INFECTION PREVENTION (INCLUDING HIV) AND STANDARD SAFETY MEASURES, BMW

MANAGEMENT:
Introduction:
Infection is one of the leading causes of preventable deaths in hospitals every year. A large number of
micro-organisms live and multiply on every surface. They are in the air, grow on skin and flourish in the
digestive tract. Certain organisms are necessary for the normal body functioning. Some microorganisms help
produce food and maintain the planet’s ecology. Most of the times, humans and microorganisms live in
harmony. When this balance is upset, microorganisms are capable of causing infection.
Definition:
An infection is the entry and multiplication of an infectious agent in the tissue of host.
Chain of infection:
A variety of microorganisms – including bacteria, viruses, fungi and parasites – can either colonize or cause
infection, depending on the susceptibility of the host. The ability of a microorganism to invade, establish and
multiply in the cells and tissues of a host and produce signs and symptoms of disease depends upon the
following factors.

An Infectious Agent or pathogen:

The microorganism capable of causing the infection is known as the infective agent. Infective agents include
bacteria, viruses, fungi, protozoa, helminths and prions. The ability of a microorganism to cause infection
depends upon its ability to invade, proficiency in overcoming the host defences, its pathogenicity, degree of
virulence, and the infectious dose. Equally important is the agent’s capability to survive in the environment,
and its resistance to antimicrobials.
A Reservoir or source for pathogen growth:
A reservoir is the source of the infectious agent where it lives and multiplies. These can be animate (humans,
animals) or inanimate (the environment, contaminated food and water).
Human reservoirs can be symptomatic (exhibiting signs and symptoms of the disease) or asymptomatic
(without signs and symptoms) or they can be carriers (presence of organisms for varying periods without
signs or symptoms).
Asymptomatic cases and carriers are more likely to transmit the disease as precautions may not be taken
since it is not known that the person is harbouring the organisms.
Portal of exit from the reservoir:
Portals of exit are necessary for the organism to exit the body of one person and be transmitted to another
person. The portal of exit can be the excretions/secretions of the respiratory tract, gastrointestinal tract,
genital tract, blood or any other body fluid.
Modes of transmission
This is the way an agent is transmitted from a reservoir to a susceptible host. Transmission can occur by:
 Portal of contact – direct contact through hands or indirectly through an inanimate object;
 Droplets – large-sized droplets released by sneezing, coughing or even talking;
 Airborne route – through very small particles which can travel from room to room via air currents;
 Common vehicle – where a contaminated vehicle serves as the means of spreading infection to
several persons such as food in a salmonella epidemic or blood in a blood-borne epidemic (hepatitis
B); and
 Inoculation – a percutaneous injury with a contaminated needle or other sharp resulting in direct
inoculation of the organism into the bloodstream.
A Portal of entry to host
Similar to the portal of exit, it is the site of entry of the organism into the body such as the mucous
membrane of the respiratory, genital, gastrointestinal or urinary tract, conjunctiva and skin.
A Susceptible host
A susceptible host is a person who is susceptible to the infection or lacking in resistance to the infective
organism. Host factors that influence susceptibility to infection are:
 Age – individuals at extremes of age are more susceptible to infection, e.g. neonates and old people;
 Socioeconomic status such as health literacy, nutritional status;
 Comorbidities such as diabetes, cancer;
 Immunization status;
 Medications such as immunosuppressive agents and chemotherapeutic agents
 Pregnancy;
 Interventions and devices – surgery, intubation, mechanical ventilation, urinary catheterization,
vascular catheterization;
 Host factors – related to the host that prevent the entry and establishment of infective agents
including: - endogenous organisms inhabiting body sites such as the gastrointestinal tract, skin,
respiratory tract, genital tract that prevent the establishment of pathogenic organisms at that site;
- natural antibodies;
- natural barriers such as intact skin, mucous membranes, fascial planes, cough reflex and gastric
acid secretion.
Control measures:
1. Control or elimination of infectious agents:
Cleaning, disinfection and sterilization of contaminated objects significantly reduce and often
eliminate microorganism.
a) Cleaning:
Cleaning is the removal of all soil from object and surface by water and mechanical action with
or without detergents. When cleaning equipment that is soiled by organic material such as blood,
faecal matter or pus, this need applies a mask and protective eyewear and water proof gloves.
b) Asepsis:
Asepsis is the absence of pathogenic microorganisms. The aseptic techniques refer to practices
that keep a client as free from pathogens as much as possible. There are 2 types of aseptic
techniques.
i) Medical asepsis
ii) Surgical asepsis
c) Disinfection:
It describes a process that eliminates many or all microorganisms with the exception of bacterial
spores.
d) Sterilization:
 It is the complete elimination or destruction of all microorganisms including spores steam under
pressure, gas hydrogenperoxide, plasma.
Disinfectants :
High-level disinfectants Low-level disinfectants
Activated glutaraldehyde (Cidex 2%) Methylated spirit 70%
Sodium hypochlorite 1% Betadine solution 10%
Carbolic solution 5% Savlon 1%
Bleaching powder 1%

