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CHAPTER 1. INTRODUCTION…………………………………………
2
CHAPTER 2. HOSPITAL INFECTION CONTROL COMMITTEE ……
4
CHAPTER 3
HOSPITAL HYGIENE…………………………………….
7
CHAPTER 4
OUTBREAK MANAGEMENT & ISOLATION………….
20
CHAPTER 5
ANTIBIOTIC POLICY…………………………………….
25
2
CHAPTER 1
INTRODUCTION
A hospital is a place where sick people congregate to avail of the services of d
octors in different specialties. The provision of an effective infection control
programme is a key to the quality and a reflection of the overall standard of c
are provided by that health care institution. It is thus the primary responsibil
ity of every hospital administrator to ensure that adequate resources are alloca
ted for hospital infection control. Employers also have a responsibility to prov
ide a safe working environment for the Health care Workers and the employees are
duty bound to comply with safety standards and procedures set by the institutio
n. The administration should include an infection control committee that monitor
s the infections acquired within the hospital and goes about implementing measur
es to combat this. Infection control specialists and the representatives from th
e various departments should form a committee, designated the Hospital Infection
Control Committee (HICC) to develop the manual keeping the needs of all special
ties in mind and to monitor the implementation and effectiveness of the control
programme.
In general, infections that occur more than 48-72 hrs after admission and
within 10 days after discharge are considered as nosocomial. Hospitalized patien
ts are
generally more vulnerable to infection than any other healthy individual, since
the host is immunosuppressed, the environment is conducive to the growth of resi
stant bacteria and the transmission of these bacteria is very much facilitated b
y the activities of the Health Care Workers (HCW) and other patients. The epidem
iological triad of host, environment and agent work together with strong links o
f transmission. Sometimes there is a large increase in the commonly occurring ty
pes of infection, or appearance of a new kind of infection e.g. Salmonella infec
tion in newborns. This is called an outbreak of nosocomial infection. Such an in
fection is usually due to a single type of bacteria and the source can be traced
e.g. a solution contaminated with Pseudomonas causing wound infection in one wa
rd.
The importance of hospital infection can be considered both in terms of morbidit
y
and of prolonged occupancy of the hospital bed. Approximately 10% of hospitalize
d patients
3
develop infections every year .In developing countries, this may go up to 25%. O
ne-third of these are preventable. Diagnosing and treating these infections puts
intense pressure on the health services and health budget.
A Hospital Infection Control Manual is an essential part of any infection contro
l programme. It should establish standards in all aspects of infection control.
In a large referral hospital, doctors and nursing staff work in different specia
lties and super specialties. Each specialty has evolved its own style of working
and they have varied procedures which can be performed only by skilled personne
l. The procedures of infection control should thus be adapted to suit the needs
of all specialties and still maintain the basic principles needed for effective
control of infection. Over time all precautions tend to get diluted and recruitm
ent of new staff members without knowledge of infection control procedures follo
wed will lead to an increase in the hazard of spread of infection within the hos
pital. This can be overcome by a standard manual which is updated yearly and is
available to all staff for easy reference over the hospital computer network sys
tem or in the wards/reading rooms.
The manual should include policy and procedures on:
1. Standard Precautions for HCWs
2. Isolation policies
3. Cleaning and decontamination of surfaces and equipment and management of spil
ls
4. Antibiotic policy
5. Outbreak management.
6. Waste management and disposal of sharps. (Damani)
The Health Act 2006 Code of Practice for the Prevention and Control of Health Ca
re
Associated Infections, Dept. of Health, UK
“The term “Health Care Associated Infections” (HCAI) encompasses any infection by any
infectious agent acquired as a consequence of a person’s treatment by the hospital
or which is acquired by health care workers in the course of their duties. Effe
ctive prevention and control of HCAI has to be embedded into everyday practice a
nd applied consistently by everyone. It is particularly important to have a high
awareness of the possibility of HCAI in both patient and health care workers to
ensure early and rapid diagnosis. This should result in effective treatment and
containment of the infection. Effective action relies on an accumulating body o
f evidence that takes account of current clinical practices. This evidence base
should be used to review and inform practice. All staff should demonstrate good
infection control and hygiene practice. However, it is not possible to prevent a
ll infections.”
4
CHAPTER 2
HOSPITAL INFECTION CONTROL
COMMITTEE
The Hospital Infection Control Committee (HICC) is an essential part of good inf
ection control practices and must function effectively. The Head of the Institut
ion may be nominated as the Chairperson. The Secretary should be a Senior Clinic
al Microbiologist, Infectious disease specialist or Epidemiologist. Other member
s should include:
1. Heads of all clinical and paraclinical departments.
2. Administrator or his representative e.g. Medical Superintendent or Resident M
edical
Officer (RMO).
3. Chief of Nursing staff e.g. Nursing Superintendent or Assistant
4. Engineer from the Public Works Dept. e.g. Asst. Engineer
5. Engineer from the Water supply Dept. e.g. AE, PHED
6. Head of Pharmacy services
7. Infection Control Team(ICT) including Infection Control Doctor(ICD) and
Nurse(ICN)
8. Chief technician of infection control lab or chief technician responsible for
processing
of all outbreak and surveillance samples.
9. Chief Security Officer
10. Chief Biomedical Engineer(BM Engineer) responsible for the working of all th
e
Medical equipment in the hospital.
The committee should meet every 6 months. The ICT is responsible for the day-to-
day
activities in infection control and monitoring their implementation and effectiv
eness.
AIMS OF THE HICC:
1. Recommend appropriate policies for the prevention of Hospital Acquired Infect
ion
and ensure that they are implemented.
2. Maintain records on surveillance, outbreaks and needle stick injury incidents
. These are compiled by the Infection Control Team and come up for discussion du
ring the meetings.
5
3. Formulate an antibiotic policy based on the needs of the different specialtie
s and
prevalent susceptibility patterns.
4. Implement policies for the safety of health care workers.
5. Regulate and give recommendations on purchase of equipment needed for infecti
on
control e.g. autoclaves in CSSD, steam sterilizers etc.
6. Regulate and give recommendations on any construction or renovation work in t
he
hospital. The plan should be approved by the committee.
