheter-associated urinary tract infections:
epidemiology, pathogenesis, and prevention. Am J Med 1991;
91:65S-71S.
5. Burke JP. Infection controla problem for patient safety. N Eng J
Med 2003;348:651-6.
6. Weinstein R. Epidemiology and control of nosocomial infections
in adult intensive care units, Am J Med 1991;91 Suppl 3B:179S-
84S.
7. Memish ZA, Arabi Y, Cunningham G, et al. Comparison of US
and non-US central venous catheter infection rates: Evaluation of
processes and indicators in infection control study. Am J Infect
Control 2003;31:237-42.

17
IFIC Basic Concepts of Infection Control

8. Geubbels ELPE, Bakker HG, Houtman P, et al. Promoting quality

through surveillance of surgical site infections: Five prevention
success stories. Am J Infect Control 2004;32:424-30.

18
 Surveillance for Healthcare-Associated Infections

Chapter 3
Surveillance for
Healthcare-Associated
Infections
Gary French

Key points
Monitor infection patterns (sites, pathogens, risk factors,
location within the facility); only collect data that will be
useful in decision-making.
Detect changes in the patterns that may indicate an infection
problem.
Direct the rapid implementation of control measures.
Monitor antibiotic use and resistance.
Provide the staff with exactly the information they need in
order to improve infection prevention practices.

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IFIC Basic Concepts of Infection Control

Introduction

Hospital programmes of infection prevention and control (IC) should

include surveillance to detect common source outbreaks, identify
problem areas, help set priorities for IC activity, and meet national
standards. Surveillance can also provide data to help clinicians and
managers improve IC practices.

Surveillance can be defined as the systematic, active, on-going

observation of the occurrence and distribution of disease within a
population and of the events that increase or decrease the risk of the
disease occurrence. If the incidence, distribution and associations of a
disease are known, then resources can be targeted, predisposing factors
can be reduced or eliminated, and the incidence of the disease reduced.

The purpose of surveillance for healthcare-associated infections (HAI) is

to reduce the incidence of HAI and thus to reduce associated morbidity,
mortality, and costs. It can have a significant impact on rates of HAI.
The Study on the Efficacy of Nosocomial Infection Control (SENIC)1
found that hospitals with a surveillance program providing data to
clinical staff had considerably lower infection rates. French and
colleagues demonstrated the effectiveness of repeated prevalence
surveys2 and the US National Nosocomial Infections Surveillance
System (NNIS) has shown a significant reduction of healthcare-
associated infection rates in the US.3

Before beginning surveillance activities it is essential to develop a clear

plan. It should address 1) what questions are being asked, 2) how
infections are to be defined, 3) how the data are to be collected, stored,
retrieved, summarized and interpreted, 4) how to provide the results to
frontline practitioners, and 5) how to use the information to bring about
change.

Surveillance practices are similar to clinical audit, except that for an

audit the practice and outcomes of medical care (in this case the
prevention and control of HAI) is compared with a standard. By
repeated audit cycles, practice is brought closer to the ideal.

20
 Surveillance for Healthcare-Associated Infections

Methods of Surveillance for HAI

Surveillance requires strict definitions. In many cases there are no

universally agreed definitions and so the infection rate will vary with
the definition used. Comparisons can only be made if the same set of
definitions is used and applied in exactly the same way. It is often more
meaningful to use surveillance data from a single institution to measure
trends over time, either to alert staff to increasing problems or to
monitor the effectiveness of interventions.

The definitions should distinguish between HAI and community-

acquired infection (CAI). Healthcare-associated infections can be
defined as those that were neither present nor incubating at the time the
patient was admitted. Detailed definitions of specific infections have
been published by several organisations, including the World Health
Organization4, the US NNIS5, and the Hospital Infection Society.6

Some infections may present after the patient leaves hospital. In

surveillance for surgical site infection, as many as 70% of infections may
present after discharge. This has led to post-discharge surveillance.
However, this often poses considerable logistic problems and may add
further expense to surveillance activities.

Formal surveillance for infections requires each patient to be assessed,

often repeatedly, by trained staff. For this reason, true infection
surveillance (and especially incidence surveillance) is very expensive.
Because of this, routine surveillance is often performed by analyzing
laboratory reports, by informal ward visits, or by a combination of the
two. However these methods are not accurate. Laboratory reports are
not always indicative of true infection. Negative reports (or no report)
do not always mean infection is absent. Case finding using active
surveillance by an Infection Control Nurse (ICN) increased detection
from approximately 25% of defined infections to more than 85% in
some studies. These methods are particularly useful for identifying
infections that may require action by the Infection Control Team (ICT)
and for measuring trends over periods when laboratory, medical, and
IC nursing practice remain constant. (See Table 3.1)

21
IFIC Basic Concepts of Infection Control

Table 3.1. Types of Surveillance

Type Advantages Disadvantages

Comprehensive all Provides a global view Labour intensive

infections Detects trends Time consuming

Flexible
Provides limited
Selective/targeted, e.g., Resource efficient
information
by ICU, by device Can focus on high-risk
May miss outbreaks
areas

Timely
Provides only an
Prevalence Can evaluate the
estimate of infections
surveillance system

Post-discharge Increases case-finding Not timely

Incidence and prevalence of HAI

The prevalence of HAI is the number of cases of active HAI in a defined

patient population either during a specified period of time (the period
prevalence) or at a specified point in time (point prevalence). The
prevalence rate is the proportion of patients in the population who have
an active infection at the time of the survey. The incidence of HAI is the
number of new cases of disease that occur in the defined patient
population during a specified time period. The incidence rate is the
number of new cases of HAI that appear in the population at risk
during the specified time period.

Alert condition surveillance

Alert condition surveillance means monitoring the incidence of specific

clinical conditions, such as infectious diarrhoea or tuberculosis. This is
part of the daily work of the ICT which is directed towards, for

22
 Surveillance for Healthcare-Associated Infections

example, the early identification of outbreaks of viral diarrhoea and the

implementation of control procedures. Because this activity is usually
not performed in a systematic way, it is not an accurate measure of true
incidence.

Alert organism surveillance

Alert organism surveillance is the continuous monitoring of the

incidence of specified microorganisms isolated by the microbiology
laboratory. Alert organisms might include methicillin-resistant S. aureus
(MRSA), glycopeptide-resistant enterococci, gentamicin-resistant
coliforms and Clostridium difficile (by identification of its toxin). The
isolation of an organism is not necessarily indicative of infection and the
failure to isolate a microorganism does not prove the absence of
infection. Furthermore, care must be taken to avoid bias produced by
duplicates and screening cultures. When tracking an organism it should
only be counted once. Nevertheless, this surveillance is useful for IC
purposes. It has the advantages of simplicity and economy, and in
computerized laboratories, the surveillance can be automated. In
particular, in an individual hospital, it can show trends in the isolation
of specific microorganisms in different wards over time.

Prevalence surveys

In this method, hospital inpatients are surveyed over a short period of

time, ideally on a single day. These surveys are more practical than
incidence surveillance since they can be performed by just a few people
- often temporarily recruited from other tasks - once or twice a year.
Repeated prevalence surveys are not a complete substitute for incidence
surveillance, but helpful where resources are limited.

Prevalence surveys are useful to indicate the extent of HAI within a

hospital or region, to indicate specific problems requiring more
extensive investigation, and to define the changing patterns of HAIs in
a single hospital. If prevalence surveys are repeated at regular intervals
with the results provided to medical and nursing staff they can perform
some of the same functions as continuous surveillance.

Prevalence rates tend to be lower than incidence rates since prevalence

studies are less effective at identifying acute or short-lived infections.

23
IFIC Basic Concepts of Infection Control

Repeated prevalence surveys are useful for monitoring trends in rates

of both HAI and CAI. They can be performed with relatively limited
resources and produce information on both infected and uninfected
patients that can be used to identify independent risk factors. When
properly applied, prevalence surveys can also be used to analyse the
effectiveness of intervention strategies.

Prevalence studies have shown that, depending on the patient

population, the prevalence of HAI averages around 9-10%. Although
most prevalence studies have been applied to the entire hospital, it is
probably more effective to target certain areas or services where
infection rates are suspected or known to be high.

Incidence surveillance

In this method, all patients are monitored for HAI. This produces
accurate measures of infection rates. However it requires structured
analysis, strict definitions, and trained staff to visit all patients
repeatedly. Because it is time consuming, incidence surveillance usually
cannot be performed continuously; rather it is often targeted in areas
where problems are known or suspected. For example, surgical teams
should survey clean surgical wound infection, supervised by the ICT.
This means the surgical teams take ownership of the problem and are
more likely to make interventions if rates are high.

Numerator data

The patient's name, identifying number or code, ward or unit, medical

service at the time the infection began to develop, and date of admission
are required. The date of onset of the infection, preceding risk factors
such as respiratory therapy before new pneumonia, site of infection,
significant microorganisms and their sensitivity patterns help to
describe the infection. Additional information should not be collected
routinely unless it will be used. Other information may include patient's
primary diagnosis, age, sex, a measurement of severity of illness,
physician's name, antimicrobial therapy, and indirect risk factors such
as immunosuppressive diseases or therapies.

24
 Surveillance for Healthcare-Associated Infections

Denominator data (population at risk)

Rates are always calculated with the numerator (number of persons

with the infection or condition) divided by the denominator (number of
persons at risk for the infection). The more precisely the denominator
captures the potentially preventable risk elements the better. For
example, healthcare-associated pneumonia cases among patients who
had respiratory therapy divided by number of patients discharged in a
month or on a specific care unit provides some estimate of risk.
However, healthcare-associated pneumonia among such patients
divided by number of patients receiving respiratory therapy, e.g., on a
ventilator, yields a much better and more useful rate. Thus, when
evaluating risks associated with procedures that are long term, such as
urinary catheterisation, it is important to use the number of catheter
days as the denominator instead of the number of patients.

What are the standards for rates of HAI?

There are no published standard HAI rates. The rate will vary with
patient risk and, therefore, there will be different rates in different units.
Ayliffe pointed out that there is an irreducible minimum rate due to
the inherent risks of underlying disease and medical interventions.
Rates will also vary depending on the level of facilities and staffing
available. In general rates should be compared with peer institutions.

Prevalence surveys show average whole hospital rates of HAI of 7-10%.

About 30% of these may be preventable, depending on the patient
population. Surgical site infection rates in clean surgery should
probably be less than 5%, and even less than 1% may be achievable.

Feedback

It is pointless to collect masses of data if they are only seen by the ICT.
Surveillance results must be provided regularly to the front-line clinical
staff in order to help them choose actions to reduce infection rates. It
has been shown on many occasions that feedback with educational
and practical help from the ICT is one of the most effective ways of
effecting change in hygienic practice.

25
IFIC Basic Concepts of Infection Control

There should be a written surveillance plan for the health care facility.
It should include the definitions used, which infections are followed,
how data are collected, and the frequency of data collection. It should
also outline who is responsible for surveillance activities.

References and Further Reading

1. Haley RW, Culver DH, White JW, et al. The efficacy of infection
surveillance and control programs in preventing nosocomial
infections in US hospitals. Amer J Epidemiol 1985;121:182-205.
2. French GL. Repeated prevalence surveys. Ballires Clin Infect
Dis 1996;3:179-95.
3. Monitoring Hospital-Acquired Infections to Promote Patient
Safety -- United States, 1990-1999. MMWR 2000;49:149-53.
4. WHO. Prevention of hospital-acquired infections, A practical
guide [online]. 2nd edition, 2002 [cited 2007 August 10]. (WHO/
CDS/CSR/EPH/2002.12). Available from: URL:
http://www.who.int/emc-documents/antimicrobial_resistance/
whocdscsreph200212.html#english%20contents
5. Horan TC, Emori TG. Definitions of nosocomial infections. In:
Abrutyn E, Goldmann DA, Scheckler WE, editors. Infection
Control Reference Service. Philadelphia: WB Saunders; 1998. p.
17-22.
6. National prevalence survey of hospital-acquired infection:
definitions. A preliminary report of the Steering Group of the
Second National Prevalence Survey. J Hosp Infect 1993; 24:69-76.
7. Gaynes RP. Surveillance of nosocomial infections. In: Bennett JV,
Brachman PS, editors. Hospital Infections, 4th Edition.
Philadelphia: Lippincott-Raven; 1998. p. 65-84.

26
 Outbreak Management

Chapter 4
Outbreak Management
Peter Heeg and Ossama Rasslan

Key points
Outbreaks of infection should be clearly defined, identified,
and promptly investigated because of their importance in
terms of morbidity, cost, improvement of patient care practice
and institutional image.
Proper steps and effective techniques should be used to
investigate a suspected outbreak.
Clear recommendations should be formulated to prevent
further transmission and/or outbreaks.

27
IFIC Basic Concepts of Infection Control

Introduction

Communicable disease outbreak investigation reflects what an

epidemiologist does when investigating disease patterns. Analysis of
patterns of disease occurrence leads to an understanding of their spread
and control.1 Outbreaks should be identified and investigated promptly
because of their importance in terms of morbidity, cost, and
institutional image.2 Outbreak investigations may lead to sustained
improvement in patient care.

Early identification of an outbreak is important to limit spread by health

care workers or contaminated materials. A potential problem may be
initially identified by nurses, physicians, microbiologists, or other
healthcare workers, or through an infection surveillance program.
Appropriate investigations are required to identify the source of the
outbreak and to justify control measures.3

Definitions

Outbreak or epidemic: An excess over the expected (usual) level of a

disease within a geographic area; however, one case of an unusual
disease (e.g., botulism) may constitute an epidemic.3

Pandemic: An epidemic that spreads in several countries, usually

affecting many people.

Endemic: The usual level of a disease within a geographic area (e.g., a

hospital); these sporadic infections (baseline incidence) represent
most preventable healthcare-associated infections.

Relative risk: The relative risk (RR) is a measure of association

between a disease or condition and a factor under study. It is calculated
by dividing the incidence rate of those exposed to the factor by the
incidence rate of those not exposed to the factor. If the RR = 1, the
incidence in the exposed is the same as the incidence in the
non-exposed; thus there is no association between exposure and
disease. RR > 1 denotes a larger incidence in the exposed than in the
non-exposed; thus exposure seems to increase the probability of
developing the disease. RR < 1 denotes a smaller incidence in the
exposed than in the non-exposed; thus exposure seems to decrease the
probability of developing the disease.1

28
 Outbreak Management

Case definition

A case definition should be developed. It must include a unit of time

and place and specific biological and/or clinical criteria. The inclusion
and exclusion criteria for cases must be precisely identified. A graded
definition (definite, probable or possible) often helps. The definition
should differentiate between infection and colonization.3

Example of case definition: A definite case patient will be defined as a

patient hospitalised in the geriatric ward in January, with diarrhoea,
cramps, and vomiting and in whom routine culture of faeces identifies
Salmonella species.

Why Epidemics Occur

There are many reasons why an outbreak occurs. However, four

common reasons are:

1. When susceptible individuals travel into an area where the

infectious disease already exists and is endemic.
2. When humans or animals travel from an endemic area into a
susceptible human population in whom the disease is not
endemic, or when contamination of food, water or other vehicles
takes place by an agent not normally present, such as anthrax
spores placed into mail as a terrorist act.
3. When a preexisting infection occurs in an area of low endemicity
and reaches susceptible persons as a result of new or unusual
social, behavioral, sexual or cultural practices. Examples include
migration of refugees during war time and pilgrimages to
religious places.
4. When host susceptibility and response are modified by natural or
drug-induced immunosuppression (e.g., cancer treatment,
malnutrition or diseases such as acquired immunodeficiency
syndrome).

In health care settings, outbreaks are typically related to hand or

environmental contamination, invasive devices, and procedures.

29
IFIC Basic Concepts of Infection Control

Types of Outbreaks

1. Community-acquired: e.g., possible foodborne outbreak, measles.

2. Healthcare-associated: when two or more cases of infection
appear to be epidemiologically related.4

Investigating an Outbreak

A. Purpose and objectives of an outbreak investigation

The purpose of an epidemic or outbreak investigation is to identify
ways to prevent further transmission or outbreaks of the disease.

The three main objectives are:

1. Identify the responsible etiologic agent,
2. Find the source of infection by studying the occurrence of the
disease among persons, place or time, as well as determining
specific attack rates,
3. Formulate recommendations to prevent further transmission.

B. Outbreak Investigation Tasks

The Infection Control Committee takes the following steps to
investigate a suspected outbreak of a communicable disease. These
steps provide a guideline and may not proceed in sequence.

1. Verify if an outbreak really exists. Compare the number of

current cases with the usual baseline incidence (from previous
months or years). If local data are not available, compare to
information found in national surveillance systems or the
literature (however, these data may not be applicable to the local
situation).

2. Establish diagnosis of reported cases (identify agent).

Define cases based on the following common factors:
Population risk factors: e.g., age, race, sex, socioeconomic
status.
Clinical data (e.g., onset of signs and symptoms, frequency
and duration of clinical features associated with the
outbreak, treatments, devices).
Laboratory results.

30
 Outbreak Management

3. Search for other cases that may have occurred retrospectively or

concurrently. Collect critical data and specimen information from:
Laboratory reports
Medical records
Patient charts
Physicians and nursing staff
Public health data

4. Characterize cases.
a. Assemble and organize available information (in terms of time,
place, and person) for analysis.
Time
- The exact period of the outbreak
- The probable period of exposure
- Date of onset of illness for cases; draw an epidemic curve.
- Is the outbreak common source (single point source) or
propagated (ongoing transmission)?
Place
- Service, ward, operating room.
- Clustering of cases.
Person
- Patient characteristics (i.e., age, sex, underlying disease).
- Possible exposures (i.e., surgery, nursing and medical
staff, infected patients).
- Therapeutic modalities (i.e., invasive procedures,
medications, antibiotics).
- From this information, the population at risk can be
accurately described.

b. Calculate rates
Incidence rate: The number of new cases occurring in the
population during a specified period of time / number of
persons exposed to the risk of developing the disease during
that period of time.1
Attack rate: The cumulative incidence rate of infection in a
group over a period of an epidemic. The attack rate = Number
of people at risk who are infected / Total number of people at
risk.

31
IFIC Basic Concepts of Infection Control

The attack rate can also be stratified by relevant characteristics such as

sex, age, location, or specific exposure (e.g., ventilation, catheterisation,
operating rooms, and occupational exposure). 2

5. Formulate a hypothesis about the cause of the outbreak from

epidemiological and clinical data. Make a best guess to explain the
observations. The hypothesis should explain the majority of cases.

6. Test the hypothesis. This may require a special study.

a. Many investigations do not reach this stage; investigation may end
with descriptive epidemiology and then the problem goes away
without intervention or does not require a special study. Whether or
not an investigation is carried out, the hypothesis testing phase is a
function of available personnel, severity of the problem, and
resource allocation.

b. Examples of situations that should be studied:

- Infection associated with a commercial product.
- Infection associated with considerable morbidity
(e.g., bacteraemia) and/or mortality.
- Infections associated with multiple services.
For example: during an outbreak of food poisoning the
rate of disease in young adults was 40% and in older
individuals was 2%. It was 65% for those who ate in a
popular cafeteria and only 3% for those who ate in other
places. Therefore young children eating in the popular
cafeteria are the ones who should be investigated
regarding specific foods eaten.

c. Analyze data derived from case investigation. Determine sources

of transmission and risk factors associated with disease.

d. Refine hypothesis and carry out additional studies if necessary.

7. Institute control measures and follow up. The aims are:

- To control the current outbreak by interrupting the chain
of transmission.
- To prevent similar outbreaks.

The selection of control measures is determined by the results of the

initial analysis in consultation with appropriate professionals

32
 Outbreak Management

(i.e., infection control staff, epidemiologist, clinicians, microbiologists,

nursing, and technicians). The control measures will vary depending on
the agent and the mode of transmission.3 (See Table 4.1)

Table 4.1. Immediate control measures for outbreak management

Type of transmission suspected Suggested action

Cross-transmission Patient isolation and barrier precautions

(transmission between individuals) determined by infectious agent(s)

Improvements in hand hygiene

Hand transmission
(e.g., washing, disinfection, glove use)

Patient isolation with appropriate

Airborne agent
ventilation

Check water supply and all liquid

Waterborne agent
containers; use of disposable devices

Foodborne agent Elimination of the food at risk

8. Evaluate efficacy of control measures.

- Cases cease to occur or return to endemic level.
- No change occurs (if so, re-evaluate cases).
- Use the opportunity of an outbreak to review and correct
other hospital practices which may contribute to an
outbreak in the future.

9. Communicate, and write a final report.

During the investigation of an outbreak, timely, up-to-date information
must be communicated to the hospital administration, and public health
authorities. In some cases information may be provided to the public
and the media with agreement of the outbreak team, administration and
local authorities.

A final report on the outbreak investigation should be prepared

describing the outbreak, interventions, and effectiveness, and
summarize the contribution of each team member participating in the
investigation. It should include recommendations to prevent any future
occurrence. This report can be published in the medical literature and
may be considered as a legal document.

33
IFIC Basic Concepts of Infection Control

Determination of the source of infection in an outbreak

The source of infection may be:

1. Common source (singlepoint source): Same origin (i.e., the same

person or vehicle is identified as the primary reservoir or means of
transmission).

2. Propagated or continuing source (ongoing transmission): Infections

are transmitted from person to person in such a way that cases
identified cannot be attributed to agent(s) transmitted from a single
source.

3. Both common and propagated source (intermittent source):

Intermittent exposure to a common source produces an epidemic curve
with irregularly spaced peaks.

Epidemic Curve

The character of an epidemic is determined by an epidemic curve. This

is a graph in which cases are plotted according to the time of onset of
illness.3

Reasons for constructing an epidemic curve

To determine whether the source of infection was common, propagated,
or both; the shape of the curve is determined by the epidemic pattern.
To identify the probable time of exposure of the cases to the source(s) of
infection.
To identify the probable incubation period.
To determine if the problem is ongoing.

Characteristics of an epidemic curve

1. An epidemic curve is a histogram.
2. Cases are plotted by date of onset of illness.
3. Time intervals (on the X axis) must be based on the incubation or
latency period of the disease and the length of the period over
which cases are distributed.3

34
 Outbreak Management

KEY
A Propagated source: single exposure, no secondary cases (e.g., measles).
B Propagated source: secondary and tertiary cases (e.g., hepatitis A).
C Common source: point exposure (e.g., Salmonellosis following a company
picnic) (food handler = x).
D Common source: Intermittent exposure (e.g., bacteraemia associated with
contaminated blood product).

Fig 4.1. Epidemic curves: common vs. propagated source outbreak. In practice,
other information gathered in the course of investigation is also used to
interpret epidemic curves. [Reproduced with permission from the Association
for Professionals in Infection Control and Epidemiology, Inc.]3

35
IFIC Basic Concepts of Infection Control

Characteristics of common vs. propagated sources

(See Figure 4.1)
Common source
1. Curve approximates to a normal distribution curve if there are
enough cases and if they are limited to a short exposure with
maximum incubation of few days (common source).
2. Exposure may be continuous or intermittent; intermittent
exposure to a common source produces a curve with irregularly
spaced peaks.

Propagated source
1. Cases occur over a long period.
2. Explosive epidemics due to person-to-person transmission may
occur (i.e., chickenpox); if secondary and tertiary cases occur,
intervals between peaks usually approximate to the average
incubation period.

Determination of the probable period of exposure of cases

in a common-source outbreak
(See Figure 4.2)

Necessary information
1. Specific disease involved
2. Either mean or median, or minimum and maximum, incubation
period(s) for the specific disease
3. Dates of onset of cases

Fig 4.2 Determining the probable period of exposure in common source

outbreaks using mean or median incubation period (A) or minimum and
maximum incubation periods (B). [Reproduced with permission from the
Association for Professionals in Infection Control and Epidemiology, Inc.]3

36
 Outbreak Management

Draw epidemic curve and calculate by either of the following

methods.
1. Using the mean or median incubation period: identify the peak of
the epidemic or the date of onset of the median case; count back
into one incubation period.
2. Using minimum and maximum incubation periods: start with the
first case identified and count back in time the minimum
incubation period; then using the last case, count back in time the
maximum incubation period.

Control measures and follow up

Interventions commonly used to control an outbreak are as follows:

1. Control the source of the pathogen.

- Remove the source of contamination, e.g., discard
contaminated food.
- Remove persons from exposure, e.g., keep people from being
exposed to mosquito bites to prevent West Nile virus
encephalitis.
- Inactivate or neutralize pathogen, e.g., disinfect and filter
contaminated water.
- Treat infected persons.

2. Interrupt transmission.
- Patient isolation and barrier precautions determined by
infectious agents.
- Disinfect environmental sources of transmission, e.g., milk,
water, air.
- Control mosquito or vector transmission using skin repellents,
improve personal sanitation (e.g., washing hands).

3. Control or modify the host response to exposure.

Immunise susceptible hosts, use prophylactic chemotherapy, modify
behaviour or use a barrier (e.g., prevent exposure to mosquito bites by
wearing protective clothing and repellents).

37
IFIC Basic Concepts of Infection Control

Why Some Outbreaks End

Outbreaks may end for the following reasons:

- No more susceptible individuals. Everybody who was

susceptible got the disease.
- No more exposure to the source. The individuals move away
from the source of infection.
- No more source of contamination. The source of contamination
ends (e.g., all the contaminated food is consumed).
- Individuals decrease their susceptibility. People get naturally
immunised or are vaccinated or use preventive measures to
avoid disease.
- The pathogen becomes less pathogenic. Sometimes when
germs (bacteria, viruses) pass from one individual to another
they change or mutate, becoming less pathogenic, or less
capable of producing disease.

Conclusion

Performing surveillance, monitoring trends and detecting outbreaks,

investigating outbreaks and eliminating sources, providing technical
assistance and education to the medical community and designing and
implementing special epidemiologic studies are important for
controlling outbreaks of communicable diseases.

Acknowledgement

We thank Dr. Amany Tharwat, assistant professor of microbiology and

immunology, Ain Shams School of Medicine, Cairo, Egypt, for
invaluable assistance in preparation of this chapter.

References and Further Reading

1. Flora IH, Manuel B. Disease Outbreak Investigation [online]. 2005

[cited 2007 August 10]. Available from: URL: http://
www.collegeboard.com/yes/ft/iu/home.html
2. Ducel G, Fabry J, Nicolle L. Prevention of hospital-acquired
infections; A practical guide 2nd ed. [online]. World Health
Organization. 2002. [cited 2007 August 10].

38
 Outbreak Management

Available from: URL: http://ww.who.int/emc

3. Checko PJ. Outbreak Investigation. In: APIC Text of Infection
Control and Epidemiology. 2nd ed. Washington, DC: Association
for Professionals in Infection Control and Epidemiology; 2005.
p. 1-10.
4. Arthur, LR. Outbreak InvestigationsA Perspective. Atlanta,
GA: National Center for Infectious Diseases, Centers for Disease
Control and Prevention; 1998. Vol 4, No 1.
5. Friis RH and Sellers TA. Epidemiology for Public Health Practice.
Gaithersburg, MD: Aspen Publishers; 1996.
6. Susan P. Outbreak Investigation [online]. 2004. [cited 2007
August 10]. Available from: URL: http://www.uth.tmc.edu/
uth_orgs/hcpc/procedures/volume1/chapter6/infection_control-
51.htm

39
 Audits in Infection Prevention and Control

Chapter 5
Audits in Infection
Prevention and Control
Elizabeth Bryce, Sydney Sharf, Gertie van
Knippenberg-Gordebeke and Moira Walker

Key points
Non-compliance with appropriate infection prevention and
control policies and procedures may lead to outbreaks of
infection.
A well-constructed audit tool will provide consistent
benchmarking across the facility.
Audits can help improve quality, infection prevention
practices, and patient safety.

41
IFIC Basic Concepts of Infection Control

Introduction

Compliance with a good infection prevention and control (IC) policy is

vital for preventing the spread of infection. A practical, objective way to
determine whether a policy is appropriate and sound infection
prevention and control is being practiced is an audit process using a
tool.1 Audit means checking actual practice against a standard; the
process should facilitate identification of risks of infection and unsafe
practices for both patients and staff. The audit should permit reporting
of noncompliance or issues of concern by either healthcare workers
(HCW) or the Infection Control Team (ICT). Providing results to staff
enables them to identify where improvement is needed.

