Introduction

Welcome to the 2nd Edition of Infection Control: Basic Concepts and Practices. The Board of
Directors of the International Federation of Infection Control (IFIC), the corporate sponsors and the
athors of this te!t hope that "o find it sefl.
IFIC, fonded in #$%&, is a federation of infection pre'ention and control societies from more than
() contries arond the *lo+e. The prpose of IFIC is to help translate research findin*s into
infection control practices sita+le for the particlar sitation in ,hich each mem+er or*anisation is
,or-in*. Ths IFIC is an or*ani.ation for edcation and applied science related to pre'ention of
infections related to health care. To accomplish this, the or*ani.ation pro'ides a commnication
net,or- to promote edcation, trainin* and e!chan*e of information amon* the mem+er societies
,ith particlar emphasis on assistin* those ,ith limited resorces. The *oals of the federation are
to:
promote hi*h /alit" edcational opportnities, materials and trainin* pro*rams across
contries at lo, cost. Conferences are held at least annall"0 in addition, IFIC pro'ides
edcational infection control content and spea-ers for conferences or*ani.ed +" other
or*ani.ations.
pro'ide a commnication net,or- of spport +" mem+ers 'ia the ne,sletter, IFIC Blletin,
the ,e+site (,,,.ific.narod.r), and email.
maintain a liaison ,ith the World 1ealth 2r*anisation and other or*anisations that promote
infection pre'ention incldin* pre'ention and mana*ement of occpational +lood e!posres
amon* health care ,or-ers.
dra, on the e!pertise of mem+er or*ani.ations to help each other and to assist ,ith
formation of national societies in contries that are in earl" sta*es of infection control
de'elopment.
The prpose of infection control is to redce ris- for patients and personnel for infections related to
health care. 3an" of the essential methods to accomplish this in an" and all health care settin*s are
inclded in Basic Concepts and Practices. Three ne, chapters are inclded: 4The costs of hospital
infection5 +" 6ar" French, 3D0 4Economic e'alation in infection control5 +" 7an8a" 7aint, 3D,
3P10 4Infection control information resorces5 +" 9i.am Damani, 3BB7, 37c. :eferences *ide
the reader to information in more depth. ;dditionall", a series of mono*raphs that e!plore each
fndamental concept are +ein* de'eloped0 information ,ill +e posted to the ,e+site:
,,,.ific.narod.r
Members of the IFIC Infection Control: Basic Concepts Working Group:
6ar" French, 3D, F:CPath, F:CP; , <=
Patricia >"nch, :9, 3B; , <7;
;nna 1am+raes, 3D, PhD , 7,eden
7haheen 3ehtar , 3B B7 F:CPath
Prof. Dr. Peter 1ee*, 6erman"
7an8a" 7aint, 3D, 3P1 , <7;
1ans ?oern =olmos 3D D37c, Denmar-
3oira Wal-er, :9, CIC, Canada
9i.am Damani, 3BB7, 37c, F:CPath, 9. Ireland
6e rtie 'an =nippen+er*@6orde+e-e, 1olland
Candace Friedman, B7, 3T(;7CP), 3P1, CIC
7pecial than-s to the editors, 6ar" French and Candace Friedman
1. Organisation of Infection Control
Introduction
Infection control (IC) is a /alit" standard and is essential for the ,ell +ein* and safet" of patients,
staff and 'isitors. It affects most departments of the hospital and in'ol'es isses of /alit", ris-
mana*ement, clinical *o'ernance and health and safet".
;n infection control pro*ramme ,ith a firm strctre shold +e in e!istence in all instittions that
pro'ide health care in order to esta+lish a mana*ed en'ironment that
7ecres the lo,est possi+le rate of hospital ac/ired infection
Protects staff and 'isitors from nnecessar" ris-s
The hospital mana*er or medical director is ltimatel" responsi+le for safet" and /alit" ,ithin the
hospital. 1e or she mst ensre that appropriate arran*ements are in place for effecti'e infection
control practices and that there is an Infection Control Team (ICT) and an Infection Control
Committee (ICC). If the health care settin* is too small to spport sch an or*anisation, e!perts in
infection control shold +e a'aila+le for consltation at re*lar inter'als and ,hen needed in an
acte sitation. Pro'iders of home care shold ensre that e!pertise in infection control is a'aila+le
for their staff.
Infection Control Team
The ICT shold ha'e a ran*e of e!pertise co'erin* -no,led*e of infection control, medical
micro+iolo*", infectios diseases and nrsin* procedres. The team shold ha'e a close liaison ,ith
the micro+iolo*" la+orator" and ideall" a micro+iolo*ist shold +e a mem+er of the team.
The team shold consist of at least one ph"sician, the infection control officer (IC2), and at least
one nrse, the infection control nurse (IC9). 2ne IC9 for 2)A acte +eds on a fll@time +asis ,as
recommended in the <7 drin* the #$%As. ; recent std" in se'eral different t"pes of health care
facilities reported A.% to #.A IC9s as ade/ate staffin*. 1o,e'er the nm+er of acte care +eds is
decreasin*, ot patient mana*ement, da" sr*er" and home care are e!pandin*, and pro+lems of
hospital infection and anti+iotic resistance are increasin*. Ths the optimal nm+er of IC9s cannot
+e calclated simpl" on the +asis of the nm+er of acte care +eds +t rather depends on the case
mi! and ,or-load. The nm+er of IC2s in a team is pro+a+l" +est related to the nm+er of IC9s:
e.*. # to ).
The team is responsi+le for da" to da" decisions on infection control as ,ell as lon* term plannin*
of infection control polic". It shold meet se'eral times a ,ee- or prefera+l" dail". The team shold
+e ade/atel" fnded to pro'ide secretarial assistance, information technolo*" capa+ilities, facilities
and trainin* materials, and to allo, mem+ers to attend edcational corses and professional
meetin*s.
The composition and or*anisation of the ICT shold ta-e into accont the local social and reli*ios
cltre in the contr" concerned and the hierarchical strctre of the hospital.
Infection Control Officer - duties and responsibilities
The IC2 shold prefera+l" +e a senior mem+er of the hospital staff ,ith e!perience and trainin* in
infection control, sch as a medical micro+iolo*ist, epidemiolo*ist or infectios diseases ph"sician.
In the a+sence of one of these, a sr*eon, paediatrician or other appropriate ph"sician ,ith special
interest in the field cold +e appointed. Whiche'er person is appointed, the" mst +e *aranteed the
e!tra time needed to flfil the responsi+ilit" of an Infection Control 2fficer. The IC2 is sall" the
chairman of the Infection Control Committee and is responsi+le to the hospital mana*er or medical
director for infection control in the health care settin*.
Infection control nurse - duties and responsibilities
The IC9 shold +e a+le to fnction as a clinical nrse specialist. The dties of the IC9 are
primaril" associated ,ith IC practices ,ith special responsi+ilit" for nrsin* pro+lems and
edcation.
In a lar*e hospital the IC9 can train Blin-C nrses. These indi'idals ha'e special responsi+ilit" for
maintainin* *ood infection control practices and edcation ,ithin their clinical departments. This
person is the Dlin-D +et,een the IC9 and the ,ard and helps identif" pro+lems, implement soltions
and maintain commnications.
Basic qualifications of the ICN
; re*istered nrse (or e/i'alent /alified person) ,ith clinical and administrati'e e!pertise. 6ood
interpersonal and edcational s-ills are important. :eco*nised trainin* in IC is essential.
Infection control committee
The need for an ICC depends on the strctre of the health care settin*. In smaller hospitals, the
ICC ma" report directl" to the senior hospital mana*ement committee0 in lar*er ones it ma" +e a
s+committee of a ris- mana*ement or clinical *o'ernance committees. It shold +e made p of
representati'es from 'arios hospital departments. ;ll the clinical departments shold +e
represented, to*ether ,ith mem+ers of other -e" departments, sch as occpational health, caterin*,
cleanin*, facilitiesE+ildin*s and mana*ement. The committee shold act as a liaison +et,een
departments responsi+le for patient care and spporti'e departments (e.*., pharmac", maintenance).
Its aim shold +e to impro'e hospital IC practice and recommend appropriate policies, ,hich
shold +e s+8ect to fre/ent re'ie,.
The committee shold +e responsi+le to the hospital mana*er or medical director and shold ha'e a
ph"sician, prefera+l" the infection control officer or hospital epidemiolo*ist as a chairman. The
hospital mana*er and the chief nrsin* officer, or their representati'es, shold attend meetin*s. The
si.e of the committee ,ill 'ar" dependin* on the re/irements of the hospital. The departments
shold nominate their representati'es and if not the departmental head, the representati'e shold +e
in a position to ma-e decisions.
The committee shold hold re*lar minted meetin*s and the mintes shold *o to the 3edical
Director and the 1ospital 3ana*ement Board as ,ell as to departments directl" in'ol'ed in the
s+8ects discssed drin* the meetin*. It shold prodce an annal report and an annal +siness
plan for infection control.
The following are the most important activities to ensure adequate infection control practices
where health care is provided.
Pro'ide facilities and e/ipment that ma-e it possi+le for the staff to maintain *ood
infection control practices.
Prodce standards (policies, *idelines) for procedres or s"stems sed ,ithin the health
care settin*
Implement edcational pro*rammes for all personnel in the se of sch standards.
Esta+lish sr'eillance s"stems that identif" pro+lem areas.
Prodce a polic" for the prdent se of anti+iotics and ,or- to ensre adherence to the
polic".
Prodce *idelines for cleanin*, disinfection and decontamination and ,or- to ensre
adherence to those *idelines.
Infection control is the responsibility of every individual in the healthcare facility. However,
the hospital management and the infection control team can provide expertise, education and
support to help staff maintain proper standards and minimise the risks of infection.
Responsibilities of the health care provider
Ensre facilities are a'aila+le to the hospital staff to maintain *ood infection control
practices.
Ensre an infection control team is a'aila+le.
7pport the acti'ities of the infection control team
Responsibilities of the infection control team
;d'ise staff on all aspects of infection control and maintain a safe en'ironment for patients
and staff
Pro'ide edcational pro*rammes on the pre'ention of hospital infection for all hospital
personnel
Pro'ide a +asic manal of policies and procedres and ensre that local ,ritten *idelines
+ased on these are in e!istence.
Esta+lish s"stems of sr'eillance of hospital infection in order to identif" at@ris- patients
and pro+lem areas that need inter'ention. 3ethods for sr'eillance ma" inclde case findin*
+" ,ard ronds and chart re'ie,s, re'ie,s of la+orator" reports, and tar*eted pre'alence or
incidence sr'e"s.
;d'ise mana*ement of patients re/irin* special isolation and control measres.
In'esti*ate and control ot+rea-s of infection in colla+oration ,ith medical and nrsin*
staff.
Ensre that an anti+iotic polic" is in e!istence.
>iaise ,ith the hospital doctors and administration (mana*erial and nrsin*), commnit"
health doctors and nrses, and infection control staff in ad8acent hospitals.
Pro'ide rele'ant information on infection pro+lems to mana*ement and the ICC.
Perform other dties as re/ired, e.*., -itchen inspections, pest control, ,aste disposal.
Examples
Topics of importance for a procedure manual
Patient care
1and h"*iene
Isolation practices
In'asi'e procedres (intra'asclar, rinar" catheterisation, mechanical 'entilation,
tracheostom" care, and ,ond mana*ement).
2ral alimentation
ard specific procedures
Isolation procedres for infectios patients
7r*ical and operatin* theatre techni/es
2+stetrical, neonatal, and intensi'e care techni/es
Production of items of critical importance
7terilisation and disinfection
3edication and infsion preparation (incldin* +lood prodcts)
!taff health
Immni.ation
Post@e!posre mana*ement for emplo"ees, patients and others e!posed to infectios
diseases ,ithin the facilit"
Investigation and management of specific infections
3ethicillin resistant Staphylococcus aureus (3:7;)
Diarrhoea
1IF
T+erclosis
3ltiresistant 6ram@ne*ati'e +acteria
etails of components of safe environment for patients and staff
"esponsibility of the hospital manager
Ensre a safe, clean en'ironment.
Ensre the a'aila+ilit" of sterile ,ater for in'asi'e procedres.
Ensre the a'aila+ilit" of safe food.
Ensre the a'aila+ilit" of an air sppl" appropriate for the le'el of sr*er" pro'ided.
"esponsibility of the infection control team
Pro'ide ad'ice on *eneral architectral featres (e.*. operatin* and isolation rooms).
Pro'ide ad'ice on clean ,ater and proper facilities for hand,ashin* and drin-in*.
;rran*e for the separation of clean and dirt" materials and procedres (e.*., stora*e of
sterile spplies in a room separate from one sed for reprocessin* of dirt" e/ipment or
stora*e of ,aste).
Pro'ide ,ritten policies for critical elements of infection control.
!inimal administrative re"uirements
; ph"sician and a nrse ,ith responsi+ilities for infection control.
; manal of critical infection control policies.
;n edcational pro*ramme for staff.
; clear line of responsi+ilit" to the senior mana*ement of the hospital.
#. $urveillance for %osocomial Infections
Introduction
1ospital pro*rammes of infection control (IC) shold inclde sr'eillance to detect common sorce
ot+rea-s, identif" pro+lem areas, help set priorities for infection control acti'it", and meet national
standards. 7r'eillance can also pro'ide data to help con'ince clinicians and mana*ers of the need
for impro'ements in infection control practices. 7r'eillance mst +e performed in a s"stematic
,a" ,ith the aim of redcin* rates of hospital infection. 7r'eillance reslts shold +e fed +ac- to
clinical and mana*erial staff and shold lead to action.
7r'eillance follo,ed +" action for impro'ement can ha'e a si*nificant impact on rates of hospital
ac/ired infection (1;I), called nosocomial infection or health care facilit"@associated infection in
some contries. The 7td" on the Efficac" of 9osocomial Infection Control (7E9IC) G#H fond that
hospitals that had a pro*ramme of sr'eillance and fed reslts +ac- to clinical staff had
considera+l" lo,er infection rates than others. French and collea*es ha'e demonstrated the
effecti'eness of repeated pre'alence sr'e"s G2H and the <7 9ational 9osocomial Infections
7r'eillance (99I7) s"stem has sho,n a si*nificant redction of nosocomial infection rates
nationall" in the <7 G(H.
7r'eillance can +e defined as the s"stematic, acti'e on@*oin* o+ser'ation of the occrrence and
distri+tion of a disease ,ithin a poplation and of the e'ents that increase or decrease the ris- of
the disease occrrence. If the incidence, distri+tion and associations of a disease are -no,n, then
resorces can +e tar*eted, predisposin* factors can +e redced or eliminated, and the incidence of
the disease redced.
The prpose of sr'eillance of nosocomial infections is to redce the incidence of 1;I and ths to
redce the associated mor+idit", mortalit", and costs. Before +e*innin* sr'eillance acti'ities it is
essential to de'elop a clear plan. It shold address #) ,hat /estions are +ein* as-ed, 2) ho,
infections are to +e defined, () ho, the data are to +e collected, stored, retrie'ed, smmarised and
interpreted, I) ho, to feed the reslts +ac- to frontline practitioners, and )) ho, to se the
information to +rin* a+ot chan*e.
7r'eillance practices are similar to clinical adit, e!cept that for an adit the practice and otcomes
of medical care (in this case the pre'ention and control of 1;I) is compared ,ith a standard. B"
repeated adit c"cles, practice is +ro*ht closer to the ideal.
!ethods of $urveillance of &'I
7r'eillance of infectios conditions re/ires strict definitions. In man" cases there are no
ni'ersall" a*reed definitions therefore the infection rate ,ill 'ar" ,ith the definition sed. For this
reason, comparisons can +e made +et,een nits or instittions onl" if the same set of definitions is
sed and applied in e!actl" the same ,a". It is often more meanin*fl and more sefl to se
sr'eillance data from a sin*le instittion to measre trends o'er time, either to alert staff to
increasin* pro+lems or to monitor the effecti'eness of inter'entions.
The definitions sed shold distin*ish +et,een 1;I and commnit"@ac/ired infection (C;I).
1ospital@ac/ired infections can +e defined as those that ,ere neither present nor inc+atin* at the
time the patient ,as admitted. Detailed definitions of specific infections ha'e +een p+lished +"
se'eral or*anisations, incldin* the World 1ealth 2r*ani.ation GIH, the <7 99I7 G)H, and the
1ospital Infection 7ociet" GJH.
7ome infections ma" present after the patient has +een dischar*ed from hospital. In sr'eillance for
sr*ical site infection, as man" as &AK of infections ma" present after dischar*e. This has led to the
de'elopment of Dpost@dischar*e sr'eillanceD. 1o,e'er, post@dischar*e sr'eillance often poses
considera+le lo*istic pro+lems and ma" add frther e!pense to sr'eillance acti'ities.
Formal sr'eillance of infections re/ires each patient to +e assessed, often repeatedl", +" trained
staff. For this reason, tre infection sr'eillance (and especiall" incidence sr'eillance) is 'er"
e!pensi'e de to the need for staff time. Becase of this, sr'eillance is often done rotinel" +"
anal"sin* la+orator" reports, or +" informal ,ard 'isits, or +" a com+ination of the t,o. 1o,e'er, it
mst +e reco*nised that these methods are not accrate. >a+orator" reports are not al,a"s
indicati'e of tre infection. 9e*ati'e reports (or no report) do not al,a"s mean infection is a+sent.
9e'ertheless, acti'e sr'eillance (case findin* +" the Infection Control 9rse GIC9H ) increased
detection from appro!imatel" 2)K of defined infections to more than %)K in some stdies G&H .
These methods are particlarl" sefl for identif"in* infections that ma" re/ire action +" the
Infection Control Team and for measrin* trends o'er periods ,hen la+orator", medical, and
infection control nrsin* practice remain constant.
Incidence and prevalence of &'I
The pre'alence of 1;I is the nm+er of cases of acti'e 1;I in a defined patient poplation either
drin* a specified period of time (the period pre'alence) or at a specified point in time (point
pre'alence). The pre'alence rate is the proportion of patients in the poplation ,ho ha'e an acti'e
infection at the time of the sr'e". The incidence of 1;I is the nm+er of ne, cases of disease that
occr in the defined patient poplation drin* a specified time period. The incidence rate is the
nm+er of ne, cases of 1;I that appear in the poplation at ris- drin* the specified time period.
