English Part1

NATIONAL GUIDELINES
FOR INFECTION CONTROL

PART I
STANDARD PRECAUTIONS
Infections acquired in the health care setting have emerged as
important public health problems worldwide and are a leading cause of
morbidity and mortality in developed and developing countries. They
contribute significantly to increased costs of health care services due to
prolonged hospital stay. During the past 10 years, health care delivery in
Egypt has undergone enormous changes with rapid advances in technology
and increasing numbers of staff performing complex invasive procedures.
These diagnostic and therapeutic technologic advances modernize health
care, but also place patients at increasing risk for health-care related
problems.
Maintaining quality health care while modernizing is the challenge that Egypt
must face. The national program for promotion of infection control and safe
injection practices in Egypt is the Ministry of Health’s response to this
challenge and is of utmost importance. The strategy of the program relies on
a multidisciplinary approach that focuses on improving the quality of services
in the health care setting. A national plan for infection control was established
with realistic goals of improving quality of health care by preventing disease
transmission. The program is committed to prevent adverse outcomes such
I
as health care associated infections and their related events, to minimize
occupational hazards associated with the delivery of health care, to promote
sound infection control practices focusing on injection safety, and to raise the
capacity and skills of health care providers. In the long term, the program will
contribute not only to a substantial decrease in hospital-acquired infection
rates, but also to a qualitative improvement of the services provided in any
health care setting.
The present document “The National Guidelines for Infection Control” takes a
big step in addressing this challenge. It represents the summary of more than
tow years of searches, discussion, debate and resolution. It is the product of a
participatory process involving numerous Egyptian and International Technical
Staff.
I encourage all health professionals providing health services to implement

policies and procedures of infection control for the safety of their patients and
for protection of their own health.
I wish to express my sincere thanks to all colleagues that shared in the

development of this important document for their active participation and for
their efforts in improving the health of the Egyptian citizen.
Minister of Health and Population

Professor Dr. Mohamed Awad Tag El-Din
II
Acknowledgments
Nosocomial infections occur worldwide and affect both developed and
developing countries. Infections acquired in health care settings are among the
major causes of death and increased morbidity among hospitalized patients.
They are a significant burden both for the patient and for the country. Infection
control standards in the health care facilities in Egypt are necessary to assure
good quality of service and to reduce transmission of nosocomial infections. The
development of the “National Guidelines for Infection Control in Egypt” was a
high priority for the Arab Republic of Egypt and a successful model of effective
collaboration between different institutions and partners in and outside of Egypt.
The recommendations in this document originated from Egyptian and

international sources including considerable material from the Association of
Professionals in Infection Control (APIC) and AVSC International. The
recommendations have been adapted to the context of health care services
provided in Egypt after considerable review and revisions by the Egyptian team.
The development of the guidelines passed through several stages. The outline
was developed by stakeholders in the Ministry of Health and Population in
collaboration with members from Egyptian Universities and international faculty
members. A first draft was developed which passed through a series of revisions
from infection control experts from Egypt and from abroad. The final guidelines
were approved in a consensus workshop with the attendance of Ministry of
Health and Population, faculty members from almost all universities in Egypt, and
experts from international organizations.
The guidelines are organized into two parts: Part I describes the basic
standard precautions that should be followed in all health care settings. Part II
describes infection control practices adopted in special high risk settings such as
intensive care units, hemodialysis units, dentistry, and others.
III
The editorial group wishes to acknowledge all contributors for their
valuable time and assistance. Special thanks to Prof. Dr. Ossama Rasslan, Dr.
Judene Bartley and Dr. Russ Olmstead. We wish also to thank the World Health
Organization (WHO), the United States Agency for International Development
(USAID), the U.S. Naval Medical Research Unit 3 (NAMRU3), and the Ford
Foundation for their support.
Editorial Group
Ms. Caroline Bodenschatz
Dr. Frank Mahoney
Dr. Maha Talaat
Dr. Amr Kandeel
Dr. Kenneth Earhart
Dr. Zoheir Hallaj
Revised By
Dr. Khaled Abd El-Aziz Abulsaad
Dr. Ehab Attia
Dr. Ashraf El-Kilani
Dr. Mohamed Genedy
IV
Contributors
Contributors
Ministry of Health and Population
Dr. Magda Rakha
Dr. Nasr El-Sayed
Dr. Hassan El-Kalla
Dr. Essmat Mansour
Dr. Enayat Ibrahim
Dr. Seham Hussein
Dr. Bahia Fouad
Dr. Abd Allah Kaddah
Dr. Abdel-Nasser Ahmed
Dr. Bassiouny Zaki
Dr. Yehia Sultan
Dr. Nadia Wassef
Dr. Abdel-Hamid Youssef
Dr. Mohamed Rabei
Dr. Soraya Terzaki
Dr. Wegdan Mokhtar
Dr. Mohamed Abu Kifo
Dr. Ossama Ibrahim
Dr. Wafa Abu Rabei
Dr. Walid El-Shoubari
Dr. Ihab Ahmed
Infection Control Department - MOHP

Dr. Amr Kandeel
Dr. Ihab Attia
Dr. Ashraf El-Kilani
Dr. Mohamed Genedi
V
Contributors
Egyptian Universities
Prof. Dr. Ossama Rasslan Ain-Shams University
Prof. Dr. Mohamed El Batanouny Cairo University
Prof. Dr. Mona Gharib Cairo University
Prof. Dr. Abdel-Aziz Kamal Ain Shams University
Prof. Dr. Tarek El-Sharkawy Cairo University
Prof. Dr. Ahmed Ramadan Alexandria University
Prof. Dr. Ahmed Shaheen Zagazig University
Prof. Dr. Sabri Rezk Mansoura University
Egyptian Syndicates
Prof. Dr. Ossama Raslan Medical Syndicate
Prof. Dr. Morad Abdel-Salam Oral Syndicate
High Nursing Institute

Dr. Tahani El-Senoussy
Dr. Neamatallah Gomaa
International Faculty
Ms. Lucile James Engender Health, USA
Ms. Judith English Bethesda Hospital, USA
Ms. Sylvia Froelicher Egyptian-Swiss Blood Bank
Dr. Shaheen Mehtar Cape Town, South Africa
Dr. Linda Chiarello Centers for Disease Control, USA
Dr. Judene Bartley Independent Consultant, USA
Dr. Russ Olmstead Independent Consultant, USA
Mr. John Boos Independent Consultant
Dr. Noordin Nizam Damani Craigavon Area Hospital, Ireland, UK
Dr. Peter Hoffman Senior Scientist, C.P.H. Lab., UK
Dr. Mary Carr Catlin Nurse Epidemiologist, USA
Dr. Peter Heeg Universität Tübingen, Duetchland
VI
Contributors
Dr. Shaheen Mehtar MBBS, FRC Path, Dept. of Community

Health, South Africa
World Health Organization

Dr. Zuhair Hallaj
Dr. Ezzedin Mohseni
John Snow Incorporated
Dr. Reginald Gipson
Dr. Hassan El-Sheikh
Dr. Lamia Mohsen
International Organizations
United States Agency for International Development (USAID)
World Health Organization (WHO)
Ford Foundation
US Naval Medical Research Unit – No.3 (NAMRU-3)

Dr. Frank Mahoney
Dr. Kenneth Earhart
Dr. Maha Talaat
Ms. Caroline Bodenschatz
Dr. Khaled Abdel-Aziz Abulsaad
Dr. Iman Khairy
Dr. Sahar Yassin
Dr. Tamer Saeed
Mr. Mohamed Ghamrawy (Designs & Illustrations)
VII
Table of contents
Table of Contents
Part 1
List of Figures……………………………………………………………………. XI
List of Tables……………………….……………………….……………………. XIII
Importance of Infection Control in the Health Care Setting……………... 1

Importance of Infection Control Programs……………………….…………... 1
Infection in Health Care Settings……………………….……………………... 2
Modes of Transmission……………………….……………………….……….. 6
Importance of Following Infection Control Practices ………………………. 13
Risk Management and Risk Assessment……………………….…………… 14
Organizational Structure……………………….……………………….……… 20
Introduction……………………….……………………….…………………….. 20
National Level……………………….……………………….………………….. 20
Governorate Level……………………….……………………….…………….. 23
District Level……………………….……………………….…………………… 26
Health Facility Level……………………….……………………….…………... 27
Functional Aspects of the Health Care Facility Infection Control

Program……………………….……………………….………………………….. 33
Introduction……………………….……………………….…………………….. 33
Surveillance of Hospital – Acquired infections……………………….……… 33
Investigation and Control of Outbreaks……………………….……………… 38
Aseptic Techniques……………………….……………………….……………. 39
Introduction……………………….……………………….…………………….. 39
Principles of Asepsis……………………….……………………….………….. 40
Intravenous Therapy……………………….……………………….………….. 43
Injection Safety and Proper Use of Multidose Vials………………………… 49
Urinary Catheterization……………………….……………………….……….. 55
Wound Inspection and Wound Care……………………….…………………. 58
Hand Hygiene……………………….……………………….…………………… 60
Introduction……………………….……………………….…………………….. 60
Microbial Flora of the Skin……………………….……………………….……. 61
VIII
Table of contents
Types of Hand Hygiene……………………….……………………….………. 62

Routine Hand Wash……………………….……………………….…………... 62
Antiseptic Hand Wash or Alcohol Based Handrub……………………….…. 68
Personal Protective Equipment (PPE) ……………………….……………… 71

Introduction……………………….……………………….…………………….. 71
Gloves……………………….……………………….……………………….…. 71
Aprons and Gowns……………………….……………………….……………. 74
Headgear……………………….……………………….………………………. 74
Face, Eye and Respiratory Protection……………………….……………….. 74
Overshoes and Footwear……………………….……………………….…….. 75
Isolation Precautions in Health Care Facilities (HCF) ……………………. 76

Introduction……………………….……………………….…………………….. 76
Notification of Communicable Diseases to District Health Office………….. 77
Transmission of Infection……………………….……………………….…….. 77
Standard Precautions (SP) ……………………….……………………….….. 78
Practical Issues and Considerations……………………….…………………. 79
Transmission-Based Precautions……………………….……………………. 81
Practical Guidance for Decision Makers on Isolation……………………….. 90
Occupational Safety and Employee Health…………………………………. 97

Introduction……………………….……………………….…………………….. 97
Services Provided by the Occupational Health Program…………………… 98
Sharps Injury Prevention Program……………………….…………………… 105
Control and Prevention of Antimicrobial Resistant Organisms in HCF.. 109

Introduction……………………….……………………….…………………….. 109
Acquisition and Transmission of antimicrobial resistant organisms………. 111
Antibiotic Usage……………………….……………………….……………….. 113
Formulating an Antibiotic Policy……………………….……………………… 114
Linen Management……………………….……………………….…………...... 117
Environmental Cleaning……………………….……………………….………. 120

Introduction……………………….……………………….…………………….. 120
Definition……………………….……………………….……………………….. 120
General Guidelines for Cleaning……………………….……………………... 120
Common Methods for Cleaning……………………….………………………. 122
Environmental Disinfection……………………….……………………………. 124
Cleaning Techniques……………………….……………………….…………. 127
Cleaning Levels for Different Clinic Areas……………………….…………... 127
Cleaning Supplies/Equipment……………………….………………………… 128
Ineffective Practices……………………….……………………….…………... 129
Cleaning of Equipment and Patient-Care Articles…………………………... 131
IX
Table of contents
Cleaning, Disinfection, and Sterilization of Medical Equipment………... 137

Introduction……………………….……………………….…………………….. 137
Processing Instruments……………………….……………………….………. 137
Cleaning……………………….……………………….………………………... 142
Soaking of Instruments Prior to Cleaning……………………………………. 145
Disinfection……………………….……………………….…………………….. 145
Sterilization……………………….……………………….…………………….. 152
Sterile Services Department (SSD) ……………………….…………………. 164
Waste Management I……………………….……………………….…………... 168

Introduction……………………….……………………….…………………….. 168
Magnitude of Medical Waste in Egypt……………………….……………….. 168
Legislation for Egypt……………………….……………………….………….. 169
General Principles of Waste Management…………………………………... 169
The Different Types of Waste……………………….………………………… 169
Sorting, Handling, Interim Storage, and Disposal of Medical Waste……… 172
Waste Management II: Safe Sharps Disposal………………………………. 178

Introduction……………………….……………………….…………………….. 178
Risk from Needlestick Injuries……………………….………………………… 178
Management of Sharps Injuries……………………….………………………. 181
Sharps Disposal Containers (Safety Box) ……………………….………….. 181
Glossary……………………….……………………….…………………………. 182
References……………………….……………………….………………………. 193
X
List of figures
List of Figures
Figure Page
Title
Number Number
Fig. 1 Transmission Cycle 6
Fig. 2 Hepatitis B transition 9
Fig. 3 Ways of infections transmission in Health Care Settings 15
Fig. 4 Organizational Structure 32
Fig. 5 Sites of the most common nosocomial infections 35
Fig. 6 Simplified example of steps in a surveillance system 35
Fig. 7 Intravenous Infusion System 43
Fig. 8 Sources and routes of transmission of infection from IV System 44

Areas of a sterile syringe and needle that should not be
Fig. 9 touched 51
Fig. 10 IV Injection 53
Fig. 11 Use of multi-dose vial 54
Fig. 12 Urinary Catheterization System 55
Fig. 13 Steps for Routine Hand Wash 64
Fig. 14 Handwashing Technique 65
Fig. 15 Frequently Missed Areas When Handwashing 66
Fig. 16 Sterile Gloves 71
Fig. 17 Non-sterile Gloves 72
Fig. 18 Utility Gloves 72
Fig. 19 Commonly used protective Barriers 75
Fig. 20 Sharps Injuries in Egypt 106
Fig. 21 Decontamination Steps 140
XI
List of figures
Fig. 22 Relation between type of item & its decontamination 142
Fig. 23 Steps for cleaning 144
Fig. 24 Steps for boiling 146
Fig. 25 Wrapping instruments and other items for steam sterilization 156
Fig. 26 Steps for wrapping instruments and other items 157
Fig. 27 Flow diagram of items processed in SSD 165
Fig. 28 Single room for processing instruments and other items 167
Fig. 29 Steps of Medical-Waste Management 172
Fig. 30 Waste transportation 173
Fig. 31 Burial pit 175
Fig. 32 Incinerator 176
Fig. 33 One Hand recapping technique 179
Fig. 34 Hands-free Technique 180
Fig. 35 Safety Boxes 181
XII
List of Tables
List of Tables
Table Page
Title
Number Number
Table 1 Classification of Pathogenic Microorganisms 5
Table 2 Essential standard precautions 12-13
Table 3 Simplified criteria for surveillance of nosocomial infections 36
Table 4 Prevalence and incidence rates 37
Recommendations for preparing hands and skin during

Table 5 41-42
procedures requiring aseptic techniques
Table 6 Types of Hand Hygiene 62
Table 7 Summary of Airborne Precautions 83-84
Table 8 Summary of Droplet Precautions 85
Table 9 Summary of Contact Precautions 86
Table 10 Summary of Airborne & Contact precautions 87-88
Summary of components of standard infection control

Table 11 precautions and of transmission based precautions in 89
isolation procedures
Risk Assessment Scoring System for Assigning the Priority of
Table 12 91
Isolation (Lewisham Isolation Priority System-LIPS)
Table 13 Isolation Precautions Reference Table 92-96
XIII
List of Tables
Guidelines for work restrictions for HCP with infectious

Table 14 diseases 100
Table 15 Table of Vaccines that are recommended for HCP 102
Table 16 HB Post Exposure Prophylaxis 104
Table 17 Control of antibiotic resistance 113
Table 18 Antibiotics against nosocomial infections 115-116
Table 19 Commonly Used Disinfectants 125
Table 20 Classification of Chlorine Concentrations 126
Table 21 Cleaning of Equipment and Patient-Care Articles 131-136
Decreasing order of resistance of microorganisms to

Table 22 disinfection and sterilization and the level of disinfection or 140
sterilization
Comparison of the characteristics of chemical sterilants used

Table 23 primarily as high–level disinfectants 150
Table 24 Disinfectant properties (High level disinfection) 151
Table 25 Sterilization times 154
Table 26 Dry heat sterilization temperatures & times 158
XIV
Importance of Infection Control in the Health Care Setting
Importance of Infection
Control in the Health Care
Setting
Importance of Infection Control Programs
Health care associated or hospital-acquired infections (HAI)

(nosocomial infections) are a worldwide problem. They
represent infections acquired during or associated with
delivery of care in contrast to infections present or incubating
at the time of the care delivery episode. Hospital-acquired
infections are among the leading causes of death and they
cause significant morbidity among patients who receive health
care.1 These complications of care require expensive use of
health care resources and they often lead to increased use of medication and
supplies, to more laboratory studies, and to increased duration of
hospitalization. They also may impair the quality of life of the patient with a
Hospital acquired infections even after treatment.2, 3 Prevention of Hospital-
acquired infections is therefore cost effective and achievable even when
resources are limited.
Technologic advances and increased use of invasive procedures, patient

populations that are getting older or are suffering more chronic diseases, and
increasing proportions of patients with immunocompromised conditions or
diseases are all factors that contribute to a greater recognition and frequency
of Hospital-acquired infections. Further, the widespread use of antimicrobials,
especially over- or inappropriate use of antibiotics, has contributed to an
increased incidence of antimicrobial-resistant organisms.4 Hospital-acquired
infections are often caused by antimicrobial-resistant microorganisms. Factors
associated with transmission of resistant strains of these microorganisms
include poor attention to hygiene, overcrowding, lack of an effective infection
control program, and shortage of trained infection control providers
There is a misconception that infection control programs are expensive and

are therefore beyond the reach of most hospitals. In fact, the opposite is true.
Infection control is based on common sense and on safe practice and can be
implemented with minimal cost.
1
A well-balanced infection control program should save the hospital a

considerable amount of money. For example, high rates of sepsis among
patients admitted to intensive care units can be controlled by meticulous hand
hygiene and by use of aseptic techniques rather than by prescribing
expensive antimicrobials, which may further contribute to the problem.
Further, inattention to safe injection practices can result in iatrogenic
transmission of blood-borne pathogens such as hepatitis C virus and human
immunodeficiency virus (HIV). For example, community-based initiatives
aimed at treatment of schistosomiasis in Egypt using injection of potassium-
antimony tartarate between 1918 and 1982 facilitated transmission of hepatitis
C virus because needles and syringes were reused without sterilization
between each use.5, 6
Because a high proportion of those with HCV develop chronic infection, both
morbidity and mortality from hepatitis C can be prolonged. High prevalence of
this disease offers opportunity for continued HCV transmission, including risk
to health care personnel who may experience injuries from contaminated
sharps used for care of patients with chronic HCV infection.7 HIV transmission
due to poor infection control precautions in dialysis centers has also been
observed. 8
The principles of infection prevention and control are the same throughout the
world. Most of the technical expertise and recommendations for infection
control have been developed in countries with well-developed health care
systems. Considerable time was spent in these countries in the training of
specialists in infection control. Unfortunately, the discipline of infection control
is poorly developed in countries such as Egypt where there is a rapidly
developing health care system and where there is little expertise in infection
control training. Establishing a cost effective program for Egypt is a leading
priority for the Ministry of Health and is an essential component of efforts to
improve the quality of health care.9
Infection in Health Care Settings

Although we do not often think about it, health care facilities may support
transmission of infection. Hospitals and clinics are intended to treat the sick.
Reflection leads to the following considerations:
• People seeking health care services may be more susceptible to
infections.
• People seeking treatment may have infections that can be
transmitted to others.
• Patients undergoing invasive procedures may be at increased risk
of infection if basic infection control (IC) practices are not observed.
• Health care providers may transmit infectious agents directly or
indirectly to clients and to themselves unless basic IC practices are
observed.
2
• Other general factors that contribute to potential cross-transmission

include:
- Overcrowding during periods of high admissions with limited physical
space for carrying out appropriate IC practices.
- Staff shortages.
- Poor infrastructure to support infection control (IC) practices.
Modes of Infectious Disease Transmission

There are two sources of infection occurring in a hospital or health care setting:
• Endogenous source: The causative agent of the infection is present
in the patient at the time of admission to the hospital as part of his/her
normal flora but there are no signs of infection. The infection develops
during the stay in the hospital as a result of the patient’s altered
resistance or through introduction of microbes into normally sterile
areas such as insertion of an intravenous catheter into a vein or from a
surgical procedure.
• Exogenous source: Infection occurs from introduction of microbes
into or on the patient from an outside source. For example, the patient
may acquire infectious agents from the hands of staff or from
contaminated equipment and subsequently may develop an infection.
Natural Barriers to Infection Within the Body
Healthy people are naturally colonized with microorganisms, many of which are
essential to good health. Feces contain about 1013 bacteria per gram; these
bacteria assist with digestion. The skin can carry between 100 and 10,000
microorganisms per cm2 and this normal skin flora can secrete substances that
assist in good skin integrity. Many species of microorganisms live on mucous
membranes and form a normal flora. None of these tissues, however, are
infected. Microorganisms that penetrate the skin or the mucous membrane
barrier reach subcutaneous tissue, muscles, bones, and body cavities (e.g.
pleural cavity, bladder) which are normally sterile (i.e. contain no detectable
organisms). If a general or local reaction to this penetration develops with clinical
symptoms, the response is termed an infection.
A healthy person, is protected from acquiring nosocomial pathogens by virtue of
natural barriers:
• Skin is the first line of defense. In healthy people it is intact and even if
a person has contact with microorganisms, they can be removed by
washing. If the skin is breached or broken in any way, such as
eczema, cuts, or wounds, the organisms can enter the person’s body.
• Mucous membranes: In healthy people mucous membranes are
covered in natural secretions that defend against a small number of
3
organisms coming into contact with them. Also, mucous membranes

regularly shed and replace cells in order to maintain integrity. Mucous
membranes are also covered in normal flora, which protect against
acquiring “outside” bacteria. Any alteration in this normal flora, due, for
example, to receipt of medications, may permit colonization and
subsequent infection with pathogens. Also, the use of antibiotics can
destroy normal flora, which can be rapidly replaced by nosocomial
pathogens.
• Humoral immunity: These are antibodies or proteins produced by
certain cells in the body, which attack pathogens that enter the body
and try to stop them from spreading or from attaching themselves to
specific cells or sites.
• Cellular immunity: This is controlled by certain types of white blood
cells that coordinate and memorize exposure to microorganisms
foreign to the body. It is a critical part of the body’s immune defense.
These cells have the capacity to coordinate destruction of invading
pathogens by direct contact or by the activation of substances
(antibodies, interferon) that will inactivate them. Cellular immunity is
also the component of the immune system that memorizes the
antigens on microbes and activates a protective response should there
be subsequent exposure to a pathogen. This system is used, for
example, when immunizations such as hepatitis B vaccine are
provided and can assure lifelong immunity against this virus.
The Transition from Colonization to Infection

Whether or not a tissue will develop an infection after contact with
microorganisms depends upon the interaction between the contaminating
organisms and the host. Not all individuals who are colonized will develop
infection. In fact, those who have progressed from colonization to infection may
represent only the “tip of the iceberg” of persons carrying a particular pathogen.
Risk groups for developing hospital–acquired infections

