Blood Safety and Clinical Technology

Guidelines on Prevention and Control of Hospital Associated Infections

Acknowledgements
The draft Guidelines on Prevention and Control of Hospital Associated Infections were finalized during a Consultative Meeting on Prevention and Control of Hospital Associated Infections organized in Bangkok, Thailand, fro !" to !# $une !%%&' The first draft was prepared () *r Geeta Mehta, Head of the Micro(iolog) *epart ent, +ad) Hardinge Medical College, ,ew *elhi, India and finalized in the Consultative Meeting' The valua(le contri(utions of all the e-perts listed in the Anne- are gratefull) acknowledged

Introduction
Infections which arise in hospitals are ter ed .hospital associated infections. /HAI0' 1uch infections have also (een called .nosco ial infections. and so eti es .hospital ac2uired infections.' As ore health care is now (eing provided in a (ulant patients, the ter .health care associated infections. is also used' efinition Hospital Associated Infections /HAI0 or nosco ial infections are those infections that were neither present nor incu(ating at the ti e the patient was ad itted to the health care facilit)' The a3orit) of HAI (eco e evident 45 hours or (eco e clinicall) evident until after discharge' ore following ad ission' However, it a) not

There are various reasons wh) patients in hospital ac2uire infection' Patients with infectious diseases are fre2uentl) ad itted to hospital' 1o e of these patients are a(le to spread their organis s to other patients and the) provide one source of infection in hospital patients ad itted for other causes' 6-a ples of such infections spreading in hospital include 7 sal onellosis, group A streptococcal infections, tu(erculosis, viral hepatitis and other infections' 8hen such patients re2uire ad ission to hospital, the risk has to (e assessed for other patients and appropriate easures taken to contain the infection with isolation procedures of var)ing degrees of strictness depending on the infection' The co onest for s of hospital9ac2uired infection are due to invasive procedures carried out on patients such as surgical operations, intravenous therap), intu(ation and catheterization' A variet) of easures is needed to control such infections' I uno9co petence of var)ing degrees is seen in an) of the patients ad itted to hospital' These include patients at the e-tre es of age, those with dia(etes, receiving i unosuppressive drugs and those with cancer, in particular those undergoing che otherap)' These patients are prone to infection with (acteria which have little threat for health) persons' Sources of infection in hospital Bacteria and viruses are natural inha(itants of the environ ent, (oth in the co unit) and in the hospital' The a3orit) of these organis s are not pathogens and a) even have a (eneficial role to pla) in hu an (od)' The organis s in the natural environ ent a) provide a reservoir fro which the) a) (e passed to other patients and cause infections' However, there are ver) an) reservoirs: the one fro which infections arise is usuall) called the source' Identification of the correct source is essential to arrest the spread fro this source' The sources of spread can (e classified along the sa e lines as the t)pes of infection' &' 1pread fro co unit)9ac2uired infections to other patients in hospital can (e via; The respirator) tract as in tu(erculosis and respirator) viruses: Infected (lood as with viral hepatitis and HI<: =aeces with sal onella, shigella, vi(rio: The air or skin scales as with chicken po-, herpes, staph)lococci, streptococci, and Infected discharges such as pus' Prevention of such spread re2uires interventions specific to the individual infectious diseases' !' Patients undergoing hospital treat ent fre2uentl) (eco e infected' These infections arise fro an) different sources and are usuall) associated with operative or other invasive procedures carried out in operating theatres, wards, >9ra) depart ents and clinics'

The organis s co e fro

an) possi(le sources, such as;

The patients? own resident flora 7 the outh, gastrointestinal tract, vagina or the skin: The resident icro(ial flora of health care workers and fro other patients on the ward: Transient (acteria carried on the hands of health care workers fro one patient to another: Conta inated instru ents, dressings, needles, etc' used for invasive procedures, and Infusions' The wide variet) of opportunities for ac2uisition of hospital pathogens re2uires general standards of hospital practice to protect all patients' At the sa e ti e, each risk group or procedure a) re2uire specific easures related to re oving special sources of infection' The general procedures include ite s such as; 1uppl) of ade2uatel) sterilized instru ents and dressings: @perating theatre design, discipline and procedures: General application of aseptic techni2ues: Good environ ent cleaning, safe food, effective laundr) procedures and waste disposal, and 1pecific easures include ite s such as; catheterization, venous access and investigative

1tandardized procedures for intu(ation, procedures and Peri9operative surgical che oproph)la-is' A'

The groups at high risk of ac2uisition of infection due to di inished defences re2uire additional protection including hospital areas where there are enhanced invasive procedures' The specific re2uire ents of ICB, special (a() units, oncolog) depart ents and long9sta) surgical wards need to (e docu ented and i ple ented' =or neutropenic patients, special isolation procedures providing a protective environ ent rather than contain ent facilit) are necessar)' 8ith such a co ple- series of events, it is necessar) to appl) a scientific approach to the assess ent of risks in order to esta(lish priorities for infection control' All hospital staff re2uire infor ation on control of hospital infection and the particular role each group has to pla) in the process' The practicalities of the situation have to (e discussed with staff at all levels to ensure that the) are capa(le of carr)ing out the reco ended procedures' Instructions are ore readil) co plied with if the procedures have (een e-plained and are accepta(le to the surgeons, nurses, technicians and do estic staff who have to i ple ent the ' !agnitude of pro"lem Hospital9associated infections are considered as a3or causes of ortalit), e otional stress and enhanced or(idit) in hospitalized patients' These also account for significant econo ic loss and additional (urden on health care institutions' In a stud) conducted () 8H@, the highest fre2uencies of HAI were reported fro hospitals in the 6astern Mediterranean Cegion /&&'5D0 followed () 1outh96ast Asia, where it was &%D' It has also (een esti ated that at an) ti e over &'4 illion people worldwide suffer fro infectious co plications ac2uired in hospital' The infections ac2uired in the hospitals a) (e due to resistant organis s that further accentuate the pro(le ' It has also (een esti ated that these infections cost ore than B1E 4% illion ever) )ear in Thailand alone'

Infection Control Programme

6ach hospital needs to develop a progra e for the i ple entation of good infection control practices and to ensure the well (eing of (oth patients and staff () preventing and controlling HAI' #"$ectives of the infection control programme Monitoring of hospital9associated infections: Training of staff in prevention and control of HAI: Investigation of out(reaks: Controlling the out(reak () rectification of technical lapses, if an): Monitoring of staff health to prevent staff to patient and patient to staff spread of infection: Advice on isolation procedures and infection control easures: Infection control audit including inspection of waste disposal, laundr) and kitchen, and Monitoring and advice on the safe use of anti(iotics' %esponsi"ility of hospital administrator&head of health care facility

The hospital ad inistratorFhead of hospital should; Provide the funds and resources for infection control progra 6nsure a safe and clean environ ent: 6nsure the availa(ilit) of safe food and drinking water: 6nsure the availa(ilit) of sterile supplies and aterial, and 6sta(lish an infection control co ittee and tea ' Infection control organi'ations in a hospital Infection control organizations are essential features of an infection control progra organizations are; () Infection Control Committee *ICC+ e' These e:

Cepresentatives of edical, nursing, engineering, ad inistrative, phar ac), C11* and icro(iolog) depart ents are the e (ers' The co ittee for ulates the policies for the prevention and control of infection' @ne e (er of the co ittee is elected chairperson and has direct access to the head of the hospital ad inistration' The infection control officer is the e (er secretar)' The co ittee eets regularl) and not less than three ti es a )ear' ,) Infection Control Team *ICT+ easures for the control of infection'