7. Discuss and find solutions to problems related to infection control encounter
ed by
different doctors in their specialties.(Damani)
INFECTION CONTROL TEAM (ICT)
Infection Control Team (ICT) – Consists of: -
a)Infection Control Doctor (ICD).
b)Infection Control Nurse (ICN)
a) ICD – Microbiologist / Infectious Disease Specialist / Epidemiologist
Should be a Registered Medical Practitioner. One for every 1000 beds
Experience in: -
1.Sterilization / Disinfection
2.Microbiolog y
3.Hospital Infection Epidemiology
4.S urveillance
Functions:
1. Draws up annual plans for prevention of hospital infection.
2. Implementation of agreed policies
3. Sets quality standards and coordinates surveillance activities.
4. Coordinates with administrator, PWD, PHED and BM engineer for proper maintena
nce, or upgradation of existing facilities. Should be involved in the design ,co
nstruction and commissioning of any new building.
5. Help the ICN to conduct continuing education programmes in infection
control practices for the staff members.
b) ICN– Senior Registered Nurse(BSc or MSc)
Training in Infection Control is preferred.
Full-time job. One for 250 beds.
6
This includes: -
1. Assists ICD and ICC in drawing up annual plans for prevention of hospital inf
ection
2. Monitor all infection control procedures, e.g. sterilization procedures in th
e CSSD,
use of disinfectants and adherence to universal precautions by all members of st
aff.
3. Surveillance of infection to prevent outbreaks. She will identify, investigat
e and
follow-up on infections acquired from the hospital which will help in prevention
of
outbreaks.
4. Conduct continuing education programmes on infection control practices to all
grades
of staff.
In a large hospital there will be a team of ICDs and ICNs, who make up the ICT.
The
ICT is responsible for the day-to-day activities of the infection control progra
mme. The ICT
conducts monthly meetings presided over by the seniormost ICD.(Damani)
Infection Control Lab
It is recommended that for surveillance and outbreak investigation activities, a
n infection control lab may be set up under the Microbiology Department. This ma
y be supervised by the senior most ICD who is also a Microbiologist. The process
ing of specimens in the lab is done by:
1. Senior lab technician/Scientist - Preferably BSc MLT /MSc. Microbiology and p
reference given to person with PhD in any subject related to infection control.
Experience in typing of organisms will be an added advantage.
2. Junior Lab technician – BSc MLT or DMLT
3. Junior Lab assistant(JLA) – Passed Higher secondary with experience in lab work
4. Cleaner/Attender .
Functions of the Lab:
1. Participate in Surveillance activities and outbreak investigation as instruct
ed by the
ICD.
2. Maintain in stock all the pathogens identified in outbreaks.
3. Typing of nosocomial pathogens – phage typing, biocin typing, molecular methods
. All the other bacteriology labs should send the multi-drug resistant nosocomia
l strains identified in pus, blood samples etc. to this lab for full identificat
ion and typing.
7
CHAPTER 3
HOSPITAL HYGIENE
In the chain of infection, the mode of transmission is the easiest link to break
and is the
key to control of cross-infection in hospitals.
Based on the above, the 5 pillars of infection control are: -
1. Hand washing
2. Isolation of infected patients
3. Barrier nursing of immuno suppressed.
4. Prudent use of antibiotics
5. Decontamination and proper disinfection / sterilization of items and equipmen
ts
used in invasive procedures (Damani)
These guidelines are divided into two parts:
1. General policies to be followed uniformly all over the hospital.
2. Specific policies for special areas.
GENERAL POLICIES:
I STANDARD PRECAUTIONS : (CDC GUIDELINES 1987)
A set of precautions to protect health care worker from occupational exposure to
blood-
borne infections.
1. BARRIER PROTECTION
2. HAND WASHING
3. SAFE TECHNIQUE
4. SAFE HANDLING OF SHARP
5. SAFE HANDLING OF SPECIMEN
6. SAFE HANDLING OF SPILLS
7. USE OF DISPOSABLES
8. IMMUNISATION WITH HEP-B VACCINE
8
1. BARRIER PROTECTION: Materials that protect the HCW from infection.
Gloves
Mask
Apron
Eye wear
Foot wear
Gloves
All skin defects must be covered with water proof dressing
Use well fitting, disposable / autoclaved
Change if visibly contaminated / breached
Remove before handling telephones, performing office work, leaving workplace
Mask & Goggles
Facial protection – When splashing or spraying of blood / blood fluids expected
Apron
Gowns/Special uniforms – in high risk areas
Foot wear
·Feet should be well covered on all sides, especially while working in areas where
spillage of infectious material is common, like operation theatres, labour room,
laboratories. Soft shoes are preferred to sandals.
2. HAND WASHING: Protects both HCW and patients .The single measure that is
universally acknowledged and proved to reduce HCAI.
The main forms are:
a) Social handwashing – Done for simple cleaning of hands with soap and water. Red
uces the transient flora. A modification is careful handwashing which is done im
mediately after touching a patient or after contamination. All areas of the hand
upto the wrist are cleaned by rubbing for at least 2 minutes. Fig 1 below shows
the areas commonly missed while washing, in red.
b) Hygienic hand disinfection – After social hand washing, to get a more sustained
effect, especially while caring for infected patients in special care units lik
e ICUs and neonatal units. 70% ethyl alcohol hand disinfectants may be rubbed th
oroughly over the hands. This effectively kills all transient flora, the action
is fast and short-lived, hence has to be repeated after touching each patient.
9
c) Surgical hand disinfection – Preoperative washing hands by surgeon. Done with a
ntibacterial soap e.g containing chlorhexidine or an iodophore, followed by 70%a
lcohol rub. Hands are scrubbed thoroughly for 5-10 minutes upto the elbows, taki
ng care to scrub nails and interdigital areas. (Hospital Hygiene and infection c
ontrol, WHO 1999)
Fig.1 Areas missed (in red)
Running water is an essential pre-requisite for proper handwashing. In its absen
ce, Fig 2 shows how hands can be washed using a container with a tap fitted (Mod
el Injection Practices Manual, IndiaClen Programme evaluation Network 2006)
Fig 2. Washing hands when running water is not available
3. SAFE TECHNIQUE & SAFE HANDLING OF SHARPS : These are techniques to
be followed while using sharp instruments like scalpel, scissors and needles.
a) Dispose your own sharps yourself.
b) Never pass used sharps to another person. e.g. give used scalpel to assistant
in a kidney
tray, not directly
c) During exposure-prone procedures, minimize the risk of injury by ensuring tha
t the
operator has the best possible visibility. E.g. by positioning the patient, adju
sting good
light source and controlling bleeding. (CDC guidelines 1987)
d) Protect fingers from injury by using forceps instead of fingers for guiding s
uturing.