Healthy individuals have a normal general resistance to infection.
Immunocompromised patients, newborn babies, persons with chronic diseases,
and the elderly have less resistance and are more likely to develop an infection
after colonization. Healthy personnel are thus less likely to become infected in
the hospital setting than are patients who are often at very high risk because of
preexisting health conditions.
Conventional, conditional, and opportunistic pathogens

Local resistance of the tissue to infection is an important factor in whether a
person develops an infection after colonization. The skin and the mucous
4
membranes act as barriers in contact with the environment. Infection may follow
when these barriers are breached.
The first line of defense, skin, may be overcome by the long-term presence of a
foreign body or device such as an intravenous (I.V.) cannula or indwelling urinary
catheter. The likelihood of infection in patients with devices increases over time,
given the opportunity for microorganisms to gain entrance to the normally
inaccessible tissue.
Among the important determinants of infection, however, are the nature and
number of the colonizing organisms. Microorganisms that may cause infection
include fungi, bacteria, viruses and parasites. Pathogenicity is the measure of the
microbes’ ability to induce disease. Fortunately, vaccines or preventive
treatments (immunoglobulins) are available for many.
Pathogens may be classified as conventional, conditional, or opportunistic based
on their ability to cause disease in normal versus immunocompromised hosts.
However is it important to appreciate that almost any microbe, if introduced into a
normally sterile area, can cause infection.
Table 1: Classification of Pathogenic Microorganisms

Conventional (acute) Opportunistic
Conditional pathogens
pathogens pathogens
Cause disease in Cause disease, other than Cause generalized
healthy individuals, trivial local infections, only in disease, but only in
including, when persons with reduced patients with
applicable, in the resistance to infection (incl. profoundly diminished
absence of specific newborn infants) or when resistance to infection.
immunity. implanted directly into tissue
or in a normally sterile body
Examples:
area. Examples:
Bacteria:
Staphylococcus Examples: Atypical mycobacteria,
aureus, Streptococcus Streptococcus agalactiae, Nocardia asteroides,
pyogenes, Salmonella Enterococcus spp., Pneumocystis carinii,
spp., Shigella spp., Clostridium tetani, Cryptococcus
Corynebacterium Escherichia coli, Klebsiella neoformans,
diphtheriae, spp., Serratia marcescens, Histoplasma spp,
Mycobacterium Acinetobacter baumanii, Cryptosporidium.
tuberculosis, Pseudomonas aeruginosa, In addition to those
Bordetella pertussis, Candida spp.,Listeria from the previous
Viruses: monocytogenes, columns.
hepatitis A, B, C, Toxoplasma, Aspergillus spp,
rubella virus, rotavirus, Legionella spp.
human
immunodeficiency
virus (HIV).
5
Minimal infective dose of a microorganism

When only a few organisms are present on or in a tissue, an infection will not
necessarily develop. However, when a critical number is exceeded, it is very
likely that the tissue will become infected. This will vary by microorganism and by
point of entry or invasion. Many causative agents of Hospital-acquired infections
have a relatively high minimal infective dose. For Klebsiella and Serratia spp. and
for other Enterobacteriaceae, for example, it is more than 100,000
microorganisms (105 cfu/ml). Some causative agents, however, require very few
particles to infect, such as hepatitis B virus (less than 10 viral particles).
Modes of Transmission
The Chain of Infection or Disease-Transmission Cycle
Infection cannot occur unless all key elements are present: an infectious agent, a
source of the agent, a susceptible host to receive the agent, and most critically, a
way for the agent to be transmitted from the source to the host. The interaction
among these elements is known as the “chain of infection,” or “disease-
transmission cycle,” which emphasizes the necessary linkages among all
elements.
The disease-transmission cycle below describes how infections are transmitted
from one person to another. To prevent the transmission of infections, the
disease-transmission cycle needs to be broken at some point along the chain.
Fig. 1: Transmission Cycle
6
The Six Components of the Disease-Transmission Cycle

1. Infectious agent
The infectious agent is the microorganism that can cause infection or disease.
The infectious agent includes bacteria, viruses, fungi, and parasites.
2. Reservoir
A reservoir is the place where the agent survives, grows, and/or multiplies.
People, animals, plants, soil, air, water and other solutions, and instruments and
other items used in clinical procedures can serve as reservoirs for potentially
infectious microorganisms.
3. Place of exit
The route by which the infectious agent leaves the reservoir is called the exit.
The infectious agent can leave the reservoir through the bloodstream, broken
skin (e.g. puncture, cut, surgical site, or rash), mucous membranes (e.g., eyes,
nose, and mouth), the respiratory tract (e.g., lungs), the genitourinary tract (e.g.,
vagina, penis), the gastrointestinal tract (e.g., mouth, anus), or the placenta by
means of blood, excretions, secretions, or droplets that come from these sites.
For environmental reservoirs, for example, exit may be accomplished by
contamination of patient care equipment by microorganisms in tap water used to
rinse the equipment.
4. Mode of transmission
The way in which the infectious agent moves from the reservoir to a susceptible
host is called the mode of transmission. Transmission can occur by 5 modes:
• Contact: The infectious agent can be transmitted directly from the
reservoir to a susceptible host through touch (e.g., Staphylococcus) or
sexual intercourse (e.g., gonorrhea, HIV). Contact mode of
transmission is the most important and frequent mode of transmission
of Hospital-acquired infections. It is divided into two subgroups:
a) Direct contact: direct body surface-to-body surface contact and
physical transfer of microorganisms between a susceptible host and
an infected or colonized person.
b) Indirect contact: contact of a susceptible host with a contaminated
intermediate object, usually inanimate, such as contaminated medical
instruments, needles, or dressings or contaminated gloves, e.g., of
health care personnel if gloves are not changed between patient care.
• Droplet transmission: Transmission occurs via droplets containing
microbes generated by the source person when they cough, sneeze,
or talk or by procedures such as respiratory tract suctioning or
bronchoscopy. These contaminated droplets are propelled through the
7
air a short distance, usually no more than 1 meter, and are deposited
on the susceptible host’s conjunctivae, nasal mucosa, or mouth. These
droplets are too heavy to become suspended and therefore agents
transmitted by droplet are distinct from other agents that are
transmitted via the air. Special air handling and ventilation are not
necessary to interrupt transmission of microbes carried by this mode.
• Airborne transmission: The infectious agent can be transmitted via
tiny droplet nuclei (< 5 microns) containing microorganisms that remain
suspended in the air and that can be carried by air currents (e.g.,
measles, M. tuberculosis) at greater distances than large droplets.
These droplets are then inhaled by the susceptible host. The droplet
nuclei may remain suspended in the air for varying periods of time and
special air handling and ventilation are required in order to prevent
transmission of these microorganisms.
• Common Vehicle transmission: The infectious agent can be
transmitted indirectly from the reservoir to a susceptible host by
material contaminated with the infectious agent. Examples of common
vehicles include food (e.g., Salmonella spp.), blood, (e.g., hepatitis B
virus, hepatitis C virus, and HIV), water (e.g., Cholera, Shigella), or
contaminated instruments and other items (e.g., hepatitis B virus,
hepatitis C virus, and HIV, Pseudomonas spp.).
• Vector transmission: The infectious agent can be transmitted to a
susceptible host through insects and other invertebrate animals (e.g.,
mosquitoes can transmit malaria and yellow fever; fleas can transmit
plague).
5. Place of entry
The place of entry is the route by which the infectious agent moves into the
susceptible host. The infectious agent can enter the susceptible host through:
• Bloodstream (site of invasive procedures such as injections or
intravenous catheters).
• Broken skin (e.g., puncture, cut, surgical site, rash).
• Mucous membranes (e.g., eyes, nose, mouth).
• Respiratory tract (e.g., lungs).
• Genitourinary tract (e.g., vagina, penis).
• Gastrointestinal tract (e.g., mouth, anus).
• Placenta.
8
6. Susceptible host
A susceptible host is a person who can become infected by the infectious agent.
Susceptible hosts include patients, health care personnel, ancillary staff, and
visitors from the community, and will vary with the infectious agent. Vaccination
to specific agents reduces susceptibility to specific agents.
An example of how hepatitis B may be transmitted in the health care setting
Fig 2: Hepatitis B transmission
The Prevention of Nosocomial Infection

Principles
Three basic principles govern the main measures that should be taken in order to
prevent the transmission of Hospital-acquired infections infections in health-care
facilities:
• Identify and separate known infected patients, patients with certain
symptoms or behaviors (e.g., poor hygiene), or patients with high
potential for contamination of the environment (uncontained, draining
surgical wound) from other patients;
9
• Eliminate or minimize potential routes of transmission from sources of

microorganisms (e.g., use aseptic technique when inserting IV
catheters);
• Use basic barrier techniques to eliminate or to minimize the risk of
transmitting infectious agents from patient to patient, from patient to
caregiver, and from caregiver to patient. Presume all patients may be
infected but not show symptoms or signs of infection
The separation of the source has to be interpreted in a broad sense. It includes
not only the isolation of known infected patients but also the creation of a barrier
between infected or potentially contaminated tissue and the environment,
including other patients and personnel.
It is impossible to avoid all contact with infected tissue or potentially
contaminated body fluids, excreta, and secretions. Appropriate barriers (e.g.,
gloves) should be used when handling potentially contaminated instruments,
containers, linen, etc. followed by hand hygiene after glove removal. If an object
is disposable, it should be used once and discarded as waste. If it is reusable,
transmission of infective agents is prevented by cleaning and by appropriate
disinfection or sterilization.
Isolation Precautions for Known, Infected Patients

The policy for managing patients with suspected or known infection is referred to
as isolation precautions. The method is based on a two-tier precautions system.
• Tier One: Routine or Standard infection control precautions that are

designed for the care of all patients regardless of their diagnosis or
presumed infectious status.
• Tier Two: The second tier of precautions is based on the route of
transmission of infectious agents. It is designed to supplement the
routine infection control precautions, which should be used for patients
known or suspected to be infected or colonized with transmissible or
epidemiologically important microorganisms.
The second tier of precautions is grouped into various categories according to

mode of transmission [e.g., contact (direct or indirect) droplet, airborne, vehicle,
or vector transmission]. It is important to understand that some microorganisms
have more than one mode of transmission and, therefore, more than one
category of source isolation precautions may be required. In such cases, advice
should be sought and isolation precautions modified according to local needs.
The following points are common to all categories of isolation precautions:
• All patients with suspected or proven infection should be isolated as
much as possible from other patients. If a private room is not available,
seek advice from a member of the Infection Control team regarding
patient placement. In some cases they may suggest that the patient be
10
nursed on an open ward provided that the specific precautions are

followed meticulously, but this is the least favorable option. Placement
of the patient at one end of the ward close to the wash hand basin and
rinse may minimize traffic and may increase staff awareness of the
need for hand hygiene. If more than one patient is affected (e.g., in an
outbreak caused by a similar microorganism), the Infection Control
team may recommend cohorting (grouping) patients in a single
cubicle/area with care provided by nursing staff assigned only to
infected patients. In other instances the Infection Control team may
advise that for shared or multi-patient rooms the infected or colonized
patient be placed with others who do not have indwelling devices, e.g.,
urinary catheters, or recent surgical incisions.
• All visitors must report to the nurse-in-charge before entering the room
of a patient in isolation and must be instructed on protective clothing
and other precautions, such as hand hygiene.
• Staff should use hand hygiene, e.g. wash hands, immediately after
leaving the room to avoid the transfer of microorganisms to other
patients or to the environment.
• If possible, the nursing staff should attend the patient in isolation last,
after dealing with all non-infected patients.
• If common equipment is unavoidable, then items must be adequately
cleaned and appropriately disinfected or sterilized (e.g., autoclaved)
before use on another patient.
• The room should be cleaned after discharge of the patient.
• It is important to consider the psychological effect of isolation on
patients and a member of the Infection Control team should discuss
concerns expressed by the patient or by their family members.11
[For more information see chapter on “Isolation Precautions in Health Care Facilities”]
Protective Clothing
Personal protective equipment (PPE) should be worn by health care personnel to
protect themselves against exposure to microbes and to minimize potential for
contamination of their clothing.11
[For more information see chapter “Personal Protective Equipment”]
Standard Precautions
Standard precautions (SP) are required for all care in the health care facility in
order to prevent transmission of communicable diseases and Hospital-acquired
infections. Standard precautions should be part of standard health care practice
for all patients in all levels of health care services. Before embarking on
extensive and complex infection control (IC) policies and procedures, all health
11
care facilities should have the following six procedures in place. The first role of
the Infection Control team is to assess the status of these procedures and, if they
are not adequate, to ensure that provisions are made to improve adherence and
application.
Table 2: Essential standard precautions used in the care of all patients

irrespective of whether or not they are diagnosed infectious
• Wash hands after touching blood, secretions,
excretions, and contaminated items, and after removal
of gloves.
Hand hygiene
• Use plain soap for routine handwashing.
• Use an antimicrobial cleaning agent for specific
circumstances.
• Use appropriate barrier equipment designed to shield
the employee from blood and body fluid contamination.
Personal
This equipment includes gloves, fluid resistant masks
protective
and gowns, splash shields, and eye protection, and is
equipment (PPE)
used whenever there is a risk of exposure to blood or
other potentially infectious material.
• Aseptic techniques refer to the practices performed just
before or during a clinical or surgical procedure in order
to reduce the patient’s risk of infection by reducing the
likelihood that microorganisms will enter areas of the
body where they can cause infection. These practices
include:
Aseptic • Surgical attire,

techniques • Surgical scrub and gloving,
• Establishing and maintaining a sterile field,
• Using good surgical technique, and
• Employing measures to minimize contamination
of medical devices during insertion, care and
maintenance.
Reprocessing of • Ensure that reusable equipment is not used for the care
instruments/ of another patient until it has been cleaned and
Sterile services reprocessed appropriately.
• Ensure that the hospital has adequate procedures for
Environmental
the routine care, cleaning, and disinfection of
cleaning
environmental surfaces.
12
Table 2: (continued)
• Take care to prevent injuries when using needles,
scalpels, and other sharp instruments and devices.
Proper sharps
and waste • Manage health care waste properly to prevent
disposal exposures to infections, and toxic effects and injuries to
health care personnel, waste handlers, and the
community.
Importance of Following Infection Control

Practices
As stated in the previous section, in order to prevent the transmission of
infections, the disease-transmission cycle needs to be broken at some point in
the chain. The most reasonable point at which to break the cycle is at the mode
of transmission. Following appropriate infection control practices breaks the cycle
by preventing infectious agents from leaving the source or from invading a
susceptible host.
Following appropriate infection Control practices can:

• Prevent post procedure infections including surgical-site infections;
• Provide high-quality, safe services;
• Prevent infections in staff;
• Protect the community from infections that may originate in health care
facilities;
• Prevent or reduce the transmission of antimicrobial-resistant microorganisms;
and
• Lower the costs of health care services, since prevention is more economical
than treatment.
Infection control has traditionally focused on preventing post procedure infections

in patients. However, awareness of the potential for infection from HBV and HCV,
as well as from HIV, has broadened the scope of infection control activity.
Attention is now directed towards minimizing the risk of transmitting infections not
only to patients but also to service providers, to ancillary staff, including cleaning
and housekeeping personnel, and to members of the community.
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Risk Management and Risk Assessment

Risk Management (RM)
Risk is defined as “the possibility of incurring misfortune or loss”. There are
numerous well-defined risks for the transmission of communicable diseases to
patients, to staff, or to the community during the provision of health care.
Generally the risk of acquiring an infection during delivery of health care
increases among patients who are critically ill and who are subjected to invasive
medical procedures. Risk assessment/management is an essential tool that is
used by the Infection Control team to assess and to evaluate situations or care
being delivered, to minimize these risks by implementing appropriate
interventions, and to provide high quality health care. Risk assessment and other
tools such as application of epidemiological methods are proactive rather than
reactive. Risk Management (RM) is concerned with developing the expertise of
individuals within the organization to minimize risk and to “reduce loss.”
Risk Assessment in Infection Control (IC)

Risk assessment (RA) is an essential activity that needs to be done before
constructing an IC program. The assessment should include a study of the
patient population, staffing (types and levels), and the clinical practices and their
attendant risks as well as a study of administrative needs necessary to minimize
these risks. The RA should include a review of the community from which the
patients come, identifying as much as possible the likely types and volume of
communicable diseases prevalent in the local area,and the intensity/complexity
of services being provided. The assessment should review existing policies to
address the availability of critical supplies and infrastructure to ensure the safety
of high-risk procedures. The RA should be based on scientific fact as much as
possible. Once the RA profile has been determined, a plan of action should be
established. Initial action steps include developing and communicating IC policies
in language that is simple and easy to understand. It is often helpful to use
graphic illustrations that are displayed in the work area to reinforce infection
control policies.
Risk Assessment should:

• Produce logical well considered guidelines;
• Be cost effective;
• Not overwhelm the staff;
• Not scare the patients;
• Permit workable hospital practice.
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Steps for Risk Assessment:

• Assess critical activities where transmission of infectious agents can
occur,
• Consider all the available evidence and facts regarding these activities
and preventive measures that can be taken through infection control,
• Recognize the necessary interventions to stop or to reduce
transmission of infectious diseases, and
• Develop guidelines or policies to minimize likelihood of disease
transmission.
The precautions should be workable and simple.
Principles To Know:
• What the offending agent is (microbial or body substance),
• How it causes danger (mode of transmission or toxic side effects), and
• How to reduce this risk (intervention).
• Use the principles above to influence policy makers and to lead to logical
expenditure of resources.
Examples of Ways Infection Can Be Transmitted

• To personnel from patients or from visitors
• To patients from personnel or from visitors
• From patient to patient
• Between personnel
Health care worker

To Health care worker
Health care Patient to

worker health care
To patient Worker
Patient to Patient
Fig. 3: Ways of infections transmission in Health Care Settings
15
Examples of Risk Assessment and Management

Procedure - Setting up an IV line
• Risk Assessment – Staff contact with patient blood (potential risk for
exposure). Patient may be infected if health care worker uses non-
sterile equipment or poor aseptic technique.
• Risk Management – Reduce risk to staff by wearing gloves and
washing hands. Reduce risk to patient through the use of aseptic
techniques and sterile equipment when inserting IV.
Procedure - Taking blood pressure

• Risk Assessment – No risk, since procedure is non invasive.
• Risk Management - No need to reduce risk, protective clothing not
advised.
Procedure - Cleaning the ward floor

• Risk Assessment – No risk since staff not in contact with patient.
• Risk Management - No need to reduce infectious risk, additional
protective clothing not advised; standard equipment adequate for staff.
Emphasize use of PPE to protect against exposure of staff to
chemicals that might be in cleaning materials.
Procedure - Cleaning the toilet area or handling bedpans

• Risk Assessment – Exposure to fecal pathogens during cleaning.
• Risk Management - Reduce risk, by wearing gloves and washing
hands.
Note
- It is the procedure that carries the risk rather than the patient!
- Standard precautions are applied because of the procedure rather than the type
of patient.
- Everyone who works at a health care facility is potentially at risk of infections
unless they follow proper IC procedures. This includes not only doctors and
nurses who have direct contact with clients at risk, but also those who wash the
instruments and other items, those who clean the procedure rooms, and those
who manage waste disposal.
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Mode of Transmission of HBV, HCV and HIV

Scientific studies have shown that HIV, HBV, and HCV are transmitted from
direct contact with blood or with body fluids contaminated with blood that
penetrate the skin or mucous membrane. Still, one survey of health care
personnel revealed disproportionate concern over exposure to HIV and a
misunderstanding of transmission. 12 Blood-borne pathogens are transmitted by:
• Direct contact with blood or with fluids containing the blood-borne
pathogen.
• Introduction of contaminated blood onto nonintact skin.
• Injuries from contaminated needles or other sharps instruments.
• Transfusion of contaminated blood or blood products.
• Infusion of intravenous fluids/medications or injection using
contaminated needles (e.g., reused), syringes, or drugs.
• Splashes of contaminated body fluids into or onto the mucous
membranes of a health care worker.
• Use of contaminated razors, toothbrushes, or tattooing needles.
• Sexual contact- through unprotected vaginal or anal intercourse.
Transmission through oral sex has been reported but is much lower
than through vaginal or anal intercourse.
• Perinatal transmission – virus may be passed from mother to infant
during pregnancy, labor and delivery, or during breastfeeding.
• HCV is transmitted through blood and other body fluids. However, the
risk of transmitting HCV through sexual contact or perinatal
transmission is considered to be low compared to direct transfusion or
sharps injuries.
Note:
There is no evidence of transmission of HBV, HCV, and HIV from:
• Casual social contact,
• Sharing eating utensils,
• Insect bites,
• Infection with shistosomiasis,
• Donating blood,
• Consuming food or drink, or
• Contact with environmental surfaces that are not contaminated with visible
blood.
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Misconceptions about the Incidence of Health Care

Associated or Hospital-Acquired Infections
Health care personnel often believe that the incidence of post-procedure and
other hospital-acquired infections at their facility is low. Similarly, they may
believe that the incidence of serious infections (such as HIV or HCV) in their
community is low and thus not of concern. In reality, it is difficult to track the
incidence of post-procedure and other hospital-acquired infections and to know
how many people have blood-borne infections because:
• There is little to no surveillance of infection.
• Post-procedure infections may be difficult to identify, especially for
many outpatient services. On average, early onset surgical site
infections occur within 7-10 days after a clinical procedure has been
performed; other late onset surgical site infections may develop up to a
year later.
• Infections do not always cause problems serious enough to make
clients seek medical attention. Though the infections may prolong the
healing process, eventually they may resolve on their own.
• Patients may seek treatment of post-procedure infections at another
facility or pharmacy.
• Patients or staff may not find out they are infected with HIV or with the
hepatitis viruses until years after the incident of exposure occurred,
when little connection to a past clinical procedure or workplace
accident would be evident.
Misconceptions about a Health Care Worker’s Safety

when appropriate infection control practices are not
followed
Many health care personnel believe that they need to follow appropriate infection
control practices only with clients whom they know to be infected. Staff may be in
favor of screening clients for HIV and HBV before providing clinical services (e.g.,
surgery) in order to identify those clients who are infected. This practice is not
recommended because:
• Some blood-borne infections (e.g., hepatitis C) may be detected
through screening tests but cannot detect when the infection occurred.
• Test results may appear negative for a period of time after a person
becomes infected (the time periods varies, depending on the type of
infection and on the test being used).
• Screening is not possible during emergency situations. If infection
control practices are not followed routinely, health care personnel may
18
not have the knowledge or supplies needed to follow the practices and
to protect themselves in an emergency.
• Screening is costly and may divert money away from needed training,
supplies, and equipment.
• Screening may lead to a false sense of security on the part of health
care personnel, who may believe that they are not at risk of infections
when treating clients who have tested negative on screening tests.
Misconceptions about the Feasibility of Following