'lert condition surveillance
;lert condition sr'eillance means monitorin* the incidence of specific clinical conditions, sch as
infectios diarrhoea or t+erclosis. This is part of the dail" ,or- of the Infection Control Team,
,hich is directed to,ards, for e!ample, the earl" identification of ot+rea-s of 'iral diarrhoea and
the implementation of control procedres. Becase this acti'it" is sall" not performed in a
s"stematic ,a", it is not an accrate measre of tre incidence.
'lert organism surveillance
;lert or*anism sr'eillance is the continos monitorin* of the incidence of specified or*anisms
isolated +" the micro+iolo*" la+orator". ;lert or*anisms mi*ht inclde methicillin@resistant S.
aureus (3:7;), *l"copeptide@resistant enterococci, *entamicin@resistant coliforms and Clostridium
difficile (+" identification of its to!in). The isolation of an or*anism is not necessaril" indicati'e of
infection and the failre to isolate an or*anism does not pro'e the a+sence of infection.
Frthermore, care mst +e ta-en to a'oid the +ias prodced +" dplicates and screenin* cltres.
That is, ,hen trac-in* an or*anism it shold onl" +e conted once. 9e'ertheless, this is a sefl
method of sr'eillance for infection control prposes. It has the ad'anta*es of simplicit" and +ein*
ine!pensi'e, and in compterised la+oratories the sr'eillance can +e atomated. In particlar, in a
*i'en hospital it can sho, trends in the isolation of specific or*anisms in different ,ards o'er time.
(revalence surve)s
In this method hospital in@patients are sr'e"ed o'er a short period of time, ideall" on a sin*le da".
3an" hospitals and Infection Control Teams find pre'alence sr'e"s to +e more practical than
incidence sr'eillance since the" can +e performed +" 8st a fe, people @ often temporaril"
recrited from other tas-s @ once or t,ice a "ear. :epeated pre'alence sr'e"s are not a complete
s+stitte for incidence sr'eillance, +t the" are sefl ,here resorces are limited.
Pre'alence sr'e"s are sefl to indicate the e!tent of nosocomial infection ,ithin a hospital or
re*ion, to indicate specific pro+lems re/irin* more e!tensi'e in'esti*ation, and to define the
chan*in* patterns of 1;Is in a sin*le hospital. If pre'alence sr'e"s are repeated at re*lar
inter'als and the reslts fed +ac- to medical and nrsin* staff the" can perform some of the same
fnctions as continos sr'eillance.
In *eneral, pre'alence rates tend to +e lo,er than incidence rates since pre'alence stdies are less
effecti'e in identif"in* acte or short@li'ed infections. :epeated pre'alence sr'e"s ha'e sho,n
themsel'es to +e sefl for monitorin* trends in rates of +oth 1;I and C;I. The" are practical to
perform ,ith relati'el" limited resorces and the" prodce information on +oth infected and
ninfected patients that can +e sed to identif" independent ris- factors. When properl" applied,
pre'alence sr'e"s can also +e sed to anal"se the effecti'eness of inter'ention strate*ies.
Pre'alence stdies ha'e sho,n that, dependin* on the patient poplation, the pre'alence of 1;I
a'era*es arond $ @#AK. ;ltho*h most pre'alence stdies ha'e +een applied to the entire hospital,
it is pro+a+l" more effecti'e to tar*et certain areas or ser'ices ,here infection rates are sspected or
-no,n to +e hi*h.
Incidence surveillance
In this method, all patients are monitored o'er a period of time for the presence or a+sence of 1;I.
This is the +est method for prodcin* accrate measres of infection rates, ho,e'er as ,ith
pre'alence stdies, it re/ires strctred anal"sis, strict definitions and trained staff to 'isit all
patients repeatedl". Becase it is time consmin*, incidence sr'eillance sall" cannot +e done
continosl"0 rather it is often tar*eted in areas ,here pro+lems are -no,n or sspected. It is
desira+le to *et sr*ical teams to do their o,n incidence sr'eillance of (sa") clean sr*ical ,ond
infection, sper'ised +" the Infection Control Team. This means the sr*ical teams ta-e o,nership
of the pro+lem and are more li-el" to ta-e action if rates are hi*h.
%umerator data
The patientCs name, identif"in* nm+er or code, ,ard or nit, medical ser'ice at the time the
infection +e*an to de'elop, and date of admission are the necessar" nmerator information to
collect. The date of onset of the infection, precedin* ris- factors sch as respirator" therap" +efore
ne, pnemonia, site of infection, si*nificant or*anisms cltred and their sensiti'it" patterns help
to descri+e the infection. ;dditional information ma" +e helpfl +t shold not +e collected
rotinel" nless it ,ill +e sed. (PatientCs primar" dia*nosis, a*e, se!, a measrement of se'erit" of
illness, ph"sicianCs name, antimicro+ial therap", indirect ris- factors sch as immnosppressi'e
diseases or therapies are e!amples.)
enominator data *population at ris+,
:ates are al,a"s calclated ,ith the nmerator (nm+er of persons ,ith the infection or condition)
di'ided +" the denominator (nm+er of persons at ris- for the infection). The more precisel" the
denominator captres the potentiall" pre'enta+le ris- elements the +etter. For e!ample, nosocomial
pnemonia cases amon* patients ,ho had respirator" therap" di'ided +" nm+er of patients
dischar*ed in a month or on a specific care nit pro'ides some estimate of ris-. 1o,e'er
nosocomial pnemonias amon* sch patients di'ided +" nm+er of patients recei'in* respirator"
therap" "ields a mch +etter rate.
-hat are the standards for rates of &'I.
There are no p+lished standards of 1;I rates. The rate of 1;I ,ill 'ar" ,ith patient ris-, and
therefore, there ,ill +e different rates in different nits. ;"liffe has pointed ot that there is an
Birredci+le minimm B rate of 1;I de to the inherent ris-s of nderl"in* disease and medical
inter'entions. :ates ,ill also 'ar" dependin* on the le'el of facilities and staffin* a'aila+le in
different hospitals of medical s"stems. In *eneral rates shold +e compared ,ith peer instittions.
Pre'alence sr'e"s sho, a'era*e ,hole hospital rates of 1;I of &@#AK. It is tho*ht that a+ot
(AK of these ma" +e pre'enta+le, dependin* on the patient poplation. 7r*ical site infection rates
in clean sr*er" shold pro+a+l" +e less than )K, and e'en less than #K ma" +e achie'a+le.
/eedbac+
It is pointless to collect masses of data if it is onl" seen +" the Infection Control Team. It is essential
that sr'eillance reslts are fed +ac- re*larl" to the front@line clinical staff in order to help them
choose actions to redce infection rates. It has +een sho,n on man" occasions that feed+ac- L ,ith
edcational and practical help from the Infection Control Team L is one of the most effecti'e ,a"s
of effectin* chan*e in h"*ienic practice.
!inimal Re"uirements for $urveillance
1 Monitor infection patterns !sites" pathogens" risk factors" location #ithin the facilit$%
& 'etect changes in the patterns that ma$ indicate an infection problem
( 'irect the rapid implementation of control measures
) Monitor antibiotic use and resistance
* +ro,ide the staff #ith e-actl$ the information the$ need in order to impro,e infection
pre,ention practices
References
#. 1ale" :W, Cl'er D1, White ?W, 3or*an W3, Emori T6, 3nn FP. 1ooton T3. The
efficac" of infection sr'eillance and control pro*rams in pre'entin* nosocomial infections
in <7 hospitals. American Journal of Epidemiology #$%)0 #2#:#%2@2A). Bac- to te!t
2. French 6>. :epeated pre'alence sr'e"s. Ballire's Clinical Infectious Diseases
#$$J0(:#&$@#$). Bac- to te!t
(. :eport. 3onitorin* 1ospital@;c/ired Infections to Promote Patient 7afet" @@ <nited 7tates,
#$$A@#$$$. !" 2AAA0 I$:#I$@#)(. Bac- to te!t
I. W12 #re$ention of hospital%ac&uired infections' A practical guide. 2nd edition, 2AA2
(W12ECD7EC7:EEP1E2AA2.#2). Bac- to te!t
). 1oran TC, Emori T6. Definitions of nosocomial infections. In: ;+rt"n E, 6oldmann D;,
7chec-ler WE, eds. Saunders Infection Control "eference Ser$ice . Philadelphia : W. B.
7anders, #$$%:#&@22. Bac- to te!t
J. :eport. 9ational pre'alence sr'e" of hospital@ac/ired infection: definitions. ; preliminar"
report of the 7teerin* 6rop of the 7econd 9ational Pre'alence 7r'e". Journal of (ospital
Infection #$$(02I:J$@&J. Bac- to te!t
&. Perl T3. 7r'eillance, reportin* and the se of compters. In Wen.el :P(ed.). #re$ention
and control of nosocomial infections. Third Edition. Williams M Wil-ins, Baltimore #$$&.
Bac- to te!t
0ibliograph)
6a"nes :P. 7r'eillance of nosocomial infections. In, Bennett ?F, Brachman P7 (eds) (ospital
Infections' I th Edition. Philadelphia: >ippincott@:a'en, #$$%.
1. Cleaning2 disinfection2 and sterili3ation
'econtamination of equipment and the en,ironment
Decontamination is a process ,hich remo'es or destro"s microor*anisms to render an o+8ect safe
for se. It incldes cleanin*, disinfection and sterilisation.
efinitions
Cleaning
Cleanin* is a process that remo'es forei*n material (e.*. soil, or*anic material, micro@or*anisms)
from an o+8ect.
Disinfection
Disinfection is a process that redces the nm+er of patho*enic microor*anisms, +t not necessaril"
+acterial spores, from inanimate o+8ects or s-in, to a le'el ,hich is not harmfl to health.
(igh le$el disinfection
1i*h le'el disinfection is often sed for a process ,hich -ills yco)acterium tu)erculosis and
entero'irses in addition to other 'e*atati'e +acteria, fn*i and more sensiti'e 'irses.
Sterilisation
7terilisation is a process that destro"s all microor*anisms incldin* +acterial spores. 7terilisation
cannot +e pro'ed e!cept +" cltrin*, so normall" an o+8ect is said to ha'e +een sterili.ed if it has
*one thro*h a controlled process of sterilisation.
The le'el of decontamination shold +e sch that there is no ris- for infection ,hen sin* the
e/ipment. The choice of the method depends of a nm+er of factors, incldin* t"pe of material of
o+8ect, nm+er and t"pe of or*anisms in'ol'ed and ris- of infection to patients or staff.
Classification of infection ris+ from e"uipment or environment into three categories
and suggested level of decontamination.
*o+ ris,
Items in contact ,ith normal and intact s-in, or the inanimate en'ironment not in contact ,ith the
patient (e.*. ,alls, floors, ceilin*s, frnitre, sin-s and drains). Cleanin* and dr"in* is sall"
ade/ate.
Intermediate ris,
E/ipment that does not penetrate the s-in or enter sterile areas of the +od" +t is in contact ,ith
intact mcos mem+ranes or non@intact s-in0 or other items contaminated ,ith 'irlent or
transmissi+le or*anisms e.*. respirator" e/ipment, *astrointestinal endoscopes, 'a*inal
instrments, thermometers. Cleanin* follo,ed +" disinfection is sall" ade/ate.
(igh ris,
Items that penetrate sterile tisses, incldin* +od" ca'ities and the 'asclar s"stem, e.*. sr*ical
instrments, intra@terine de'ices, 'asclar catheters. Cleanin* follo,ed +" sterilisation is re/ired.
Cleaning methods
Thoro*h cleanin* and dr"in* ,ill remo'e most or*anisms from a srface and shold al,a"s
precede disinfection and sterilisation procedres. Cleanin* is normall" accomplished +" the se of
,ater, mechanical action and deter*ents. It ma" +e manal or mechanical, sin* ltrasonic cleaners
or ,asherEdisinfectors that ma" facilitate cleanin* and decontamination of some items and redce
the need for handlin*.
#anual $leaning
;ll items re/irin* disinfection or sterilisation shold +e dismantled +efore cleanin*. Cold ,ater is
preferred for cleanin* as it ,ill remo'e most of the protein materials (+lood, sptm, etc.) that
,old +e coa*lated +" heat or disinfectants and ,old s+se/entl" +e difficlt to remo'e. The
most simple, cost effecti'e method is to thoro*hl" +rsh the item, -eepin* the +rsh +elo, the
srface of the ,ater to pre'ent the release of aerosols. The +rsh shold +e decontaminated after se
and dried.
:inse items finall" in clean, ,arm ,ater and dr". Items are then read" for se or disinfection or
sterilisation. Personnel handlin* contaminated items shold ,ear *ood /alit" *lo'es for personal
protection.
;dditional recommendations ha'e recentl" +een p+lished: ;ssociation for the ;d'ancement of
3edical Instrmentation (;;3I) s**ests initial rinse in cold ,ater follo,ed +" ,arm
,aterEdeter*ent soltion and final rinse. ?1PIE62, an a*enc" that is sall" in'ol'ed in 'er"
resorce@poor settin*s, s**ests soa-in* instrments and other soiled materials in cold ,ater ,ith
+leach to A.)K to decontaminate, follo,ed +" cold ,ater ,ash and rinse.
%nvironmental cleaning
Floors, srfaces, sin-s and drains shold +e cleaned ,ith ,ater and deter*ent. :otine se of
disinfectants is nnecessar".
If there is spilla*e, e.*. +lood, sptm, altho*h cleanin* is preferred, disinfection +efore cleanin* is
sometimes recommended. CleanE,ipe ,earin* *lo'es sin* A.)@#K sodim h"pochlorite (),AAA@
#A,AAA ppm of Cl2 ) (hosehold +leach) or a disinfectant ,ith appropriate acti'it". 6lo'es shold
+e ,orn. :elease of chlorine *as from disinfection of lar*e spilla*e can +e ha.ardos to staff.
If spilla*e is immediatel" remo'ed, *eneral disinfection of the room is not necessar"0 thoro*h
cleanin* ,ill sffice.
isinfection
Disinfection can +e carried ot +" either thermal or chemical processes. Thermal disinfection is
preferred ,hene'er possi+le. It is *enerall" more relia+le than chemical processes, lea'es no
resides, is more easil" controlled and is non@to!ic.
2r*anic matter (serm, +lood, ps or faecal material) interferes ,ith the antimicro+ial efficienc" of
either method. The lar*er the nm+ers of micro+es present the lon*er it ta-es to disinfect. Ths
scrplos cleanin* +efore disinfection is of the *reatest importance.
Thermal methods
;ltho*h not necessar" for disinfection, atocla'in* or steam sterili.ation (or a pressre coo-er)
ma" +e preferred if a'aila+le for the decontamination of certain items, e.*. 'a*inal speclae.
Moist heat at 70-100C
Boiling (#AANC) for at least ) mintes (holdin* time) is a simple and 'er" relia+le method for the
inacti'ation of microor*anisms incldin* hepatitis B 'irs, hman immnodeficienc" 'irs and
m"co+acteria. Pro'ided it is carefll" carried ot, it is a hi*h@le'el disinfection procedre.
The items shold +e thoro*hl" cleaned, placed in a container and co'ered ,ith ,ater. The ,ater is
heated ntil it reaches +oilin* point. Disinfection shold +e timed (at least ) min) from ,hen
+oilin* commences. ;ddition of a 2K soltion of sodim +icar+onate helps to pre'ent corrosion of
the instrments and tensils. If cheatle forceps are sed these shold +e +oiled (or atocla'ed) ,ith
the holder at least dail" and stored dr". The +oiler shold +e emptied and dried dail".
Disinfection at lower temperatures is possi+le (e.*. %ANC for ) min) for items dama*ed +" +oilin*,
if sita+le temperatre controllin* e/ipment is a'aila+le.
Disinfection by hot water can also +e performed in speciall" constrcted ,ashin* machines e.*. for
linen, +edpans, dishes and ctler", respirator" circits, la+orator" *lass,are and sed sr*ical
instrments +efore atocla'in*. In these machines the process of cleanin*, hot ,ater disinfection
and dr"in* are com+ined in a 'er" effecti'e procedre, pro'idin* some items read" for se, e.*.
respirator" circits, or safe to handle e.*. sr*ical instrments. The thoro*h initial rinsin* and
,ashin* remo'es most of the microor*anisms and shorter disinfection times ma" +e appropriate,
e.*. &ANC for ( min, %ANC for # minte. If machines are sed the" shold +e re*larl" maintained
and chec-ed for efficac". >o, to hi*h le'el disinfection is achie'ed dependin* on t"pe of machine
and comple!it" of the items.
$hemical #ethods
Before decidin* to se a disinfectant, consider ,hether a more appropriate method is a'aila+le. The
main se of chemical disinfection is for heat@la+ile e/ipment ,here sin*le se is not cost effecti'e.
7ome of these items (e.*. +ronchoscopes) re/ire hi*h@le'el disinfection. ; limited nm+er of
disinfectants (e.*. *ltaraldeh"de 2K, JK h"dro*en pero!ide, A.2@A.(K peracetic acid) can +e sed
for this prpose. If a sporicidal action is re/ired, immersion in 2K *ltaraldeh"de for at least (
hors is re/ired.
Chemical disinfectants mst +e made p freshl" to the correct concentrations accordin* to the
manfactresC instrctions and discarded after the correct period of time or nm+er of ses. The"
shold +e stored in clean +ottles ,ith plastic stoppers. When the +ottle is empt" it shold +e
thoro*hl" cleaned +efore re@fillin*. Partiall" empt" +ottles shold not +e topped p since this ,ill
encora*e contamination ,ith and mltiplication of disinfectant resistant or*anisms.
The o+8ect mst +e thoro*hl" rinsed ,ith sterile ,ater after disinfection. If sterile ,ater is not
a'aila+le, freshl" +oiled ,ater can +e sed. ;fter rinsin*, items mst +e -ept dr" and ,ell protected
from +ein* recontaminated.
