UNIT I NOSOCOMIAl OR

HOSPITAl ACQUIRED INFECTION

· I · f ·
Definition · N oso~onua
·. m ect10ns commonly known as hospital acquired infections or
health associated mfections or health care-associated infections are defined as infections
de~eloping in patients after admission to the hospital (nosocomion-hospital), which were
neither present nor in incubation at the time of hospitalization. Infection that first appears
between 48 hours & four days after admission are usually considered nosocomial infections.

I. COMMON HOSPITAL-ACQU IRED INFECTIONS

1. Urinary tract infection: This is the most common nosocomial infectio~, 80% of infection
are associated with catheterization or instrumentation of urethra, bladder or kidneys that
are referred to as Catheter Associated Urinary Tract Infections (CAUTI). Urinary
infections are associated with less morbidity than other nosocomial infections, but can
occasionally lead to bacteraemia & death. The bacteria responsible arise from the gut
flora (E.coli) or acquired in hospital (Klebsialla). Initial infection is caused by E.coli, Staph.
epidermis, Proteus, Serratia & Pseudomonas. Beside prolonged catheterization, older age and
impaired immunity (including diabetes and Renal dysfunction) are other causes of
CAUTI.

Urinary
Catheter
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foblo : Indications for urinary c:ithoteris:itlon

Haematuria
H
Obstructed
0
u Urologic surgery

Decubltus ulcers : open sacral or pertneal

D preuure ulcer In an lncontlntnl pereon

Input/output monitoring
I
Not for resuscitation/end
N of life care: comfort
Immobility due to physical
I restraints

Fig. 1.1. Indications of Urinary Catheterization

2. Nosocomial pneumonia: Nosocomial pneumonia is the second moS t common _type of

HAI and occurs in several different patient groups. The inost important are patients on
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. . re the rate of pneumonia is 3 % per day. Ther .
. . care umts, w 11e . d . M· e is a
tilators in intensive . 'tl ventilator-associate pneumonia. icroorga n1s11'\ .
ven cia ted w1 1 .
lug. 11 case fatality rate asso ·a Staph. aureus, Klebszella, Proteus 5 .s
. 11 11 Strep p11e111110 111 , , erratia
(Haemophilus 111f1 c zn, · d . t the throat by treatment procedures perform d '
. ily introduce 111 0 . . e to
Enterobacter) aie eas . ·" 'tl chronic obstructive lung disease, for exam.pl
. ·11 .:>sses Patients w1 1 e, are
treat respiratory 1 ne L •• • _.
1, ause of frequent and prolonged antibiotic the
,tible to mtection oec, . rapy
especially susceF . , t'lation used in their treatment. The infe i;_
t rm mechamca 1 ven 1 ' c,111g
and long- e .. taminated equipment or the hands of health care
. · ms can come h om con '
m1croorgams i . . onducted such as respiratory intubation, suctioning f
. o
1

v,,orkers as proceL mes ai e c . ·1 .

. .
material from t11e t1uoa anc . t i mouLl--. ' and mechanical
. venh
.. ahon. Once mtroduc ed
through tl1e nose an d mouth , microorganisms quickly colonize. the throat area, aspirated
into the lungs, where infection develops that leads to pneumonia.
3. Surgical site infection (wound infection & skin sepsis): Surgical site infections are also
frequent, incidence varying from 0.5 to 15% depending on the type of operation &
underlying patient status. Incidence of post-operative infection is much higher in elderly
patients above age of 60. The infection is acquired usually during the operation itself;
either exogenously (e.g., from air, medical equipment, surgeon or other stafO,
endogenously from the skin flora or rarely from blood used in surgery. Staph. aureus is
the predominant pathogen followed' by E.coli, Proteus, Enterococcus, certain anaerobes &
Staph. epidermis.
4
· ~ oso~omial bacteraemia: These infections represent a small proportion of nosocomial
m~ections (~pproximately 5%) but case fatality rates are high - more than 50% for some
m1croorgamsms. lnfection may occur at th k'111 .
· th b es entry site of the intravascular device,.or
m e su cutaneous path of the catheter (t 1. f .
Blood Stream Infection(CLABSI) unne 111 echon) are referred to as Central Lme

Fig. 1.2 Center Venous Ace

ess Oev·ices
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OTHER NOSO COM IAL INFECTIO NS:
bedso res) encou rage
• Skin a11d soft tissue infections : open sores (ulcers, burns and
. aureus and Strep.
bacte rial colon izatio n and may lead to system ic infection. Staph
pyogenes are main patho gens.
en, where rotavi rus is
• Gastr oente ritis is the most comm on nosoc omial infection in childr
omial gastro enteri tis in
a chief patho gen. Clostridium difficile is the major cause of nosoc
adult s in devel oped count ries.
nctiva .
• Sinus itis and other enteri c infections, infections of the eye and conju
ing childb irth .
• Endo metri tis and other infections of the repro ductiv e organ s follow

Table 1.1 : Common Noso comia l Infections & Causative Agents

1. Urina ry tract Candida species E.coli Klebsiella, Proteus sp.,

Pseudomonas,
Staph.aureus(coag.+ve) Strep.fecalis.

