HOSPITAL INFECTION

CONTROL
 INTRODUCTION

“Hospitals are intended to heal the sick, but they are also
sources of infection.

Ironically, advances in medicine are partly responsible

for the fact that, today, hospital infections
are a leading cause of death in
some parts of the world.”

--The World Health Report 1996

— Fighting disease, fostering
development.
BRIEF HISTORY OF INFECTION CONTROL

 Infection control practices have changed over the years.

 Ignaz Semmelweis is referred as father of infection prevention in hospitals in 1847.
He identified “childbed fever (puerperal sepsis)” among women after child birth. He
observed that frequency of infection reduced when hand washing was practiced by
the physicians.
 In 1863 Florence Nightingale founded a school of nursing in London. Nightingale
emphasized cleanliness both for personnel and for the environment. Generic practice
of cleanliness was given importance in prevention of infection.
 Advancement in medicine enabled people to identify infected persons, isolating them
in special communicable disease hospitals or isolating them in special areas in general
hospitals, and taking precautions with their body excretions and the air they breathed
out. Elaborate “isolation routines” were developed for them.
 By the middle of 20th century, immunizations had reduced the incidence of
communicable diseases and antibiotics often cured infections. In hospitals barrier
precautions consisting of gowns, masks, and gloves as part of isolation routines was
practiced. To protect the uninfected, gowns, caps, masks, and gloves were used in
surgery.
 BRIEF HISTORY OF INFECTION CONTROL
 Shortly after mid century, hospital acquired staphylococcal infections began to appear,
affecting surgical clients and new borns. Health care workers often transmitted the
infectious agents. Newer microbes like Pseudomonas, Serratia, and Acinetobacter,
began to cause infections in critical care units.
 In late 1970s researchers identified that older methods of isolation routines were
ineffective in prevention of infection. Protocols for managing the invasive devices
were identified and practiced. Precautions were focused on susceptible mucous
membrane, non intact skin and moist body substances of all people.
 In 1980s acquired immune deficiency syndrome (AIDS) was identified. Nosocomial
HIV infection spread to patients and health care workers. Hepatitis B another blood
borne disease was rampant among them. The generic practices of Semmelweis and
Nightingale returned to health care settings.
 In 1983 the Centers for Disease Control (CDC) revised the recommendations for
isolation. BODY SUBSTANCE ISOLATION was introduced. In 1987 CDC published
introduced universal precautions,ie, recommendations to reduce risk for transmission
of blood-borne pathogens to health care workers.
 INFECTIOUS AGENTS
 Sources of infectious agents include:
 An individual’s own flora.
 Colonized body substances from other
people.
 Objects or fluids in the environment with
infectious agents.
 NORMAL FLORA AND COMMON
INFECTIOUS AGENTS FOND IN VARIOUS
HUMAN BODY SITES.
SITE SPECIMEN NORMAL FLORA PATHOGENS

Nasopharynx Throat swab Staphylococcus aureus,haemophilus Streptococcuspyogenes

influenza,klebsiella species. (group A)

Normally sterile
sputum
Streptococcus
Lower
pneumoniae,
respiratory
tract Haemophilus influenza

Gram negative rods.

Skin, hair, Surgical or Staph. auereus, Staph. Auereus,
perianal skin traumatic streptococcous pyogenes,
Strptococcous pyogens, enterobacter
wound, lesions, enterobacteriacaea group,
species, gram positive and negative
pustules, deep anaerobic gram positive
rods ,diphtheriods.
wound. and negative rods.
Normally sterile.
Streptococcous
pneumoniae, Neisseria
menigitidis, haemophilus
influenzae, gram negative
Central
rods.
nervous Cerebrospinal
system. fluid.
 NORMAL FLORA AND COMMON
INFECTIOUS AGENTS FOND IN VARIOUS
HUMAN BODY SITES.
SITE SPECIMEN NORMAL FLORA PATHOGENS

Small Stool. Enterobacter family, pseudomonas Salmonella species,

bowel and species, streptococcous faecalis, shigella species,
colon. clostidium perfringens, Yersinia species,
campylobacter species.

Bladder urine Normally sterile. E. Coli, Enterobacter

and urinary species, gram negative
tract. rods, streptococci
faecallis.

Vagina Endocervical Lactobacillus species, acidophilic Neisseria gonorrhoeae,

(adult). swab. species, staph. epidermidis, yeasts. Chiamydia species.
gram negative rods.
Aim: this session aims at upgrading knowledge
about infection control protocols and practices .
Objectives:
 At the end of this session group is able to:
 Define infection control and hospital acquired
infection,
 Appreciates need for infection control
 Lists common types of HAI in ICU
 Explains measures for prevention of such HAIs
 Appreciate individual’s role in prevention of
infection.
What are Hospital acquired(HAI)
or Nosocomial infections….???