Appropriate Infection Control Practices
Many health care personnel believe that infection control practices require
expensive equipment or supplies. But this is not the case. It is just as feasible to
institute appropriate infection control practices in low-resource settings as in
high-resource settings because it is based on common sense and sound
knowledge of procedures.
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Organizational Structure
Introduction
Infection control (IC) is a necessary component of safe, high quality patient care
and is essential for the well being of the patients and of the staff. The
fundamentals of infection control are applicable across all settings where health
care is being provided throughout the world. These fundamentals need to be
employed regardless of constraints in resources and support, as they are
designed to protect the patient and provider against exposure to infectious
microorganisms and against the morbidity and mortality associated with these
agents should infection occur.
In order to achieve reduction in infection rates among patients and staff, an
infection control program has to develop a clear and firm organizational structure.
As a first step, the infection control program needs to establish the appropriate
organizational structure within each level of the health care system and to have
defined roles and responsibilities for key personnel. This organizational structure
is an essential component to the success of any public health program. Each
level of the infection control program, from the person(s) charged with
administrative support to the direct care provider at the patient bedside, should
share in the overall responsibility of preventing infection. The hierarchy of the
infection control program in Egypt is presenting all levels of health care e.g. the
national, governorate, district, and hospital facility levels.
National Level
There are two groups supervising the implementation of the infection control
program at the national level:
• National Infection Control Advisory Committee (NIC-AC)
• Central Infection Control Unit (CIC-U)
National Infection Control Advisory Committee (NIC-AC)

This is a generic committee that should advise all staff of infection control at
central level. It is headed by H.E. Minister of Health and Population.
20
Personnel
Chairman
• Minister of Health and Population
Members
• Director of Preventive affairs
• Director of Curative department
• Director of Central Laboratory
• Director of Dentistry
• Director of Primary health care
Director of Family planning
• Director of Free treatment (Private Sector )
• Director of Pharmacy
• Director of Medical supply
• Director of Nursing
• Representative from the Medical Syndicate
• VACSERA
• Representative from University Hospitals
• Representative from Health Insurance Organization
• Representative from Military hospitals
• Representative from Police hospitals
• Representative from GOTHI
• Representative from Environmental AffairsHead of Central Infection
Control Unit (MOHP)
Terms of reference
• Review, update and approve national Guidelines/Policy/Standards for
Infection Control practices
• Approve the national plan for the program of promotion of infection control
• Approve standards for infection control practices
21
• Approve annual plan submitted by representatives

• Liaison to legislation
• Raise funds
• Accreditation in cooperation with independent team
• Collaboration (Coordination/Advocacy/Partnership with MOHP – (Internal
and External)
Meetings and Minutes

The national infection control advisory committee (NIC-AC) will meet at least
twice annually. Additional meetings of full or partial membership may be called by
the Chairman as indicated by current concerns, problems, or important issues.
Ad Hoc subcommittees or task forces will be scheduled to meet by the respective
chairperson. Reports to the Infection Prevention Advisory Committee will be
made in writing. Establishment of the meeting schedules allow for routine
review, evaluation, and discussion of infection control issues and to provide
support and guidance to the Central Infection Control Unit (CICU) staff.
Central Infection Control Unit (CIC-U)

The CIC-U is under the umbrella of the Preventive affairs department and will be
responsible for supervision and monitoring of all activities related to
implementation of infection control program in all MOHP facilities in all
governorates in Egypt. The CIC-U reports to the head of preventive affairs.
Personnel
Chairman
• An epidemiologist with a master degree of public health, epidemiology or
equivalent
Members
• Medical epidemiologist (5)
• Sanitarians (2)
• Infection control nurse (1)
• Microbiologist (if available)
• Statistician
• IT (if available)
22
Terms of reference:
• Prepare national plan for the program of promotion of infection control
• Supervise implementation of the plan and training in all governorates
• Problem solving
• Ensure availability of required supplies and equipment
• Develop a system for surveillance of nosocomial infections in all levels of
health care facilities and follow up this system
• Inspection of facilities
• Coordination/Advocacy between different partners interested in infection
control
• Feed back to the governorate infection control units
• Prepare bi-annual progress reports to the head of preventive affairs
Required resources for implementation

• Office in the MOHP
• Unit staff members
• Staff training
• Procure equipment (computers, printer, phone line, fax)
Meetings and minutes

The members of the CIC-U will meet on monthly basis. Minutes should be made
available and submitted to the NIC-AC upon request.
Governorate Level
Governorate Infection Control Advisory Committee (GIC-
AC)
This is a committee that guides advise all staff of infection control at governorate
level. It has almost the same responsibilities as the NIC-AC but focuses on
implementation. This committee report to the CIC-U and has direct authority over
the Governorate Infection Control Unit (GIC-U).
23
Personnel
Chairman
• First Undersecretary or General director of health directorate at
governorate level
Members
• Director of preventive affairs
• Director of curative department
• Director of primary health care
• Director of child and maternal Health
• Director of laboratories
• Director of dentistry
• Director of blood banks
• Director of free treatment sector (Private sector)
• Director of pharmacy
• Director of medical supply
• Director of nursing
• Head of Governorate Infection Prevention Unit (GIC-U)
Terms of reference for GIC-AC:

• Supervise all activities implemented by the GIC-U
• Monitor progress of GIC-U
• Mobilize resources at governorate level to support infection prevention.
• Problem Solving
• Approve standards for infection control practice
• Approve annual plan submitted by the GIC-U
• Collaboration Coordination Advocacy Partnership with other stakeholders
• Approve annual reports submitted by GIC-U and submit them to the CIC-U
• Support training of staff
• Distribute Infection Control guidelines to Committees of HCF
Meet at least twice annually and keep minutes for all meetings
24
Governorate Infection Control Unit (GIC-U)

This unit is responsible for implementation of the infection control activities in the
whole governorate. It works with close collaboration and guidance of the CICU.
GIC-AC has direct authority over the District and Facility Infection Control
Advisory Committees (DIC-ACs and FIC-ACs).
Personnel
Chairman
Full time epidemiologist preferably with a master degree of public health,
epidemiology or equivalent
Members
• Medical epidemiologist (1)
• Sanitarian (1)
• Infection control nurse (1)
• Microbiologist (if available)
• Statistician
• IT (if available)
Terms of reference:
• Develop-governorate level annual plan for infection control program based
on governorate needs.
• Supervision, monitoring, and evaluation of infection control activities inside
health care facilities in the governorate.
• Problem solving
• Ensure availability of required supplies and equipment at governorate
level
• Request and assist in Outbreak investigations in health care facilities/
• Follow-up and interpretation of surveillance data
• Inspection of facilities (needs tools for inspection)
• Submit request for resources
• Develop annual training plans for infection control for governorate wide
expansion of the program.
25
• Coordination /Advocacy
• Feed back to the infection control committees and teams at facility level.
• Prepare bi-annual progress reports to be submitted to the GIC-AC and
CIC-U
• Report any problems or constraints to the GIC-AC and the CIC-U,
Needs to establish an GICU required resources for implementation

• Office in the health directorate
• Identifying staff for the unit
• Training of staff
• Purchasing equipment (computer, printer, phone line, fax)

The members of the GICU will meet on monthly basis. Minutes should be made
available and submitted to the GIC-AC and CIC-U upon request.
District Level
District Infection Control Committee (DIC-C)
At the district level only an infection control committee will be formed. This
committee reports to the GIC-U and has supervision and implementation
responsibilities to infection control staff in facilities with no beds or with less than
30 beds.
Personnel
Chairman
Director of health district
Members
• Deputy director of health district (if available)
• Director of preventive affairs
• Director of primary health careDirector of Dentistry (if available)
• Director of nursing (if available)
• Director of Laboratory
26
• Health educator (if available)

• Director of free treatment sector
• Sanitarian supervisor
Terms of reference
• Implement recommendations of the GIC-U
• Coordinate or implement training of Infection Control staff in primary
health care facilities and health care facilities with less than 30 beds or no
beds.
• Develop plan for supervision and monitoring of infection control practices
in all primary care facilities
• Oversee, supervise and monitor all activities of infection control by
inspection of facilities (mainly primary care facilities)
• Problem solving in primary health care facilities with less than thirty beds
or with no beds.
• Ensure availability of supplies and equipment needed for infection control
• Report to GIC-U every 3 months

The DIC-AC will meet every 3 months. Minutes should be kept and sent regularly
to the GIC-U.
Health Facility Level

The hospital director should be responsible for ensuring that appropriate
arrangements (IC professionals and appropriate IC program infrastructure) are in
place for effective infection control.
• In large health facilities (more than 30 beds) two groups should be formed:
Infection Control committees (IC-committees)
Infection Control teams (IC-team)
• In hospitals of less than 30 beds and in primary care facilities with no
beds:
Infection Control committees (IC-committees)
Infection Control nurse
27
Hospital Infection Control Committees (IC-Committees)

Hospital Infection Control committees should be developed in any health care
facility in Egypt. The IC-committee should be made up of key personnel from the
various health facility departments. It should act as a liaison between
departments that are responsible for patient care and departments responsible
for support (nursing, medicine, pharmacy, central store, engineering, etc).
Infection Control Committees In Primary Health Care

Facilities
They should be developed in all primary health care facilities that have no beds
or less than 30 beds. It will be limited in number according to available staff.
Personnel
Chairman
• The director of the facility or his Deputy
Members
• Three directors of clinical departments
• The head nurse
• All members of the infection control team in facilities that have more
than 30 beds
• Director of the pharmacy
• Director of the medical supply unit
• The financial and administrative director of the hospital
• Others as appropriate, e.g., occupational health specialist,
microbiology laboratory professional, surgeon, etc.
Note:
All infection control committees at all levels should consist of the staff available
from those listed above. The committee has the right to invite any other eligible
members.
Roles and Responsibilities of the IC-com

• To approve the annual plan for infection control at the level of the facility.
• To approve the infection control policies in the facility.
28
• To support the IC-teams and to direct resources to address problems as

identified.
• To ensure availability of appropriate supplies needed for IC at the facility
level.
• To facilitate and to support the training of the staff.
• To encourage communication among the involved disciplines and among the
different departments in the facility.
• To report outbreaks of nosocomial infections in the facility to the governorate
IC-unit.
• Participate in outbreak investigations of nosocomial infections.
• To submit monthly reports to the governorate IC-unit.
Meetings and minutes:

Meetings should occur once every 3 months and minutes should be widely
distributed to staff, with a request for feedback to the committee.
Hospital infection control committees should report to the GIC-U
PHC infection control committees should report to the DIP-U
Health Care Facility Infection Control Team

Infection Control team should be established in each health care facility that have
more than 30 beds. The Infection Control team should have the authority to
manage an effective infection control program and should have full support from
the director of the health facility. While in PHC facilities with no beds or with less
than 30 beds an infection control nurse should be assigned to be responsible for
implementation of infection control activities within the facility.
IC-team Personnel
The IC team should include a doctor and a nurse for the facility with 150 beds (or
less). In facilities with more than 150 beds, the team is formed of a doctor and
two nurses. All members of the team should be full-time employees dedicated to
infection control activities. Some nurses, called “link nurses” or “representatives”
affiliated with various departments should be assigned to the IC teams. The
infection control nurse in PHC facilities may not be a full timer for infection
control.
Team Leader
• Infection control doctor ( a clinician, epidemiologist or a microbiologist )
Members
29
• Infection control nurses

Roles and responsibilities of the Infection Control team
• To prepare an annual action plan for implementation of the Infection Control
Program and to get approval from the IC-committee.
• To implement a plan to ensure safety of practices.
• To advise the staff on all aspects of infection control needed to maintain a
safe environment for patients and for staff.
• To supervise and to monitor daily practices of patient care designed to
prevent infection.
• To formulate infection control policies within the health facility.
• To develop surveillance program for nosocomial infection.
• To identify problems in the implementation of infection control activities which
need to be solved or transferred to the hospital IC-committee.
• To develop an annual training plan for the health care workers and to submit
this plan to the hospital IC-committee for approval.
• To implement the infection control training activities within the health facility.
• To ensure availability of supplies and equipment needed for infection control.
• To report outbreaks to the IC-committee and to investigate outbreaks with the
health care facility.
• To submit monthly reports on activities to the IC-committee.
Meetings and minutes:

The team should meet regularly on daily basis to discuss relevant issues. A
standing agenda may include updates on surveillance, including clusters of
infections or outbreaks, observations of IC practice, policy review or revisions
status of educational efforts, and follow-up on any problems identified, e.g.,
supply/equipment issues. Minutes should be prepared for all meetings. Also, any
regulations or rules that are discussed that will facilitate the monitoring of the
activities of the wards and the departments should be widely distributed.
Feedback from the ward staff should be encouraged.
30
Nursing Representatives or “Link Nurses”

Nursing representatives work in the different wards of the hospital and act as a
liaison between the Infection Control team and all of the staff of the department
or ward. Preferably, this nurse should be the head nurse of the department.
Examples of link nurse role or liaisons for the IC program have been published. 14
Responsibilities of the nursing representative:

• To convey the recommendations of the Infection Control team to the staff of
the ward and to send feedback to the Infection Control team.
• To ensure implementation of infection control activities in the Link Nurses’
department.
• To be responsible for reporting any infections in the department.
31
Fig. 4: Organizational Structure
• NIC-AC : National Infection Control Advisory Committee

• CIC-U : Central Infection Control Unit
• GIC-AC: Governorate Infection Control Advisory Committee
• GIC-U : Governorate Infection Control Unit
• DIC-C : District Infection Control Committee
• HIC-AC: Hospital Infection Control Advisory Committee
• ICT: Infection Control Team
• PHC IC-AC: Primary Health Care Infection Control Advisory Committee
• ICO : Infection Control Officer
• Direct authority
• Reporting
32
Functional Aspects of the Health Care Facility Infection Control Program
Functional Aspects of the

Health Care Facility
Infection Control Program
Introduction
Health care associated infections (HAI) are a worldwide problem. They occur across
all points of health care delivery ranging from care provided in the home of the
patient to the tertiary facility that provides complex procedures such as organ
transplantation. 15 Regardless of the setting, availability of resources, country, or
populations at risk, infection control and control programs strive to achieve the
following goals in all health care facilities (HCF):
• Protect the patient;

• Protect health care personnel, visitors, and others in the healthcare
environment;
• Accomplish the previous two goals in a cost effective manner whenever
possible. 16
Hospital-acquired infections and the importance of preventing these complications of

health care have been described in the chapter on Importance of Infection Control.
There are examples of very effective infection control programs even when
resources are limited and the epidemiologic principles upon which infection control
and control are based have universal application. 17-20
Surveillance of Hospital – Acquired infections

Surveillance is the ongoing, systematic collection, analysis, interpretation, and
dissemination of data regarding a health-related event for use in public health action
in order to reduce morbidity and mortality and to improve health. Data disseminated
by a public health surveillance system can be used for immediate public health
action, program planning, and evaluation and for formulating research hypotheses.
For example, data from a public health surveillance system can be used to:
• Guide immediate action for cases of public health importance;
• Measure the burden of a disease (or other health-related event), including
changes in related factors, the identification of populations at high risk, and
the identification of new or emerging health concerns;
33
• Monitor trends in the burden of a disease (or other health-related event),

including the detection of epidemics (outbreaks) and pandemics;
• Guide the planning, implementation, and evaluation of programs to
prevent and control disease, injury, or adverse exposure;
• Evaluate public policy;
• Detect changes in health practices and the effects of these changes;
• Prioritize the allocation of health resources;
• Describe the clinical course of disease; and
• Provide a basis for epidemiological research. 21
Surveillance of Hospital-acquired infections is a key function of the Infection Control

team. The same principles of surveillance used for public health can be applied to
the HCF. The major sites of Hospital-acquired infections are:
• Urinary tract
• Lower respiratory tract
• Surgical Site
• IV catheter
• Skin and soft tissue
The relative distribution of these is illustrated graphically (Figure 1) using data

derived from a prevalence survey of infections in France. 22 The steps involved in
surveillance are outlined in the flow diagram (Figure 2). The collection, analysis, and
dissemination of surveillance data have been shown to be the single most important
factor in prevention of Hospital-acquired infections.
34
Fig. 5: Sites of the most common nosocomial infections

(Distribution according to the French national prevalence survey (1996)*)
Adapted from (Enquete nationale de prevalence des infections nosocomiales, 1996, BEH, 1997, 36: 161-163)
Fig. 6: Simplified example of steps in a surveillance system
Occurrence of health-related event
Health-related event recognized by

reporting source
Health-related event reported to

responsible public health agency
Control and prevention activities Feedback to stakeholders
35
Some of the critical elements of a surveillance program for Hospital-acquired

infections include standardized definitions and a clear purpose. The program
needs to balance the resources available, the priorities for data collection (e.g.,
ongoing evidence of infusion-associated bloodstream infection), the population
served by the facility, and the facility’s objectives. Standardized definitions have
been developed. 23-24 If a facility has limited laboratory or other diagnostic
facilities, more simplified definitions such as those in the table below might be
helpful. When diagnostic capabilities are constrained, there have been
successful examples of international collaboration using cohorts of patients with
simple symptom-driven criteria for finite time periods. 25 However, if external,
standardized definitions are not available, then written ones can be developed.
These should emphasize intra-facility standardization. 22
Table 3: Simplified criteria for surveillance of nosocomial infections
Type of nosocomial infection Simplified criteria
Any purulent discharge, abscess, or

Surgical site infection spreading cellulites at the surgical site
during the month after the operation
Positive urine culture (1 or 2 species ) with
Urinary infection at least 10 bacteria/ml with or without
clinical symptoms
Respiratory symptoms with at least 2 of
the following signs appearing during
hospitalization
Respiratory infection Cough
Purulent sputum
New infiltrate on chest radiograph
consistent with infection
Inflammation, lymphangitis, or purulent
Vascular catheter infection
discharge at the site of catheter
Fever or rigors with at least one positive
Septicemia
blood culture
One step that often is incomplete or missed in a surveillance program is

dissemination of findings from the program to those who need to know, e.g.,
direct care personnel. A description of one such program that has been
successful is the National Nosocomial Infections Surveillance (NNIS) system. 26
Recommended practices for surveillance have been described. 27
36
The steps outlined in these practices are:

• Assess the population served by the facility so that interventions can
be directed at those complications of greatest importance given
available resources.
• Select the outcome (surgical site infection) or process (frequency that
the personnel disinfect tops of stoppers in multiuse medication vials)
for surveillance.
• Define all data elements and assure criteria definitions are valid,
accurate, and reproducible.
• Collect the surveillance data.
• Calculate and analyze surveillance rates.
• Apply risk stratification methodology.
• Report and distribute surveillance information.
Table 4: Prevalence and incidence rates

Prevalence rate Examples
Prevalence (%) of nosocomial
Number of infected patients* at the time infections (NI) for 100 hospitalized
of study / Number of patients observed at patients
the same time x 100 Prevalence (%) of urinary tract
(*or number of infections) infections (UTI) for 100 hospitalized
patients
Number of infected patients at the time of
Prevalence (%) of UTI for 100 patients
study / Number of patients exposed at
with a urinary catheter
the same time x 100
Attack rate (cumulative incidence
Examples
rate)
Number of new infections acquired in a
Attack rate (%) of UTI for 100
period / Number of patients observed in
hospitalized patients
the same period x 100
Number of new infections acquired in a Attack rate (%) of surgical site
period / Number of patients exposed in infections (SSI) for 100 hospitalized
the same period x 100 patients who went through surgery
Incidence rate Examples
Number of new nosocomial infections
acquired in a period / Incidence of bloodstream infection
Total of patient-days for the same period (BSI) for 1000 patient-days
x 1000
Number of new device-associated
nosocomial infections in a period / Incidence of ventilator-associated
Total device-days for the same period pneumonia for 1000 ventilation-days
x 1000
37
In general, collection of numerators and denominators for the surveillance

program is one that requires active methods. Passive surveillance, which relies
on reports from others, has low sensitivity. Additional examples of surveillance
methods and tools are available and should be reviewed for additional details.22
Investigation and Control of Outbreaks

Outbreaks or clusters of Hospital-acquired infections are usually rare. These
consume <5% of the Infection Control team’s time and have an estimated
frequency of 1/10,000 admissions. However when they occur, prompt
investigation and control is important to prevent additional cases and to assure a
return to safe care of patients. 28
Components of an outbreak investigation are:
• Confirmation that an outbreak or cluster exists (are the numbers
unusual or more than expected?).
• Establishment or verification of diagnosis of observed cases;
assurance of proper identification of the pathogen involved.
• Search for additional cases; collection of critical data and specimens
(important: save isolates from the patients for molecular typing).
• Characterization of cases by time, place, person, procedures,
equipment used, etc.
• Formulation of a tentative hypothesis on potential reservoir and mode
of transmission.
• Institution of control measures as indicated and appropriation and then
evaluation of the efficacy of these.
• Communication of findings; write final report.
38
Hand Hygiene
Hand Hygiene
Introduction
Hand hygiene is one of the most important procedures for preventing the
transmission of hospital-acquired infections. 37 Hand hygiene is a general term
that encompasses handwashing, antiseptic hand wash, antiseptic handrub or
surgical hand antisepsis. The importance of hand hygiene in preventing
transmission of Hospital-acquired infections has been demonstrated in numerous
studies. The challenge, however, is to improve adherence with appropriate hand
hygiene on the part of health care personnel (HCP). Studies have shown that an
average of only 40% of HCP adhere to handwashing policies in their institutions.
Risk factors for poor adherence to recommended hand hygiene include:
• Physician status (versus nurse)
• Nursing assistant status
• Males show less commitment than females
• Working in an Intensive Care Unit
• Wearing gowns/gloves
• Activities with high risk of cross-transmission
• High number of opportunities for hand hygiene per hour of patient care
Self-reported factors for poor adherence with hand hygiene include:

• Handwashing agents cause skin irritation or dryness
• Inconvenient or no sinks
• Lack of soap or paper towels
• Too busy/insufficient time
• Understaffing/overcrowding
• Perception of low risk of acquiring infection from patients
• Beliefs that glove use obviates the need for hand hygiene
• No role model from colleagues or superiors
• Skepticism about the value of hand hygiene
• Lack of appreciation for its importance or lack of knowledge of
guidelines/protocols
39
Hand Hygiene
Improving adherence with hand hygiene requires considerable effort to ensure

HCP have access to appropriate equipment and supplies and have sufficient
knowledge about the importance of handwashing. 38 This chapter will focus
primarily on handwashing and on antiseptic hand wash/handrub. Refer to the
chapter on “Operating Theater” in Part II of these guidelines: Infection Control in
Specialty Settings for additional information on surgical hand antisepsis.
Microbial Flora of the Skin

The microbial flora of the skin can be divided into two categories:
• Resident microorganisms (colonizing or endogenous flora) include
Staphylococcus species and diptheroids. These microorganisms are
considered permanent residents of the skin and are not readily
removed by mechanical friction. Resident microorganisms in the deep
layers may not be removed by handwashing with plain soaps and
detergents, but they can usually be killed or inhibited by hand hygiene
with products that contain antimicrobial ingredients.
• Transient microorganisms (non-colonizing or exogenous flora) include
microorganisms that come into contact with skin through interactions
with patients, with equipment, or with the environment. Non-colonizing
flora are not consistently present in the majority of persons and survive
only a limited period of time. These organisms are most frequently
associated with Hospital-acquired infections and are often acquired
through activities that involve close contact with a patient’s secretions
or excreta. Non-colonizing flora are easily removed by routine
handwashing. 38
40
Hand Hygiene
Table 6: Types of Hand Hygiene
Speed of
Influence
antimicr Residual
Technique Main purpose on hand Agents
obial effect
flora
action
Routine Cleansing Partly Plain non- Slow Short
Hand wash after patient removes antimicrobial soap
contact & transient
contamination flora
Antiseptic Hand Kills -Chlorhexidine; Varies by Can be
Hand wash antisepsis transient Hexachloraphene, type of sustained for
or alcohol- prior to and Iodine;Iodophors; agent. agents such
based invasive reduces Para-chloro-meta- Fastest as
handrub procedures, or resident xylenol for Chlorhexidine;
to remove flora alcohol. less so for
-Alcohol-based
pathogens waterless alcohol and
(e.g., antiseptic; iodophors
antimicrobial
resistant
strains)
Surgical Preoperative Kills -Chlorhexidine; Varies by Can be
Hand antisepsis transient Hexachloraphene, type of sustained for
Antisepsis flora and Iodine;Iodophors; agent. agents such
reduces Para-chloro-meta- Fastest as
resident xylenol (PCMX) for Chlorhexidine;
flora -Alcohol-based alcohol less so for
waterless alcohol and
iodophors
antiseptic (after
washing hands by
soap and water,
see chapter on
Operating theatre)
Routine Hand Wash

Routine handwashing is the removal of dirt, organic material, and transient
microorganisms. 38 For most routine activities washing with plain soap is
sufficient, since soap will remove most transient microorganisms. 40 Routine
handwashing is an essential step before surgical scrub and it is preferably done
before aseptic handwash or alcohol rub if the hands are visibly contaminated.
41
Hand Hygiene
Indications
The purpose of handwashing for routine patient care is to remove microbial
contamination acquired by recent contact with infected or colonized patients or
with environmental sources and to remove contamination with organic matter
from the hands.
In the absence of a true emergency, personnel should always wash their hands:
• AFTER completing invasive procedures.
• AFTER taking care of particularly susceptible patitnes, such as those
who are severely immunocompromised and newborns.
• AFTER dealing with wounds, whether surgical, traumatic, or
associated with an invasive device.
• AFTER situations during which microbial contamination of hands is
likely to occur, especially those involving contact with mucous
membranes, blood or body fluids, secretions, or excretions.
• AFTER touching inanimate sources that are likely to be contaminated
with virulent or epidemiologically important microorganisms; these
sources include urine-measuring devices or secretions collection
apparatuses.
• BEFORE and AFTER contact with patients.
• AFTER using the toilet or latrine.
• AFTER removing gloves.
• BEFORE serving meals or drinks.
• BEFORE leaving work.
42
Hand Hygiene
Fig. 13: Steps for Routine Hand Wash
1. Remove all jewelry.