Disinfection of surfaces
7oiled srfaces ma" +e cleaned of 'isi+le soila*e and disinfected ,ith a chemical a*ent sita+le for
the tas-. 2n a clean srface alcohol is rapidl" +actericidal and rinsin* is not re/ired.
$terilisation
7terilisation is accomplished principall" +" steam nder pressre (atocla'in*), dr" heat, +"
eth"lene o!ide *as or lo, temperatre steam and formaldeh"de.
!team !terili&ation
7team sterilisation is the most common and preferred method emplo"ed for sterilisation of all items
that penetrate the s-in and mcosa, pro'idin* the" are not dama*ed +" heat and moistre. 7team
sterilisation is dependa+le, non to!ic, ine!pensi'e, sporicidal, ,ith rapid heatin* and *ood
penetration of fa+rics.
ethod
The steam mst +e applied for a specified time so that the items reach a specified temperatre.
#2#NC for 2A min for n,rapped items, (A mintes for pac-a*ed items at #.A(J Bar
(#).A(psi) a+o'e atmospheric pressre.
#(INC for I min for n,rapped items in a *ra'it" sterili.er or ,rapped items in a 'acm
assisted steriliser at 2.A2J Bar (2$.I# psi) a+o'e atmospheric pressre.
;s a possi+le alternati'e for n,rapped instrments or tensils, a domestic pressre coo-er ma" +e
sed. 1oldin* time at least (A min.
'ry heat
Dr" heat is preferred for resa+le *lass s"rin*es, and ointments, po,ders, oils etc.
ethod
; hot air o'en e/ipped ,ith fan or con'e"or, ,hich ,ill ensre e'en distri+tion of heat. The
recommended temperatre and time for sterilisation of medical e/ipment is as follo,s:
#&ANC for 2 hors
#%ANC for # hor
7terile items shold +e protected a*ainst recontamination.
%thylene oxide gas
This is sed for lo, temperatre sterilisation of selected items in hospitals. Eth"lene o!ide *as is
to!ic so the manfactrersC instrctions for installation and se shold +e follo,ed. There are for
parameters that mst +e maintained to ensre E2 sterilisation: *as concentration, temperatre,
hmidit", and e!posre time. 6as concentration shold +e I)A to #2AA m*E>, temperatre ran*es
2$N to J)N C, hmidit" from I)K to %)K, and e!posre times from t,o to fi'e hors. The process
has a lon* c"cle as aeration of the items is re/ired. 3icro+iolo*ical control of the process is
recommended.
Organisation of (h)sical /acilities in a $terile $ervice epartment
The ser'ice shold +e mana*ed +" a sita+l" /alified indi'idal. ;ll staff shold +e trained and
nder*o continos professional de'elopment. Written protocols for all procedres shold +e
maintained and there shold +e an adited pro*ramme of /alit" assrance.
The central processin* areas shold consist of decontamination, pac-a*in*, sterilisation and stora*e
areas.
'econtamination
:ecei'e materials, sort, clean and prefera+l" disinfect. Wear appropriate *lo'es and plastic aprons.
6o,n slee'es that are flid@resistant are desira+le as are sr*ical face mas-s and e"e protection.
Packaging
;ssem+lin*. i.e. oilin* (mil-in*) and pac-a*in* clean +t nsterile materials prior to sterilisation.
>a+el accratel" ,ith contents, date of processin* and e!pire date
!terili&ation Process
;tocla'in* is preferred.
;n" sterilisation procedre shold +e monitored rotinel" +" ph"sical (mechanical), chemical and
+iolo*ical techni/es. 3echanical techni/es inclde the dail" assessment of c"cle time,
temperatre and pressre *a*e. ; lo* +oo- shold +e -ept.
Chan*e of color of chemical indicators placed on the otside of each pac- sho,s that the pac- has
+een e!posed to the sterilisation process. 7imilarl", chemical indicators shold +e sed inside the
pac- to 'erif" steam penetration efficienc" in addition to ph"sical measrements. The Bo,ieEDic-
test in #(IN C 'acm@assisted atocla'in* is recommended dail" +efore the sterili.er is sed.
Biolo*ical indicators (BI) of -eo)acillus stearothermophilus spores are sed to monitor steam and
dr" heat sterilisation processes in some contries, ,hile Bacillus atrophaeus spores are sed for
monitorin* eth"lene o!ide. Biolo*ical indicators shold +e placed in a process control de'ice or test
pac- that is representati'e of the load to +e sterili.ed. ;;3I recommends that steam atocla'es +e
tested ,ith BI at least ,ee-l" and ,ith e'er" load of implanta+le de'ices and that implanta+les +e
/arantined ntil the BI is read. ;;3I recommends that e'er" eth"lene o!ide load +e monitored
,ith BI. ;;3I also recommends BIs sed ,hen sterili.ers are installed, after ma8or repairs,
malfnctions or sterili.er failres.
!torage
Ensre stoc- rotation and store dr".
Sterile items should be protected against recontamination
.ousekeeping and laundr$
Transmission of micro+es ma" occr if the en'ironment immediatel" arond a patient +ecomes
contaminated either +" soila*e of articles ,ith +od" secretions, or +" healthcare ,or-ers tochin*
instrments or other srfaces and e/ipment ,ith contaminated hands. Increased infection ris- ,as
reported ,hen patients ,ere admitted to rooms pre'iosl" occpied +" patients ,ith C difficile
diarrhoea, G#H demonstratin* that it is necessar" to implement a schedle to clean patient care areas
and pre'ent +ild@p of dst, soil, or other material that ma" har+or potential patho*ens and
spport their *ro,th. 3oreo'er, a clean, ,ell@maintained healthcare en'ironment inspires
confidence in patients, staff, and the p+lic of the facilit"Cs commitment to pro'idin* a safe
en'ironment condci'e to achie'in* a hi*h standard of care.
Housekeeping
Cleanin* staff mst +e trained properl" and sper'ised. ;n on*oin* maintenance cleanin* schedle
mst +e esta+lished. This schedle shold specif":
Who has responsi+ilit" and acconta+ilit" for specific 8o+s
Wor- procedres, incldin* special e/ipment, spplies, cleanin* and stora*e of e/ipment,
mop head chan*in*
:e/irements for t"pes of cleanin* soltions and fre/enc" of soltion chan*in*
<se of personal protecti'e attire
Fre/encies for cleanin* floors, frnitre, ,alls, toilets and commode, fi!tres, incldin*
sch as ice machines, and air dcts and *rilles
Fre/enc" of crtain chan*in*
7pecial cleanin* procedres ma" +e considered in certain circmstances, e.*., drin* an ot+rea- of
Clostridium difficile associated diarrhoea.
Walls do not accmlate dst and associated contaminants and do not need to +e cleaned fre/entl".
1ori.ontal srfaces sch as floors, and simple de'ices sch as IF poles and +ed frames, can +e
maintained +" cleanin* ,ith ,ater and a deter*ent. 1o,e'er, some de'ices or areas that are
repeatedl" toched ma" need more fre/ent and intensi'e cleanin*, incldin* disinfection.
E!amples are +edrails, door handles, and areas li-el" to recei'e spatter.
4aundr) services
Carefl handlin* and reprocessin* of soiled linens pre'ents the transmission of infectios a*ents.
Pro'ision of fresh clean linen also enhances patient comfort.
!orting procedures(
;'oid contaminatin* hands ,ith soila*e
Place soiled linen in a landr" +a* or container
7ecre +a* ,hen O fll. If onl" cloth +a*s are a'aila+le, ,or-ers shold ,ear *lo'es and
handle +a*s ,ith care. Ba*s of soiled linen shold +e left in a secre place for pic-@p and
transport
Ba*s of soiled linen shold +e ta-en to an area dedicated for pre@,ash sortin*
>andr" sorters mst recei'e edcation on procedres and the proper se of +arriers
>andr" sorters mst +e pro'ided ,ith ,ater resistant *lo'es and plastic aprons or ,ater
resistant *o,ns for protection.
ashing processes(
; pre,ash rinse c"cle of #) mintes ,ill remo'e *ross soila*e
If sin* a cold ,ater ,ash, chemicals sch as +leach mst +e added (2 ml of hosehold
+leach for e'er" litre of ,ater) ,ith deter*ent to facilitate disinfection
; hi*h temperatre ,ash mst +e done (P&# 2 C) if cold ,ater deter*ents ,ith +leach are
not sed
Drin* the rinse c"cle, a sorin* a*ent shold +e added to the rinse c"cle to redce
al-alinit". This decreases s-in irritation and frther redces the nm+er of +acteria present
1ot air dr"in* or dr"in* on a clothesline in snli*ht ,ill also redce the nm+ers of +acteria
present, as ,ill ironin* ,ith a hot iron
Clean linen mst +e stored and transported in sch a manner that cross contamination is
a'oided
>inen to +e sterilised mst +e appropriatel" ,rapped +efore +ein* sent to the sterile
processin* department
;ll staff mst +e made a,are of the ris- to landr" ,or-ers if sharp o+8ects are left in soiled linen.
>andr" ,or-ers shold ha'e immnisations crrent.
Waste management
>andfill, +rial and incineration remain the most common means of hospital ,aste disposal. 7taff
responsi+le for cleanin* contaminated e/ipment re/ire ade/ate trainin*, shold ,ear appropriate
protecti'e apparel, sch as *lo'es, *o,ns or aprons, mas-s, protecti'e e"e,ear, and ha'e crrent
immnisations incldin* hepatitis B.
Clinical (potentiall" contaminated) ,aste can +e di'ided into la+orator" ,aste (incldin*
anatomical and micro+iolo*ical materials), +lood and +od" flids, and other ,aste, incldin*
contaminated dressin*s and sharps. In epidemic circmstances some potentiall" infectios material
ma" re/ire special handlin* or disposal. Clinical ,aste *enerall" re/ires special disposal and can
+e distin*ished from other *eneral ,aste +" sin* color coded plastic +a*s.
Chemotherap" ,aste re/ires special handlin*, sch as incineration at hi*h temperatres. 2ther
chemical ha.ards (e.*., formaldeh"de or sodim h"dro!ide) ma" need to +e disposed of +" special
means. :efer to local *idelines.
Ta+le (.( illstrates recommendations for mana*ement of infectios ,aste.
Ta+le (.#.;ntimicro+ial acti'it" of disinfectants
Ta+le (.2.2ther characteristics of disinfectants
Ta+le (.(. :ecommendations for 3ana*ement of <ntreated Infectios Waste G2H
Ta+le (.I. 7terilisin* ;nd Disinfectin* ;*ents
Ta+le (.). <sin* an ;tocla'e
References
#. 3cFarland >F , 3lli*an 3E, =,o- :QQ, 7tamm WE. 9osocomial ac/isition of
Clostridium difficile infection. 9e, En*l ? 3ed #$%$0(2A:2AI@%. Bac- to te!t
2. Canada Commnica+le Disease :eport 7pplement Infection Control 6idelines:
1and,ashin*, Cleanin* Disinfection and 7terilisation in 1ealthcare, 1ealth Canada ,
>a+orator" Centre for Disease Control, Brea of Infectios Disease, 9osocomial and
2ccpational Infections. #$$%. Bac- to ta+le
0ibliograph)
#. Bennett ?F, Brachman P7, Eds.. (ospital Infections , Ith ed. >ippincott @ :a'en P+lishers,
Philadelphia and 9e, Qor-, #$$%.
2. Wen.el :P, Ed. #re$ention and Control of .osocomial Infections . Williams M Wil-ins,
Baltimore,#$$I.
(. :eichert 3, Qon* ?1. Sterili/ation Technology for the (ealth Care 0acility' 2nd ed., ?ones
and Bartlett, P+lishers, #$$&. Boston, Toronto, >ondon, 7in*apore.
I. ;ssociation for the ;d'ancement of 3edical Instrmentation. ;merican 9ational 7tandard:
7afe handlin* and +iolo*ical decontamination of resa+le medical de'ices in health care
facilities and nonclinical settin*s. ;;3I P+lishers.( ###A 6le+e :d., 7ite 22A, ;rlin*ton,
F;, 222A#, <7; ) 3arch 2AA(.
). Tiet8en >, Bosseme"er, D, 3cIntosh 9. Infection pre'ention: 6idelines for healthcare
facilities ,ith limited resorces. ?1PIE62. (?1PIE62 Corporation, Bro,nCs Wharf, #J#)
Thames 7treet, Baltimore, 3D , 2#2(# , <7; ) 2AA(.
5. &and &)giene
Introduction
The natral flora of the moth and the +o,el has +acterial concentrations p to #AR#A per ml and
are si*nificant reser'oirs of nosocomial or hospital patho*ens. In hospitalised patients, the s-in ma"
+ecome colonised ,ith mltidr* resistant (3D:) patho*ens, and infected ,onds and other
lesions are also potential sorces of cross@infectin* or*anisms. Patho*enic or*anisms from
coloni.ed and infected patients (and sometimes from the en'ironment) transientl" contaminate the
hands of staff drin* normal clinical acti'ities and can then +e transferred to other patients. 1and
transmission is one of the most important methods of spread of infectios a*ents in health care
facilities. Proper hand h"*iene is an effecti'e method for pre'entin* the transfer of micro+es
+et,een staff and patients.
The micro+ial flora of the s-in consists of resident and transient microor*anisms. :esident
or*anisms (e.*., coa*lase ne*ati'e staph"lococci, diphtheroids) sr'i'e and mltipl" in the
sperficial s-in la"ers. The transient micro+ial flora of the s-in consists of recent contaminants that
sr'i'e onl" for a limited period of time. These microor*anisms (e.*., S. aureus, E. coli,
enterococci) ma" +e ac/ired +" contact ,ith the normal flora or colonised or infected sites of the
patient or from the inanimate hospital en'ironment. If the s-in of staff mem+ersC hands is dama*ed,
the +acterial cont on the s-in +ecomes hi*her. There is also a ris- for colonisation ,ith +acteria not
normall" +elon*in* to the hand flora.
Three le'els of decontamination of hands are reco*ni.ed.
Social handwashing ,ith plain soap and ,ater remo'es most transient microor*anisms from
moderatel" soiled hands.
!ygienic handwashing or disinfection is a procedre ,here an antiseptic deter*ent preparation is
sed for ,ashin* or hands are disinfected ,ith alcohol (alcoholic r+). This is a more effecti'e
method to remo'e and -ill transient microor*anisms.
The distinction +et,een the need for social hand,ashin* and h"*ienic hand ,ashin* ma" not
al,a"s +e clear. ; thoro*h social hand ,ash ma" +e appropriate if disinfectants are not a'aila+le.
Surgical handwashing is performed ,ith the aim of remo'in* and -illin* the transient flora and
decreasin* the resident flora in order to redce the ris- of ,ond contamination if sr*ical *lo'es
+ecome dama*ed. ;*ents are the same as for the h"*ienic hand ,ash.
; defined techni/e for decontamination of hands is pro+a+l" of *reater importance than the a*ent
sed. The techni/e presented in Fi*re I.# is recommended.
-hen to 6ash hands
Social handwashing
+efore handlin* food, eatin*
+efore feedin* the patient
after 'isitin* the toilet.
!ygienic handwashing or alcoholic rub
+efore and after nrsin* the patient
+efore performin* in'asi'e procedres
+efore carin* for sscepti+le patients (sch as the immnocompromised)
+efore and after tochin* ,onds, rethral catheters, and other ind,ellin* de'ices
+efore and after ,earin* *lo'es
after contact ,ith +lood secretions or else follo,in* sitations in ,hich micro+ial
contamination is li-el" to ha'e occrred
after contact ,ith a patient -no,n to +e colonised ,ith a si*nificant nosocomial patho*en
(sch as 3:7;, 3D: 1le)siella)
;n alcoholic hand r+, ideall" from a dispenser at the patientCs +edside is the most efficient and
least time consmin* procedre for hand decontamination.
Surgical handwashing
+efore all sr*ical procedres
!ethods
Watches and rin*s redce hand ,ashin*Edisinfection effecti'eness and shold +e remo'ed drin*
hand h"*iene. 7ome s**est that the" not +e ,orn in patient care.
!ocial hand washing
In social hand ,ashin*, 'i*oros and mechanical friction is applied to all srfaces of lathered hands
sin* plain soap and ,ater for at least #A seconds sin* a defined techni/e (Fi*. I.#). The hands
are rinsed nder a stream of ,ater and dried ,ith paper to,el. In the a+sence of rnnin* ,ater, a
clean +o,l of ,ater shold +e sed. The +o,l shold +e cleaned and ,ater chan*ed +et,een each
se. ;lternati'el", a drm ,ith a drain spot cold +e ele'ated to ser'e as rnnin* ,ater. 7imilarl",
in the a+sence of paper to,els, a small clean cloth cold +e sed, +t the to,el shold not +e sed
for e!tended commnal se and shold +e discarded after each se into a +a* desi*nated for
landerin* and rese.
In places ,here there is fre/ent disrption of ,ater sppl", ,ater shold +e stored in lar*e
receptacles ,hene'er ,ater is a'aila+le. The ,ater shold +e free from infectios a*ents.
Recommended hand 6ash agents
Hygienic hand washing)disinfection
A&ueous
IK chlorhe!idine *lconateEdeter*ent soltion
Po'idone @ iodineEdeter*ent soltion containin* A.&)K a'aila+le iodine
Wet hands ,ith clean (rnnin*) ,ater or, if not a'aila+le, from ,ater in a +o,l. ;ppl" cleanser ((@)
ml) dependin* on the prodct or thoro*hl" lather ,ith soap. Wash the hands for #A@#) seconds,
appl"in* friction o'er all hand srfaces, rinse and dr" as descri+ed a+o'e.
Alcoholic
A.)K chlorhe!idine or po'idone@iodine in &AK isopropanol or ethanol
JAK isopropanol or &AK ethanol ,ithot antiseptic
;ppl" not less than (ml of the preparation to the hands and r+ to dr"ness (appro!imatel" (A
seconds). ;lcohol is more effecti'e than a/eos antiseptic soltions, +t a preliminar" ,ash ma"
+e needed for ph"sicall" soiled hands. ;lcohol is an effecti'e alternati'e ,hen there is no ,ater or
to,els readil" a'aila+le and there is need for rapid hand disinfection. ;lcohol prodcts ,ith
emollients added ,ill case less s-in irritation and dr"in* to hands (#@(K *l"cerol).