2. Respi ra tory tract H.infiuenzae Streptococcus pneumonia Staph.aureus

Klebsiella species, Proteus spp.
Serratia spp. Enterobacter,

3. Woun ds/Bu rns Clostr idium (rnay lead to tetanu s and gas
gangre ne) Colifo rm bacilli
P-hern olytic strepto cocci Proteus species
P.aeruginosa Staph.aureus(coag. +ve)
Strep.fecalis

Entero bacter
4. Bacter ernia, Septic emia P.. aeruginosa S.typhimurium

II. SYMPTOMS OF HAis

signs of infection are rapid
Fever is often the first sign of infection. Other symp toms and
outpu t, and a high white
breath ing, menta l confu sion, low blood press ure, reduc ed urine
ting and blood in the urine
blood cell count . Patien ts with a UTI may have pain while urina
breath ing and inabil ity to
(uremia). Symp toms of pneum onia may includ e difficulty in
tende rness on the skin or
cough. A locali zed infection begin s with swell ing, redne ss, and
progr ess rapid ly to the
aroun d a surgic al woun d or other open woun ds, which can I
.
destru ction of deepe r layers of musc le tissue , and event ually sepsis
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Ill CAUSES OF HAis . . f t' from their treatmen t or surgery.

. .. k f acquirmg an m ec wn .
. l' d patients are at ns o
All hosp1ta ize . k tl1311 others, especrn . 11 young children, t h e e lder1y, and
y . 1 .
Some pa t1en . t are at greater ns d ' to database of nahona nosocom1al
s . terns. Accor mg . . .
persons w1·tl1 comprom ised immune sys all infect10n. t mong children in intensive care is
ra e a
1
. fection surveillance system, t , e over theters and ventilato r-associa ted pneumon ia.
m 01 being venous ca
6. 1 io , with the primary causes
. 1
. .
. ·ed mfecttons m c i
. h'ldren include parentera1 nu t n. t·10n (tube
. . .
Tl,e n·sk factors for hosp1ta -acqunf antibiotic s for more than 10 days use of invasive devices
' . ,
or intravenous feeding), the use _0 dysfuncti on. Other risk factors that increase
. t t and immune ~vstem .
poor post-operative s a us, d . 'ld en to acquire infection s are:
the opportum·tY for hospitaliz ed adults an cm r
• A prolonged hospital stay.
• Severity of underlyin g illness.
• Compromised nutritiona l or immune status.
• Use of indwelling catheters.
• Failure of health care workers to wash their hands before procedur es.
• Prevalence of antibiotic-resistant bacteria from the overuse of antibiotic s.

IV. FACTORS INDUCING HAis

• Age: Neonates & elderly persons of extreme ages are at greater risk of acquiring hospital
infections because of their longer stay and with inefficien t immunit y.
• Susceptib ility: Hospitali zed patients with pre-exist ing diseases like diabetes,
immunos uppressio n etc. are high risk groups and more susceptib le to infection s.
• Infected patients: Commun ity acquired or a non-hosp ital infection with which the
patient enters the hospital is due to pathogen ic microorg anisms. From these patients
there is risk of spread of infections from their close contacts to susceptib le patients and
attending staff.
• Hospital environment: The hospital environm ent is heavily laden with a variety of
pathogen s. Unhygien ic hospital environm ents can lead to transmis sion of diseases easily.
• If the hospital infection control policies are not accuratel y followed , spread of disease
could occur through food, water, personne l's handling patients etc.
• Surgical and diagnost ic procedures: The natural defense mechani sms of the body
surface may be bypassed by injury or by a diagnosti c of therapeu tic intervent ion like
usage of urethral or intraveno us catheters , endoscop ic tube t
sec.
• Drug resistance: The occurren~ e of drug resistant organism s like Colifor:rns an_d
Staphylococcus aureus that sometime s show increased virulence or transmiss ibility 15
usually hospital acquired .
• Transfusion: Blood, blood products or intraveno us fl ·a
transmit infections , if not properly screened . u1 s used for trans fusion can
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ial or Hos pita l Acq uire d Intiect,a
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V. SOURCES OF HAis:
·
, pat hog emc
A. Endogenous sources·· Here tlle pat ·ien ts own normal flora (which are not d
• cho . n or disease. These path oge ns are calle
tmd er nor mal condition s) cause mfe
oge nic only whe n there is underlying disease & suc h
~ opp~rtunis~ic' as they bec ome path
o-infection.
infection as opportunistic infection or aut