10
e) To collect blood a vacuum system is ideal
f) Never recap, bend or break disposable needles.
g) Place used needles and syringes in a rigid puncture resistant container or de
stroy using
needle destroyer.
Every institute should have a Sharps Policy to provide a safe working environmen
t, the
basis of which should be:
A. Reduce use and Select the right devices.
B. Care in use - Handle used items with care for reuse or disposal.
C. Disposal -
Dispose infected waste safely.
4. SAFE HANDLING OF SPECIMEN: These are to be followed while sending blood
or other body fluids to a laboratory for tests.
a) Wear gloves while collecting any specimen from a patient.
b) Keep all containers labeled and ready before collection
c) Use aseptic techniques
d) Keep all disinfectant containers ready before collection
e) Collect into a screw capped unbreakable container , screw it tight and dispat
ch safely
f) If it has to be sent to a distant lab follow packing instructions as for infe
ctious material
and put a biohazard label on the package.
5. SAFE HANDLING OF SPILLS: Spilling of blood and body fluids is a common hazard
in the laboratory, theatres and wards. A uniform policy is necessary to protect
both HCWs and patients from spread of blood-borne infections by this route.
Chemical Disinfectants effective in inactivating all blood-borne pathogens:
Disinfectant
Concentration
Period of contact
1. Hypochlorite
1%
30min
2. Formalin
4%
30min
3. Gluteraldehyde(Cidex)
2%
30min
4. Hydrogen peroxide
6%
30min
11
The following steps should be followed if there is a spill:
Spill on floor/ work surface should be covered with paper towel / blotting paper
/ newspaper / absorbent cotton. 1% (10,000 ppm) Hypochlorite solution should be
poured on the spill and covered with paper for 30 minutes. All the paper / cott
on should be removed with gloved hands.
0.1% or 0.5% Hypochlorite is used for general disinfection.
6. USE OF DISPOSABLES
It is impossible to avoid all contact with infected tissue or potentially contam
inated body fluids. Even when they are not touched with the bare hands, they com
e into contact with instruments, containers, linen etc. All objects that come in
to contact with patients should
be considered as potentially contaminated. If an object that comes into such con
tact is
disposable it should be discarded as waste. If it is reusable transmission of in
fectious agents
should be prevented by cleaning, disinfection or sterilization.
7. IMMUNISATION WITH HEP-B VACCINE
Every Hospital should have facilities for immunization of all the HCWs against H
epatitis B.
II. CLEANING AND DECONTAMINATION
“The ‘environment’ means the totality of a patient’s surroundings which includes the fab
ric of the building and related fixtures, fittings and services such as air and
water supplies. It is the duty of the administration to see to it that all parts
of the premises in which it provides health care are suitable for the purpose,
are kept clean and are maintained in good physical repair and condition.” The Heal
th Act 2006C ode
of Practice for the Prevention and Control of Health Care Associated Infections,
Dept. of
Health, UK.
The cleaning arrangements should
1. Detail the standards of cleanliness required in each part of the premises
2. Make available a schedule of cleaning frequencies
3. Include adequate provision of suitable hand wash facilities and antibacterial
hand rubs.
4. Include effective arrangements for the appropriate decontamination of instrum
ents and
other equipment.
12
A. SURFACES: These are meant to be clean and not sterile. Cleanliness can be
ensured only if cleaning is repeated as often as contamination occurs.
The physical action of scrubbing with detergents and rinsing with water during e
nvironmental cleaning effectively removes 90% of micro-organisms. Non-sporulatin
g bacteria are unlikely to survive on clean surfaces. It is essential that metho
ds of cleaning do not produce aerosols or dispersion of dust in patient care are
as. Brooms should not be used in intensive care facilities. Fresh cleaning solut
ion should be made before each cleaning procedure and discarded after use. There
should be an area for cleaning and drying of used mops.
1. Floors: Vacuum clean or dry mop twice daily.
Wet mop with detergent and phenol (1%) solution. Use 2% if there is obvious
contamination.
2. Furniture and ledges: Wet mopping daily with warm water and detergent.
3. Washbasin and sink: Clean with detergent. If contaminated use 0.5%Hypochlorit
e.
4. Mattresses and pillows: These should be enclosed in a waterproof cover. This
should be cleaned with a detergent after a patient is discharged and disinfected
with 0.5% hypochlorite, if contaminated.
5. Medicine trays: Keep all trays, with medicines and dressings inside a drawer
or closed
cupboard. If kept exposed in a tray, keep covered and away from open windows.
6. Toilet seats: Wash daily with detergent and dry. Use 0.5% hypochlorite if soi
ling with
blood is likely as in Urology and Gynaecology units.
7.Beds, bed-frames: For normal cleaning use detergent and hot water. Perform cle
aning
after discharge of patient and weekly in case of long stay patients. Use 0.5% hy
pochlorite
to disinfect if there is any contamination with blood or body fluids.
8. Cleaning of a room after source isolation of an infected patient:Fumigation o
f the
room or swabbing to monitor effectiveness of the cleaning procedure is NOT
needed.a. Cleaner should wear apron and thick household gloves
b. Dust the high ledges window frames etc.
c. Wet mop all ledges, fixtures and fittings including taps and door handles
d. Vacuum clean the floor.
13
e. Wash floor with detergent and 1% phenol solution.
f. Wipe mattresses with freshly prepared 0.5% hypochlorite solution.
B. EQUIPMENT: Disposables to be discarded after contamination and autoclavable
items to be autoclaved after use on one patient.
1. Fibre-optic endoscopes (and other heat sensitive instruments): Manufacturers
instructions
for sterilization, if present should be followed.
i. All accessories should be disconnected as far as possible and immersed in a
detergent solution
ii. All channels should be flushed and brushed ,if accessible ,to remove all
organic materials
iii. External surfaces and accessories should be cleaned with a sponge or soft
cloth. Accessories that are reusable should be autoclaved
iv. Immerse the instrument in 2% Gluteraldehyde, so that all channels are
perfused, for 30 minutes. Discard the detergent after use.
v. If tuberculosis is suspected, the period of contact may be extended to 1 hr.
vi. After disinfection, endoscopes should be rinsed with with sterile water,
followed by a rinse with 70% alcohol.