2. Control or elimination of reservoirs:

To control or eliminate reservoir site for infection the nurse eliminates or controls sources of body
fluids drainage or solutions that might harbour microorganisms. The nurse carefully disinfects
articles that become contaminated with infected material. The Occupational Safety and Health Act of
1991 set standards for minimizing occupational exposure to blood borne pathogens or other
potentially infectious material.

3. Control of portals of exist:

The nurse follows prevention and control practice to minimize or prevent infection organism from
existing the body. To control organisms existing via respiratory tract, the nurse should avoid talking
directly into clients faces, sneezing or coughing directly over surgical wounds or sterile dressing
fields. A nurse who has an upper respiratory tract infection and continues to work clients should
wear a mask when working closely with the client and pay attention to hand washing. Another way
of controlling the exist of microorganisms is through the careful handling of exudates. E.g., urine,
feces, emesis, etc. Contaminated fluids can easily splash while being discarded in toilets or hoppers.

4. Control of transmission:
Effective control of infection requires a nurse to remain aware of the mode of the transmission and
ways to control them. In the hospital, home or extended care facility a client should have a personal
set of care items. Sharing bedpans, urinals, basins, eating utensils can easily lead to transmission of
infection. To prevent transmission through indirect contact, soiled items and equipment must be kept
away from touching the nurses clothing. A common error is to carry dirty linen in the arms against
the uniform. Laundry hampers should be replaced before they are overflowing. Handwashing is the
most important and most basic technique in preventing and controlling transmission of infection.

5. Control of portal of entry:

Maintaining the integrity of skin and mucous membrane reduces the chances of microorganisms
reaching a host. Proper positioning of tubings, etc. may prevent injuries and skin breakdown. Turning
and positioning are needed before the clients’ skin become reddened. Ensuring personal hygiene of
clients regularly. Disposing contaminated syringes and needles properly to prevent accidental injuries to
hospital personnel as well as clients. Proper handling of catheters, drainage sets, etc. is essential. Care
should be taken while collecting and handling specimen.
6. Protecting susceptive host:
Procedures and practices for infection prevention and control

A two-tiered approach to precautions is used to interrupt the mode of transmission of infectious

agents.

 Standard precautions: these refer to work practices that are applied to all patients receiving care in
health facilities, regardless of their diagnosis or presumed infectious status so as to minimize the risk
of transmission of infectious agents in all situations. Standard precautions minimize the likelihood of
transmission of infectious agents between HCWs and patients, and from patient to patient.
  Transmission-based precautions: Transmission-based precautions are precautions required to be
taken based on the route of transmission of organisms like contact precautions, airborne precautions,
etc.

STANDARD PRECAUTIONS
 The use of standard precautions is the primary strategy for minimizing the risk of transmission of
microorganisms in healthcare facilities.
 Standard precautions are to be followed for all patients, irrespective of their infection status. These
are to be used to avoid contact with blood, body fluids, secretions and excretions regardless of
whether contaminated grossly with blood or not; non-intact skin; and mucous membrane. The key
components of standard precautions are:
1. Hand hygiene
2. Personal protective equipment
3. Respiratory hygiene and cough etiquette
4. Prevention of injuries from sharps
5. Safe handling of patient-care equipment
6. Principles of asepsis
7. Environmental infection control
A. Patient placement
B. Environmental cleaning
C. Linen and laundry
D. Waste disposal

1. Hand hygiene
The WHO guidelines on hand hygiene in healthcare (2009) suggest that hand hygiene is the single
most important measure for prevention of infection. Hands can become contaminated with infectious
agents through contact with a patient, patient surroundings, the environment, or other HCWs. Hand
hygiene removes dust/soil, organic material and transient microorganisms from the skin and reduces
the risk of cross-contamination. Evidence suggests that the hands of the HCWs are the most common
vehicle for the transmission of healthcare-associated pathogens from patient to patient and within the
healthcare environment (Box 4.1).