Audit tools are templates for ICTs to evaluate implementation of

procedures, such as standard/routine practices, hand hygiene, isolation
precautions, environmental cleaning, disinfection of equipment,
handling linen/waste/sharps/supplies, etc., in place in their facility. In
addition, specific practices may be monitored, e.g., use of personal
protective equipment, insertion and care of intravascular and urinary
devices, and wound care. The audit can be performed by the ICT or
other designated staff. This audit tool must match the practice and
resources of the healthcare setting.

Audit Method

An effective audit process should include a description of the physical

layout, review of traffic flow, protocols and policies, supplies and
equipment and observations of appropriate IC practice. The audit tool
should be standardised to permit consistent application throughout the
healthcare facility. (See Figure 5.1 for an example tool) Allow for
modifications according to the services to be audited.2 The ICT must be
able to explain the reasons for any changes. The audit should take place
over a defined time. Link personnel and ward staff may assist with the
process.

42
 Audits in Infection Prevention and Control

SAMPLE HAND HYGIENE AUDIT TOOL3

Date: ________________________ Ward:__________________________________

Auditor:________________________________________________________________

Advantages Yes No Comments

1 Liquid soap is available at all hand washing sinks

1a Alcohol-based hand rub is available

2 Liquid soap must be in single use cartridge dispensers

3 Dispenser nozzles are visibly clean

Soft absorbent paper towels are available at all hand

4
washing sinks

Wall mounted or pump dispenser hand cream is

5
available for use

Antibacterial solutions/scrubs are not used for social

6
hand washing

Antibacterial solutions are used for invasive

7
procedures and surgical scrubs

There are no nail brushes on hand wash sinks in

8
clinical areas

The hand wash sinks are free from used equipment

9
and inappropriate items

10 Hand wash sinks are dedicated for that purpose

Hand wash sinks, check that they do not have plugs,

11 overflows or that the water jet does not flow directly
into the plughole

There are sufficient numbers of hand wash sinks

available in accordance with national and local
12
guidance (e.g., one sink per four beds in acute care
settings)

13 Access to hand wash sinks is clear

Hand washing facilities are clean and intact

14
(Check sinks, taps, splash backs)

There is appropriate temperature control to provide

15
suitable hand wash water at all sinks

43
IFIC Basic Concepts of Infection Control

Advantages Yes No Comments

Elbow operated or automated taps are available on

16
hand wash sinks in clinical areas

17a Soap dispensers are readily available

Directly accessible at the point of care (e.g., one

17b dispenser per bed/per four beds as per local and
national standards)

17c Portable for clinical procedures

No wrist watches are worn by staff carrying out

18
patient care

18a No rings are worn by staff carrying out patient care

No wrist jewellery worn by staff carrying out patient

18b
care

19 Staff nails are short, clean and free from nail varnish

19a Artificial nails are not worn

Posters promoting hand decontamination are

20 available and displayed in areas visible to staff before
and after patient contact

Staff has received training in hand hygiene

procedures within the last year.
21 - Ask a member of medical staff
- Ask a member of nursing staff
- Ask a member of ancillary staff

Patients are offered hand hygiene facilities after using

22
the toilet/commode/bedpan, e.g., hand wipe

Patients are offered hand hygiene facilities prior to

23
meals

Observational audit: Observe practice

Nursing staff use the correct procedure for

24
decontaminating hands.

Medical staff uses the correct procedure for

25
decontaminating hands.

44
 Audits in Infection Prevention and Control

Advantages Yes No Comments

Allied Health Care Professionals use the correct

26
procedure for decontaminating hands.

Ancillary staff uses the correct procedure for

27
decontaminating hands.

Nursing staff can indicate when it is appropriate to

28
use alcohol rub

Medical staff can indicate when it is appropriate to

29
use alcohol rub

Allied Health Care Professionals can indicate when it

30
is appropriate to use alcohol rub

Ancillary Staff can indicate when it is appropriate to

31
use alcohol rub

Hand hygiene is performed in the following

circumstances: Observe practice

32a After removal of gloves

32b Prior to clinical procedures

32c After a clinical procedure

32d Prior to handling food

32e After handling contaminated items

32f After leaving an isolation room

45
IFIC Basic Concepts of Infection Control

Preparation of Staff

All HCWs and support staff must be included in preparing for an audit
and understand that its purpose is to improve IC practice. It is in no
way punitive. Pre-audit meetings are essential to explain and discuss
the goals and objectives of the audit, how it will be conducted, and how
the results will be reported. Staff should understand that an objective
approach will be maintained, that the audit will be performed
consistently across the facility, and anonymity will be protected. The
audit team must identify the leaders in the area being audited and
maintain communication with them. Management and other key
decision makers (e.g., educators) need to support the audit team in any
changes required post-audit.

Knowledge Assessment

A questionnaire on employees' knowledge of safe infection prevention

and control practice should be developed and distributed prior to any
audit.2 The questionnaire can assist in determining what areas of
practice should be audited. Respondents should be identified only by
job title (e.g., nurse, physician, radiographer, and cleaner). The
questionnaire can be modified to suit the department or area being
audited. A deadline must be provided so that questionnaires are
returned on time. One person in each survey area should be asked to
ensure that questionnaires are filled in and kept securely for collection
and tabulation by the audit team. The results will allow the ICT to
determine where more education is needed. Dissemination of results
and discussion of the correct answers can be used as an educational
tool.

Preliminary Audit Report

Once the audit is completed, a draft detailed report must be written and
reviewed with management and key staff in the audit area before it is
finalized and distributed. The report should include information on
why the audit was performed, method used, findings, and
recommendations. Compliance data should be included as appropriate.
(See Table 5.1)

46
 Audits in Infection Prevention and Control

Scoring formula:

total number of yes answers

x 100 = %
total number of yes and no responses

It is advisable to mark either Categories can be allocated as

criteria yes/no or non- follows:
applicable. Manual scoring - - minimal compliance 75%
add the total number of yes or less
answers and divide by the total - partial compliance 76-84%
number of questions answered - compliant 85% or above
(including all yes and no
answers) excluding the non-
applicable; multiply by 100 to
get the percentage.

Table 5.1. Example of scoring chart

Advantages Yes No Comments

1 Liquid soap is available at all hand washing sinks X

2 Liquid soap must be single use cartridge dispensers X

3 Dispenser nozzles are visibly clean X

The score for the above table would be calculated as follows:

(2 x 100)/3 = 66.6= 67%

An executive summary should be added and the staff in the area should
be acknowledged and thanked for their support. Staff must appreciate
that the intent is to promote good practice, improve patient care, and
ensure safety. A key person must be identified in each area to help
facilitate implementation of any recommendations within a specified
time.

Follow Up

The introduction of any recommended changes in practice rests with

the unit/department. However, the ICT and other appropriate staff

47
IFIC Basic Concepts of Infection Control

must follow up any recommendations. Identification of key personnel

and specification of deadlines will aid timely follow-up. A system of
feedback to the ICT on actions taken should be in place.

Summary

Development of a consistent method for auditing infection prevention

and control policies and practices and implementation by both IC and
the involved health care staff is a practical method for ensuring a safe
health care environment for patients, staff and the public at large.

References and Further Reading

1. Millward S, Barnett J, Tomlinson D. A clinical infection control

audit programme. J Hosp Infect 1993; 24: 219-232.
2. Bryce EA, Scharf SL, Walker MM. Infection control practitioner
audit form for patient/resident service units. Canadian J Infect
Control 2002; 17:23-26.
3. Infection Control Nurses Association (ICNA), Department of
Health UK, Audit tools for monitoring infection control standards,
2004.

48
 The Role of the Microbiology Laboratory

Chapter 6
The Role of the
Microbiology
Laboratory
Smilja Kalenic

Key points
Diagnosis of infection by the microbiology laboratory has two
important functions: clinical and epidemiological.
The microbiology laboratory should be able to determine the
most frequent microbes causing infections, especially
healthcare-associated infections.
The microbiology laboratory should produce routine reports
for infection prevention and control personnel to make
incidence graphs for specific pathogens, wards, and groups of
patients.
Microbiologists, knowing the role of normal colonizing flora
of humans, the pathogenesis of infections, and the
characteristics of specific pathogens can interpret
microbiological findings for infection prevention and control
personnel.

49
IFIC Basic Concepts of Infection Control

Introduction

The diagnosis of infections performed by the microbiology laboratory

has two important functions. The first is clinical - everyday
management of infections. The second is epidemiological - knowledge
of an infective microbe in a patient can lead to finding its source and
route of transmission. This allows staff to stop infections from
spreading.

The microbiology laboratory has many roles in the control of

healthcare-associated infections (HAI): outbreak management,
performing additional tests for epidemiology, infection surveillance,
knowledge about new alert microbes or unusual resistance, design of an
antibiotic formulary, interpretation of microbiological results, and
education of health care staff. Daily communication of laboratory staff
with the Infection Control Team (ICT) is vital, allowing for timely and
rapid information transmission about HAIs. The clinical microbiologist
should be a member of the Infection Control and Antibiotic Committees
and a member of the ICT.

Microbiology is becoming more important in the prevention of HAIs,

especially as new or antibiotic-resistant pathogens emerge, and more
diagnostic technologies are developed. An important new technology is
molecular diagnostics. Diagnosis can be rapid as it is not dependent on
waiting for bacterial growth in cultures; it is sensitive, as it is based on
detection of only a few microorganisms; it is specific, as it detects
microbe-specific genes.

Clinical practice

Some infections must be diagnosed clinically and treated empirically,

without isolation of causative microorganisms or determination of
antibiotic susceptibility. However if there is a clinical suspicion of
infection, laboratory tests may confirm the diagnosis. The microbiology
laboratory should be able to isolate the commonest infectious agents,
especially those causing HAIs. It should produce periodic reports on
infections for each ward, broken down by pathogen species, infection
site and antibiotic resistance. These reports are very important for the
design of empirical therapy.

50
 The Role of the Microbiology Laboratory

Most HAIs are caused by bacteria and fungi that are more antibiotic
resistant than community acquired pathogens and their susceptibility to
antibiotics is less predictable. Etiological diagnosis in hospitals is
exceptionally important. Targeted antimicrobial therapy will lead to
better outcomes, and as eradication of a pathogen is achieved earlier,
the danger of transmission to other patients will be decreased.

The right specimens from appropriate sites must be taken using proper
techniques. Microbiology laboratory staff can assist in ensuring good
specimens by educating other staff. Identification of the microorganism
and its antibiotic susceptibility should be as precise as possible
(identification to the species level).

Infection control

Outbreaks
To determine the cause of a single-source outbreak the causative
microorganism must be defined. A microbial species may contain
subspecies and variants that differ in particular characteristics.
Individual bacteria can differ as much as 30% in their genomes. Genetic
differences are often phenotypically expressed, however this is not a
rule.

Bacterial typing
Bacterial typing has to determine whether two epidemiologically
connected strains are really related and differ from strains that are not
epidemiologically connected. If strains are unrelated, the patients do not
belong to the same outbreak. If strains are related it is impossible to say
that the patients are involved in an outbreak without epidemiological
analysis. So, epidemiology and typing are complementary.

Typing methods differ in several important points:

Typability, i.e., the method can type most or even all strains of
the same species;
Discriminatory power, i.e., the method can differentiate well
between different types;
Interlaboratory and intra-laboratory reproducibility, i.e., the
method can provide the same typing results in repeated testing
on different sites;
The method should be simple, unambiguous to interpret, and
inexpensive.

51
IFIC Basic Concepts of Infection Control

There are two groups of typing methods: phenotyping and genotyping.

Phenotyping
Using phenotyping methods we can determine characteristics that
can differ between different strains of the same bacterial species.
These methods may be based on antigenic structure (serotyping),
physiologic properties/metabolic reactions (biotyping), susceptibility to
antimicrobial agents (resistotyping) and to colicines (colicinotyping), or
bacteriophages (phage typing).

Phenotyping methods are well standardized with high reproducibility.

Discriminatory power is not always high (if only a few types exist), but
can be very high (if many types exist). They are simple and
unambiguous to interpret. Many are cheap enough to be performed in
every microbiology laboratory.

The main objection to phenotyping is that bacterial genes are not always
expressed. Two phenotypically different strains can actually have the
same genetic background or two phenotypically identical strains can
actually differ genetically. Sometimes the emergence of a particular
phenotype is specific enough to explain an outbreak. However, if a
phenotype is widespread and frequent, genotyping will be required for
outbreak management.

Genotyping
Molecular techniques have revolutionized the potential of the
microbiology laboratory because they have very high typability and
discriminatory power. Genotyping can demonstrate definitely the
relatedness or difference between two isolates of the same species.
However, genotyping methods require use of sophisticated and
expensive equipment and materials by trained staff. Furthermore, some
have a low reproducibility, especially in interlaboratory comparisons.
Result interpretation is neither always simple nor unambiguous.

Additional tests
Sometimes the ICT requires data to clarify endemic or epidemic
situations. Microbiological tests of blood products, environmental
surfaces, disinfectants and antiseptics, air, water, hands of personnel,
anterior nares of personnel, etc., may be required. During an outbreak
or in endemic situations when the causative agent is known, the

52
 The Role of the Microbiology Laboratory

microbiology laboratory can use selective culture media for the agent in
question to minimise expense.

Surveillance of HAIs

The microbiology laboratory should produce routine periodic reports to

allow the ICT to make incidence graphs for specific pathogens, wards,
and groups of patients. These data can be made available immediately if
the laboratory is computerized. A baseline incidence can be
established and any new isolates can then be compared with this
incidence. Graphs enable the ICT to discover the beginning of an
outbreak earlier than it can be discovered clinically. Periodic reports are
also important because they demonstrate trends of specific pathogens,
and can be very useful in planning preventive measures.

Alert organism reports

The early isolation of a new or unusual microorganism, without any
further typing, enables the ICT to take appropriate measures to stop it
from spreading. The ICT should identify, together with laboratory
personnel, possible alert microorganisms, such as multiresistant or
highly pathogenic microorganisms (methicillin-resistant S. aureus,
vancomycin-intermediate S. aureus, vancomycin-resistant enterococci,
multi-drug resistant (MDR) Ps. aeruginosa, MDR A. baumannii, MDR
M. tuberculosis, C. difficile, etc.). Any new isolates should be reported
immediately to the wards and the ICT. Alert organism surveillance may
be all that can be performed if the facility is understaffed. In addition,
laboratory staff may report clustering of infections (two related isolates
in different patients in the same time frame).

Role in antibiotic policy

Determining antibiotic susceptibility patterns for microorganisms

causing HAIs is vital for individual patient care. It can also help in
planning antibiotic policy and designing the antibiotic formulary. The
microbiology laboratory should produce periodic resistance reports for
specific wards and for the whole hospital. These reports should be
available for every physician who prescribes antibiotics.

53
IFIC Basic Concepts of Infection Control

Interpretation of microbiology data

Microbiologists are required to interpret microbiological data (results of

isolation, identification, susceptibility tests, typing). Ideally he/she
should be a medical doctor specialising in clinical microbiology. If this
is not possible, then a properly educated scientist is required. Well
educated microbiologists, knowing the role of normal colonizing flora
of humans, the pathogenesis of infections (incubation period, inoculum
size, kind of vehicle), and the characteristics of specific pathogens
(natural habitat, resistance to drying, to disinfectants and to antibiotics)
can interpret laboratory data for the ICT.

Minimal Requirements for Microbiology Laboratories in

the Control of HAIs

1. Should be within the hospital; if this is not possible, then

negotiate a contract for diagnostic microbiology with the nearest
laboratory.
2. Should be available every day, including Sundays and holidays,
ideally on a 24-hour basis.
3. Should be able to examine blood, cerebrospinal fluid, urine, stool,
wound exudates or swab, respiratory secretions, and perform
basic serological tests (HIV, HBV, HCV).
4. Should be able to identify common bacteria and fungi to species
level (Staphylococcus aureus, Escherichia coli, Salmonella, Shigella,
Pseudomonas aeruginosa, Klebsiella pneumoniae, Group A
streptococci, Group B streptococci, enterococci, Streptococcus
pneumoniae, Campylobacter jejuni/coli, other enterobacteria,
Haemophilus influenzae, Neisseria meningitidis and N. gonorrhoeae,
Stenotrophomonas maltophilia, Candida albicans, aspergilli, etc.).
5. Should be able to perform susceptibility testing to relevant
antibiotics using disc-diffusion methodology.
6. Should be able to perform basic typing - serotyping (for
salmonellae, shigellae, P. aeruginosa, N. meningitidis) and
biotyping (e.g., for S. typhi).
7. Should have quality assurance procedures (both internal quality
control and external quality control [national or international]).
8. Should have a clinical microbiologist (if possible a medical
doctor) who has good skills of communication with clinical and
ICT staff.

54
 The Role of the Microbiology Laboratory

9. May have the ability to perform simpler genotyping methods or

access to genotyping methods centrally at state or regional
laboratories. The central laboratory can then assist with
epidemiological investigations of HAIs.

References and Further Reading

1. Diekema DJ, Pfaller MA. Infection Control Epidemiology and

Microbiology Laboratory. In: Murray PR, Editor in Chief. Manual
of Clinical Microbiology, 8th ed. Washington, DC: ASM Press;
2003. p. 129-38.
2. Stratton CW IV, Greene JN. Role of the Microbiology Laboratory
in Hospital Epidemiology and Infection Control. In: Mayhall CG,
editor. Hospital Epidemiology and Infection Control, 3rd ed.
Philadelphia: Lippincott, Williams & Wilkins; 2004. p. 1809-25.
3. Poutanen SM, Tompkins LS. Molecular Methods in Nosocomial
Epidemiology. In: Wenzel RP, editor. Prevention and Control of
Nosocomial Infections, 4th ed. Philadelphia: Lippincott, Williams
& Wilkins; 2003. p. 481-99.
4. Gill VJ, Fedorko DP, Witebsky FG. The clinician and the
Microbiology Laboratory. In: Mandell GL, Bennett JE, Dolin R,
Editors. Mandell, Douglas and Bennetts Principles and Practice
of Infectious Diseases, 6th ed. Philadelphia: Elsevier; 2005. p. 203-
41.
5. Peterson LR, Hamilton JD, Baron EJ, et al. Role of clinical
microbiology laboratory in the management and control of
infectious diseases and the delivery of health care. Clin Infect Dis
2001;32:605-11.

55
 Principles of Antibiotic Policies

Chapter 7
Principles of
Antibiotic Policies
Smilja Kalenic and Michael Borg

Key points
Resistant bacterial strains are selected in hospitals due to the
huge usage of antibiotics.
To preserve the susceptibility of microorganisms, and
postpone the development of resistance, antibiotics should be
used rationally.
If resistant bacteria develop in an environment where the
specific antibiotic is used, they will become prevalent in that
environment.
Good antibiotic prescribing practices should be encouraged
within hospitals.
The microbiology laboratory service can assist clinicians to
use targeted antibiotic treatment for patients.

57
IFIC Basic Concepts of Infection Control

Introduction

The discovery of antibiotics was a revolutionary event in the history of

medicine that saved millions of lives. However their effectiveness has
lessened because microorganisms develop resistance. A vicious cycle
has been created, requiring new antibiotics which are invariably more
expensive. Many medical services cannot afford such expensive agents,
and so patients, especially in developing countries, will be denied
appropriate treatment. To preserve susceptibility or at least postpone
development of resistance, antibiotics should be used rationally. This is
of prime interest to everyone government, physicians and the public.
Resistance can be delayed by measures aimed at better prescribing:
education, guidelines and protocols, surveillance of antibiotic usage and
bacterial resistance with regular feedback to physicians. Any such
initiative must exist together with effective infection prevention and
control.

Antibiotic resistance develops through the natural process of mutation.

As bacteria multiply rapidly (sometimes once every 20 minutes),
mutations can be expressed very quickly. If this happens in an
environment where the antibiotic is commonly used, resistant strains of
bacteria will be selected and become prevalent. Resistance can be
transferred not only to their offspring, but to totally different bacteria. If
this happens in a hospital with an inadequate infection prevention and
control (IC) programme then the resistant bacteria may spread, and
cause outbreaks.

Antibiotics affect normal human flora, which can become resistant and
then act as a reservoir of resistance genes. This poses a unique problem
in that treatment of one patient's infection may potentially affect all
microorganisms in a certain population. Therefore narrow spectrum
antibiotics should be used whenever possible. Antibiotics are also used
extensively in veterinary medicine (for infections and as growth
promoters) and agriculture, creating additional reservoirs of antibiotic
resistant microbes that may infect humans.

Most authorities believe that excessive antimicrobial use is directly

responsible for development of resistance, and that good antibiotic
prescribing practices should be encouraged. Effective IC interventions
should also be used, although mathematical models suggest that in

58
 Principles of Antibiotic Policies

situations where there is both a high level of antibiotic resistance and a

high antimicrobial consumption, control of antibiotic use provides the
best solution.

The microbiology laboratory can assist clinicians to use targeted

antibiotic treatment for particular patients, and reduce unnecessary
antibiotic therapy. This can be undertaken through:

Surveillance of bacterial resistance with regular feedback to

prescribers.
Restrict reporting of antibiotic sensitivities to narrow spectrum
agents, only reporting second and third line antimicrobials when
first-line will not work.

Antibiotic stewardship

Antibiotic stewardship programmes often help to modify prescribing

practices of physicians, usually resulting in decreased use. However,
few investigators have studied the outcomes, particularly in terms of
the reduction of bacterial resistance.

Any programme should be well designed, and implemented through a

mixture of voluntary, persuasive or restrictive means. Education is
important, as is production and dissemination of guidelines. The
programme should be audited regularly and feedback provided both to
users and programme directors. If an audit indicates that voluntary
methods are not working, restriction of certain classes of antibiotics may
be necessary.

Antibiotic Guidelines

Antibiotic guidelines or policies demonstrate a commitment to rational

and prudent use of antibiotics. If an antibiotic policy exists in a country,
it means that government, medical society, and public are aware of the
problem and committed to try to solve it. Policies should focus on using
antibiotics with the narrowest spectrum, which are cheap, have minimal
toxicity, and have the least impact on development of resistance.

National Antibiotic Policy

Antibiotic policy initiatives should start at the national level with

59
IFIC Basic Concepts of Infection Control

regulation of production and import of antibiotics as well as control of

local production. Antibiotics should be prescribed only by medical
doctors. The government has to ensure a sufficient quantity of essential
antibiotics is available to meet local needs. Furthermore, it should
ensure that every hospital has access to effective microbiology and
infection prevention and control services. The national policy should
include education on antibiotic use and misuse at both the graduate and
postgraduate level. There should be written guidelines for the treatment
of important community-acquired infections. In addition, the general
population should be educated about the consequences of antibiotic
misuse.

Hospital Antibiotic Policy

Hospitals should have guidelines and protocols for antibiotic use.
Protocols may be ward specific, especially if there are special problems
due to bacterial resistance for example in oncology or intensive care
wards.

Improper antibiotic prescribing in hospitals has been described as too

many patients receiving unnecessary broad spectrum antibiotics by the
wrong route, in the wrong dose and for too long. Such practices often
result from resistance among prescribers who believe that personal
experience is more relevant than evidence-based recommendations, or
view initiatives simply as excuses to cut costs. Physicians often question
why they should not use any antibiotic. The answer is simple:
antibiotics do not act on the patients, but on their microorganisms.
Individual treatments can and do impact other patients through spread
of resistance. In addition, infections happen in patients under the care of
many different medical specialists, most of whom are not specially
educated in infectious diseases.

An antibiotic policy requires a holistic approach including prioritisation

by hospital administrators and involvement of multiple stakeholders as
well as dedicating sufficient manpower and financial resources.
Important initiatives are:

1. The Antibiotic Committee This committee can be either stand-alone

or a part of the Drug and Therapeutics Committee. The members
should be:
doctors who prescribe antibiotics (specialists in infectious

60
 Principles of Antibiotic Policies

diseases, intensive medicine, internal medicine, paediatrics,

clinical pharmacology, surgery);
nurses, especially in countries where they prescribe antibiotics;
pharmacists (will provide data about antibiotic use);
microbiologists (will provide data about bacterial resistance, as
well as mechanisms and development of resistance);
members of the hospital management;
member of the Infection Control Committee (often, especially in
small hospitals, this is the microbiologist).
Others may be co-opted as needed.

2. The antibiotic management team Larger hospitals should have a

team to advise on antibiotic use and audit prescribing. It could include
infectious disease physicians, clinical pharmacologists, pharmacists,
clinical microbiologists, and any doctors authorised to use reserve
antibiotics. An antibiotic pharmacist (at least part-time) with the
support of the Infection Control Doctor (ICD) is a minimum
requirement for smaller institutions.

3. Guidelines and protocols Antibiotic Committees must prepare local

guidelines / protocols for antibiotic use. Some hospitals prefer to issue
guidelines that can be followed by physicians whereas others issue
protocols with which physicians are expected to adhere. The areas most
often covered by an antibiotic policy are:

list of antibiotics in the hospital formulary - no antibiotic outside

the list should be used.
guidelines for empiric and targeted treatment of the most
frequent infections, including dosage and duration of treatment;
it usually contains first and second line therapy, and what to use
for allergic patients.
protocol for surgical prophylaxis (including stop-orders after 24
hours)
protocol for evaluation of parenteral use of antibiotics, including
stop-orders after 3-5 days (depending on severity of infection)
and recommendation of sequential treatment.
protocol for a reserve antibiotic, how to order, who can authorise
its use (usually the microbiologist, ICD or infectious disease
physician).

61
IFIC Basic Concepts of Infection Control

The guidelines and protocols should be developed after discussions

with all the hospital physicians, and take into consideration their views
on type of antibiotic, route of administration, dosing and duration of
therapy. They will then be owned by everyone and easier to implement.

Antibiotics for surgical prophylaxis should vary according to the type

of operation and particular epidemiological situation. Prophylactic
antimicrobials should be different from those normally used to treat
surgical infections.

The list of antibiotics available depends on a country's politics and

funding of the health care system. The WHO recommends a list of
essential antibiotics in the Model List for Essential Drugs, which is
updated every two years. The most recent list (2005) includes 26
antibacterial antibiotics (18 on the basic list, 2 for sexually transmitted
diseases, and six on the complementary list to be used for exceptionally
severe healthcare-associated infections caused by resistant pathogens
(ceftazidime, ceftriaxone, imipenem, sulphadiazine, clindamycin and
vancomycin).

Antibiotics recommended in local guidelines/protocols should be

chosen according to local bacterial resistance patterns. If a hospital does
not have a microbiological service, regional or national resistance data
can be used. If such data do not exist, then guidelines/protocols could
be based on international resistance data, although this is least
appropriate.

4. Education Correct use of guidelines/protocols requires education,

especially of younger physicians. Further education should be planned
as formal meetings, clinical rounds with antibiotic committee members
or antibiotic management team, and formal lectures. Education must
focus on new antibiotics, new methods of administration, and the
influence on bacterial ecology. Education has to be provided by
employees or an independent professional outside of the hospital. It
must NOT be provided by individuals from the pharmaceutical
industry. Drug company presentations require the endorsement of the
Antibiotic Committee and should not be provided unless a committee
member is present.

Microbiology laboratories should only test the recommended

antibiotics. Only report first line antibiotics if an isolate is sensitive; if

62
 Principles of Antibiotic Policies

resistant, add the second line antibiotic. This makes it less likely that
second line antibiotics (usually broader spectrum, more toxic, more
expensive) will be prescribed.

Feedback to clinicians on antibiotic use and cost as well as resistance on

their wards is often the most effective educational tool for changing
prescribing habits.

Control of Healthcare-Associated Infections

Resistant bacterial strains are selected in hospitals by excessive

antibiotic use, but may also enter a hospital when patients come from
another hospital, nursing home, or even the community. When patients
are discharged, resistant strains leave hospitals. If hospital IC is
effective, there is an equilibrium between introduced, selected and
discharged resistant strains and containment of resistance will be
possible.

Effective infection prevention and control should decrease healthcare-

associated infections, stopping outbreaks and decreasing transmission
of pathogens. This will decrease antibiotic usage and reduce antibiotic
pressure. Hence, there will be less selection of resistant strains.
However it cannot stop the emergence of new resistance patterns, and
so will only be successful in combination with effective antibiotic
policies. Of course, poor IC leads to more infections, more antibiotic
usage, more resistance, etc., and so a vicious cycle occurs.