 Acquired by a patient during time spent in hospital

 Not present or incubating at admission.

 Become evident 48 hours or more of admission

 PATIENT SHOULD NOT ACQUIRE AN
INFECTION FROM THE HOSPITAL
The staff
The inanimate structures
The other patients
Own Body Flora
Visitors
 STAFF SHOULD NOT ACQUIRE INFECTION
FROM THE HOSPITAL
The other patients
The inanimate
structures
Visitors
 VISITORS SHOULD NOT ACQUIRE
INFECTION FROM THE HOSPITAL
 CHAIN OF INFECTION
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Characteristics of the Organism
 MAGNITUDE OF PROBLEM
 Nosocomial infections occur worldwide
• WHO survey in 2002 in 55 hospitals of 14 countries
(Both Developed and Resource poor countries)
representing 4 WHO regions
 Europe 7.7%
 Eastern Mediterranean 11.8%
 South East Asia 10%
 West Pacific 9%
 Average of 8.7% of hospital patients had
nosocomial infections
 MAGNITUDE OF PROBLEM
• CDC (2007) --2.2 million patients of HAI in USA
with 103,000 deaths annually. (about 10%of
population) costing 5-6 billion annually. 4 th leading
cause of death.
• India- 7.8 million annually.
• India-according to HIS 2007- 10-30%.
 Highest prevalence of Nosocomial infections
occurs in ICU, Acute surgical, Orthopaedic wards.
Higher among patients with old age, underlying
disease, chemotherapy
 Types of Device associated
HAI
 Catheter associated Laboratory Confirmed
Bloodstream infections (LCBI)

 Catheter associated Clinical Sepsis (CSEP)

 Ventilator associated Pneumonia (VAP)

– clinical and lab confirmed

 Catheter associated Urinary

tract infection (CAUTI)
 NON-INVASIVE MEDICAL
DEVICES
 Commonly used medical devices are:-
 Cardiac monitor with electrodes and chest leads.
 Pulse oximeter
 Mechanical ventilator-portable, non-portable.
 Defibrillator.
 ECG machine.
 External pulse generator.
 IABP machine.
 CPAP or BiPAP machine.
 Infusion pumps.
 Suction apparatus.
 NON INVASIVE MEDICAL
DEVICES
 OXYGEN DELIVERY SYSTEMS:-

 Flow meter and humidifier.

 Face mask, nasal cannula.
 venturi mask.
 NIV mask
 AMBU bag and mask

 Nebulisation kit.
 INVASIVE DEVICES
 SHORT TERM USE OR TEMPORARY USE.
 IABP catheter.
 Pacing electrode.
 Central line(CVP catheter).
 Swan-Ganz catheter.
 Chest tubes.
 Endotracheal tube.
 Tracheostomy tube.
 IV canula, arterial canula.
 Foleys catheter.
 INVASIVE DEVICES.
 LONG TERM USE.

 Peripherally inserted central catheter line

(PICC line) used for IV chemotherapy, long
term IV antibiotics, nutrition, and for blood
draws.
 Hickmans catheter.
 Left ventricular assist devices.
 INVASIVE PERMANENT
DEVICES
 Permanent pacemaker.
 Automated implantable cardiovertor
defibrillator (AICD).

 All invasive devices used in ICUs are at

high risk for bacterial colonisation.
 Meticulous infection control measures can
prevent risk of infection.
 COMMON INFECTIONS
ENCOUNTERD
 Ventilator associated pneumonia
 Central line associated bacterial systemic
infection.
 Peripheral line associated bacterial systemic
infection.
 Catheter associated urinary tract infection.
 Bacterial endocarditis related to implanted
devices.
 Skin and wound infection.
 Hospital Associated Infections
(HAI)
 Many infections are related to invasive
procedures
 Often agents are transmitted on the hands
of healthcare workers
 Most HAI increase the morbidity, mortality,
and cost of care
 6% of patients in hospital have HAI
 How to prevent HAI
 Hand hygine
 Care of peripheral & central lines,foleys
catheter ,ET & trachy
 Care of surgical site
 Isolation precautions
 Care of occupational exposure
 Care of biomedical waste
 Antibiotic policy
Hospital Infection Control Team
(HICT) and Hospital Infection
Control Committee (HICC).
• Guidelines for prevention & control of
infections
• Antimicrobial policy
• Surveillance policy
• Disinfection policy
• Isolation policy
• Policy for investigation of an outbreak of
infection

25
 Standard Precautions
Standard Precautions are designed to
reduce the risk of transmission of micro-
organisms from both recognized and
unrecognized sources of infection in the
hospital.
Requires:

Blood
Body fluids –secrétions & Excretions with the
exception of sweat
Non intact skin, Mucus membrane
26
Personal protective Equipment
Gloves
Mask & Face shield
Gown
Goggles

27
 ACTIVE SURVEILLANCE
Active surveillance shall be done at least for high risk areas.
High risk areas under various setting include:
• Intensive care units (Neonatal ICU, Pediatric ICU, ICUs –
Cardio- Thoracic Vascular Surgery, Respiratory infections
(H1N1) units).
• Operation Theatres
• Dialysis Unit
• Burns Unit
• Transfusion services unit
• Food handlers
• Drinking water
• Central Sterile Services Department

28
Recommendations to Prevent
Catheter-associated UTI-
• Personnel
• Hand hygiene
• Catheter Insertion
• Catheter Use
Closed Sterile Drainage
Irrigation not recommended
Urinary Flow – undisturbed
Specimen Collection
Meatal Care
Catheter Change Interval
29
 SURGICAL SITE INFECTIONS (SSI)
Surgical site infection prevention- Preparation of the
patient: Chlorehexidine pre bath

Antimicrobial prophylaxis – 60 mts before

the surgery
Microbiological sampling – swab and air sampling of O.R

Cleaning and disinfection of environmental

surfaces – from clean zone to dirty zone
30
Protect patients…protect healthcare
personnel…
promote quality healthcare!
Hand hygiene
is
most crucial
 FATHER OF HAND HYGIENE

Ignaz Philipp Semmelweis (July 1, 1818 – August 13, 1865

before and after he insisted that students and doctors clean their
hands with a chlorine solution between each patient
 Hand Hygiene
 Hand hygiene is the primary measure to
reduce infections
 The Global Patient Safety Challenge 2005–
2006: “Clean Care is Safer Care”
As per WHO
 Hand hygiene- Routine hand wash
What to use
 Alcohol based chlorhexidine hand rub if hands not visibly
contaminated
 Else antimicrobial soap and water (15 seconds), dry
completely

When to use
 Before and after each patient contact
 Before wearing sterile gloves for procedures (central
line, urinary catheter, peripheral line)
 After removing gloves
 After contact with inanimate objects in vicinity of patient
 When moving from contaminated site to cleaned site
 Hand hygiene- Surgical wash

When
 Prior to any surgical procedure

How
 Remove all rings, watches, bracelets

 Antimicrobial soap and water for 2-6 minutes

OR
 Soap and water as for routine hand wash

followed by alcohol based chlorhexidine hand

rub
 Peripheral lines

 Upper extremity preferred

 Routine hand wash/ hand rub
 Clean with alcohol and povidone iodine- 3
swab method
 Don’t touch disinfected site (non sterile
gloves okay)
 Change peripheral lines every 72-96 hrs
(except children)
 Administration sets, tubings
 IV sets change every 72 hrs
 Blood sets change every 24 hrs
 Tubings for propofol every 6-12 hrs
 Transducer domes every 72 hrs
 IV lipids should be given within 12 hrs
 Use collapsible bags for IV fluids
 Use single dose vials
 Needleless systems (Vygon, Clave) no advantage
 Central Lines
 Hand hygiene, maximum barrier precautions
 Minimum lumens, antibiotic coated catheters
 Subclavian > Jugular > Femoral
 Clean site with 2% w/v chlorhexidine
 No antibiotic ointment at exit site
 Gauze dressing 2 days, transparent 7 days
 Clean bivalves with alcohol prior to use
 Remove catheters when not needed
 No need for surveillance cultures/ routine culture
of tips on removal
 Prevention of UTI
 Catheterize only if necessary
 Asepsis during insertion
 Maintain closed drainage
 Bag at level lower than catheter
 Avoid routine irrigation
 Maintain asepsis during urine sample
collection
 Remove catheter as soon as possible
 VAP bundle
1. Maintaining hand hygiene
2. Oral hygiene
3. Head of the bed elevated (30- 40 degree)
4. Change of position every two hrly
5. Nebulisation, Suctioning
6. Maintaining endotracheal tube cuff pressure
7. Procedure of intubation
8. Collection of culture sample
9. Drugs ( stress ulcer prophylaxis and antibiotics)
10. Care of respiratory equipments
11. Interruption of sedation and readiness to extubate
12. Extubation
Prevention of surgical site infections

 Limit pre operative stay

 MRSA screen for high risk patients
 Chlorhexidine shower night before surgery
 Use of clippers/ depilators and not shaving
 Strict asepsis
 Perioperative prophylaxis
 For clean/ clean contaminated cases
 Cefazolin/ cefuroxime
 Within 60 minutes of incision
 Repeat dose if surgery more than 4 hrs
 Stop within 24 hrs of surgery
Simple Solutions for
Expensive
Issues
Handrub by each bed
Devoted instruments- avoid cross
contamination
 Surveillance
“You can not manage what you can’t measure”