B. Exogenous sources:
son nel
Patients & staff: HA is ma y be acquire
d by contact with pat ien t or hospital per
1.
carriers.
suffering from infection or asymptomatic
2. Environmental sources: These incl
ude:
wit h
be acquired indirectly by coming in contact
a. Inanimate objects (fomites): HA is may ,
h as sanitary installation (bed pan , urin als)
con tam ina ted equ ipm ents , materials suc
tabl e, blan ket, med ical equ ipm ent (end oscopes, catheters, needles, spa tula &
lights,
oth er inst rum ent s), floor, food & water.
flora of
b. Hospital air: Hos pita l air harbors
Gram positive cocci derived from bod y
stant bacteria which are often pathogenic.
hos pita l pop ula tion & also other dru g resi
pop ula tion of thes e bac teri a in hos pital air increases wit h overcrowding in
The
hospitals.
& bod y
c. Surfaces: Surfaces con tam inat ed
by patient's secretions, excretion, blood
fluids ma y also act as source of HAis.

VI. ROUTES OF TRANSMISSION OF HAis

There are fou r ma in rou tes of HAis;
ocomial pathogens.
1. Contact route: It is the mai n rou te of nos
sing : Han ds & dre ssin g of hos pita l personnel contain microorganisms
a. Hands or dres of
bod y which serves as important vehicle
received eith er from pat ien t or own udes
oge n that spre ad by han d contact incl
transmission of HAis. Imp orta nt path
albicans.
Staph.aureus, Strep.pyogenes, coliforms & Candida
kets, m~dical
b. Inanimate objects: Ina nim ate obje
cts (equipments, materials, urinals, blan
.
reservoir of potentially pathogenic bactena
equipments, floors, food & water) serve as
al route may occur by:
2. Air borne route: Transmission by aeri
alat ion of dro plet s from infe cted per son lead to respiratory infections in
a. Droplet: Inh
hospitalized patients.
ersed from wou nd dur ing dressing & from
b. Dust: Dus t from floors, bedding, exudate disp
ad to the susceptible site of the body.
skin by nat ura l she ddi ng of skin scales spre
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c. Aerosols: Aerosols produced by nebulizers, humidifiers & air conditionin g apparatus

transmit certain respiratory tract p athogens.
3. Oral route: Food prepared in hospitals may contain Gram -ve bacilli which are most
often antib iotics resistant (E.coli, Klebsiella) . These bacteria may colonize the recipient's
intestine & becom e established in fecal flora of these patients.
4. Parenteral route: Trans1nissio n of infection by parenteral route has been limited & is
infrequen t d ue to introduction of single use disposable syringes & needles. However
certain in fections like Hep B & HIV may be transmitted by blood transfusion or tissue
donation, contaminate d blood products, contaminat ed infusion fluid or accidental injury
fron1 sharp instruments.
s. Body fluids: Through semen, vaginal secretions, milk, saliva, sweat etc.
VII. DIAGNOSIS OF HAis
Diagnosis of a hospital-acq uired infection is determined by:
i. Evaluation of symptoms and signs of infection.
ii. Examination of wounds and catheter entry sites for redness, swelling, or the presence of
p us or an abscess.
iii. A complete physical examination and review of underlying illness.

iv. Chest X-ray may be done when pneumonia is suspected to look for the presence of white
blood cells and other inflammato ry substances in lung tissue.
v. Laboratory tests including;
• Complete blood count to look for an increase in white blood cells .

- Urine analysis (urinalysis) to look for white cells or evidence of blood in the urinary
tract.
• Cultures of the infected area, blood, sputum, urine, or other body fluids or tissue to
find the causative organism.

VIII . TREATMENT OF HAis

Treatment depends upon the organisms responsible for infection which is established in
diagnosis and it varies for different organisms.

• Bacterial infections:_ !he isolated organism is tested for sen sitivity to a range of
antibiotics. While waiting for thes~ t~s~ results, treatment m ay b egin w ith common bro~d
spectrum antibiotics such as p~nicillm, cephalospo rins, tetracycline s or erythromycin-
Since bacteria are becoming resistant to these standard antibiotic treatments; therefore,
more specific antibiotics must be used. Two such antibiotics that have been found

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effective against ..
resistant b
bacteria are develo . acteria are vanco .
F ping · resistance t th mycm
ese a r b · . and imipenem' a1th ough some
0
• ungal infections· A t"fu n 1 iohcs as well.
• · n i ng 1
itraconazole, and flu a agents like amphotericin B, nystat1·n,
. conazole are used. ketoconazole,
• . drugs that 1
Viral infection·. A n t·iviral
acyclovir, ganciclovir, foscarnet, ands ow the _growth or reproduction of viruses, such as
amantadme have been used
IX. PREVENTION OF HAis .