Minimal Requirements for Hospital Antibiotic Policy

1. Antibiotic Committee producing a hospital formulary and

guidelines for empiric and targeted therapy of infection in the
particular setting.
2. Microbiology service - in the hospital or contracted out.
3. Surveillance of antibiotic consumption and antimicrobial
resistance; regular feedback to prescribers.
4. Effective IC programme.
5. Education programme on antibiotic use and consequences of
antibiotic misuse.

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IFIC Basic Concepts of Infection Control

References and Further Reading

1. WHO Global Strategy for Containment of Antimicrobial

Resistance. WHO, 2005. [cited 2007 August 17]
http://www.wpro.who.int/health_topics/antimicrobial_resistance
2. Interventions and strategies to improve the use of antimicrobials
in developing countries. WHO, Drug Management Program,
2001. [cited 2007 August 17] Available from: URL: http://
www.who.int/drugresistance/
Interventions_and_strategies_to_improve_the_use_of_antim.pdf
3. WHO Model List (Essential medicines); 15th edition, March 2007.
[cited 2007 August 17] Available from: URL: http://
www.who.int/medicines/publications/EssMedList15.pdf
4. French GL. Antimicrobial resistance in hospital flora and
nosocomial infections. In: Mayhall CG ed. Hospital Epidemiology
and Infection Control, 3rd ed. Philadelphia: Lippincott Williams
& Wilkins; 2004. p. 1613-38.
5. vanSaene HKF, Reilly NJ, deSilvestre A, Nardi G. Antibiotic
policies in the intensive care unit. In: vanSaene HKF, Silvestri L,
de la Cas MA, editors. Infection Control in Intensive Care Units.
Berlin: Springer; 2005. p. 231-46
6. Nicolle LE. Infection control programmes to contain antimicrobial
resistance [online]. 2001 [cited 2007 August 10]. Available from:
URL: www.who.int/emc

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 Hand Hygiene

Chapter 8
Hand Hygiene
Gertie van Knippenberg-Gordebeke,
Pola Brenner and Peter Heeg

Key points
Hand hygiene is one of the most important ways to prevent
cross contamination.
Alcoholic hand rub is a quick safe method to reduce skin flora.
Alcoholic hand rub can replace routine hand washing and
routine surgical scrub if hands are not visibly soiled.
Long nails, nail polish, rings, bracelets and wrist watches
should not be worn.
All personnel should follow written hand hygiene guidelines.
Gloves should only be worn for specific tasks.
Continuous education and regular audit can improve hand
hygiene compliance.

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IFIC Basic Concepts of Infection Control

Introduction

Since ancient times, personal hygiene and environmental cleaning have

been associated with less illness and death. In Vienna in 1846, Ignaz
Semmelweis demonstrated that washing hands with a chlorine solution
before examining patients in an obstetric unit reduced the mortality due
to puerperal endometritis. This was the first objective evidence that
hand hygiene may reduce transmission of infections. Nowadays hand
hygiene is still the central component of a patient safety program.

Many other researchers have demonstrated that colonised or infected

patients can contaminate the hands of healthcare workers (HCW) who
can transmit infections to other patients if they don't wash their hands.
Hands are the most frequent route of transmission for pathogens in
hospitals.

Although the effectiveness of hand hygiene in reducing infections is

generally accepted, changes in techniques based on rational approaches
or on laboratory-based evidence are occurring. These relate to choice of
products: antimicrobial or plain soaps or alcohol-based hand rubs.
However todays main problems are not related to technique or
products but to improving compliance. Compliance with
recommendations is generally low (average 40%-60%). Combined
strategies of education, supervision, feedback, and alcohol based
waterless bedside antiseptics could improve compliance. Healthcare
institutions are different, so the right strategy must be worked out for
each.

Skin flora

Microbes on the hands can be divided into transient and resident.

Transient flora rest on the superficial layers of the skin; they are often
acquired by HCWs during contact with patients. These microorganisms
are easily transmitted by contact. Transient flora is most frequently
associated with cross transmission.

Resident flora lives permanently in the deeper layers of the skin

(epidermis), and is more resistant to removal. Most resident flora (e.g.,
coagulase-negative staphylococci and diphtheroids) are unlikely to be
associated with infections. However the hands of HCWs may become

66
 Hand Hygiene

persistently colonised or infected with pathogens (e.g., S. aureus,

Gram-negative bacilli, or yeasts). This flora is transmitted like transient
flora and constitutes a serious danger within hospitals.

Damaged or diseased skin, for example cuts, eczema or psoriasis, can

allow multiplication of flora, often without obvious infection. This can
be the most dangerous of all situations. HCWs with skin lesions should
not participate in direct contact with patients.

Techniques for Washing and Decontamination

Fingernails, Nail polish and Artificial nails

Fingernails must be kept short and clean. Chipped nail polish may
support the growth of larger numbers of microorganisms. Artificial
nails have been implicated in several outbreaks of infection caused by
Gram-negative bacteria and yeasts and therefore have to be avoided.

Jewellery
Rings (including wedding/marriage ring), bracelets and wrist watches
may not be worn. Several studies have demonstrated that skin
underneath jewellery and watches is more heavily colonised. It is
impossible to clean and/or decontaminate the skin adequately when it is
covered by jewellery. Rings and watches make donning gloves more
difficult and may cause gloves to tear more easily.

Gloves
Gloves should only be worn for the chosen task and removed
immediately afterward. Gloves reduce the risk of transmission of
pathogens and acquiring infections from the hands of personnel by
70-80%. Gloves also protect HCWs hands from patients flora and
infectious body fluids. However, wearing gloves does not provide total
protection and does not eliminate the need for hand hygiene.
Microorganisms can contaminate the HCWs hands via small defects in
gloves or during glove removal, therefore hand hygiene is strongly
recommended after glove removal.

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IFIC Basic Concepts of Infection Control

Lesions
Minor wounds on the hands or skin lesions must be covered with
moisture proof dressings. If possible, HCWs with skin lesions should
not participate in direct contact with patients.

Hand hygiene technique

Use of an alcohol-based hand rub is the preferable method to
decontaminate hands. Apply a sufficient volume of product to the palm
of one hand and rub hands together, covering all surfaces and fingers,
until hands are dry. Covering the whole surface of the hands is
important see Figure 8.1.

Hand washing
Wash hands with soap and water when visibly dirty, if contaminated
with proteinaceous material, blood or other body fluids, if exposed to
spore-forming microorganisms, and after using the restroom/toilet - see
Figure 8.2. When washing hands with soap and water: wet hands first
with water, apply the product and rub together vigorously covering all
surfaces of the hands and fingers. Rinse with water and dry thoroughly
with a disposable towel. Use towel to turn off the faucet.

Improving Compliance

The full support of health care institutions is needed to ensure good

hand hygiene compliance. A clear written policy on hand hygiene is
essential and should be followed by all HCWs, including medical
doctors. Easy access to hand hygiene facilities is essential.

On-going promotion campaigns, communication, and information

rounds should be used to increase awareness of all staff to the need for
good hand hygiene. Monitoring technique and performance feedback
on hand hygiene are also critical elements see Figure 8.3. Careful
selection of products may improve compliance staff will not use one
that they see as damaging to their skin or difficult to use.

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 Hand Hygiene

Alcohol Hand Rub Technique

Figure 8.1. Alcohol Hand Rub Technique

[Adapted with permission from an original poster of the WHO World Alliance
for Patient Safety. http://www.who.int/gpcs]

69
IFIC Basic Concepts of Infection Control

How to Handwash?

Figure 8.2. Handwashing Technique [Adapted with permission from an original

poster of the WHO World Alliance for Patient Safety. http://www.who.int/gpcs]

70
 Hand Hygiene

The 5 Moments for Hand Hygiene

Figure 8.3. Your Five Moments for Hand Hygiene.

[Adapted with permission from an original poster of the WHO World Alliance
for Patient Safety. http://www.who.int/gpcs]

71
IFIC Basic Concepts of Infection Control

Basic Recommendations

If hands are not visibly soiled, use an alcohol-based hand rub for
routine antisepsis (hygienic hand disinfection). Rub till hands are
dry.
Wash your hands before starting work, before entering the OR,
before eating, after using a restroom and in all cases where hands
are visibly soiled.
Keep nails short and clean.
Do not wear artificial fingernails, nail polish or jewellery.
Do not wash gloves between uses with different patients.
Multiple-use cloth towels of the hanging or roll type are not
recommended for health care institutions.
When bar soap is used, soap racks that facilitate drainage and
small bars of soap should be used; liquid detergents in dispensers
are preferred.
To prevent contamination, do not add soap to a partially empty
liquid soap dispenser. Empty the dispenser completely and clean
it thoroughly before refilling.
Hand hygiene products should have low irritancy, particularly in
multiple use areas, such as intensive care or operating rooms.
Ask personnel for input regarding the tolerance of any products
under consideration.
For surgical scrub preferably use an alcohol-based hand rub.
When using an alcohol-based surgical hand-scrub
pre-wash with soap and dry hands and forearms completely
(including removal of debris from underneath the nails using a
nail cleaner) once a day before starting surgery and when hands
get soiled (e.g., glove perforation) or sweaty. Brushes are not
necessary and can be a source of contamination. Hand washing
immediately prior to every rub does not improve its efficacy and
should be abandoned. Scrub for 1-5 minutes according to the
manufacturers recommendation After application, rub till hands
are dry before donning sterile gloves.
Hands must be fully dry before touching the patient or patients
environment/equipment for the alcohol hand rub to be effective.
This will also eliminate the extremely rare risk of flammability.
Use hand lotions frequently to minimize irritant contact
dermatitis.

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 Hand Hygiene

Encourage personnel to report any adverse event related with a

hand hygiene product to the infection prevention and control
person and to the Occupational Health Department.

Strategies to improve hand hygiene

Make an alcohol-based hand rub available at the entrance to the

patient's room or at the bedside.
Educate personnel continuously regarding the relevance of hand
hygiene and when and how they must do it.
Provide appropriate administrative support and financial
resources.
Provide HCWs with a readily accessible alcohol-based hand-rub
in individual pocket-sized containers to be carried.
Provide HCWs with hand lotions or creams, especially in critical
areas, if there is no possibility for a wall fixed container.
Provide diagrams on how to use a rub to ensure complete
coverage of the hands.
Monitor HCWs' adherence with local recommendations and
guidelines and provide feedback to personnel with information
regarding their performance.
Evaluate adherence to hand hygiene using a performance
indicator. For example, number of hand-hygiene episodes
performed by personnel divided by the number of hand-hygiene
opportunities, by ward or by service.

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IFIC Basic Concepts of Infection Control

References and Further Reading

1. Centers for Disease Control and Prevention (CDC). Hand

Hygiene in Healthcare Settings [online]. 2002 [cited 2007 August
10]. Available from: URL: http://www.cdc.gov/handhygiene/
2. Dutch Working Party Infection Control (WIP), WIP Guidelines
Hand hygiene [online]. 2004 [cited 2007 August 10]. Available
from: URL: www.wip.nl
3. World Health Organization. WHO Guidelines on hand hygiene in
health care. (advanced draft) [online]. 2005 [cited 2007 August
10]. Available from: URL: http://www.who.int/patientsafety/
events/05/HH_en.pdf
4. Ministry of Health and Long term Care of Ontario. PIDAC
Provincial Infectious Diseases Advisory Committee Fact Sheet
Hand hygiene [online]. 2006 [cited 2007 August 10]. Available
from: URL: http://www.health.gov.on.ca/english/providers/
program/pubhealth/handwashing/hw_about.html

74
 Isolation Precautions

Chapter 9
Isolation Precautions
Pola Brenner and Ulrika Ransj

Key points
Microorganisms causing healthcare associated infections
(HAI) can be transmitted from infected and colonised patients
to other patients and staff.
Appropriate isolation precautions (IP) for infected and
colonised patients can reduce the risk of transmission if they
are applied properly.
The objective of IP policy is to decrease the transmission of
infectious agents between staff and patients to such a level
that infection or colonisation does not occur.
IP policies have several parts: hand hygiene, protective
clothing, single rooms with more or less sophisticated
ventilation, and restrictions for movement of patients and
staff.
Apply IP according to signs and symptoms; do not wait for
laboratory results. Infectious patients include those with
diarrhoea and vomiting, gross bleeding, fever and exanthema,
cough and fever, and large discharging wounds.

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IFIC Basic Concepts of Infection Control

Introduction

There are three fundamental principles for health care of patients with a
transmissible infection:
1. What will IP achieve?
2. What is the route of transmission of the infectious agent?
3. Can you prevent infection between patients, or between patients
and health care workers (HCW)?

IP policies are debated, internationally, nationally and locally. Some of

the main areas of debate are:
Ventilation of isolation rooms
Nature and significance of airborne transmission
Placement of patients and the role of screening cultures
Importance of clothing in transmission of infection
Hand hygiene - soap and water or alcoholic rub
Gloves and gowns for close contact only or when entering an
isolation room
Use of masks
Environmental disinfection at regular intervals or when needed

Evidence is sometimes difficult to find. Publications rarely provide

detailed information or take into account the relative importance of a
preventive measure (e.g., if hand hygiene is poor, single rooms do not
help). Investigations on IP are difficult and costly and are therefore rare.
Outbreak reports are numerous, but cannot be used to estimate the
effects of preventive measures, as it is usually very hard to determine
what actually terminated the outbreak.

Transmission of Infection

To interrupt the chain of transmission, we first need to review the

routes for transmission of microorganisms. They can be categorized as
follows:

Contact Transmission
Direct contact, e.g., a surgeon with an infected wound on a finger
performs a wound dressing.

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 Isolation Precautions

Indirect contact, e.g., secretions transferred from one patient to

another via the hands of a HCW.
Faecal-oral via food.

Bloodborne Transmission
Blood is transferred via sharps or needle stick injuries, transfusion or
injection.

Droplet Transmission
Infectious droplets that are expelled, e.g., when sneezing, coughing,
vomiting. The droplets are too heavy to float in the air and fall < 2 m
from the source.
Direct droplet transmission. Droplets reach mucous membranes
or are inhaled.
Droplet to contact transmission. Droplets contaminate surfaces/
hands and are transmitted to another site, e.g., mucous
membranes. Indirect droplet transmission is often more efficient
than direct transmission. Examples are: common cold, respiratory
syncytial virus.

Airborne Transmission
Small particles carrying microbes are transferred as aerosols via air
currents for > 2m from the source, e.g., droplet nuclei or skin scales.
Direct airborne transmission. Particles are inhaled (e.g., Varicella
zoster) or contaminate wounds (e.g., S. aureus).

Standard Precautions

These precautions are taken with every patient, independent of any

known condition (e.g., infected or colonised). Standard precautions are
designed to prevent cross transmission before a diagnosis is known.
Some areas use the term routine practices instead of standard
precautions.

Standard precautions include

hand disinfection with alcohol, or hand washing before and after
patient care;
disposable gloves on contact with blood and body fluids;
protective apron or gown if there is an expectation of contact with

77
IFIC Basic Concepts of Infection Control

body fluids; and

mask and goggles or other face protection if there is an
expectation of splashing to the face.

The routes of transmission that are prevented by basic hygienic

precautions are
Contact
Bloodborne
Droplet

Ward Design

Wards can be designed to facilitate standard precautions. Washbasins

are needed for good hand hygiene, as hands should be washed when
visibly dirty. However, hand hygiene is not improved by installing >1
sink per 6 beds.1 Dispensers for alcohol hand rubs must be placed where
they are easy to reach. In high-risk wards one per bed is desirable.

Space between beds is important. Beds should be at least far enough

apart that a nurse cannot touch both beds at the same time. Decreasing
the distance between beds from 2.5 to 1.9 m increases transfer of MRSA
3.15 times.2 Spread of MRSA can be directly related to overcrowding.3 If
gowns are used, a separate gowning area may be useful.

Prevention of Airborne Transmission

Airborne transmission between patients can be prevented in several

ways. Simply placing the patient in a single room (including bathroom
facilities) reduces the risk of transmission.

Use of single rooms prevents transmission, but ventilated rooms with

negative or positive pressure are difficult to maintain, and have not
been shown to be more effective for preventing spread of tuberculosis
than single rooms with the doors closed. Single rooms with ventilated
anterooms (airlocks) reduce the risk of air movement between room and
corridor. They are easier to maintain but costly to build. If several
patients have an infection caused by the same agent, they can share the
same room (cohort isolation).

78
 Isolation Precautions

Prevention of airborne transmission within a room by turbulent

ventilation (dilution of aerosols) is extremely difficult. High numbers of
particles are emitted from a patient with tuberculosis (TB) when
coughing or sneezing. These are unlikely to be rapidly diluted by
ventilation.4

Placement of Patients

In most cases standard precautions are sufficient; however placement of

patients into different types of rooms may be useful in some
circumstances. Placement of patients should be based on clinical signs
and not on culture results.

When placing patients, the following should be considered:

Single room (including bathroom) when gross contamination of
the environment is likely (e.g., large wounds with heavy
discharge, massive uncontrolled bleeding, diarrhoea).
Single room, door closed when airborne to contact transfer is
likely (e.g., injured skin with Gram positive infection).
Single room ventilated to the outside when airborne transfer is
likely (e.g., TB).
Single room with airlock when massive airborne transfer is likely
(e.g., varicella).

Use of a single room is not the whole solution to preventing spread of

microbes. In an intensive care unit with eight single rooms observed for
three years, methicillin-resistant S. aureus (MRSA) isolation was
practiced after positive surveillance culture. Despite this, 56 patients
admitted from the community with undiagnosed MRSA caused 80
healthcare-associated cases. Transmission stopped when barrier nursing
of ALL patents was introduced.5 Surveillance cultures are costly, have a
low sensitivity, usually focus on one or two infectious agents and divert
attention and resources from more important areas of concern. They
may, however, be helpful in an outbreak.

Staff, Equipment and Surfaces

To keep staff, equipment and surfaces clean is one of the main objectives
of infection prevention and control. The Oxford English Dictionary

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IFIC Basic Concepts of Infection Control

defines clean as:

free from dirt, marks, or stains
having been washed since last worn or used
(of a person) attentive to personal hygiene
free from pollutants or unpleasant substances

Hands
Hand disinfection is a most important part of patient IP see Chapter 8.

Gloves
Where contamination is great, hand disinfection may not be enough to
block contact transmission. When touching secretions, hands need
protection by using clean disposable gloves. However gloves are often
overused. In one study, 120 HCW were observed during 784 patient
contacts. Gloves were used in 93,5% of contacts but were needed only in
58%. 82% of the contacts that should have been aseptic were performed
with dirty gloves. Hand disinfection was not performed in 64% of
contacts.6 Disinfection of gloves with alcohol is ineffective, dissolves the
glove material, and should not be practised.

Clothes
Contamination of working clothes can be considerable, and can be
reduced 20-100 times by wearing a protective gown.7 Wearing a plastic
apron during nursing procedures reduced the transmission of S. aureus
in abdominal surgery cases to the patients bed by thirty times, as
compared to wearing a uniform changed daily.8

Masks
Masks, goggles, and visors are protection against blood splashes. There
is no evidence that an operating room mask protects staff or patients
against colonisation or infection of the respiratory tract. A respirator
may be used as protection against tuberculosis (especially multi- or
extended-drug resistant).

Environmental Surface
Surfaces are becoming more of a problem in infection prevention and
control. See Chapter 17 for information.

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 Isolation Precautions

Family Members Providing Care to Patients in Hospitals

It is very important that family members providing care to patients in

hospitals be educated by the staff to use good hygiene and appropriate
IP to prevent spread of infections to themselves and to other patients.
The precautions for family members should be the same as those used
by the staff, excluding the use of gloves.

IP Policy

In all patient care, transfer of potentially harmful microorganisms

between patients and staff must be avoided. For this reason, the
following general precautions are used:
Regard all patient blood, excretions and secretions as potentially
infectious and institute standard precautions for all patients to
minimise risks of transmission of infection
Decontaminate hands between each patient contact.
Wash hands promptly after touching infective material (blood,
body fluids, secretions, or excretions).
Use no touch technique when possible to avoid touching infective
material.
Wear gloves, if available, when in contact with blood, body
fluids, secretions, excretions and contaminated items. Disinfect
hands immediately after removing gloves. Change gloves
between patients.
Dispose of faeces, urine and other patient secretions via
designated sinks, and clean and disinfect bedpans, urinals and
other containers appropriately. (See Chapter 10)
Clean up spills of infective material promptly. (See Chapter 10)
General disinfection of floors and walls is then not necessary.
Ensure that patient-care equipment, supplies, and linen
contaminated with infective material is cleaned and/or
disinfected between each patient use. (See Chapters 10 and 17)

References and Further Reading

1. Vernon MO, Trick WE, Welbel SF, et al. Adherence with hand
hygiene: does number of sinks matter? Infect Control Hosp
Epidemiol 2003;24: 224-5.

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IFIC Basic Concepts of Infection Control

2. Kibbler CC, Quick A, ONeill AM. The effect of increased bed

numbers in MRSA transmission in acute medical wards. J Hosp
Infect 1998;39:213 -9.
3. Borg MA. Bed occupancy and overcrowding as determining
factors in the incidence of MRSA infections in the general ward
setting. J Hosp Infect 2003;54:316-8.
4. Fennelly KP, Nardell EA. The relative efficacy of respirators and
room ventilation in preventing occupational tuberculosis. Infect
Control Hosp Epidemiol 1998;19:754-9.
5. Hartstein AI, Denny MA, Morthland VH, et al. Control of
methicillin-resistant Staphylococcus aureus in a hospital and an
intensive care unit. Infect Control Hosp Epidemiol 1995;16(7):405-
11.
6. Girou E, Chai HT, Oppein F, et al. Misuse of gloves: the
foundation for poor compliance with hand hygiene and potential
for microbial transmission? J Hosp Infect 2004;57:162-9.
7. Hambraeus A. Transfer of Staphylococcus aureus via nurses'
uniforms. J Hygiene 1973;71:799-814.
8. Lidwell OM, Towers AG, Ballard J, Gladstone B. Transfer of
micro-organisms between nurses and patients in a clean air
environment. J Applied Bacteriology 1974;37:649-56.
9. Ayliffe GA, Collins BJ, Lowbury EJ, et al. Ward floors and other
surfaces as reservoirs of hospital infection. J Hygiene 1967;65
(4):515-36.
10. Cooper BS, Stone SP, Kibbler CC, et al. Isolation measures in the
hospital management of methicillin resistant Staphylococcus aureus
(MRSA): systematic review of the literature. Brit Med J
2004;329:1-8.

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 Cleaning, Disinfection and Sterilisation

Chapter 10
Cleaning, Disinfection
and Sterilisation
Ulrika Ransj and Ossama Rasslan

Key points
The failure to disinfect or sterilise medical equipment
properly may result in infection.
The level of decontamination required depends upon the
intended use of the item.
Cleaning is essential before disinfection or sterilisation.
Chemical disinfection must be used only when required by
written policies.
Thermal decontamination is safer and more effective than
chemical.
Steam sterilisation is effective only when preceded by
cleaning and carefully monitored.
Staff members responsible for processing contaminated
devices must be fully trained and wear protective apparel.

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IFIC Basic Concepts of Infection Control

Introduction

Contaminated medical equipment and instruments can transmit

infection to both patients and staff, so they must be effectively
decontaminated after each use. Devices that cannot be properly cleaned
and decontaminated (e.g., injection needles), must be single use, and
not re-processed. Decontaminated items must be protected from
contamination or damage during storage.

Earle H. Spaulding1 categorised equipment as: critical, semi-critical and

non-critical according to the degree of risk of infection from their use:

Critical items are those that enter sterile tissues, including body
cavities, and the vascular system, e.g., surgical instruments and vascular
catheters. Any microbial contamination (including bacterial spores)
presents a high risk of infection if such an item is contaminated, so they
must be cleaned and sterilised before use.

Semi-critical items are those that come into contact with intact
mucous membranes or broken skin, such as respiratory equipment,
gastrointestinal endoscopes, vaginal instruments, and thermometers.
These should be free from vegetative microorganisms (i.e.,
mycobacteria, fungi, viruses, bacteria), although small numbers of
bacterial spores are acceptable. Semi-critical items require cleaning
followed by a minimum of high-level disinfection.

Non-critical items such as bedpans, blood pressure cuffs, ear

examination funnels, and patient furniture present a low risk of
infection from contact with normal skin. Such items (sometimes called
fomites) could contribute to the spread of infection via staff hands or
contact with other medical equipment. Cleaning is usually adequate,
but may be followed by low-level disinfection.

Staff responsible for processing contaminated equipment should:

Have received adequate training
Wear appropriate protection - gloves, gowns or aprons, and
splash protection (mask and goggles, or visor)
Receive adequate immunisations

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 Cleaning, Disinfection and Sterilisation

Cleaning

Cleaning removes organic soil (blood, etc.) and reduces the bacterial
load about 1000 fold or more. Organic soil protects microbes from
disinfection and sterilisation processes, and so items must be
thoroughly cleaned before processing.

Cleaning processes may involve chemical energy (detergents or

enzymes), mechanical energy (friction), or thermal energy. Cleaning can
be manual or by use of washing/washer disinfector machines or
ultrasonic cleaners.

Manual cleaning requires a neutral detergent and friction to remove soil

from the surface of instruments. Cleaning-disinfecting agents, also
known as two-in-one products, may be used for manual processing of
instruments. Washing machines require an alkaline detergent to make
up for the lack of friction. Soil remains in the cleaning solution of an
ultrasonic nebuliser so instruments must be rinsed after processing.

Items must be disassembled and cleaned as soon as possible after use to

prevent soil drying on them. Scissors and forceps require opening to
allow contact with cleaning agents. Rinsing is needed to remove
residual chemicals, and then drying is important to prevent moisture
from interfering with further processing, or allowing re-contamination.

Processing

Disinfection
Disinfection reduces the number of pathogenic microbes (except
bacterial spores) to a level that is not harmful to human health. This can
be achieved by heat or chemicals.

Thermal (heat) disinfection

Heat is preferable to chemicals, and can be combined with cleaning in a
washer (flusher) disinfector. Standard specifications for such machines
are available.2 The machine cycle must start with a low-temperature
rinse to remove soil, which is followed by exposure to 85C for 15
minutes. Machines require electricity and a reliable water supply.
Times and temperatures of exposure must be monitored, and machines
require regular maintenance and validation. Pasteurisation is another

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IFIC Basic Concepts of Infection Control

thermal process, which involves exposure to >70C (158F) for 30

minutes in a water bath. This is useful for respiratory and anaesthetic
equipment. All items must remain in contact with the hot water
throughout the process.

Chemical disinfection
Chemical disinfectants can be used alone or in combinations. They
include alcohols, chlorine and chlorine compounds, glutaraldehyde,
ortho-phthalaldehyde, hydrogen peroxide, peracetic acid, phenolics,
biguanides, and quaternary ammonium compounds. Many
commercially available formulations based on these chemicals are
available; the labels should be read carefully to ensure that the right
product is selected and used efficiently. Disinfectants are designed to
harm living cells and are thus harmful to staff. They may damage the
environment and are expensive, so chemical disinfection should only be
used when absolutely necessary.

Chemical disinfectants are categorized according to spectrum of activity

into high-level, intermediate level and low level. They are tested by
standardised processes as to their activity in suspension and in carrier
tests.2

High-level disinfectants kill all viruses and vegetative bacteria; they

may not reliably kill spores (unless used for long exposure times). They
are used for heat sensitive semi-critical items such as endoscopes.
Aldehydes such as glutaraldehyde or ortho-phthalaldehyde are
commonly used high-level disinfectants. They also fix proteins, thus
protecting microbes. Items must be made protein-free by careful
cleaning before disinfection. Per-acids, peroxides and other oxidizing
agents, e.g., 0.20.35% peracetic acid or 6-7.5% hydrogen peroxide are
more effective than aldehydes in the removal of biofilms, and also less
harmful to the environment as they can be readily inactivated. A recent
addition is a stabilised chlorine dioxide.

High-level disinfection requires 10-45 minutes exposure to disinfectant

at 20-26C; longer exposures are required to achieve sterilisation. After
disinfection items such as endoscopes require rinsing with sterile or
filtered water to remove any residual disinfectant. They can then be
dried with an alcohol rinse.

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 Cleaning, Disinfection and Sterilisation

Intermediate - level disinfectants destroy all vegetative bacteria

including mycobacteria, fungi and most but not all viruses. They do not
kill endospores even with prolonged exposure.

Low - level disinfectants only destroy fungi, vegetative bacteria

(except mycobacteria), and enveloped viruses.