2. Turn on tap with elbow or hands.
3. Wet hands with running water that is as
warm as tolerable.
4. Apply soap agent and thoroughly distribute

over hands. Make sure to rub all parts of
your hand.
5. Rub fingers together back and forth for 15-

30 seconds (longer if hands are visibly
soiled). Wash area around the nails and
remove debris under the fingernails because
the subungual area has higher microbial
counts. Rub all parts of the hands paying
attention to the frequently missed areas.
6. Rinse hands under a stream of running

water until all soap is gone. Never dip hands
into a basin or standing pool of water.
7. Dry hands with a clean single use towel
8. If possible, turn tap with elbows, or with a

paper towel after drying of the hands. 38, 42
43
Hand Hygiene
Fig. 14: Handwashing Technique

Repeat each movement 5 times
44
Hand Hygiene
Fig. 15: Frequently Missed Areas When Handwashing
45
Hand Hygiene
Routine handwashing tips

Jewelry
-- Rings should either be removed or moved to ensure washing underneath them.
-- Rings can make donning gloves more difficult and may cause gloves to tear more
readily.
Condition of nails and of hands

-- Nails should be kept short, rounded, and unvarnished, and the routine use of nail
brushes should be avoided.
-- The hands, including the nails, should be inflammation free.
-- Artificial nails should be avoided.
Drying hands. A variety of methods are used for drying hands:

-- Paper towels are the best method to dry hands.
-- Cloth towels could be used if appropriately recycled.
-- Warm air dryers shorten the time for hands to dry, however, they can only be used
by one person at a time and are noisy and have the evidence of infection.
-- Hand-drying materials should be placed near the sink in an area that will not
become contaminated by splashing.
Soap. Plain (non-antimicrobial) soap comes in several forms

-- If bar soap is used, small bars (that can be changed frequently) are preferred.
-- Soap should have drainage and should be kept on racks.
-- Liquid soap containers should be cleaned when empty and refilled with fresh soap;
liquids should not be added to a partially full dispenser;
Water. Always use running water. If running water is not available consider using:
-- Containers with a tap that can be turned on and off;
-- Containers and pitchers; or
-- Alcohol handrubs. 42
46
Hand Hygiene
Provision for Handwashing

The hand wash basin should be close to the clinical care area. There should be
at least one dedicated hand wash basin per 4-bedded bay area, treatment room,
sluice, and toilet area. This basin should be used for no other purpose, including
tipping fluids or solutions, washing patient articles, or washing instruments.
• Handwashing material such as plain soap or antiseptic soap must be
provided.
• There should be no topping off of liquid soap or antiseptic soap
containers. All containers must be washed thoroughly and disinfected
then dried before refilling.
• There should be an ample supply of hand drying material.
• Forced air driers are not recommended in clinical areas.
Antiseptic Hand Wash or Alcohol Based

Handrub
An antiseptic hand wash or alcohol based handrub is one that will reduce
concentration of resident flora as well as inactivate transient microorganisms
from hands. Hand antisepsis is achieved by handwashing with antiseptic
preparations (iodophors or chlorhexidine) or by use of alcohol-based antiseptic
handrubs. 42
Indications for hand antisepsis:

Hand antisepsis is recommended in the following instances:
• BEFORE the performance of invasive procedures (e.g., placement of
intravascular catheters, indwelling urinary catheters, or other invasive
devices).
• BEFORE dressing wounds.
• BEFORE patient care at high risk of infection (e.g. newborns,
immunocompromised patients).
• BEFORE preparation of intravenous fluids and medication.
• When persistent antimicrobial activity on the hands is desired. When it
is important to reduce numbers of resident skin flora in addition to
transient microorganisms.
In settings where hand washing facilities are inadequate and where hands are
not soiled with dirt or heavily contaminated with blood or other organic material,
alcohol-based hand rubs are recommended for use.42 In case the hands are
soiled with dirt, it is necessary to wash hands routinely before the alcohol-based
hand rub. Because using alcohol alone tends to dry the skin, it is best to use an
47
Hand Hygiene
alcohol hand rub solution by adding 2 ml of glycerine, propylene glycol, or

sorbitol and 100 ml of 60%-90% alcohol. 42
Antiseptic handwashing tips
Products: Most antimicrobial products have a dose response effect and a
minimum of 3 to 5 ml is recommended. Betadine™ (Iodophor) or a 70-90% ethyl
alcohol + 0.5% glycerine solution (alcohol handrub) are highly effective.
Duration:
The duration of antiseptic handwashing is important not only for mechanical
action to be effective, but also to allow antimicrobial products sufficient time to be
effective. Minimal time required for handrub before rinsing is 2 minutes or
according to manufacturer’s instructions.
Antiseptic handwash technique

• Wet hands and forearms till 2.5 cm below the elbow.
• Use an antiseptic hand wash preparation (e.g. Chlorhexidine gluconate 4% or
betadine (Iodophor).
• Apply the selected product to palm of one hand and rub hands and fingers
together, covering all surfaces of hands and forearm (as described in the
routine hand washing steps) till 2.5 cm below the elbow for at least 2 minutes.
• Follow the manufacturer’s recommendations on volume and duration of use
of the antiseptic used.
• Dry the hands using sterile towels before wearing sterile gloves.
Alcohol handrub technique

• Make sure that your hands are clean and have no visible dirt or blood.
• If hands are visibly dirty, wash your hands by routine hand wash.
• Pour 3-5 ml of an alcohol hand rub (70-90% ethyl alcohol + 0.5% glycerine
solution) into the palm of your hand and rub hands together using the same
technique of hand antisepsis until they are completely dry.
Other Aspects Related to Hand Hygiene

Fingernails and artificial nails: Numerous studies have documented that
subungual (under the nail) area of the hand harbor high concentrations of
microorganisms. In addition, long, natural and artificial nails have been
associated with several outbreaks of Hospital-acquired infections. 43-45 For
prevention, do not wear artificial nails or extenders when providing patient care
and keep natural nails less than ¼ inch long.
Irritant contact dermatitis: Frequent exposure of skin to soap and water can result
in irritation and damage to skin. In some surveys as many as 25% of nurses have
signs and symptoms of dermatitis. Further, HCP may wash their hands as many
48
Hand Hygiene
as 30 times in an eight hours shift. Waterless alcohol hand antiseptics that

contain emollients can actually improve skin condition with repeated use.
Hand washing Facilities

• Hand washing facilities should be conveniently located throughout the
hospital.
• A sink should be located in or just outside every patient room. More
than one sink per room may be necessary if a large room is used for
several patients.
• Hand washing facilities should be located in or adjacent to rooms
where diagnostic or invasive procedures that require hand washing are
performed (e.g., cardiac catheterization, bronchoscopy,
sigmoidoscopy, etc.).
Recommended reading:
Pratt RJ, et al. Standard principles for preventing hospital-acquired infections. J
Hosp Infect 2001;47(Suppl): S21-S37
49
Personal Protective Equipment (PPE)
Personal Protective
Equipment (PPE)
Introduction
Personal protective equipment (PPE) involves use of protective barriers such as
gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk
of exposure of health care personnel (HCP) skin, mucous membranes, and
respiratory tract to potentially infective materials and certain airborne agents.
PPE also provides protection against other hazards in the health care facility
such as chemicals and physical injury. Employers and personnel share in the
responsibility for ensuring use of PPE. Employers need to provide PPE and
assure that it is accessible to all personnel. Personnel need to consistently use
PPE for their own protection. Some components of PPE, e.g. gloves and gowns,
are also used for protection of patients during invasive procedures such as
insertion of a central venous catheter or surgical operations where a sterile field
and aseptic technique are required. 46
The selection of PPE should be based on assessment of the risk of

contamination of HCP’s clothing and skin by blood, body fluids, secretions and
excretions and – if applicable- to minimize risk of exposure to splashes or sprays
of blood and body fluids or certain airborne microorganisms, e.g., Mycobacterium
tuberculosis. Use of PPE also should include assessment of the risk of
transmission of microorganisms from HCP or the environment to the patient.
Gloves
Types of Gloves
There are three main types of gloves used in the health care setting
1. Sterile gloves: Mostly used for surgery. They are

disposable, sterile, and individually wrapped items. They
are used whenever there will be a percutaneous or
permucosal contact with tissues (e.g. surgical procedures,
insertion of central venous catheter and urinary catheter). 46
Fig. 16: Sterile

Gloves
50
2. Non-sterile gloves: Non-sterile disposable, single use

gloves (e.g. latex gloves) are usually not individually
wrapped. They are used to protect against direct skin
exposure to blood or other body fluids or for anticipated
contact with mucous membranes and prior to contact with
contaminated equipment or surfaces. Examples of
application include putting on gloves prior to insertion of a
Fig. 17: Non-
peripheral IV catheter (except in high risk areas). These
sterile Gloves
types of gloves should be discarded after one use followed
by hand hygiene.
3. Utility or heavy-duty household gloves: Utility gloves

are used for handling contaminated items and waste and for
performing environmental cleaning activities. They can be
reused after decontamination, but they should be discarded
when punctured or torn.
Fig. 18: Utility

Gloves
General Indications for Gloves
Staff should wear gloves when they anticipate their hands will come into contact
with blood, body fluids, nonintact skin or tissue or equipment and surfaces that
are visibly contaminated with body fluids.
Indications for Sterile Gloves

• Before surgery
• Before any invasive procedure that require aseptic technique (e.g.
insertion of urinary catheter, insertion of central venous catheter, insertion
of canulas in immunocompromised patients and newborns).
• Before wound dressing.
• Mixing I.V. fluids and using multidose vials.
Indications for Disposable Non-sterile gloves

• When starting intravenous (I.V.) lines or performing phlebotomy.
• When changing dressings or handling soiled dressings.
• When cleaning or handling soiled equipment, instruments, or other
items that may be contaminated with blood, urine, feces, or drainage.
• When handling specimens and their containers.
51
• When suctioning the respiratory tract of a patient or performing oral

care in which fingers need to be placed inside the patient’s mouth.
Indications for Utility gloves:
• When handling medical waste (red bag trash).
• When cleaning up spills of blood or body fluids (As they are difficult to
be cleaned, it is preferable to use double non-sterile disposable
gloves).
• When using chemicals such as cleaning products and disinfectants.42
For most chemical disinfectants latex exam gloves that protect hands
and forearms are sufficient. Other glove materials such as nitrile offer
additional protection against certain chemicals if prolonged contact
with the chemical is anticipated.
Gloving tips
Washing utility gloves: Always wash utility gloves before you take the gloves
off your hands.
Washing hands: Hand hygiene is always recommended after removing gloves
because gloves may become perforated during use and bacteria can multiply
rapidly on gloved hands.
Reusing disposable gloves: Never reuse any type of disposable gloves (e.g.,
latex gloves, surgical gloves) as they are difficult to reprocess properly and the
protective integrity of the glove is usually compromised when attempting to
clean and reuse.
Latex allergy: If you or your patient has a latex allergy, wear nonlatex gloves,
e.g., vinyl or nitrile.
Changing gloves: Gloves must be changed:

• Between patients.
• Before each procedure if more than one procedure is done for the same
patient.
• If they become soiled, contaminated or perforated while caring for a single
patient.
Removing gloves: When removing gloves, you should not allow the outside
surface of the gloves to come into contact with your skin. Avoid letting the
gloves snap, as this may cause contaminates to splash into your eyes or mouth
or onto your skin or other people in the area. It is important to remove used
gloves before touching anything that can become contaminated through
contact, such as surfaces, faucets, or pens.
52
Aprons and Gowns

Single use plastic aprons or gowns should be used during procedures that are
likely to generate splashes of blood or body fluids or during activities that may
contaminate clothing or uniforms with microorganisms or infectious material.
Most often, aprons can be used to minimize potential for contamination of HCP
uniforms or personal clothing. The neck strap and the waist tie should be torn
and the apron should be discarded into a clinical waste bag before it is carried
out of the room.11 More extensive coverage, such as a gown covering arms,
trunk, and upper thighs are only needed if the patient care might involve splashes
or sprays of blood or body fluids. Ideally gowns worn for such purposes should
be fluid resistant.
Note:
Cotton gowns are permeable to water and are no longer recommended.
Disinfection of heavy duty aprons

Heavier duty plastic aprons can be reused provided that they can be disinfected
by a wash with warm water and detergent and dried; followed by wiping the
apron with 70% isopropyl alcohol. Another option would be immersing the heavy
duty plastic aprons in water and chlorine. Cleaning and disinfection should be
done between each patient. 9
Headgear
Disposable caps, balaclavas, or scarves should be worn to confine and contain
hair during certain procedures such as surgical procedures performed in the
operating theater. They should be well-fitting and sealed.
Note:
Well fitting cotton caps and scarves may be recycled (by laundering at a high
temperature) if disposable ones are not available. Recycled caps must be
changed frequently (at least after every shift; in hot climates they should be
changed more frequently). 9
Face, Eye and Respiratory Protection

Face masks and eye protection should be worn when there is risk of splashes or
sprays of blood or body fluids into the face and eyes of HCP. Options for this
type of PPE include separate mask and eye protection or combination products
wherein an eye shield is bonded to a standard mask. Most masks are designed
to be used one time and then discarded. Another option however is a full-face
shield that protects the eyes and mouth. This can be disposable or reusable. If
reusable it should be cleaned and disinfected after contamination. Splashes of
53
chemicals are additional examples of the need for face and eye protection of
HCP. 9
Respiratory Protection
Use a standard mask alone when there is risk of exposure to droplets that might
contain infectious agents. Examples of microorganisms that are transmitted by
exposure to droplets from patients with infection include Neisseria meningitidis,
Bordetella pertussis, and influenza virus. 9 Both disposable paper and cotton
masks offer less protection once they become moist; however, if resources are
limited these do provide some protection against large droplets. If available,
disposable paper masks with synthetic material for filtration are ideal for most
patient care needs. Most masks should be used once and then discarded;
reusable, cotton masks must be laundered. Cotton masks offer less protection
against airborne infectious agents such as M. tuberculosis but are better than no
respiratory protection if no alternative is available.
Airborne disease and respiratory protection
For airborne infectious agents such as M. tuberculosis a high filtration respiratory
protective device is ideal, and if available, should be used to care for patients
with suspected or proven active pulmonary tuberculosis. Such devices may be
labeled as high efficiency masks or respirators and are designed to capture high
percentages (>95%) of particles that are less than 1 micron in size. Instructions
for use of these devices are usually supplied by the manufacturer and are
designed to assure a good seal around the nose and mouth of the wearer. If
such devices are not available, a standard mask still offers some protection of
personnel and therefore should be worn. Other measures to prevent exposure to
airborne disease such as tuberculosis should be employed. These include asking
the patient to cough into a disposable tissue and, if tolerable, to have the patient
wear a mask when in corridors or in areas that do not have negative pressure
airflow and exhaust.
Overshoes and Footwear

Overshoes worn over the ordinary shoes are not
recommended, as it is an ideal way of transferring
microorganisms from floor and shoes to hands.
Closed footwears replacing the ordinary shoes are
not generally needed with the exception of some
special areas such as the Operating Theatre (OT).
The intent is to confine contaminants on footwear
prior to entering an OT. In addition, certain surgical
procedures, such as hip replacement, may result in
spills of blood around the patient table and onto the
floor. Fluid resistant shoe covers or boots are
recommended for this situation to protect operative
personnel from skin exposure to blood. 9
Fig. 19: Commonly used protective B
54
Aseptic Techniques
Aseptic Techniques
Introduction
Aseptic technique is a general term involving practices that minimize the
introduction of microorganisms to patients during patient care. There are two
categories of asepsis; general asepsis which applies to patient care
procedures outside the operating theatre and surgical asepsis relating to
procedures/processes designed to prevent surgical site infection. This chapter
will focus primarily on general aseptic procedures as insertion of intravenous
catheters or urinary catheters and examples of “no-touch” technique.
Aseptic techniques are used to reduce the risk of post-procedure infections
and to minimize the exposure of health care providers to potentially infectious
microorganisms.
Aseptic techniques include practices performed just before, during, or after

any invasive procedures.
Poor adherence to aseptic techniques results in considerable morbidity and

mortality. Even in countries with well-established infection control programs,
hospital-acquired infections (HAI) related to poor compliance with aseptic
techniques is an important public health problem. For example, in the United
States surgical site infections are the third most frequently reported infection
accounting for 14% to16% of all hospital-acquired infections. 30 Data on
surgical site infections is not available in Egypt; however, other sources of
data suggest that there is poor compliance in aseptic techniques during
critical procedures. For example, extrinsic contamination of intravenous fluids
has been observed in intensive care units, in obstetric wards, and in dialysis
centers. 8 These studies suggest that breakdowns in aseptic techniques occur
both in the preparation and in the maintenance of IV fluids. Poor adherence to
aseptic techniques, such as the reuse of needles and syringes between
patients has also been implicated in transmission of blood-borne pathogens
(e.g., HIV and HCV) in Egypt. 6
It is important that all health care facilities establish policies regarding
procedures that require aseptic techniques. Health care personnel who
perform these procedures should be trained in aseptic technique and should
55
Aseptic Techniques
demonstrate competency. It is particularly important for staff to understand

why aseptic techniques are needed and for the hospital director to ensure that
adequate equipment and supplies are available. Supervision and monitoring
of infection control activities is a critical element of infection control.
Principles of Asepsis
Numerous non-surgical procedures require aseptic techniques in order to
prevent transmission of infectious agents.
Procedures with the highest risk for causing infections include:
• The placement of medications or devices into sterile body spaces such as:
- The placement of intravenous lines.
- The placement of indwelling urinary catheters.
• Wound care.
• During the preparation and administration of intravenous fluids
• During insertion of intravenous and intramuscular injections of medication,
especially from multidose vials.
Key processes for performing medical (non-surgical) procedures with

aseptic techniques include:
• Hand antisepsis and the appropriate use of gloves.
• Skin antisepsis of the site of insertion of invasive devices, e.g., IVs
• Using and maintaining sterile patient care equipment, e.g., multidose
medication vials, IV fluids and devices, by minimizing contact with non-
sterile surfaces or reuse of equipment and devices intended for single
patient use.
• The introduction of a sterile item into a patient should always be performed
with a no-touch-technique. This means that the skin in the area of insertion
should not be touched after skin antisepsis. Similarly, IV administration
tubing should be kept sterile and tops of vials of medication should be
disinfected prior to entry.
Aseptic techniques are practiced for all invasive medical procedures. Types of
handwashing and gloves are different according to the procedure performed
(see table below). Most disease transmission occurs due to actions of health
care personnel (HCP) that ignore basic concepts of aseptic techniques such
as the reuse of syringes/needles, the touching of a sterile device onto a non-
sterile surface, and the entering of a sterile solution without adequate
decontamination of the port of entry.
56
Aseptic Techniques
Table 5: Recommendations for preparing hands and skin during procedures requiring aseptic techniques
Hand Preparation
Procedure Example PPE Critical steps
hygiene of skin
Insertion of IV therapy Routine Disposable Fast acting • Do not touch the area of insertion after antisepsis of the skin.
peripheral handwash. nonsterile antiseptic is
(IV) catheter (Antiseptic gloves (Use needed • Apply sterile dressing after insertion.
hand wash/ sterile gloves (Alcohol is OK • Remove IV:
handrub (in in high risk but the site - If any sign of infection (redness, swelling, pus, tenderness) or no longer
high risk areas areas or needs to be needed.
or immunocomp thoroughly
immunocompro romised cleaned). - After 72-96 hours.
mised patients) patients).
Preparation Mixing of IV As indicated As indicated Not applicable • Use a special clean area that is not in contact with biological materials and
of IV fluids fluids and above above that has a surface that can be easily cleaned.
and medication
medications • Disinfect the port of entry (rubber or plastic) with alcohol prior to each
insertion of a needle.
• Use only sterile diluent to reconstitute the medication
• Use a new sterile syringe and needle every time you add something to the IV
fluid.
Administrati IV injection As indicated As indicated Fast acting • Disinfect rubber opening with alcohol prior to administration of medication.
on of above above antiseptic is
injectable needed • For ampoules and multidose vials:
medications (alcohol is OK - Use a new sterile syringe and needle each time you enter an IV;
but the site - Never enter vial with a syringe that has been used on another patient;
needs to be - Get rid of ampoules immediately after single use;
thoroughly - Never reuse opened ampoules.
cleaned) • Follow manufacturers recommendations for storing and discarding multidose
vials
57
Aseptic Techniques
Hand Preparation of
Procedure Example PPE Critical steps
hygiene skin
Insertion of a central Chemo- Hand -Sterile gloves Fast acting • Prepare sterile area prior to insertion
venous catheter therapy line in antisepsis recommended antiseptic is
adults, with - Gown desirable • Do not allow the catheter to touch any non-sterile
Umbilical antiseptic - Eye area (no touch technique)
artery catheter hand wash Protection • After insertion, apply sterile dressing.
in neonates or antiseptic
handrub • Remove catheter after any sign of infection.
• Avoid placing in areas that are easily contaminated
(groin)
Collection of body fluids Spinal tap, Hand -Sterile gloves Fast acting • Use no-touch technique
from sterile body sites thoracentesis, antisepsis - Gown antiseptic is
abdominal - Eye desirable
paracentesis Protection
Procedures that come in Bronch- Hand Nonsterile In general,
contact with mucous oscopy, antisepsis gloves none is required
membranes Endoscopy, sufficient
Tracheal
suction
Urinary tract Hand Sterile Mild soap & • Maintain a closed drainage system.
catheterization antisepsis water to
cleanse urethral • Handwashing before and after emptying drainage
meatus is bags.
sufficient • Catheters should not be changed routinely as this
exposes the patient to increased risk of bladder or
urethral trauma
58
Aseptic Techniques
Hands of health care workers are the most common source of cross-infection. A
clear policy on hand hygiene is therefore essential and should be followed by all
personnel. Although the use of gloves reduces the transmission of bacteria, hand
washing is still essential after the gloves have been taken off in order to remove
any contamination that might have occurred via small punctures, and the
multiplication of organisms that occurred in the warm, moist environment caused
by glove wearing.
Intravenous Therapy
At any given time 25% of in-patients may have a peripheral cannula in situ. This
is one of the most common invasive procedures performed in the hospital and
yet application of aseptic technique during this procedure is often neglected. 9
Definition
An intravenous catheter is a catheter with a lumen that is inserted into a vein to
provide intravenous therapy. Since this is a foreign body, which produces a
reaction in the host, it can cause production of a film of a fibrinous material on the
inner and outer surfaces of the catheter. This biofilm may become colonized by
microorganisms and will protect them from host defense mechanisms. Microbial
contamination may cause local sepsis or septic thrombophlebitis or bacteremia /
septicemia. Infection control measures are designed to prevent the
microorganisms from entering the equipment, the catheter insertion site, or the
bloodstream.
Intravenous Infusion – Sites of Possible Contamination