Me (ers are the Infection undertake out the da) to da) -) Infection Control #fficer *IC#+ edical

The Infection Control @fficer is usuall) a hospital associated infections' .unctions &' !' A' 4' G' "' H' /)

icro(iologist or an) other ph)sician with an interest in

1ecretar) of Infection Control Co ittee and responsi(le for recording inutes and arranging eetings: Consultant e (er of ICC and leader of ICT: Identification and reporting of pathogens and their anti(iotic sensitivit): Cegular anal)sis and disse ination of anti(iotic resistance data, e erging pathogens and unusual la(orator) findings: Initiating surveillance of hospital infections and detection of out(reaks: Investigation of out(reaks, and Training and education in infection control procedures and practice' Infection Control 0urse *IC0+

A senior nursing sister should (e appointed full9ti e for this position' Ade2uate full9ti e or part9ti e nursing staff should (e provided to support the progra e' .unctions &' !' A' 4' G' 1) To liaise (etween icro(iolog) depart ent and clinical depart ents for detection and control of HAI: To colla(orate with the IC@ on surveillance of infection and detection of out(reaks: To collect speci ens and preli inar) processing: the IC,s should (e trained in (asic icro(iologic techni2ues: Training and education under the supervision of IC@, and To increase awareness a ong patients and visitors a(out infection control' Infection Control !anual*IC!+ anual (ased upon e-isting

It is reco ended that each hospital develops its own infection control docu ents (ut odified, for local circu stances and risks' %ole of the micro"iology la"oratory

The icro(iolog) la(orator) has a pivotal role in the control of hospital associated infections' The icro(iologist is usuall) the Infection Control @fficer' The role of the depart ent in the HAI control

progra

e includes;

Identification of pathogens 9 the la(orator) should (e capa(le of identif)ing the co on (acteria to the species level: Provision of advice on anti icro(ial therap): Provision of advice on speci en collection and transport: Provision of infor ation on anti icro(ial suscepti(ilit) of co on pathogens, and Periodic reporting of hospital infection data and anti icro(ial resistance pattern 9 The periodic reporting of such dates is an i portant service provided () the icro(iolog) depart ent' The fre2uenc) of this should (e as deter ined () the ICC' Identification of sources and ode of trans ission of infection 9 Culture of carriers, environ ent for identif)ing the source of the organis causing infection /out(reak organis 0' The selection of sites for culture depends upon the known epide iolog) and survival characteristics of the organis : 6pide iological t)ping of the isolates fro cases, carriers and environ ent: Micro(iological testing of hospital personnel or environ ent 9 Testing for potential carriers of epide iologicall) significant organis s' As a part of the infection control progra e, the icro(iolog) la(orator) at ti es a) need to culture potential environ ental and personnel sources of nosco ial infections' Bsuall) this is li ited to out(reak situation when the source and ethod of trans ission needs to (e identified' Coutine icro(iological sa pling and testing is not reco ended: Provide support for sterilization and disinfection in the facilit) including (iological onitoring of sterilization' Provide facilities for icro(iological testing of hospital aterials when considered necessar) 9 These a) include; sa pling of infant feeds: onitoring of (lood products and dial)sis fluids: 2ualit) control sa pling of disinfected e2uip ent: additional sterilit) testing of co erciall) sterilized e2uip ent is not reco ended: Provide training for personnel involved in infection control 9This for s an i portant part of the Infection Control Progra e' 6ach hospital should develop an e plo)ee training progra e' *ifferent categories of staff should (e targeted through this progra e training relevant to their functions' The Infection Control ,urse pla)s a a3or part in training and education' The ai of the training progra e is to thoroughl) orient all hospital personnel to the nature of HAI and to wa)s of prevention and treat ent' As the various hospital e plo)ees have different functions and their level of education is different, the training progra e needs to (e altered to suit the functional re2uire ents of each categor) of staff and should (e adapted accordingl)' Training should (e preceded () a needs assess ent surve)' The training progra e should include the following; Basic concepts of infection: Hazards associated with their particular categor) of work': Acceptance of their personal responsi(ilit) and role in the control of hospital infection: Methods to prevent the trans ission of infection in the hospital, and 1afe work practice' Training should provide the infor ation needed to odif) staff (ehaviour' Innovative techni2ues such as role9pla), pro(le solving, 2uiz co petitions and poster aking etc should (e e plo)ed' The ICC should agree to the level and fre2uenc) of training'

The Hospital 2nvironment and Hospital Associated Infections

2nvironment The environ ent in the hospital pla)s an i portant role in the occurrence of hospital associated infections' The hospital environ ent consists of an) co ponents' Man) have a direct (earing upon HAI including design of ward and operating theatre facilities, air 2ualit), water suppl), food and handling of edical waste and laundr)' () Premises&"uildings

An infection control tea e (er should (e involved in the planning of an) new facilit) or renovation' The role of infection control in this process is to ini ize hospital associated infections' These include ite s such as; 6nsuring appropriate hand washing facilities: A safe water suppl): Ade2uate isolation facilities for the hospital:

Ade2uate ventilation for isolation roo s and high risk areas like operation theatres, transplant units and intensive care units: Ceco ending traffic flow to ini ize e-posure of high risk patients and facilitate patient transport: Preventing e-posure of patients to fungal spores during renovations, and @utlining precautions to (e taken to control rodents, pests and other vectors responsi(le for trans ission of infection' ,) Air

Air(orne droplet nuclei generated during coughing or sneezing are a potential source of trans ission of infection either () direct inhalation or indirectl) through conta inated edical devices' *roplets generated fro infected respirator) tracts can re ain air(orne for long periods of ti e and trans it infections like tu(erculosis, respirator) viral illnesses and anti(iotic9resistant hospital (acteria' 1o e housekeeping activities /such as sweeping, using dr) ops or cloths or shaking linen0 can aerosolize dust particles that a) contain icro9organis s' Therefore, wet opping is preferred' The nu (er of organis s present in roo air will depend on the nu (er of people occup)ing the roo , the a ount of activit), and the rate of air e-change' 1kin s2ua ae and lint are i portant sources of conta ination' 3entilation4 1o e HAI are caused () air(orne pathogens and appropriate ventilation is necessar)' 1o e la(orator) onitoring a) (e needed in high9risk areas such as operation theatres for cardiac surger), neurosurger) and transplant surger) after a3or (uilding works in the unit' Circulation of fresh filtered air dilutes and re oves air(orne (acterial conta ination, in addition to re oving odour' All hospital areas and in particular the high9risk areas, should (e well ventilated as far as possi(le' <entilation s)ste s should (e designed and aintained to ini ize icro(ial conta ination' The air conditioning filters should (e cleaned periodicall) and fans that can spread air(orne pathogens should (e avoided in high9 risk areas' Good housekeeping should ensure that unnecessar) ite s like e pt) (o-es do not clutter and i pede ventilation in high9risk areas' Positive air pressure is reco ended for high9risk areas that ust (e kept clean' ,egative air pressure vented to the air is reco ended for conta inated areas and is re2uired also for isolation of patients with infections spread () the air(orne route' =iltration s)ste s /air handling units0 designed to provide clean air should have H6PA filters in high9risk areas' Bnidirectional la inar airflow s)ste s should (e availa(le in appropriate areas in the hospital construction' Bltraclean air is valua(le in so e t)pes of cardiac surger) F neurosurger) F i plant surger) theatres and transplant units' Critical para eters for air 2ualit) include; &' !' A' 4' -) Maintenance F validation of efficac) of filters Pressure gradient across the filter (ed and in the operation theatre Air changes per hour / ini u &G air changes per hour0 Te perature and hu idit) should (e aintained (etween !%9!!I C and A%9"%D, respectivel) to inhi(it (acterial ultiplication' 5ater