Table 10.1 shows the most commonly used chemical disinfectants in

health care facilities.3,4

Sterilisation
Sterilisation is used to render an object free from all viable agents
including bacteria, viruses and bacterial spores (though not necessarily
prions).5 The degree of sterility can be measured by the probability of a
single product remaining contaminated after the process. This is called
the Sterility Assurance level (SAL). SAL is expressed as 10n, for
example if the probability of a single product remaining unsterile is one
in a million, the SAL is 106. This is the generally accepted SAL, although
this is an empirical value and not supported by documented adverse
effects (patient infections).

Heat is the most reliable sterilant; fortunately most medical devices are
made from heat-resistant material. Heat is usually applied by transfer of
latent heat from steam under pressure in an autoclave, which denatures
microbial proteins. Dry heat in an oven is needed for materials such as
powders that may be damaged by moisture, or those which steam
cannot penetrate, such as oils and waxes. Dry heat works by oxidation
and is a much slower process.

Heat sensitive items (usually those containing plastics such as

polythene) require low-temperature sterilisation. Low temperature
sterilising processes include ethylene oxide gas, hydrogen peroxide
gas-plasma, and chemicals such as the aldehydes.

Sterilisation processes are determined by their D-value: the decimal

reduction time. This is the process time required for a 1 log reduction in
microbial count (90%). So if the D-value for a steam steriliser is 1 minute
at 121C, and you have 102 spores, then after 1 minute you should have
101 spores, and to reach a SAL of 106 you will need 8 minutes exposure.
If the bioburden (contamination) on the device is high, some

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 Table 10.1. The most widely used chemical disinfectants in healthcare

Agents Spectrum Uses Advantages Disadvantages

Used for some semicritical and noncritical Volatile, flammable, and

items, e.g., oral and rectal thermometers Fast acting. irritant to mucous
Alcohols and stethoscopes. Also to disinfect small No residue. membranes.
(60-90%) including Low to intermediate surfaces such as rubber stoppers of multi- No staining. Inactivated by organic
ethanol or level disinfectant dose vials. Alcohols with detergent are safe Low cost. matter.
isopropanol and effective for spot disinfection of Readily available in all May harden rubber, cause
countertops, floors, and other surfaces. countries. glue to deteriorate, or crack
acrylate plastic.
IFIC Basic Concepts of Infection Control

88
Corrosive to metals in high
concentrations (>500 ppm).
Chlorine and chlorine
Used for disinfecting tonometers and for Inactivated by organic
compounds: the most
spot disinfection of countertops and floors. material.
widely used is an
Can be used for decontaminating blood Causes discoloration or
aqueous solution of
spills. Low cost, fast acting. bleaching of fabrics.
sodium hypochlorite Low to high level
Concentrated hypochlorite or chlorine gas Readily available in most Releases toxic chlorine gas
5.25-6.15% (house disinfectant
is used for disinfection of large and small settings. Available as liquid, when mixed with ammonia.
bleach) at a
water distribution systems such as dental tablets or powders. Irritant to skin and mucous
concentration of
appliances, hydrotherapy tanks, and water membranes.
100-5000 ppm free
distribution systems in haemodialysis Unstable if left uncovered,
chlorine
centres. exposed to light or diluted;
store in opaque container.
 Agents Spectrum Uses Advantages Disadvantages
Aldehydes

Glutaraldehyde: 2% Allergenic and its fumes are

aqueous solutions irritating to skin and
buffered to pH 7.5-8.5 respiratory tract.
with sodium Causes severe injury to skin
bicarbonate. Most widely used as high-level disinfectant and mucous membranes on
Novel Glutaraldehyde High level for heat sensitive semicritical items such as direct contact.
Good material compatibility.
formulations include: disinfectant/sterilant endoscopes (for 20 minutes at 20C). Relatively slow activity
glutaraldehyde- against some mycobacterial
phenol-sodium- species.
phenate, potentiated Must be monitored for
acid glutaraldehyde continuing efficacy levels.

89
and stabilized alkaline
glutaraldehyde

Rapid sterilization cycle time

Used in automated endoscope at low temperature (30-45
Corrosive to some metals.
Peracetic acid reprocessors. Can be used for cold min. at 50-55C).
Unstable when activated.
0.2-0.35% and other sterilisation of heat sensitive critical items, Active in presence of organic
High level May be irritating to skin,
stabilised organic e.g., haemodialysers. matter.
disinfectant/sterilant conjunctive and mucous
acids Environment friendly by-
membranes.
Also suitable for manual instrument products (oxygen, water,
processing [depends on formulation]. acetic acid)
Cleaning, Disinfection and Sterilisation
 Agents Spectrum Uses Advantages Disadvantages
More expensive.
Stains skin and mucous
membranes. May stain items
not thoroughly cleaned.
Excellent stability over wide Eye irritation with contact.
pH range, no need for May cause hypersensitivity
activation. reactions in cancer bladder
Orthophthalaldehyde High level
High level disinfectant for endoscopes. Superior mycobactericidal patients following repeated
(OPA) 0.55% disinfectant/sterilant
activity compared to exposure to manually
glutaraldehyde. processed urological
Does not require activation. instruments.
Slow sporicidal activity.
IFIC Basic Concepts of Infection Control

Must be monitored for

90
continuing efficacy levels.

Can be used for cold sterilization of heat No activation

Hydrogen peroxide sensitive critical items. No odour. Material compatibility
High level
7.5% Environment friendly by- concerns with brass, copper,
disinfectant/sterilant
Requires 30 minutes at 20C. products (oxygen, water). zinc, nickel/silver plating.

Material compatibility
Fast acting (high level
concerns with brass, copper,
Hydrogen peroxide disinfection in 15 min.).
High level zinc, and lead.
7.5% and peracetic For disinfecting haemodialysers No activation required.
disinfectant/sterilant Potential for eye and skin
acid 0.23% No odour.
damage.
 Agents Spectrum Uses Advantages Disadvantages
Manual reprocessing of endoscopes. Highly effective against
High level mycobacteria. Lack of efficacy against some
Glucoprotamin
disinfectant Requires 15 minutes at 20C. High cleansing performance. enteroviruses and spores.
No odour.

Leaves residual film on

surfaces. Harmful to the
environment. No activity
Have been used for decontaminating
Low to intermediate Not inactivated by organic against viruses.
Phenolics environmental surfaces and non-critical
level disinfectant matter. Use in nurseries should be
items. Should be avoided.
avoided due to reports of
hyberbilirubinemia in
infants.

91
Have been used for disinfecting some non Inactivated by organic
Iodophores
Low level critical items, e.g., hydrotherapy tanks, Relatively free of toxicity or matter. Adversely affects
(30-50 ppm free
disinfectant however it is used mainly as an antiseptic irritancy. silicone tubing. May stain
iodine)*
(2-3 ppm free iodine). some fabrics.

Has relatively narrow

microbiocidal spectrum, but
Stable and has good range of activity can be
Quaternary
Low level Used mainly on environmental surfaces. detergent properties expanded when combined
ammonium
disinfectant Can be used as a skin antiseptic. (cationic detergent). with other disinfectants, e.g.,
compounds*
Usually non-irritating. alcohols. Few advantages
over household detergent.
Cleaning, Disinfection and Sterilisation

* These chemicals are rarely recommended

IFIC Basic Concepts of Infection Control

sterilisation processes (for example irradiation) cannot render it sterile.

Thus cleaning is essential before a device is packed for sterilisation.

Steam sterilisation
This is the most widely used method of sterilisation. It is non-toxic, has
good penetrating ability, is relatively inexpensive, and can easily be
monitored for efficacy.

Steam sterilisation requires exposure to direct steam contact at a

required temperature and pressure for a specified time. Pressurized
steam sterilisers (autoclaves) are fed with steam under pressure; thus
high temperatures are produced.

There are two basic mechanisms of steam sterilisers:

Gravity (downward) displacement in which steam is introduced

at the top of the chamber, the cooler and denser air-steam mixture
and any condensate is discharged by gravity from the bottom of
the chamber. The exhaust has a near to steam valve, which
closes when all the air has been removed, and allows pressure to
build up. This type of steriliser is being phased out, but some are
still in use for unwrapped instruments and fluids. The sterilising
hold time is 15 minutes at 121C at 1.036 Bar (15.03 psi).

Porous load (pre-vacuum) sterilisers are fitted with a vacuum

pump to remove the air from the sterilising chamber before the
chamber is pressurized with steam. To ensure complete air
removal, the pump is operated for several cycles, with repeated
injections of steam. They allow faster and more positive steam
penetration throughout the entire load. This type of steriliser
usually has a holding time of 3 minutes at 134C at 2.026 Bar
(29.41 psi).

As heat is generated only on surfaces where steam can condense, the

autoclave load must be placed so that steam can reach all packages.

Items should be packaged in materials such as paper and/or polymers

that can be penetrated by steam and still keep the items sterile during
storage. Packages must be marked to identify their contents, date of
sterilisation, and steriliser and load number. This helps to facilitate

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 Cleaning, Disinfection and Sterilisation

recall action and to aid in rotation of supplies.

Autoclaves must be tested before being used and regularly thereafter.

Users must be trained on autoclave operation and safety, and keep a
written record of maintenance.

There are two approaches to checking that a sterilising cycle has worked
- product testing or parametric release. If you have an SAL of 106 you
cannot test a million items for sterility so instead biological indicators
(spore tests) can be used. They assess the process directly by killing
known highly resistant microorganisms (Geobacillus stearothermophilus).
Autoclaves should be tested at least weekly using a biological indicator.
Biological indicator results take up to 3-7 days, which is often too long
for quarantine of devices run in the process. Spore strips must be
obtained from a reputable supplier and their use requires a laboratory
facility.

Chemical indicators can also be used to assess physical conditions (e.g.,

time and temperature) during the sterilisation process. They include
external chemical indicators applied to the outside of a package (e.g.,
chemical indicator tape) or internal indicators. Autoclave tape on the
outside of the package only shows if the package has been exposed to
heat and is not a process indicator. Chemical indicators change colour
rapidly when a specific parameter is reached and they verify that the
package has been exposed to the sterilisation process. Although
chemical indicators do not prove sterilisation has been achieved, they
allow detection of certain equipment malfunctions and they can help
identify procedural errors.

The alternative approach is parametric release. This relies on ensuring

that the autoclave cycle has fulfilled the specifications with regard to
temperature, pressure and time using calibrated instruments instead of
biological microorganisms. Since this approach is based on measurable
data and calibrated equipment, the results tend to be more reliable. One
important function is removal of all air and non-condensable gases from
the autoclave, so allowing proper penetration of steam throughout the
load.

Air removal in a high-vacuum steriliser can be monitored in two ways

firstly by a leak test: can the vacuum be held or will air leak in (often

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IFIC Basic Concepts of Infection Control

around the door), and secondly by the ability of steam to penetrate into
a small load such as the small pack of towels used in the Bowie-Dick
test. If these results are satisfactory then each cycle of the autoclave
should have the pressure, temperature (in the drain) and time recorded.
If all three are satisfactory the load can be parametrically released,
without the need for biological indicators.

Sterilised items must be stored appropriately. Packages containing

sterile supplies should be inspected before use to verify barrier integrity
and dryness. If packaging is compromised, the instruments should be
re-cleaned, packaged in new wrap, and sterilised again.

Small, portable steam sterilisers are used in certain healthcare settings,

e.g., outpatient and dental clinics. These sterilisers are designed for
small instruments, such as dental instruments. They should also be
monitored by mechanical, chemical, and biological indicators.

Flash sterilisation is a method for sterilising unwrapped patient-care

items for immediate use (often used for dropped instruments in
operating theatres). Disadvantages of flash sterilisation include: the lack
of timely biological indicators to monitor performance, absence of
protective packaging following sterilisation, and possibility for
contamination of processed items during transportation to the point of
use. Some rigid, reusable sterilisation container systems have been
designed and validated by the container manufacturer for use with
flash cycles. Care should be taken to avoid thermal injury to personnel
during transportation of flash sterilised items to the point of use.

Dry heat sterilisation

Dry heat sterilisation can be achieved in a hot air oven equipped with
fan or conveyor which will ensure even distribution of heat. It can be
used for glassware, powders and anhydrous material like oil and
grease. Sterilisation times vary according to temperature (160C for 2
hours and 180C for 1 hour).

Ethylene oxide sterilisation

Ethylene oxide (EO) is used for sterilisation of items that cannot
withstand heat, pressure or moisture. EO is a colourless gas that is
flammable and explosive. The main disadvantages associated with EO
are the lengthy cycle time, the cost, and its potential hazards to patients

94
 Cleaning, Disinfection and Sterilisation

and staff. Sterilised items must be aerated after processing to remove

dissolved EO according to manufacturers instructions.

There are four parameters that must be maintained to ensure EO

sterilisation: gas concentration, temperature, humidity and exposure
time. Gas concentration should be 450 to 1200 mgm/l, temperature
ranges from 37 to 63C, humidity from 40% to 80%, and exposure times
from one to six hours. Parametric release is not possible as gas
concentrations and relative humidity cannot readily be measured, and
so a biological indicator should be included with each load. The
recommended biological indicator is Bacillus atrophaeus. This implies
that loads must be quarantined for several days to allow growth of the
indicators.

Two EO gas mixtures are available. One is EO mixed with

hydrochlorofluorocarbons (HCFC). HCFCs are approximately 50-fold
less damaging to the earths ozone layer than are CFCs. The other
mixture is EO-carbon dioxide (CO2) mixture consisting of 8.5% EO and
91.5% CO2. This mixture is less expensive than EO- HCFC.

Hydrogen peroxide gas plasma

Gas plasmas have been referred to as the fourth state of matter (i.e.,
liquids, solids, gases, and gas plasmas). Gas plasmas are generated in an
enclosed chamber under deep vacuum using radio frequency or
microwave energy to excite hydrogen peroxide gas molecules and
produce charged particles, many of which are in the form of free
radicals (e.g., hydroxyl and hydroperoxyl).

Gas plasma can be used to sterilise materials and devices that cannot
tolerate high temperatures and humidity, such as some plastics,
electrical devices, and corrosion-susceptible metal alloys. The biological
indicator used with this system is Geobacillus stearothermophilus spores.
Advantages of this method include: safety, no aeration necessary, items
may be used immediately after processing or stored for later use.
However, gas plasma is not designed for use on cellulose-based
products such as linen and paper, and it is not useful for dead-end
lumens, powders or liquids or certain lumen lengths and diameters.

Disadvantages of this system include high cost and need for special
packing material since paper or linen cannot be used. In addition, any

95
IFIC Basic Concepts of Infection Control

liquid or organic residues present interrupt the process and long dead-
end lumens are poorly penetrated. Nonetheless gas plasma machines
are widely used, particularly for endoscope decontamination.

Chemical sterilisation
Chemical sterilisation should only be used as a last resort. Before
deciding to use a chemical sterilant, consider whether a more
appropriate method is available. Chemical sterilants are primarily used
for heat-labile equipment where single use is not cost effective.
Instruments and other items can be sterilised by soaking in a chemical
solution followed by rinsing in sterile water. The immersion time to
achieve sterilisation or sporicidal activity is specific for each type of
chemical sterilant. Difficulties arise due to challenges in the need to
immerse for the appropriate time, rinse with sterile water, and then
transfer the device to a sterile field for use.

Re-processing

Devices that are intended for single use are marked by the manufacturer
with a . If they are re-used, the manufacturer is no longer responsible
for the quality of the device. Any re-processor needs to ask five
questions concerning the end status of the device to determine if
reprocessing is appropriate:

Is it undamaged and functional?

Can it be cleaned?
Is it sterile?
Is it cost effective?
Who takes the responsibility if anything goes wrong?

Only when the answers to all these questions are positive, can patient
safety be guaranteed.

References and Further Reading

1. Spaulding EH. Chemical Disinfection of Medical and Surgical

Materials. In: Lawrence C, Block SS, editors. Disinfection,
Sterilisation, and Preservation. Philadelphia: Lea & Febiger; 1968.

96
 Cleaning, Disinfection and Sterilisation

p. 517-31.
2. World Forum for Hospital Sterile Supply [online].
[cited 2007 August 10].Available from: URL:
www.efhss.com/html/educ
3. Infection Control Guidelines - Hand Washing, Cleaning,
Disinfection and Sterilisation in Health Care. Canada Comm Dis
Report 1198; 24S8. [online]. 1998 [cited 2007 August 10].
Available from: URL: http://www.phac-aspc.gc.ca/publicat/ccdr-
rmtc/98pdf/cdr24s8e.pdf
4. Sterilisation, Disinfection and Cleaning of Medical Equipment:
Guidance on Decontamination from the Microbiology Advisory
Committee to the Department of Health (The MAC Manual)
[online]. 2006 [cited 2007 August 10]. Available from: URL:
http://www.mhra.gov.uk/home/idcplg?
IdcService=SS_GET_PAGE&useSecondary=true&ssDocName=CO
N007438&ssTargetNodeId=575
5. Sterilisation of medical devices. European Committee for
Standardization. BS EN 556-1:2001.

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 Prevention of Surgical Site Infections

Chapter 11
Prevention of Surgical
Site Infections
Pola Brenner and Patricio Nercelles

Key points
In many countries surgical site infections are the most
common healthcare-associated infections accounting for up to
25% of infections.
Although sterilisation of instruments, aseptic technique, clean
air and antimicrobial prophylaxis have been shown to reduce
the incidence of SSI, it remains an important cause of
morbidity and mortality worldwide.
Risk factors involve the patient, the operation, and the
environment.

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IFIC Basic Concepts of Infection Control

Introduction

Surgical site infections (SSI) are one of the most important healthcare-
associated infections (HAI). In many countries SSI account for up to 25%
of HAIs. SSIs may prolong hospital stay after surgery from 6-30 days,
increase antimicrobial prescribing and laboratory costs, and require
added interventions. Although sterilisation of instruments, aseptic
technique, clean air and antimicrobial prophylaxis reduce the incidence
of SSI, it remains an important cause of morbidity and mortality.

Microorganisms responsible for SSI can be either endogenous (from the

patient) or exogenous (from the hands of personnel or the inanimate
environment). Some are deep-seated and may occur many months after
surgery.

By definition, any infection occurring within 30 days of an operation or

within 1 year of an implant procedure is classified as a SSI. Infection
rates vary with wound contamination.

More than 30% of SSIs are detected after the patient leaves hospital.
Therefore post-discharge surveillance is essential (particularly for day
cases). However this type of surveillance is resource intensive requiring
direct examination of patients, review of medical records, or patient
surveys by mail/telephone.

Surveillance

Surveillance of SSIs with appropriate feedback to surgeons has been

shown to reduce SSI risk. A surveillance system should include
standard definitions and risk stratification of patients. The main
predictor of SSI was regarded as the intrinsic degree of wound
contamination. Wounds were classified as clean, clean contaminated,
contaminated and dirty (1964 NAS/NRC Cooperative Research* ).

Many SSI surveillance systems also include the duration of an operation

and ASA (American Society of Anesthesiologists) score to their SSI risk
stratification system.

Some recommend SSI surveillance based on specific surgery (e.g.,

cholecystectomy, hernia repair, Caesarean section, hip replacement).

100
 Prevention of Surgical Site Infections

This approach assumes that patients having similar operations have

similar risk factors. Another approach is to compare the clean wound
SSI rates from different surgeons. This strategy has been shown to
decrease SSIs in some studies. However, it may be unpopular and
unfair if the data are not adjusted for patient's risk factors.

Risk Factors and Prevention Measures

Patient risk factors, surgical team practices, and the operating room
have been associated with an increased risk of SSI. Recommendations
for the prevention of SSI should be evidence based; however, evidence
for lowering SSI rates in clean surgical procedures requires large, costly
studies. Surrogate markers for infection are often used, e.g., wound
cultures and length of stay.

Patient Risk Factors

Nutritional Status
In theory malnutrition should increase the risk of SSI. However, this is
difficult to demonstrate. Some studies of malnutrition predict mortality
but not SSI. The benefits of preoperative total parenteral nutrition in
reducing SSI risk are not proven and also has a risk of infection;
however providing appropriate nourishment prior to an operation is
important.

*Class I/Clean: An uninfected operative wound in which no inflammation is encountered

and the respiratory, alimentary, genital, or uninfected urinary tract is not entered. In
addition, clean wounds are primarily closed and, if necessary, drained with closed
drainage. Operative incisional wounds that follow non-penetrating (blunt) trauma should
be included in this category if they meet the criteria.

Class II/Clean-Contaminated: An operative wound in which the respiratory, alimentary,

genital or urinary tracts are entered under controlled conditions and without unusual
contamination. Specifically, operations involving the biliary tract, appendix, vagina, and
oropharynx are included in this category, provided no evidence of infection or major
break in technique is encountered.

Class III/Contaminated: Open, fresh, accidental wounds. In addition, operations with

major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the
gastrointestinal tract, and incisions in which acute, non purulent inflammation is
encountered are included in this category.

Class IV/Dirty-Infected: Old traumatic wounds with retained devitalized tissue and
those that involve existing clinical infection or perforated viscera. This definition suggests
that the microorganisms causing postoperative infection were present in the operative
field before the operation.

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IFIC Basic Concepts of Infection Control

Diabetes
There is a significant relationship between increased glucose levels
(>200 mg/dL) in the peri-operative period with risk of SSI. Good
diabetes control is essential.

Obesity
Obesity (Body Mass Index >40) has been associated with SSI especially
after cardiac and orthopaedic implant surgery.

Coexistent Remote Infections

Active infection, especially of the skin and respiratory tract, increase the
risk of SSI in all types of surgery. Urinary tract and dental infections
have been related to SSI following orthopaedic implants.

Colonisation with Microorganisms

Nasal and skin carriage of S. aureus is a risk factor for SSI. A
preoperative antiseptic shower or bath decreases microbial colony
counts on skin, however it has not been shown to definitively reduce
SSI rates.

Length of Preoperative Stay

Prolonged preoperative hospitalisation has been associated with
increased SSI risk, probably because it may indicate severe illness. In
addition, patients may become colonised with resistant bacteria while in
the hospital.

Antimicrobial Prophylaxis
Antimicrobial prophylaxis reduces SSI and is recommended when a SSI
would represent a catastrophe, e.g., in orthopaedic and other high-risk
(cardiac) implant procedures. A single dose is usually sufficient
(maximum of 3), timed to give a bactericidal concentration of the drug
in the tissues at the time of the incision. Usually it is given at the
induction of anaesthesia, and in any case not more than 30 minutes
before the skin is incised.

The prophylactic agent should be safe, inexpensive, and have a

spectrum that covers likely intraoperative contaminants. First and
second generation cephalosporins are often used for prophylaxis, e.g.,
cefazolin 1-2 g or cefuroxime 1.5 g. A second dose is recommended in
some studies if the operation lasts >3 hours or involves rapid blood loss.

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 Prevention of Surgical Site Infections

Prophylaxis is not indicated in contaminated or dirty interventions,

when treatment is required.

Preoperative Shaving
Preoperative shaving of the surgical site is associated with a
significantly higher SSI risk than using depilatory agents or no hair
removal. Clipping hair immediately before an operation lessens the risk.
However the risk from either shaving or clipping increases when it is
performed the night before surgery. Use of depilatories is better, but
sometimes causes hypersensitivity. In addition, depilatories are
expensive and may cause skin damage; they are no longer
recommended. Some studies show that any hair removal is associated
with increased SSI rates and suggest that no hair should be removed
unless essential.

Skin Antisepsis
Disinfection of the surgical site immediately prior to the incision
reduces SSI rates. Antiseptics decrease skin colonisation of
microorganisms. Preoperative skin preparation with an antiseptic
solution is recommended for all operations. Alcohol, usually combined
with chlorhexidine or iodophores, is strongly recommended.

Surgical Team Risk Factors

Surgical Scrub
The aim of a surgical scrub/rub is to reduce colonisation of the surgical
team's hands. Various antiseptics have been used, e.g., alcohols,
chlorhexidine, iodine/iodophores, parachloro-meta-xylenol, and
triclosan. Isopropyl alcohol is effective and rapid-acting; chlorhexidine
is also used because of its persistent action. Artificial nails increase
bacterial and fungal colonisation of the hands despite adequate hand
scrubs. The use of a brush during a surgical scrub has not been
associated with reduction of SSI.

Infected or Colonized Surgical Personnel

Personnel with skin diseases such as psoriasis or active infections or
who are colonised with microorganisms such as staphylococci have
been linked to outbreaks of SSIs. Healthcare organisations should
exclude infected individuals from surgical activities whenever feasible.

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IFIC Basic Concepts of Infection Control

Duration of Operation
Lengthy operations are associated with increased risk of SSI. Long
exposures of tissues could be due to poor surgical technique, poor
organisation in the operating room, or failure of common procedures
such as provision of correct instruments, intra-operative radiology or
microscopy. Operation time should be kept to a minimum.

Foreign Material in the Surgical Site

Foreign bodies, such as sutures and drains, may promote inflammation
and act as a point of entry for microorganisms. Drains used to evacuate
postoperative haematomas or serous fluids in the post-operative period
increase incisional SSI risk. Drains should be passed through a separate
incision away from the operative wound and removed as soon as
possible. Use closed suction. Monofilament suture material is the least
irritating.

Aseptic and Surgical Technique

Breaks in aseptic technique such as use of communal syringes or
contamination of intravenous fluids or equipment have been associated
with SSI. Hypothermia causes vasoconstriction, decreased delivery of
oxygen to the wound space, and impairment of leukocyte function, and
is also a risk factor.

The risk of SSI is strongly associated with the experience of surgical

teams. Good surgical technique (effective homeostasis, gentle handling
of tissues and removal of devitalized tissues) reduces the risk of SSI.
Institutions should select experienced surgeons for complex
interventions and monitor surgical technique.

Operating Room Environment Risk Factors

Ventilation
The microbial count in operating room air is directly proportional to the
number of people present and their movement. Therefore movement
must be controlled and numbers kept to a minimum.

An operating room should be at positive pressure to adjacent areas and

supplied with enough filtered air to provide 20 air changes per hour.
This will help dilute contaminants in the air, e.g., microorganisms and
gases. Use of ultra-clean air in the prevention of SSI in implant surgery
is well established. Ultraviolet radiation has not been shown to decrease
SSI.

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 Prevention of Surgical Site Infections

Sterilisation of Instruments
Sterilisation of instruments is an essential part of aseptic technique and
must be performed with validated methods using appropriate quality
control. Flash sterilisation should only be used in an emergency,
because of lack of indicators, absence of protective packaging,
possibility for contamination of processed items during transportation,
and difficulty in monitoring cycle parameters (time, temperature, and
pressure). Flash sterilisation should be never be used for implants or
invasive devices.

Surgical Clothes
Barrier clothing is necessary to minimise exposure of a patients wound
to the skin, mucous membranes, and hair of the surgical team; clothing
is also used to protect the team from exposure to a patients blood.
Masks can prevent contamination of patients with respiratory
pathogens. Surgical caps reduce contamination of the surgical field by
microbes from the hair and scalp. Footwear should be enclosed and
protect the team from accidentally dropped sharps, blood, and other
contaminated items. If there is a risk of spillage of blood or other high-
risk body fluids, surgical waterproof boots should be worn. Plastic
overshoes must not be used to protect footwear.

Gloves
Sterile gloves minimize transmission of microbes from the hands of the
surgical team to patients and prevent contamination of team members
with blood and body fluids. Gloves may also reduce the risk of infection
through sharps injuries. Wearing two pairs of gloves provides added
protection and may be used for orthopaedic procedures.

Inanimate Surfaces
Environmental surfaces (floor, walls, tables, etc.) have not been
associated with SSI. There are no data to support the use of
environmental disinfectants. Tacky mats placed outside the theatre
entrance and use of overshoes are unnecessary.

Prevention Recommendations

The Patient
Identify and treat all infections before elective operations.
Keep preoperative hospital stay to a minimum.

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IFIC Basic Concepts of Infection Control

Do not remove hair preoperatively unless the hair at or around

the incision site will interfere with the operation. If considered
essential, remove hair immediately before the operation with a
non-invasive procedure, e.g., clipper.
Good control of diabetes is essential in the perioperative period.
Use an antiseptic for skin preparation.
Administer prophylactic antibiotics when indicated according to
established criteria and local policy.