Fig. 7: Intravenous Infusion System
59
Aseptic Techniques
Note:
• Indications for insertion of catheters should be strict (e.g. severe dehydration,
blood transfusion, parenteral feeding).
• Good asepsis is required during insertion of the catheter and during
maintenance of the insertion site. The site should be kept dry and free from
contamination by covering with a dressing that is secure and comfortable for
the patient.
Sources and routes of transmission

Sources of infection may be:
• Intrinsic: This is usually due to contamination or faulty sterilization of fluids
during manufacture. Examples of organisms growing in the infusate are
Klebsiella, Enterobacter or Pseudomonas spp. Infection will arise only rarely
from intrinsic contamination; however, if the infusate is contaminated during
preparation it can result in widespread infection among recipients of this
product.
• Extrinsic: This is due to contamination of the IV catheter during the insertion,
the administration of the fluid, or from the hands of the HCP inserting or
caring for the IV device. However, the most important reservoirs of pathogens
causing catheter-related infection are the skin flora at the insertion site and at
the hub. Infection is caused mainly by microorganisms residing on the
patient’s skin, e.g., Staphylococcus epidermidis, Staphylococcus. aureus, and
diphteroids. Microorganisms almost universally grow in a biofilm on the
catheter surfaces (initially on the external surface but with longer duration,
also the inner surface) and may be released into the bloodstream. 11, 31
Fig. 8: Sources and routes of transmission of infection from IV System
60
Aseptic Techniques
Procedure for Inserting Peripheral IV Cannulae

1. Ensure that the patient is comfortable and is aware of the procedure – this
reduces anxiety.
1. Collect all equipment necessary to set up an IV infusion.
3. Select a cannula that will fit easily into the vein – size 18 or 20 gauge is usually
appropriate. The correct sized cannula reduces trauma and congestion of the
vein.
4. Place the patient’s arm on a clean towel.
5. Avoid shaving the skin insertion site. Instead, clip hair if necessary.
6. Wash hands routinely & wear clean gloves. If the patient is in high risk ward or
immunocompromised, use antiseptic hand wash or antiseptic handrub &
sterile gloves.
7. Apply a tourniquet to the patient’s non-dominant forearm.
8. Apply skin antiseptic to the IV insertion site with 70% isopropyl alcohol for at
least 30 seconds and allow to dry before inserting the cannula.
Note:
The IV site should not be touched after disinfection. If the tourniquet has been in
place for a sufficient length of time, touching should not be necessary.
9. Insert the cannula into a vein, preferably of an upper limb, using the no touch
technique. Do not attempt repeated insertions with the same cannula. If the
first insertion is not successful, then the procedure should be repeated with a
new cannula.
10. Look out for flash-back and advance the cannula slowly.
11. Release the tourniquet and apply a sterile dressing.
12. Connect up the administration set.
13. Clean site with a 70% isopropyl alcohol swab.
14. Anchor the cannula with clean tape and label the tape with insertion date.
15. Leave the site visible and dry.
16. Discard all sharps carefully in the container provided.
17. Wash and dry hands.
Possible Sources of Infection

1. Factors related to equipment and to fluids:
61
Aseptic Techniques
• Cannula-material that is itself thrombogenic. For example, polyethylene

and polypropylene are more reactive than Teflon©, which is in turn more
reactive than steel or silicone-coated Teflon©.
• Contaminated administration sets.
• Needles puncturing IV fluid bottles used as air inlets or for other reasons.
• Three-way taps and stopcocks.
• Infusion fluids.
• Contaminated or loose dressings, adhesive tapes, or film.
• Contaminated splints used to stabilize joints.
• Large bandages used to cover the insertion site (these can be
contaminated by the patient’s blood and body fluids).
2. Factors related to insertion and to duration:
• Patient’s skin flora if skin antisepsis is inadequate.
• Hands of staff, other patients, or visitors.
• Contaminated skin antiseptics.
• Unstable cannulae – movement increases the risk of bacterial
contamination.
• Cannulae left in for over 96 hours.
• Insertion of cannula into a previously infected vein. Alternate arms should
be used for IV therapy that lasts longer than 96 hours.
• Septicaemia (endogenous infection).
Protective Clothing for Inserting IV Cannula

Masks, caps, and gowns are not necessary. Non-sterile gloves are used when
inserting IV cannula (sterile gloves are used in high risk and
immunocompromised patients). The use of gloves and of an apron or gown will
protect the HCP if profuse bleeding is likely. 31
Maintenance of IV Lines
• Inspect regularly for swelling or for signs of infection.
• Keep the insertion site clean and dry.
• Assess the need for continuing catheterization every 24 hours.
• Remove the catheter at first sign of infection or at 72-96 hours.
• The change of IV administration set:
62
Aseptic Techniques
o The closed circuit system should always be maintained and it is not

allowed to disconnect the IV set from the cannula unless for changing it.
o When changing solutions, this may require a change of IV line if solutions
are known to have expected interactions. If not, we may use the same IV
administration line, if the iv line is removed from the port of the completed
solution and reinserted at the new one immediately and the port
sterilization and disinfection is guaranteed.
o IF closed circuit system is maintained, iv administration line could be
changed after 72 hours or within 24 hours if initiation of an infusion of lipid
emulsions if initiation of an infusion of blood, blood products.
• Avoid cut downs especially in legs.
• Wipe the hub of the cannula with an alcohol-impregnated swab before
attaching the administration set. The Luer lock should be kept as clean and
dry as possible.
Minimal requirements:
• Thorough hand washing /hand rub by the HCP before the insertion of the
catheter and during maintenance procedures.
• Thorough antisepsis of skin at insertion site.
• No touch technique during insertion, maintenance, and removal of catheter.
• Secure the IV line to prevent movement of catheter.
• Maintain the closed system.
• Protect the insertion site with a sterile dressing.
• Inspect the insertion site daily and remove catheter as early as possible and if
there are any signs of infection.
• Only well trained staff should set up and maintain infusions.
Procedure for Inserting Central Venous Catheters CVC

1. Collect all necessary equipment.
2. Place the patient in a suitable position.
3. Wash hands using an antiseptic solution or an alcohol handrub.
4. Wear sterile gloves.
5. Apply antiseptic to the insertion site (e.g. alcoholic povidone iodine), with
friction for at least 3 minutes prior to venipuncture. Allow the site to dry
before inserting the catheter.
6. Surround the site with a large sheet of sterile drapes.
63
Aseptic Techniques
7. Insert the central line as swiftly as possible maintaining “no touch”

technique throughout the procedure.
8. Blood should be aspirated freely to ensure that the catheter is in a
vascular space before injecting fluid.
9. Leave the site clean and dry after insertion.
10. Cover the site with a sterile (transparent) dressing for easy inspection.
Sterile gauze may be used but should not be covered with an impervious
dressing, as this increases the risk of infection.
11. Disinfect the hub with an alcohol swab before each connection to the
administration set.
12. Check drug incompatibilities.
13. Do not routinely replace CVCs to prevent catheter-related infection.
14. Central venous catheters should be removed if infected or at the end of
therapy.
15. Gloves should be removed and hands washed.
Protective Clothing during Insertion of CVC

The insertion of CVC lines requires medical asepsis and should be carried out
wearing gown, gloves, and a mask. Large sterile drapes should also be used.
Tips:
• Fluids and hyperalimentation should be administered via a closed system.
Potential points of entry for bacteria occur when the system is broken, e.g. by
three-way taps and stop corks.
• Suitable alternatives, e.g. multi-flow systems, can be shut off independently
and the administration set changed as required.
• Triple-lumen catheters can also be connected and disconnected individually.
Discontinued administration sets should not be left hanging on the drip stand
awaiting re-connection.
• Use clinical judgment regarding the need to remove a CVC in a patient who is
febrile.
Management of the Febrile Patient Receiving IV Therapy

Patients with IV devices can become febrile. All such cases require further
investigation:
• Redness and swelling: The insertion site should be inspected for redness or
swelling – if it appears infected, the tip of the intravenous catheter should be
removed and sent (in a sterile container) for semi-quantitative culture.
64
Aseptic Techniques
• Peripheral IV site: Peripheral blood cultures should be taken from a

peripheral site, preferably the opposite arm.
• CVC site: Cultures of blood obtained through a CVC are frequently
contaminated by microorganisms in the hub. Unless the laboratory has
techniques to quantify microbes from these cultures, the information obtained
may be misleading and, therefore, this should be avoided.
• Chemotherapy: A patient showing signs of infection during a course of
chemotherapy, when the central line cannot be removed, should be given
appropriate antibiotics (e.g. a glycopeptide alone or with an aminoglycoside)
until the end of therapy. The line should be removed and sent for culture.
• Hyperalimentation: There seems to be no advantage in covering the feeding
period with antibiotics and it is best to replace the line as soon as possible,
under antibiotic cover (to reduce the risk of septicemia), and then maintain
therapy for 5-7 days if clinically indicated.
• Catheter care: The after-care of IV catheters is crucial. The site should be
inspected daily and dressed aseptically when any moisture around the
insertion site is noted.
Injection Safety and Proper Use of Multidose

Vials
WHO estimates that at least 50% of the world’s 12 billion injections administered
each year are unsafe. Among adverse events associated with injections,
infections with the blood-borne pathogens hepatitis B virus (HBV), hepatitis C
virus (HCV), and human immunodeficiency virus (HIV)) contribute to the heaviest
disease burden. WHO estimates that unsafe injections result in 80,000 – 160,000
new HIV infections, 8 – 16 million new HBV infections, and 2.3 – 4.7 million new
HCV infections each year and result in 1.3 million deaths. 32 Unsafe injections
also transmit parasitic (malaria), bacterial, and other viral infections. Some
adverse events associated with injections, such as abscesses, appear relatively
quickly, whereas other infections may not be obvious for years or decades, e.g.
HIV, and HCV. 6, 8
Note: Reported infectious injection adverse events33

Bacterial infections Viral Parasitic
• • •
Abscesses Hepatitis B virus infection Malaria
• •
Septicemia Hepatitis C virus infection
• •
Toxic shock Human Immunodeficiency
syndrome Virus infection
• •
Tetanus Viral hemorrhagic fevers
65
Aseptic Techniques
In Egypt a high percentage of injections occur outside the formal health care
setting. It is estimated that 20-40% of injections are provided by persons who
have no formal training in the provision of medical care. Injection-associated
transmission of blood-borne pathogens can be prevented through a strategy to
reduce injection overuse and to achieve injection safety.
Instruction for Giving a Safe Injection

Definition
A safe injection does not harm the recipient, does not expose the provider to any
avoidable risks, and does not result in any waste that is dangerous for other
people.
The best infection control practice for safe injections is to eliminate unnecessary
injections. Besides decreasing the risk of infection transmission, this also saves
resources. If an injection is unavoidable, providers should follow the following
guidelines:
1. Use sterile injection equipment

• Use a sterile syringe and needle for each injection and to reconstitute
each unit of medication.
• Inspect the packaging for breaks in the package. Discard needle and/or
syringe if the package has been punctured, torn, damaged by exposure to
moisture, or if it has expired. 34
2. Prevent contamination of injection equipment

• Prepare each injection in a clean designated area where blood or body
fluid contamination is unlikely.
• Discard any needle that has been touched or contaminated in a safety
box. 34
3. Prevent needle stick injuries to the provider
• Anticipate and take measures to prevent sudden patient movement during
injection.
• Avoid recapping and other hand manipulations of needles. If recapping is
necessary, use a single-handed scoop technique. Do not bend, break, or
cut needles prior to disposal.
• Collect used syringes and needles at the point of use in a safety box that
is puncture-proof and leak-proof and that can be sealed before becoming
completely full. 34
4. Prevent access to used needles
66
Aseptic Techniques
• Close and seal safety boxes when they are three quarters full for transport
to a secure area for disposal. After closing and sealing safety boxes, do
not open, empty, re-use, or sell them.
• Manage sharps waste in an efficient, safe, and environment-friendly way
in order to protect people from voluntary and accidental exposure to used
injection equipment. 34
5. Other practice issues

• Provider’s hand hygiene and skin integrity. Perform hand hygiene (i.e.,
wash or antiseptic hand wash/handrub) prior to preparing injection
material and before giving injections. Avoid giving injections if skin integrity
is compromised by local infection or other skin condition (e.g., weeping
dermatitis, skin lesions, cuts).
• Swabbing of vial tops or ampoules. Swabbing of ports of multi-dose
vials with disinfectant before re-entering with a new needle is
recommended. For swabbing use an appropriate disinfectant (e.g., alcohol
70-90%) and a clean disposable swab and maintain appropriate contact
time. Do not use cotton balls that have been stored wet.
• Skin preparation prior to injection. Wash skin that is visibly dirty. Swab
the skin with an appropriate antiseptic (e.g., alcohol 70-90%) prior to
giving an injection. Use a clean disposable swab and maintain appropriate
contact time. Do not use cotton balls that have been stored wet. 34
Aseptic Injection Practices

Keep the needle and syringe sterile. Because any part of the syringe that you
touch becomes contaminated, you should not touch parts that come into contact
with the injectable medication. If you touch any of these parts by accident, the
syringe and needle are no longer sterile. Discard them immediately and replace
them with a sterile syringe and needle. 35
Fig. 9: Areas of a sterile syringe and needle that should not be touched
DON’T EVER TOUCH!! DON’T EVER TOUCH!!
DON’T EVER TOUCH!!

67
Aseptic Techniques
Don’t touch the needle with your fingers. Health workers sometimes place their
fingers on the needle to help guide it in when pushing through the skin. Touching
the needle with your fingers contaminates the needle. 35
Don’t touch the injection site with your fingers

After an injection health workers sometimes apply pressure to the injection site
with their fingers or with a piece of cotton wool to reduce bleeding. It is a better
practice to ask the patient or the adult accompanying small children to hold the
cotton on the injection site. If the nurse contaminates his or her fingers with
blood, he or she can transmit pathogens from a patient’s injection site to another
patient. 35
Tips for injection safety
Practices that can harm recipients and should be avoided
• Changing the needle but reusing the syringe.
• Loading the syringe with multiple doses and injecting multiple doses.
• Applying pressure to the bleeding sites using a finger.
• Leaving the needle in the vial to withdraw additional doses.
• Touching the needle.
• Reusing a syringe or needle.
Practices that can harm the health care worker and should be avoided
• Recapping, bending, breaking, and cutting needles.
• Placing needles on a surface or carrying them any distance prior to disposal.
Practices that can harm the community and should be avoided

• Leaving used syringes in areas with public access.
• Giving or selling used syringes to vendors who resell them.
• Providing used syringes to patients for personal reuse.
Procedure for Injection Administration

1. Gather all items needed for the injection, e.g.:
- Sterile needle and syringe
- Medication
- 70-90% alcohol
68
Aseptic Techniques
- Cotton pads
- Gloves, if necessary
- Band aid, if necessary
- Tourniquet, if necessary
2. Prepare patient (position)
3. Wash hands (routine hand-wash), and
4. Put on gloves when indicated
Ten steps to administer an intravenous injection (IV) or taking

blood sample
1. Apply tourniquet.
2. Search for an appropriate vein.
3. Wash your hands and wear gloves.
4. Apply skin antiseptic (e.g., alcohol) to insertion site.
5. Insert the IV injection using a new sterile syringe.
6. Remove tourniquet
7. Inject medication slowly under strict aseptic
conditions (observe patient’s reaction carefully).
8. Remove needle while pressing cotton pad onto the Fig. 10: IV Injection
1 Skin; 2 Vein beneath
injection site. the skin;
9. Discard needle/syringe immediately in a puncture 3 Muscle; 4 Syringe
resistant safety box - do not recap needle.
10. Cover the site with an adhesive bandage if
necessary.
(N.B. The same steps should be applied for drawing blood sample)
Seven steps to administer an intramuscular injection (IM)

1. Define injection area.
2. Wash hands if possible.
3. Apply antiseptic to injection site.
4. Inject medication under strict aseptic conditions using a new sterile
syringe.
5. Remove needle while pressing cotton pad onto injection site.
6. Discard needle/syringe immediately in a puncture resistant safety box -
do not recap needle.
7. Cover the site with an adhesive bandage if necessary.
69
Aseptic Techniques
Observe the patient when beginning an IV infusion

If fever or shivering develops during infusion of an IV fluid, stop using the IV fluid
even if the fluid is clear and change to a new sterile fluid since pyrogens or
bacteria which are not visible could be responsible.
Proper use of multi-dose vials

Multi dose-vials of medication or of other fluids can become
vehicles for transmitting infections between patients. 34, 36
Before filling a syringe from a multi-dose vial:

• Inspect for and discard medications with visible
contamination or breaches of integrity (e.g., cracks,
leaks). Fig. 11: Use of
multi-dose vial
• Check the safety of the product (e.g. not expired, read
the label of vial, no particulate matter in the vial, and not turbid).
• Wipe the top of the vial with a fresh cotton swab soaked with 70-90%
alcohol and allow it to dry.
To reduce the risk of transmitting infections between patients:

• Use single dose-vials rather than multi-dose vials.
• If multi-dose vials must be used, always pierce the stopper with a
sterile needle and syringe every time fluid is withdrawn from a multi-
dose vial. Reusing the same syringe to give injections to multiple
patients – even if the needle is changed – is not a safe practice,
because infections contaminate the multi-dose vial and can be
transmitted from patient to patient.
• Avoid leaving a needle in place in the stopper of the vial. This provides
a direct route for microorganisms to enter the vial and to contaminate
the fluid between each use.
• If multi-dose vials are used that need to be reconstituted, the needle
and syringe that was used to reconstitute must be discarded, and for
each draw from the vial a new sterile needle and syringe must be
used.
• Follow product-specific recommendations for reconstitution, storage,
handling, and discarding unused doses.
• Discard needles that have touched an unsterile surface. 34, 36
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Aseptic Techniques
Urinary Catheterization
Fig. 12: Urinary Catheterization System
Urinary catheterization is an aseptic procedure but is also the most common

cause of hospital-acquired infections, which can occur during insertion or
removal of the catheter. Repeated catheterization causes trauma and results in
infection. Patients should be catheterized only if clinically indicated and certainly
should not be catheterized only for the convenience of the nursing staff. 9
About 10% of hospitalized patients have an indwelling catheter. 20-25% of these
patients develop urinary tract infections (UTI). It is estimated that hospital
acquired UTI accounts for 40% of nosocomial infections. Most of these are
associated with instrumentation, particularly indwelling catheterization.
The incidence of infection is directly related to the duration of catheterization;
50% of patients are infected by day 15 of catheterization and almost 100% by 1
month. This means that the first line of prevention is to avoid catheterization as
much as possible and to remove the catheter as soon as possible (preferably
within 5 days). 9
Procedure for Insertion of a Urinary Catheter:

1. Inform the patient and explain the indication and the procedure of
catheterization.
2. Lay all necessary equipment on a trolley.
71
Aseptic Techniques
3. Select a catheter that fits the urethra without traumatizing the patient
4. Wash hands thoroughly with an antiseptic hand wash preparation.
5. Put on sterile gloves and use a “no touch” technique.
6. If the patient is male, draw back the foreskin and clean the glans
thoroughly with soap and water to remove secretions, followed by
swabbing the area with antiseptic. If the patient is a woman, clean the
periurethral area by separating the labia and cleanse the vulva, using
front to back technique.
7. Insert 2-3 ml of the lubricant (e.g.anesthetic jelly into the urethra).
Multiple-use tubes are not recommended because they become
contaminated and increase cross-infection.
8. Insert the catheter gently – advance it by holding the inner sterile
sleeve. A “no touch technique” should be used in which the operator has
no contact with the sterile shaft of the catheter.
9. Collect the urine in a suitable container.
10.Inflate the balloon by instilling the manufacturer’s recommended
amount of sterile water.
11. Anchor the catheter to the patient’s thigh.
12. Connect the catheter to the closed drainage bag and hang it below the
level of the bed to stop reflux.
Note:
It is important to use the correct urinary catheter for the condition. Foley
catheters require no more than 5-10 ml water, while hemostasis catheters require
30 ml. The balloon can cause obstruction and stasis of the urine if it is too large,
thus increasing the risk of infection.
Emptying the Drainage Bag

This should be done wearing non-sterile gloves and via the drainage tap at the
bottom of the bag. When the bag is empty, the tap should be closed securely and
wiped with a tissue. If the bag does not have a tap, then replace it when full. Do
not disconnect the bag to empty and then reconnect it.
Wash and dry hands thoroughly after touching the drainage bag.
With proper handling, drainage bags with taps can be left in situ for long periods
and are more cost-effective in the long run. 9
A separate urine bag-collecting receptacle must be used for each patient and
each bag should be emptied separately as required. For purposes of measuring
urinary output, an integral measuring device is necessary. The urine receptacle
72
Aseptic Techniques
should be heat disinfected if possible and should be stored dry after each use. If
heat labile, chemical disinfection could be used. Single-use disposable
receptacles may be used. After emptying the receptacle, the gloves should be
discarded and hands washed and dried thoroughly.
Collecting Urine Samples