8ater is used in hospitals for an) different uses' The purpose for which the water is to (e used deter ines the criteria for water 2ualit)' The criteria for drinking water are usuall) not ade2uate for the edical uses of water' *rinking water should (e safe for oral intake' =or water 2ualit)'& ore details, refer to 8H@ guidelines for drinking of

The water suppl) s)ste should ensure the provision of safe water' The overhead storage tanks should (e cleaned regularl) and the 2ualit) of water should (e sa pled periodicall) to check for faecal conta ination' 1o e icro9organis s in the hospital have caused infection of wounds, respirator) tract and other areas where e2uip ent such as endoscopes were rinsed with tap water after disinfection' Infection control tea s should have written valid policies for water 2ualit) to ini ize risk of infections due to water in hospitals' Safe drinking water 8here safe water is not availa(le, water should (e (oiled for five inutes to render it safe' Alternativel), water purification units can also (e used' The storage of water should (e as h)gienic as possi(le' Hands should not enter the storage

container' 8ater should (e dispensed fro the storage container () an outlet fitted with a closure device or tap' 1torage containers and water coolers should (e cleaned regularl)' /) 6itchens and food handling

6nsuring safe food is an i portant service in health care facilities 9 inappropriate food handling practices per it conta ination, survival and growth of infecting (acteria' The co on errors contri(uting to out(reaks of food poisoning include;

Bsing conta inated, uncooked food: Advance preparation of food, i'e' ore than a half da), should (e avoided Bndercooked food: Cross9conta ination of cooked food () raw food during preparation or storage: Conta ination () food handlers: 1toring food at roo te perature or inade2uate refrigeration: Inade2uate reheating, and Bnh)gienic preparation of enteral or (a() feeds' =ood conta ination should (e prevented () using relia(le supplies of food: providing ade2uate storage facilities: separation of raw and cooked food to prevent cross9conta ination: preparation of food taking all h)gienic precautions: use of appropriate cooking ethods to prevent icro(ial growth in food, and ade2uate refrigeration of uncooked and prepared food: kitchen staff should change work clothes at least once a da) and keep hair covered' =ood handlers h)giene' ust carefull) wash their hands (efore preparing food and aintain scrupulous personal

The) should avoid handling food when suffering fro infection0 and report all infections' 1) The 6itchen

an infectious disease /enteric, respirator) or skin

=ood(orne diseases are i portant, particularl) in i uno9co pro ised patients' As the co unit) incidence of enteric infections a) (e high in so e countries, it (eco es all the ore i portant that special attention is given to food preparation and handling in order to avoid conta ination' The kitchen ust have ade2uate suppl) of clean and pota(le water' All work surfaces and food storage areas ust (e kept clean and sanitar)' =ood should (e served as soon as possi(le after preparation' =ood storage refrigerators and freezers should (e properl) aintained and the te perature checked dail) () provided ther o eters' +eft9over food should (e discarded' In regions where enteric infections are co on, food handlers should undergo pre9e plo) ent faecal e-a ination for the presence of 1higella, 1al onella and parasites such as 6nta oe(a, Giardia, etc *ishwashing achines should (e prefera(l) used for crocker) and utensils' 7) Cleaning of the hospital environment Coutine cleaning is i portant to ensure a clean and dust9free hospital environ ent' There are usuall) an) icro9organis s present in .visi(le dirt., and routine cleaning helps to eli inate this dirt' 1oap or detergents do not have anti icro(ial activit), and the cleaning process depends essentiall) on echanical action' Methods ust (e appropriate for the likelihood of conta ination, and necessar) level of asepsis' This a) (e achieved () classif)ing areas into the following zones; Ad inistrative and office areas with no patient contact re2uire nor al do estic cleaning' Most patient care areas are cleaned () wet opping' *r) sweeping is not reco ended' The use of a detergent solution i proves the 2ualit) of cleaning' An) areas with visi(le conta ination with (lood or (od) fluids ust (e disinfected' High risk areas like the isolation roo s and other areas with infected patients need cleaning with a detergentFdisinfectant solution' All horizontal surfaces and all toilet areas should (e cleaned dail)' Hot water /5%I C0 is a useful and effective environ ental cleaner'

Bacteriological testing of the environ ent is not reco ended unless indicated on epide iological grounds when seeking a potential source of an out(reak' 8) 5aste

Hospital waste is a potential reservoir of pathogenic icro9organis s and re2uires appropriate handling' The co onest docu ented trans ission of infection fro waste to health care workers is through conta inated etallic wastes' Principles of waste anage ent anage ent

The .Cradle to grave. concept of waste

Hospital waste re2uires anage ent at ever) step fro generation, segregation, collection, transportation, storage, treat ent to final disposal' 1egregation of wastes into the prescri(ed categories ust (e done at the source i'e' at the point of generation' Colour coded (ags as per international nor sJ need to (e placed in appropriate containers with the appropriate la(elFlogo e'g' (iohazard s) (ol for infectious waste' Puncture proof containers ade of plastic or etal with a (iohazard s) (ol, in (lood collection areas, in3ection trolle)s and nursing stations, and operation theatres should (e ade availa(le for collecting etallic wastes' A collection s)ste for the transport of segregated wastes i'e' carts need to (e provided' A storage area for wastes prior to treat ent needs to (e de arcated' Practical Classification of Hospital 5aste H#SPITA9 5AST2 Ha'ardous 0on:ha'ardous Ha'ardous Infectious 6itchen %ecycla"les /C)toto-ic drugs, /Biodegrada(le0 Card(oard (o-, to-ic che icals, Glass (ottles' Cadioactive waste0 Sharps 0on:sharps Patient contaminated 9a"oratory Plastics 0on:plastics Specimens !icro : Anatomical parts "iology Animal carcasses 9a" waste *isposa(les Cotton Blood 1)ringes Gauze Bod) fluids I< setsFcatheters *ressings Pus Catheters 1ecretions 6T tu(es 6-cretions Treatment of ha'ardous and infectious wastes 1harps Alternatives availa(le include; ,eedle (urners at the work station: Puncture proof containers which can (e autoclaved, shredded and land9filled or icrowaved, shredded and land9filled or treated () plas a p)rol)sis: *eep (urial in a secure area, and Cutting of needles which is a echanical ethod of disfigure ent to avoid rec)cling (ut is not a disinfection odalit)' 8astes re2uiring incineration Anato ical parts and ani al carcasses, and C)toto-ic drugs /outdated0, to-ic la(orator) che icals other than Patient conta inated non9plastics and non9chlorinated plastics' ercur)'

8aste that cannot (e incinerated Chlorinated plastics, volatile to-ic wastes such as ercur)'

Patient9conta inated plastics, non9plastics and infectious la(orator) wastes a) (e treated () stea sterilization in autoclava(le (ags or icrowave treat ent' 1hredding should follow (oth these ethods' In case of non9availa(ilit) of the a(ove, che ical treat ent with &D h)pochlorite or a si ilar disinfectant is reco ended' However, e-cessive use of che ical disinfectants a) (e a health and environ ental hazard' Cadioactive wastes These are dealt with according to local laws' ;) 9aundry