!urgical hand washing)disinfection
;*ents for sr*ical hand ,ashin* are the same as for the h"*ienic hand ,ash. The difference is the
time of scr+ that is increased to 2@( min and shold inclde ,rists and forearms. If an alcoholic
preparation is sed, t,o applications of )ml each r++ed to dr"ness are s**ested.
7terile disposa+le or atocla'a+le nail+rshes ma" +e sed to clean the fin*ernails onl", +t
not to scr+ the hands.
; +rsh shold onl" +e sed for the first scr+ of the da".
;fter hand ,ashin* ,ith soap and ,ater, a hand r+ ,ith an alcoholic +ase formlation
(&AK) shold +e sed if possi+le. This enhances the destrction or inhi+ition of resident s-in
flora.
7terile to,els shold +e sed to dr" the hands thoro*hl" after ,ashin* and +efore alcohol
is applied.
Important (oints to %ote
When +ar soap is in se, it shold +e -ept dr" to pre'ent contamination ,ith
microor*anisms that *ro, in moist conditions.
>i/id soap dispensers shold +e re*larl" cleaned and maintained.
6lo'es shold not +e re*arded as a s+stitte for hand h"*iene. ; *lo'e is not al,a"s a
complete impermea+le +arrier (2A@(AK of sr*ical *lo'es are pnctred drin* sr*er").
1o,e'er, *lo'es redce 'er" s+stantiall" the nm+er of microor*anisms +ein* transferred
to the patient or to the 1CW ,ho is ,earin* the *lo'es. 6lo'es also pro'ide some
protection a*ainst the transmission of +lood@+orne 'irses.
In an epidemic sitation, hand h"*iene and the se of *lo'es are important protecti'e
measres to pre'ent the transmission of infectios a*ents to sscepti+le patients or staff. The
same *lo'e mst not +e ,orn from one patient to another patient, or +et,een clean and dirt"
procedres on the same patient.
;n alcoholic r+ or hand ,ash shold +e performed after remo'in* *lo'es and +efore sterile
*lo'es are ,orn.
In areas ,here *lo'es are not readil" a'aila+le, late! *lo'es can +e ,ashed ,ith soap and ,ater,
dried, po,dered, sterili.ed or hi*h le'el disinfected and resed. 7terilisation is prefera+le for
sr*ical procedres.
Minimal requirements
Watches and rin*s redce hand ,ashin* effecti'eness and shold +e remo'ed.
Wash hands ,ith soap and ,ater and dr" thoro*hl" ,ith a clean to,el at the start of a
clinical shift or if hands +ecome *rossl" soiled.
Decontaminate hands ,ith a hand disinfectant or alcoholic rinse or r+ +et,een each patient
contact.
Perform a sr*ical scr+ +efore each operation.
Wear *lo'es as necessar" to redce transfer of or*anisms to patient and to redce
transmission of +lood +orne 'irses.
Bibliograph$
#. 7tandard principles for pre'entin* hospital@ac/ired infections. Journal of (ospital
Infection 2AA#0I&(7ppl):72#@7(&.
2. 6ideline for 1and 1"*iene in 1ealthcare 7ettin*s @ 2AA2. !" 2AA20)#(::@#J):#@II.
7. Occupational &ealth Ris+s for &ealth
Care -or+ers
Introduction
1ealth care ,or-ers are at ris- of e!posre to a 'ariet" of infectios diseases ,hich ma" case them
illness and ,hich ma" +e transmitted from them to other staff and patients. 2ccpational 1ealth
Departments (21D) that ,or- closel" ,ith the infection control department ma" minimi.e this ris-
+" maintainin* necessar" records, performin* immni.ations, edcatin* staff a+ot ris- and
pre'ention, and condctin* e!posre mana*ement and in'esti*ations.
/e$ elements of 0. programs
;ssess infection ris-s to personnel and prioritise pre'enti'e measres.
Implement an on*oin* edcation pro*ramme a+ot safet" and infection pre'ention related
to the specific ris-s of ,or- in the facilit".
Determine sscepti+ilit" to 'accine pre'enta+le diseases and implement an appropriate
immni.ation pro*ramme.
Condct e!posre in'esti*ations, incldin* re'ie, of post@e!posre mana*ement.
Implement sr'eillance of occpational +lood e!posres and de'elop pre'ention strate*ies
for hi*h@ris- practices or departments.
Ta+le ).# presents a list of nosocomial infections in patients and emplo"ees in health care settin*s.
It is important for local Infection Control Committees and 21Ds to re'ie, this list and prioritise
the allocation of resorces for ris- redction strate*ies in their specific facilit". The rotes of
transmission of each microor*anism mst +e nderstood +efore appropriate pre'ention measres
can +e selected.
+re,ention of infection1 General measures
=eep accrate, easil" retrie'a+le occpational health records.
7creen ne, emplo"ees for a histor" of commnica+le diseases. Immni.e for 'accine
pre'enta+le diseases.
:ecord needlestic- and other in8ries in an DaccidentC lo*0 data on the epidemiolo*" of +lood
e!posres shold +e anal"sed periodicall" to adit practice and identif" pre'enta+le ris-s.
Pro'ide e'alation and *ide ,or- restrictions for staff ,ith infectios diseases or
e!posres.
Ensre that all staff co'er lesions on e!posed s-in ,ith a ,aterproof dressin*.
'efinitions for modes of transmission1
$ontact : Incldes direct person@to@person contact (e.*., +lood from a patient directl" into a health
care ,or-erCs open ct) and indirect contact (transmission from one person to another 'ia an
intermediate o+8ect sch as a health care ,or-erCs hands or a de'ice sch as a needle).
'roplet( Droplet spread ma" occr ,hen the infected person and the sscepti+le host are ,ithin
a+ot ( feet of each other. 2ral and respirator" secretions ma" +e transmitted into e"es or mcos
mem+ranes +" co*hin*, either +" direct droplet spread or indirectl" +" contamination of srfaces
s+se/entl" toched +" another person.
*irborne( 2ccrs +" dissemination of air+orne droplet nclei (small@particles S ) microns in si.e)
that ma" remain sspended in the air for lon* periods of time.
$ommon vehicle transmission( 3icroor*anisms transmitted +" contaminated items sch as food,
,ater, medications, de'ices, and e/ipment.
+ectorborne transmission( :e/ires 'ectors sch as mos/itoes, flies, rats, and other 'ermin to
transmit microor*anisms.
Minimal requirements for personnel and patient protection
Pre'entin* the spread of infection often re/ires s to C+rea- the chain of infectionC, i.e., to interrpt
the normal rotes of transmission.
$ontact( Wash hands ,hen the" are li-el" to ha'e +een soiled and +efore +e*innin* care for a ne,
patient. Waterless hand antiseptics are accepta+le nless the hands are 'isi+l" soiled. For contact
,ith all mcos mem+ranes and non@intact s-in, ,ear *lo'es that are clean at the time of se. <se
sterile *lo'es for normall" sterile +od" sites. Wear appropriate +arriers for the tas-, e.*., e"e,ear
for spatter and appropriate *lo'es for contact ,ith all moist +od" s+stances. Disinfect all items
+et,een patients. 1andle all clinical specimens as if -no,n to +e infectios. 1andle soiled linen
and trash to a'oid s-in contact.
*irborne( :estrictin* sscepti+le staff from e!posre is the +est and often the onl" pre'ention
strate*" for diseases transmitted in ,hole or in part +" air. Common sr*ical mas-s pro'ide
minimal protection. 1i*h efficienc", respirator t"pe mas-s ma" offer some protection ,hen in close
contact ,ith a co*hin* patient ,ith t+erclosis. 1o,e'er, the" are e!pensi'e and often not
a'aila+le. It is not clear if the" are sefl to protect sscepti+le staff ,hen there is ,idespread
dissemination of measles or 'aricella 'irs.
,loodborne( Becase of potential e!posre to hepatitis B 'irs (1BF) in patientCs +lood,
immnisation is recommended for all healthcare ,or-ers ,ho ha'e e!posre to +lood and +od"
flids. 1o,e'er, this does not decrease the need to o+ser'e safe practices to redce needlestic-
in8ries and other +lood e!posres. For e!ample, onl" re@cap disposa+le needles sin* a one@handed
techni/e. Place sed sharps in pnctre@proof containers +efore reprocessin* or disposal. <se no
toch techni/es (forceps or *lo'es) to handle +lood or +lood contaminated material. Wear *lo'es
for handlin* sharp items0 one la"er of late! redces +lood inoclm si*nificantl" G#H .
Esta+lish a procedre for reportin* +lood e!posres to the 21D and mana*ement actions to +e
ta-en. 7r'eillance for occpational +lood e!posres can pro'ide data to direct pre'ention efforts.
:otine accident reports ma" not pro'ide accrate or sfficient information to *ide these
pre'ention strate*ies0 therefore focsed stdies ma" +e re/ired. G2H 7ch stdies in departments
,here the ris- for occpational +lood e!posres is hi*h ha'e reported that personnel ,ere a+le to
redce the fre/enc" of e!posres more than half +" chan*in* practices and increasin* +arrier
precations G(H. Post@ e!posre mana*ement recommendations for hman immnodeficienc" 'irs
(1IF) chan*e fre/entl" and are +e"ond the scope of this chapter, +t the" are some,hat sccessfl
and healthcare facilities shold ha'e appropriate policies in place.
The 7afe In8ection 6lo+al 9et,or- GIH estimates that appro!imatel" #J +illion in8ections are *i'en
annall" in the ,orld. 3an" in8ections are sed nnecessaril" ,hen oral medication ,old +e
+etter. In addition, in settin*s ,ith limited resorces, more than half of all in8ections are *i'en ,ith
s"rin*es resed ,ithot sterili.ation or hi*h le'el disinfection. 7tdies in China, Pa-istan, India,
3oldo'a, :omania, E*"pt, ;frican nations and other contries ha'e reported an association
+et,een nsterile in8ections and s+se/ent 1BF, hepatitis C 'irs (1CF) and 1IF infection to +e
'er" hi*h. In 2AAA, contaminated in8ections cased an estimated 2# million 1BF infections, t,o
million 1CF infections and 2JA,AAA 1IF infections, accontin* for (2K, IAK and )K respecti'el"
of ne, infections GIH .
;ltho*h health care personnel are also at ris- for e!posre to +lood+orne patho*ens, these fi*res
inclde onl" the estimated ris- to patients.
7ome ris-s to health care ,or-ers can +e eliminated +" sin* de'ices that minimi.e pnctre
opportnities0 man" others can +e redced +" infection pre'ention pro*rams that mandate
appropriate se of +arrier precations and safe ,or- practices.
In the 7prin* of 2AA(, a ne,l" emer*ed corona'irs ,as identified as the case of 7e'ere ;cte
:espirator" 7"ndrome (7;:7). B" mid@smmer, more than %)AA cases had +een identified ,ith
more than %AA fatalities, most in ;sian contries. ;ppro!imatel" JAK ,ere hospital ac/ired and
man" occrred in health care personnel. Transmission to health care ,or-ers occrred most
fre/entl" after nprotected, close contact ,ith s"mptomatic indi'idals. Pre'ention strate*ies
inclde a hi*h inde! of sspicion and immediate isolation for patients ,ith s"stemic 'iral
s"ndromes that prodce fe'er and co*h, especiall" amon* people ,ho ha'e tra'eled to re*ions
that ,ere affected +" 7;:7. Cleanin* and srface disinfection in care areas is also important.
Personal protecti'e e/ipment for 7tandard Precations, and Contact and ;ir+orne Isolation inclde
hand h"*iene, *lo'es, *o,ns, and 9$) or e/i'alent respirator.
Information a+ot 7;:7 ,ith lin-s to crrent p+lications and recommendations is al,a"s
a'aila+le on the IFIC ,e+site (,,,.ific.narod.r)
2eferences
#. 3ast 7T, Wool,ine ?D, 6er+erdin* ?>. Efficac" of *lo'es in redcin* +lood 'olmes
transferred drin* simlated needlestic- in8r". ? Infect Dis #$$(0#J%:#)%$@$2. Bac- to te!t
2. >"nch P, White 3C. Perioperati'e +lood contact and e!posres: ; comparison of incident
reports and focsed stdies. ;m ? Infec Control #$$(0 2#:()&@(J(. Bac- to te!t
(. White 3C, >"nch P. Blood contacts in the 2: after hospital@specific data anal"sis and
action. ;m ? Infect Control#$$&02):2A$@2#I. Bac- to te!t
I. 1ari ;3, ;rmstron* 6>, 1tin Q?F. The 6lo+al Brden of Disease ;ttri+ta+le to
Contaminated In8ections 6i'en in 1ealth Care 7ettin*s. Int ? 7TD and ;ID7. 2AA(. (In
press) Bac- to te!t
The following references describe occupational health programs :
Dec-er 3D, 7chaffner W. Chapter J): 9osocomial diseases of health care ,or-ers spread
+" the air+orne or contact rotes (other than t+erclosis). I9: 3a"hall C6 (editor).
(ospital Epidemiology and Infection Control . Baltimore : Williams M Wil-ins, #$$J:%)$@
%%(.
Fal-, P. Chapter %(: Infection control and the emplo"ee health ser'ice. I9: 3a"hall C6
(editor). (ospital Epidemiology and Infection Control . Baltimore : Williams M Wil-ins,
#$$J:#A$I@#A$$.
>"nch P. 3ana*in* emplo"ee and patient e!posres in health care settin*s. I9: >"nch P,
?ac-son 33, Preston 6; , 7ole B3. Infection pre$ention +ith limited resources2 A
hand)oo, for infection committees . Chica*o : Etna P+lications0 #$$&.
7heret. :?, 3aroso- :D, 7treed 7;. Chapter #I: Infection control aspects of hospital
emplo"ee health. I9: Wen.el :P (ed). #re$ention and Control of .osocomial Infections ,
2nd edition. Baltimore : Williams M Wil-ins, #$$(:2$)@((2.
8. Isolation (recautions
Introduction
2r*anisms casin* hospital@ac/ired infections can +e transmitted from infected and colonised
patients +oth to other patients and to staff. ;ppropriate isolation precations for all patients,
incldin* those ,ho are infected and colonised redce the ris- of transmission.
Transmission of infection
2r*anisms can +e spread +" se'eral rotes ,hich are listed in the chapter on occpational health.
These rotes inclde direct person@to@person contact, indirect contact 'ia an intermediate o+8ect,
and air+orne transmission. Patient@to@patient transmission 'ia staff hands is re*arded as the most
important rote0 therefore proper hand h"*iene is an important means of pre'entin* spread of
infection in the hospital. (7ee additional information in the chapter on hand h"*iene).
$tandard (recautions for 'll (atients
In all patient care, transfer of potentiall" harmfl microor*anisms +et,een patients and staff mst
+e a'oided. For this reason, the follo,in* *eneral precations are sed:
:e*ard all patient +lood, e!cretions and secretions as potentiall" infectios and institte
appropriate precations to minimise ris-s of transmission.
Wear *lo'es that are clean at the time of se for contact ,ith mcos mem+ranes and
nonintact s-in of all patients.
Decontaminate hands +et,een each patient contact.
Decontaminate hands promptl" after tochin* infecti'e material (e.*., +lood, +od" flids,
secretions, or e!cretions), infected patients or their immediate en'ironment, and
contaminated articles sed for patient care. Waterless hand antiseptics are efficient nless
the hands are 'isi+l" soiled in ,hich case the" shold +e ,ashed first. (7ee the chapter on
hand h"*iene)
<se no toch techni/e ,hen possi+le to a'oid tochin* infecti'e material.
Wear *lo'es ,hen in contact ,ith +lood, +od" flids, secretions, e!cretions and
contaminated items. Wash hands immediatel" after remo'in* *lo'es. If *lo'es are not
readil" a'aila+le, ,ash hands thoro*hl" as soon as patient safet" permits.
Dispose of faeces, rine, and other patient secretions 'ia desi*nated sin-s. Clean and
disinfect +edpans, rinals and other containers appropriatel" (see chapter on cleanin*,
disinfection and sterili.ation).
Clean p spills of infecti'e material promptl" (see chapter on cleanin*, disinfection and
sterili.ation). 6eneral disinfection of floors and ,alls is then not necessar".
Ensre that patient@care e/ipment, spplies, and linen contaminated ,ith infecti'e material
are disinfected or sterili.ed +et,een each patient se (7ee chapter on cleanin*, disinfection
and sterili.ation).
If no ,ashin* machine is a'aila+le for linen soiled ,ith infecti'e material the linen can +e
+oiled.
<sed dressin*s and other medical ,aste shold +e disposed of in sealed, la+eled plastic +a*s
and prefera+l" incinerated or deepl" +ried.
9o6ns and 'prons
6o,ns and aprons are fre/entl" recommended to pre'ent transmission of infectios a*ents,
ho,e'er the" are of less importance than hand h"*iene and are costl". The" cold +e of +enefit in
sitations ,here soilin* of staff clothin* is li-el" ,hen dealin* ,ith patients ,ith infected or
dischar*in* ,onds or ,hen cleanin* soiled material.
!as+s
Thin, sr*ical t"pe mas-s pro'ide minimal protection a*ainst air+orne patho*ens. 1i*h efficienc",
respirator t"pe mas-s, ma" offer additional protection, ho,e'er these are costl" and ma" not +e
a'aila+le for se. When mas-s are re/ired to stop spread of air+orne@spread micro+es, a hi*h@
efficienc" mas- shold +e ,orn ,hene'er a'aila+le. For patients ,ith childhood commnica+le
diseases, limitin* staff contact to those ,ho are alread" immne is important as is immni.ation of
sscepti+le staff.
$hoe covers and protective headgear
7hoe co'ers and hats or caps do not pre'ent transmission of infectios a*ents and are costl". The"
shold not +e sed.