Do not disconnect the drainage bag to obtain a urine sample as this causes an
interruption in the closed drainage system and may pose a risk of infection to the
patient. If a sample of urine is required for bacteriological examination, it should
be obtained from a sampling port or sleeve. This must first be disinfected by
wiping with a 70% isopropyl alcohol impregnated swab. The sample may then be
aspirated using a sterile needle and syringe and transferred into a sterile
container. Do not obtain a sample for bacteriological culture from the drainage
bag. 11 If there is no port or sleeve for collecting urine samples, antiseptic hand
wash and wearing sterile gloves should be attempted, wipe the connection
between the urinary bag and the catheter with alcohol, disconnect the drainage
bag, collect a urine sample in a sterile container, wipe the port of the urinary bag
and reconnect.
Irrigate Bladder
Routine irrigation of the bladder (bladder washout) with chlorhexidine or other
antiseptics is not effective in prevention of infection and should not be performed.
Irrigations rarely eradicate organisms but may introduce infection and can cause
inflammation of the bladder wall, and, therefore, can increase the likelihood of
systemic invasion. They may also cause damage to the catheter.
If the catheter becomes obstructed and can be kept open only by frequent
irrigation, the catheter should be changed, as it is likely that the catheter itself is
contributing to obstruction. 11
Prophylaxis and Treatment with Antibiotics

Routine use of prophylactic antibiotic administration in catheterized patients is
not recommended because of its tendency to encourage the emergence of
resistant organisms. Treat patients with antibiotics only if there is evidence of
clinical infection.
Patients with infected urine at the time of catheterization or of operation should
be treated with appropriate antibiotics according to the antibiotic sensitivity of the
organism. If antibiotic sensitivity testing is not available, empiric antibiotic
treatment can be given according to the local antibiotic policy or to the advice of
a medical microbiologist. 11
Other precautions:
• The spout from the tap should be completely emptied to prevent a build-up of
organisms in stagnant urine.
73
Aseptic Techniques
• The bag should not be allowed to stand on the floor or to rise above waist
level.
• Catheters should not be changed routinely as this exposes the patient to
increased risk of bladder and urethral trauma. They can be changed if
associated with urinary tract infection and antibiotic treatment started.If the
catheter will not pass any part of the urethra with gentle pressure or if a trace
of blood is seen on the catheter tip on withdrawal, do not preserve or push
harder, as serious damage may ensue. In this case, seek help from a more
experienced colleague.
Minimal requirements
• Hand hygiene and cleaning of periurethral area before insertion of a sterile
catheter.
• Maintenance of a closed drainage system.
• Hand hygiene before and after emptying bags.
Wound Inspection and Wound Care

Surgical Wounds
These should be sterile at operation and, in most cases, after operation. Infection
can be introduced during the operation or post-operatively via hands and
contaminated dressings. It is best not to interfere with surgical wounds unless
indicated, e.g. if there are signs of infection and a change of dressing is required.
Traumatic Wounds
These are potentially contaminated with environmental and fecal bacteria and
may become colonized with hospital pathogens, which may then be transferred
to other patients via the hands of the staff.
Procedure for Wound Care

Wounds must not be touched with dirty hands and wound care should be an
aseptic procedure:
1. Lay up a trolley with a sterile wound dressing pack.
2. Remove old dressing and inspect the wound.
3. Wash hands aseptically, dry hands and wear sterile gloves.
4. Clean the wound thoroughly using forceps and cotton wool or gauze
soaked in a cleaning solution. Do not use hands.
74
Aseptic Techniques
5. Exude any fluids from an infected wound by pressing with two sterile
gauze pieces held with two forceps.
6. Take specimens of pus or exudates for bacteriological examination.
7. Apply necessary medication.
8. Wipe the wound site as dry as possible.
9. Cover the wound if indicated.
10. Discard all dirty dressings in a clinical waste bag.
Note:
Individual sterile wound dressing packs containing all of the sterile items required
to dress a wound are preferable.
75
Isolation Precautions
Isolation Precautions in
Health Care Facilities (HCF)
Introduction
As highlighted in the chapter on Importance of Infection Control in the Health
Care Setting, there are three elements needed to allow transmission of
microorganisms within a health care facility. These are a source of the
microorganism (e.g., patients, personnel, visitors, equipment or the inanimate
environment), a susceptible host and a mode of transmission. The former two
elements are more difficult to control or prevent; therefore, the emphasis on
interrupting transmission is to prevent the mode of transmission. This is
accomplished by two main tiers of precautions: Standard Precautions (SP) and
Transmission-Based Precautions. Standard precautions (SP) are the primary
strategy for preventing transmission of microorganisms to patients, personnel,
and others in the health care facility (HCF). They are applied to all patients
because microorganisms are likely present in patients with recognized and
unrecognized infection. In addition, far greater numbers of patients are colonized
with epidemiologically important microorganisms in HCF than those with clinical
signs of infection.
The purpose of this chapter is to outline components of SP and Transmission-
based precautions. The latter are designed for patients with documented or
suspected infection with communicable or epidemiologically important pathogens
for which additional precautions beyond SP are needed to interrupt transmission.
9
The aim of isolating a patient is to prevent the spread of communicable
diseases.
Some key aspects of transmission-based precautious include:

• An understanding of the epidemiology of communicable diseases is
helpful to assist with decisions regarding specific isolation precaution
procedures. 47
• The essence of a successful isolation policy is to create a barrier
between the patient and other people, e.g., staff and patients. Isolating
the patient in a single cubicle or in a room with en suite facilities, when
available, is optimal.
• A high index of suspicion-often using clinical clues alone at the time of
admission- should trigger an assessment for need for precautions
76
beyond SP. Appropriate infection precautions must commence on

clinical suspicion; laboratory confirmation is not necessary.
• All the recommendations of an isolation precautions program should
be based on the real capabilities of the hospital. A continuing
education program must first be directed to nurses, as they are the
personnel with the greatest physical contact with patients. 48 In
addition, HCP should recognize that isolation precautions have
disadvantages for the patient including negative psychological aspects
of separation from others and additional equipment for care.
Note:
If more than one patient is affected (e.g. in an outbreak) they should be nursed
together in one room (cohort isolation) and looked after by dedicated staff. 9
Limited movement and transport of isolated patients is essential. They must
leave their rooms only for essential purposes in order to minimize spread in the
hospital. 11
Notification of Communicable Diseases to

District Health Office
Medical practitioners attending patients known to be suffering from or suspected
to be suffering from a notifiable communicable disease, have an obligation to
inform the District Surveillance Unit (at the district health office). It is also
important that all such cases are reported to a member of the Infection Control
Team. This should be done as soon as possible. Notification should occur on
clinical suspicion of the disease and not dependent on laboratory confirmation. 11
Transmission of Infection
Microorganisms are transmitted in HCF by several routes and the same
microorganism may be transmitted by more than one route.
There are five main routes of transmission:
• Contact
a) Direct-contact: Direct body surface-to-body surface contact and
physical transfer of microorganisms between susceptible host and
infected or colonized person.
b) Indirect-contact: Contact of a susceptible host with a contaminated
intermediate object, usually inanimate, such as a contaminated
instrument, needle, or dressing, or contaminated hands of HCP.
• Droplet:
Droplets generated by the infected person by cough, sneeze, talking,
or during a procedure such as suctioning the person’s respiratory tract
77
travel a short distance (1-2 meters) and are deposited on a susceptible

host’s conjunctivae, nasal mucosa, or mouth.
• Airborne
Dissemination of either droplet nuclei (small particle residue <5
microns) or dust particles containing microorganisms into the air are
then inhaled by a susceptible host. This can occur over significant
distances via normal air and ventilation systems.
• Common vehicle
Transmission via contaminated food, water, medications, blood
products, devices, and equipment.
• Vector-borne
Transmission of microorganisms via mosquitoes, flies, ticks, etc.
Neither common vehicle nor vector-borne transmission play a significant role in
typical hospital-associated infections (HAI) and will not be discussed here.
Routes of transmission of infection from infected hospital patients:

• Hands of the HCP (the most common route);
• Contact with contaminated instruments;
• Exposure of the respiratory tract;
• Environmental factors (dust, fluids) and skin scales. (Environmental factors
contribute when the colonization rates are high and when the bacteria are
widely dispersed).
[For more details see chapter “Importance and Purpose of Infection Control in the Health
Care Setting”]
Standard Precautions (SP)

A significant proportion of infectious diseases can be incubating, can cause no
symptoms, or can result in chronic infection (e.g. hepatitis C virus) among
patients who are exposed to these pathogens. SP is the foundation of protection
for personnel against exposure to infectious agents during all patient care
activity. SP is a system of precautions that is designed to reduce the risk of
transmission of blood-borne pathogens and other pathogens present in body
substances.
Terminology applied to precautions against blood-borne pathogens that often is
confused with SP, is universal precautions (UP). UP were developed originally to
focus attention on precautions against occupational exposure to body fluids that
were likely to contain blood-borne pathogens (i.e. blood, semen and vaginal
secretions, cerebrospinal, pericardial, peritoneal, pleural, and synovial fluids, and
other body fluids visibly contaminated with blood). 49, 50 UP against blood-borne
pathogens did not apply to feces, nasal secretions, sputum, sweat, tears, urine,
78
or vomitus unless visibly contaminated with blood. In the mid-1980s a group of

infection control professionals in the US developed a system of precautions
called body substance isolation (BSI) whose aim was to interrupt transmission of
endemic infection in HCFs and to protect HCP and others. BSI was applied to all
moist and potentially infectious body substances (blood, secretions and
excretions) and surfaces and equipment -if contaminated. SP is a synthesis of
these two systems. They apply to: 1) blood; 2) all body fluids, secretions, and
excretions regardless of whether they contain visible blood, 3) nonintact skin, 4)
mucous membranes and contaminated surfaces or equipment.
The components of SP are discussed earlier in chapter 1 “Importance of Infection
Control in the Health Care Setting”, page 22.
Practical Issues and Considerations

Hand Hygiene
Hand hygiene is essential in reducing the risk of infection transmission from
patient to patient or from one site to another site on the same patient. Routine
handwashing or antiseptic hand wash should be performed promptly between
patient contacts, after contact with infective material (blood, body fluids,
secretions or excretion), and after contact with contaminated items used for
patient care. Hands should be washed or an alcohol based handrub should be
used immediately after removing gloves.
Covering Cuts
Cover cuts or areas of broken skin with waterproof dressings while at work.
Health care personnel with large areas of broken skin must avoid invasive
procedures. Staff with eczema or other skin conditions or with large wounds
which cannot be adequately protected by plastic gloves or impermeable
dressings should refrain from patient care and from handling patient care
equipment until the condition resolves.
Personnel Protective Equipment (PPE)

Appropriate PPE, e.g., gloves, masks, gowns, protective eyewear, should be
worn for the procedures that are likely to generate droplets, splashes, or sprays
of blood or body fluids in order to protect skin and mucous membranes.
(For more details see below: PPE for Isolation Procedures)
Safe Use of Sharps

Avoid sharps usage whenever possible. If the use of sharps is necessary, then
sharps must be used and handled with care. Never leave sharps lying around;
dispose of them carefully into a designated sharps container. HCP should be
79
instructed that it is the personal responsibility of the person using a sharp to

dispose of it safely as soon as possible after use or to ensure that it has been
safely discarded.
[For more details see chapter “Waste Management II Sharps Disposal”]
Monitoring Staff Health

It is important that HCP are appropriately and adequately immunized against
infectious diseases, both for their own protection and for the protection of others.
Staff who are suffering from a known or suspected infectious disease must report
this to the Occupational Health Department, which will advise on the
management and on exclusion from work if necessary. Sharps injuries and any
exposure of non-intact skin, conjunctiva, or mucous membrane to blood or high-
risk body fluids should be recorded and reported to a responsible person from
the Occupational Health Department.
[For more details see chapter “Occupational Safety and Employee Health”]
Removing Spills of Blood and Body Fluids

Spillage of blood and body fluids must be cleaned carefully and promptly using a
safe method including protective measures for housekeeping staff.
Cleaning and Disinfecting Patient Care Equipment

Patient care equipment is either single-use disposable or re-usable. Single-use
items should be discarded as clinical waste while non-disposable items should
be appropriately cleaned and disinfected or sterilized before re-use.
Disposing of Waste Safely

Waste from patients with a known or suspected infection should not be treated
any differently than waste from patients without known infection. Studies of waste
from patients under isolation precautions have shown it carries no greater
microbial load than from those who are not on isolation precautions.
[For more details see chapters ”Waste Management II Sharps Disposal” and
“Environmental Cleaning”]
Collecting and Reprocessing Linen Safely

Although soiled linen may be contaminated with pathogenic microorganisms, the
risk of transmission is negligible. Soiled linen should be handled with a minimum
of agitation and should be placed in a laundry bag.
[For more details see “Linen Management”]
80
Cleaning the Environment

Special attention must be given to ensure the environment is maintained in a
clean state and is in line with good housekeeping practices.
• Terminal cleaning of the patient rooms should be carried out at the discharge
of the patient before admitting another patient:
• When visibly soiled, all the surfaces and walls must be washed thoroughly
with warm water and detergent and be dried (wiped over with a disinfectant if
indicated).
• Launder all bed linen and cubicle curtains, etc. when visibly soiled
• The covers of bed mattresses and pillowa should be wiped with warm water
and detergent and dried thoroughly. Occasionally, a disinfectant may be
indicated.
• Where special cleaning arrangements are required, the supervisor must be
informed of the infection risk (not of the patient’s diagnosis) and of any
protective measures necessary for the staff.
[For more information see chapter “Environmental Cleaning”]
Dishes, Glasses, Cups, and Eating Utensils

No special precautions are needed for dishes, glasses, cups, or eating utensils.
Either disposable or reusable dishes or utensils can be used for patients on
isolation precautions. The combination of hot water and detergents used in
hospital dishwashers is sufficient to decontaminate dishes, glasses, cups, and
eating utensils.
PPE for Isolation Procedures

The indications for the use of protective clothing for isolation aseptic procedures
are uniform. Recommendations for protective clothing for different isolation
categories are discussed later in the transmission based precautions sections. 9
Deceased Patients
As a general rule the infection control precautions prescribed during life are
continued after death. In cases where there is an infection risk from the body, a
“Danger of Infection” label must be attached to the patient’s armband.
If a person that is known to be infected or that is suspected to be infected dies,
either in the hospital or elsewhere, it is the duty of those with knowledge of the
case to ensure that those who handle the body are aware that there is a potential
risk of infection that is minimized by using the appropriate control measures.
Even without any information about the presence of infection in the deceased,
SP should always be used. 11
81
Transmission-Based Precautions
Whenever isolation of a patient is considered, assessment of risk should be
carried out and the disadvantages should be weighed against the benefits. The
placement of a patient into isolation should never be undertaken as a matter of
convenience.
Second tier precautions are designed only for patients that are known or
suspected to be infected with highly transmissible or epidemiologically important
pathogens for which additional precautions beyond “Standard Precautions” are
needed in order to interrupt transmission in hospitals. 11, 48 Please note however
that SP still need to be employed even for patients placed on transmission-based
precautions.
There are three types of “Transmission-Based Precautions”:

• Airborne precautions (prevent transmission by air current).
• Droplet precautions (prevent transmission by small and large droplets).
• Contact precautions (prevent transmission by direct or indirect contact).
• Combination of airborne and contact precautions
Airborne Precautions
Airborne precautions (AP) are used for infections which are transmittd by droplet
nuclei. Droplets are generated in the course of talking, coughing, or sneezing and
during procedures that involve the respiratory tract such as suction,
physiotherapy, intubation, or bronchoscopy.
Small droplet nuclei size of ≤ 5µ can be widely dispersed by air currents and can
reach the alveoli of the susceptible host and cause infection. Patients under
airborne isolation precautions should be in a single room with negative airflow
ventilation with respect to the surrounding areas. The door must be kept closed.
Examples of diseases in this category include:

• Tuberculosis
• Measles
Large droplet nuclei particle size is ≥ 5µ in diameter containing infectious

particles. These droplets do not remain suspended in the air long and travel only
short distances. Transmission from larger droplets requires close contact (e.g.
within 2 m) between the infected source and the recipient.
82
Examples of diseases in this category include:

• Meningococcal meningitis
• Pertussis
• Streptococcal pharyngitis, and
• Multidrug resistant Streptococcus pneumoniae
Table 7: Summary of Airborne Precautions

• A single room under negative pressure ventilation
with a wash hand basin and preferably with an en
suite toilet.
• The door must be kept closed at all times except
during necessary entrances and exits.
Location
• Unnecessary items of equipment must be removed
before the patient occupies the room.
• Disposable paper towels and an antiseptic/detergent
hand cleanser in an elbow operated pump dispenser
should be provided.
When applicable, only personnel that have immunity
Staff against varicella and measles should care for these
patients.
All visitors must seek advice from the nurse-in-charge of
Visitors
the ward before visiting the patient.
• A high efficiency mask, if available, should be worn
when entering the room of a patient with known or
Protective clothing suspected tuberculosis.
• Other PPE should be used consistent with SP.
Table 7: Summary of Airborne Precautions (continued)

Hands must be washed with an antiseptic preparation
and must be dried thoroughly with a disposable paper
towel, or use a waterless alcohol handrub/gel
Hand hygiene
• AFTER touching the patient or potentially
contaminated items,
• AFTER removing gloves, and
83
• BEFORE taking care of another patient.

Linen No special handling is needed for used or soiled linen.
Limit the movement and the transport of the patient to
Inter-departmental
essential purposes only. Seek advice of the Infection
visits
Control team
Laboratory No special labeling or precautions are needed.
specimens
The infection control precautions employed during life
must be continued after death. In the case of open
Last offices tuberculosis, the body must be labeled with a ”Danger of
infection” label on the wrapping sheet or shroud and on
the information sheet.
Droplet Precautions
For those infections which are spread by large droplets.
Examples
• Pneumonic plague
• Influenza
• Rubella
• Invasive miningococcal disease (meningitis, pneumonia meningococcemia
etc.)
Table 8: Summary of Droplet Precautions

A private room with a wash hand basin and an en
Location
suite toilet is necessary.
Staff No exclusions.
Visitors must always report to the nurse in charge
Visitors
before entering the room.
Put on a standard mask prior to entering the isolation
PPE
room.
Hand hygiene and must be dried thoroughly with a disposable paper
towel or washed with a waterless alcohol handrub/gel:
84
• AFTER contact with the patient or potentially

contaminated items,
Decontamination and No specific precautions.
waste disposal
Contact Precautions (CP)

These precautions are used for patients to prevent the transmission of
communicable diseases and of epidemiologically important microorganisms
which are causing infection or colonization and which are transmitted by direct
patient contact or by indirect contact with the patient or the patient’s environment,
excretion, and secretion.
Examples of these infections include:

• Respiratory syncytial virus
• Disseminated herpes simplex (e.g., neonatal)
• Streptococcal and staphylococcal infections (e.g., major skin infection)
• Methicillin-resistant Staphylococcus aureus (MRSA)
• Multi-resistant Gram-negative bacteria,
• Vancomycin resistant enterococci (VRE)
• Clostridium difficile associated diarrhea
Table 9: Summary of Contact Precautions

A single room with an en suite toilet is necessary if the
infective agent might be disseminated into the
Location
environment or if the microorganism has
epidemiological importance at the HCF.
Staff There are no special qualifications for personnel.
Visitors must always report to the nurse-in-charge
Visitors
before entering the room.
Non-sterile, disposable gloves are needed
when there is contact with an infected site,
PPE
with dressings, or with secretions.
A mask when performing procedures that may
85
generate aerosols or when performing

suctioning is recommended.
and must be dried thoroughly with a disposable paper
towel or washed with a waterless alcohol handrub
especially:
Hand hygiene • AFTER contact with the patient or potentially
contaminated items,
Linen No special handling is needed for used or soiled linen.
• Non-disposable items should be sent to Sterile
Service Department (SSD) for
Decontamination and disinfection/sterilization.
waste disposal
• Waste: Contaminated waste is disposed of as
clinical waste according to local policy.
Combination of Airborne + Contact (A+C) Precautions

This type of isolation is used to prevent transmission of diseases spread both by
air and by contact and is used for patients with highly transmissible and
dangerous infections.
Diseases requiring combination Airborne & Contact isolation include:

• Chicken pox (Varicella).
• Others as determined by Hospital Infection Control team.
Table 10: Summary of Airborne & Contact precautions11
86
Patients must be admitted into a single room under

negative pressure ventilation and, if available, with an
ante room with wash hand basin and en suite toilet
facilities.
• The door must be kept closed except during
necessary entrances and exits.
• Unnecessary items of equipment must be removed
Location before the patient occupies the room.
• The mattress and pillows must have non-permeable,
intact covers.
• Disposable paper towels and an antiseptic/detergent
hand cleanser in an elbow operated pump dispenser
must be provided.
• The patient’s charts should be kept outside the room.
Minimize the number of personnel needed for care and

Staff assure those assigned are immune to the disease for
which the patient is isolated, if appplicable.
Visitors must be be kept to a minimum and must always
report to the sister or nurse-in-charge before entering the
Visitors
room. Visitors must observe the same infection control
precautions as personnel.
• Non-sterile gloves, a gown, or disposable apron, and a
high-filtration mask, if available.
PPE
• Eye protection is needed for any procedure that might
cause splashes of blood and body fluids.
Hands must be washed or a handrub containing an
antiseptic applied:
• BEFORE leaving the room. This is extremely
important.
• AFTER touching the patient or touching potentially
contaminated items,
Hand Hygiene
• AFTER removing gloves and AFTER removing
protective clothing.
When leaving the room the door should be pushed open
from the outside by an assistant in order to avoid touching
the door handle which may be contaminated. When
outside, repeat the hand-disinfection.
87
Table 10: Summary of Airborne & Contact precautions ( continued)

• Non-disposable items should be sent to Sterile
Decontamination Service Department (SSD) for disinfection/sterilization.
and Waste
Disposal • Waste: Contaminated waste is disposed of as clinical
waste according to local policy.
Routine laundering is sufficient for used linen.
Laundry
Inter-departmental The patient must not leave the room without prior
visits consultation with the Infection Control Physician.
• Routine procedures should be used for laboratory
Laboratory specimen.
specimens • Special labeling is not indicated and only promotes a
false sense of security.
• The infection control measures employed during life
must be continued after death.
• Any bleeding part must be covered with an occlusive
Last offices dressing.
• The body must be transported in an appropriate
sealed cadaver bag and labeled with a ”Danger of
Infection”-sticker.
88
Table 11: Summary of components of standard infection control precautions and

of transmission based precautions in isolation procedures: 51
Standard Contact Droplet Airborne
Hand Hygiene √ √ √ √
When likely to On entering As per As per “Standard”

touch blood, room, during “Standard”
care
body fluids
Gloves
and
contaminated
items
During procedures As per As per On enteringthe
likely to generate “Standard” “Standard” room. Non-essential
contamination and if present susceptible people
Mask with blood and within 1 meter should be excluded.
body fluids of patient For TB wear high-
efficiency mask
During procedures As per As per As per “Standard”
likely to generate “Standard” “Standard”
Eye protection
contamination
/face shield with blood and
body fluids
During procedures On entering if As per As per “Standard”
likely to generate contact with “Standard”
Apron/gown contamination patient or
with blood and environment
body fluids anticipated
Equipment √ √ √ √
Environment √ √ √ √
(Cleaning, etc.)
Linen √ √ √ √
Single room not Single room and Single room, Single room with
required minimize time minimize time negative pressure
outside outside to ventilation,
when patient minimize time
Isolation room may wear outside to when
mask patient may wear
mask. Exclude non-
essential susceptible
people
√ = According to description in text
89
Practical Guidance for Decision Makers on