• High-risk procedures and other. .

possible sources of infection should be identified.
• Reg~lar hand-washing . by health care w ..
passing infectious microor . orkers and visitors .should be done to avoid
. . gamsms to or between hospitalized patients.
• . 1 d. techniques in th e performance of procedures should be strictly followed,
Aseptic
inc u ing use of sterile gowns, gloves, masks, and barriers.
• 5terilizatio_n of all reu~able equipment such as ventilators, humidifiers, and any devices
that come 1n contact with the respiratory tract should be done.
• Disinfection of excreta .and infected material shoud be done to control the exit point of
infection.
Contact between respiratory secretions and health care providers should be prevented by
•
using barriers and masks.
An antibacterial-coated venous catheter (that destroys bacteria before they can get into
•
the blood stream) and silver alloy-coated urinary catheters (that destroy bacteria before
they can migrate up into the bladder) should be used.
Patients with known infections should be isolated .
•
Medical instruments and equipments should be sterilized to prevent contamination .
•
An infection control practitioner for every 200 beds should be employed
•
CATHETER-ASSOCIATED URINARY TRACT INFECTION (CAUTI) PREVENTION BUNDLE

Prevention involves:
i. Appropriate Catheter use
n. Proper Techniques of Urinary Catheter Insertion
... p h . es of Urinary Catheter Maintenance
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APPROPRIATE CATHETER USE

A. Insert catheter on1y for appropna
· te indications, and leave in place only as long as
needed.
♦ Minimize urinary catheter use and duration of use on all the patients, particularly those
at high risk of cauti.
♦ Avoid the use of urinary catheter in patients who have lost the control of urinary bladder
(urinary incontinence).
♦ For operative patients who have indwelling catheter, remove the c~the~er _a s ~oon as
postoperativ ely, preferably within 24 hours, unless there are appropnate md1cations for
continued use.
B. Consider using alternatives to indwelling urethral catheteriza tion in selected patients
when appropriate
• Use external catheters in cooperative male patients without urinary retention or bladder
outlet obstruction.
♦ Consider alternative to chronic indwelling catheters such as intermitten t catheterization
in spinal cord injury patients.
♦ Consider intermittent catheterizat ion in children with myelomeni ngocele and neurogenic
bladder to reduce the risk of urinary tract deterioratio n.

PROPER TECHNIQUES OF URINARY CATHETER INSERTION

• Perform hand hygiene immediatel y before and after insertion or manipulati on of catheter
insertion device.

• ~nsur: that only trained personnel who know the correct technique of aseptic catheter
msertion and maintenanc e are given this responsibil ity.
♦ Use. sterile gloves: drape, spon
ges and an appropnate· •
antiseptic • or sterile
• solution
· for
penurethra l clearung and a single-use packet of 1 b · · 11y f or insertion.
u ncan t Je · ·
♦ Properly secure indwelling c th t
. a e ers a ft er msertion
· · to prevent movement and urethral
tractions.
♦ Unless otherwise clinically indicated
. . . , consi·der usmg
·
smallest bore catheter poss1·bl e,
consistent with good drainage to minimize bladde k d
r nee an ure thral trauma.
♦ If intermitten t catheter is used, perform it at regular · t
. . . m erva1s to prevent bl a d d er over-
distens10ns. Use a portable ultrasound device to access ·
. . urme vo1ume .m p atien
. t as
so , t0
reduce unnecessary catheter insertions.

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' --. --------
a Ur in ar y
nd Hy gi en e fo cu s on ca rin g fo r a pa tie nt wi th
fo r Ha
Fig. 1.3 Th e 5 M om en ts Ca th ete r

INTENANCE
ER TE CH NI QU ES OF UR IN AR Y CATHETER MA
OP ge
PR
e Ur in ar y Ca th ete r, M ai nt ai n A Cl os ed Dr ai na
A. Fo llo wing As ep tic
In se rti on O f Th
an d
Sy ste m
cti on or lea ka ge oc cu rs, rep lac e the ca th ete r
♦ If br ea k in as ep tic
tec hn iq ue , di sc on ne
t.
m us in g as ep tic tec hn iq ue an d ste ril e eq ui pm en
co lle cti ng sy ste ng jun cti on s.
ou ld be pr ec on ne cte d wi th se ale d ca th ete r tu bi
♦ Ca th ete r sy ste m
sh
te d Ur in e Fl ow
B. M ain ta in Un ob str uc
kin g.
th e ca th ete r an d co lle cti ng tu be fre e fro m kin the
• Ke ep
el of bl ad de r at all tim es . Do no t re st the ba g on
g be lo w th e lev
• Ke ep th e bl ad de r ba
floor.
ba g reg ul arl y.
• Em pt y th e co lle cti ng es an d g ow n as ap prop riate,
durin g
di ng th e us e of gl ov
tio ns , in clu
C. Us e sta nd ar d pr ec au
y m an ip ul at io n of ca th ete r or co lle ct in g sy ste m. an d
an
ut i is to av oi d in se rti on of un ne ce ss ar y ca th ete rs
pr ev en tio n of ca
The be st str ate gy fo r th e ry .
ov e ca th ete rs on ce th ey ar e no lo ng er ne ce ssa
to rem
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1. Sheath/condom catheter