'dditional (recautions for $ome Infected (atients
!ingle "ooms
In addition to 7tandard Precations, some patients, particlarl" those infected ,ith patho*ens
transmitted +" the air+orne rote, need to +e placed in sin*le rooms. These rooms shold +e
ph"sicall" separated from other patients to redce the ris- of transmission.
If appropriate 'entilation is pro'ided for these rooms, the air shold +e e!tracted to the otside of
the +ildin* and a,a" from entrances or areas ,here people are standin* or *atherin*. Patients ,ith
the same infection can +e placed to*ether in the same room.
7in*le rooms are also desira+le for patients ,hose infections reslt in *ross soilin* or contamination
of the en'ironment, sch as occrs ,ith lar*e ,onds ,ith hea'" dischar*e, massi'e ncontrolled
+leedin* or diarrhoea, or hea'" dispersal of s-in scales (+rn patients).
Dressin*s, secretions and e!cretions, contaminated linen, *lo'es, or other +arrier items shold +e
disposed of in +a*s ,ithin the room +efore +ein* remo'ed for incineration or disinfection.
;fter patients are dischar*ed, the room, +ed, and e/ipment shold +e cleaned +efore the admission
of a ne, patient.
Patients ,ho ma" re/ire sin*le room isolation inclde those ,ith the follo,in* infections:
D"senter" incldin* cholera ,ith nmana*ea+le diarrhoea
3ethicillin@resistant S. aureus' particlarl" if there is li-el" to +e considera+le
contamination of articles in the room
T+erclosis
Infected lar*e +rns
In hi*h ris- areas, patients infected or colonised ,ith mltidr* resistant patho*ens
7;:7
(recautions for /amil) !embers (roviding Care to (atients in &ospitals
It is 'er" important that famil" mem+ers pro'idin* care to patients in hospitals +e edcated +" the
staff to se *ood h"*iene and appropriate precations to pre'ent spread of infections to themsel'es
and to other patients. The precations for famil" mem+ers ma" need to +e the same as those sed +"
staff.
!inimal Re"uirements
1and h"*iene after handlin* secretions, e!cretions or contaminated items from an" patient.
Isolation in a sin*le room, if a'aila+le, for air+orne or particlarl" ha.ardos infections, and
for sitations in ,hich a patients soil the room en'ironment ,ith secretions or e!cretions.
0ibliograph)
7tandard Principles for pre'entin* hospital@ac/ired infections. Journal (ospital Infection
2AA#0I&(7ppl):72#@7(&.
1ICP;C. 6ideline for Isolation Precations in 1ospitals. American Journal Infection
Control #$$J02I:2I@)2.
:. (revention of (ost-operative -ound
Infections
Introduction
Post@operati'e ,ond infections or sr*ical site infections (77Is) dela" reco'er", increase len*th of
sta" and are associated ,ith increased mor+idit" and mortalit". The" increase healthcare costs +"
dela"in* dischar*e and increasin* the need for in'esti*ation, treatment and nrsin* care. Pre'ention
or redction of 77Is is ths an essential part of /alit" patient care. >o, rates of 77Is are directl"
related to edcation, a,areness of the cases of infection, and the introdction of practices that
redce ris-. G#H Pre'ention is *reatl" aided +" sr'eillance for ,ond infections ,ith re*lar
reportin* of the reslts +ac- to indi'idal sr*eons in sfficient detail to allo, them to identif" and
eliminate ris- factors for infection. G2H
2isk Factors
3ltiple ris- factors for 77I ha'e +een identified. 7r*ical procedres ma" +e di'ided into the
follo,in* cate*ories:
clean, ,hen no inflammation is encontered and no coloni.ed +od" s"stem is entered0
clean contaminated, ,hen a coloni.ed s"stem (e.*., *astrointestinal or respirator" tract), is
entered, +t there is no si*nificant spilla*e0
contaminated, ,hen inflammation, +t not ps, is encontered or spilla*e from a 'iscs
occrs0 and
dirt", ,hen a perforated 'iscs or ps is encontered.
The incidence of infection shold +e less than )K for clean operations, +t rises to more than (AK
in dirt" operations. 7ome other ris- factors are sho,n in Ta+le &.#.
Table -..( "isk factors for surgical site infection
"is, factors related to patient condition
a*e (elderl" and neonates)
concrrent diseases, e.*., dia+etes
malntrition or o+esit"
s-in diseases, particlarl" infections
Surgical categories
Contaminated or dirt" sr*ical procedres
transplant or implant operations
Surgical procedure
lon* dration of operation (ma" +e a pro!" for difficlt procedres)
haemorrha*e and haematomas
tisse trama, dr"in*, or de'itali.ation
location and t"pes of drains
#erioperati$e patient care
inappropriate anti+iotic proph"la!is
inade/ate s-in preparation or care
inade/ate staffin* le'els and theatre desi*n
staff ,ith s-in infections in the theatre
e!cessi'e mo'ement of staff
inade/ate operatin* theatre 'entilation
simltaneos operations in the same room
E&uipment
inade/ate sterilisationEdisinfection
re@se of inade/atel" processed in'asi'e de'ices
The surgical +ard
prolon*ed preoperati'e sta"
inappropriate dressin* techni/es
+re,enti,e Measures
Patient factors
In case of concrrent disease, dela" operation and treat an" infections.
;nti+iotic proph"la!is for dirt" or contaminated operations
Proph"la!is is sall" *i'en for clean operations ,here an infection ,old +e a catastrophe for the
patient, e.*., insertion of 8oint or cardiac prostheses, h"sterectom", or Caesarean section ,ith
prolon*ed rptre of mem+ranes. :ecommendations for sr*ical proph"la!is are chan*ed
fre/entl" in response to research and ne, antimicro+ial a*ents.
!urgical procedure
;de/ate sr*ical trainin* and e!perience is important to pre'ent 77Is.
ound drains
Wond drains pro'ide access for +acterial entr" and shold not +e sed as an alternati'e to *ood
haemostasis. The closed s"stem of ,ond draina*e is preferred ,here draina*e is essential. 2pen
,ond drains ma" lead to an increase in 77I and shold +e placed thro*h a separate sta+ ,ond
rather than +ein* +ro*ht thro*h the operati'e incision.
Perioperative patient care
Correct timin* of anti+iotic proph"la!is
;n anti+iotic that pro'ides co'era*e for the t"pes of or*anisms li-el" to +e encontered shold +e
*i'en at the correct time, i.e. at indction of anaesthesia, ,ithin # hor of incision. It shold not +e
*i'en for more than 2I hors, prefera+l" one or t,o doses shold +e pro'ided.
!having
7ha'in* is no lon*er recommended +ecase it a+rades the s-in and increases the ris- of micro+ial
colonisation and infection. Where necessar", remo'e hair ,ith clippers or depilator" cream.
!kin disinfection
It is essential that the operatin* site +e ,ell disinfected +efore incision. ; rapid redction of s-in
flora is re/ired. &AK ethanol or isopropanol are effecti'e disinfectants. 1o,e'er, alcoholic
soltions that contain lon*@actin* s-in disinfectants, sch as chlorhe!idine or po'idone iodine, are
preferred. The antiseptic shold +e applied ,ith friction ,ell +e"ond the operation site for (@I
mintes. The area mst +e allo,ed to dr" +efore operatin*. <se of disinfectants ,ith *reater than
IAK alcohol content increases the ris- of +rns to the patient drin* diatherm".
!taff movement
E!cessi'e nm+ers and mo'ement of staff contri+te to an increase in air@+orne +acterial particles.
In the case of +acterial s-in infections, dispersal of patho*ens (sch as S. aureus and +eta@hemol"tic
streptococci) ma" +e lar*e. It is ad'isa+le to -eep the operatin* theatre staff to the essential
minimm. 7taff ,ith +oils or septic lesions of the s-in or ec.ema colonised ,ith S.aureus shold
not +e allo,ed in the theatre.
Theatre clothing
7taff shold chan*e into clean theatre clothin* prior to an operation. To a'oid transfer of patho*ens
into the operation site, clothes intended for ,or- in the site shold not +e ,orn in patient care
areas otside the site. The operatin* team shold ,ear sterile *o,ns and *lo'es. For sr*ical hand
,ashin* see chapter on hand h"*iene.
/pen containers of solutions or disinfectants
These containers mst not +e sed since the" can +ecome contaminated ,ith or*anisms that ma"
then colonise the ,ond. Disinfectants shold +e stored in +ottles ntil immediatel" +efore se.
Water@+aths shold +e disinfected after se.
/perating theatre ventilation
Ideall", operatin* theatre air shold +e filtered to redce the concentration of air+orne +acteria
(especiall" S. aureus ) *enerated +" staff. If ,indo,s ha'e to +e left open, the" shold +e co'ered
,ith fl" or insect@proof nettin*.
;ir conditionin* s"stems shold ensre that a minimm of #) air chan*es per hor of filtered air is
deli'ered. G(H With correct desi*n and *ood control of staff mo'ement, the le'el of air+orne
contamination ,old then +e +elo, #AA cf (colon" formin* nit) per mR( drin* operations.
<ltra Clean ;ir (S #A cfEmR( ) redces the ris- of infection in implant sr*er". To achie'e this,
laminar flo, s"stems ,hich ha'e an airflo, of A.) TmEsecond or special 'entilation com+ined ,ith
+acteria impermea+le clothin* mst +e sed. :e*lar maintenance and chec-in* of the 'entilation
filters and airflo, are imperati'e.
:otine +acteriolo*ical testin* of operatin* room air is nnecessar". It shold +e performed ,hen
commissionin* a ne, theatre site and ma" occasionall" +e sefl ,hen in'esti*atin* an ot+rea-.
The surgical ward
;'oid a prolon*ed preoperati'e sta" in the ,ard. If this is necessar" for medical reasons, protect the
patient from colonisation ,ith +acteria from infected patients. Do not se proph"lactic anti+iotics in
the ,ard.
Minimal requirements
7terilisation or hi*h le'el disinfection of instrments
Disinfection of hands of the sr*ical team and s-in of operation site
7terile *lo'es
Clean en'ironment, ade/ate 'entilation
2eferences
#. 3an*ram ;?, 1oran TC, Pearson 3>, et al. 6ideline for pre'ention of sr*ical site
infection, #$$$. Infect Control (osp Epidemiology 2A0 2I&@&%. Bac- to te!t
2. 1ale" :W, Cl'er D1, et al. The efficac" of infection sr'eillance and control pro*rams in
pre'entin* nosocomial infections in <7 hospitals. Am J Epipdemiol #$%)0#2#:#%2@2A).
Bac- to te!t
(. ;I; 6idelines for Desi*n and Constrction of 1ospitals and 1ealth Care Facilities.
Dallas , TU : Facilities 6idelines Institte, 2AA#. Bac- to te!t
,ibliography
3a"hall C6. 7r*ical infections incldin* +rns. In: Wen.el :P, Ed. #re$ention and
Control of .osocomial Infections . 2nd Edition. Baltimore : Williams M Wil-ins #$$(:J#I@
JJI.
;. (revention of Intravascular evice
'ssociated Infection
Introduction
Intra'enos infsions are amon*st the most common in'asi'e procedres performed in hospitals
and are administered either +" the peripheral or central rotes. Infections associated ,ith these
de'ices are common, and in man" contries intra'enos catheters are the most common sorce of
nosocomial or hospital ac/ired +acteraemia. The principles sed for pre'ention of infection are
similar for +oth central and peripheral catheters.
;n intra'enos catheter is a forei*n +od" that prodces a reaction in the host resltin* in the
formation of a film of fi+rinos material on the inner and oter srfaces of the catheter. This +iofilm
ma" +ecome colonised +" micro@or*anisms ,hich are protected from host defence mechanisms and
the effect of anti+iotics. 3icro+ial contamination ma" case local sepsis, or septic
throm+ophle+itis, or +acteraemiaEsepticaemia G#H .
Infection control measres are desi*ned to pre'ent micro@or*anisms from enterin* the e/ipment,
the catheter insertion site, or the +loodstream (Fi*re %.#).
Becase of the dan*ers of infection, catheters shold not +e inserted nnecessaril", and indications
for insertion of catheters shold +e strict (e.*., se'ere deh"dration, +lood transfsion, and parenteral
feedin*). <se alternati'e rotes ,here possi+le for h"dration or parenteral therap". If catheters need
to +e inserted, the" shold +e remo'ed as soon as possi+le and shold not +e left in B8st in case
the" mi*ht +e needed later.
6ood aseptic techni/e is re/ired drin* insertion of the catheter and maintenance of the insertion
site G2H . The site shold +e -ept dr", free from contamination, secre, and comforta+le for the
patient.
$ources and Routes of Transmission of infection
7orces of contamination are either intrinsic (contamination +efore se), or e!trinsic (contamination
introdced drin* therap").
3ost infections are ac/ired from the patientCs o,n s-in flora G(H. The or*anisms are sall"
coa*lase@ne*ati'e staph"lococci or occasionall" Staphylococcus aureus. >ess fre/entl", 6ram@
ne*ati'e +acilli or Candida al)icans ma" +e identified de to *ro,th in the infsate.
7-in or*anisms enter the catheter insertion site alon* the otside of the catheter. 2ccasionall"
or*anisms from the hands of staff or the patientCs s-in enter thro*h the h+ ,hen the catheter is
disconnected, or from the in8ection ports. The or*anisms *ro, in the +iofilm on the catheter
srfaces, sall" the oter, and ma" +e released in the +loodstream. :arel", infection ,ill arise from
or*anisms *ro,in* in commerciall" prepared infsate de to falt" sterilisation or from
contaminated added medicaments GIH. Finall", metastatic colonisation of the catheter tip ma" occr,
seeded from a distant site of infection (e.*. ,ond, ln*, or -idne").
$ource of infection and prevention
Main source of
infection
"re#ention
Infsion flid
Ensre flid is p"ro*en free.
3onitor sterilisation process.
;'oid dama*e to container drin*
stora*e.
Inspect container for crac-s, lea-s,
clodiness, and particlate matter.
;ddition of medicaments
<se aseptic precations (hand
disinfection, no toch techni/e).
;dd sterile medicaments.
Carr" ot procedre prefera+l" in the
pharmac".
<se sin*le@dose 'ials ,hene'er possi+le.
If mltidose 'ials ha'e to +e sed:
o :efri*erate after openin* (if not
other,ise recommended +"
manfactrer).
o Wipe diaphra*m ,ith &AK
alcohol +efore insertin* a cannla.
o <se a sterile de'ice for access.
Container and ,ater sed Ensre no contamination from ,armin*
flid.
Prefer dr" ,armin* s"stems.
Insertion of catheter Thoro*h hand disinfection and se of
sterile *lo'es +" operator.
Thoro*hl" disinfect the insertion site.
Catheter site Co'er ,ith sterile dressin* as soon as
possi+le and remo'e if si*ns of infection
occr.
Inspect e'er" 2I hors.
Chan*e dressin* onl" ,hen soiled,
loosened or ,etEdamp, sin* *ood aseptic
techni/e.
Do not se antimicro+ial ointments.
In8ection ports Clean ,ith &AK alcohol and allo, to dr"
+efore se.
Close ports that are not needed ,ith
sterile stopcoc-s.
Chan*in* of infsion set :eplace no more fre/entl" than &2 hors
(+lood and lipids 2I horsV).
Thoro*h hand disinfection +" operator.
<se *ood aseptic techni/e
V In some contries, national *idelines or recommendations e!ist for infsion of +lood or +lood
prodcts incldin* infsion times S 2I hors. Certain lipid prodcts ma" re/ire more fre/ent
replacement G)H.
9eneral Comments
<nless si*ns of infection or irritation occr, peripheral 'enos catheters ma" +e
sed as lon* as the" are needed. (The CDC *idelines recommend chan*in*
peripheral 'enos catheters e'er" &2@$J hors in adlts.) Central catheters shold
not +e replaced rotinel" GJH.
The ris- of infection in peripheral IF sites increases ,ith len*th of time of
catheterisation. Catheters shold therefore +e remo'ed as soon as possi+le G&H.
Infection rates are lo,est ,ith small needles. Teflon catheters are also associated
,ith lo, rates, ho,e'er are not necessar" for short periods of infsion.
Well trained staff shold set p and maintain infsions. 3as-s, caps and *o,ns
are not necessar" for insertion of peripheral lines. The se of non@sterile *lo'es
and an apron or *o,n ,ill protect the operator if profse +leedin* is li-el".
(rotocol for peripheral infusions
Place arm on clean to,el.
2perator shold se an alcohol r+ or antiseptic deter*ent to disinfect hands. If
antiseptic is not a'aila+le, ,ash hands thoro*hl" for 2A seconds.
Dr" hands thoro*hl" on a paper to,el or clean linen to,el, nless alcohol is
sed.
;'oid sha'in* s-in site0 clip hair instead, if necessar".
Disinfect s-in site ,ith A.)K alcoholic chlorhe!idine, 2K tinctre of iodine, #AK
alcoholic po'idone@iodine, or &AK alcohol. ;ppl" ,ith r++in* for (A seconds
and allo, to dr" +efore insertin* cannla.
Insert cannla into 'ein, prefera+l" of pper lim+, sin* no toch techni/e.
;ppl" sterile dressin* (*a.e or e/i'alent, or clear semi@permea+le) and secre.
7emi@permea+le adhesi'e dressin*s are more e!pensi'e, +t ha'e the ad'anta*e
of allo,in* inspection of the site ,ithot remo'al of the dressin* G%H.
7ecre cannla to a'oid mo'ement and la+el ,ith insertion date.
;ssess the need for continin* catheterisation e'er" 2I hors.
Inspect catheter dail" and remo'e at first si*n of infection.
;'oid ct do,ns, especiall" in the le*.
Cannlae and *i'in* sets shold +e sterilised +efore se and prefera+l"
disposa+le.
o If rese is necessar", clean thoro*hl" and atocla'e if possi+le.
o If this is not possi+le, se +oilin* ,ater (see Cleanin*Edisinfection section)
o Chemical disinfection is ndesira+le +t if resa+le items are heat@la+ile,
immerse in A.)K sodim h"pochlorite or other chlorine@releasin* soltion
for #) mintes after thoro*h cleanin*. <se s"rin*e and needle for cleanin*
interior of cannla. Ensre a*ent remains in contact ,ith all srfaces of
t+es and catheters. 1"pochlorites are corrosi'e to metals and some
plastics0 thoro*h rinsin* in sterile ,ater is re/ired after disinfection.