The Surgical Team

Perform a preoperative surgical scrub for at least 2-4 minutes
using an appropriate antiseptic. Do not use a brush. Remove
debris underneath the fingernails using a nail cleaner before the
first procedure in the morning.
Personnel with draining skin lesions must be excluded from
surgical activities until it is fully resolved.
Limit the duration of the procedure as much as possible.
Wear sterile gloves. Put gloves on after donning a sterile gown.
Use sterile water repellent surgical gowns and drapes. Wear a
surgical mask and a cap or hood to fully cover hair.
Adhere to principles of asepsis when performing interventions
and invasive procedures in the operating room, e.g., placing
central venous, spinal or epidural anaesthesia catheters or when
dispensing and administering intravenous drugs.
Handle tissue gently, maintain effective homeostasis, minimize
devitalized tissue and foreign bodies (e.g., sutures, charred
tissues, necrotic debris), and eradicate dead space at the surgical
site.
Use closed suction drains. Place a drain through a separate
incision distant from the operative incision. Remove it as soon as
possible.

The Operating Room Environment

Maintain positive pressure ventilation in the operating room with
respect to the corridors and adjacent areas. Twenty air changes
per hour are recommended. Filter all air, recirculated and fresh.
Keep operating room doors closed except as needed for passage
of equipment, personnel, and the patient.

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 Prevention of Surgical Site Infections

Restrict the number of personnel entering the operating room to

necessary personnel only, and restrict their movement.
Sterilise all surgical instruments with validated methods. Do not
use flash sterilisation routinely.
Do not perform special cleaning or closing of operating rooms
after contaminated or dirty operations.
Do not use over-shoes and tacky mats at the entrance to the
operating room suite.

Postoperative
Don't touch the wound unless it is necessary.
Have an on-going surveillance system for SSI using standard
definitions and risk classifications. Perform post-discharge
surveillance for patients with ambulatory surgery or a short
hospital stay.

References and Further Reading

1. Ayliffe GAJ. Role of the environment of the operating suite in

surgical wound infection. Rev Infect Dis 1991;13 Suppl 10:S800-4.
2. Cruse P, Foord R. The epidemiology of wound infection. A 10-
year prospective study of 62,939 wounds. Surg Clin North Am
1980;60:27-40.
3. Holtz TH, Wenzel RP. Postdischarge surveillance for nosocomial
wound infection: a brief review and commentary. Amer J Infect
Control 1992;20:206-13.
4. Lauwers S, de Smet F. Surgical site infections. Acta Clin Belg
1998;53:303-10.
5. Mangram, AJ, Horan TC. Pearson ML, et al. Guideline for
Prevention of Surgical Site Infection, 1999. The Hospital Infection
Control Practices Advisory Committee. Infect Control Hosp
Epidemiol 1999;20:250-78.
6. Pittet D, Ducel G. Infectious risk factors related to operating
rooms. Infect Control Hosp Epidemiol 1994;15:456-62.

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 Prevention of Lower Respiratory Tract Infection

Chapter 12
Prevention of Lower
Respiratory Tract
Infection
Gary French and Ulrika Ransj

Key points
Pneumonia is the healthcare-associated infection that results
in the highest mortality; prevention is therefore vital.
Prevention measures include raising the head of the bed to
facilitate chest movement, use of gloves when handling
respiratory secretions and proper use, cleaning and
disinfection of respiratory equipment.

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IFIC Basic Concepts of Infection Control

Introduction

The cough reflex, together with a healthy respiratory mucosa with its
ciliary epithelium, antimicrobial secretions, phagocytosis and other local
immunity mechanisms, effectively prevents microorganisms from
reaching the lower respiratory tract (LRT). Microorganisms are
normally cleared from the LRT efficiently.

Pneumonia is the healthcare-associated infection that results in the

highest mortality; prevention is therefore vital. Post-operative
pneumonia is a common surgical complication, often resulting from the
patient failing to cough or breathe deeply because of pain. In these
patients infection is due to common respiratory pathogens.

Ventilator-associated pneumonia is a more serious condition seen in

intensive care units in intubated and ventilated patients. In this group of
patients, mechanical or chemical injury to the ciliated epithelium
impairs the normal removal of mucus and microorganisms from the
lower airways. In addition, reduction of gastric pH due to H2 blocking
agents is associated with colonisation of the upper gastrointestinal tract
and oropharynx by aerobic Gram-negative bacilli derived from the
patients own bowel. These microorganisms may then pass into the LRT
and cause infection. These patients have usually had prolonged
hospitalisation and received (sometimes several courses of) antibiotics.
(See Table 12.1) Because of this, the microorganisms involved are often
multidrug-resistant (MDR) opportunistic pathogens. These microbes
may also be introduced into the respiratory tract via contaminated
equipment or the hands of staff. However, often they are
microorganisms that have first colonised the patients bowel.
(See Figure 12.1)

Definition and diagnosis

Healthcare-associated pneumonia is a LRT infection that appears

during or after hospitalisation in a patient who was not incubating the
infection on admission. It is diagnosed by the following:
clinical signs,
pyrexia,
purulent sputum,

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 Prevention of Lower Respiratory Tract Infection

Table 12.1. Risk factors for healthcare-associated pneumonia

Severely ill, e.g., septic shock

Age (elderly or neonate)
Surgical operation (chest\abdomen)
Major injuries
Condition of patient
Chronic obstructive lung diseases
Existing cardiopulmonary disease
Cerebrovascular accidents
Coma
Heavy smoker

Sedation
General anaesthesia
Tracheal intubation
Tracheostomy
Therapy
Prolonged artificial ventilation
Enteral feeding
Broad-spectrum antibiotic therapy
H2 blockers
Immunosuppressive and cytotoxic drugs

Figure 12.1. Mode of acquisition of healthcare-associated pneumonia

111
IFIC Basic Concepts of Infection Control

relevant X-ray changes and

preferably microbiological diagnosis from bronchial lavage,
transtracheal aspirate or protected brush culture.

Etiologic agents of healthcare-associated pneumonia

Early onset healthcare-associated pneumonia (within one week of

admission) is usually caused by community-acquired microorganisms
such as Streptococcus pneumoniae and Haemophilus influenzae. Pneumonia
occurs in intensive care and after surgery, particularly in patients with
existing pulmonary disease.

Late onset healthcare-associated pneumonia is usually caused by

Gram-negative bacilli, e.g., Klebsiella pneumoniae, Escherichia coli,
Pseudomonas aeruginosa, Serratia marcesens, Enterobacter species and
Acinetobacter.

Respiratory syncytial and other respiratory viruses cause severe

pneumonia spread by contact, particularly to immunocompromised
patients and young children. Legionella infection may be acquired from
the hospital air conditioning system or from water supplies, particularly
by immunocompromised patients. Fungi, e.g., Candida albicans and,
rarely, Aspergillus fumigatus, may also cause healthcare-associated
pneumonia. Legionella and Aspergillus infections are not spread between
patients.

Pneumocystis carinii causes pneumonia in immunosuppressed patients,

particularly if HIV positive, however this is usually a community-
acquired infection. Opportunistic pulmonary diseases caused by
different mycobacteria including Mycobacterium tuberculosis can be
transmitted to other patients.

Important Measures for Prevention

Table 12.2 outlines many of the important measures to prevent

healthcare-associated pneumonia. Additional measures include:

Hand hygiene before and after contact with patients, whether or

not gloves are worn.

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 Prevention of Lower Respiratory Tract Infection

Use of disposable or reprocessed gloves when handling

respiratory secretions.
Use of sterile disposable or reprocessed gloves and catheters for
tracheal aspiration and tracheostomy care.
Proper cleaning and disinfection of respiratory equipment.
(See Table 12.3)
Education of staff in patient care and cleaning areas.

Table 12.2. Basic methods of prevention

Risk Prevention

Treat lung disease prior to surgery, if possible.

Elevate head of the bed to 30.
Avoid unnecessary suctioning of airways.
Patients Oral cavity care at least 6 times a day.
Deep breathing and coughing exercises before and after operation.
Percussion and postural drainage to stimulate coughing.
Mobilise early after operation.

Decontamination of respiratory equipment routinely.

Use ventilator tubing up to one week if a heat-moisture exchanger
is in place.
Do not tip condensate into patient when reconnecting ventilator
tubing.
Artificial Closed suction tubes are expensive and do not increase protection
ventilation for staff or patients.
Sterile or boiled water in humidifiers changed every 8-24 hours.
Suction bottles changed daily. [Autoclaved or disposable]
A ventilator-close filter changed with tubing may reduce the need
to disinfect after each patient.
Bacterial or viral filters have no proven efficacy.

Minimal requirements

Adequately decontaminated equipment.

Hand hygiene before and after patient contact.
Gloves and disposable suction catheters for tracheal aspiration if
available.
Change gloves between patients and procedures
Dispose of or decontaminate suction catheters between
patients

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IFIC Basic Concepts of Infection Control

Table 12.3. Cleaning and Disinfection of Respiratory Equipment

Risk factors Prevention

Cleaning, drying and filling with sterile distilled or freshly
Humidifiers boiled water every 8 to 24 hours. Never store with fluid in
them.

Nebulizers Autoclaving or thermal disinfection preferred after cleaning.

Endotracheal airway
Autoclaving or thermal disinfection. Disposable items are
tubes, face masks,
safe but expensive. Chemical disinfection may be required.
tubing, ambu-bags

Oral cavity cleaning

Sterile or freshly boiled water for each use.
solution

Mouthpiece for each patient should be sterile, disinfected or

Spirometry
disposable.

Sterile, disposable, for each procedure. May use for 24 hours

Endotracheal airway/
on the same patient. Flush for each aspiration with sterile or
suction tube
freshly boiled water.

Washing in detergent and dried or disinfected with solution

Suction bottles and of chlorine-releasing agent, rinsed and dried. Preferably
tubing disinfect in washing machine or autoclave or disinfect in hot
water and dried. Disposables available but expensive.

References and Further Reading

1. Johanson Jr WG, Dever LL. Nosocomial pneumonia.

Intensive Care Med 2003;29:23-9.
2. Isakow W, Kollef MH. Preventing Ventilator-Associated
Pneumonia: An Evidence-Based Approach of Modifiable Risk
Factors. Sem Resp Crit Care Med 2006;27:5-17.

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 Prevention of Intravascular Device Associated Infection

Chapter 13
Prevention of
Intravascular Device
Associated Infection
Peter Heeg

Key points
Thorough hand disinfection by operator before insertion of
catheter and during maintenance procedures.
Thorough disinfection of skin at insertion site.
No touch technique or gloved hands during insertion,
maintenance and removal of catheter.
Secure the IV line to prevent movement of the catheter.
Maintain a closed system.
Protect the insertion site with a sterile dressing.
Inspect insertion site daily.
Remove the catheter as early as possible and immediately if
any signs of infection are present.

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IFIC Basic Concepts of Infection Control

Introduction

Intravenous infusions are among the most common invasive procedures

performed in health care and are administered either by peripheral or
central routes. Infections are common and in many countries
intravenous catheters are the main source of healthcare-associated
bacteraemia. The principles used for prevention of infection are similar
for both central and peripheral catheters.

An intravenous catheter is a foreign body that produces a reaction in the

host resulting in a film of fibrinous material on its inner and outer
surfaces. This biofilm may become colonized by microorganisms which
are then protected from host defense mechanisms and the effect of
antibiotics. Microbial contamination may cause local infection,
thrombophlebitis, or bacteremia/sepsis.1 Infection prevention and
control measures are designed to prevent microorganisms from
entering equipment, catheter insertion site, or bloodstream. (See Figure
13.1)

Because of the danger of infection, catheters should not be inserted

unnecessarily and indications for insertion of catheters should be strict
(e.g., severe dehydration, blood transfusion, and parenteral feeding).
Use alternative routes where possible for hydration or parenteral
therapy. Once catheters have been inserted, they should be removed as
soon as possible. Good aseptic technique is required during insertion of
the catheter and maintenance of the insertion site.2 The site should be
kept dry, free from contamination, secured, and dressed in a
comfortable position for the patient.

Sources and Routes of Transmission of Infection

Sources of contamination are either intrinsic (contamination before use)

or extrinsic (contamination introduced during therapy). Most infections
are acquired from the patients own skin flora.3 The microorganisms
involved are typically coagulase-negative staphylococci or occasionally
Staphylococcus aureus. Less frequently, Gram-negative bacilli or Candida
albicans may be identified due to growth in the infusate.

Skin microorganisms enter the catheter insertion site along the outside
of the catheter. Occasionally microorganisms from the hands of staff or

116
 Prevention of Intravascular Device Associated Infection

Figure 13.1. Sites of Possible Contamination of Intravascular Infusions

[Reproduced with permission from Damani NN and Keyes JK. Craigavon
Infection Control Manual, 2004]

the patients skin enter through the hub when the catheter is
disconnected or through injection ports. The microbes grow in the
biofilm, usually on the catheters outer surface, and may be released
into the bloodstream. Rare infections have been caused by
microorganisms growing in commercially prepared infusate due to
faulty sterilization or by contaminated medications.4 Finally,
colonisation of the catheter tip may occur, seeded from a distant site of
infection (e.g., wound, lung, or kidney).

Source of infection and prevention

Table 13.1 outlines the major sources of contamination related to

intravascular catheters.

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IFIC Basic Concepts of Infection Control

Table 13.1. Major sources of contamination related to intravascular catheters

Main source of
Prevention
infection
Ensure fluid is pyrogen free.
Monitor sterilisation process.
Infusion fluid Avoid damage to container during storage.
Inspect container for cracks, leaks, cloudiness,
and particulate matter.

Use aseptic precautions (hand disinfection, no touch

technique).
Add sterile medications.
Carry out procedure preferably in the pharmacy.
Addition of Use a sterile device for access.
medications Use single-dose vials whenever possible.
If multidose vials have to be used:
Refrigerate after opening (if not otherwise recommended
by manufacturer).
Wipe diaphragm with 70% alcohol before entering vial.

Container and water Ensure no contamination from warming fluid.

used Dry warming systems are preferred.

Thorough hand disinfection and use of sterile gloves by

Insertion of catheter operator.
Thoroughly disinfect the skin insertion site.

Cover with sterile dressing as soon as possible.

Remove catheter if signs of infection occur.
Inspect site every 24 hours.
Catheter site
Change dressing only when soiled, loosened or wet/damp,
using good aseptic technique.
Do not use antimicrobial ointments.

Clean with 70% alcohol (isopropanol) and allow drying

Injection ports before use.
Close ports that are not needed with sterile stopcocks.

Replace no more frequently than 72 hours

Changing of infusion (blood and lipids 24 hours*).
set Thorough hand disinfection by operator.
Use good aseptic technique.

* In some countries, national guidelines or recommendations exist for infusion

of blood or blood products including infusion times <24 hours. Certain lipid
products may require more frequent replacement.5

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 Prevention of Intravascular Device Associated Infection

General Comments

Unless signs of infection or irritation occur, peripheral

intravenous (IV) catheters may be used as long as they are
needed. Some guidelines recommend changing peripheral
venous catheters every 72-96 hours in adults. Central catheters
should not be replaced routinely.5,6
The risk of infection in peripheral IV sites increases with length of
time of catheterisation. Catheters should be removed as soon as
possible.7
Infection rates are lowest with smaller needles. Teflon catheters
are also associated with low rates; however they are not necessary
for short periods of infusion.
Well-trained staff should set up and maintain infusions. Masks,
caps and gowns are not necessary for insertion of peripheral
lines. The use of non-sterile gloves and an apron or gown will
protect the operator if profuse bleeding is likely.

Protocol for peripheral infusions

Place arm on clean towel.

Operator should use an alcohol hand rub or antiseptic soap to
disinfect hands. If alcohol or antiseptic are not available, wash
hands thoroughly for 20 seconds.
Dry hands thoroughly on a paper or clean linen towel, unless
alcohol is used.
Avoid shaving skin site; clip hair instead, if necessary.
Disinfect skin site with 0.5% chlorhexidine-alcohol, 2% tincture of
iodine, 10% alcoholic povidone-iodine, or 70% alcohol
(isopropanol). Apply with rubbing for 30 seconds and allow
drying before inserting the cannula.
Insert cannula into vein, preferably in an upper limb, using no
touch technique.
Apply sterile dressing (gauze or equivalent or clear semi-
permeable) and secure. Semi-permeable adhesive dressings are
more expensive, but have the advantage of allowing inspection of
the site without removal of the dressing.8
Secure cannula to avoid movement and label with insertion date.

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IFIC Basic Concepts of Infection Control

Assess the need for continuing catheterisation every 24 hours.

Inspect catheter daily and remove at first sign of infection.
Avoid cut downs, especially in the leg.
Cannulae and administration sets should be sterilized before use.
It is preferable to use disposable products.
If reuse is necessary, clean thoroughly and autoclave if
possible.
If this is not possible, use boiling water.
Chemical disinfection is undesirable. However, if reusable
items are heat-labile, immerse in 0.5% sodium hypochlorite
or other chlorine-releasing solution for 15 minutes after
thorough cleaning (hypochlorites are neutralised by
proteins such as blood). Use syringe and needle for
cleaning the interior of the cannula. Ensure the agent
remains in contact with all surfaces of tubes and catheters.
Hypochlorites are corrosive to metals and some plastics;
thorough rinsing in sterile water is required after
disinfection.

Additional guidelines for central catheters

Use maximum barrier precautions: sterile gloves, gowns, cap and

mask for operator and a large sterile drape to cover the patient.2
Preferably disinfect skin site with 2% chlorhexidine-alcohol.
Allow drying before inserting the catheter.
Change dressings regularly, at least once a week (individually
determined, depending on the state of the patient).

References and Further Reading

1. Gastmeier P, Weist K, Rueden H. Catheter-associated primary

bloodstream infections: epidemiology and preventive methods.
Infection 1999;27 Suppl 1:S1-6.
2. Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central
venous catheter-related infections by using maximal sterile
barrier precautions during insertion. Infect Control Hosp
Epidemiol 1994;15:231-8.
3. Darouiche RO, Raad II. Prevention of catheter-related infections:

120
 Prevention of Intravascular Device Associated Infection

the skin. Nutrition 1997;13:S26-9.

4. Trautmann M, Zauser B, Wiedeck H, et al. Bacterial colonization
and endotoxin contamination of intravenous infusion fluids.
J Hosp Infect 1997;37:225-36.
5. Guidelines for the Prevention of Intravascular Catheter-Related
Infections. MMWR 2002;51:1-26. Available from: URL: http://
www.cdc.gov/ncidod/dhqp/gl_intravascular.html
6. Cook D, Randolph A, Kernerman B, et al. Central venous catheter
replacement strategies: a systematic review of the literature. Crit
Care Med 1997;25:1417-24.
7. Bregenzer T, Conen D, Sakmann P, Widmer AF. Is routine
replacement of peripheral intravenous catheters necessary? Arch
Intern Med 1998;158:151-6.
8. Madeo M, Martin C, Nobbs A. A randomized study comparing
IV 3000 (transparent polyurethane dressing) to a dry gauze
dressing for peripheral intravenous catheter sites. J Intraven Nurs
1997;20:253-6.
9. Mermel LA, Farr BM, Sherertz RJ, et al. Guidelines for the
management of intravascular catheter-related infections. Clin
Infect Dis 2001;32:1249-72.
10. Seifert H, Jansen B, Farr BM, editors. Catheter-related infections.
New York: Marcel Dekker; 1997.
11. Guidelines for preventing infections associated with the insertion
and maintenance of central venous catheters. J Hosp Infect 2001;
47(Suppl):S47-S67.

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 Prevention of Urinary Tract Infections

Chapter 14
Prevention of Urinary
Tract Infections
Nizam Damani, Gary French and Ulrika Ransj

Key points
Urinary catheterisation should be avoided if possible.
Do not use urinary catheters for incontinence of urine.
The catheter should be removed as soon as clinically possible,
preferably within 5 days.
Urinary catheterisation should be performed with sterile
equipment. If not possible, high-level disinfection using heat
should be performed.
Aseptic technique should always be maintained during
insertion and aftercare procedures.
Catheters should not be changed routinely as this exposes the
patient to increased risk of bladder and urethral trauma.
Maintain the closed drainage system; open systems should be
avoided if at all possible.
Bladder irrigation or washout and instillation of antiseptics or
antimicrobial agents do not prevent catheter-associated
urinary tract infection and should not be used.
The drainage bag should be emptied once per nursing session
into a clean receptacle used only on one patient.

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IFIC Basic Concepts of Infection Control

Introduction

Urinary tract infections (UTIs) are the commonest healthcare-associated

infections, accounting for up to 30% of all. Most are associated with the
use of urinary drainage devices, such as bladder catheters. The risk of
acquiring bacteriuria in a catheterised patient increases with the
duration of catheterisation, rising from approximately 5% per day
during the first week to almost 100% at 4 weeks. 1-4% of patients with
bacteriuria will ultimately develop clinically significant infection, e.g.,
cystitis, pyelonephritis and septicaemia. Therefore urinary catheters
must only be inserted when there are clear medical indications, such as
problems with emptying the bladder or measurement of urine
production, and should be removed as soon as no longer needed. In
suitable patients, clean intermittent urinary catheterization should be
considered, as it has a much lower risk of infection. Urinary
incontinence is not an indication for urinary catheterisation; use napkins
or absorbent pads instead.

Pathogenesis

Under normal circumstances urethral flora, which tends to migrate into

the bladder, is constantly flushed out during urination. When a catheter
is inserted this flushing mechanism is circumvented and perineal and
urethral flora can pass up into the bladder in the fluid layer between the
outside of the catheter and the urethral mucosa. Because of this, bladder
colonisation is almost inevitable if catheters are left in place for
prolonged periods. In addition, bladder infection can be caused by
bacterial reflux from contaminated urine in the drainage bag, therefore
closed drainage systems should be used to reduce infection, when
possible. Hands of personnel may also contaminate the urinary catheter
system during insertion or management. (See Figure 14.1)

Microbiology

A UTI is usually endogenous, caused by microorganisms from the

patient's own bowel. In community-acquired infection, the commonest
microorganisms are E. coli and Proteus spp. which are usually sensitive
to most antibiotics and are relatively easy to treat. However healthcare-
associated UTIs are more resistant to antibiotics. This is because

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 Prevention of Urinary Tract Infections

Figure 14.1 The four main sites through which bacteria may reach the bladder
of a patient with an indwelling urethral catheter. The recommended measures
for prevention are listed in Table 14.1.
(Reproduced with permission from Damani N N, Keyes JK. Infection Control
Manual, 2004.)

hospitalised patients become colonised with resistant organisms, a

process encouraged by increasing length of hospital stay and exposure
to antibiotics. In communities where indiscriminate antimicrobial use is
common, multiresistant Gram-negative bacteria are also prevalent in
the human bowel outside the hospital.

E. coli is the commonest cause of healthcare-associated UTI, however,

these infections are increasingly caused by more resistant
Gram-negative species, such as Klebsiella and Pseudomonas. Similarly,
ampicillin-sensitive Enterococcus faecalis is gradually being replaced by
the resistant E. faecium. Then, with additional antibiotic exposure,
infections occur with multiply drug resistant versions of these and other
species.

In addition, resistant organisms may be acquired by transfer from other

patients, most commonly via contaminated staff hands, but sometimes
from environmental sources. Infected urine is a potent source of staff
hand contamination. Urine and urinary catheter systems should be

125
IFIC Basic Concepts of Infection Control

carefully disposed of, bottles and jugs cleaned and disinfected, and
hands properly washed and decontaminated during insertion and
management.

Diagnosis

The diagnosis of UTI in hospitals depends on laboratory support.

Where this is good and a careful, midstream specimen is collected:
finding 105 bacterial colony forming units (CFU)/ml in a patient
without an indwelling catheter is diagnostic of UTI. Bacterial
concentrations >102 CFU/ml suggest infection if the specimen is obtained
aseptically by needle aspiration from the proximal drainage tubing port
in a patient with an indwelling catheter. Although UTIs in non-
catheterised patients are usually caused by a single microorganism, in
catheterised patients infections are frequently polymicrobial.

The presence of multiple microorganisms does not necessarily indicate

contamination. Urine must be processed promptly, since even with
good technique urine samples may contain small numbers of
contaminants. These microbes can multiply at room temperature
(especially in hot climates) and give falsely high colony counts. If delay
is expected, the specimen should be transported in an ice box and
refrigerated on arrival. Alternatively, boric acid (1% W/V or 1 g/10 ml of
urine) should be added to the urine. Specimens containing boric acid
need not be refrigerated.

Where microbiological support is poor or unavailable, clinical

symptoms (e.g., fever, supra-pubic tenderness, frequency, and dysuria)
may be useful in diagnosis, principally in non-catheterised patients.
The presence of pyuria on either microscopic examination or by dip
stick (leukocyte esterase) is highly suggestive of UTI. If dip sticks are
available, a positive nitrite reaction in combination with a positive
leukocyte esterase reaction is virtually diagnostic. In catheterised
patients, as stated above, a positive urinary culture or dip-stick is not
sufficient for diagnosis of infection. In such patients, fever and
leukocytosis or leucopenia are additional diagnostic criteria.

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 Prevention of Urinary Tract Infections

Strategies to prevent infection (See Table 14.1)

Staff training
Healthcare personnel performing urinary catheterisation should receive
training on correct procedures for insertion and maintenance of urinary
catheters based on local written protocols.

Catheter size
Catheters are available in different sizes. The smallest diameter catheter
that allows free flow of urine should be used. Larger diameter catheters
are more likely to cause unnecessary pressure on the urethral mucosa,
which may result in trauma and ischaemic necrosis. Urological patients
and some other patient groups may require larger sized catheters; these
should only be used on the advice of specialists.

Catheter insertion
Urinary catheterisation should always be performed using sterile or
high level disinfected equipment and aseptic technique. To minimize
trauma to the urethra and discomfort to the patient, a sterile lubricant or
local anaesthetic gel should be used.

Meatal cleansing
Meatal cleansing should be performed regularly to ensure that the
meatus is free from encrustations. Cleansing with soap and water is
sufficient; application of antimicrobial ointment or disinfectant to the
urethral meatus is harmful and should be avoided.

Drainage bag
To help prevent trauma to the urethra, the urinary drainage tubing
should be secured to the patients thigh and straps adjusted to a
comfortable fit. The catheter drainage bag must always be placed below
the level of the bladder to promote good drainage. If a 3/4 catheter stand
is used, the drainage bag and drainage tap must not come in contact
with the floor. During patient movement, the drainage tube should be
temporarily clamped to prevent back-flow or reflux of urine. Do not
disconnect the drainage bag unnecessarily as this causes interruption to
the closed drainage system.

Emptying the drainage bag

The drainage bag should be emptied regularly (i.e., when 3/4 full or

127
IFIC Basic Concepts of Infection Control

sooner if it fills rapidly) via the drainage tap at the bottom of the bag. If
the bag does not have a tap, it must be replaced when 3/4 full using
aseptic technique.

Extreme care must be taken when emptying a drainage bag to prevent

cross-infection between patients. Hands must be washed or disinfected
with an alcohol hand rub and non-sterile disposable gloves should be
worn when emptying the bag. Alcohol impregnated swabs should be
used to decontaminate the outlet of the drainage tap (inside and
outside). After emptying the bag, gloves must be removed and hands
must be washed.

When emptying the drainage bag, use a separate container for each
patients urine and avoid contact between the urinary drainage tap and
the container. The urine container should be rinsed and heat disinfected
(preferably in a washer-disinfector unit), dried and stored in a clean
place before further use.

Bladder irrigation
Bladder irrigation or washout and instillation of antiseptics or
antimicrobial agents do not prevent catheter-associated UTI and
therefore should not be used for this purpose. The use of these agents
may damage the bladder mucosa or catheter and promote the
development of resistant bacteria which are difficult to treat.

Specimen collection
Samples of urine for bacteriological examination should be obtained
from the sampling port or sleeve using aseptic technique. The sampling
port should be disinfected by wiping with a 70% isopropyl alcohol
impregnated swab. The sample may then be aspirated using a sterile
needle and syringe and transferred into a sterile universal container.
Never obtain a sample from the drainage bag. In asymptomatic patients,
routine bacteriological testing is of no clinical benefit.

Use of antimicrobial agents

The routine administration of systemic antibiotics at the time of catheter
insertion/removal is not recommended. The administration of a
prophylactic antibiotic as a single dose at catheter change may be used
in selected patients who either have clinical infection or have a higher
risk of developing UTIs. Use of prophylactic antibiotics should be
assessed on an individual basis.

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 Prevention of Urinary Tract Infections

The antibiotic treatment of catheter associated UTIs in the presence of

long-term indwelling catheters may breed resistant bacteria and may
not be successful because the causative bacteria are often embedded in
biofilm on the surface of the catheter and are therefore protected from
the action of antibiotics.