2. Suprapubic catheterization

3. lntermitted catheterization

4. Timed voiding program

5. Bedside commode/urinal

6. Incontinence pads/diapers Its up to the patient

condition & treating
7. Environmental changes physician

Fig. 1.4. Alternatives to Urinary Catheter

SURGICAL SITE INFECTION BUNDLE APPROACH

A bundle of care consisting of five elements covering the surgical process was introduced in
September 2013. The elements of the bundle were perioperative antibiotic prophylaxis, hair
removal before surgery, perioperative normothermia, perioperative . euglycemia and
operating room discipline.
There are key infection control initiatives within the perioperative service line that should be
used with a bundled approach such as the 7 S Bundle, a perioperative nurse can control ss.r
risk before, during, and after a surgical procedure.
Safety - A safe operating room (OR) is crucial for preventing SSL Surface sterilization
procedures should be performed in advance including all equipment, lights, and the
operating bed. Airborne sterilization should be kept intact through traffic control and air
ventilation monitoring along with keeping door openings to a minimum for reduced SSI risk
Screen - By analyzing a patient's pre-operation condition, a nurse can determine any risk
factors and the presence of methicillin-resistant Staphylococcus aureus (MRSA) an~
Methicillin- resistant Staphylococcus aureus (MSSA) prior to surgery. Nasal decolonization 15
becoming an important step for screening • . response to COVID-19 and nasal carnag
m · e of
S.aureus.
Showers - Patients should arrive to their surgical appointment with physically clean 5~ ;
Patient should be instructed to shower with soap or chlorhexidine gluconate (CHG) the nigh
before and morning of their surgery.
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Ski n Pre p - Ski n· pre.par afion wit ·l
1 alco hol- base d anti sept ics,
suc h as CH G/ alcohol or
. · f after the
10d oph or I alco hol pro vid e rap id pro t ech on o the surg ical site surf ace befo re and
pro ced ure for con trol led SSI prev enti on.
· nd clos ure
Sol utio n - Sur gica l irrig atio n to rem ove exo gen eou s con tam man ts prio r to wou · ion.
prac tice in eve ry OR, b ut th ere 1s · a lack of pro cess stan dard izat
sho uld be a com mon . use of
anti biot ic irrig atio ns and mor e tow ards the
Pro_cess~s _ar~ m~v mg awa y from usin g
e.
anti sep tic 1rn gati ons suc h as chlo rhex idin
- . Sut ure s can be colo nize d by bac teri a like othe r fore ign bod ies; therefore, an
Su~ur~s
sutu re pro vid es nee ded pro tect ion in com pari son to a trad itio nal sutu re.
anti mic rob ial sure to
mic rob ial sutu res is a sim ple con trol mea
Clo sing sutu res wit h Tric losa n coa ted anti
prev ent SSL ·
eou s
be the bes t app roac h to prev enti ng exo gen
Ski n Clo sur e- Top ical skin adh esiv es can sing s.
in add itio n to tran spa ren t anti mic robi al dres
con tam inat ion in a pos top erat ive sett ing dres sing
iaTe ct is a tran spa ren t, chlo roh exid ine gluc ona te CH G-e mbe dde d pos t-op erat ion
Rel
ct dres sing for sev en day s.
that ena bles wou nd mon itor ing wit h an inta
ATED BLOOD STREAM INFECTION (CLABSI)
PREVENTION OF CENTRAL LINE ASSOCI
-qu ality
erst and the imp orta nce of pro vid ing high
The inte nsiv e care uni t (ICU) team s und pre ven t
that reli es on a cult ure of safe ty and evid enc e-ba sed clinical prac tice s to help
care tral
ns. Thi s cus tom izab le, edu cati ona l tool kit aim s to help ICUs redu ce rate s of cen
infe ctio
blo ods trea m infe ctio n (CL ABS I) and cath eter -ass ocia ted urin ary trac t
line -ass ocia ted % of all
urin ary trac t infe ctio ns acc oun t for 75
infe ctio n (CAUTI). Cat hete r-as soc iate d ctions
ns. Cen tral line -ass ocia ted bloo dstr eam infe
hea lthc are- asso ciat ed urin ary trac t infe ctio
the mat eria ls in one of thre e way s:
sign ific antl y incr ease risk of dea th. Access
to
s to asse ss cur ren t prac tice s and create a plan
The firs t acc ess poi nt, Ass ess, sup por ts team s vari ous
nt, Imp lem ent, is a guid e that exp lain
mov e forw ard . The sec ond acce ss poi . The
s to sup por t the imp lem enta tion pro cess of dec reas ing infections in you r unit
reso urce
nt, Ove rco me, ack now ledg es com mon cha llen ges that ICU team s face whe n
last ent ry poi nect you
CLABSI and CAUTI, and will quickly con
atte mpt ing to dec reas e the rate of thei r
ent.
wit h reso urc es that you nee d at that mom
BSI
RISK FACTORS ASSOCIATED WITH CLA
• Intr insi c as wel l as extr insi c . .
, gen der and und erly ing hea lth con diti ons are all exa mpl es of intrinsi~ factors.
• Age
s and high est ped iatr ic
. h er amo ng chil dre n , part icul arly neo nate
• CLABSI rate s are h 1g . .
unit s.
ICU s, adu lt bur n, trau ma and crit ical care t pati ents hav e high er nsk of CLABSI as well
. d · nolo gica l defi cien
• H aem ato l og1 ca 1 an 1mm u
. • tes t·ma I a nd card iac diseases . . .
mg gas trom . not lim ited
as und erly her mea sure s but are
·nfe cti·on pre ven tion pro vide s furt
Vascu Iar cath eter re1a t e d 1
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to:-
• Dressing change frequency
• Catheter replacement
• Antisepsis of injection port