'dditional guidelines for central catheters
<se ma!imm +arrier precations: sterile *lo'es, *o,ns, cap and mas- for
operator and a lar*e sterile drape to co'er the patient G2H.
Chan*e dressin*s re*larl", at least once a ,ee- (indi'idall" determined,
dependin* on the state of the patient) G$H.
!inimal re"uirements
Do not insert catheters nnecessaril" and minimise maniplations.
The operator shold disinfect his or her hands +efore insertion of catheter and
drin* maintenance procedres.
Thoro*hl" disinfect the s-in site +efore insertion.
<se a no toch techni/e (i.e., *lo'ed hands) drin* insertion, maintenance and
remo'al of catheter.
7ecre the IF line to pre'ent mo'ement of the catheter.
3aintain a closed s"stem.
Protect the insertion site ,ith a sterile dressin*.
Inspect the insertion site dail".
:emo'e the catheter as earl" as possi+le, and immediatel" if an" si*ns of
infection are present.
2eferences
#. 6astmeier P, Weist =, :eden 1 (#$$$) Catheter@associated primar" +loodstream
infections: epidemiolo*" and pre'enti'e methods. Infection 2& 7ppl #: 7# L 7J.
Bac- to te!t
2. :aad II, 1ohn DC, 6il+reath B?, 7leiman 9 et al (#$$I) Pre'ention of central
'enos catheter@related infections +" sin* ma!imal sterile +arrier precations
drin* insertion. Infect Control 1osp Epidemiol #): 2(# L 2(%. Bac- to te!t
(. Daroiche :2, :aad II (#$$&) Pre'ention of catheter@related infections: the s-in.
9trition #(: 2J7 L 2$7. Bac- to te!t
I. Tratmann 3, Waser B, Wiedec- 1, Bttenschon =, 3arre : (#$$&) Bacterial
coloni.ation and endoto!in contamination of intra'enos infsion flids. ? 1osp
Inf (&: 22) L 2(J. Bac- to te!t
). 6idelines for the Pre'ention of Intra'asclar Catheter@:elated Infection s, 2AA2.
!" 2AA20)#:#@2J. Bac- to te!t
J. Coo- D, :andolph ;, =ernerman B, Cpido C et al (#$$&) Central 'enos
catheter replacement strate*ies: a s"stematic re'ie, of the literatre. Crit Care
3ed 2): #I2& L #I2I Bac- to te!t
&. Bre*en.er T, Conen D, 7a-mann P, Widmer ;F (#$$%) Is rotine replacement of
peripheral intra'enos catheters neccessar"X ;rch Intern 3ed #)%: #)# L #)J
Bac- to te!t
%. 3adeo 3, 3artin C, 9o++s ; (#$$&) ; randomi.ed std" comparin* IF (AAA
(transparent pol"rethane dressin*) to a dr" *a.e dressin* for peripheral
intra'enos catheter sites. ? Intra'en 9rs 2A: 2)( L 2)J Bac- to te!t
$. Po,ell C:, Traeto, 3?, Fa+ri P?, =ds- =;, :+er* :> (#$%)) 2p@7ite
dressin* std": a prospecti'e randomi.ed std" e'alatin* po'idone iodine
ointment and e!tension set chan*es ,ith & da" 2p@7ite dressin*s applied to total
parenteral ntrition s+cla'ian sites. ? Parenter Enteral 9tr $: II( @ IIJ Bac- to
te!t
3uggestions for further reading1
3ermel >;, Farr B3, 7herert. :?, :aad II et al (2AA#) 6idelines for the
mana*ement of intra'asclar catheter@related infections. Clin Infect Dis (2: #2I$
@ #2&2.
7eifert 1, ?ansen B, Farr B3, eds (#$$&) Catheter@related infections. 3arcel
De--er , 9e, Qor- .
6idelines for pre'entin* infections associated ,ith the insertion and
maintenance of central 'enos catheters. Journal of (ospital Infection 2AA#0
I&(7ppl):7I&@7J&.
<. (revention of nosocomial lo6er
respirator) tract infection *4RTI,
Introduction
The co*h refle! to*ether ,ith a health" respirator" mcosa, ,ith its ciliated epithelim,
antimicro+ial secretions, pha*oc"tosis, and other local immnit" mechanisms, effecti'el" pre'ents
microor*anisms reachin* the lo,er respirator" tract (>:T). The >:T is ths normall" sterile.
Post@operati'e pnemonia is a common sr*ical complication, often resltin* from the patient
failin* to co*h or +reath deepl" +ecase of pain. In these patients infection is cased +" common
respirator" patho*ens.
Fentilator@associated pnemonia is a more serios condition seen in intensi'e care nits in int+ated
and 'entilated patients. It is often cased +" anti+iotic resistant, opportnistic patho*ens. In this
*rop of patients, mechanical or chemical in8r" to the ciliated epithelim impairs the normal
remo'al of mcos and microor*anisms from the lo,er air,a"s. In addition, redction of the
*astric p1 de to 12 +loc-in* a*ents is associated ,ith colonisation of the pper *astro@intestinal
tract and orophar"n! +" aero+ic 6ram@ne*ati'e +acilli deri'ed from the patientCs o,n +o,el. These
or*anisms ma" then pass into the >:T and case infection. This *rop of patients has sall" had
prolon*ed hospitalisation and recei'ed (sometimes se'eral corses of) anti+iotics. Becase of this,
the or*anisms in'ol'ed are often mltidr* resistant (3D:) opportnistic patho*ens. These
micro+es ma" +e introdced into the respirator" tract 'ia contaminated e/ipment or staff hands,
+t often the" are or*anisms that ha'e first colonised the patientCs +o,el.
efinition and diagnosis
9osocomial or hospital ac/ired pnemonia is a lo,er respirator" tract infection that appears
drin* or after hospitalisation in a patient ,ho ,as not inc+atin* the infection on admission. It is
dia*nosed +" the follo,in*: clinical si*ns, p"re!ia, sall" prlent sptm, rele'ant U@ra" chan*es
and prefera+l" micro+iolo*ical dia*nosis from +ronchial la'a*e, transtracheal aspirate or protected
+rsh cltre.
0igure 1.. #ode of acquisition of hospital acquired pneumonia
2isk factors for nosocomial pneumonia
$ondition of patient
Therapy
7e'erel" ill, e.*. septic shoc-
;*e (elderl" or neonate)
7r*ical operation
(ChestYa+domen)
3a8or in8ries
Coronar" +"pass sr*er"
E!istin* cardioplmonar"
disease
Cere+ro'asclar accidents
Coma
1ea'" smo-er
7edation
6eneral anaesthesia
Tracheal int+ation
Tracheostom", artificial
'entilation, enteral feedin*
>en*th of time of 'entilation
;nti+iotic therap", 1@2
+loc-ers
Immnosppressi'e and
c"toto!ic dr*s
Etiologic agents of nosocomial pneumonia
Streptococcus pneumoniae and (aemophilus influen/ae can case post@operati'e pnemonia,
particlarl" in patients ,ith e!istin* plmonar" disease.
6ram@ne*ati'e +acilli, e.*., 1le)siella pneumoniae' Escherichia coli' #seudomonas aeruginosa'
Serratia marcesens' Entero)acter species, and Acineto)acter species.
*egionella infection ma" +e ac/ired from the hospital air conditionin* s"stem or from ,ater
spplies, particlarl" in immnocompromised patients.
2ther or*anisms, e.*., respirator" s"nc"tial and other respirator" 'irses, Candida al)icans , and,
rarel", Aspergillus fumigatus.
#neumocystis carinii cases pnemonia in immnosppressed patients, particlarl" if 1IF positi'e,
+t this is sall" a commnit"@ac/ired infection. 2pportnistic plmonar" diseases cased +"
different m"co+acteria, incldin* yco)acterium tu)erculosis' can occr and can +e transmitted to
other patients.
0asic methods of prevention
"isk Prevention
7r*ical operation
Identif"in* patients at hi*h ris-.
Deep +reathin* and co*hin* e!ercises
+efore and after operation.
Percssion and postral draina*e to
stimlate co*hin*.
3o+ilise earl" after operation.
Cardioplmonar"
illnesses
Clearin* air,a"s.
2ral ca'it" care at least J times a da".
:espirator" failre and
artificial 'entilation
Decontamination of respirator" e/ipment
after I% to &2 hors. The fre/enc" of
decontamination depends on its se.
Protection of mechanical 'entilation ,ith
filters redces the need to disinfect after
each patient.
7ction +ottles chan*ed dail", atocla'ed
or disposa+le.
Other important measures
1and h"*iene +efore and after contact ,ith patients, ,hether or not *lo'es are ,orn.
Clean disposa+le or reprocessed *lo'es and catheters for tracheal aspiration and tracheostom" care.
Disposa+le or reprocessed *lo'es ,hen handlin* respirator" secretions.
Edcation of staff in patient care practices and cleanin* and disinfection of respirator" e/ipment.
Cleaning and isinfection of Respirator) E"uipment
1midifiers Cleanin*, dr"in* and fillin* ,ith sterile
distilled or freshl" +oiled ,ater e'er" % to 2I
hors.
9e+li.ers ;tocla'in* or thermal disinfection preferred
after cleanin*0 sterile ne+li.er flids as
aerosols are *enerated.
Endotracheal air,a"
t+es, face mas-s,
t+in*, am+@+a*s
;tocla'in* or thermal disinfection
Disposa+le items are safe +t e!pensi'e
Chemical disinfection ma" +e re/ired
2ral ca'it" cleanin*
soltion
7terile or freshl" +oiled ,ater for each se
7pirometr" 3othpiece for each patient shold +e sterile,
disinfected or disposa+le
Endotracheal air,a"
maniplations
7terile, disposa+le, for each procedre e!cept
,hen sed for the same patient for 2I hors0
flshed for each aspiration ,ith sterile or
freshl" +oiled ,ater
7ction +ottles and
t+in*
Washin* in deter*ent and dried, or disinfected
,ith soltion of chlorine@releasin* a*ent,
rinsed and dried. Prefera+l" disinfected in
,ashin* machine or atocla'ed or disinfected
in hot ,ater and dried. Disposa+les a'aila+le
+t e!pensi'e
!inimal re"uirements
;de/atel" decontaminated e/ipment.
1and h"*iene +efore and after patient contact
6lo'es (non@sterile) and disposa+le sction catheters for tracheal aspiration, if a'aila+le.
Chan*e *lo'es +et,een patients and procedres
Dispose of or decontaminate sction catheters +et,een patients
0ibliograph)
6ideline for Pre'ention of 9osocomial Pnemonia. Amer J Infect Control #$$I022:2I&@
2$2.
:hame F7, 7treifel ;, 3cCom+ C, Bo"le 3. B++lin* hmidifiers prodce microaerosols
,hich can carr" +acteria. Infection Control #$%J0&:IA(@&.
1=. (revention of urinar) tract infection
*>TI,
Introduction
The *reat ma8orit" of <TIs in hospitalised patients are associated ,ith the se of rinar" draina*e
de'ices, sch as +ladder catheters. <nder normal circmstances rethral flora, ,hich tends to
mi*rate into the +ladder, is constantl" flshed ot drin* rination. When a catheter is inserted, this
flshin* mechanism is circm'ented and perineal and rethral flora (sall" aero+ic +o,el
or*anisms) can pass p into the +ladder in the flid la"er +et,een the otside of the catheter and the
rethral mcosa. Becase of this, +ladder colonisation is almost ine'ita+le if catheters are left in
place for prolon*ed periods. In addition, +ladder infection can +e cased +" +acterial refl! from
contaminated rine in the draina*e +a*. It has +een clearl" demonstrated that the se of closed
draina*e s"stems si*nificantl" redce rine contamination and ths infection rates, and open
s"stems shold +e a'oided if at all possi+le.
Where the se of +ladder catheters is common, <TIs ma" +e the most fre/ent nosocomial or
hospital ac/ired infections encontered. ;ltho*h most patients ,ill ha'e as"mptomatic
+acteriria or mild infections that tend to +e self limitin* ,hen the draina*e de'ice is remo'ed,
some patients ma" ha'e more se'ere infections, sometimes leadin* to p"elonephritis, septicaemia
and death. 3oreo'er, e'en less se'ere <TIs tend to increase the len*th of hospitalisation and
increase hospital costs +ecase of the need for additional dia*nostic tests and anti+iotic therap".
Fortnatel", most <TIs are easil" pre'ented +" redcin* nnecessar" and inappropriatel" prolon*ed
+ladder catheterisation and +" the se of closed draina*e s"stems and standard aseptic techni/es.
+re,ention
<rinar" catheters shold +e inserted onl" ,hen there are clear medical indications. These inclde:
the relief of acte o+strction or retention that cannot +e treated ,ith non@tramatic
intermittent catheterisation
the measrement of rine prodction in criticall" ill patients and
perioperati'e se in patients ,ho mst ha'e a completel" empt" +ladder, for e!ample, in
selected *"naecolo*ical or rolo*ical procedres.
The dia*nosis of <TI in hospitals depends on the micro+iolo*ical spport a'aila+le in the hospital.
Where micro+iolo*ical spport is *ood and a carefl midstream specimen is collected, findin*
P#ARI +acterial colon" formin* nits (cf) per ml in a patient ,ithot an ind,ellin* catheter is
dia*nostic of <TI. Bacterial concentrations P#AR2 cf per ml s**ests infection if the specimen is
o+tained asepticall" +" needle aspiration of the pro!imal draina*e t+in* in a patient ,ith an
ind,ellin* catheter. It is important to reco*ni.e that altho*h in non@catheterised patients <TIs are
sall" cased +" a sin*le or*anism, in patients ,ith ind,ellin* catheters infections are fre/entl"
pol"micro+ial. The presence of mltiple or*anisms does not necessaril" indicate contamination.
It is essential to process rine promptl", since e'en ,ith *ood techni/e rine samples ma" contain
small nm+ers of contaminants. These micro+es can mltipl" at room temperatre (especiall" in hot
climates) and *i'e falsel" hi*h colon" conts. If dela" is e!pected, the specimen shold +e
refri*erated.
Where micro+iolo*ical spport is poor or totall" na'aila+le, clinical s"mptoms (e.*., fe'er, spra@
p+ic tenderness, fre/enc", and d"sria) ma" +e sefl in dia*nosis, principall" in non@
catheterised patients. The presence of p"ria on either microscopic e!amination or +" dip stic-
(le-oc"te esterase) is hi*hl" s**esti'e of <TI. If dip stic-s are a'aila+le, a positi'e nitrite
reaction in com+ination ,ith a positi'e le-oc"te esterase reaction is 'irtall" dia*nostic. ; positi'e
6ram stain of nspn rine also is dia*nostic, +t this is rarel" possi+le ,ithot the presence of
trained micro+iolo*ists.
;n <TI is sall" an endo*enos infection cased +" or*anisms from the patientCs o,n +o,el. In
commnit"@ac/ired infection, the commonest or*anism is E. coli, follo,ed +" #roteus species and
Enterococcus faecalis . (in "on* se!all" acti'e ,omen the perineal or*anism Staphylococcus
saprophyticus is also common). Characteristicall", these commnit"@ac/ired infections are de to
anti+iotic@sensiti'e or*anisms that are relati'el" eas" to treat.
1ospital ac/ired <TIs are also sall" endo*enos infections, +t the or*anisms in'ol'ed are
commonl" more resistant to anti+iotics. This is +ecase hospitalised patients +ecome colonised ,ith
these resistant or*anisms, a process encora*ed +" increasin* len*th of hospital sta" and e!posre
to anti+iotics. ;nti+iotic therap" ma" lead to infection ,ith more resistant commnit" or*anisms
alread" present in the patientCs +o,el on admission. In addition, resistant or*anisms ma" +e
ac/ired +" transfer from other patients, most commonl" 'ia contaminated staff hands, +t
sometimes from en'ironmental sorces. In hospital patients, 6ram@ne*ati'e +acteria can colonise
the s-in, especiall" in moist areas sch as the *roin. 1and transfer from patient to patient is sall"
de to contact ,ith s-in0 then or*anisms *o on to colonise the +o,el. Infected rine is also a potent
sorce of staff hand contamination. <rine and rinar" catheter s"stems shold +e carefll" disposed
of, +ottles and 8*s cleaned and disinfected, and hands properl" ,ashed and decontaminated.
E. coli is still the most common case of nosocomial <TI, ho,e'er increasin*l" hospital@ac/ired
infections are cased +" more inherentl" resistant 6ram@ne*ati'e species, sch as 1le)siella and
#seudomonas. 7imilarl", the ampicillin@sensiti'e Enterococcus faecalis is *radall" replaced +" the
resistant E. faecium. Then, ,ith additional anti+iotic e!posre, infections occr ,ith more mltipl"
dr* resistant (3D:) 'ersions of these and other species. E'entall", these or*anisms ma"
themsel'es +e replaced +" the completel" anti+iotic resistant Candida spp., sall" from the
patientCs o,n commensal flora.
7hort term (S) da"s) proph"lactic anti+iotic administration in catheterised patients has +een sho,n
to redce the ris- of +acteriria and infection, +t cannot +e recommended +ecase of its e!pense
and tendenc" to encora*e the emer*ence of resistant or*anisms. >on*er proph"la!is is ineffecti'e
and predisposes to infection ,ith e'en more resistant or*anisms. Treatment of as"mptomatic
+acteriria in catheterised patients is not sall" indicated and often the +ladder colonisation
disappears once the catheter is remo'ed.