Two categories of used linen are recognized' 8here there is visi(le conta ination () (lood, faeces or other (iological fluids, it is ter ed .conta inated.' @ther linen is ter ed .soiled.' These two categories should (e segregated and treated separatel)' All linen should (e handled with ini u agitation to avoid aerosolization of pathogenic icro9 organis s' Conta inated linen a) (e a source of infection to patients and staff and should (e placed in i pervious (ags for transportation' *isinfection can (e achieved () using hot water and F or (leach, using heav)9dut) gloves, e)e protection and asks to protect against splashes' Heav)9dut) washers F dr)ers are reco ended for hospital laundr)' +aundered linen should (e autoclaved (efore (eing supplied to the operating roo s F theatres and high risk areas e'g' (urns units and transplant units' ,o linen should leave the hospital pre ises unless it has (een deconta inated'

Prevention of Hospital Associated Infections

Standard&universal precautions 8ith the onset of the AI*1 pande ic, the concept of universal precautions has (een adopted i'e' precautions that should (e practised with all patients and la(orator) speci ens regardless of diagnosis' It is presu ed that ever) patientFspeci en could (e potentiall) infected with (lood (orne pathogens such as HI<, hepatitis B and C' Bniversal /1tandard0 precautions are applied to all patients regardless of diagnosis, instead of universal testing' The ain o(3ective is to prevent e-posure of staff and patients to (lood and (od) fluids' Bod) fluids considered to (e potentiall) infected with (lood9(orne pathogens are; se en, vaginal secretions, a niotic fluid, pericardial fluid, pleural fluid, cere(rospinal fluid, s)novial fluid or an) (od) fluid that is visi(l) conta inated with (lood' 1pills of (lood or (od) fluids should (e treated with h)pochlorite' Bniversal precautions do not appl) to the following unless the) contain visi(le (lood; faeces, nasal secretions, sputu , tears, urine, vo itus, (reast ilk and saliva' 1ince the a(ove a) have the potential to trans it other pathogens, precautions should also (e applied to all (od) secretions and e-cretions' 1pills of (lood or (od) fluids should (e treated with h)pochlorite' 1tandard precautions also appl) to unfi-ed tissue and all pathological and la(orator) speci ens'

()

Procedures for standard precautions

Hand decontamination The role of hands in the trans ission of hospital infections has (een well de onstrated, and can (e ini ized with appropriate hand h)giene' Co pliance with handwashing, however, is fre2uentl) su(opti al' This is due to a variet) of reasons, including lack of appropriate accessi(le e2uip ent, high patient to staff ratios, allergies to handwashing products and insufficient knowledge of staff a(out risks and procedures' Handwashing is the single ost i portant eans of preventing the spread of infection' Hands should (e washed (etween patient contacts and after contact with (lood, (od) fluids, secretions, e-cretions and

e2uip ent or articles conta inated () these' .or hand washing< the following facilities are re=uired4 Cunning water; large wash(asins with hands free controls, which re2uire little aintenance and with anti9splash devices' Products; dr) soap or li2uid antiseptic depending on the procedure' 1uita(le aterial for dr)ing of hands; disposa(le towels, reusa(le sterile single use towels or roller towels which are suita(l) aintained' .or hand disinfection The specific hand disinfectants 7 antiseptics reco ended are; !94D chlorhe-idine, G9H'GD povidone iodine, &D triclosan or alcoholic ru(s' Alcoholic handru(s are not a su(stitute for hand washing, e-cept for rapid hand deconta ination (etween patient contacts' .or surgical scru" *surgical care+ Training is needed in the current procedure for preparation of the hands prior to surgical procedures' 1cru((ing of the hands for A9G inutes is sufficient' The reco ended antiseptics are 4D chlorhe-idine or H'GD povidone iodine' 62uip ent and products are not e2uall) accessi(le in all countries or health care facilities' =le-i(ilit) in products and procedures, and sensitivit) to local needs, will i prove co pliance' In all cases, the (est procedure possi(le should (e instituted' Clothing 1taff can nor all) wear clean street clothes' In special areas such as (urn or intensive care units, unifor trousers and a short9sleeved gown are re2uired for en and wo en' The working outfit ust (e ade of a aterial eas) to wash and deconta inate' If possi(le, a clean outfit should (e worn each da)' An outfit ust (e changed after e-posure to (lood or if it (eco es wet through e-cessive sweating or other fluid e-posure' Shoes In aseptic units and in operating roo s, staff ust wear dedicated shoes, which In other areas, change of footwear is unnecessar) for prevention of infection' Caps In aseptic units, operating roo s, or perfor ing selected invasive procedures, staff hoods which co pletel) cover the hair' !asks Masks of cotton wool, gauze, or paper asks are ineffective' Paper asks with s)nthetic aterial for filtration are an effective (arrier against icro9organis s' Masks are used in various situations and their re2uire ents differ depending on the purposes for which the) are needed' Patient protection4 1taff wear asks to work in the operating roo , to care for i uno9co pro ised patients, to puncture (od) cavities' A surgical deflector ask which directs aerosols awa) fro the surgical site is sufficient' Staff protection4 1taff ust wear asks when caring for patients with air(orne infections, or when perfor ing (ronchoscopies or si ilar e-a ination' A high efficienc) filter ask is reco ended' =ilter asks re ove organis s which ight (e inhaled' Patients with air(orne infections Gloves Gloves are used for; Patient protection; 1taff should wear sterile gloves for surger), care for i uno9co pro ised patients and invasive procedures which enter (od) cavities' ,on9sterile gloves should (e worn for all patient contacts where hands are likel) to (eco e conta inated, or for an) ucous e (rane contact' 8hen perfor ing ultiple procedures, the gloves should (e deconta inated (etween patients' If visi(l) soiled with (lood, a fresh pair should (e used' 1taff protection; 1taff should wear non9sterile e-a ination gloves to care for patients with co unica(le disease trans itted () contact' Hands ust (e washed when gloves are re oved or changed' ust use surgical deflector asks when outside their isolation roo ' ust wear caps or ust (e eas) to clean'

*isposa(le gloves should not (e reused' The wearing of gloves, asks and other protective clothing is onl) necessar) for the tasks at hand and these ite s should (e re oved after the procedure'

,)

Safe in$ection practices4

To prevent trans ission of infections (etween patients; Bnnecessar) in3ections ust (e eli inated' Man) edicines can (e given orall) and this is preferred to parenteral ad inistration' 1terile needle and s)ringe should alwa)s (e used' These should (e disposa(le, if possi(le' Conta ination of edications ust (e prevented () using single use vials' 1afe disposal practices in respect of etallic waste should (e followed'

Additional precautions for prevention of transmission of infection In addition to standard precautions which are re2uired for all patients in all situations, special precautions need to (e taken for patients suffering fro certain infections' These are (ased on the ode of trans ission of these infections' The ICC should decide the polic) for the individual hospital and procedures which are feasi(le in its situation' () %outes of transmission ore of the following odes;