2. Suction equipment: Following use the reservoir should be emptied (according t
o hospital
waste disposal policy) washed with hot water and detergent, rinsed and stored dr
y.
3. Anaesthetic or ventilator tubings: Wash and sterilize in CSSD. Never use Glut
eraldehyde to disinfect respiratory equipment. For patients with tuberculosis or
AIDS, use disposable tubing. For ventilator, follow manufacturer’s instructions.
Use disposable filters or autoclave between patients.
4. Humidifiers/Nebulizers: Clean and sterilize device between patients. Fill wit
h sterile
distilled water which has to be changed every 24hrs, if not used up.
5. Infant incubators: Wash all removable parts, clean with detergent and dry. If
contaminated, wipe with 70% ethyl alcohol or isopropyl alcohol (if metallic) an
d with 0.5%hypochlorite (if plastic).
14
Taken from the Guidelines for prevention of Nosocomial Pneumonia, CDC, Atlanta
C. INSTRUMENTS :
1. Speculums and rigid endoscopes: Clean and wash thoroughly. Rinse and dry. Sen
d to CSSD for autoclaving. An alternative is immersion in 2%Gluteraldehyde for 1
0 minutes after disassembling any accessories. Rinse with sterile distilled wate
r after disinfection.
2. Thermometers: Individual thermometers are recommended for each patient (at le
ast in ICUs). For multi-use, after each use wipe with 70%alcohol and store dry.
Wash with detergent at least twice daily. Alternatively, for individual thermome
ters, wash with detergent and immerse in 70% alcohol for 10 minutes after the pa
tient is discharged. Store dry.
3. Scissors: Surface disinfect with a 70% alcohol wipe.
4. Urinals and bedpans: Wash with detergent between each use. Store dry. Heat di
sinfect at
80oC between patients, clean and reuse.
15
5. Cheatle forceps: Do not use. If necessary to use, autoclave daily and store d
ry in a closed
container.
6. Oxygen face mask: Wash with detergent and dry if contaminated. Before each us
e, wipe
with 70% ethyl or isopropyl alcohol.
SPECIFIC POLICIES
I.
WARDS
1. Beds (centre) should be at least 3.6m away from each other.
2. There should be good ventilation.
3. Toilets and baths should be easy to clean and conveniently located.
4. Wash basins to be located within easy walking distance. One wash basin per 6
beds is
recommended.
5. Walls and ceilings should be kept in good repair, because micro organisms ten
d to
colonise only walls that are moist or sticky.
6. Pipe penetrations and plumbing fixtures should be smooth, and tightly sealed.
.
7. Overcrowding of wards should be avoided. Visiting hours should be fixed for 2
hours
daily and only one bystander allowed per patient.
8. It is recommended that food for the patient is provided by the hospital dieta
ry department based on recommendations by the attending doctor /dietician. This
will reduce the traffic in the wards during the day.
9. Cleaning schedule should be decided and followed. Brooms which raise dust are
NOT recommended. Instead, vacuum cleaning or dry mopping followed by wet moppin
g may be done at least twice daily and after any contamination.
10. Detergent and 1% phenolic disinfectants may be used for floors. For non-meta
llic
surfaces 0.5% hypochlorite may also be used.
11. 70% ethyl or isopropyl alcohol may be used to wipe medicine trolleys and she
lves
where instruments or medicines are kept, after thorough wet mopping.
Cleaning: Wet mopping with 1% phenol and detergent at least twice daily.
0.5% hypochlorite if there is visible contamination
1% hypochlorite for blood spills.
Clean ledges and window frames daily
16
II.INTENSIVE TREATMENT UNITS
1. No bystanders allowed.
2. Restrict entry of visitors to 2hrs per day.
3. Floors and shelves to be cleaned as for wards.
4. Staff should wear masks and aprons while working in the unit.
5. Staff from the unit should not be sent outside for any purpose.
6. Staff from outside should not enter the unit.
7. Ventilators, nebulisers and humidifiers to be cleaned, sterilized/disinfected
as
recommended above.
8. Environmental samples to be taken and Fumigation to be done only after any re
novation work and during outbreak investigation. Routine fumigation or swabbing
is not required.
III.
OPERATION THEATRES
A.Envi ronm ent :
1. Positive pressure ventilation, High Efficiency Particulate Air filtration (HE
PA)
filtered air with at least 20 air exchanges per hour.
2. Temperature – 18-25oC, Humidity – 40 – 60%, Bacterial count of air(using slit
samplers) - < 30cfu/m3
3. Air-conditioning – Monitoring and servicing by accredited technicians.
4. Number of staff and movement inside the operating theater – to be minimum.
5. Proper cleaning of the floor, walls and the lights above the operating table
is essential
B. STAFF & INSTRUMENTS
1. The surgeon, anesthetist and assisting nurse should scrub thoroughly before t
he
procedure.
2. All articles used for surgical procedures must be STERILE.
3. Staff working in the theatre should on no account be sent outside for any err
and
during working hours.
4. All staff should change to theatre dress before entering. No other staff work
ing in
other parts of the hospital should be allowed inside.
17
C.P AT IENT
1.Pre-existing skin lesion diabetes and other immunosuppressive condition - to b
e
corrected.
2. Pre-operative stay in hospital – to be kept to a minimum.
3.Pre-operative shaving using razors & brushes – to be avoided. Clip the hair or u
se
depilatory creams.
4. Antibiotic prophylaxis – not to exceed 24 hrs.
5. Operative site - to be disinfected properly. Use 0.5% Chlorhexidine / 10% Pov
idone Iodine followed by 70% Ethyl alcohol/Iso propanol. First incision to be pu
t only after the alcohol has dried.
IV.
NEONATAL UNITS
A.ENV IRONMEN T:
1. Floors: Cleaning should be performed in the following order – patient areas, ac
cessory areas and then adjacent halls. Brooms are NOT recommended inside the uni
t. In the cleaning procedure, dust should not be dispersed into the air. Wet mop
ping with detergent and 1% phenol/0.5% Hypochlorite should be performed twice da
ily and at the time of any contamination. Mop heads should be machine laundered
and thoroughly dried daily.