Hand washing with soap and water

Indications: when there is visibly heavy contamination, e.g. with proteinaceous material, blood or
body fluids (Fig. 4.1).
 After attending to a patient with suspected/confirmed C. difficile infection
 After using toilet x Before and after having food
 Adequate number of sinks with running water and soap should be available in the
haemodialysis unit to facilitate hand washing.
Hand rubbing using alcohol-based preparation Use alcohol-based hand rubs (ABHR), when
hands are not visibly soiled or tap and running water is not available (Fig. 4.2)
Surgical hand scrub
Hand scrubbing with an antiseptic agent before beginning a surgical procedure reduces the
number of microorganisms, and inhibits the growth of microorganisms on hands under the
gloves. Chlorhexidine or povidone-iodine-containing soaps are the most commonly used
products for surgical hand scrub. The antimicrobial effi cacy of alcohol-based formulations is
superior to that of all other currently available methods of preoperative surgical hand
 preparation.

2. Personal protective equipment Personal protective equipment (PPE) refers to physical barriers, which
are used alone or in combination, to protect mucous membranes, airways, skin and clothing from
contact with infectious agents.
PPE includes gloves, aprons and gowns, facial protection, footwear and hair cover or cap.
Gloves
 Gloves should be worn as an additional measure, not as a substitute for handwashing.
 Gloves are not required for routine care activities in which contact is limited to a patient’s
intact skin.
 Wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes,
non-intact skin.
 Change gloves between tasks and procedures on the same patient after contact with
potentially infectious material.
 If gloves become torn or heavily soiled and additional patient care tasks must be performed,
then change them before starting the next task.
 Remove gloves immediately after completion of care or a specified task, at point of use
before touching non-contaminated items and clean environmental surfaces and before moving
to another patient or using a mobile phone.
 Perform hand hygiene immediately after removing gloves.
Types and indications for wearing gloves
There are three types of gloves:
1. Clean, non-sterile gloves should be worn:
For examinations and non-surgical procedures;
For handling items visibly soiled with blood, body fluids, secretions or excretions when
the HCW has open skin lesions on the hands; and
When the HCW has non-intact skin on the hands.
2. Sterile, single-use gloves should be used for aseptic procedures.
3. Heavy duty/ utility gloves should be used for decontamination of large equipment, cleaning of floors,
walls, HCF furniture such as beds, etc. These gloves can be reused after cleaning.
Glove pyramid
The glove pyramid in Fig 4.4 shows indications for sterile gloves, examination (clean) gloves and where
gloves are not indicated.
Aprons and gowns
International guidelines recommend that protective clothing (apron or gown) should be worn by all HCWs
when:
 there is close contact with the patient, materials or equipment that may lead to contamination of skin,
uniforms or other clothing with infectious agents; and
 there is a risk of contamination with blood, body substances, secretions or excretions (except sweat).
The type of apron or gown required depends on the degree of risk, including the anticipated degree of
contact with infectious material and the potential for blood and body substances to penetrate through to
clothes or skin.
 A clean non-sterile apron or gown is generally adequate to protect skin and prevent soiling of
clothing during procedures and/ or patient-care activities that are likely to bring contact with blood,
body substances, secretions or excretions (except sweat).
 A fluid-resistant apron or gown should be worn when procedures are likely to generate splashing or
sprays of blood or body substances and there is a risk that clothing may become contaminated with
blood and body substances.
 Gowns and aprons preferably must be changed between patients.
Facial protection
Usual facial protection includes a medical/ surgical mask (triple-layer surgical mask) and eye protection
(face shield or goggles), to protect the conjunctivae and the mucous membranes of the nose, eyes and mouth
during activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions.
Eye protection should also be used while providing care to patients with respiratory symptoms such as
coughing and sneezing, since sprays of secretions may occur.
Footwear
A closed footwear, which can be easily cleaned and disinfected, must be used whenever work processes or
environments could cause foot injuries or spillage of blood or body fluids.
Personal footwear should be changed when entering clean areas such as OTs, labour rooms, ICU.
Shoe covers may be used over street shoes to protect clean areas from soil and dirt brought in by shoes.
Hair covers
Long hair must be secured with a rubber band and hair cover worn to protect the hair and to protect the
patient from falling hair.