Table 14.1. Prevention of bacterial colonization/infection of the bladder in

patients with indwelling urethral catheters

Entry points for

Preventive measures
bacteria
1. External urethral
meatus and urethra

Pass catheter when bladder is full for washout effect

Before catheterisation, clean urethral meatus using
Bacteria carried into sterile water or saline. Instil 2% lidocaine,
bladder during insertion 0.25% chlorhexidine gluconate into urethra and hold
of catheter there for at least 3 minutes before inserting catheter
Use sterile or adequately decontaminated catheter
Use no-touch technique for insertion

Ascending colonization or
infection of urethra Keep peri-urethral area clean and dry
around outside of Secure catheter to prevent movement in urethra
catheter

Do not disconnect catheter unless absolutely necessary

Always use aseptic technique
2. Junction between
Collect urine specimen from sampling port
catheter and drainage
Apply alcohol impregnated wipe and allow it to dry
tube
completely then aspirate urine with a sterile needle and
syringe and transfer specimen into sterile container

3. Junction between
drainage tube and
collection bag

Keep bag below level of bladder

Reflux from bag into tube Empty bag regularly
Do not hold bag upside down when emptying

Collection bag must never touch floor

4. Tap at bottom of Always wash or disinfect hands before and after
collection bag -emptying opening tap
of bag Use a separate jug to collect urine from each bag

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IFIC Basic Concepts of Infection Control

There may be a place for the use of condom catheters for short-term
drainage in cooperative patients. Frequent changes, e.g., daily, may
avoid complications together with penile care. They should be removed
at the first sign of penile irritation or skin breakdown. Condom use for
24 hour periods should also be avoided and other methods, such as
napkins or absorbent pads, used at night.

References and Further Reading

1. Department of Health. Epic Guidelines. Guidelines for preventing

infections associated with the insertion and maintenance of short-
term indwelling urethral catheters in acute care. J Hosp Infect
2001;47 Suppl:S3946.
2. Society for Healthcare Epidemiology of America. Urinary tract
infections in long-term care facilities. Infect Control Hosp
Epidemiol 2001;167:16775.
3. Huang W-C, Wann S-R, Lin S-L, et al. Catheter-associated urinary
tract infections in intensive care units can be reduced by
prompting physicians to remove unnecessary catheters. Infect
Control Hosp Epidemiol 2004;25:974-8.

130
 Prevention of Blood-Borne Virus Infections in Patients and Personnel

Chapter 15
Prevention of
Blood-Borne Virus
Infections in Patients
and Personnel
Patricia Lynch

Key points
Many pathogens can be transmitted efficiently through blood
exposure:
Bacteria including streptococci, staphylococci, and syphilis
Viruses including hepatitis, hemorrhagic fevers, HIV, herpes
and dengue
Fungi including blastomyces and cryptococci
Protozoa including malaria and toxoplasmosis
Risk for patients is reduced by using only sterile injection
equipment and solutions and only using injections when
necessary
Risk for HCWs is reduced through a combination of barrier
precautions, safe sharps practices, post-exposure prophylaxis
and immunization for vaccine preventable diseases.

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IFIC Basic Concepts of Infection Control

Introduction

For more than a century, transmission of blood-borne (BB) infectious

agents has been recognized as an important risk for patients and
personnel. Health care workers (HCW) acquire BB infections as a result
of lacerations, punctures and non-intact skin exposures to blood or
body fluids of infected patients. Patients acquire BB infections from
improperly sterilized injection equipment, unsterile injection fluids, and
exposure to the blood of infected HCWs during invasive procedures.

Many studies have shown that patient and HCW risk for exposure can
be reduced substantially at relatively low cost; risk for disease following
exposure can also be reduced, although at higher cost. There are few
infection prevention and control opportunities that would result in
greater improvement of global health than reducing frequency of BB
diseases.

Risk for BB infections in patients

Injections received for health care have been viewed as safe when
compared to illicit injection drug use. However, this view is certainly
incorrect: large epidemics of hepatitis B virus (HBV), hepatitis C virus
(HCV), and human immunodeficiency virus (HIV) infections have been
reported as a result of health care injections. Most are probably never
recognized or reported.

The Safe Injection Global Network (SIGN) 1 estimated in the 2000 Global
Burden of Disease study that approximately 16 billion injections are
performed annually in the world. Many are unnecessary as oral
medication would be better. In addition, in settings with limited
resources, more than half of all injections are given with syringes reused
without sterilisation or high-level disinfection. Shortage of supplies
leads to ineffective strategies such as using a single syringe repeatedly
for a single day, for a particular drug or family.

Studies in China, Pakistan, India, Moldova, Romania, Egypt, some

African nations and other countries have reported the association
between unsterile injections and subsequent HBV, HCV and HIV
infection to be very high. Using a complex model, SIGN estimated that
in 2000, contaminated injections caused 21 million HBV infections, two

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 Prevention of Blood-Borne Virus Infections in Patients and Personnel

million HCV infections and 260,000 HIV infections, accounting for 32%,
40% and 5% respectively of new infections.

Reducing risk for BB infections in patients

Since the cost of sterile injection equipment and solutions is often a

problem, no effort to reduce risk will be effective without first reducing
frequency of unnecessary injections. This will certainly require changing
the injection culture among healthcare personnel and changing both
education and culture among patients and their families. WHO
proposes that national strategies for the safe and appropriate use of
injections address behaviour change among health care workers and
patients, provision of equipment and supplies and sharps waste
management. Such initiatives should not constitute separate programs
but should be integrated with other activities, including HIV prevention
and care, essential medicines, immunization and health system
management. 2

In general, a successful program should include:

1. Reduce unnecessary injections by:
a) Developing a policy in the health care facility on appropriate
drugs and circumstances for injections and publicize it.
b) Carry out public campaigns in schools and the media to reduce
injections.
2. Educate HCWs, patients and the public about injection risk by
a) Developing teaching materials (posters, lectures) about
injection risk and the importance of reducing injection frequency.
b) Enlisting influential institutions, such as churches, hospitals,
and government officials, to campaign against unnecessary
injections.
3. Eliminate use of unsterile needles, syringes, and solutions for
injections.

Risk for BB infections in health care workers

Because of potential exposure to HBV in patient's blood, immunisation

is recommended for all HCWs who have exposure to blood and body
fluids. However, this does not reduce the need to observe safe practices
to reduce needlestick injuries and other blood exposures.

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IFIC Basic Concepts of Infection Control

For example, only re-cap disposable needles using a one-handed

technique. Place used sharps in puncture-proof containers before
reprocessing or disposal. Use no touch techniques (e.g., forceps) to
handle blood or blood contaminated material. Wear gloves for handling
sharp items; one layer of latex reduces the blood inoculum
significantly.3

Establish a procedure for reporting blood exposures to the Occupational

Health Department and the appropriate management actions to be
taken. Surveillance for occupational blood exposures can provide data
for prevention efforts. Routine accident reports may not provide
accurate or sufficient information to guide these prevention strategies;
therefore, focused studies may be required.4 Studies in departments
where the risk for occupational blood exposures is high have shown
that personnel were able to reduce the frequency of exposure more than
half by changing practices and increasing barrier precautions.5
Post-exposure management recommendations for HIV change
frequently and are beyond the scope of this chapter, but they are
somewhat successful and healthcare facilities should have appropriate
policies in place.

Reducing risk for BB infections in health care workers

A HCW risk assessment found that risk of exposure was highest when
sharp tools were involved, when HCWs were inexperienced at the task,
or when the patient was unable to be fully cooperative. In addition, risk
of exposure is higher if HCWs anticipate difficulty managing a
particular situation.

Some risks to health care workers can be eliminated by using devices

that minimize puncture opportunities; many others can be reduced by
infection prevention programs that mandate appropriate use of barrier
precautions and safe work practices.

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 Prevention of Blood-Borne Virus Infections in Patients and Personnel

References and Further Reading

1. Hauri AM, Armstrong GL, Hutin YJF. The Global Burden of

Disease Attributable to Contaminated Injections Given in Health
Care Settings. Int J STD and AIDS 2004;15:7-16.
2. World Health Organisation. Injection Safety [online] 2004 cited
2007 August 10]. Available from: URL: http://www.who.int/
injection_safety/en/.
3. Herwaldt LA, Pottinger JM, Carter CD, et al. Exposure Workups.
Infect Control Hosp Epidemiol 1997;18:850-71.
4. Heffernan R, Mostashari F, Das D, et al. Syndromic surveillance
in public health practice, New York City. Emerg Infect Dis 2004;
10:858-864.
5. Patterson JE. Isolation of Patients with Communicable Diseases:
In: Mayhall CG, editor. Hospital Epidemiology and Infection
Control, 3rd ed. Philadelphia: Lippincott Williams & Wilkins;
2004. p. 1703-1725.

135
 Occupational Health Risks for Healthcare Workers

Chapter 16
Occupational Health
Risks for Healthcare
Workers
Patricia Lynch with Liz Bryce and Eva Thomas

Key points
Assess infection risks to personnel and prioritise preventive
measures.
Implement an education programme about safety and
infection prevention related to the specific risks of work in the
facility.
Determine susceptibility to vaccine preventable diseases and
implement an appropriate immunisation programme.
Conduct exposure investigations including review of post-
exposure management.
Implement surveillance of occupational blood exposures and
develop prevention strategies for high-risk practices or
departments.

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IFIC Basic Concepts of Infection Control

Introduction

Healthcare workers are at risk of exposure to a variety of infectious

agents which may cause them illness and which they may transmit to
other staff and patients. Occupational Health Departments (OHD) that
work closely with the infection prevention and control department may
minimise this risk by maintaining necessary records, performing
screening and immunisations, educating staff about risk and
prevention, and conducting exposure management and investigations.

Table 16.1 presents a list of healthcare-associated infections in patients

and employees in health care settings. Local infection control teams
(ICT) and OHDs must review this list, determine potential risks, and
prioritise the allocation of resources for risk reduction in their facility.
The routes of transmission of each microorganism must be understood
before appropriate prevention measures can be selected.

Prevention of infection: General measures

Maintain easily retrievable occupational health records.

Screen new employees for a history of communicable diseases.
Immunise for vaccine preventable diseases.
Record needlestick and other injuries in an 'accident' log; data on
the epidemiology of blood exposures should be analysed
periodically to audit practices and identify preventable risks.
Provide evaluation and guide work restrictions for staff with
infectious diseases or exposures.
Ensure that all staff members cover lesions on exposed skin with
a waterproof dressing.

Minimal Requirements for Personnel and Patient

Protection

Preventing the spread of infection often requires us to 'break the chain

of infection', i.e., to interrupt the normal routes of transmission. The
following measures are targeted at specific methods of spread.

138
 Occupational Health Risks for Healthcare Workers

Contact
Wash hands when they are likely to have been soiled and before
beginning care for a new patient. Alcohol hand rubs are
acceptable unless hands are visibly soiled.
For contact with all mucosa and broken skin, wear gloves that are
clean at the time of use. Use sterile gloves for normally sterile
body sites.
Wear appropriate barriers for a task, e.g., eyewear for spatter and
appropriate gloves for contact with all moist body substances.
Disinfect all items between patients.
Handle all clinical specimens as if known to be infectious.
Handle soiled linen and trash so as to avoid skin contact.

Airborne
Restricting susceptible staff from exposure is the best and often the only
prevention strategy for diseases transmitted in whole or in part by air.
Common surgical masks provide minimal protection. High efficiency,
respirator type masks may offer some protection when in close contact
with a coughing patient with tuberculosis. However, they are expensive
and often not available. It is not clear if they are useful to protect
susceptible staff from measles or varicella virus.

Post Exposure Prevention

Once exposure to a communicable disease has been identified, the ICT

must try to prevent spread of the pathogen. To begin with, they must
identify and list those individuals who have been significantly exposed,
using definitions which must be clearly listed in the infection
prevention and control manual. The next step is to determine which
exposed persons need intervention. Individuals immune either from
previous natural infection or vaccination must be identified. The OHD
should keep a register of each staff members immune status.

Limiting Exposures

The key to limiting exposures in a healthcare institution is developing

policies and procedures that:
consistently identify individuals at high-risk for communicable
diseases;

139
 Table 16.1. Risks for transmission of infectious agents in health care settings and risk reduction strategies for employee to
patient and patient to employee transmission

Estimated
transmission risk to a
Modes of susceptible host
Infection Primary risk reduction strategies
Transmission
Staff to Patient to
patient staff

Chickenpox,
Contact with vesicles; High High
disseminated zoster Varicella vaccine for susceptible individuals; varicella
droplet or airborne
IFIC Basic Concepts of Infection Control

zoster immune globulin (VZIG) for

spread from respiratory

140
immunocompromised contacts of cases.
tract of acute cases and
Major risk: adults and immunocompromised hosts;
perhaps from
Localized varicella-zoster bone marrow transplant patients at greatest risk.
disseminated zoster. Moderate Moderate
(shingles)

Contact with eye Identify and eliminate environmental reservoirs;

Conjunctivitis, viral (e.g.,
secretions and High High restrict infected personnel; emphasise hand hygiene
adenovirus)
contaminated objects. and disinfection of shared ophthalmic equipment.
 Estimated
transmission risk to a
Modes of susceptible host
Infection Primary risk reduction strategies
Transmission
Staff to Patient to
patient staff
Contact with urine,
Use care in handling diapers and oral secretions.
saliva, breast milk,
Appropriate gloves and hand hygiene. CMV is very
cervical secretions, and
Cytomegalovirus (CMV) Rare Rare common in young children, organ-transplant
semen from infected
patients, and patients with HIV/AIDS; undiagnosed
person who is actively
cases are far more common than diagnosed cases.
shedding virus.

141
Moderate Bloodborne disease precautions: safe handling of
Bloodborne; some
Hemorrhagic fever (risk from needles and sharps; use gloves, other barriers
question of contact Low
(Ebola & Marburg virus) puncture including protective eyewear, and hand hygiene
transmission.
unknown) appropriately.

Person-to-person by
Use care in handling diapers and faecal materials; use
faecal-oral route; rarely
gloves and hand hygiene appropriately; use immune
via blood transfusion;
serum globulin prophylaxis for significant exposures;
Hepatitis A infected food handlers Rare Rare
provide hepatitis A vaccine, when appropriate.
with poor personal
Hospital outbreaks almost always from an
hygiene can contaminate
unrecognised case.
food.
Occupational Health Risks for Healthcare Workers
 Estimated
transmission risk to a
Modes of susceptible host
Infection Primary risk reduction strategies
Transmission
Staff to Patient to
patient staff

Hepatitis B vaccine for all personnel at risk for blood

Via percutaneous,
Moderate exposure; emphasise safe handling of needles and
mucosal, and nonintact
(risk from sharps; use gloves, other barriers, and hand hygiene
Hepatitis B virus skin contact with blood, Low
puncture: appropriately; use high titre hepatitis B immune
semen, vaginal secretions,
6-35%) globulin (HBIG) prophylaxis for significant
IFIC Basic Concepts of Infection Control

and bloody fluids.

exposures in susceptible personnel.

142
Low
Emphasise safe handling of needles and sharps; use
(risk from
Hepatitis C virus Same as for Hepatitis B. Rare gloves, other barriers, and hand hygiene
puncture:
appropriately.
1-7%)

To protect personnel, use gloves for contact with oral

Contact with virus in secretions, mouth care and vesicles; to protect
Herpes simplex saliva of carriers; contact Rare Low patients, employee should cover lesion with dressing
with vesicle fluid. or wear gloves with herpetic whitlow. May need to
restrict infected staff from patient contact.
 Estimated
transmission risk to a
Modes of susceptible host
Infection Primary risk reduction strategies
Transmission
Staff to Patient to
patient staff
Emphasise safe handling of needles and sharps; use
Primarily via
gloves, other barriers, and hand hygiene
percutaneous contact
appropriately.
with blood; mucosal or Rare
Human
nonintact skin contact (risk from
immunodeficiency virus Very rare Manage post-exposure prophylaxis in accordance
with blood. Semen, puncture:
(HIV) with current guidelines. Healthcare workers who
vaginal secretions, and 0.03%)
know or suspect themselves to be HIV or Hepatitis B

143
bloody body fluids less
e-antigen positive should seek advice; it may not be
likely to transmit.
appropriate to perform exposure-prone procedures

Airborne; direct or Influenza vaccine for high-risk employees and

Influenza droplet contact with Moderate Moderate patients; amantadine or other prophylaxis for
respiratory secretions. influenza A exposures, as appropriate.

Natural immunity or measles vaccine for health care

Airborne; direct or personnel; vaccine for patients, as appropriate.
droplet contact with nasal Measles outbreaks have been reported in poorly-
Measles High High
or throat secretions of ventilated medical offices; many health care facilities
infected person. require measles immunity as a condition of
employment.
Occupational Health Risks for Healthcare Workers
 Estimated
transmission risk to a
Modes of susceptible host
Infection Primary risk reduction strategies
Transmission
Staff to Patient to
patient staff
Appropriate use of gloves and hand hygiene;
Direct contact with oral None antibiotic prophylaxis indicated only for personnel
Meningococcal infection Rare
secretions. reported with mucosal contact with oral secretions
(e.g., performing mouth-to-mouth resuscitation).

Droplet contact or direct

Mumps vaccine is effective for personnel and
IFIC Basic Concepts of Infection Control

Mumps contact with oral Moderate Moderate

144
patients; adults may have complications.
secretions.

Droplet contact or direct Appropriate use of gloves, other barriers, and hand
Pertussis contact with respiratory Moderate Moderate hygiene; antibiotic prophylaxis of exposed health
secretions. care workers; hospital outbreaks reported.

Droplet contact or direct Appropriate use of gloves, other barriers, and hand
Respiratory syncytial
contact with respiratory Moderate Moderate hygiene; eye protection may reduce risk of
virus
secretions. self-inoculation via contaminated hands.

Appropriate use of gloves, other barriers, and hand

Person-to-person via
Rotavirus Moderate Moderate hygiene; many outbreaks have been reported in adult
faecal-oral route.
and child units.
 Estimated
transmission risk to a
Modes of susceptible host
Infection Primary risk reduction strategies
Transmission
Staff to Patient to
patient staff

Droplet contact or direct

Natural immunity or rubella vaccine for health care
contact with respiratory
personnel and vaccine for patients, as appropriate.
Rubella secretions: airborne Moderate Moderate
Many health care facilities require employees to be
transmission not
immune to rubella.
demonstrated.

145
Hand hygiene, especially after using the toilet and
Person-to-person via
before preparing food; appropriate use of gloves and
faecal-oral route; via
hand hygiene when caring for incontinent patients.
contaminated food or
Salmonella or Shigella Low Low Shigella only requires a very small inoculum (10 - 100
water; food handlers with
microorganisms) and is easy to transmit; Salmonella
poor personal hygiene
(except typhoid) requires larger inoculum and is
can contaminate food.
common in eggs and poultry.

Index of suspicion for scabies with any undiagnosed

Direct skin-to-skin rash; use of acaricide (such as lindane or permethrin)
Scabies contact with infested Low Low promptly to eradicate infestation; gloves, other
person. barriers, and hand hygiene. Outbreaks have often
involved patients, personnel and household contacts.
Occupational Health Risks for Healthcare Workers
 Estimated
transmission risk to a
Modes of susceptible host
Infection Primary risk reduction strategies
Transmission
Staff to Patient to
patient staff
Appropriate use of gloves, other barriers and hand
hygiene. S. aureus intermittently colonises normal
Staphylococcus aureus
human skin and the nares of 2 - 30% of the population.
(includes wound and skin Direct and indirect contact. Rare No data
Transmission from patient to patient common.
infection)
Treatment to eradicate colonisation is controversial., but
mupirocin has been recommended for nasal carriage.
IFIC Basic Concepts of Infection Control

Droplet contact or direct

146
Appropriate use of gloves, other barriers and hand
contact with oral secretions
Streptococcus, Group A Rare No data hygiene; antibiotic treatment for symptomatic persons or
or drainage from infected
those identified as shedders.
wounds.

Direct contact with lesions

Appropriate use of gloves when touching any lesions;
Syphilis of primary or secondary No data Rare
other barriers as appropriate; hand hygiene.
syphilis.

Airborne transmission
from sources with active Index of suspicion for a TB case; appropriate ventilation
pulmonary or laryngeal of locations where TB patients receive care; airborne
Tuberculosis (TB) tuberculosis; susceptible Low to high Low to high precautions for identified cases; respiratory protection
person must inhale for personnel. Exposure management and treatment of
airborne droplet nuclei to individuals with new infections.
become infected.
 Occupational Health Risks for Healthcare Workers

employ dependable and easily implemented methods to limit the

exposure at the source (i.e., the patient);
are based on symptoms rather than diagnosis;
are readily communicated and understood;
protect staff, other patients and visitors.

Support

Infection prevention and control activities require a mandate from

administration for exposure management in conjunction with the OHD.
This mandate must define responsibility, lines of communication, and
authority.1 Policies and procedures should be developed that cover
workload, finances, medico-legal issues (including sick leave with or
without pay), immunisations and confidentiality.

References and Further Reading

1. Herwaldt LA, Pottinger JM, Carter CD, et al. Exposure Workups.

Infect Control Hosp Epidemiol 1997;18:850-71.
2. Mast ST, Woolwine JD, Gerberding JL. Efficacy of gloves in
reducing blood volumes transferred during simulated needlestick
injury. J Infect Dis 1993;168:1589-92.
3. Lynch P, White MC. Perioperative blood contact and exposures:
A comparison of incident reports and focused studies. Am J Infect
Control 1993;21:357-63.
4. White MC, Lynch P. Blood contacts in the OR after hospital-
specific data analysis and action. Am J Infect Control 1997;
25:209-14.
5. Hauri AM, Armstrong GL, Hutin YJF. The Global Burden of
Disease Attributable to Contaminated Injections Given in Health
Care Settings. Int J STD and AIDS 2004;15:7-16.
6. Decker MD, Schaffner W. Chapter 65: Nosocomial diseases of
health care workers spread by the airborne or contact routes
(other than tuberculosis). In: Mayhall CG, editor. Hospital
Epidemiology and Infection Control. Baltimore: Williams &
Wilkins; 1996. p.859-83.
7. Falk, P. Chapter 83: Infection control and the employee health
service. In: Mayhall CG, editor. Hospital Epidemiology and
Infection Control. Baltimore: Williams & Wilkins; 1996. p. 1094-9.

147
IFIC Basic Concepts of Infection Control

8. Lynch P. Managing employee and patient exposures in health

care settings. In: Lynch P, Jackson MM, Preston GA, Soule BM.
Editors. Infection prevention with limited resources: A handbook
for infection committees. Chicago: Etna Publications; 1997.
9. Sheretz RJ, Marosok RD, Streed SA. Chapter 14: Infection control
aspects of hospital employee health. In: Wenzel RP editor.
Prevention and Control of Nosocomial Infections, 2nd edition.
Baltimore: Williams & Wilkins; 1993. p. 295-332.
10. CDC. Guideline for infection control in health care personnel
[online] 1998 [cited 2007 August 10). Available from: URL: http://
www.cdc.gov/ncidod/dhqp/gl_hcpersonnel.html.
11. Prevention and Control of Occupational Infections in Health
Care, Public Health Agency of Canada, Health Canada [online].
2002 [cited 2007 August 10]. Available from: URL: http://
www.phac-aspc.gc.ca/publicat/ccdr-rmtc/02vol28/28s1/
index.html

148
 Housekeeping and Laundry

Chapter 17
Housekeeping and
Laundry
Ulrika Ransj

Key points
Neutral detergents are adequate for most cleaning purposes.
Cleaning staff must be properly trained and supervised.
An ongoing cleaning schedule must be established.
All linen, whether visibly soiled or superficially clean,
must be processed to the same high standard.

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IFIC Basic Concepts of Infection Control

Housekeeping

The inanimate environment is rarely the primary source of infection

outbreaks, however contaminated water and bedding may result in
opportunistic infections. If the environment immediately around a
patient becomes contaminated, either by direct patient shedding
(droplet-contact or airborne-contact) or by healthcare workers touching
instruments, door knobs or other surfaces and equipment with
contaminated hands (indirect contact), secondary transmission may
occur.

Thus, it is necessary to clean the environment especially around recently

discharged patients to prevent build-up of material that may harbour
potential pathogens. A clean, well-maintained healthcare facility
inspires confidence in patients, staff and the public in its commitment to
provide a safe, high standard of care.

Disinfection

Surface disinfectants are hazardous substances and must be handled

only by trained staff. To use disinfectants for housekeeping is an unsafe
practice that poses risks to the environment as well as to staff. There is
no evidence that overuse of disinfectants prevents infection. Detergent/
disinfectant products are available that clean well and are not readily
affected by organic matter.

Housekeeping cleaning

Vigorous cleaning with water and neutral detergents reduces or

eliminates reservoirs of potential pathogens and is adequate for most
purposes. Cleaners must be properly trained and supervised. An
ongoing cleaning schedule must be established, which should specify:

Who is responsible for specific jobs

Work procedures, including special equipment and supplies,
e.g., cleaning and storage of equipment, mop head changing
Use of protective clothing
Accountability
Frequency of floor cleaning

150
 Housekeeping and Laundry

Frequency of solution and mop change

Frequency of furniture cleaning
Frequency of toilet, commode and fixture cleaning
Frequency of cleaning items such as ice machines
Frequency of cleaning grilles and air-ducts

If a spill of moist body substances occurs, it should be spot disinfected

with a detergent/disinfectant solution. This is particularly important
above floor level where hands may come into direct contact with
potential pathogens.

Walls rarely become contaminated and so do not need frequent

cleaning. Horizontal surfaces, such as floors, and simple devices, such
as intravenous poles and bed frames, collect dust. They can be
maintained by cleaning with water and a detergent. However, areas
that are repeatedly touched may need more frequent and intensive
cleaning, for example handrails, door handles and light switches.
Special cleaning procedures may be considered in certain
circumstances, e.g., during an outbreak of Clostridium difficile-associated
diarrhoea.

The manufacturers instructions must be followed when preparing

disinfectant and cleaning solutions. Some disinfectants, e.g., phenolics,
must not be used in newborn nurseries or food preparation areas
because of toxicity.

Laundry Services

Careful handling and reprocessing of soiled linen prevents the

transmission of infectious disease between patients and staff. Provision
of fresh clean linen enhances patient comfort. All linen, whether visibly
soiled or superficially clean, must be processed to the same high
standard. Gross soil, (e.g., faeces) should be removed as close to the
source as possible, preferably by dumping it into a sluice, clinical sink,
or down a toilet.

All staff must be made aware of the risk to laundry workers from sharp
objects left in soiled linen. Laundry workers should be offered
vaccination against hepatitis A and B viruses. Special procedures need

151
IFIC Basic Concepts of Infection Control

to be developed for linen contaminated with viral haemorrhagic fever

viruses.

Sorting procedures

Avoid contaminating hands with soil.

Place soiled linen in a water-impermeable laundry bag.
Secure bag when full. If cloth bags are used, workers should
wear gloves and handle bags with care. Bags of soiled linen
should be left in a secure place for pick-up and transport.
Bags should be taken to an area in the laundry dedicated for
pre-wash sorting.
Laundry sorters must be educated on procedures and the proper
use of barriers, and provided with puncture and water resistant
gloves and plastic aprons or water resistant gowns.
Safely presorting soiled linen into washer loads of sheets, pillow
cases, towels, gowns, etc., facilitates laundry turn-around times.
Minimise handling soiled linen as much as possible.

Washing processes

A prewash rinse cycle of 15 minutes will remove remaining gross

soilage.
If using a cold water wash, chemicals such as bleach must be
added (2 ml of household bleach for every litre of water) with
detergent to facilitate disinfection.
A high temperature wash must be performed (>71C) if cold
water detergents with bleach are not used.
During the rinse cycle, a souring agent should be added to the
rinse cycle to reduce alkalinity and prevent yellowing. This
decreases the likelihood of skin irritation and further reduces the
number of bacteria present.
Linen should be dried as soon as possible after washing to
prevent regrowth of any bacteria not killed by the washing
procedure.
Hot air drying or drying on a clothesline in sunlight will reduce
the numbers of bacteria present.
Ironing (especially using a steam iron) will destroy pathogens.

152
 Housekeeping and Laundry

Clean linen must be stored and transported in such a manner that

contamination is avoided. It must be stored at least 4-6 inches off the
floor and covered during transport.