2. Surfaces: All ledges and fixtures should be cleaned by wet mopping with deter
gent once daily. In addition, wipe surfaces where medicines and equipment are ke
pt with 70% ethyl alcohol. Cabinet counters, work surfaces, and similar horizont
al areas should be cleaned once a day and between patient use with a disinfectan
t/detergent and clean cloths, as they may be subject to heavy contamination duri
ng routine use. Friction cleaning is important to ensure physical removal of dir
t and contaminating microorganisms.
3. Walls, windows, storage shelves and similar non-critical surfaces should be s
crubbed periodically with a disinfectant/detergent solution as part of the gener
al housekeeping program. Keep all medicines, vials and other minor equipment in
closed shelves if not in use. 4. Sinks should be scrubbed clean at least daily w
ith a detergent.
5. Always keep the doorscl osed with a self-closing device.
6. There should be a separate isolation room for babies with suspected sepsis, w
here source
isolation precautions are to be followed.
18
B.EQU IP MENT:
1. Cradles / incubators/baby warmers: Surface clean once daily with detergent an
d 70% ethyl alcohol. The mattresses may be cleaned between babies with detergent
and wiped with 70%alcohol. Change sheets daily and use laundered linen from the
hospital supply.
When the incubators / open care units are being cleaned and disinfected after th
e baby is discharged, all detachable parts should be removed and scrubbed meticu
lously. If the incubator has a fan, it should be cleaned and disinfected; the ma
nufacturer’s instructions should be followed to avoid equipment damage. The air fi
lter should be maintained as recommended by the manufacturer. Mattresses should
be replaced when the surface covering is broken, because such a break precludes
effective disinfection or sterilization. Incubators not in use should be thoroug
hly dried by running the incubator hot without water in the reservoir for 24 hou
rs after disinfection.
Infants who remain in the nursery for an extended period should be transferred p
eriodically to a different, disinfected unit so that the originally occupied uni
t can be cleaned.
2. Suction catheters: Catheter tips should be sterile, disposable. Keep the bott
les and rubber tubes clean and dry when not in use. Wash the bottles with deterg
ent and dry, daily and between patients. Flush catheter with sterile distilled w
ater after each use.
C. BABY CARE:
1. Hand washing: Medical and hospital personnel must follow careful hand-washing
techniques to minimize transmission of disease. The following steps are recommen
ded by
the CDC, Atlanta:
I. Personnel should remove rings, watches, and bracelets before washing their ha
nds and entering the neonatal nursery. Fingernails should be trimmed short and n
o nail polish should be permitted.
II. Before handling neonates for the first time, personnel should scrub their ha
nds and arms to a point above the elbow thoroughly with an antiseptic soap. Afte
r vigorous washing, the hands should be rinsed thoroughly and dried. Antiseptic
preparations (e.g. Chlorhexidine 4 % or 70% alcohol ) should be used for scrubbi
ng before entering the nursery, before providing care for neonates, before perfo
rming invasive procedures, and after providing care for neonates.
19
III. A 10-second wash without a brush, but with soap and vigorous rubbing follow
ed by thorough rinsing under a stream of water, is required before and after han
dling each neonate and after touching objects or surfaces likely to be contamina
ted with virulent microorganisms or hospital pathogens.
Hand washing is necessary even when gloves have been worn in direct contact with
the infant. Hand washing should immediately follow removal of gloves, before to
uching another infant. Alcohol-containing foams kill bacteria satisfactorily whe
n applied to clean hands and with sufficient contact. They can be used in areas
where no sinks are available or during emergency. But they are not sufficient in
cleaning physically soiled hands, because transient organisms are not removed.
2. Feeding of babies
Mother s milk is the best food for both normal and low birth weight babies. The
borderline term and growth retarded low birth weight babies can suckle fairly we
ll at the breast and should be given expressed breast milk in preference to form
ula feeds by appropriate techniques such as clean cup and spoon or cleaned and s
terilized ‘gokarnam’. Milk should not be kept for long periods in open containers. T
he child should be put directly to the breast as soon as possible. (IAP recommen
dation). The mother may be given appropriate instructions regarding personal hyg
iene, which should include hand washing techniques: a) Always wash your hands be
fore expressing or handling your milk.
b) Be sure to use only clean containers to store expressed milk. Try to use scre
w- cap bottles or hard plastic cups with tight caps. Do not use ordinary plastic
bags or formula- bottle bags. Do not store milk for more than 1 hr at room temp
erature. Use chilled milk (kept at 0-4oC) within 24 hours.
3. Invasive procedures: For all invasive procedures, including lumbar puncture,
introducing a cannula or withdrawing blood for any investigation, ALL aseptic pr
ecautions have to be taken. This includes STERILE gloves and wipe with povidone
iodine and 70% alcohol, over the area.
20
CHAPTER 4
ISOLATION POLICY AND OUTBREAK
MANAGEMENT
1.ISOLATION STRATEGIES
In order to prevent the spread of infectious diseases the patients with communic
able diseases were often segregated. However as the knowledge about the differen
t modes of transmission increased the strategies involved have become more evide
nce based and targeted. Though the Centres for Disease Control (CDC), Atlanta, U
SA, has published guidelines regarding isolation practices in hospitals, each he
alth care facility should devise its own strategies based on the local needs. Th
ough appropriate door signs may be necessary,
care must be taken to ensure no breach of confidentiality and not to stigmatise
the patient.
Isolation procedures can be divided into two main categories:
Protective isolation — This is to prevent infection in immunocompromised patients
who are at increased risk of infection both from other patients and from the env
ironment. Isolation measures are usually maximal for those undergoing transplant
ation. A specialized room with positive pressure ventilation and HEPA filtration
is required.
Source isolation – A two- tier approach is recommended by the CDC. The Standard
precautions are for all patients admitted in the health care facility regardless
of their disease
status. It reduces the risk of transmission of microbes from both known and unkn
own sources of infection. These include: hand washing, gloves for body substance
s, gown if soiling is likely, and mask if splash is likely. The additional preca
utions are dependent on the different modes of transmission. Under this there ar
e six categories of isolation or precaution:
1.