• Catheter selection
Prophylactic antimicrobials
•
• Education BSI
Female gender has lower incidence of CLA .
•
STRATEGIES TO PREVENT CLABSI

TRAINING AND STAFFING

EDUCATION, . . . d maintenance of intravascular catheters
♦ Standardization of aseptic care, insertion an
♦ Assess knowledge and adherence to guidelines
♦ Proper nursing staff to patient ratio.
+ Proper catheter site selection
+ Proper catheter material selection

INFECTION CONTROL PRECAUTION S

+ Wash hands before and after palpating, inserting, replacing or dressing any IV catheter.
+ Use an antiseptic detergent or waterless alcohol based hand rub if the hands are visibly
clean.
♦ Use maximal sterile barrier precautions including the using a cap, mask, sterile gown,
sterile gloves and sterile full body drapeI

♦ Use a sterile sleeve to protect pulmonary artery catheters during insertion.

♦ Main tain aseptic technique for insertion and care of intravascular devices.
♦ Wear clean or sterile gloves when changing the dressings on IV catheter.

CAIBETER SITE PREPARATION DRESSING AND CARE

♦ Wash the insertion site if visible unclean and dry.

♦ Scrub insertion site with 2% chlorohexidine in 70% isopropanol, leave it to dry.

♦ Use transparent, semipermeable urethane dressing or chlorohexidin e impregnated
sponge.
♦ Replace dressing when it becomes damp, loosened or soiled or when the inspection of
site is necessary.
♦ Waterproof sterile dressings should be changed weekly
Nosocomial or Hospital Acquired lnfi .
.• · - ~ • T ' 1 1 i l l " f t " ' 1 , . , . ect,on
I~•--...:.."'

ANTIBIOTICS AND ANTICOA

GULANTS
♦ Use prophylactic antimicrob' 1 1
ock solution
have . a history 0 f multiple1aCLABSI d . long term catheters who
. in p a t·_ien ts with
technique. espite op timal maximal adoption of aseptic

♦ Do not administer systen11c . . . .

. antimicrobial h
durmg use of an intravascula l prop ylax1s routinely before insertion or
r cat 1eter to prevent CLABSI.
♦ Do not routinely use anticoag 1 t 1
u an t 1erapy to redu th . k f
in general patient population. ce ens o catheter related infection

REPLACEMENT OF DEVICES
♦ There is no need to replace per·ip h era1 catheters frequently (can be done only in the case
of children).

♦ Replace midline catheters incase of specific indications only.

• Us~ a g~ide~ire exchange to replace malfunctioning non-tunelled catheter if no evidence

of infection 1s present.

REPLACEMENT OF ADMINSTRATIVE SETS

♦ Incase patient not receiving blood, blood components or fat emulsion, replace
administration sets that are continuously used especially tubing.

PERFORMANACE IMPROVEMENT
• Use hospital-specific or collaborative based performance improvement initiatives in
which multifaceted strategies are bundled together to improve compliance with evidence
based recommended practices.

VENTILATOR ASSOCIATED EVENTS

Ventilator associated pneumonia is the leading cause of nosocomial infection in the ICU and
reflects 60% of all death attributable to the nosocomial infection. Pneumonia rates are much
higher in mechanically ventilator associated patients due to the artificial airway which
increases the opportunity for aspiration and colonization.
"Ventilator bundle "is a package of evidence -based interventions that include:
♦ El · f • t' h d of bed to 30- 45 degrees will improve patient's ventilation.
evahon o patten s ea
 ,fi'@i@l=@ti#ifillW·M@f:

HOB at 30-459

r I
••
••
Fig. 1.5 Elevation of Head of Bed in Ventricul ar Bundle Approach

• Sedative medication should be reduced but not discontinued.

♦ Peptic ulcer prophylaxis;
♦ Deep vein thrombosis (DVT) prophylaxis.
+ Oral care may reduce the risk VAP. Suctioning of subglottic secretions and daily mouth
care with chlorhexidine are the methods to maintain oral hygiene.
♦ Wash hands or use an alcohol based waterless antiseptic agent before and after
suctioning touching ventilator equipment, and/ or coming in contact with respiratory
secretions. Wear clean gloved to avoid cross contamination.
♦ Strictly follow the guidelines in the case PPE kit that will decrease the droplet and contact
transmission.
♦ Appropriate Staffing levels in ICU.