Trans ission of HAI can occur () one or Air"orne

Through s all particles suspended in the air or large droplets e-pelled into the air () coughing, sneezing, talking /aerosols0, or () shedding of skin scales' Contact Through direct contact of hands or skin contact or indirectl) through environ ental surfaces and other ite s which co e in contact with the patient' Inoculation or parenteral Conta inated solutions, (lood and (od) fluids can enter either through a(rasions or other skin lesions, through ucous e (ranes (ut not through intact skin' .aeco:oral Micro9organis s found in the intestines can (e trans itted either directl) through conta inated food and water following unh)gienic practices or indirectl)' !ultiple routes A disease a) (e trans itted () ore than one ode e'g' respirator) viral infections can (e trans itted through air(orne /droplet0 as well as () ph)sical contact' Transmission:"ased precautions are special precautions taken in addition to standard precautions for known infections (ased on the ode of trans ission of the infection' 6ducation is ost i portant' Awareness progra es for staff, visitors and patients ust (e esta(lished' Posters outlining the precautions should (e placed at appropriate locations' As the na e i plies, additional precautions should (e applied in addition to standardFuniversal precautions' The following precautions are reco () %espiratoryprecautions icron in size which ended;

=or infections trans itted () the air(orne route through s all droplets less than G can (e dispersed over long distances e'g' tu(erculosis'

The patient should (e placed in a single roo that ideall) has good ventilation and sunlight, negative air pressure and "9&! air changes per hour' If single roo is not possi(le, patients should (e in a cohort with other patients with sa e infection' *oors should (e kept closed' =or additional respirator) protection, well9fitting filter asks should (e worn' 1uscepti(le persons should not enter the roo of patients having easles or chickenpo- whereas persons i une to

easles or chicken po- do not need to wear ask' Transportation of patient should (e done onl) when essential' Patient should wear a transportation' ,) Contact precautions

ask during

These precautions should (e used in addition to standard precautions for patients who are infected or colonized with i portant organis s that can (e trans itted directl) () hand or skin contact or indirectl) through fo ites or environ ental surfaces in contact with the patient, such as gastrointestinal, respirator), con3unctival, skin and wound infections or colonization with ultiresistant (acteria'

The patient should prefera(l) (e placed in a single roo ' If that is not possi(le, heFshe should (e placed with a cohort of patients having infection with the identical icro9organis ' Clean, non9sterile gloves should (e worn on entering the roo or patients environ ent' Gloves ust (e re oved after leaving the patient?s environ ent and hands washed i ediatel)' A clean non9sterile gown should (e worn on entering the patient?s roo and re oved on leaving the roo ' 1haring of patient care e2uip ent (etween patients should (e avoided' If sharing is necessar), the e2uip ent should (e ade2uatel) cleaned and disinfected (efore using on another patient' Transportation of patient ust (e li ited' If transport is necessar), precautions ust (e taken to avoid contact with other patients and conta ination of the environ ent' -) Blood&inoculation precautions

In addition to standard precautions, diseases trans itted through inoculation or parenteral route such as hepatitis B, HI<FAI*1, alaria can (e prevented (); Cational In3ection Practice; Bnnecessar) in3ections, suturing and (lood transfusions ust (e reduced' 1afe procedures for the handling and prevention of accidents with sharp etallic waste should (e ensured' Cecapping of needle should (e avoided: if recapping is re2uired, then well9esta(lished single9 handed procedures should (e used' Metallic waste should alwa)s (e disposed into a puncture resistant container' 6-posed sharp etallic waste should never (e passed directl) fro one person to another' *uring e-posure9prone procedures such as phle(oto ), the risk of in3ur) a) (e reduced () having a-i u visi(ilit) and proper positioning of the patient' =ingers ust (e protected fro in3ur) () using forceps for holding suturing needles' @verflow of sharp etallic waste disposal containers can (e prevented () sending the containers for disposal (efore the) are co pletel) filled' Surgical site infections efinition Infection in the surgical site that occurs within A% da)s of the surgical procedure or within one )ear if there is an i plant or foreign (od) such as prosthetic heart valve or 3oint prosthesis' Classification of operations Clean 4 An operative wound where an organ space is not entered or a wound that undergoes pri ar) closure' Clean contaminated 4 An operative wound in which an organ space is entered under controlled conditions without unusual conta ination' Contaminated 4 @pen, fresh, accidental wounds or operative wounds with spillage and conta ination fro the gastrointestinal tract' icro(ial

irty&infected 4 @ld trau atic wounds with e-isting clinical infection or following operations on perforated viscera' The ke) factors to (e recorded clinicall) are;

The severit) and the e-tent of the infection in the patient'

The t)pe of operation and The ti e period (etween the operation and the develop ent of the infection' =actors which influence the fre2uenc) of surgical site infections include; 1urgical techni2ue 6-tent of endogenous conta ination of the wound at surger) /clean, clean9conta inated0 *uration of operation Bnderl)ing patient status @perating roo environ ent The nu (er of organis s shed fro the skin of the operating roo tea and fro the skin of the patient

%isk factors for surgical site infections Patient Age ,utritional status *ia(etes 1 oking @(esit) Co9e-istent infections in a re ote (od) site Colonization with Altered i icro9organis s

Prevention Avoid operating on ver) old or ver) )oung as the) are at higher risk for developing infections

Build a good nutritional status Control and aintain (lood sugar levels onth prior to

Cessation of s oking at least one surger) Ceduce weight prior to surger) Treat ade2uatel) (efore operation

1creen and treat carriers: avoid pre9operative shaving Boost i unit) if possi(le

une response

+ength of preoperative sta) #perational procedures *uration of surgical scru( 1kin antisepsis Pre9operative shaving Preoperative skin preparation *uration of operation General factors Anti icro(ial proph)la-is @perating roo ventilation

Avoid long sta) in hospital Guidelines ! inutes as effective as &% inutes

Bse povidone9iodine F chlorhe-idine gluconate Avoid if possi(le or shave i operation Allow dr)ing of antiseptic Keep procedures as short as possi(le Guidelines Give suita(le anti icro(ial cover Adhere to specifications (elow Monitor C11* processes Maintain high level of asepsis Avoid unless reall) necessar) Maintain good surgical techni2ue and ensure ini al tissue trau a' ediatel) prior to

Inade2uate sterilization of instru ents =oreign aterial in the operative site

1urgical drains 1urgical techni2ue Poor hae ostasis =ailure to o(literate dead space Tissue trau a

A s)ste atic progra e for prevention of surgical site infections includes the practice of opti al surgical techni2ues, a clean operating roo environ ent with restricted staff entr) and appropriate staff attire, sterile e2uip ent, ade2uate pre9operative preparation of the patient, appropriate use of peri9operative anti icro(ial proph)la-is, and a surgical wound surveillance progra e' 1urgical site infection rates are

decreased () continuous, standardized surveillance with reporting (ack of rates to individual surgeons'