Strict isolation - Spread is by contact or airborne. Single room with door shut.
Gloves, mask and gown for all those who enter. Diseases for which this is neede
d are – Viral haemorrhagic fevers, pneumonic plague, pharyngeal diphtheria, primar
y Varicella and disseminated zoster.
21
2.
Contact isolation – Spread is by contact. Single room. May cohort with patients wi
th same infection. Gloves and gown if there is likelihood of contact. Diseases i
nclude: Scabies, infection of wounds or burns with multiply resistant organisms(
e.g. MRSA), rabies and rubella.
3.
Droplet precautions – Spread is by large droplets. Requires close contact with the
person and occurs when the particles come into contact with eyes or mucous memb
ranes of a susceptible person. Single room. May cohort with similar patients, bu
t at least 1 m separation between patients. Gloves and gown if soiling is likely
. Masks only for those in close contact. Diseases are: Meningococcal meningitis,
measles, mumps, pertussis,H.i nf l uenzae epiglottitis.
4.
Airborne precautions – Spread is by small droplets, e.g. pulmonary tuberculosis, w
here patient is sputum positive. Small droplets remain suspended for longer peri
ods and travel farther. Single room with a negative pressure .At least six chang
es of air / hour .The air has to be exhausted well away from any air intakes. Ma
sks used should be particulate respirator type with filter. The patient is kept
here till at least three consecutive sputum samples become negative for AFB. One
month for severely ill patients and those with multi-drug resistant tuberculosi
s. This is also recommended for HIV infected patients with undiagnosed respirato
ry infection. Not needed for atypical mycobacterial infection.
5.
Enteric precautions – Diseases spread by faeco oral route. No need of separate roo
m.
Toilet facilities may be shared if patient is hygienic.
2. SURVEILLANCE & OUTBREAK MANAGEMENT
Surveillance of nosocomial infection is the foundation for organizing and mainta
ining an infection control programme. This information obtained should reach tho
se who may influence practice, implement change or provide financial resources n
ecessary to improve outcome. The data also provides a baseline to compare after
certain new infection control measures are implemented. When there is an ongoing
surveillance programme, any sudden change in the infection rates i.e. outbreak
situation, can be noted and infection control action implemented, before the act
ual outbreak occurs. The process of surveillance incorporates four key stages: D
ata collection, analysis, interpretation and dissemination.
22
Collection: Methods
1. Continuing Surveillance (CS) of all patients: All records, i.e. clinical, lab
oratory, nursing etc. are continuously surveyed. This is time-consuming and some
specialties may not have any infection. This requires staff, IT resources, and
a well organized reporting system.
2. Ward liaison (WL): Twice weekly visits to wards and review records.
3. Laboratory based: Laboratory records only. Depends wholly on the kind of inve
stigation
done
4. Laboratory based Ward Surveillance (LBWS): Follow up lab records in the ward.
This is
more accurate.
5. LBWS + WL: Time consuming but more accurate.
6. Targeted surveillance: Only high risk areas, e.g. ICUs, newborn units etc.
A minimum data set for surveillance includes:
Surveillance methods should be flexible enough to accommodate technological chan
ges,
shortening lengths of stay and to include procedures carried out after discharge
in the
community.
Analysis:
A simple comparison of actual number of cases with the expected number is routin
ely
carried out Validity of data - Incidence increases when there is awareness of a pro
blem,
Name/Hospital no.
Date of birth
Sex
Ward/Unit
Name of consultant
Date of admission
Date of onset of infection
Site of infection
Organism isolated/suspected
Antibiotic sensitivity
Treatment given
Other risk factors
Outcome
Date of discharge/death
23
improved diagnostic methods, ongoing screening programmes and higher reporting
propensity.
Interpretation
The data generated should be appropriately risk adjusted, for meaningful infecti
on
rates. Clearly defined surveillance objectives can overcome problems of data int
erpretation.
Dissemination

Active participation by all those who are engaged in filling forms and updating
data is ensured only when the final information from the various parts of the ho
spital is analyzed and sent back to them as useful information that helps in the
ir day-to-day clinical work.
The main objectives of surveillance should be:
1. Establishing endemic infection rates
2. Comparing infection rates between health care establishments
3. Evaluating control measures
4. Identifying outbreaks
5. General reduction of nosocomial infection rate.
Lab personnel or clinicians cannot be expected to conduct a surveillance program
me. This can be assigned to the Infection Control Lab and the ICD with the help
of the ICN can coordinate the data collection. Analysis and interpretation can b
e done by an Epidemiologist who is part of the ICT.
An outbreak situation is detected and can be immediately brought under control i
f their activities are well coordinated by the ICD. In the absence of an outbrea
k, the data may be used by the administrators to convince the media and general
public about the effective infection control precautions taken by the administra
tion. The ICD and ICN use the data to monitor infection rates in wards and ICUs
and post-operative infection rates. This helps in targeting continuing education
programmes and evaluating any gaps in implementation of the hygiene policies of
the hospital.
OUTBREAKS AND THEIR MANAGEMENT
Outbreaks within hospitals can involve the whole hospital, one theatre, one ward
,one
unit or one wing of the hospital The exact measures taken depends on the kind of
infection
24
and its mode of spread. The ICT with the help of the hospital management has to
plan the steps to be taken and implement it on a day-day basis. The basic steps
of outbreak control alone are discussed here:
1. Surveillance data indicate an outbreak situation.
2.Confirm the existence of an outbreak by comparison with previous data. An outb
reak is the occurrence of an infection at a rate greater than that expected with
in a defined area (unit or ICU or theatre or ward) over a defined period of time
e.g. one month or one week.
3.Create a case definition, i.e. the cases that come under the label ‘outbreak
case’, should be similar clinically / laboratory wise or both.
4.Identify the index case and construct an epidemic curve in time. This will hel
p
in narrowing down the source and mode of transmission.
5.Screen the staff (for carrier state) and environment, if necessary.
6.Take immediate control measures e.g. close down the ICU or source
ward/theatre, any major defects like a break in the chain of waste disposal or s
udden shortage of cleaning staff in that ward will have to be addressed on an ur
gent basis.
7.Summarise the investigation and report on steps taken and disseminate the
information to the appropriate authorities. Communicate this information to
the personnel involved, in the hospital.