Simply stated surveillance is careful

monitoring and relevant feed back.
Ongoing, systemic, collection analysis
interpretation of health data essential to
the planning, implementation, evaluation
of the infection control practices
 COMMON NOSOCOMIAL PATHOGENS &
EMERGING RESISTANCE
URINARY TRACT:
Pseudomonas aeruginosa , E.coli,
Acinetobacter spp, Klebsiella, Enterobacter,
Candida, Staphylococcus spp
SURGICAL SITE INFECTIONS:
Staphylococcus aureus, Coagulase negative
Staphylococcus, Enterococcus spp, E.coli
NOSOCOMIAL PNEUMONIA: E:
TA NC
, C RE ,
IS BL
Streptococcus pneumoniae, Coliform RES E, ES seud
bacteria, Pseudomonas aeruginosa, S A ,VR DR P
MR RAB, M
Aspergillus spp, Candida spp, C
Anaerobes,Yeast
BLOOD STREAM INFECTION:
Staphylococcus aureus, Acinetobacter
baumanii, Klebsiella pneumoniae, E.coli,
Pseudomonas aeruginosa
 Bio-Medical Waste
 The rules framed by the Ministry of
Environment and Forests (MoEF),
Govt. of India, known as ‘Bio-medical Waste
(Management and Handling) Rules, 1998,’
notified on 20th July 1998
 Health hazards associated with poor
management of Bio-medical waste
 Injury from sharps to staff and waste handlers
associated with the health care establishment.
 Hospital Acquired Infection (HAI) (Nosocomial) of
patients due to spread of infection.
 Risk of infection outside the hospital for waste
handlers/scavengers and eventually general public.
 Occupational risk associated with hazardous chemicals,
drugs etc.
 Un-authorized repackaging and sale of disposable
items and unused / date expired drugs.
 Waste segregation as per color code

Black waste

Red Dressing material, catheters

Yellow Expired medicines, amputed body parts

Card Empty injection vials/ ampoules,

board
box
Puncture Used needle, and other sharps, broken
proof can glass
Linen Management
Spill management

INFECTIOUS WASTE
 MRSA screening
 Indications
 Interhospital transfer
 Admission with outside central venous access
 Admission with outside Foley’s catheter
 Antibiotic exposure in past 6 months
 Immunosuppressed patients
 Previous hospitalization or surgery in past 12 months
 Sisters to send nasal, axillary swabs for such patients
 Place such patients under contact isolation till reports
received
 HBV Vaccination in HCW
 1 ml IM deltoid (never gluteal)
 Ideal schedule 0,1,6 months
 No need to restart if delay in doses
 Test recipients for anti HbS levels after
completing series
 If levels more than 10 mIU/ ml
(responders) then protected for life
 Non responders (10%) repeat vaccination
series- 50% respond, rest permanently
susceptible
 Varicella vaccination of HCW
 Varicella is a highly transmissible
 Varicella in HCW –loss of working days,
risk to patients/themselves
 If no history of varicella – test for IgG
(may have had subclinical infection)
 If negative then give 2 doses of varicella
vaccine 4 weeks apart (except pregnancy)
Prevention of occupational exposure

 Pre employment HBV vaccination for all

 Proper training and education
 Universal precautions for all patients and
not only for HIV/HCV/HBV positive
 Use of safety devices, retractable lancets,
needle less systems
 Proper disposal of sharps and waste
Safety Cannula
 Management of OE
 Do not squeeze/ suck affected area
 Wash with plenty of soap and water
 Report to casualty
 Source blood/ exposed blood for HIV/
HBsAg, HCV
 Exposed blood processed only if source
positive/ unknown source
 Initiate appropriate post exposure
prophylaxis (ART, HBV vaccine, HBIG)
 Hand
Hygiene Personal Protective
Equipments
STANDARD
PRECAUTIONS

Environmental
cleaning

VACCINATION & INFECTIO BIOMEDICAL

POST EXPOSURE N WASTE
PROPHYLAXIS CONTROL MANAGEMENT

Prevention
Antimicrobial of specific
Stewardship HAI’s

AUDIT & SURVEILLANCE

 We should come together to advance
the patient safety goal of
“First, do no harm”
and to reduce the adverse health
and social consequences of unsafe health
care.
 Success comes from doing the simple
things correctly, repeatedly and making
them a habit.
 Bibliography
 Books:
 Education on infection control basic conce
pts and training by international federation
of infection control

 www.cdc.com
 www.who.com
THANK YOU