Surveillance
%ole of Surveillance 1urveillance of hospital associated infections eans recording and counting of infections arising in the hospital' 1urveillance is done so that we know the e-tent of an) pro(le s that e-ist' There are various wa)s of recording and counting the nu (er of hospital infections' @ne is the clinical outco e of the patient?s sta) in the hospital i'e' whether or not an infection arises in a patient as a result of their sta)' Infor ation as to the site and severit) of the infection and its relationship to an) operative, investigative or treat ent carried out can (e recorded and related to the nu (er of patients (eing treated' There a) (e records of la(orator) cultures or (lood tests that would confir that an infection is present' Because there are an) patients passing through the hospital and so an) different t)pes of infection which arise, one has to focus on specific readil) recognized infections such as surgical site infection as an inde- of infection rate' Bnless there are suita(le la(orator) facilities to identit) the infection pathogen, little can (e done to deter ine the possi(le organis s responsi(le and help in finding the source of the infection' =or these reasons, ost surveillance s)ste s depend on the use of la(orator) cultures to provide the aterial for 2uantification of the HAI rates' Accurac) in this case depends on the cultures (eing ade fro ost clinical infections and a s)ste for recording the clinical data of the infected patients' In hospitals where little or no surveillance data e-ists and resources are li ited, one has to concentrate efforts on those parts of the hospital, and those procedures, which are co on sites for HAI' 1urgical site infection is clearl) one area, (ut others include intravenous infusion over a prolonged period leading to septicae ia: urinar) tract infection following indwelling urinar) catheters: hospital associated respirator) infections particularl) in echanicall) ventilated patients, and episodes of infective gastroenteritis' Patients who are particularl) prone to ac2uiring infection in hospital include the ost severel) ill, the aged, those co pro ised () dia(etes, use of steroids, cancer or hae atological alignancies' Continuous surveillance is a ti e9consu ing activit) and re2uires detailed work over a period of ti e to produce (eneficial results which can lead to a reduction in the ac2uired infection rates' Man) different hospital staff are involved in onitoring the ini al levels of hospital infections and all ust (e aware of their role in surveillance' All ust (e alert to the possi(le occurrence of an out(reak situation /see (elow0' Both clinical and icro(iological data are essential to co pile the necessar) infor ation' The infor ation gathered is 3ointl) the propert) of the clinical and la(orator) staff' The collection of infor ation should (e ade as si ple as is co pati(le with o(taining data of value in recognizing the e-tent and causation of the infections' Bnless one has so e infor ation of the kind, finding the reasons for an infection is difficult and planning the avoidance of the infection less achieva(le' Ke) factors to (e recorded clinicall) are; The severit) and the e-tent of the infection in the patient: The t)pe of operation and the e-tent of (acteriological conta ination of the wound, and The ti e period (etween the procedure and appearance of the infection' Ke) records icro(iologicall) needed are the organis s isolated and their anti icro(ial suscepti(ilit)'

Targeted surveillance 1ite9oriented surveillance; Priorities will (e to onitor fre2uent infections with significant i pact in ortalit), or(idit), costs /e'g' e-tra9hospital da)s, treat ent costs0, and which a) (e avoida(le' Co on priorit) sites are; <entilator associated pneu onia /a high ortalit) rate0, 1urgical site infections /e-tra9hospital da)s and cost0 Pri ar) (loodstrea infections /high ortalit)0, and Infection with ultiple9drug resistant (acteria /out(reak situation0' Bnit9oriented surveillance; 6fforts can focus on high risk units such as intensive care units, surgical units, oncolog)Fhae atolog), (urn units, neonatolog), etc' Priorit)9oriented surveillance; 1urveillance undertaken for a specific issue of concern to the facilit) /i'e' urinar) tract infections in patients with urinar) catheters in long ter care facilities0'

8hile surveillance is focused in high9risk sectors, so e surveillance activit) should occur for the rest of the hospital' This a) (e ost efficientl) perfor ed on a rotating (asis' Ti e spent on surveillance activities ust not (e so long that other essential infection control easures, such as staff education, are neglected' HAI surveillance includes data collection, anal)sis and interpretation, and feed(ack leading to interventions for preventive action' The infection control tea ust (e trained for surveillance' A written protocol ust descri(e the ethods used, the data to (e collected and the anal)sis that can (e e-pected' Prevalence rate4 The nu (er of infected patients /or the nu (er of infections0 at the ti e of stud) as a percentage of the nu (er of patients o(served at the sa e ti e' Incidence rate4 The nu (er of new nosoco ial infections ac2uired per &%%% patient da)s' ata collection and analysis Sources *ata collection re2uires ultiple sources of infor ation as no ethod, () itself, is sensitive enough to ensure data 2ualit)' Trained data e-tractors /training should (e organized () the infection control tea or the supervisor0 perfor ing active surveillance will increase the sensitivit) for identif)ing infections' Techni2ues for case9finding include; 5ard activity4 +ooking for clues such as; The presence of devices or procedures known to (e a risk for infection /indwelling urinar) and intravascular catheters, echanical ventilation, surgical procedures0: Cecord of fever or other clinical signs consistent with infection: Anti icro(ial therap): +a(orator) tests, and Medical and nursing chart review' +a(orator) reports; Isolation of icro9organis s potentiall) associated with infection, anti icro(ial resistance patterns and serological tests' @ne cannot rel) on la(orator) reports alone' Cultures are not o(tained for all infections: speci ens a) not (e appropriate: so e pathogens such as viruses a) not (e isolated: isolation of a pathogen a) represent colonization rather than infection' +a(orator) reports are relia(le for urinar) tract infection, (loodstrea infections and, ultiple9drug resistant (acteria surveillance, (ecause the definitions for these are essentiall) icro(iological' @ther sources of infection data include diagnostic i aging and autops) data' *iscussion of cases with the clinical staff during periodic ward visits is an essential source of infor ation' Continuing colla(oration a ong infection control staff, the la(orator), and clinical units will facilitate an e-change of infor ation and i prove data 2ualit)' 1urveillance should also include the post9discharge period' Ceduction of the average length of sta) increases the i portance of identif)ing late9onset infections' The infor ation to (e collected should include; Ad inistrative data /hospital nu (er, ad ission dateL0 Additional infor ation descri(ing de ographic risk factors /age, gender, severit) of underl)ing illness, pri ar) diagnosis, i unological status, and interventions /device e-posure, surgical procedure, treat ents0 for infected and non9infected patients' *ate of onset and site of infection, icro9organis s isolated, and anti icro(ial suscepti(ilit)' .eed"ack&dissemination Infection data should (e disse inated to the people directl) involved in patient care: surgeons need to know a(out these surgical site infections' *isse ination of infor ation should also (e organized through the Infection Control Co ittees to other units, anage ent, and la(oratories' Ceports should not identif) individual patients' Codes ph)sicians, to ensure anon) it)' Prevention and evaluation An effective surveillance s)ste ust identif) priorities for preventive interventions and i prove ent ust also (e assigned to units and responsi(le

in 2ualit) of care' B) providing 2ualit) indicators, surveillance ena(les the Infection Control Progra e, in colla(oration with units, to i prove practice, and to define and onitor new prevention policies' The final ai of surveillance is the decrease of nosoco ial infections with a reduction of costs' 1urveillance is a continuous process and needs to evaluate the i pact of changes in practices and to validate the prevention strateg), to see if initial o(3ectives are attained'