Isolation
At any one time hospitals might have more patients with potentially transmissible
infections needing isolation rooms than they have rooms available. Consistent
and evidence-based decisions should therefore be made on prioritization for the
use of such isolation.
Limited resources available and competing priorities might make the decision
difficult to make. In the absence of widely used accepted guidelines, these
decisions may not be consistent. When faced with the need to prioritize the use
of isolation facilities, the following factors, which influence transmission and its
impact, should be considered, e.g., a risk assessment should be performed:
1. Advisory Committee of Dangerous Pathogens (ACDP) Classification of
Pathogens: The ACDP classification provides an acknowledged system of
classifying organisms based on their transmissibility, pathogenicity, and on
our ability to protect against or treat individual infections.
2. The probable route of transmission: Air-borne infections are those most likely
to spread readily if not isolated; blood-borne infections are least likely to do
so.
3. Evidence for transmission: Although 1) and 2) may suggest transmission, the
emphasis placed on evidence-based medicine now supports a requirement to
demonstrate that transmission of specific infections has indeed occurred in
hospitals.
4. Occurrence of infection in the hospital: The incidence or prevalence of an
infection/colonization in a hospital is frequently a consideration when deciding
whether or not to isolate a patient. In a sporadic infection, isolation of a
patient will have a higher priority than in endemic or epidemic situation.
5. Antibiotic resistance: Emergence of antibiotic resistant bacteria is one of the
principal causes of the increased demand on isolation facilities.
6. Susceptibility of other patients: When deciding whether or not to isolate a
case, the presence of a susceptible patient population promotes the isolation
of the potential source of sepsis.
7. Dispersal characteristics of patient: While transmissibility of various infections
has been addressed in 1,2, and 3, it is well recognized that for a given
infection certain patients present greater transmission hazards than others.
The table below shows an example of a scoring system applied to risk

assessment for the prioritization of potential isolation cases.
90
Table 12: Risk Assessment Scoring System for Assigning the Priority of Isolation
(Lewisham Isolation Priority System-LIPS)
CRITERIA CLASSIFICATION SCORE COMMENTS
2 5
ACDP category 3 10
4 40
Air-borne 15
Droplet 10
Route
Contact 5 Include fecal-oral transmission
Blood-borne 0
Published evidence 10
Consensus or 5
likelihood
Evidence of transmission
No consensus or 0
likelihood
No evidence - 10
Yes 5 Such as MRSA, GRE, etc.
Significant resistance
No 0
High susceptibility of Yes 10 Specific for various infections

other patients with and patient populations
serious consequences
No 0
Sporadic 0
Endemic -5 This reflects the burden of
Prevalence infection in the hospital and
cohort measures are more
applicable
Epidemic -5 See above
High risk 10 Only for contact and droplet
transmission, e.g. eczema,
fecal, incontinence,
Dispersal tracheostomy, etc.
Medium risk 5
Low risk 0
TOTAL SCORE
91
Category of priority for isolation Score

Low 0 – 20
Medium 21 – 39
High 40 - 50
Table 13: Isolation Precautions Reference Table

Standard Precautions must be applied in all circumstances
Type of
Infective Duration of
Disease isolation Comments
Material Isolation
precaution
Acute Respiratory Droplet & Respiratory For 7 days after Infants and young
Infections Contact secretions and onset of illness children only
feces’
Anthrax Standard Respiratory Duration of illness No additional
Bacillus anthracis and/or lesion precautions
secretions
Chickenpox Airborne + Respiratory Until all lesions Persons
Contact and/or lesion are crusted. For susceptible to
secretions exposed, varicella should
susceptible not enter the
patients from 10 room
until 21 days after
last day of
exposure.
Disseminated Airborne + Lesion Duration of Persons
Herpes Zoster Contact secretions hospitalization susceptible to
varicella should
not enter the
room
Localized Herpes Airborne Lesion Duration of Persons
Zoster (Shingles) secretions hospitalization susceptible to
(immunosuppressed varicella should
patient) not enter the
room
Localized Herpes Standard Lesion
Zoster (Shingles) secretions
Clostridium Standard Secretions No special
botulium precautions
Clostridium difficile Contact Feces, Pus Duration of illness
Creutzfeldt-Jakob Standard Blood, brain, Duration of OR, Materiel
disease tissue, and hospitalization Services,
spinal fluid Pathology have
specific
procedures.
92
Table 13: Isolation Precautions Reference Table (continued)

Type of
Material Isolation
precaution
Diphtheria (pharyngeal) Droplet Respiratory Until after 2
secretions cultures, taken at
least 24 hrs apart,
are negative
(following
appropriate
therapy
Erythema infectiosum Standard Respiratory For 7 days after
(Fifth Disease) secretions onset
(also Parvovirus B19)
Haemophilus influenzae Droplet Respiratory Until after 24 hrs of
pneumonia/meningitis, secretions appropriate
Pediatrics only antibiotic therapy
Hemorrhagic fevers (for Contact Blood, body Duration of Report immediately
example, Lassa and fluids, and hospitalization to epidemiological
Ebola) respiratory and surveillance
secretions unit
Hepatitis A Standard Feces may be For 7 days after Hepatitis A is most
onset of jaundice contagious before
symptoms and
jaundice appear.
Hepatitis B (including Standard Blood and Until patient is Use caution when
hepatitis B antigen body fluids HBsAg-negative handling blood and
HBsAg carrier) blood-soiled
articles. Take
special care to
avoid needlestick-
injuries
Herpes simplex Standard Lesion For neonate or
secretions severe
mucocutaneous –
Contact
Precautions
Herpes Zoster See Chickenpox
HIV, AIDS, Hepatitis C Standard Blood and Use caution when
body fluids handling blood and
blood-soiled
articles. Take
special care to
avoid needlestick
injuries.
93

Type of
Material Isolation
precaution
Viral influenza Droplet Respiratory 7 days after the Group of
(A,B,C) secretions symptoms patients during
epidemics
Legionella Standard No person to
person
transmission
Lice (pediculosis) Contact Gown/glove for
direct patient care
x24 hrs after
treatment
Measles (rubeola), Airborne Respiratory For 5 days after Only
all presentations secretions rash; if patient is susceptible
immunosuppressed, persons should
duration of wear a mask, or
hospitalization if possible stay
out of the room
Meningitis See Feces For 7 days after Enteroviruses
Aseptic enterovirus onset are the most
(nonbacterial infections common cause
or viral meningitis) of aseptic
meningitis
Fungal Respiratory Until after 24 hrs of
Droplet
Suspected or secretions appropriate
confirmed antibiotic therapy
meningitis
due to Neisseria
meningitidis
Mumps Droplet Respiratory Until 9 days after Personnel who
secretions onset of swelling. are not
(infectious
Mask not required if susceptible do
parotitis)
immune not have to
wear a mask
MRSA (Methicillin Contact Until after 24 hrs of
resistant S. aureus appropriate
infections) antibiotic therapy
NRSA (Nafcillin
resistant S. aureus
infections)
Neisseria Droplet Respiratory Until after 24 hrs of
meningitidis, secretion appropriate
invasive antibiotic therapy
(meningitis,
pneumonia, sepsis)
94

Type of
Material Isolation
precaution
Parvovirus B19 Droplet Blood and For 7 days if patient
(Fifth disease) respiratory is in aplastic crisis.
(patients in aplastic secretions For duration of
crisis) hospitalization
when chronic
disease occurs in
an immune deficient
patient
Pertussis Droplet Respiratory Until after 5 days of
(whooping cough) secretions appropriate
antibiotic therapy
Pneumonic plague Standard Respiratory Duration of
secretions Hospitalization
Rabies Standard Respiratory Duration of
secretions hospitalization
Rubella (German Droplet Respiratory 7 days after onset Mask not
measles)/ Rubella secretions rash. [Infants with required if
Syndrome congenital Rubella immune.
may shed virus for Susceptible
months, call I.C.] person should
stay out of the
room if possible
Scabies Contact Gown/glove for
direct patient care x
24 hours after
treatment
Small pox A+C Lesion Duration of
secretions Hospitalization
Streptococcus, Contact Purulent Until cultures are
Group A material negative for group
*Necrotizing A streptococcus.
Fasciitis, Wound
Respiratory, Respiratory Until cultures are

Droplet negative for group
Pharyngitis secretions
A streptococcus.
95

Type of
Material Isolation
precaution
Tuberculosis Airborne Respiratory/AFB Minimum of 14
Pulmonary, days after
pharyngeal chemotherapy is
begun. Reduction
in number of TB
organisms on
sputum smear and
clinical response
Extrapulmonary Standard Pus must also be
present. If patient
is smear negative
and demonstrates
clinical
improvement,
duration of
precautions may
be 5 days. If
MDRTB, duration
of hospitalization.
Varicella Zoster Airborne See chickenpox See chickenpox
Viral hemorrhagic Contact Duration of
infection (Ebola, hospitalization
Lassa, Marburg)
Vancomycin Contact Duration of
Resistant hospitalization or
Enterococcus until original site
(VRE) and 3 perianal
cultures are
negative
Whooping cough Droplet Respiratory See pertussis
(pertussis) secretions
• If patient has any respiratory symptoms, implement Respiratory Secretion

Precautions until group A streptococcal respiratory infection is ruled out.
96
Occupational Safety and Employee Health
Occupational Safety and

Employee Health
Introduction
In Egypt, there are about 1 million people employed in the health care field. The
great majority of health care personnel (HCP) are employed in the formal (public
or private) health care sector; however, a significant number of people in the
community provide care in informal settings.
HCP are at particular risk for occupational exposure to blood-borne pathogens
including hepatitis B virus (HBV), hepatitis C virus (HCV), and human
immunodeficiency virus (HIV). A seroprevalence survey of 765 HCP in health
facilities in Cairo indicated an overall prevalence of antibody against HBV (anti-
HBs) of 28% before the availability of Hep B vaccine.53 Another seroprevalent
survey for HCV infection revealed 7.7% of HCP tested had evidence of exposure
to HCV. 54 Exposures can occur through needlesticks or through cuts from other
sharp instruments that are contaminated with blood from an infected patient.
Important factors that may determine the overall risk for occupational
transmission of a blood-borne pathogen include:
• The nature and type of sharps injury (e.g., blood filled, hollow bore
needle carries greater risk than contaminated scalpel blade);
• The prevalence of blood-borne infection in the patient population;
• Concentration of blood-borne pathogen circulating in the patient who is
the source of the sharps injury (e.g. may be higher during acute or later
stages of disease).
• The number of blood exposures to which a health care worker is
exposed (e.g. new personnel or personnel in training may be less
familiar with medical devices and experience greater frequency of
injuries).
The frequency of needlestick injuries among HCP is high in Egypt. In surveys
conducted in Upper and Lower Egypt in 2001, approximately 30% of HCP
reported a needlestick injury within the past 3 months. There was an average of
5 needlestick injuries per year per HCP. The frequency of needlestick injuries
was similar across a broad category of HCP that included dental personnel,
laboratory workers, nurses and nursing assistants, housekeeping personnel,
sanitarians, physicians, technicians, and other allied health professionals.
97
Underreporting of needlestick injuries in studies published outside of Egypt is

estimated to be between 30-96 percent, suggesting that the actual rate of such
injuries is much higher. 55- 57 In general, HCP who have more intense contact with
patients or more opportunity for exposure to blood and body fluids (nurses,
physicians, dentists, laboratory technicians) have an increased risk of blood-
borne pathogen infection than do HCP who have only brief or casual contact with
patients. Studies of sharps injuries elsewhere indicate that nurses experience the
greatest proportion of these; however, others, such as environmental services
(housekeeping) personnel, also rank high (third behind nurses and physicians). 58
An effective occupational health program in the healthcare setting should help to
protect patients and HCP. It should:
• Ensure and maintain a health standard that is required for all
employees before they are allowed to perform their assigned duties.
• Ensure that employees are not at risk of acquiring communicable
diseases and are not potentially disseminating infectious agents to
other hospital personnel or patients.
Any occupational health program should include:

• Pre-employment screening and employee health screening of staff.
• Training in personal health and safety precautions.
• Immunization of health care personnel.
• Management of occupational exposures.
• Monitoring of injuries and of infectious diseases among HCP.
Services Provided by the Occupational

Health Program
Pre-employment Screening and Employee Health
The primary aim of occupational health screening is to prevent disease in the
individual. A second function is to prevent transmission of infectious agents to
patients. It is important that all staff in the health care setting be screened by the
Occupational Health Department on their first day of employment.
The screening process includes assessment by:
• Completion of a health questionnaire by the employee that covers
questions related to general health, pregnancy, past infectious
diseases (e.g. chickenpox), and immunization status of all prior
vaccinations such as measles/rubella.
98
• Determination of skin disorders such as eczema or a history of an

underlying immunosuppressive disorder that might require a
reassessment of the staff member’s work assignments.
• Offering of hepatitis B vaccine to HCP who have not yet been
immunized and who are at occupational risk of exposure to blood or to
body fluids as part of their regular duties.
Note!
The employee must be given assurance of the complete confidentiality of the
health questioning and of their occupational health record.
The health of all personnel should be supported by policies that address the
following elements of the program:
• Maintenance of records related to occupationally acquired infections,
needlesticks and/or sharps injuries, and notification of the designated
Occupational Health/IC personnel of work-related infections and/or
sharps injuries for appropriate follow-up and prevention activities.
• Clinical and laboratory evaluation of HCP who report work related
injuries or illnesses.
• Evaluation of personnel who report to work with communicable
diseases for fitness to work.
• Clearance of employees to resume work assignments after reporting
an episode of a communicable disease to their supervisor.
• Periodic review of key employee health indicators used as
performance measures of the program, such as hepatitis B vaccination
status, frequency of needlestick injuries, and work-related illnesses or
disease.
Infection control programs should have a system to monitor medical conditions

among staff and to provide guidance on work restrictions. The employee health
physician should evaluate health care personnel with selected communicable
diseases and should recommend work restrictions according to the following
guidelines: 59
99
Table 14: Guidelines for work restrictions for HCP with infectious diseases
Relieve from
Partial work
Disease problem direct patient Duration
restriction
contact
Until discharge from eye
Conjunctivitis Yes
ceases
Yes; include
Diarrhea restriction of food Until symptoms resolve
handlers
Until 24 hours after
Group A Strep Yes adequate treatment is
started
Until 7 days after onset
Hepatitis A Yes
(jaundice)
Hepatitis B or C Strict adherence to
No
(chronic) standard precautions
Herpes on the hands

Yes Until lesions heal
(herpetic whitlow)
Until 7 days after the
Measles/Rubella Yes
rash appears
Yes; include
Staphylococcal skin
restriction of food Until treated
infection handlers
Until receiving adequate
therapy including proof
Tuberculosis,
Yes with 3 negative sputum
pulmonary smears and resolved
cough
Personnel with a upper
respiratory tract
infection should not
Until acute symptoms
take care of high risk
Upper respiratory are resolved HCP
No patients (i.e., intensive
tract infection should stay away from
care unit, immuno-
high-risk patients
compromised patients,
or patients with chronic
lung disease)
Until all lesions dry and
Varicella, active Yes
crust
From the 10th through
the 21st day after
Varicella,
Yes exposure or if varicella
postexposure occurs, until all lesions
dry and crust
Relieve from contact
Strict adherence to
HIV/Aids with highly infectious
standard precautions
patients
100
Training in Personal Health and Safety Precautions

All health care facilities should provide training to personnel who are at risk of
occupational exposure to blood and to infectious body fluids. This training should
include the use of standard precautions for personal protection.
All health care personnel should be trained in the following essential health
and safety precautions:
• Hand hygiene;
• Use of gloves and protective clothing during contact with patients’ blood or
body fluids;
• Proper disposal (do not recap needles) of sharps and infectious waste;
• Reporting of sharps/needlestick injuries;
• Reporting of certain conditions such as jaundice, rash-like illness, skin
infections that are vesicular or pustular, and illnesses that do not resolve
within a designated period (fever more than 2 days, cough > 2 weeks,
diarrheal disease).
Immunization of Health Care Personnel

Occupational health programs should maintain immunization records on all
employees. HCP may be exposed to infectious disease agents that may be
transmitted through the airborne route, through direct contact with patients and
through the blood-borne route by way of sharps/needlestick injuries.
For example:
• Airborne: Many airborne infectious agents are vaccine preventable (e.g.,
rubella, chickenpox), and determining HCP immunization status for such
infections is an essential element in the employee health program.
• Blood-borne: Hepatitis B is one of the three major blood-borne pathogens of

concern to HCP that can be prevented by immunization. All medical, nursing,
and ancillary staff who have potential for exposure to patient blood and body
fluids as part of their assigned tasks should be offered hepatitis B vaccine. It
is critically important to ensure that they are protected through immunization
and as early as possible, prior to potential blood exposures or sharps injuries.
101
Table 15: Table of Vaccines that are recommended for HCP

Vaccine Indication Vaccine/Route/Schedule Booster dose
All Health care 3 doses i.m. Not

Hepatitis B
staff 0, 1 month, 6 months; recommended
Every 10
years
If exposed to
Persons without
3 doses i.m. a dirty wound
Td (Tetanus) a history or an
0, 1-2 months, 6 months and last
unknown history
booster dose
is > 5 years,
give booster
Un-immunized
Rubella women of child- Single dose i.m. or s.c.
bearing age
Tips about hepatitis B vaccination of HCP:

• All Health care staff should be offered hepatitis B vaccine prior to beginning
assigned tasks.
• Ensure that all students and trainees are vaccinated.
• There is no need to provide booster doses or to revaccinate HCP who have
previously received hepatitis B vaccine.
• If a HCP has not completed the series, do not restart the series but do
complete the series.*
• If the vaccine supply is limited, then offer the vaccine to HCP who are
exposed to blood or who have potential for sharps or needlestick injuries as
part of their routine duties.
• Do not perform serologic testing before vaccination.
• Perform serologic testing 2 months after the 3rd dose to ensure adequate
immune response (HbsAb +ve). Non-responders should repeat the
vaccination schedule again (3 doses).
• Provide hepatitis B vaccine according to a routine schedule as post-exposure
prophylaxis for unvaccinated HCPs who receive needlestick injuries.
• Seroconversion (HbsAb +ve) occurs 1-2 months after the 3rd dose.
102
Notes:
On Vaccine series interruption:
• If the series of HB vaccine is interrupted after the first dose, administer the
second as soon as possible. The second and third dose should be separated
by an interval of at least 2 months.
• If only the 3rd dose of vaccine is delayed, administer when convenient.
Management of Occupational Exposure

HCP in contact with patients may be exposed to infectious agents. Pregnant
HCP are not at greater risk that other HCP from acquiring infections from
patients, but if they do, the infection could affect their newborn.
Infection control programs should have written procedures to monitor and to
manage exposures to health care staff. Preventative measures include routine
precautions to prevent exposure and post-exposure prophylaxis in the event of
needlestick or other sharp injuries.
Management of needlestick injuries

1. Immediately following an exposure to blood or body fluids with visible blood:
• Wash needlesticks/sharps injury site and cuts with soap and water.
• Irrigate eyes with clean water, saline, or sterile irrigants. There is no
scientific evidence that using antiseptics prevents infection or that by
squeezing the injured site can remove contaminants.
2. Report to a designated person (e.g., supervisor).
3. Procedures should describe where the injured HCP should seek initial
assessment and counseling for follow-up testing and appropriate treatment.
4. The occupational safety program should provide post-exposure prophylaxis

based on the hepatitis B vaccination status of the HCP and on the serology
status of the source patient according the following table.
103
Table 16: HB Post Exposure Prophylaxis

Hepatitis B vaccination
Source patient Treatment
status of HCP
Not vaccinated Start vaccine immediately*
1 dose vaccine Complete series*
HBsAg +
2 doses vaccine Complete series*
3 doses vaccine No treatment
Not vaccinated Vaccinate
HBsAg negative
Vaccinated No treatment
Not vaccinated Vaccinate**
Unknown
Vaccinated No treatment
Anti-HCV positive No vaccine for HCV No treatment***
No vaccine for HV 1.Four week course of 3
antiretroviral drug therapy
(e.g., zidovudine and
HIV-positive lamivudine) ***
2. Start treatment
immediately (within
hours)**
* If available, unvaccinated persons exposed to a HBsAg-positive patient

should receive a dose of hepatitis B immune globulin (HBIG) within 24 hours
of exposure in addition to hepatitis B vaccine.
** All HCPs exposed to a needlestick injury should be offered hepatitis B
vaccine.
*** Consult with an infectious disease specialist for further assessment.
Note
• There is no vaccine against HIV and post exposure treatment is only
recommended for exposures that may cause a greater risk for transmitting
HIV.
• There is no vaccine against HCV and no treatment after an exposure that will
prevent infection. Immune globulin is not recommended.
104
Tips on prevention of needlestick injuries in HCPs

• Educate HCP on the proper disposal of needles.
• Place needle without manipulation into MOHP-approved sharps container.
• Do not recap/bend/break used needles.
• Do not overfill sharps containers.
• Ensure availability of sharps containers in all settings where injections are
provided.
Monitoring Injuries among Health Care Personnel

One of the most important ways that infection control programs can help maintain
the safety of the facility environment is by reporting incidents and by monitoring
disease occurrences that have the potential for disseminating infections to staff
or to patients. All injuries or conditions that predispose HCP to injuries should be
reported to the infection control program including:
• Needlestick and sharps injuries;
• Conditions that exist in the facility that increase the risk of disease
transmission such as a shortage of needles for injections (which may
increase likelihood of reuse);
• Shortage of sharps boxes and hazardous waste containers;
• Conditions that exist in the facility that increase the risk of injury to the
community at large such as improper disposal of waste.
• Based upon the analysis of these reports, the infection control team
should implement appropriate measures to minimize the risk to the
clinician, to fellow staff, to patients, to visitors, and to the community at
large.
Sharps Injury Prevention Program

Prevention of occupational sharps injuries among personnel is an important
component of the Infection Control program. Personnel in Egypt are at risk of
occupational exposure to blood-borne pathogens during the course of their
duties. A Sharp Injury Prevention Program therefore should be developed that
balances availability of resources and devices with care activities that have been
identified as placing personnel at risk. For example, there is evidence that
inappropriate sharps disposal containers or the absence of puncture-resistant
sharps disposal containers place waste disposal personnel at risk of exposure. 60-
61
An intervention to reduce this risk could include implementation of puncture-
resistant containers for disposal of contaminated sharps. One of these studies
identified use of cardboard shipping containers being converted to use as sharps
containers. This material is not puncture resistant. Instead alternatives such as
empty containers previously used for bleach could be thoroughly rinsed and
105
distributed to points throughout the facility where sharps are being generated.
The cap would need to be attached to the container to assure it could be sealed
once ¾ full.
Background on sharps injuries: Whenever a needle or other sharp device is
exposed, injuries can occur. Data from a recent study conducted in 98 health
care facilities in Egypt 100 show that approximately 36% of percutaneous injuries
occur due to two hand recapping. Behaviors associated with needlestick injuries
are presented in the figure below.
Fig. 20: Sharps Injuries in Egypt
The circumstances leading to a needlestick injury depend partly on the type and
design of the device used. For example, needle devices that must be taken apart
or manipulated after use (e.g., prefilled cartridge syringes and phlebotomy
needle) are an obvious hazard and have been associated with increased injury
rates. In addition, needles attached to a length of flexible tubing (e.g., winged-
steel needles and needles attached to IV tubing) are sometimes difficult to place
in sharps containers and thus present another injury hazard. Injuries involving
needles attached to IV tubing may occur when a health care personnel insert or
withdraw a needle from an IV port or tries to temporarily remove the needlestick
hazard by inserting the needle into a drip chamber, IV port or bag, or even
bedding. In addition to risks related to device characteristics, needlestick injuries
have been related to certain work practices such as:
106
• Recapping.
• Transferring a body fluid between containers.
• Failing to properly dispose of used needles in puncture-resistant
sharps containers.
Examples of Strategies for Health Care Facility Sharp