Linen to be sterilised must be appropriately wrapped before being sent

to the sterile processing department.

References and Further Reading

1. Malik RE, Cooper RA, Griffith CJ. Use of audit tools to evaluate
the efficacy of cleaning systems in hospitals. Amer J Infect
Control 2003;31:181-7.
2. Rutala WA, Weber DJ. Uses of inorganic hypochlorite (bleach) in
health care facilities. Clin Microbiol Rev 1997;10:597-610.
3. Tompkins DS, Johnsson P, Fittall BR. Low-temperature washing
of patients' clothing; effects of detergent with disinfectant and a
tunnel drier on bacterial survival. J Hosp Infect 1988;12:51-8.
4. Rden H, Daschner F. Should we routinely disinfect floors?
J Hosp Infect 2002;51:309-11.

153
 Healthcare Waste Management

Chapter 18
Healthcare Waste
Management
Edward Krisiunas

Key points
Sharps are the most likely healthcare waste to cause injury and/
or exposure. Therefore, a waste management program must
focus on sharps handling.
Proper segregation will reduce the risk of disease transmission
and minimise the amount of potentially infectious health care
waste generated.
A range of treatment options for waste are available.
Consideration should be given to those that reduce the
opportunity for exposure and not necessarily inactivation of
microorganisms.
Education and regular reinforcement of practices are the keys to
success.

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IFIC Basic Concepts of Infection Control

Introduction

Healthcare activities inevitably generate health care waste (HTCW). The

proper management of HTCW creates a safer environment for staff,
solid waste workers, and the public. HTCW management is dictated by
professional standards, local laws and national legislation, and, most
importantly, available resources.

Definitions

HTCW can be considered any waste generated in a healthcare setting.

There is more concern regarding the hazardous aspect of waste, i.e.,
infectious, chemical, or radioactive waste, as listed in Table 18.1.

Table 18.1: World Health Organization categories of Health Care Waste

(abbreviated)

Waste category Description and examples

Waste suspected to contain pathogens, i.e., laboratory

cultures, waste from isolation wards, tissues (swabs),
Infectious waste materials or equipment that have been in contact with
infected patients, excreta. This category also includes
pathological and sharps waste.

Waste containing pharmaceuticals, i.e., pharmaceuticals

that are expired or no longer needed, items
Pharmaceutical waste
contaminated by or containing pharmaceuticals (bottles,
boxes).

Waste containing substances that are capable of causing

Genotoxic waste damage to DNA, i.e., waste containing cytostatic drugs
(often used in cancer therapy), genotoxic chemicals.

Waste containing chemical substances, i.e., laboratory

Chemical waste reagents, film developer, disinfectants that are expired
or no longer needed, solvents.

Waste containing radioactive substances, i.e., unused

liquids from radiotherapy or laboratory research,
Radioactive waste contaminated glassware, packages or absorbent paper,
urine and excreta from patients treated or tested with
unsealed radionuclides, sealed sources.

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 Healthcare Waste Management

Infectious waste includes the following 5 categories:

1. Microbiological - culture plates, growth media, etc.

2. Sharps any object that can cause percutaneous injury
3. Pathological human tissues
4. Swabs, dressings, bandages contaminated with potentially
infectious fluids
5. Blood tubes of blood, units of blood, blood and blood products,
and other containers used to collect blood

Collection

Once waste is identified it must be collected using containers that

reduce the risk of exposure. Containers must meet the minimum
specifications shown in Table 18.2. They should be labelled with the
international biohazard symbol and not overfilled. The biohazard label
can be painted on containers or rolls of self-adhesive labels can be used.

HTCW should be segregated from regular garbage at all health care

facilities. It should be placed in special collection containers at the point
of generation and kept separate from other waste. Labelled containers
should be placed in areas where the specific waste is generated, along
with containers for general garbage. Non-infectious and non-hazardous
wastes should be disposed of with regular garbage, recycled or
composted as appropriate.

In-House Transport

Waste transporters should wear gloves. Any cart for transporting

HTCW within the facility should be fully enclosed. HTCW carts should
be used only for that purpose and not for regular garbage. They should
be cleaned and disinfected regularly.

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Table 18.2. Specifications for Collection Containers

Type of Specifications for Container

Examples
Waste or Bag

Container should be puncture- Empty bleach bottle with a

resistant, leak-proof on the sides biohazard label
and bottom, and durable. Thick rigid puncture-
Container should have a resistant cardboard box with
Sharps
biohazard label. a biohazard label
Container should be closable if Rigid plastic container with a
used to transport sharps waste. biohazard label

Plastic bag that is leak-proof;

designed to prevent ripping, Red or yellow plastic bags
tearing, or bursting under should be used
Non-sharps normal use. The plastic bag Whenever coloured bags are
biomedical should be placed inside a rigid not available, plastic bag with
solid and container. a biohazard label can be
semi-liquid Rigid container should be leak- placed in a red or yellow-
waste proof, durable, labelled with a painted garbage can or dust
biohazard symbol, and red or bin
yellow in colour.

Container should be leak-proof

and durable.
Container should be marked Bottles, vials, plastic
Non-sharps
with a biohazard label if it will containers, canisters, pails
biomedical
be used to transport waste. marked with biohazard labels
liquid waste
Container should be designed to
be transported without spillage.

Storage

If storage of waste is necessary, the storage area (skip, shed, etc.) should
meet the following parameters:

Be protected from water, rain, or wind;

Minimise the impact of odours, putrescent waste (waste that can

decompose and produce odours after several days). Do not store
for more than 3 days. Putrescent waste should be transported to
the landfill immediately and buried in special trenches;

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Be accessible to authorized employees and lockable to prevent

unauthorized access;

Be protected from animals and not provide a breeding place or

food source for insects and rodents;

Keep clean and free at all times of any loose debris and standing
water. Container should be disinfected weekly and whenever a
spill occurs.

Treatment and Off-Site Transport

Use of campfire-style open-pit burning, burning in a cement firebox,

burning in drums, and open-burn cement-block incinerators should be
discontinued. The World Health Organization does not recommend
these methods because they are inefficient in destroying pathogens and
release high levels of toxic pollutants. Use the low-cost interim options
shown in Table 18.3. The use of a small in-house incinerator, the local
crematorium, and newer large-scale medical waste incinerator should
be replaced where possible by interim options and, eventually, by
cleaner, state-of-the-art non-burn treatment technologies.

These treatment methods can be used in combination. HTCW from

outlying areas could be transported and centralized. The waste should
be contained in sealed plastic bags and/or sharps containers and placed
in hard corrugated cardboard boxes for transport to the main health
centre every few days (sooner for putrescent waste) or whenever
sufficient waste has accumulated. The containers should have a
biohazard label.

Health centres may decide to bury blood-soaked material, small tissues, and
placentas in small burial pits and transport sharps for disposal in special
landfill trenches. This would reduce the amount of waste being transported
to the landfill and avoid the problem of storing putrescent waste for
extended periods. Another approach is to use sharps disposal burial pits
only for needles, syringes and items that may injure waste pickers and
transporters; other waste such as blood-soaked material, can be picked up
and disposed in special landfill trenches.

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Table 18.3. Waste Treatment and Disposal Options

Type of Waste Methods Notes

Packaging, transport, and

This method should be used by
burial in special landfill
large facilities (hospitals).
trenches

This method could be used in

health centres away from coastal
All infectious areas and local wells, in areas that
Small on-site burial pits
wastes except do not flood, and where the water
cultures and table is at least 1.5 metres deeper
anatomical parts than the bottom of the pit.

This method could be used in

health centres near coastal areas or
Cement encasings
in areas with a shallow water
table.

Cultures Small on-site autoclave Preferably in the laboratory

Interment at burial This is the basic method for body

grounds or cemeteries parts.
Anatomical parts

Cremation Use a local crematorium.

Small on-site burial pits

or interment at burial These are acceptable methods.
Placenta waste and grounds or cemeteries
small-tissue waste

Composting method This is an acceptable method.

Free-flowing blood This method applies to all health

Sanitary sewer
and body fluids facilities with sanitary sewers.

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A scheme1 is available that outlines the packaging and transportation

requirements of infectious waste based upon the types of
microorganisms that may be contained in the waste. Infectious waste is
classified into two categories

Category A: an infectious substance which is transported in a

form that, when exposure to it occurs, is capable of causing
permanent disability, life-threatening or fatal disease to humans
or animals. Category A waste includes waste from highly
infectious diseases, such as the Ebola virus, and cultures of certain
infectious diseases including Clostridium botulinum.

Category B: an infectious substance which does not meet the

criteria for inclusion in Category A.

Management

All health care facilities should have a person or group responsible for
HTCW and waste management plans. Waste management can be
incorporated into policies, procedures, and programmes to minimize
the risk of spreading infection in and from the hospital, thereby
protecting patients, health-care workers, and the public.

Training

A training programme should be initiated to present the elements of a

plan and begin its implementation. Initial training could emphasise safe
HTCW management practices and address issues related to the
comprehensive, long-term plan. Practical training should be provided
to all those involved in handling, packaging, transporting, and
disposing of HTCW.

Conclusions

Healthcare waste is an inevitable part of health care. Infection

prevention and control practitioners must use their experience and
understanding of the chain of infection when developing a practical
approach to waste management. Even lacking resources, if one focuses
on the true risks of HTCW, a safe and effective program can still be
achieved.

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References and Further Reading

1. Health Technical Memorandum 07-01: Safe Management of

Healthcare Waste 30 November, 2006.
2. Rushbrook, P. Starting Health Care Waste Management in
Medical Institutions: A Practical Approach [online]. 2000 [cited
2007 August 10]. Available from: URL: http://
www.healthcarewaste.org/linked/onlinedocs/
HCW_practicalInfo1.pdf
3. Pruss, A, Townend, WK. Teachers Guide Management of
wastes from health-care activities [online]. 1998 [cited 2007
August 10]. Available from: URL: http://www.who.int/
water_sanitation_health/medicalwaste/wsh9806/en/
4. Healthcare Waste Management at a glance [online]. Year [cited
2007 August 10]. Available from: URL: http://
www.healthcarewaste.org/linked/onlinedocs/WW08383.pdf
5. MedWaste Treatment Minimizing Harm, Maximizing Health
[online]. 2003 [cited 2007 August 10]. Available from: URL: http://
www.noharm.org/details.cfm?ID=998&type=document
6. World Health Organization. Healthcare Waste Management
[online]. 2007 (cited 2007 August 10]. Available from: URL:
http://www.healthcarewaste.org/
7. Health Care without Harm. Environmentally Responsible
Healthcare (online]. 2007 (cited 2007 August 10]. Available from:
URL: http://www.hcwh.org/

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 Food Hygiene and Gastroenteritis

Chapter 19
Food Hygiene and
Gastroenteritis
Michael Borg

Key points
The Infection Control Team should provide input into the
management of outbreaks of foodborne illness and promote
safe practices in food hygiene.
Proper training of staff in food hygiene practices is important.
Control of microbiological hazards in food production is
usually undertaken using temperature control.
Routine testing of food handlers faeces, blood or rectal swabs
is neither cost effective nor generally indicated.
Inspection and auditing of kitchen practices often reveals
deficiencies in catering practices and allows corrective action
to be taken.
All refrigerated items should be labelled, dated and used
within 72 hours.

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Introduction

The burden of foodborne illness due to toxin and/or infection in low

resource countries is well documented. Intestinal diseases are very
prevalent in the community and transmission to the hospital setting is
common. The prevalence of healthcare-associated foodborne illness in
developing countries varies, however healthcare-associated Salmonella
and Shigella rates reaching 3% and 2.5% respectively have been quoted.
Significantly fewer healthcare-associated foodborne illnesses occur in
developed countries. Nevertheless, 247 outbreaks of Salmonella were
documented in United Kingdom hospitals over a 10-year study period.
Other microbes causing food related illness include hepatitis A and
other viruses, Campylobacter and Yersinia.

Outbreaks of foodborne illness may carry significant costs, requiring

considerable manpower interventions and numerous laboratory
analyses for investigation and control. The direct cost of a healthcare-
associated outbreak of salmonella within an Australian hospital was
estimated to be greater than AU $120,000.

Viral gastroenteritis

Outbreaks of viral gastroenteritis in hospitals are often caused by

noroviruses, members of the Caliciviridae family. Vomiting, often
sudden in onset and projectile in nature, is the major symptom,
although diarrhoea (mainly mild and short-term) can also be present as
well or on its own. Cases often tend to occur in elderly patients.
Noroviruses are highly infectious and may be acquired through
consumption of contaminated food or water or, more commonly, pass
from one patient to another via faeco-oral, fomite or aerosol routes.

Symptomatic individuals should be cohorted or isolated. Healthcare

workers should wear gloves and apron for contact with an affected
patient or environment and wash hands with soap and water after such
contact and after removing gloves and apron. Affected staff should be
excluded from the ward immediately and stay away until they have
been symptom-free for 48 hours. Staff from affected areas must not
work in unaffected areas in the following 48 hours.

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If there is continued spread, the ward should be closed to new

admissions and the patients should not be transferred to unaffected
wards or departments unless urgent specialist care is needed, and then
only after consultation with infection control staff. The ward should not
be re-opened until 72 hours after the last new case. Terminal
disinfection of the ward and changing of bed curtains should be
performed before re-opening.

Visitors should be restricted and requested to wash their hands on

leaving the unit. Spillages of vomit and faeces must be cleaned and
disinfected promptly. The frequency of routine ward cleaning,
especially bathrooms and toilets, should be increased and followed by
disinfection using freshly prepared 0.1% hypochlorite solution.

Role of Infection Control Teams (ICT)

Hospital ICTs can play diverse roles in the prevention and control of
foodborne illness. Of course, prevention is key, however at a minimum,
they will intervene wherever there are suspected or confirmed cases of
foodborne gastroenteritis. They should collaborate with catering
managers and/or environmental health officers in drafting and
implementing the hospital food hygiene policy.

ICTs should provide several inputs into the management of outbreaks

of healthcare-associated foodborne illness. Their major role is likely to
involve cohort isolation of symptomatic individuals and supervision of
patient placement to ensure that the risk of cross transmission of any
pathogen is minimized. They may also need to contribute toward
education of hospital staff and possibly the general public.

The role of ICTs in promoting safe practices in food hygiene in hospitals

depends on the type of catering used and the presence or absence of
other stakeholders such as catering managers and/or environmental
health officers. Where the hospital out-sources catering, the role of ICTs
may be limited to contribution toward a due diligence approach
through supervision of food distribution within the hospital as well as
inspections and audits of the suppliers kitchen premises. If food is
prepared in the hospital the ICTs may need to provide a more
significant contribution. Therefore, infection prevention and control
personnel need to have a clear understanding of effective food hygiene.

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Training

The concepts of food hygiene are similar to those used in other areas of
hospital infection prevention and control. Infection prevention and
control staff members are ideal candidates to spearhead food hygiene
training in hospitals. Numerous tools are available, both on the Internet
and in print, to aid development of effective programs. The importance
of preventing conditions for temperature and time to allow bacteria to
reach infecting doses in food must be stressed. Effective personal and
environmental hygiene and potential sources of contamination should
also be part of any food hygiene training program.

The dangers of prolonged exposure of food to warm temperatures must

be extensively covered, including situations that may lead to it, such as
preparation of food too far in advance, storage at room temperature,
and slow cooling. The need to avoid possible contamination, whether
by under cooking of high risk meat products such as poultry or by
cross-contamination between raw and cooked items, must be
emphasised.

Hazard Analysis Critical Control Points

Hazard Analysis Critical Control Points (HACCP) analysis was

pioneered in the 1960s within the United States National Aeronautics
and Space Administration program and is nowadays incorporated into
legislation of food safety both in the United States and the European
Union. HACCP analyzes the food production process to determine
possible microbiological, physical or chemical hazards that may
contaminate food as it is produced. Critical control points (steps in the
process after which any contamination cannot be reversed) are
identified. Preventive interventions are devised which are then
monitored and corrected if any unacceptable deviation takes place.
HACCP systems need to be recorded, audited and verified routinely.

HACCP systems have been shown to provide significant improvement

in the quality and the safety of food served in hospitals. A successful
HACCP system consists of a number of good hygiene practices
including regular equipment cleaning and maintenance, provision of
effective hygiene facilities, systems to control insects and other pests
and regular training for staff on food hygiene. (See Table 19.1)

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Table 19.1. Adapting HACCP to hospital food production

Step in Foodborne
Prevention Methods
Process Illness Concern
Ready to eat foods
Visual and temperature checks on food
Receipt of contaminated with food
received. Accept frozen foods at <-18C
food poisoning bacteria or
and chilled foods at < 4C
toxins.

Growth of food poisoning High-risk perishable foods stored

bacteria, toxins on high- covered and dated at safe temperatures.
Storage
risk (ready to eat) foods. Rotate stock and use by recommended
Further contamination. date. Ensure a pest free environment.

Limit exposure to ambient temperatures

Contamination of high-
during preparation. Prepare with clean
risk (ready to eat) foods.
Preparation equipment used for high-risk (ready to
Growth of pathogenic
eat) foods only. Separate cooked and raw
bacteria.
foods. Wash hands before handling food.

Thaw frozen items completely at

Survival of pathogenic temperatures <15C. Cook food
Cooking
bacteria. (especially chicken and minced meats)
to 75C in thickest part for two minutes.

Cool foods as quickly as possible.

Contamination.
Chill rapidly and refrigerate within
Cooling Growth of pathogens.
90 minutes. Do not leave out at room
Toxin production.
temperature to cool.

Temperature control. Date code high-risk

(ready to eat) foods.
Chilled Growth of pathogenic
Use in rotation and always within shelf
storage bacteria.
life. Consume within three days of
cooking.

Hot Growth of pathogenic

holding/ bacteria. Keep food hot at >63C.
Distribution Toxin production.

Survival of pathogenic
Reheating Avoid if possible. Reheat to >75C.
bacteria.

Serve cold high-risk foods as soon

Growth of pathogens. as possible after removing from
Serving Toxin production. refrigerated storage. Serve hot foods
Contamination. quickly. Ensure hands and equipment
used to serve food are clean.

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Food pathogens will survive and may multiply if food is left within the
temperature danger zone (6C to 63C). Control of microbiological
hazards in food production is usually undertaken by temperature
control. Heating food to achieve 75C for 1-2 minutes in its thickest part
will guarantee destruction of any biological hazards. When food is
cooked and then cooled, cooling must be rapid, and then the food
should be held at temperatures that prevent microbial growth.
Temperature control should be maintained until food is served within
the hospital wards and units. Therefore cold served food must be
served as soon as possible after removal from refrigerated storage. On
the other hand, hot food must have reached at least 75C if re-heated;
this temperature should be maintained until served to the client. This is
particularly important in systems where food is prepared in the kitchen
and transported hot to be served without further re-heating. These
systems are particularly risky and ICTs must pay special attention to
ensuring that hot holding temperatures are maintained above 63C.

Testing of food, environment and individuals

Food and environmental testing in the microbiology laboratory is

expensive and labour intensive. It is not actually vital to monitor food
safety since a complete and functional HACCP system is more than
satisfactory. Nevertheless there are occasions when food and
environmental testing is useful. It can provide confirmation of
microbiological quality and safety. One useful spin-off is the impact
such tests often have on food handlers, who can see visual evidence of
the theoretical principals that they had been taught. A simple way of
quality control that can be performed in all laboratories and is quite cost
effective is semi-quantitative testing of environmental swabs taken from
the production area. Routine testing for pathogens is of little benefit; it
is more cost effective to count indicator microrganisms, especially
E. coli, to identify poor hygienic food production.

Routine testing of food handlers faeces, blood or rectal swabs is neither

cost effective nor generally indicated. An individual who screens
negative may become a carrier; more worryingly, a negative screen may
induce a false sense of security and result in negligence toward general
and personal hygiene practices. It is much more cost effective for any
money set aside for food handler testing to be invested in better training
of food handling personnel.

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Kitchen auditing

Inspection and auditing of kitchen practices often reveals deficiencies in

catering practices and allows corrective action to be taken in a timely
manner. When undertaking an audit, particularly for the first time, the
infection control practitioner would do well to keep in mind the most
common causes of foodborne illness already mentioned, and structure
the kitchen audit accordingly. Particular attention should be given to
evidence of prolonged exposure of food to warm temperatures. Other
critical factors include: cross-contamination arising from lack of
compliance with hygiene practices for hand or equipment cleaning;
undercooking of high risk meat products such as poultry; and
cross-contamination between raw and cooked items. If an audit is likely
to be repeated regularly, an itemised audit sheet should be formulated
and include all the different areas in the kitchen being reviewed. In this
way it is easier to achieve standardisation and reproducibility from one
audit to the next and variations with time are more easily identified.

Special attention should be directed at items such as blenders. All

components must be easy to clean.

Ward kitchens

Ward kitchens should be kept clean. Refrigerators should be sited away

from direct heat or sunlight, and have a temperature monitoring device
with the internal temperature documented at least once daily. All items
should be labelled, dated and used within 72 hours. Any items that are
not labelled, outdated or left exposed or unwrapped should be
discarded. Attention should be given to separation between raw and
cooked items, cooked items always being placed above the raw items if
in the same refrigerator.

References and Further Reading

1. World Health Organisation. Five keys to Safer Food Manual

[online]. 2006 [cited 2007 August 10]. Available from: URL:
http://www.who.int/foodsafety/publications/consumer/
manual_keys.pdf
2. Richards J, Parr E, Riseborough P. Hospital food hygiene: the

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IFIC Basic Concepts of Infection Control

application of Hazard Analysis Critical Control Points to

conventional hospital catering. J Hosp Infect 1993;24:273-82.
3. Food and Agriculture Organization of the United Nations. Food
Quality and Safety Systems - A Training Manual on Food
Hygiene and the Hazard Analysis and Critical Control Point
(HACCP) System [online]. 1998 [cited 2007 August 10]. Available
from: URL: http://www.fao.org/docrep/W8088E/W8088E00.htm
4. Cowden, JM. Foodborne infectious risks: do we need a wide
system of data collection and survey? The lessons learned from
the study of infectious intestinal disease in England. Revue d
Epidemiologie et de Sante Publique 2002;50(1):89-92.
5. Spearing NM, Jensen A, McCall BJ, et al. Direct costs associated
with a nosocomial outbreak of Salmonella infection: an ounce of
prevention is worth a pound of cure. Amer J Infect Control 2000;
28(1):54-7.
6. Chadwick PR, Beards G, Brown D, et al. Management of hospital
outbreaks of gastro-enteritis due to small round structured
viruses. J Hosp Infect 2000;45:1-10. Available from: URL: http://
www.hpa.org.uk/infections/topics_az/norovirus/
hospital_norovirus.pdf
7. Mattner F, Mattner L, Borck HU, Gastmeier P. Evaluation of the
impact of the source (patient versus staff) on nosocomial
norovirus outbreak severity. Infect Control Hosp Epidemiol 2005;
26(3):268-72.

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 Water Hygiene

Chapter 20
Water Hygiene
Shaheen Mehtar

Key points
Water is required for drinking, hygiene, health related
processes and generating energy.
Unclean water leads to ill health, outbreaks of infectious
disease in the community and healthcare-associated infections
in healthcare facilities.
The integrity of systems used to collect, transport, store and
distribute water is essential.
Potable water can be rendered safe by boiling water for 2-5
minutes or filtering/adding chlorine.
Water used in healthcare facilities additionally may require
distillation, removing chemical impurities or sterilizing.

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Introduction

Water is the essence of life. Water for human consumption and

domestic use is usually drawn from natural sources and stored before
distribution. In some rural communities, water is obtained directly from
rivers or dams; however, in established communities water is usually
piped. The availability of water for domestic use is inversely
proportional to the level of health. Distance from the source of water
and improper storage have been identified as major risk factors for
ill-health.

Water used in healthcare facilities should be in constant supply, of good

quality, with low bacterial counts and low mineral content. In instances
where water is of poor quality with erratic supply and systems not
maintained, high levels of contamination are inevitable.

Uses of Water

There are various domestic and healthcare uses for water as outlined in
Table 20.1.

Domestic use
The World Health Organization defines domestic water as being water
used for all usual domestic purposes including consumption, bathing
and food preparation. The minimum requirement is 15 litres per person
per day, of which 5 litres is recommended for drinking, cooking and
sanitation. Water contaminated by microbes or chemicals may affect
large populations; the burden of disease is usually carried by children.

In Bangladesh, high levels of chemicals like arsenic and fluoride are

found in the water supply and it is estimated that between 55 and 77
million people are at risk of arsenic poisoning.

Health care facilities

A constant water supply is fundamental for health provision, without
which the following may occur:

Non-compliance with hand hygiene and subsequent increased

cross infection
Inadequate support from sterile services, especially autoclaves

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Table 20.1. Uses of Water

Domestic Healthcare
Hand hygiene
Processing clinical and non clinical
equipment
Dialysis
Drinking
Injections
Washing & laundry
Operating theatres
Sanitation
Laser equipment
Cooking
Energy source-steam
Kitchen
Laundry
Sanitation

Failure of essential departments to function optimally, such as

operating theatres, endoscopy units, laundry and kitchens.
Risk of contamination (sewerage and chemicals) of water pipes
when supplies are erratic

A well maintained water system prevents transmission of healthcare-

associated infection such as Legionella pneumophila, cholera and typhoid
in endemic areas and diarrhoeal disease. Thus it supports good
infection prevention and control practice.

Diseases associated with water

These diseases can be divided into four categories (See Table 20.2):

Water-borne. Disease associated with consumption of

contaminated water
Water-washed. Disease caused by inadequate volumes of water for
personal hygiene
Water-based. Disease where an intermediate aquatic host is
required
Water-related vector. Disease spread through insect vectors associated
with water

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IFIC Basic Concepts of Infection Control

Table 20.2. Examples of water related diseases in the community and hospital

Community Healthcare facility

Diarrhoeal disease Diarrhoeal disease
Hepatitis A Legionnaires disease
Water-borne
Typhoid Typhoid
Cholera Cholera

Impetigo
Diarrhoeal disease
Water-washed Group A streptococcal
Trachoma
infection

Schistosomiasis
Water-based
Guinea worm

Malaria
Malaria
Water-related vector Dengue
Dengue
Yellow Fever

Rendering Water Safe in Community

Boiling
Boiling occurs when the water temperature reaches 100C or more.
During the process, water should be observed to bubble for a minimum
of 2-5 minutes before it is considered safe to drink or use. Heating water
up to 75C will remove most vegetative bacterial forms, however not
spores or parasites.

Water which has been boiled and then allowed to cool in the same
container will be safe to drink providing dirty hands or contaminated
items are not used to decant the water. A member of the family is
typically chosen to be responsible for dispensing water to everyone in
the family and maintaining a clean container. He or she is advised to
wash hands thoroughly before using a dedicated container to decant
water. Hand washing in a domestic setting is usually performed after
defecating or before eating.

Chemical
Chlorine is widely used for purification of water. Individual water
storage tanks should contain 0.5 parts per million (ppm) of available
chlorine at the end of the chlorination process. It is recommended that
water should not be used for 1 hour for river water and 30 minutes for
well or borehole water.5

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 Water Hygiene

Rendering Water Safe in Healthcare Facilities

Potable water
Drinking water generally, but particularly in hospitals, should contain
no more than 500 cfu/ml of a total bacterial count.

Water supplies to hospitals

Storage Tanks - prevention of Legionnaires Disease6

There should be adequate storage of water to meet the needs of
the hospital for 24 hours. Water should be stored in tanks which
are located in areas to provide a minimum heat gain.
Tanks should be well insulated and temperatures of 20C or
lower should be maintained.
Tanks should be cleaned regularly by emptying and removing
debris and flushed through with water containing >2mg/l (2 ppm)
available chlorine. After the tank is filled, the chlorine
concentration should be 1-2mg/l of free residual chlorine at
delivery point.
End point hot water should be delivered at 55C with a
circulating temperature of 60C. All hot water taps should be
clearly labelled for safety.
The hot and cold pipes should be tagged if these are close
together to avoid diffusion of heat and an increase in the cold
water tap temperature. Cold water temperatures should be less
than 20C after running for 2 minutes.
Rubber washers should be replaced with plastic ones. Shower
heads should be cleaned regularly.