8.Implement long-term measures so that such an outbreak does not occur in the
future.
25
CHAPER 5
ANTIBIOTIC POLICY
An antibiotic policy is not a restriction on the independence to prescribe antib
iotics, but a sensible guide to the practicing doctor on how to manage infection
s in the most effective manner. The policy will help the doctor solve the most i
mportant problems of rapidity of action, cost and availability, best route of ad
ministration, the most effective dose and duration of therapy. Generally the mic
robiologist insists that the antibiotic should be given according to the pattern
of sensitivity obtained after the organism is grown and identified. This takes
a minimum of 24- 48 hrs. Many of the infections can be diagnosed clinically, e.g
. meningitis, lobar pneumonia, infective endocarditis, enteric fever etc. and ne
ed early treatment. The antibiotic policy will help in the following ways:
1. Giving the correct advice to the clinician regarding the antibiotic to be sta
rted, after appropriate cultures have been taken. The sensitivity report will th
en confirm whether the same antibiotics may be continued. If the policy is good,
there will be almost no change in the antibiotics started.
2. Another important bonus to the administration is that the number of multi dru
g resistant strains that typically cause nosocomial outbreaks will also dramatic
ally decrease.
3. The pharmacy can order the needed antibiotics in greater quantities rather th
an
spreading out the resources over drugs that are rarely needed.
The ICT cannot make this policy on its own. The HICC has a big role here. Since
all the specialists are members, the policy may be made by the Microbiologist or
Infectious disease specialist, after receiving suggestions from all of them. Th
e policy can be reviewed by the committee every year and updated. It should be a
vailable for easy reference in tabular form in all the wards, ICUs and casualty
services. If the hospital has a computer networking system, this will help in ea
sy dissemination to all the medical officers.
26
The following policy is based on one followed by the National Health Services (N
HS), UK. These guidelines were developed by a multi-disciplinary working group t
o ensure balanced input. It has considered the antimicrobial choice for specific
conditions, and the existing policies for specific agents. By following the gui
delines it will be possible to maintain a high standard of patient care, deliver
ed in a consistent way, by all the doctors in the hospital.
It may be modified appropriately based on cost and availability.
INDICATIONS FOR ANTIMICROBIAL THERAPY
The use of antimicrobials has adverse consequences which compromise the efficacy
of
therapy for individual patients and the hospital as a whole. These include:
1. Adverse drug-related effects for patients
2. Alteration of normal flora leading to superinfection with organisms such as
Pseudomonas aeruginosa, Candida spp. and Clostridium difficile.
3. Selection of drug-resistant strains 4. Increased rates of cross infection 5.
Unnecessary cost
The decision to use antimicrobial agents must take these effects into account an
d is always a
balance of risk against benefit.
Directed Therapy
Antimicrobial treatment should normally be directed by the results of microbiolo
gical investigations confirming the presence of a true infection which is amenab
le to antimicrobial therapy.
Empiric Therapy
Where delay in initiating therapy to await microbiological results would be life
threatening or risk serious morbidity antimicrobial therapy based on a clinical
ly defined infection is justified. Where empiric therapy is used the accuracy of
diagnosis should be reviewed regularly and treatment altered/stopped when micro
biological results become available.
Microbiological samples must always be sent prior to initiating antimicrobial th
erapy. Rapid tests, such as Gram films, can help determine therapeutic choices w
hen empiric therapy is required.
27
CHOICE OF ANTIMICROBIAL
The sections in this policy indicate the suggested approach to treating the most
common forms of infection encountered in a hospital setting. The use of a restr
icted range of antimicrobial agents provides greater familiarity with their effi
cacy and potential side effects. It also allows the Microbiology services to pro
vide appropriate sensitivity data to guide therapy.
However this general guidance is not applicable to all patients. The choice of a
ntimicrobial
may need to be modified in the following situations:
1. Hypersensitivity to first choice antimicrobial (see guidance on hypersensitiv
ity)
2. Recent antimicrobial therapy or preceding cultures indicating presence of res
istant
organisms
3. In pregnant or lactating patients
4. In renal or hepatic failure
MONITORING TREATMENT
The continued need for antimicrobial therapy should be reviewed at least daily.
For most types of infection treatment should continue until the clinical signs a
nd symptoms of infection have resolved – exceptions to this are indicated in the r
elevant sections. Parenteral therapy is normally used in seriously ill patients
and those with gastrointestinal upset. Oral therapy can often be substituted as
the patient improves. Where treatment is apparently
failing, advice from a clinical microbiologist should normally be sought rather
than
blindly changing to an alternative choice of antimicrobial agent.
ANTIBIOTIC POLICY
1. SPECIFIC GASTROINTESTINAL INFECTIONS
As most cases of gastroenteritis are self-limiting, antimicrobials are not indic
ated and management should focus on fluid and electrolyte replacement. Furthermo
re, many cases have a viral aetiology and current antimicrobials are ineffective
. Moreover, in some situations, antimicrobial therapy may be associated with an
adverse clinical outcome.
28
Shigellosis and Salmonellosis: First choice: Ciprofloxacin 500mg po bd for 5 day
s.
Although this can be commenced empirically, it should be noted that resistance t
o
ciprofloxacin is increasing and therapy may have to be modified according to in-
vitro
susceptibility testing. Second choice: III gen. Cephalosporins, especially for c
hildren.
Giardiasis and amoebiasis: First choice:Metron id azole 2g daily for 3 days (if
tolerated) or
400mg tds for 5 days. Second choice: single doseT in id azole 2g
2. COMMUNITY ACQUIRED PNEUMONIA
Pneumonia is defined as community acquired if it presents within the first thr
ee days of
hospital admission.
Mild - moderate infection
Amoxicillin 500mg TDS PO
Penicillin allergy - Erythromycin 500mg QDS PO/Azithromycin
Severe infection
Crystalline penicillin IV
Penicillin allergy - Cefuroxime 1.5g TDS IV
Continue IV therapy for at least 24 hours. Severe CAP - 10 to 14 days treatment
Staphylococcus suspected (eg post influenza during epidemics and cavitation seen
on CXR)
add Cloxacillin 1g 6th hrly IV.
3.
COMMUNITY ACQUIRED MENINGITIS
If meningitis is suspected, take blood samples and then give antibiotics before
LP or CT
scan. LP may be done within one hour of starting antibiotics.