Investigation of an #ut"reak
Identification of an >out"reak> The occurrence of two or ore si ilar cases relating to place and ti e is identified as a cluster or an out(reak and needs investigation to discover the route of trans ission of infection, and possi(le sources of infection in order to appl) easures to prevent further spread' If the cases occur in steadil) increasing nu (ers and are separated () an interval appro-i ating the incu(ation period, the spread of the disease is pro(a(l) due to person to person spread' @n the other hand if a large nu (er of cases occur following a shared e-posure e'g' an operation, it is ter ed a co on source out(reak, i pl)ing a co on source for the occurrence of the disease' 2pidemiological methods The investigation of an out(reak a) re2uire e-pert epide iological advice on procedures' =or ulation of a h)pothesis regarding source and spread should (e ade (efore undertaking icro(iological investigations in order that the ost appropriate speci ens are collected' Steps to "e taken to investigate an out"reak Step ( Cecognition of the out(reak' Is there an increase in the nu (er of cases of a particular infection or a rise in the prevalence of an organis M 1uch findings indicate a possi(le out(reak' Preli inar) investigation ust (e (egun () developing a case definition, identif)ing the site, pathogen and effected population' *eter ination of the agnitude of the pro(le and if i ediate control easures are re2uired' If so general control easures such as isolation or cohorting of infected cases: strict hand washing and asepsis should (e i ediatel) applied' <erification of the diagnosis' 6ach case should (e reviewed to eet the definition' Confir ation that an out(reak e-ists () co paring the present rate of occurrence with the ende ic rate should (e ade' Step , The appropriate depart ents and personnel and the hospital ad inistration should (e notified and involved' Step Additional cases ust (e searched for () e-a ining the clinical and icro(iological records' +ine listings for ever) case, patient details, place and ti e of occurrence and infection details should (e developed' An epide ic curve (ased on place and ti e of occurrence should (e developed, the data anal)zed, the co on features of the cases e'g' age, se-, e-posure to various risk factors, underl)ing disease etc' should (e identified' A h)pothesis (ased on literature search and the features co on to the cases: should (e for ulated to arrive at a h)pothesis a(out suspected causes of the out(reak' Micro(iological investigations depending upon the suspected epide iolog) of the causative organis should (e carried out' This will include /a0 icro(ial culture of cases, carriers and environ ent /(0 epide iological t)ping of the isolates to identif) clonal relatedness' The h)pothesis should (e tested () reviewing additional cases in a case control stud), cohort stud), icro(iological stud)' Step /

1pecific control easures should (e i ple ented as soon as the cause of out(reak is identified' Monitoring for further cases and effectiveness of control easures should (e done' A report should (e prepared for presentation to the ICC, depart ents involved in the out(reak, ad inistration' Immediate control measures Control easures should (e initiated during the process of investigation' An intensive review of infection control easures should (e ade and general control easures initiated at once' General easures include; 1trict hand washing: Intensification of environ ental cleaning and h)giene: Adherence to aseptic protocols, and 1trengthening of disinfection and sterilization' 2pidemic curve This is constructed to stud) the epide ic pattern of the disease' An epide ic curve is a graph /histogra 0 in which the cases of disease that occurred during the out(reak are plotted according to ti e of onset of HAI of the cases' The epide ic curve is constructed to help deter ine whether the source of infection is co on and continuing, and identif) the pro(a(le ti e of e-posure of the cases to the source of infection and pro(a(le incu(ation period' !icro"iological study Micro(iological stud) is planned depending upon the known epide iolog) of the infection pro(le ' The stud) is carried out to identif) possi(le sources and routes of trans ission' The investigation a) include cultures fro other (od) sites of the patient, other patients, staff and environ ent' Careful selection of speci ens to (e cultured is essential to o(tain eaningful data' 2pidemiological studies Case control stud); A group of uninfected patients /the control group0 is co pared with infected patients /the case group0' The differences in characteristics, suscepti(ilit) and e-posure factors are co pared' These factors include age, se-, ti e, place, duration of sta), intervention, anti(iotic therap) and other therapies' A statisticall) significant difference (etween the groups is identified and the pro(le can (e delineated' Cohort stud); *epending upon the infection pro(le , a defined high9risk population /cohort0 is identified and followed prospectivel)' This high9risk population is followed prospectivel) for the develop ent of infection' After following these cases for so e ti e, the differences in host factors (etween the patients that develop the infection and those that do not (eco es evident and will identif) the source of the pro(le ' Specific control measures 1pecific control easures are instituted on the (asis of nature of agent and characteristics of the high9 risk group and the possi(le sources' These easures a) include; Identification and eli ination of the conta inated product: Modification of nursing procedures: Identification and treat ent of carriers, and Cectification of lapse in techni2ue or procedure' 2valuation of efficacy of control measures The efficac) of control easures should (e evaluated () a continued follow9up of cases after the out(reak clinicall) as well as icro(iologicall)' Control easures are effective if cases cease to occur or return to the ende ic level' The out(reak should (e docu ented'

Health Care Staff

Transmission of infection from health care workers to the patients Health care workers with infections should report their illnesses to the staff clinics when the) are at risk of trans itting infection to patients' The closer the contact the) have with the patients, the ore likel) the) are to trans it the infection' The list of co unica(le diseases /Chapter 50 indicates which infections a) (e trans issi(le (ut organis s of special concern in hospitals are as follows; &' Staph) aureus4 A(out A%D of nor al persons carr) staph)lococci in their nose, (ut nor all) there is no trans ission to patients fro this site' 1o e persons e'g' with ecze a, heavil) colonized with staph)lococci, a) (e shedding staph)lococci in a ward environ ent' If there is an) evidence indicating spread of 1taph' aureus, the shedder status should (e investigated () collecting swa(s fro the nose, skin, hair and perineu ' If heavil) colonized, the) should (e treated with upirocin oint ent &D and given dail) (athFsha poo with triclosan &D or chlorhe-idine !D for G da)s, and status checked (efore their return to nor al work' Theatre and ward staff with purulent skin lesions due to staph)lococci should re ain awa) fro dut) until the lesions have healed' !ulti:resistant Staph aureus4 ,asal carriers of MC1A a) (e found a ong health care staff during investigation of out(reaks' The su(3ect should (e swa((ed to deter ine the e-tent of colonization and su(se2uentl) treated with upirocin F triclosan F chlorhe-idine to re ove carriage' !ulti:resistant Staph epidermidis4 1taff colonized with MC16 do not re2uire an) intervention' iarrhoeal disease4 1taff with diarrhoea should report this to the staff health depart ent' 1o e staff e'g' food handlers a) need to (e e-cluded fro dut) during this period' =or other staff, careful application of enteric precautions is essential' Preventing infection in health care personnel +arge hospitals generall) have a clinic for resident and non9resident staff' A ong the tasks of such clinics is the onitoring of infection risks (oth to staff who are at risk of ac2uiring infection fro patients and to patients who a) have an infection that a) (e transferred to patients' Hepatitis B Hepatitis B virus can (e transferred fro patients to staff and vice9versa () inute 2uantities of (lood' The ain wa) of preventing this trans ission is () i unization of health care staff' All staff who a) co e into direct contact with patients or their secretions, should have their hepatitis B status deter ined () easure ent of (lood arkers for hepatitis B' ,on9i une staff need to (e i unized' 1taff who have hepatitis B antigen present in (lood, particularl) the envelope antigen, are capa(le of spreading hepatitis B to patients and a) (e e-cluded fro high risk duties in the hospital to prevent trans ission' Sharps in$uries Minor in3uries to the hands of health care workers co onl) occur while perfor ing invasive procedures on patients' The co onest are needle9stick in3uries during phle(oto ) or while giving in3ections' 1o eti es sharp instru ents conta inated with (lood a) also (e involved' 1uch in3uries should (e i ediatel) treated () encouraging (leeding and washing thoroughl) with running water and an antiseptic solution' The infection control tea should (e consulted for further easures in use locall)' The risk of hepatitis B, hepatitis C and HI< infection should (e assessed and appropriate i unization or che oproph)lactic steps taken if necessar)' Tu"erculosis Tu(erculosis a) (e a high risk for so e staff e'g' icro(iolog) la(orator) workers and so e clinical staff' 1o e onitoring s)ste e'g' onitoring at entr) to the occupation or during e plo) ent is needed depending on the degree of risk involved' !eningococcal meningitis Trans ission of eningococci to health care staff is ost likel) within !4 hours of ad ission of the