SURVEILLANCE OF HAis

HAI surveillance is a core component of infection preventio n and control programm es

worldwide. The aim of HAI surveillance is to:
• To measure their burden
• Identify high risk population and procedure s
• Guide effort to reduce HAI incidence

KEY POINTS IN SURVEILLANCE

• Active Surveillance (Prevalence and Incidence studies)
• Targeted Surveillance (site, unit and priority oriented)
I • Appropriate trained investigato~
JP
r!J
_ ,iu
,M
_ _M_ii·
_ ilh
-•ti
-mht
- t§•UhM™'if!f'H~
•
lo gy
• St an da rd iz ed m et ho do
s fo r co m pa ris on s
• Risk-adjus te d ra te
(INFEC TI O N CO N TR OL POLI CY) : Every ho sp ita l m us
t ha ve an
co N TR O L O F H A is . (H AI CC ) to tackle all H A I re la te d
· t 1 co m m itt ee
. 1 re d in fe ct io n co nt ro l •
effective 10spi a ac qm en t of ho sp ita l The H A IC C cons1s • t ff ow m
s o o 11 g se tu p:
issues & go od m an ag em ·
TEE (HAICC)
QU IR ED IN FE CT IO N CONTROL COMMIT
HOSPITAL AC
ic al su pe rin te nd en t.
• Chairperson - M ed
y- In fe ct io n co nt ro l officer (microbiologist).
• Member se cr et ar ief of
he m ic al un its , ch ie f bl oo d ba nk se rv ic e, ch
of al l de pa rtm en ts /c r.
• Members - C hi ef al re co rd of fic er an d infection co nt ro l siste
, m ed ic
nu rs in g se rv ic es (NS) rv ic es (O .T .), C.S.S.D, Dietetics,
pp or tiv e se
--. Ch ie fs of all su
• In vi te d m em be rs dr y etc. ·
ho us ek ee pi ng , la un nt ro l
up da te th e po lic y re la te d to pr ev en tio n/ co
le as t on ce a m on th to
HAICC m us t m ee t at
re vi ew :
of HAI' s. Th ey sh ou ld
i. Infection co nt ro
l ac tiv iti es of ho sp ita l.

ii. H os pi ta l en vi ro
nm en t.
es .
iii. St er ili za tio n &
di si nf ec tio n pr oc ed ur
th og en .
ic ro bi al se ns iti vi ty pa tte rn of pr ev al en t pa
iv. A nt im
og en s.
re si st an ce am on g pa th
v. Em er ge nc e of dr ug og en s sh ow no re sis ta
nc e.
ts ag ai ns t w hi ch pa th
tim ic ro bi al ag en
vi. Use of di ff er en t an nt ro l Te am
or ke rs , H os pi ta l A cq ui re d Infection Co
ve a te am of w ro l H A is.
The HAIC sh ou ld ha bi lit y fo r th e po lic y ad op te d to co nt
da y re sp on si
(HAICT) to ta ke da y to

IR ED IN FE CT IO N CO NTROL TEAM (HAICT)

HOSPITAL ACQU
fic er (Microbiologist).
• Infection co nt ro l of
st er (H os pi ta l sister).
• Infection co nt ro l si
ia n fr om ho sp ita l).
• Clinician (o ne cl in ic
NTROL TEAM
ROLE OF INFECTION CO clearly de fin ed obje~tiv
e.
io n co nt ro l pl an w ith
al in fe ct da te .
• To de ve lo p an an nu ur es in cl ud in g re gu la. r ev al ua tio n an d up
. • an d pr oc ed
• To d ev e1op w nt. te n po11c1es tie nt ca re de si gn ed to pr ev en t in fe ct io
n.
pr ac tic es of pa
. e an d m om·tor da1·1y
• To su pe rv is
lie s.
lit y of ap pr op ria te su pp
• To en su re av ai la bi
 . .
fV A Te. xt ~?-":!-~~ Infe. .
ction Control
•
~,,~
I '
I
1
T o orga n ize an ep . . .
• 1d en n o 1o g K a 1 su rv ei ll an ce p ro g ra m (p a rt ic
"' . , d ~t ec h o n o u la rl y in h ig h Ii.
t'a l 1) e f o u tb re a k) • k
• T o ed u ca te aH g d f t H in in fe ct io
n co n tr o l p o li.cy
s ar,,\\
ra es o s a , p ra c ti.c e a n d p Sf~
ro ce d u r t

es .