(rinciple causes of urinar) tract infection and interventions that reduce infection
rates (7ee Fi*re #A.#)
$ause of Infection Preventive #easure
Poor aseptic
insertion of catheter:
perirethral flora
inserted into +ladder
Catheter shold +e sterile, or if this is not
possi+le, shold +e effecti'el" disinfected
Perirethral area shold +e thoro*hl"
cleaned, prefera+l" ,ith a disinfectant
1ands shold +e ,ashed and non@sterile
disposa+le or ade/atel" processed *lo'es
,orn, if a'aila+le
Catheter shold +e secred to a'oid mo'ement
in rethra
3i*ration of
+acteria alon* oter
srface of catheter
9o esta+lished method of pre'ention:
anti+iotic ointments and repeated cleanin* of
no 'ale
1and h"*iene ,ill redce ris- for hand
transmission of sal flora and also more
'irlent or anti+iotic@resistant or*anisms
2pen draina*e
Closed draina*e ,ith compati+le ti*ht fittin*
s"stems
If not a'aila+le, intermittent catheterisation
ma" +e preferred
If not possi+le, and catheterisation is
prolon*ed, open draina*e ma" +e sed, +t for
as short a time as possi+le
Brea-s in the closed
draina*e s"stem
<rine samples shold +e collected ,ith a
s"rin*e and needle from a samplin* area of the
t+in* after cleanin* the area ,ith alcohol.
The +a* shold not +e disconnected
If irri*ation is re/ired to remo'e +lood clots,
se aseptic techni/e. :otine irri*ation of the
+ladder to pre'ent infection is not effecti'e
The draina*e +a* shold +e emptied once per
nrsin* session into a clean receptacle sed
onl" on one patient. 1ands of staff empt"in*
+a* shold +e ,ashed and prefera+l" non@
sterile disposa+le *lo'es shold +e ,orn
Fi*re #A.# Bac- to te!t
Other precautions
The spot from the tap shold +e completel" emptied to pre'ent a +ild@p of or*anisms in
sta*nant rine.
The +a* shold not +e allo,ed to stand on the floor or to rise a+o'e the le'el of the +ladder.
Disinfectants in the +a* are not cost@effecti'e nless the infection rate is hi*h and cannot +e
controlled +" other means.
Catheters shold not +e chan*ed rotinel" as this e!poses the patient to increased ris- of
+ladder and rethral trama. The" shold +e chan*ed if associated ,ith anti+iotic treatment
or if there is an o+strction.
<se condom catheters for short@term draina*e in co@operati'e patients. Fre/ent chan*es
(e.*. dail") ma" also a'oid complications, to*ether ,ith penile care, +t the" shold +e
remo'ed at first si*n of penile irritation or s-in +rea-do,n. Condom se for 2I@hor periods
shold also +e a'oided and other methods, sch as nap-ins or a+sor+ent pads, sed at ni*ht.
!inimal Re"uirements
Decontamination of staff hands and cleanin* of perirethral area +efore insertion of sterile
(or ade/atel" decontaminated) catheter.
3aintenance of closed draina*e s"stem.
1and h"*iene +efore and after empt"in* drainin* +a*s.
Bibliograph$
6idelines for pre'entin* infections associated ,ith the insertion and maintenance of short@
term ind,ellin* rethral catheters in acte care. Journal (ospital Infection
2AA#0I&(7ppl):7($@7IJ.
11. (rinciples of antibiotic polic)
Introduction
In contries ,here there is nrestricted sale 4o'er the conterD of anti+iotics, ncontrolled misse of
anti+iotics is responsi+le for a *eneral pool of resistant strains in the micro+ial poplation. 7ales of
anti+iotics shold +e restricted to medical prescription onl".
Within hospitals, the nnecessar" se or o'erse of anti+iotics encora*es the selection and
proliferation of resistant and mltipl" resistant strains of +acteria. 2nce selected, resistant strains
are fa'ored +" anti+iotic sa*e and spread +" cross@infection. Where resistance is encoded on
transmissi+le plasmids, resistance can also spread +et,een +acterial species.
There is ths a lin- +et,een anti+iotic se (or a+se) and the emer*ence of anti+iotic resistant
+acteria casin* hospital@ac/ired infections. It is not possi+le to completel" eliminate this
e'oltionar" phenomenon, +t it can +e slo,ed or modified +" prdent anti+iotic se. This re/ires
the inclsion of an anti+iotic polic" in the infection control pro*ramme.
-h) is an antibiotic polic) necessar).
$n antibiotic policy will%
impro'e patient care +" promotin* the +est practice in anti+iotic proph"la!is and therap",
ma-e +etter se of resorces +" sin* cheaper dr*s ,here possi+le
retard the emer*ence and spread of mltiple anti+iotic@resistant +acteria.
impro'e edcation of 8nior doctors +" pro'idin* *idelines for appropriate therap"
eliminate the se of nnecessar" or ineffecti'e anti+iotics and restrict the se of e!pensi'e
or nnecessaril" po,erfl ones
/ormation of a &ospital 'ntibiotic Committee
The medical director andEor hospital mana*er shold ensre that the hospital plan for pre'ention
and control of nosocomial infection incldes an official committee that has responsi+ilit" for the
formlation and sper'ision of an anti+iotic polic". This mi*ht +e a s+committee of the hospital
Dr*s and Therapetics Committee or of the Infection Control Committee. The ;nti+iotic
Committee shold ha'e the spport of the 3edical Director and the athorit" to ensre that its
policies are implemented thro*hot the hospital.
/unction of the antibiotic committee
The main tas-s of an anti+iotic committee are the follo,in*:
to conslt ,idel" ,ith the clinical staff to *et a*reement on anti+iotic sa*e in different
specialities
to then esta+lish an anti+iotic formlar", ,hich ma" pre'ent the se of some dr*s and
restrict the se of others
to formlate *idelines for anti+iotic prescri+in*, incldin* indications for proph"la!is and
therap" of infection, the optimm dosa*es, timin*s and dration of therap" and policies for
minimisin* the ris-s of to!icit"
to re'ie, the appropriateness of anti+iotic se and the emer*ence of antimicro+ial resistance
and pro'ide feed+ac- on this to clinicians
to +e responsi+le for edcation and dissemination of information
to ,or- closel" ,ith the Infection Control Team and the 3icro+iolo*" Department
The ?e) !embers of the 'ntibiotic Committee
3em+ership of an anti+iotic committee ma" 'ar" accordin* to local conditions and needs. The
committee shold +e responsi+le for prodcin* *eneral *idelines and policies for the health care
areas after ,ide consltation ,ith the sers.
&f possible' the following (ey persons should be included in the committee%
The #harmacist ,ho ,ill report +ac- to the ;nti+iotic Committee at each meetin* on dr*
tilisation and cost.
The icro)iologist ,ho ,ill report on anti+iotic sscepti+ilit" patterns of +acteria isolated
from ma8or infections.
Clinical doctors and nurses responsi+le for direct patient care ,ho pro'ide a lin- +et,een
clinical practice and the ;nti+iotic Committee.
anger3s4 ,ho ,ill ensre the resorces are a'aila+le for implementation of the anti+iotic
polic".
"eciprocal em)ership +et,een the Infection Control Committee and the Dr*s Committee
shold +e ensred.
2ther mem+ers can +e co@opted as necessar".
The anti+iotic committee ,ill ha'e to ma-e rational choices amon*st De/i'alent dr*sD and classes
of dr*s in order to select the least e!pensi'e, most effecti'e a*ents. Cost shold determine the
selection, ,hen micro+iolo*ical, pharmacolo*ical, and other rele'ant properties are similar.
9uidelines
; ma8or tas- of the ;nti+iotic Committee ,ill +e to esta+lish *idelines for anti+iotic se. This ,ill
lead to prodction of a formlar" that restricts a*ents a'aila+le to the minimm nm+er needed for
most effecti'e therap".
)he guidelines should
+e dra,n p after ,ide consltation and a*reement in the hospital
+e simple, clear and short, and ideall" p+lished in a +oo-let small eno*h to +e carried in a
poc-et
+e pro'ided to all ne,l" appointed doctors and nrses and readil" a'aila+le in the hospital,
for e!ample, a'aila+le on ,ards
contain *idance on anti+iotic proph"la!is (e.*. in sr*er" ,ith details of timin*, rote,
dosa*e and fre/enc")
contain *idance on the choice of anti+iotics for empirical and tar*eted therap" of ma8or
infections
indicate first and second line therap" for common infections (mi*ht limit the se of certain
second line dr*s to consltant prescription onl")
Good +ractices
Consider ,hether or not the patient actall" re/ires an anti+iotic.
;'oid treatin* colonised patients ,ho are not actall" infected.
In *eneral do not chan*e anti+iotic therap" if the clinical condition is impro'in*.
If there is no clinical response ,ithin &2 hors, the clinical dia*nosis, the choice of
anti+iotic andEor the possi+ilit" of a secondar" infection shold +e reconsidered.
6i'e the anti+iotic for the minimm len*th of time that is effecti'e.
:e'ie, the dration of anti+iotic therap" after ) da"s.
Consider the se of pharmac" BstopC policies, ,here dr*s are ,ritten p for a specified
period and are then onl" contined if a ne, prescription is issed.
For sr*ical proph"la!is start the anti+iotic ,ith the indction of anaesthesia and contine
for a ma!imm of 2I hors onl".
Contribution from the !icrobiolog) 4aborator)
The micro+iolo*" la+orator" contri+tes in se'eral ,a"s to,ards the dail" clinical mana*ement of
infection.
The clinician shold recei'e reports of anti+iotic sscepti+ilit" +ased on the dr*s a'aila+le in the
a*reed formlar". The testin* shold +e performed ,ith a limited nm+er of anti+iotics selected to
optimise patient care and cost effecti'eness. The nm+er of anti+iotics reported mi*ht +e limited in
order to encora*e +etter prescri+in* (e.*. a*mentin need not +e reported if the or*anism is
sensiti'e to ampicillin). The report shold also indicate ,here or*anisms are in'aria+l" resistant
(e.*., methicillin@resistant S. aureus are resistant to all +eta@lactams).
The ;nti+iotic Committee and the Infection Control Committee shold recei'e re*lar pdates on
anti+iotic sscepti+ilit" of +acterial isolates from the local area. This ,ill assist the Committees in
prodcin* effecti'e *idance for the local patient poplation. The la+orator" shold also alert the
Committees to the emer*ence of ,idespread resistance to certain a*ents so that the inclsion of
those a*ents in the *idelines can +e re'ie,ed.
When no local micro+iolo*" la+orator" e!ists, anti+iotic polic" shold +e +ased pon a +asic
formlar", if possi+le esta+lished after consltation ,ith re*ional or national *rops. When
resorces for micro+iolo*" are scarce, priorit" shold +e *i'en to e!amination of samples from
nosocomial, life@threatenin* cases, or arran*ements shold +e made for micro+iolo*" tests ,ith a
referral hospital. Cltrin* of the en'ironment or screenin* of staff shold +e discora*ed and onl"
done after athorisation +" the Infection Control Team.
Education
;n effecti'e anti+iotic polic" also pro'ides and ensres edcation on the se of anti+iotics at
nder*radate and post*radate le'el for medical and nrsin* staff.
The edcational pro*ramme shold teach ho, to criticall" e'alate and assess ne, dr*s and
pro'ide edcation on the se and miss@se of anti+iotics to hospital staff and practisin* ph"sicians.
This ,ill redce inappropriate prescri+in*. The pro*ramme ,ill instrct in correct dosa*e, rote and
fre/enc" from the point of 'ie, of cost effecti'eness, and pro'ide information to prescri+ers on
the impact of their decisions on +oth economics and +acterial ecolo*".
!inimal re"uirements
>ist of a'aila+le anti+iotics a*reed +" all clinicians, indicatin* dosa*es, rotes of
administration and to!icities.
6idelines for therap" and proph"la!is.
; re*imen selection al*orithm also mi*ht +e inclded in an anti+iotic polic".
1#. Economic Evaluation in Infection
Control
Introduction
1ealthcare costs are risin* and decision@ma-ers are increasin*l" rel"in* on +oth clinical
effecti'eness and economic efficienc" ,hen ma-in* healthcare decisions. There is sond rationale
for economic anal"sis: resorces are scarce and choices mst +e made on ho, to se them.
The traditional factors addressed drin* the e'alation of ne, inter'entions inclde safet" (are the
side effects accepta+leX), efficac" ( can it ,or-X), and effecti'eness ( does it ,or-X). The
economics@+ased term, 4efficienc"5 shold +e considered ,hen 8d*in* the ,orth of a ne,
inter'ention. Efficienc" of an inter'ention helps ans,er ,hether or not the additional cost of an
inter'ention is ,orth the additional +enefit.
There are se'eral different t"pes of economic anal"sis that can +e emplo"ed, incldin* cost
minimi.ation, cost effecti'eness, cost +enefit, and cost tilit" anal"sis. Cost minimi.ation
(identif"in* the least costl" alternati'e that leads to an e/i'alent otcome) is rarel" sed +ecase
the clinical conse/ences of different inter'entions are rarel" e/i'alent. Cost +enefit anal"sis
(placin* a monetar" 'ale on +oth the costs and the +enefits) is also sed rarel" +ecase it is
difficlt to place a monetar" 'ale on states of health. Cost tilit" anal"ses are sefl ,hen there are
no e!pected mortalit" differences +et,een inter'entions, onl" differences in ph"sical ,ell@+ein*
,hich can +e e!pressed as /alit" ad8sted life "ears (Z;>Q).
Cost-Effectiveness 'nal)sis
; cost@effecti'eness anal"sis /antifies the trade@off +et,een increased healthcare e!penditre and
impro'ed healthcare otcome and measres the cost re/ired to achie'e a *i'en clinical +enefit. ;n
e!ample ,old +e the assessment of an inter'ention to redce catheter@related +loodstream
infection sin* antiseptic@coated 'asclar catheters. The cost of the antiseptic catheter is sall"
more than the standard catheter, ho,e'er this can +e compared ,ith the clinical +enefits associated
,ith the antiseptic catheter. Ths, a cost@effecti'eness ratio can +e *enerated. It is the total dollars
spent for the inter'ention di'ided +" the nm+er of cases of catheter@related +loodstream infection
pre'ented. If the antiseptic catheter prodced sperior +enefits at an increased cost, then an
incremental cost%effecti$eness ratio L the amont of mone" needed to prodce an additional clinical
+enefit L cold +e calclated. 1o,e'er, if the inter'ention led to an actal redction in o'erall costs
,hile impro'in* health otcomes, it ,old +e called a 4dominant5 inter'ention, since it ,old
pro'ide +oth clinical and economic +enefits.
Ta+le #2.# helps decide ,hen a cost@effecti'eness anal"sis is appropriate. In *eneral, there are for
possi+ilities ,hen comparin* t,o inter'entions, ; and B. The first possi+ilit" is that ; is more
effecti'e and costs less. Ths, ; is the dominant strate*" and shold +e sed ,ithot frther
anal"sis. >i-e,ise, ,hen B is more effecti'e and costs less than ;, B is dominant and a cost@
effecti'eness anal"sis is nnecessar". 1o,e'er, as is more common, ,hen ; is more effecti'e than
B +t costs more than B, it is helpfl to perform an incremental cost@effecti'eness anal"sis to
/antif" the clinical and economic conse/ences of inter'ention ;. E!amples of sch anal"ses
,old inclde antiseptic@coated 'asclar catheters to pre'ent catheter@related +loodstream infection
G#H or sil'er allo" rinar" catheters to pre'ent rinar" catheter@related infection G2H. 7ch stdies
ha'e +een performed and ha'e fond that the inter'ention is li-el" to +e ,orth,hile in man"
circmstances. ;n incremental cost@effecti'eness ratio is interpreta+le onl" ,hen compared ,ith
another incremental cost@effecti'eness ratio e!aminin* the same health otcome. For e!ample, the
cost@effecti'eness of pre'entin* local 'asclar catheter@related infection cannot +e directl"
compared to the cost@effecti'eness of pre'entin* rinar" catheter@related +acteremia.
Table .2... $hoosing among alternative interventions in a cost effectiveness analysis Bac- to
te!t
C27T7
;SB ;PB
EFFECT7
;PB
; is Dominant
3Cost%effecti$eness analysis
unnecessary4
Incremental
3Cost%effecti$eness analysis
useful4
;SB
Incremental
3Cost%effecti$eness analysis
useful4
B is Dominant
3Cost%effecti$eness analysis
unnecessary4
; [ Inter'ention D;D0 B [ Inter'ention DBD
!E'$>RI%9 E//ECTI@E%E$$ '% CO$T$
*ffecti#eness and Cost *stimates
Economic e'alations of health care inter'entions depend pon solid clinical e'idence of
effecti'eness in order to esta+lish +enefits and ris-s. The 'alidit" of the clinical data is crcial to the
o'erall seflness of the anal"sis. 3an" economic e'alations rel" on a sin*le randomi.ed trial or a
sin*le o+ser'ational std" to estimate clinical +enefit. 7ome stdies rel" on less ri*oros or non@
scientific sorces of information for otcome assessment, sch as clinical opinion and e!pert
panels. Estimates deri'ed from lar*e@scale, mlti@center trials are ,idel" considered the 4*old
standard,5 ho,e'er these data often are not a'aila+le. In addition to effecti'eness estimates, the
anal"st mst also estimate the cost inpts. 2ften, ho,e'er, cost is poorl" defined for different
infection control inter'entions as ,ell as for the nosocomial or hospital ac/ired infection nder
consideration.
Meta-analysis
3eta@anal"sis is a 4/antitati'e approach for s"stematicall" com+inin* the reslts of pre'ios
research in order to arri'e at conclsions a+ot the +od" of research.5 G(H 3eta@anal"sis is sed to
statisticall" pool the reslts from indi'idal stdies, sall" randomi.ed trials, to o+tain an estimate
of the smmar" effect si.e across stdies. The smmar" measre from a meta@anal"sis is often sed
to deri'e the pro+a+ilit" of treatment sccess in a cost@effecti'eness anal"sis GIH.
E'en if the +enefit of an inter'ention cold +e demonstrated in e'er" clinical settin*, the cost@
effecti'eness ratios ,old 'ar" considera+l" dependin* on local economics. Ths, an inter'ention
that ma" appear 4cost effecti'e5 in one contr" or hospital district (e.*., ,ith a cost@effecti'eness
ratio less than \)A,AAA per life "ear sa'ed), ma" +e considered too e!pensi'e else,here.