!' A' 4'

patient' Health care workers in close contact with such cases should receive che oproph)la-is with ciproflo-acin or an effective alternative agent

Containment of Community Ac=uired Infections

Patients with infectious disease are fre2uentl) ad itted to hospitals' 1uch patients need to (e assessed and appropriate easures taken to contain the infection' The following ta(le highlights the said precautions' However, standard precautions should (e applied when handling (lood and (od) fluids'

Infection & Pathogen

Actinomycosis Actinomyces israelii Adenovirus Anthra@ Bacillus anthracis Ac=uired immune deficiency virus Hu an i unodeficienc) virus /HI<0 Aspergillus Brucellosis Brucella abortus and melitensis Candidiasis Candida albicans Chicken po@ Varicella zoster virus Cholera Vibrio cholerae Cytomegalovirus engue iarrhoea7 Infective Campylobacter Cryptosporidium 6nteropathogenic Escherichia coli Cotavirus 1 all ground structured viruses e'g' ,orwalk and other viruses' iarrhoea7 To-igenic Bacillus cereus Staphylococcus aureus Clostridium botulinum Clostridium difficile Clostridium perfringens T)pe A strains iphtheria Corynebacterium diphtheriae ysentery A oe(ic Entamoeba histolytica Bacillar) Shigella numerous types, e.g. sonnei

Isolation & infection control precautions?

,one Cespirator) precautions Transfer to isolation unit 1ingle roo if (leeding' Blood precautions ,one' +a(el all speci ens with (iohazard F danger of infection ,one' 1ingle roo , respirator) and contact precautions 1tool precautions until faeces negative Contact ,one ' 1tool precautions

1tool precautions

Isolation unit 1tool precautions

1tool precautions

2nteric fever Salmonella typhi Salmonella paratyphi 1al onellae sp e'g' S.typhimurium Gas gangrene Clostridium perfringens Cl.oedematiens Cl.septicum Giardiasis Giardia lamblia Glandular fever 6pstein9Barr virus /6B<0 Gonorrhoea eisseria gonorrhoeae Hepatitis 9 A N 6 virus 9 B , C and * virus Herpes simple@ Herpes virus hominis t)pe I HH<" HI3 Hu an i Influen'a Influenza A Influenza B 9egionnairesA isease !egionella pneumophila 9eprosy "ycobacterium leprae +epro atous +epros) Tu(erculoid +epros) 9eptospirosis !eptospira icterohaemorrhagica 9ice #ediculus humanus #hthirus pubis 9isteriosis 9yme disease Borrelia burgdorferi !alaria #lasmodium sp !easles #aramy$ovirus morbilli !eningitis eisseria meningitidis / eningococcus0 %aemophilus influenzae Streptococcus pneumoniae !umps #aramy$ovirus parotitis !yco"acterium At)pical unodeficienc) virus

1tool precautions

,one

1tool precautions ,one ,one

1tool precautions Blood precautions ,one ,one Blood precautions

Cespirator) precautions ,one

Contact precautions ,one ,one

Contact precautions Contact precautions 1tool precautions ,one ,one

Cespirator) precautions Cespirator) precautions Cespirator) precautions ,one Cespirator) precautions ,one F Cespirator) precautions

Plague Pleurodynia Co-sackie virus B Pneumocystis carinii Poliomyelitis Polio virus Psittacosis Chlamydia psittaci B fever %a"ies &habdovirus group %elapsing fever Borrelia recurrentis %espiratory syncytial virus /C1<0 %u"ella /Cu(ella virus0 Adult ,ew(orn Sca"ies Sarcoptes scabiei Shingles %erpes zoster Staphylococcal infection Staphylococcus aureus 1kin +ung !ethicillin:resistant Staphylococcus aureus /MC1A0 Streptococcal infection Beta9hae ol)tic Syphillis 'reponema pallidum Tetanus Clostridium tetani To@oplasma gondii Trichomonas vaginalis Tu"erculosis "ycobacterium tuberculosis Pul onar) Cervical A(do inal @ther sites Cenal TB 3iral Haemorrhagic .evers e'g' Cri ean9Congo Hae orrhagic =ever 6(ola9Mar(urg <irus *isease +assa =ever /Adenovirus group0 5orms Ancylostoma/Hookwor 0 Ascaris lumbricoides /Coundwor 0 Enterobius vermicularis /Threadwor FPinwor 0 Strongyloides stercoralis 'aenia solium /Pork Tapewor 0 'aenia saginata /Beef tapewor 0

8ound and skin precautions' Cespirator) precautions 1tool precautions ,one 1tool precautions Cespirator) precautions Cespirator) precautions Contact precautions Blood precautions Cespirator) precautions Cespirator) precautions Cespirator), stool and urine precautions Contact 1ingle roo , respirator) and contact precautions

1kin contact precautions Cespirator) precautions Contact precautions ,one ,one ,one ,one ,one Cespirator) precautions ,one ,one ,one Brine precautions

Isolation Bnit Contact ,one 1tool 1tool 1tool 1tool ,one

precautions precautions precautions precautions

'richuris trichura /8hipwor 0 5hooping cough Bordetella pertussis J 1ee chapter 4 for details

Contact precautions Cespirator) precautions

Suggested .urther %eading

&' International =ederation of Infection Control' 6ducation Progra e for Infection Control' Basic Concepts and Training' 6ditors; A)eliffe GA, Ha (raeus A and Mehtar 1' &##G' !' 8enzel CP' Prevention and Control of ,osoco ial Infections' Third 6d' Balti ore, M*' 8illia s and 8ilkins' &##H A' C*C Guidelines for Infection Control in Hospital Personnel' B1 *epart ent of Health and Hu an 1ervices Centres for *isease Control and Prevention' Atlanta, Georgia' 4' C*C Guideline for Isolation Precautions in Hospitals' A erican $ournal of Infection Control, !4; !49 G!' &##"' G' Guidelines for preventing HI<, HB< and other infections in the Health Care 1etting 8H@ Cegional @ffice for 16 Asia ,ew *elhi &##"' "' A)eliffe GA$ et al Control of Hospital Infection; A Practical Hand(ook' Third 6dition' +ondon, Chap an Hall' &##!' H' APIC Infection Control and Applied 6pide iolog); Principles and Practice' Association of Practitioners in Infection Control, Mos() Inc' 1t' +ouis Missouri, &##" 5' C*C Guidelines for Prevention of Intravascular Infections &##G' *epart ent of Health and Hu an 1ervices, Center for *isease Control and Prevention, ,ational Centre for Infectious *iseases, Hospital Infections Progra e' #' ,ichols C+' Preventing 1urgical 1ite Infections; A 1urgeon?s Perspective' 6 erging Infectious *iseases' Mar9Apr !%%&' <ol' H, no' ! &%' http;FFwww' edscape'co Fgov tFC*CF6I*F!%%&Fv%H'n%!Fe%H%!'&4'nichFe%H%!'&4'nich9%&'ht l &&' Gardner $= and Peel MM' /&##&0 Introduction to 1terilization, *isinfection and Infection control, 1econd 6dition' Mel(ourne, Churchill +ivingstone' &!' 8orld Health @rganization' Guidelines for drinking water 2ualit)' <ol' &, Ceco endations, 1econd 6dition, 8H@, Geneva, &##A'