Chemical processes for water

Filtration
Filtration is a system designed to remove particles of varying structure
and sizes. In some countries it is used for removing sediment routinely
from water; however this system is expensive and requires considerable
maintenance. Therefore, filtration is recommended where heat or
chemical disinfection is inappropriate. Various methods may be used
for filtration including carbon, ion exchange/salt, and reverse osmosis.

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IFIC Basic Concepts of Infection Control

Chlorination
Chlorine is widely used for treating water supplies after filtration in
most towns and cities, particularly where water supplies are recycled. It
is also a recommended method of water purification during large
disease outbreaks, particularly in disaster areas. It is an easy and
effective method used in large water containers. The recommended
final concentration for potable water is 0.5 ppm of available chlorine.

In hydrotherapy pools, 15 ppm of available chlorine is recommended,

while for whirlpools and spas it is 2-5 ppm of available chlorine.

Ozone treatment
Ozone is being introduced in some laundries to conserve energy by
reducing the temperature of the water. Ozone has known antimicrobial
properties particularly against vegetative forms of bacteria. However,
capital outlay is expensive and there must be precise and regular
monitoring and maintenance.

Dialysis units
The water supply should be fitted with an ultra filter or pyrogen filter
with a pore size to remove particles or molecules of >1 kilodalton.

Endoscopic equipment
Rinse disinfected endoscopes with water filtered through 0.1-0.2 mm
filter

De-ionisation: used in specialised fluid production in pharmacy and

radiotherapy. An expensive process with high maintenance costs.

De-mineralization: a complex process used in surgery, particularly for

laser equipment.

Alternatives methods of using water in healthcare

facilities

In low resource countries water supplies may be limited by

environmental or engineering deficiencies. A short list of examples is
provided in Table 20.3. Boil water if running water is not available.

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 Water Hygiene

Table 20.3. Alternative choices for water use

Use Alternative choice

Steam generation by boiling water in large tanks. Feed

Sterile services autoclaves and washing area for instruments.
Run water from clean to dirty areas.

Washing equipment Hot water (70C)

Cold running water. Do not use standing water in

Hand washing basins for multiple hands. Alcohol hand rub may also
be used.

Boiled water stored in clean, closed, dedicated

Drinking water
containers. Allow a dedicated person to decant.

General use Hot water from large tanks heated to 60C.

Wash in available water, use small quantities of bleach

Laundry
and dry in the sun.

Bedpans / urinals Clean thoroughly and lay face down in the sun.

Engineering support

A well trained team should be responsible for maintaining the

water supply within the community and healthcare facilities.
In healthcare, all water-associated equipment must be cleaned
and maintained regularly with adequate levels of disinfection.
Temperature controls for hot and cold water systems must be
maintained according to recommendations.
Water and sewerage pipes should not run parallel to each other.

Minimum requirements

Domestic use
1. Collection: from source into a clean container or directly
delivered to residence.
2. Transportation: large and small containers must be cleaned
regularly and decontaminated using chlorine.

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IFIC Basic Concepts of Infection Control

3. Storage: in containers with well fitted lids and preferably with a

tap.
4. Distribution: either via pipes or with a clean container.
5. Effluent: into a municipal system or, in the absence of sewage
systems in rural areas, it should be kept away from the source
water supply.

Healthcare use

1. Piped water: well maintained pipes with no leaks or cracks

located away from the sewerage pipes.
2. Storage: large clean tanks which are maintained regularly.
3. Distribution: piped system with clearly labelled hot and cold
water at the recommended end-point temperatures.
Multi-purpose use open containers are unacceptable.
4. Effluent: into a municipal system. If not, then treated with
chlorine before discharge.

References and Further Reading

1. Howard G, Bartram J. Domestic Water Quality, Service, Level and

Health. WHO/SDE/WSH/03.02. World Health Organisation; 2003.
2. WHO and UNICEF. Global Water Supply and Sanitation
Assessment 2000 Report. WHO/UNICEF. Geneva/New York;
2002.
3. WHO. Guidelines for drinking water quality; Volume 1
Recommendations, 2nd ed. 1993.
4. Smith AH, Lingas EO, Rahman M. Contamination of drinking
water by arsenic in Bangladesh: a public health emergency. Bull
World Health Org 2000;78(9):1093-03.
5. Mehtar S. Hospital infection control. Setting up a cost effective
programme. London: Oxford Univ Press; 1992. p. 160-4.
6. Schulster L, Chinn RYW. Guidelines for Environmental Infection
Control in Health-Care Facilities. MMWR 2003;52(RR10):15-23.

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 Risk Management

Chapter 21
Risk Management
Nizam Damani

Key points
The Infection Control Team must identify infection prevention
and control practices which are unsafe and hazardous.
Unsafe practices must be assessed for their likely severity and
frequency.
Priority must be given to hazardous practices that have high
adverse effects, occur more frequently and have low cost to
prevent.
Effectiveness of these measures should be monitored by
regular audit and/or surveillance and the information must be
provided to front-line clinical staff and relevant managers.

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Introduction

The delivery of an effective infection prevention and control (IC) service

requires trained and motivated IC practitioners whose job, amongst
other things, is to identify unsafe and hazardous IC practices,
recommend cost effective preventive measures and help healthcare
facilities to set priorities. These objectives can be achieved by applying
the concepts of risk management.

Unfortunately patterns of risk behaviour are not taught in the medical

and nursing curricula, which may explain why healthcare workers do
not always consider the consequences of errors and slips in their
practice.

Risk management

Risk is defined as the possibility of incurring misfortune and loss. Risk

management is a proactive approach and its aim is to prevent or
minimise harm. Potential problems are identified and the potential for
harm is assessed. Actions are then planned to reduce the likelihood of
the problem arising or to limit the harm caused. In IC the risks can be
biological agents that have the potential to cause infection or a
mechanism that allows the transmission of an infectious agent to occur.
The risk management process can be divided into four key stages. (See
Figure 21.1)

1. Risk identification
2. Risk analysis
3. Risk control
4. Risk monitoring

Risk identification

The process of risk management starts from risk identification and

involves:
identifying the activities and tasks that put patients, healthcare
workers and visitors at risk;
identifying the infectious agent involved; and
identifying the mode of transmission.

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 Risk Management

Figure 21.1 Risk management processes

The aim is to identify common problems/practices that impact on a

large number of patients or rarer problems which can cause severe
infection or death. Once a problem is identified, it is essential to obtain
evidence to confirm that the infection is spreading by this particular
route. This usually requires the expert knowledge of the Infection
Control Team and can be achieved by observational or experimental
studies.

Risk analysis

Once the risk has been identified, the likely consequences to patients
must be estimated. This can be achieved by analysing four key
questions:
1. Why are infections happening?
2. How frequently are they happening?
3. What are the likely consequences if the appropriate action is not
taken?
4. How much is it going to cost to prevent it?

Why are infections happening?

A range of system failures can result in patients acquiring healthcare
associated infections and it is important to analyse these in detail.

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IFIC Basic Concepts of Infection Control

Type I error: These occur due to an act of omission, e.g., failure to

comply with current professionally accepted practice. The basic cause of
a Type I error is lack of knowledge and it is typically common in
healthcare institutions where there is inadequate provision of education,
training and supervision. In developing countries a scarcity of goods
can also contribute to this type of error. Regular education and training,
good communication and availability and regular supplies of goods are
necessary to address this issue.

Type II error: These are acts of commission, i.e., an act should not have
been committed. These are due to lack of commitment or consideration
for others. This type of error is more complex and amongst other things
may also require management reinforcement.

Type III error: This mainly occurs where the management of service
fails to understand the true nature of the problem it is dealing with.
Real solutions are adopted to deal with the wrong problems, rather than
incorrect solutions to real problems. This is often due to lack of
communication, or misinterpretation of information as a result of
inadequate research or information.

How frequently are they happening?

This information is quantitative and can be obtained by ongoing
surveillance data (if available) or by performing a point prevalence
study. The information can be gathered from other sources, e.g., as a
part of outbreak investigation, local prevalence data, data published in
the literature and clinical evidence. Frequency can be measured as the
percentage or rate of persons who developed infection following either
a clinical procedure or exposure to a pathogen. If surveillance data are
not available, probability can be used instead. (See Table 21.1)

What are the likely consequences?

Severity can be measured in terms of morbidity (disability or increased
length of stay in hospital) or mortality experienced by persons who had
the procedure or exposure. Severity of the adverse effects can be ranked
as in Table 21.2 and Figure 21.2.

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 Risk Management

Table 21.1. Risk probability

Rating Probability Comments

4 1:10 Almost certain or very likely to occur.

3 1:100 Highly probable that they will occur.

2 1:1000 It is possible that they may occasionally occur.

They are rare and do not believe/expect to

1 1:10000
occur.

Table 21.2. Severity rating

Rating Description Comments

Major impact on patient which
Urgent action is
20-30 High or major may lead to death or long term
required
consequences

Moderate impact which may lead

10-19 Moderate Action required
to short term consequences

Low risk or Minimum impact with no or

1-9 Keep under review
minor minor consequences

Figure 21.2. Severity and frequency of events.

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IFIC Basic Concepts of Infection Control

How much is it going to cost to prevent it?

It is also important to estimate the cost of prevention of each risk.
Estimated costs are acceptable, as the exact cost may be difficult to
obtain. The cost of prevention of infections is important because it helps
us to target resources where they will deliver the greatest advantage in
terms of preventing harm to patients.

Risk Control

Once the risk analysis has been completed, look at the possible
solutions. Ideally, the risk should be completely eliminated; if this is
impossible then the risk should be reduced to an acceptable level. In
some situations, it may be more cost effective to transfer the risk to a
third party such as a private contractor. For example, if there is a
problem with the supply of sterile goods it may be more cost effective to
purchase these items.

If resources are severely constrained, then it may be possible to accept

the risk in both the short and possibly long term. Willingness to tolerate
known risks in a health care institution differs in different parts of the
world and is based mainly on the availability of resources and the fear
of litigation.

Risk monitoring and feedback

Once appropriate measures are in place to reduce the risk, it is essential

to monitor their effectiveness. This can be done by audit, surveillance of
infection or both, depending on the availability of resources. Feedback
must be given to the front line healthcare workers and senior
management.

Priorities for action

Once all information is available on the severity, frequency of

occurrence and cost of prevention, priorities for action can be made by
calculating risk rating as follows:

Risk rating = Severity x Frequency (probability) of disease x Cost of

prevention

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 Risk Management

A risk rating with the highest score would merit immediate attention.
Calculation of the risk rating helps us to understand the true
consequences of adverse incidence and helps the Infection Control
Team to set priorities in the most effective way. (See Figure 21.3)

Figure 21.3. Setting Priorities

References and Further Reading

1. Roberts G. Risk management in healthcare. 2nd ed. London:

Witherby & Co.; 2002.
2. Australian/New Zealand Standard: Risk Management. 3rd edition.
AS/N2S 4360:2004. ISBN 07337 2647X. This book is available from
http://www.riskmanagement.com.au/ [accessed 2007 August 17].
3. NHS Management Executive. Risk Management in the NHS.
London: Department of Health; 1993.

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 Economic Evaluation in Infection Prevention and Control

Chapter 22
Economic Evaluation in
Infection Prevention
and Control
Sanjay Saint

Key points
Given rising healthcare costs, decision-makers increasingly
rely on clinical effectiveness and economic efficiency when
making decisions.
Infection prevention and control (IC) is not immune to this
rise in cost-consciousness; thus, IC professionals should
ideally learn the basic tenets of economical evaluation.
Cost-effectiveness analysis - the most common economic
analysis used in healthcare -- quantifies the trade-off between
increased expenditure and improved outcome and measures
the cost required to achieve a given clinical benefit.
When reading an economic evaluation within IC, several
important criteria can be used to judge its validity.

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IFIC Basic Concepts of Infection Control

Introduction

Healthcare costs are rising and decision-makers increasingly rely on

both clinical effectiveness and economic efficiency when making health
care decisions. There is sound rationale for economic analysis: resources
are scarce and choices must be made.

The traditional evaluation of new interventions includes safety (are the

side effects acceptable?), efficacy (can it work?), and effectiveness (does
it work?). The economics-based term, "efficiency" should also be
considered. This helps answer whether or not the extra cost of an
intervention is worth it.

Several types of economic analysis can be employed including: cost

minimisation, cost effectiveness, cost benefit, and cost utility analysis.
Cost minimisation (identifying the least costly alternative that leads to
equivalent outcome) is rarely used because the clinical consequences of
different interventions are rarely equivalent. Cost benefit analysis
(placing a monetary value on both the costs and the benefits) is also
used rarely because it is difficult to place a monetary value on health.
Cost utility analyses are useful when there are no expected mortality
differences between interventions, only differences in physical well-
being which can be expressed as quality adjusted life years (QALY).

Cost-Effectiveness Analysis

A cost-effectiveness analysis quantifies the trade-off between increased

health care expenditure and improved outcome and measures the cost
of a given clinical benefit. An example is assessment of an intervention
to reduce catheter-related bloodstream infections using antiseptic-
coated vascular catheters. The cost of the antiseptic catheter is usually
more than a standard catheter, however this can be compared with the
clinical benefits it provides.

Thus, a cost-effectiveness ratio would be generated, which would be the

total cost of the intervention divided by the number of cases of catheter-
related bloodstream infection prevented. If the antiseptic catheter
produced superior benefits but at an increased cost, then an incremental
cost-effectiveness ratio - the amount of money needed to produce an
additional clinical benefit - could be calculated. However, if the

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 Economic Evaluation in Infection Prevention and Control

intervention led to an actual reduction in overall costs while improving

health outcomes, it would be called a "dominant" intervention, since it
would provide both clinical and economic benefits.

Table 22.1 helps decide when a cost-effectiveness analysis is

appropriate. In general, there are four possibilities when comparing two
interventions, A and B.

Table 22.1. Choosing Among Alternative Interventions in a Cost Effectiveness

Analysis

A<B A>B
A is Dominant Incremental

A>B
Cost-effectiveness analysis Cost-effectiveness analysis useful
unnecessary

Incremental B is Dominant

A<B
Cost-effectiveness analysis useful Cost-effectiveness analysis
unnecessary

A = Intervention A; B = Intervention B
Firstly A is more effective and costs less. Thus, A is the dominant
strategy and should be used without further analysis. Likewise, when B
is more effective and costs less than A, B is dominant and a cost-
effectiveness analysis is unnecessary. However, as is more common,
when A is more effective than but costs more than B, it is helpful to
perform an incremental cost-effectiveness analysis to quantify the
clinical and economic consequences of intervention A.

Examples of such analyses include antiseptic-coated vascular catheters

to prevent catheter-related bloodstream infection1 and silver alloy
urinary catheters to prevent urinary catheter-related infection.2 Such
studies have been performed and have found the intervention is likely
to be worthwhile in certain patient groups. An incremental cost-
effectiveness ratio is interpretable only when compared with one
examining the same health outcome. For example, the cost-effectiveness
of preventing local vascular catheter-related infection cannot be directly
compared to the cost-effectiveness of preventing urinary catheter-
related bacteraemia.

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IFIC Basic Concepts of Infection Control

Measuring Effectiveness and Costs

Effectiveness and Cost Estimates

Economic evaluations of health care interventions depend upon solid
clinical evidence of effectiveness in order to establish benefits and risks.
The validity of the clinical data is crucial to the analysis. Many economic
evaluations rely on a single randomised trial or a single observational
study to estimate clinical benefit. Some studies rely on less rigorous or
non-scientific sources of information such as clinical opinion or expert
panels. Estimates derived from large-scale, multi-centre trials are widely
considered the "gold standard," however these data often are not
available. In addition to effectiveness estimates, the analyst must also
estimate the cost. Often, however, cost is poorly defined for different IC
interventions as well as for healthcare-associated infections.

Meta-analysis
Meta-analysis is a "quantitative approach for systematically combining
the results of previous research in order to arrive at conclusions about
the body of research".3 Meta-analysis is used to statistically pool the
results from individual studies (usually randomised trials) to obtain an
estimate of the summary effect. The summary measure from a meta-
analysis is often used to derive the probability of treatment success in a
cost-effectiveness analysis.4 Even if the benefit of an intervention could
be demonstrated in every clinical setting, the cost-effectiveness ratios
would vary considerably depending on local economics. Thus, an
intervention that may appear "cost effective" in one country or hospital
district (e.g., with a cost-effectiveness ratio less than $50,000 per life year
saved), may be considered too expensive elsewhere.

Economic evaluation of IC can be performed in a rigorous and

straightforward manner but several barriers exist to its routine
introduction. First, since economic evaluation is not widespread in IC,
terminology must be used correctly. Often, when medical directors and
other decision-makers say, "cost effective" they imply cost savings.
However, "cost effective" technically indicates that we are spending an
additional amount of money for an additional clinical benefit and is
based on the explicit comparison of one strategy with another. Cost
savings imply that we are getting an equivalent or greater clinical
benefit and actually saving money; this scenario is rare.

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 Economic Evaluation in Infection Prevention and Control

The cost-effectiveness of intervention A compared with intervention B

can range from cost saving, cost neutral, cost effective to cost ineffective.
Another important issue within IC is that the attributable morbidity,
mortality, and costs of healthcare-associated infection are difficult to
assess.

Evaluating an Economic Analysis

There are several important criteria by which economic analyses should

be judged. (See Table 22.2) The first question is whether or not a well-
defined research question was posed. This is of fundamental
importance, since a research question that is not worth answering is
usually not worth answering well. Second, it is important that all the
legitimate and reasonable competing alternatives be evaluated. Third,
the effectiveness of the intervention must be clearly established, since an
intervention that is not effective will certainly not be cost-effective.
Finally, it is critical that all the important and relevant costs and
consequences of the intervention are identified and considered,
depending on the perspective of the analysis.

Table 22.2. Cost effectiveness decision process

Questions that should be answered when performing or reading a

cost-effectiveness analysis 5

1. Was a well-defined question posed?

2. Were all the competing alternatives evaluated?
3. Was the effectiveness of the intervention established?
4. Were all the important and relevant costs and consequences for
each alternative identified (depending on the perspective)?
5. Was uncertainty in the estimates adequately evaluated?

References and Further Reading

1. Veenstra DL, Saint S, Sullivan SD. Cost-effectiveness of antiseptic-

impregnated central venous catheters for the prevention of
catheter-related bloodstream infection. JAMA 1999; 282:554-60.
2. Saint S, Veenstra DL, Sullivan SD, et al. The potential clinical and
economic benefits of silver alloy urinary catheters in preventing
urinary tract infection. Arch Intern Med 2000;160:2670-5.

191
IFIC Basic Concepts of Infection Control

3. Petitti DB. Meta-analysis, decision analysis, and cost-effectiveness

analysis: Methods for Quantitative Synthesis in Medicine, 2nd ed.
New York: Oxford University Press; 2000.
4. Saint S, Veenstra DL, Sullivan SD. The use of meta-analysis in
cost-effectiveness analysis: issues and recommendations.
PharmacoEconomics 1999;15(1):1-8.
5. Drummond MF, O'Brien B, Stoddart GL, Torrance GW. Methods
for the Economic Evaluation of Health Care Programmes. 2nd ed.
New York: Oxford University Press; 1997.
6. Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-Effectiveness
in Health and Medicine. New York: Oxford University Press;
1996.
7. Saint S, Chenoweth C, Fendrick AM. The role of economic
evaluation in infection control. Am J Infect Cont 2001;29:338-44.
8. Bent S, Shojania KG, Saint S. The use of systematic reviews and
meta-analyses in infection control and hospital epidemiology.
Am J Infect Control 2004;32(4):246-54.

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 The Costs of Healthcare-Associated Infection

Chapter 23
The Costs of
Healthcare-Associated
Infection
Gary French

Key points
Healthcare-associated infections (HAI) delay patient
discharge and increase treatment costs.
HAI are accompanied by increasing numbers of laboratory
and imaging investigations.
HAI increase infection prevention and control costs, including
epidemiological investigations and medical, nursing and
management time.

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IFIC Basic Concepts of Infection Control

Introduction

Healthcare-associated infections (HAI) are common: at any one time

about 1 in 10 patients in acute care hospitals have an HAI and an
additional 10-60% of infections may present after discharge.

HAI is an important cause of morbidity and mortality and therefore

should be rigorously controlled as part of the general duty of patient
care. But HAI also has considerable economic impact on health care
services and on the costs of national health care.

Economic consequences of HAI

Measuring the cost of HAI is difficult and the financial impact varies
between different health care systems. Nevertheless, in simple terms,
HAI can have the following economic results:

1. HAI delay patient discharge, resulting in increased hotel costs.

In addition, the patient suffers additional costs due to increased
absence from work and relatives suffer costs of time and travel to
visit the patient;
2. Infections require increased treatment costs (for example,
increased drug therapy and increased numbers of procedures,
including repeat surgery). The patient may be discharged from
hospital while infected and the increased treatment costs then fall
on General Practice or community services;
3. HAIs involve increasing numbers of laboratory and imaging
investigations;
4. HAI increase infection prevention and control costs including
epidemiological investigations and medical, nursing, and
management time;
5. HAI is often the subject of litigation, the costs of which may be
huge.

Increased rates of HAI, associated with blocked beds and closed wards
and theatres, result in increased unit costs for admissions and
procedures, lengthening waiting lists and failure to complete contracts.
All these issues have financial penalties. Patient morbidity resulting
from HAI generates community and society costs that are difficult to
quantify but may have considerable impact. Also difficult to measure in

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 The Costs of Healthcare-Associated Infection

economic terms is loss of reputation either for the hospital or for

individual units which has significant impact on contracts and patient
referral.

Overall cost estimates

Although measuring the cost of HAI is difficult, a number of studies

have shown the probable magnitude of the problem. A study in the UK
reviewed 4,000 adult patients in an English district general (community)
hospital during 1994 - 1995.1 In this study, 7.8% of patients had HAI
identified in hospital. In addition, 19% of patients who were not
diagnosed in hospital reported symptoms of HAI after discharge.
Patients with HAI diagnosed in hospital remained in hospital about 2.5
times longer than uninfected patients, an average of 11 additional days.
(Figure 23.1) They had increased hospital costs 2.8 times greater than
uninfected patients, averaging about 3,000 ($5,000) per case. (Figure
23.2) 13% of infected patients died compared with 2% of those
uninfected. Adjusted for age, sex, co-morbidity and other factors, the
death rate was 7 times higher for patients with HAI. Estimated costs of
HAI to the hospital were 3.6m ($5.8m).

Figure 23.1. Extra length of stay due to healthcare-associated infection

by type [R Plowman, et al. The socio-economic burden of hospital acquired
infection. Public Health Laboratory Service, Health Protection Agency,
UK] 1

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IFIC Basic Concepts of Infection Control

Figure 23.2. Extra cost due to healthcare-associated infection by type

[R Plowman et al. The socio-economic burden of hospital acquired infection.
Public Health Laboratory Service, Health Protection Agency, UK] 1

Costs might be expected to be higher in tertiary referral hospitals. Costs

will be different for other countries and will change with time; however
the relative magnitudes will be similar. Table 23.1 shows the additional
length of hospital stay associated with HAI in other studies.

The extrapolated national annual cost burden of HAI for English

hospitals was about 1b ($1.6b), equivalent to about 1% of the total
national hospital budget or the resources of twenty-seven 400-bed
general hospitals. The national annual post discharge costs were
estimated to be about 56m ($90m). This included General Practice costs
of 8.4m, hospital out-patients 27m, and community nursing services
21m.

It was estimated that HAI was the direct cause of about 5,000 deaths per
annum in England (more than those caused by suicides or traffic
accidents) and contributed to an additional 15,000 deaths.

In the USA, HAI is amongst the top ten causes of death.3,4 The US
Institute of Medicine estimates that preventable adverse patient events,
including healthcare-associated infections, are responsible for 44,000-
98,000 deaths annually in the US at a cost of $17-$29 billion.5 The US
National Nosocomial Infection Surveillance system reported a positive
impact on reducing HAI rates in participating hospitals.6

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 The Costs of Healthcare-Associated Infection

Table 23.1. Studies of cost and increased hospital length of stay (LOS)
associated with HAI. From Wilcox & Dave2

Date of Type of HAI

Increased Cost/case
Study Country (Number in
LOS (days) ()
(Author) study)

1981 (Haley) USA All (177) 1 891

1983 (Girady) France Neonatal (61) 6.7 1118

1989
UK Caesarean (41) 2.1 1011
(Mugford)

ICU
1992
Germany Pneumonia 10.1 5533
(Kappstein)
(34)

1993 (Coello) UK UTI (36) 3.6 498

1993 (Coello) UK Wound (12) 10.2 1553

1996 (Wilcox) UK C. difficile 21 4107

1998
Canada Wound (108) 10.2 1780
(Zoutman)

1999
UK All (309) 11 3000
(Plowman)

In Mexico, Navarrete-Navarro and Armengol-Sanchez7 estimated costs

associated with HAI in paediatric intensive care. Infected children had
an extra hospital stay of 9.6 days. This was the major factor contributing
to an average cost per infection of nearly $12,000.

Costs of outbreaks

Several investigators have attempted to measure the costs associated

with hospital outbreaks of infection. Again, the costs are tentative and
must be considered in relation to the health care system studied and the
year of study. Nevertheless costs were considerable.

Cox et al.8, estimated the additional costs generated by a large outbreak

of methicillin-resistant S. aureus (MRSA) over three years in an English

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IFIC Basic Concepts of Infection Control

district general hospital as 400,000 ($640,000). A smaller MRSA

outbreak cost 7000, however an outbreak of multidrug resistant Gram-
negative infection increased costs by about 35,000 ($56,000) (1990
prices).9 Kim et al10 measured the costs of MRSA in their hospital and
calculated that it cost all Canadian hospitals $42m - $59m annually in
1997 dollars.

Cost benefit of infection prevention and control (IC)

In the Study on the Efficiency of Nosocomial Infection Control (SENIC)3

of 1974-1983, US hospitals with one full-time infection control nurse
(ICN) per 250 beds, an infection control doctor (ICD), moderately
intense surveillance, and systems for reporting wound infection rates to
surgeons reduced their HAI rates by 32%. In other hospitals the HAI
rate increased by 18%. The SENIC study estimated the annual cost of
HAI in US hospitals was $1b (in 1975 $). The cost of infection control
teams (0.2 ICD, 1 ICN, 1 clerk per 250 beds) was $72m per annum, only
7% of the infection costs. Therefore, if IC programmes were effective in
preventing only 7% of HAIs (normally distributed), the costs of the
programmes would be covered. A 20% effectiveness would save $200m
and 50% would save $0.5b (1975 US prices).

The Association for Professionals in Infection Control & Epidemiology

published a paper on the business case for reducing HAIs from the
perspective of the healthcare executive in 2007. Case studies of
significant cost savings are presented along with a methodology for
determining the cost of various categories of HAIs.11

Conclusions

The costs of HAI are huge and include patient morbidity and mortality,
hospital and community medical costs, the impact of blocked beds, and
wider socio-economic costs. The costs of IC programmes and staffing
are relatively small and with only a small degree of effectiveness they
can pay for themselves. Investment in IC is therefore highly cost
effective.

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 The Costs of Healthcare-Associated Infection

References and Further Reading

1. Plowman R, Graves N, Griffin M, et al. Socio-economic burden of

hospital acquired infection. London: PHLS; 1999.
2. Wilcox MH, Dave J. The cost of hospital-acquired infection and
the value of infection control. J Hosp Infect 2000;45:81-4.
3. Haley RW, Culver DH, White JW, et al. The efficacy of infection
surveillance and control programs in preventing nosocomial
infections in US hospitals. Amer J Epidemiol 1985;121:182-205.
4. Wenzel RP, Edmond MB. The Impact of Hospital-Acquired
Bloodstream Infections. Emerg Infect Dis 2001;7:174-7.
5. Kohn L, Corrigan J, Donaldson M. To err is human: building a
safer health system. Washington, DC: Institute of Medicine,
National Academy Press; 1999.
6. Report. Monitoring Hospital-Acquired Infections to Promote
Patient Safety -- United States, 1990-1999. MMWR 2000;49:149-53.
7. Navarrete-Navarro S, Armengol-Sanchez G. Secondary costs due
to nosocomial infections in 2 pediatric intensive care units. Salud
Publica de Mexico 1999; 41 Suppl 1:S51-8.
8. Cox RA, Conquest C, Mallaghan C, Marples RR. A major
outbreak of methicillin-resistant Staphylococcus aureus caused by a
new phage-type (EMRSA-16). J Hosp Infect 1995;29:87-106.
9. Mehtar S. How to cost and fund an infection control programme.
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