Economic e'alation in the area of infection control can +e performed in a ri*oros and
strai*htfor,ard manner, ho,e'er se'eral +arriers e!ist to its rotine introdction. First, since
economic e'alation is not ,idespread in infection control, terminolo*" mst +e sed correctl".
2ften, ,hen medical directors and other decision@ma-ers sa", 4cost effecti'e5 the" impl" cost
sa$ings . 1o,e'er, 4cost effecti'e5 technicall" indicates that ,e are spendin* an additional amont
of mone" for an additional clinical +enefit and is +ased on the e!plicit comparison of one strate*"
,ith another. Cost sa'in*s impl" that ,e are *ettin* an e/i'alent or *reater clinical +enefit and
actall" sa'in* mone"0 this scenario is rare. The cost@effecti'eness of inter'ention ; compared ,ith
inter'ention B can ran*e from cost sa'in*, cost netral, cost effecti'e to cost ineffecti'e. ;nother
important isse ,ithin infection control is that the attri+ta+le mor+idit", mortalit", and costs of
nosocomial infection are difficlt to assess.
456786TING 6N 4C0N0MIC 6N6793I3
There are se'eral important criteria +" ,hich economic anal"ses shold +e 8d*ed (smmari.ed in
Ta+le #2.2) G)H. The first /estion is ,hether or not a ,ell@defined research /estion ,as posed.
This is of fndamental importance, since a research /estion that is not ,orth ans,erin* is sall"
not ,orth ans,erin* +ell. 7econd, it is important that all the le*itimate and reasona+le competin*
alternati'es +e e'alated in the anal"sis. Third, it is 'ital that the effecti'eness of the inter'ention +e
clearl" esta+lished, since an inter'ention that is not effecti'e ,ill certainl" not +e cost@effecti'e.
Finall", it is critical that all the important and rele'ant costs and conse/ences of the inter'ention
are identified and considered, dependin* on the perspecti'e of the anal"sis.
Table .2.2. 3uestions that should be answered when performing
or reading a cost4effectiveness analysis Bac- to te!t
1 Was a #ell:defined question posed;
& Were all the competing alternati,es e,aluated;
( Was the effecti,eness of the inter,ention established;
) Were all the important and rele,ant costs and consequences for each alternati,e
identified !depending on the perspecti,e%;
* Was uncertaint$ in the estimates adequatel$ e,aluated;
2eferences
#. Feenstra D>, 7aint 7, 7lli'an 7D . Cost@effecti'eness of antiseptic@impre*nated central
'enos catheters for the pre'ention of catheter@related +loodstream infection. JAA .
#$$$02%2:))I@)JA. Bac- to te!t
2. 7aint 7, Feenstra D>, 7lli'an 7D, Cheno,eth C, Fendric- ;3 . The potential clinical and
economic +enefits of sil'er allo" rinar" catheters in pre'entin* rinar" tract infection. Arch
Intern ed . 2AAA0#JA:2J&A@2J&). Bac- to te!t
(. Petitti DB . eta%analysis' decision analysis' and cost%effecti$eness analysis 9e, Qor- , 9Q
: 2!ford <ni'ersit" Press0 #$$I. Bac- to te!t
I. 7aint 7, Feenstra D>, 7lli'an 7D . The se of meta@anal"sis in cost@effecti'eness anal"sis:
isses and recommendations. #harmacoEconomics . #$$$0#)(#):#@%. Bac- to te!t
). Drmmond 3F, 2DBrien B, 7toddart 6>, Torrance 6W. ethods for the Economic
E$aluation of (ealth Care #rogrammes . 2nd ed 9e, Qor- : 2!ford <ni'ersit" Press0 #$$&
Bac- to te!t
11. The Costs of &ospital Infection
Introduction
1ospital@ac/ired infections (1;Is) are common: at an" one time a+ot # in #A patients in acte
care hospitals ha'e an 1;I, and an additional #A@JAK of infections ma" present after dischar*e.
1;I is an important case of mor+idit" and mortalit" and therefore shold +e ri*orosl" controlled
as part of the *eneral dt" of patient care. Bt 1;I also has considera+le BeconomicC impact on
hospital ser'ices and on the costs of national health care.
The economic consequences of hospital:acquired infection
3easrement of the costs of 1;I is difficlt and the financial impact 'aries +et,een different
healthcare s"stems. 9e'ertheless, in simple terms, 1;I can ha'e the follo,in* economic reslts:
(#) 1;I dela"s patient dischar*e, resltin* in increased BhotelC costs. In addition, the patient sffers
additional costs de to increased a+sence from ,or- and relati'es sffer costs of time and tra'el to
'isit the patient0
(2) Infections re/ire increased treatment costs (for e!ample, increased dr* therap" and increased
nm+ers of procedres, incldin* repeat sr*er"). The patient ma" +e dischar*ed from hospital
,hile infected and the increased treatment costs then fall on 6eneral Practice or commnit"
ser'ices0
(() 1;I is accompanied +" increasin* nm+ers of la+orator" and ima*in* in'esti*ations0
(I) 1;I increases infection control costs, incldin* epidemiolo*ical in'esti*ations and medical,
nrsin* and mana*ement time0 and
()) 1;I is often the s+8ect of liti*ation, the costs of ,hich ma" +e h*e.
Increased rates of 1;I associated ,ith +loc-ed +eds and closed ,ards and theatres, reslts in
increased nit costs for admissions and procedres, len*thenin* ,aitin* lists and failre to complete
contracts. ;ll these ha'e financial penalties. Patient mor+idit" resltin* from 1;I ,ill also ha'e
lar*e commnit" and societ" costs that are difficlt to /antitate +t ma" ha'e considera+le impact.
;lso difficlt to measre in economic terms is loss of reptation L either for the ,hole hospital or
for indi'idal nits L ,hich has si*nificant impact on contracts and patient referral.
0,erall cost estimates
;ltho*h the measrement of costs of 1;I is difficlt, a nm+er of stdies ha'e sho,n the
pro+a+le ma*nitde of the pro+lem. ; #$$$ std" ,as done +" Plo,man and collea*es in the <= .
The" stdied IAAA adlt patients in an En*lish district *eneral (commnit") hospital drin* #$$I L
#$$) G#H. Costs ,ill +e different for other contries and ,ill chan*e ,ith time, ho,e'er the relati'e
ma*nitdes ,ill +e similar. ; smaller std" +" Coello et al in #$$( in En*land sho,ed similar costs
G2H.
In the Plo,man std", &.%K of patients had 1;I identified in hospital. In addition, #$K of patients
,ho ,ere not dia*nosed ,ith 1;I in hospital, and (AK of those ,ho ,ere, reported s"mptoms of
1;I after dischar*e. Patients ,ith 1;I dia*nosed in hospital remained in hospital a+ot 2.)! lon*er
than ninfected patients, an a'era*e of ## additional da"s. (Fi*re #(.#) The" had increased
hospital costs a+ot 2.%! *reater than ninfected patients, a'era*in* a+ot ](,AAA (\),AAA) per case
(Fi*re #(.2). #(K of infected patients died compared ,ith 2K of those ninfected. ;d8sted for
a*e, se!, co@mor+idit" and other factors, the death rate ,as & times hi*her for patients ,ith 1;I.
Ta+le#(.# sho,s the additional len*th of hospital sta" associated ,ith 1;I in other stdies).
Bac- to te!t
Bac- to te!t
Table .5... !tudies of cost 6 increased hospital length of stay associated with H*I.
0rom ilcox 6 'ave 7..8 Bac- to te!t
Estimated costs of 1;I to the hospital in the Plo,man std" ,as ](.Jm (\).%m). Costs mi*ht +e
e!pected to +e hi*her in tertiar" referral hospitals.
The e!trapolated national annal cost +rden of 1;I for hospitals ,as a+ot ]#+ (\#.J+),
e/i'alent to a+ot #K of the total national hospital +d*et or the resorces of t,ent"@se'en IAA@
+edded *eneral hospitals. The national annal post dischar*e costs ,ere estimated to +e a+ot ])Jm
(\$Am). This inclded 6eneral Practice costs of ]%.Im, hospital ot@patients ]2&m, and commnit"
nrsin* ser'ices ]2#m.
It ,as estimated that 1;I ,as the direct case of a+ot )AAA deaths per annm in En*land (more
than those cased +" sicides or traffic accidents) and contri+ted to an additional #),AAA.
In the <7;, 1;I is amon*st the top ten cases of death G(,IH. The <7 Institte of 3edicine
estimates that pre'enta+le ad'erse patient e'ents, incldin* hospital@ac/ired infections, are
responsi+le for II,AAA@$%,AAA deaths annall" in the <7 at a cost of \#&@\2$ +illion G)H. The <7
9ational 9osocomial Infection 7r'eillance s"stem had a positi'e impact on redcin* 1;I rates in
participatin* hospitals GJH.
In 3e!ico, 9a'arrete@9a'arro and ;rmen*ol@7anche. G&H estimated costs associated ,ith 1;I in
pediatric intensi'e care. Infected children had an e!cess hospital sta" of $.J da"s. This ,as the
ma8or factor contri+tin* to an a'era*e cost per infection of nearl" \#2,AAA.
Costs of outbrea+s
7e'eral stdies ha'e attempted to measre the costs associated ,ith hospital ot+rea-s of infection.
;*ain, the costs are tentati'e and mst +e considered in relation to the health care s"stem stdied
and the "ear of std". 9e'ertheless, a*ain the costs ha'e +een sho,n to +e considera+le.
Co! et al. G%H, estimated the additional costs *enerated +" a lar*e ot+rea- of methicillin@resistant S.
aureus (3:7;) o'er three "ears in an En*lish district *eneral hospital as ]IAA,AAA (\JIA,AAA). ;
smaller 3:7; ot+rea- cost ]&AAA, ho,e'er an ot+rea- of mltidr* resistant 6ram@ne*ati'e
infection increased costs +" a+ot ](),AAA (\)J,AAA) (#$$A prices) G$H. =im et al G#AH measred the
costs of 3:7; in their hospital and calclated that 3:7; cost all Canadian hospitals \I2m @ \)$m
annall" in #$$& dollars.
Cost benefit of infection control
In the 7td" on the Efficienc" of 9osocomial Infection Control (7E9IC) of #$&I@#$%( G(H, <7
hospitals ,ith one fll@time infection control nrse (IC9) per 2)A +eds, an infection control doctor
(ICD), moderatel" intense sr'eillance, and s"stem for reportin* ,ond infection rates to sr*eons,
redced their 1;I rates +" (2K. In the other hospitals, the 1;I rate increased +" #%K. The 7E9IC
std" estimated that (in #$&) dollars), the annal cost of 1;I in <7 hospitals ,as \#+. The cost of
infection control teams (A.2 ICD, # IC9, # cler- per 2)A +eds) ,as \&2m per annm, onl" &K of
the infection costs. Therefore, if infection control pro*rammes ,ere effecti'e in pre'entin* onl" &K
of nosocomial infections (normall" distri+ted), the costs of the pro*rammes ,old +e co'ered. ;
2AK effecti'eness ,old sa'e \2AAm, and )AK ,old sa'e \A.)+ (#$&) <7 prices).
Conclusions
The costs of 1;I are h*e and inclde patient mor+idit" and mortalit", hospital and commnit"
medical costs, the impact of +loc-ed +eds, and ,ider socio@economic costs. The costs of infection
control pro*rammes and staffin* are relati'el" small and ,ith onl" a small de*ree of effecti'eness
the" can pa" for themsel'es. In'estment in infection control is therefore hi*hl" cost effecti'e.
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(ospital Infection Control 2 #rinciples and #ractice. E; Partnership and the Infection
Control 9rses ;ssociation, 2AAA.
Infection Control Training and #olicies for (ospital. 1o,ard ?P, Case,ell 3, Desi 9.
>ondon:W B 7anders Compan",#$$%.
C0M+8T42 30FTW624
*pi &nfo
Epi Info is soft,are pro*ramme ,as de'eloped +" the Centres for Disease Control and Pre'ention
to mana*e and anal".e data collected drin* an epidemiolo*ic in'esti*ation. Epi Info also
calclates statistical tests sed in an ot+rea- sitation. Epi Info can +e do,nloaded from the CDC
,e+ site ,,,.cdc.*o' EepiinfoEinde!.htm .
*"&+et
The E!posre Pre'ention Information 9et,or- (EPI9et) s"stem collects data a+ot perctaneos
in8ries amon* health care ,or-ers. :n +" the International 1ealth Care Wor-ers 7afet" Centre at
the <ni'ersit" of Fir*inia 1ealth 7ciences Centre , EPI9et also standardises reportin* of
information pertainin* to sch in8ries, as ,ell as e!posres to patientCs +lood and +od" flids.
1ospitals can se the EPI9et s"stem to share and compare information and to identif" sccessfl
in8r"@pre'ention measres. EPI9et can +e reached at its ,e+ site ,,,.med.'ir*inia.edE^epinetE .
,!-C$.*
W12C;:E ,as de'eloped +" the World 1ealth 2r*anisation. It comes in t,o 'ersions: the Basic
'ersion, p+lished #$%$, ,as desi*ned for sr'eillance of sr*ical sites infections. The
comprehensi'e 'ersion incldes other t"pes of nosocomial infection. It is a'aila+le from the
W12C;:E distri+tion centre in Copenha*en , Denmar- (Fa!: I) (2 J% (% &&).
I%TER%ET
AO>R%'4$
9ournals ebsites
;merican ?ornal of
Infection Control
http:EE,,,.mos+".comEa8ic
Canada Commnica+le
Disease :eport
http:EE,,,.hc@sc.*c.caEmainElcdcE,e+E
Commnica+le Disease
:e'ie, (CD:)
http:EE,,,.phls.co.-Ep+licationsECD:
Emer*in* Infectios
Diseases
http:EE,,,.cdc.*o'EncidodEEIDEinde!.htm
Erosr'eillance http:EE,,,.erosr'.or*
Infection Control and
1ospital Epidemiolo*"
http:EE,,,.slac-inc.comE*eneralEiche
?ornal of 1ospital
Infection
http:EE,,,.else'ierhealth.comE8ornalsE8hin
3or+idit" M 3ortalit"
Wee-l" :eport (33W:)
http:EE,,,.cdc.*o'Emm,rE
W12 ,ee-l"
Epidemiolo*" :ecord
http:EE,,,.,ho.intE,erE
OR9'%IB'TIO%2 I%$TIT>TIO%$ '% RE9>4'TORC 0OIE$
:ames ebsites
;ssociation for
Professionals in
Infection Control and
Epidemiolo*" (;PIC),
<7;
http:EE,,,.apic.or*
;ssociation of
peri2perati'e
:e*istered 9rses
(;2:9), <7;
,,,.aorn.or*
;stralian Infection
Control ;ssociation
http:EE,,,.aica.or*.aE
Centre for Disease http:EE,,,.cdc.*o'
Control M Pre'ention
(CDC), <7;
Commnica+le Disease
7r'eillance M
response (W12)
http:EE,,,.,ho.intEemc
Commnica+le Disease
7r'eillance Centre, 9
Ireland
http:EE,,,.cdscni.or*.-
Commnit" and
1ospital Infection
Control ;ssociation
(C1IC;), Canada
http:EE,,,.chica.or*
Eropean 2peratin*
:oom 9rses
;ssociation (E2:9;)
,,,.eorna.or*
Department of 1ealth ,
En*land , <=
http:EE,,,.doh.*o'.-Edhhome.htm
Food and Dr*
;dministration (FD;),
<7;
http:EE,,,.fda.*o'
1ealth Canada Disease
Pre'ention and Control
6idelines
,,,.hc@sc.*c.caE
1ospital in Erope
>in- for Infection
Control thro*h
7r'eillance (1E>IC7)
http:EEhelics.ni'@l"on#.fr
1ospital Infection
7ociet" , <=
http:EE,,,.his.or*.-
1and 1"*iene
:esorce Centre
,,,.handh"*iene.or*
Infection Control http:EE,,,.icna.co.-
9rses ;ssociation
(IC9;), <=
Infectios Diseases
7ocieties World,ide
http:EE,,,.idlin-s.comE
Infectios Diseases
7ociet" of ;merica
http:EE,,,.idsociet",or*Einde!.htm
International
Federation of Infection
Control (IFIC)
http:EE,,,.ific.narod.r
International 1ealth
Care Wor-er 7afet"
Centre , <7;
,,,.med.'ir*inia.edE^epinetE
International 7ociet" of
Infectios Diseases
,,,.isid.or*
?ohn 1op-ins
<ni'ersit"@Infectios
Diseases , <7;
http:EE,,,.hop-ins@id.edEinde!_id_linls.html
3edical De'ices
;*enc" (3D;), <=
http:EE,,,.medical@de'ices.*o'.-
9ational Disease
7r'eillance Centre,
:ep+lic of Ireland
http:EE,,,.ndsc.ie
9ational Fondation
for Infectios Diseases,
<7;
,,,.nfid.or*E
9ational Institte for
P+lic 1ealth
7r'eillance, France
http:EE,,,.rnsp@sante.frE
9ational 9osocomial
Infections 7r'eillance
7"stem, CDC , <7;
http:EE,,,.cdc.*o'EncidodEhipE7r'eillEnnis.htm
2ccpational 7afet" M
1ealth ;dministration
(271;), <7;
http:EE,,,.osha.*o'
P+lic 1ealth
>a+orator" 7er'ices
(P1>7), <=
http:EE,,,.phls.co.-
:o+ert =och@Institt,
6erman"
http:EE,,,.r-i.deEI9DEU.1T3
7cottish Centre for
Infection and
En'ironmental 1ealth (
7CIE1)
http:EE,,,.sho,.scot.nhs.-EsciehE
7ociet" for 1ealthcare
Epidemiolo*" of
;merica (71E;), <7;
http:EE,,,.shea@online.or*
7ociete Francaise
dC1"*iene
1ospitaliere , France
(7F11)
http:EEsfhh.ni'@l"on#.frE
World 1ealth
2r*ani.ation (W12)
http:EE,,,.,ho.intE