If confident that patient has typical meningococcal rash and no allergy - Benzyl
 penicillin 2.4g IV every 4 hours. If adult without a typical meningococcal rash
- Cefotaxime IV 2g QDS. If patient > 50 years, or immuno-compromised, or pregna
nt, and no typical meningococcal rash - consider adding Amoxicillin 2g IV every
4 hours (to cover listeriosis)
For suspected meningococcal contacts(Prophylaxis):
Adults - Rifampicin 600mg PO every 12 hours for 2 days
Children over 1 year - Rifampicin 10mg/kg PO every 12 hours for 2 days
Children under 1 year - Rifampicin 5mg/kg PO every 12 hours for 2 days
Pregnant females - Ceftriaxone 250mg IM stat
29
4.UNCOMPLICATED URINARY TRACT INFECTION (UTI)
Clinical signs:
Dysuria, frequency, nocturia
Lower abdominal pain or discomfort
Asymptomatic bacteriuria is common in elderly patients, suggest treating bacteri
uria in
elderly patients if symptomatic
NB Mild symptoms may not require antibiotic treatment.
Mild clinical signs –
Consider non drug treatment until MSU available - > 2L oral fluids per day
Trimethoprim 200mg BD for 3 days
Or Nitrofurantoin 50mg QDS for 7 days
If there is no response, send urine for culture and treat accordingly.
Pregnancy – III gen. Cephalosporin,oral/IV(asymptomatic bacteriuria is common and
should
be treated.
5. PYELONEPHRITIS
Clinical signs:
Pyrexia, rigors, loin pain +/- urinary tract symptoms and renal colic
Initial antimicrobial therapy is almost always given intravenously.
Cefuroxime IV 750mg TDS for at least 5 days.
> 2L oral fluids per day.
Culture negative MSU with pyuria and/or persistent symptoms - consider urethriti
s including
Chlamydia or TB. Refer to Urologist after first time in males and second UTI in
females.
5.PELVIC INFLAMMATORY DISEASE (PID)
Empirical treatment of PID should be initiated in sexually active young women an
d others at risk of sexually transmitted diseases if all the following minimum c
riteria are present, and no other cause for illness can be identified:
Lower abdominal tenderness
Adnexal tenderness

Cervical motion tenderness ( cervical excitation )

All patients should have a negative pregnancy test and ectopic pregnancy, append
icitis and
ovarian cysts excluded before a diagnosis of PID is made.
30
Delay in diagnosis and effective treatment for PID can increase the risk of tuba
l damage.
Therefore, treatment should start immediately, without waiting for the results o
f the swabs.
The patient s sexual partner must have antibiotic therapy to prevent possible re
-
infection. She should be advised to abstain from sexual intercourse until both s
he and her
partner have completed the antibiotics.
Outpatient
Doxycycline 100mg PO BD for 14 days and Metronidazole 400mg BD for 14 days
Or Ceftriaxone 250mg IM stat
Inpatient
Cefuroxime 750mg IV TDS and Metronidazole 500mg IV TDS
Or Metronidazole 1g PR TDS and Doxycycline 100mg PO BD
IV therapy should continue for a minimum of 24 - 48 hours, then:
Doxycycline 100mg PO BD for 14 days and Metronidazole 400mg BD for 14 days
6. OTITIS MEDIA
Inflammation of the middle ear which may be followed by profuse purulent dischar
ge as the
ear-drum perforates. Discharge usually settles after a few days. Continuing disc
harge may
indicate mastoiditis. It may be associated with an obstruction of the eustachian
tube.
Non antibiotic treatment:
Drain pus through acute perforation, clean debris
Analgesics such as paracetamol, NSAIDS and dihydrocodeine
Decongestants may be of some benefit.
Amoxicillin PO 500mg TDS for 5 days
Treatment failure
Cefaclor PO 500mg TDS for 5 days
7.TONSILLO PHARYNGITIS
Inflammation of the part of the throat behind the soft palate and/or tonsils due
to bacterial or
viral infection causing a sore throat, fever and dysphagia.
There is little evidence that antibiotics are beneficial unless quinsy or necros
is are suspected.
Non antibiotic treatment:
Warm saline throat irrigations
Throat lozenges containing local anaesthetics
Analgesics such as paracetamol, NSAIDS and dihydrocodeine.
Penicillin V PO 500mg QDS for 10 days
31
Treatment failure / Penicillin allergic
Erythromycin PO 250mg QDS for 10 days
Severe infection
Parenteral treatment may be required
Benzylpenicillin IV 1.2g QDS
Treatment failure / Penicillin allergic
Clarithromycin IV 500mg BD
8.CELLULITIS / ERYSIPELAS
Intravenous antibiotics are required if patient meets one of the following crite
ria:
Systemically unwell
Rapidly spreading or extensive disease
Immuno-compromised
Cloxacillin IV 1 - 2g QID and Benzylpenicillin IV 1.2 - 2.4g every 4 to 6 hours
If confident of diagnosis of erysipelas, omit Cloxacillin IV
Add Metronidazole 500mg TDS in diabetic patients
After 48 - 72 hours if appropriate oral therapy can replace Parenteral :
Cloxacillin 1g QID and Amoxicillin 1g TDS
9. ENTERIC FEVER
Oral antibiotics are best to tackle the infection in the Peyer’s patches. Though o
ral route is recommended for uncomplicated cases, parenteral Ciprofloxacin is re
commended in the presence of complications, with switch over to oral route after
the symptoms have resolved. Ciprofloxacin resistance is coming up due to the co
ntinued misuse of quinolones in wound infections and common respiratory infectio
ns. In such cases, parenteral third gen. cephalosporin followed by oral Cefixime
is recommended.
Ciprofloxacin 250mg TDS IV or 750mg BD orally for 10 – 14 days is the drug of
choice.
These are only the common infections. A comprehensive list can be made after dis
cussion with specialists. The basic principle is that simpler antibiotics are us
ed first to preserve the efficiency of higher ones. If this is followed by all t
he doctors in a hospital and then the peripheral hospitals and dispensaries are
also made aware, spread of multi drug resistant strains in the hospitals can be
reduced, In addition the total cost of treatment of infections is reduced signif
icantly.
Hospital Infection Control Manual
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