. .
1. T he m te ns iv e ca re •t (ICU) te am s u
n d er st an d th e im
reli es o n a cu lt ur u m p o rt an ce o f p ro
e of sa fe ty an d ev v id in g high-qua
id en ce -b as ed ch. . . lity
ru ca l p ra ct ic es to h el p .
2.
T he su bc la vi an an
d in te rn al ju gu la p re v en t infectionscarethc
rs ar e th e p re fe .
Fe m al e' s ur et hr al rr ed si te s fo r in
3. op en in g is cl os er fe ct io n- co nt ro l purp
to an u s w h er e U oses.
4. H os pi ta l ca n ap po in t ep id em T I ca u si n g b ac te ri a E .c ol
io lo gi st o r in fe i ar e found .
in fe ct io n co nt ro l ct io us d is ea se sp ec ia li
ph ys ic ia n. st , m ic ro bi ol og is
t to work"
5. P at ie nt sh ou ld b e in st ru ct
ed to sh o w er w
an d m or ni ng of it h so ap o r ch lo
th ei r su rg er y. rh ex id in e gl uc
on at e (CHG) at the
C lo
ms~
6. si ng su tu re s w it h T ri
cl os an co at ed an
ti .m ic ro bi al su tu
SSL re s is a si m p le
co nt ro l measure
to pmer
7. F em al e ge nd er
ha s lo w er in ci de
8. ReliaTect is a tr nc e of C L A B S I.
an sp ar en t, ch lo
ro he xi di ne gl uc
en ab le s w o u n d on at e C H G -e m
m on it or in g w it h b ed d ed po st -o pe
9. T he ho sp it al IC an in ta ct d re ss in ra ti on dressingth·1
C is ch ar ge d w it g fo r se v en d ay s.
h th e re sp on si bi
p rac ti.ce an d rm · 1 li ty fo r th e p la n n in g , ev
p em en ta ti·on , pr al ua ti on of eviden
in fe ct io n co nt ro io ri ti za ti on an d re so u rc e ce -ba5€(
l. al lo ca ti on of al
10 . C en tr al lm · l matters re latinu0 \l
e ar e al so ca ll ed
C en tr al V en o u s
m e d ic· ·
m es , flu1· ds, nu tr A cc es s D ev ic e
d
I a lo n g th in flex
m or e.
ie nt s o r b lo o d p
ro d u ct s o v er a . ible tube use to gil't
lo n g p er io d of ~~
ti m e, us ua ll y seve 1wee/\
11. C at he te r is ra
in se rt ed in th e ar
m , ne ck o r ch es
12. B ac te ra em
ia is th e pr es en ce t th ro u g h th e sk
in in to a la rg e ve
13 . S ep ti ca em ia
of ba ct er ia in b lo o d w it h in .
re fe rs to ci rc ul at o u t an y m ul ti pl
MP io n an d m ul ti pl ic at io n.
• re va le nc e al ic at io n of b ac te
so re fe rs to a pr ri a in th e b lo o d .
ev al en ce ra te is . n,,h 0
ha ve pa rt ic ul ar th e p ro p o rt io n
in a pop ~
di se as e ov er a sp of th e pe rs on s
15. In ci de nc e ra
te f ec if ie d p er io d o
t
re er s O the ra te f ti m e.
at w h ic h n ew ev . e
en t oc cu rs o v er
a sp ec if ie d pe ri·od of tif!l .
 Revie w
Questions
QUi~•j:j:j:j!J~i*i
1. CLA BSI stands for
2. CAUTI stands for
DVT stand s for
4. MRSA stands for
s. · b ia
Closing sutures with Triclosa11-coate d an t·1m1cro ·
· a simple
. 1sutures 1s control measure to prevent
SSL
6. _____ is the causative organism of UTI.
7. Female gender has lower incidence of - - - -
8. _ __ _ is a transparent, chlorohexidi ne gluconate CHG-embed ded post-operatio n dressing that
enables wound monitoring with an intact dressing for seven days.
9. _ _ _ _ _ irrigation is preferred over antibiotic irrigation in the case of surgical site infection.
10. _ __ _ _ _ _ _is used for skin antisepsis

ANSWERS
1. central line-associat ed bloodstream infection 6. E.coli
2. catheter-asso ciated urinary tract infection 7. CLABSI
3. Deep Vein Thrombosis 8. ReliaTect
methicillin-r esistant Staphylococcus aureus 9. Antiseptic
4.
10. Chlorhexidin e
5. Triclosan-co ated

SHORT ANSWER QUESTION

__ _ S __ ....,,....

Q.1. Discuss various Nosocomial infections. . .

. 1e for H ospi·t a1 cacquired mfechons.
Q.2. Discuss the factors respons1b
Q.3. Discuss the measures to prevent HAis.
Q.4. Discuss bundle approach in the prevention of VAP.
Q.5. Discuss the risk factors associated wi th CLABSI.
Q.6. Discuss the role of Infection Control Team.

LONG ANSWER QUESTIONS

~~- .-~~-~ r ~ .. • - • - -

revention of CAUTI.
-- --

. ti
Q.1. Describe Bundle approach 111 ,e P case o f surg1•cal site infection.
. the
Q.2. Discuss 7S bundle approac h m
f HAI surveillance .
.
Q .3. Describe .
the rationale
· to prevent
CLABSI.°
Q .4. Elaborate various strategies