Injury Prevention Program
Some interventions that facilities should consider based on available

resources include:
• Eliminate the use of needles where safe and effective alternatives are
available.
• Implement the use of devices with safety features and evaluate their use
to determine which are most effective and acceptable.
• Sharps injuries can best be reduced when the use of improved
engineering controls (modifications in devices needed for patient care that
protect the sharp once used from potential contact with personnel) is
incorporated into a comprehensive program involving personnel.
Examples of engineering controls include a sheath that can slide over a
needle once an injection is given, an angiocatheter which offers a
retractable needle once the catheter is in the vein, and needleless
connectors for IV systems.
Health care facilities should also consider implementation of the following

prevention program elements:
• Analyze needlestick and other sharps-related injuries in the facility to
identify hazards and injury trends.
• Set priorities and strategies for prevention by examining local, national,
and international information about risk factors for sharps injuries and
successful intervention efforts.
• Ensure that health care personnel are properly trained in the safe use and
disposal of needles. This is particularly important for less experienced or
new personnel as the frequency of injuries tend to be higher when
learning to use invasive devices.
• Modify work practices that pose a needlestick injury hazard to make them
safer.
• Promote safety awareness in the work environment.
• Establish procedures for and encourage the reporting and timely follow-up
of all needlestick and other sharps-related injuries.
107
• Evaluate the effectiveness of prevention efforts and provide feedback on

performance to personnel.
Moving the Sharp Injury Prevention Program from

Concept to Reality:
Depending on available resources the next tier of intervention after addressing

sharps disposal issues, etc., is to consider use of safer devices. The major
elements of a process for selecting and evaluating needle devices with safety
features are listed here briefly:
1. Form a multidisciplinary team that includes personnel to:
(a) develop, implement, and evaluate a plan to reduce sharps injuries in
the institution and
(b) evaluate needle devices with safety features.
2. Identify priorities based on assessments of how sharps injuries are occurring

and patterns of device use in the institution. Give the highest priority to needle
devices with safety features that will have the greatest impact on preventing
occupational infection.
3. When selecting a safer device, identify its intended scope of use in the health
care facility and any special technique or design factors that will influence its
safety, efficiency, and user acceptability. Seek published, Internet, or other
sources of data on the safety and overall performance of the device.
4. Conduct a product evaluation, making sure that the participants represent the
scope of eventual product users. The following steps will contribute to a
successful product evaluation:
• Train health care personnel in the correct use of the new device.
• Establish clear criteria and measures to evaluate the device with regard to
both personnel safety and patient care.
• Conduct onsite follow-up to obtain informal feedback, identify problems,
and provide additional guidance.
Recommended reading:
Centers for Disease Control & Prevention (CDC). Exposure To Blood - What Health-Care
Workers Need to Know. 1999.
Available at: http://www.cdc.gov/ncidod/hip/Blood/exp_blood.htm
U.S. Public Health Service. Updated U.S. Public Health Service Guidelines for the
Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR 2001; 50(RR11). Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm
108
Control And Prevention Of Antimicrobial Resistant Organisms in HCF
Control and Prevention of

Antimicrobial Resistant
Organisms in HCF
Introduction
Antibiotics are used to prevent infection and to treat patients with proven or
suspected infection. The aim is to administer a safe and cost effective dose of
antibiotic that will eliminate the infecting or potentially infecting organism.
Antibiotics are widely used, contributing to 35% of all prescriptions in health care
facilities. Overuse of antibiotics results in bacterial resistance not only to the
antibiotic prescribed, but often to other antibiotics in the same classes or groups.
The abuse or misuse of antibiotics is costly because it leads to the emergence of
antibiotic resistance among microorganisms in the health care facility
environment as well as in the patients. Typically, there is a reservoir of patients
colonized with antimicrobial resistant organisms, which can be a source of cross
transmission to other susceptible patients in the facility. When infections from
Antimicrobial Resistant Organisms occur, there is increased mortality, especially
among those with underlying diseases or multiorgan failure. The health care
facility serves to amplify these strains because of the high prevalence of use of
antibiotics. The primary selective pressure for antimicrobial resistant organisms is
antibiotic use both in facilities and in communities. In under-resourced countries,
selection of resistance in communities is compounded by relatively easy access
to antibiotics and there is little regulation of this accessibility.4 Other factors that
promote selection and transmission of these strains in all countries are failure to
complete a full course of prescribed antibiotics, and lack of resources and
personnel for facility infection control programs. In addition, even countries that
spend considerable resources on health care do not necessarily have a lower
frequency of antimicrobial resistant organisms. 62
Normal microbial flora is protective. The administration of antibiotics kills off
susceptible strains of normal bacteria and these are replaced with resistant
strains, which are often resistant to many different classes of antibiotics. This
replacement occurs most often in the gastrointestinal tract, which carries the bulk
of bacteria, and results in stool carriage of multiply antibiotic resistant bacteria.
These antimicrobial resistant organisms bacteria can easily spread from patient
to patient in the hospital environment via hands of staff, bedpans, and non-
clinical and poorly sterilized equipment.
109
Examples of antimicrobial resistant organisms

The misuse of antibiotics has led to the emergence of multiple antibiotic resistant
bacteria in both gram positive and gram-negative bacteria 63. .
Gram Positive Cocci

Enterococci and coagulase negative staphylococci have emerged as significant
pathogens in recent years, although previously considered as commensals or
normal flora.
• Staphylococcus aureus has now acquired resistance to cloxacillin and
vancomycin. 64
• Methicillin (Flucloxacillin) resistant Staphylococcus aureus (MRSA) is
common in most hospitals worldwide and is particularly concentrated in high
risk units such as Intensive care units and Neonatal Intensive care units.
• Blood stream infections associated with IV sites, ventilator associated
pneumonia, and infections at surgical sites and of prosthetic implants are all
common infections associated with gram-positive cocci.
Gram Negative Bacilli

Gram-negative bacteria have become more resistant to routine antibiotics.
• Extended spectrum B-lactamases are now common in Klebsiella
pneumoniae, particularly in high risk units such as Intensive care units
and Neonatal Intensive care units.
• Acinetobacter spp is wide spread in most Intensive care units
worldwide and is highly resistant to most antibiotics.
• Pseudomonas aeruginosa can be isolated from wounds and from
respiratory and urinary tracts of patients in most hospitals. It is also
present in the hospital environment in open containers of disinfectant,
in wet or moist areas, and on equipment.
• Once introduced into a high risk unit, gram negative bacilli are very
difficult to eliminate.
• Antimicrobial resistant organisms gram negative bacilli can cause any
type of infection but are particularly common causes of blood stream
infections, ventilator associated pneumonia, urinary tract infections, IV
fluid infusion site infections, and surgery and burn site infections.
110
Acquisition and Transmission of

Antimicrobial Resistant Organisms
Note:
A distinction should be made between acquisition and transmission of multiple
drug resistant organism pathogens. The misuse of antibiotics leads to acquisition
of antibiotic resistance organisms, while poor infection control procedures lead to
the transmission of antimicrobial resistant organisms.
Acquisition
Antimicrobial Resistant Organisms are created by selective pressure from
antibiotics. Antibiotic pressure is more noticeable when certain classes of
antibiotics are used. The most commonly prescribed antibiotics are beta-
lactamases such as penicillins and cephalosporins. The latter are now
recognized as having a significant role in the emergence of antibiotic resistance
among bacteria, which were previously considered sensitive or commensal flora.
Large amounts of antibiotics are used in the health care setting, especially in the
ICU, and can lead to the emergence of resistant strains.
Community factors can also cause antibiotic pressure. Wide scale usage of
antibiotics for minor ailments can select for resistant pathogens which are then
circulated in the community (widescale resistance of S. pneumonia has been well
described in numerous countries).
Transmission
Having acquired antibiotic resistance, the microbe has to have certain attributes
in order that it may spread:
• Microbial fitness: ability to produce a clone, which can be transmitted from
host to host.
• Virulence: ability to attach and invade tissues.
Acquisition of resistance is not a normal activity for the microbe. It takes

increased expenditure of energy to develop resistance. Therefore the efficiency
of transmission of these antimicrobial resistant organisms may be less,
compared to susceptible strains.
Strategies for reducing transmission of antimicrobial resistant

organsims:
• An infection control policy that is simple and effective, such as one that
emphasizes good hygiene. Of note, this strategy not only addresses
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antimicrobial resistant organisms but susceptible strains, which can also

cause considerable morbidity and mortality.
• Knowledge of the infection control policy by all personnel.
• Repeated emphasis on hand hygiene.
• Appropriate use of personal protective equipment (PPE).
• Use of surveillance data to target specific areas at high risk for
antimicrobial resistant organisms.
• Identify bacterial isolates per patient rather than identification of isolates
per site.
• A well controlled testing system in place.
• Development of lab capacity to correctly identify antibiotic sensitivity
patterns.
• Use of spatial separation between patients known to be infected or
colonized with MRSA or VRE and patients who are not known to be
infected or colonized.
• If resources for physical barriers are limited, establishment of a glove
policy and hand hygiene policy are priorities.
• The goal of microbiologic screening of patients for antimicrobial resistant
organisms must be identified before it is undertaken. Variables to consider
are whether this is cost effective and whether appropriate laboratory
support is available. Screening may be considered as part of an
epidemiologic investigation of possible outbreak or cluster.
• Do not screen personnel unless they are epidemiologically linked to
ongoing transmission. There is no evidence that antimicrobial resistant
organisms are less susceptible to soap/detergent products or antiseptic
agents when compared to antibiotic susceptible organisms.
• If only soap and water are available for hand hygiene then reinforce its
use. Evidence does suggest however that removal of antimicrobial
resistant organisms from hands is improved if hand antisepsis is utilized.
This is especially applicable for high risk areas/populations (Intensive
Care Units, Dialysis, etc.).
• Extraordinary environmental cleaning or disinfection is not needed for
preventing transmission of antimicrobial resistant organisms. There is little
evidence that use of disinfectants or antiseptics in health care facilities is
selecting for antimicrobial resistant organisms.
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Table 17: Control of antibiotic resistance

Procedure Effect on acquisition Effect on transmission
+ ++
Misuse of antibiotics
(antibiotic dependent) (bacteria dependent)
Lack of IC procedures none ++
Absence of surveillance none ++
of antibiotic resistance
Absence of treatment +++ ++
protocols or guidelines
Antibiotic Usage
Antibiotic Prophylaxis
Prophylactic antibiotics are mainly used for surgery (and other invasive
procedures). Maximum blood levels of antibiotic at the time of the procedure help
ensure that circulating bacteria arising during the procedure can be reduced to a
level that can be destroyed by the patient’s body’s natural defences.
There is no benefit in starting antibiotics too early or in continuing for longer than
24 hours after the procedure. Instead this can result in emergence of resistance.
• A single dose or a maximum of three doses should be administered
starting with the induction of anesthesia.
• Prophylaxis should not continue longer than 24 hours.
• After 24 hours antibiotics are considered treatment and should be
documented as such, for example, in cases of perforation and peritonitis.
Antibiotic Therapy
Antibiotics are used to treat patients with known or suspected infection:
Empiric therapy is based on the ‘best-guess’ antibiotic for the suspected
organism and its predicted antibiotic sensitivity patterns. Knowledge of local
antibiotic sensitivity patterns is useful so that prescribing is not based on
publications from other countries. The decision should be based on:
• The site of infection.
• The probable pathogen.
• The known bacterial spectrum.
• Safety and pharmacokinetics of the chosen antibiotic.
If clinical response is noted in 72 hours, then the therapy should be continued
through completion. If there is no improvement or if the clinical picture changes,
then alternative antibiotics must be considered. The range of antibiotics is broad
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and a combination of two or more may be used initially. This may be reduced to
one when the bacteriology results become available.
Targeted therapy is instituted when microbiological results are known or when
the results are pending but the clinical picture requires immediate treatment. An
example would be treating meningococcal meningitis on the basis of a gram stain
from the cerebrospinal fluid.
Formulating an Antibiotic Policy

It is difficult to formulate a general antibiotic policy because bacterial populations
and antibiotic resistance patterns differ between hospitals, clinical choices vary,
availability of antibiotics differs from country to country, and because route and
cost of antibiotic administration varies. 9 There have been reports of successful
lowering of frequency of antimicrobial resistant organisms by controlling or
removing selective pressure from overuse of antibiotics.18, 66, 67 Each health care
facility should have an antimicrobial management program that monitors use of
antibiotics.
When formulating a policy consider doing the following:
• List the available antibiotics of similar spectrum, safety and
pharmacokinetics.
• List the indications for which antibiotics are required. Are they needed for
prophylaxis or therapy?
• Determine indications for use of each antibiotic after consultation with the
clinicians.
• When the policy has been agreed ensure that Microbiology can test for
sensitivities of selected pathogens to these antibiotics.
• Enter the policy in the hospital formulary and display the policy on the
walls of the wards.
• Review the policy periodically. Policies should change if there are changes
in the antibiotic resistance patterns, a change in the functions of a unit, a
change in staff, a price increase in a certain antibiotic, , or if there are new
antibiotics on the market.
Note:
Antibiotic Formularies or policies should be determined by the Drugs and
Therapeutics Committee and should be established after wide consultation with
the clinical and hospital staff. It requires ownership by the staff and needs
constant support from antibiotic surveillance (Microbiology). All policies should be
reviewed after 18 months.
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All Antibiotic policies need to consider a few basic principles:

• The goal is to assure treatment of confirmed infection and not to cause
unnecessary colonization of resistant strains.
• Use different classes of antibiotics for prophylaxis and therapy.
• Use a high dosage for a short duration therapy.
• The antibiotics chosen for the policy should be rotated after a set period of
time in order to reduce selective pressure.
• The policy should contain information on the class of antibiotic and the
possible impact that this class could have on emergence of resistance.
Table 18: Antibiotics against nosocomial infections
Penicillins
ANTIBIOTIC EXAMPLE ACTIVE AGAINST
Penicillins Benzyl penicillin Meningo-, strepto-, pneumococci
Aminopen. + beta lactamase
Amoxycillin + clavulanic acid Staphylococci
inhibitor (BLI)
Azlocillin Enterococci
Acylamidopenicillins
Piperacillin P. aeruginosa
Acylamidopenicillins+ BLI Piperacillin + tazobactam P. aeruginosa
Cloxacillin
Isoxazolylpenicillins S. aureus
Flucloxacillin
Cephalosporins
ANTIBIOTIC GROUP EXAMPLE ACTIVE AGAINST
Cefazolin
1st Generation Staphylococci
Cefaclor
2nd Generation Cefuroxime Staph., strept,enterobacteria
Cefotaxime Gram negatives
3rd Generation
Ceftriaxone Strept., pneumococci
Gram negatives,
Ceftazidime
4th Generation P. aeruginosa
Cefoxitin
Gram negatives, anaerobes
Carbapenems
Imipenem Gram positive
Carbapenems
Meropenem Gram negative+ anaerobes
Quinolones
Enterobacteria (staphylococci,
Ofloxacin
2nd Group enterococci.)
Ciprofloxacin
P. aeruginosa
3rd Group Levofloxacin Gram positive + gram negative
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Aminoglycosides
Gentamicin Enterobacteria
Netilmicin Enterobacteria
Aminoglycosides
Tobramicin Enterobacteria + P. aeruginosa
Amikacin Enterobacteria + P. aeruginosa
Other groups:
Gram positive cocci
Makrolides Erythromycin L. pneumophila
C. jejuni
Gram positive cocci
Lincosamides Clindamycin Anaerobes (Bacteroides,
Clostridium)
Vancomycin
Glycopeptides Gram positive,( MRSA, enterococci)
Teicoplanin
Streptogramines Quinupristine / dalfopristine GRSA , VRE
Gram positive cocci
Rifamycins Rifampicin Mycobacteria
(not used as monotherapy)
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Linen Management
Linen Management
Linen
Although soiled linen can be contaminated with pathogenic microorganisms,
actual disease transmission from linen has been demonstrated to be negligible if
it is handled, transported and laundered in a manner that avoids dispersal11.
Note:
• There is no evidence that linen used by patients who are under isolation
precautions carries any greater microbial load or risk of disease
transmission than patients who are not in isolation.
• Wet or linen saturated with body fluids should be folded with the wet areas
inside in order to minimize contamination of the health care facility
environment.
General Priniciples to Prevent Infection:
• All personnel involved in collection, transport, sorting, and washing of used

linens should be adequately trained, should wear appropriate protective
clothing, and should have access to hand-washing facilities.
• Dirty linen should be carefully removed with a minimum of agitation in order to
minimize dispersion of the microorganisms into the air. Linen should then be
placed in strong and appropriate bags or into a container at the bedside.
Never place linen on chairs or on other surfaces.
• After removal of linen, soiled linen must be handled with care at all times. It
should be placed into fluid resistant bags at the point of generation as soon
as possible. Dirty linen bags should not exceed the weight of 20 kgs and
should be be securely tied or otherwise closed to prevent leakage. Rinsing
soiled laundry at the point of generation should not be done.
• Assume all used linen is contaminated. No need for color coding.
• Laundry bags: Single bags of sufficient tensile strength are adequate for
containing laundry; leak-proof containment is needed as the laundry maybe
wet and can soak through a cloth bag.
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Linen Management
• Transport of soiled linen: Soiled linen in bags or containers should not be

transported manually to the laundry processing area. If available, carts or
containers with lids should be used for this task.
• Unnecessary handling of linen should be avoided.
Note:
Be sure that no miscellaneous items (e.g. needles) are collected with linen. Such
items constitute a special hazard to laundry staff.
Changing linen:
Change bed linens daily and whenever soiled.
Laundry
Linen, surgical drapes, window curtains, rags, mups, uniforms, gowns, lab coats
and others could be laundered. Sorting in the laundry area is essential. Sorting
should be done separate from clean areas with limited traffic. Work surfaces are
at or above the waist height. The sorting area needs to be equipped with sink,
disposable gloves, soap and towels. The area should be provided by sharps
containers.
The sorting system in the laundry:

Sorting of laundry should be done either before or after washing. Large health
facilities usually sort laundry before washing due to existence of high volumes of
laundry.
Sorting before washing:
- Remove objects that might be attached before washing.
- Sort same textile, same fiber or sort by products needed or by those
who are packed together (gowns, curtains, etc.).
Sorting after washing:
Benefits of sorting after washing includes fewer microbial exposure
by the workers, however, it shortens the life of fabrics and causes
more lint on surgical materials.
Washing, drying and storing linen:
• Linen is washed in washing machines. It is important not to overload the

washing machine. A temperature 71°C for at least 25 minutes is generally
recommended. A preheating period for at least 5 minutes should be
allowed. These temperatures along with these times are capable of killing
most vegetative bacteria and viruses. However, addition of chemicals
assists in adjusting the pH of the water- plus additional chemicals such as
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Linen Management
bleach facilitate inactivation of pathogens that might be present in the

linen.
• Addition of bleach: Bleaches provide bactericidal action and disinfect heat
labile materials when added to rinse water.
• An acidic agent (sour; e.g. vinegar) may also be added. These agents are
added to prevent yellowing of fabrics but also produce a rapid shift in pH
that aids bactericidal action.
• Facilities for manual washing of linen may be available and may offer a
temporary alternative where is there is any lack of access to or a problem
with mechanical washing processes.
• Spreading linen to dry in sunlight and open air (if away from any source of
contamination or pollution) may be possible in some situations. In addition
to cost reduction this allows exposure to ultraviolet sunrays, which
produces natural disinfection.
• Dryer heat is also effective in ensuring total bacterial kill. Ironing has the
same effect but linen need not be sterilized.
• Store clean linen and supplies in a separate place away from the soiled
linens. Three clean sets of linen per bed should be available.
Bed covers
There are two types of bed covers, one for the summer and one for the winter.
They should be changed and washed between each patient or whenever soiled.
Mattresses and pillows

• May be a major source of contamination if not properly protected.
• Wet mattresses must be changed.
• Must be covered with an impervious layer (plastic, rubber) so that they
can be cleaned thoroughly between patients.
• Covers must be cleaned with warm water and detergent.
• Never admit new patients onto soiled, stained, or contaminated
mattresses.
• Rubber covers can be uncomfortable in hot countries. It may be
possible to cover the mattress cover with absorbable paper, which
should be changed frequently. 9
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Environmental Cleaning
Introduction
The cleanliness of a health care facility is vital to the health and safety of its
patients, staff, and visitors as well as of the community. It is one of the
foundations for preventing the transmission of infections in the facility. 68 Routine
cleaning is necessary in order to ensure a hospital environment that is visibly
clean and free from soil and dust. 90% of microorganisms are present within
“visible dirt”, and the purpose of routine cleaning is to eliminate this dirt. An
additional benefit is that a clean facility looks appealing and improves the morale
of staff and patients. This orderliness has been shown to enhance both the safety
and quality of patient care and when absent can lead to clusters of Hospital-
acquired infections. 69-71
Definition
The term “environmental cleaning” refers to the general cleaning of
environmental surfaces and to the maintenance of cleanliness in a health care
facility. 72 It is the physical removal of organic materials such as soil and dirt,
which removes a large proportion of microorganisms, followed by complete
drying. 73
The staff responsible for environmental cleaning (housekeeping) is a specially
trained worker. These personnel, hereafter referred to as housekeepers, are at
risk of infection because they may be exposed to blood, body fluids, secretions,
and excretions in the process of completing their duties unless they are properly
trained in the use of protective equipment. Therefore, it is important that they
have a good understanding of standard precautions and of infection control
practices through education and training. 72
General Guidelines for Cleaning

Cleaning Schedules
Cleaning schedules should be developed by the head nurse in accordance with
hospital policies and should be posted to where all staff that responsible for
housekeeping can see and follow them closely. Regular supervision of their
120
performance is important and is provided by the “Worker Supervisor”. Routine

cleaning is necessary to maintain a standard of cleanliness.
Protective Clothing for Cleaning

During cleaning, workers should always wear gloves (preferably heavy utility
gloves) and shoes that cover the toes. If there is a potential for splashing or for
splattering (e.g., during the cleaning of toilets), they may need additional
protection such as an impermeable apron, mask, and protective eyewear.
Cleaning Principles
Warm water and detergent removes 80% of microorganisms. The majority of
these microorganisms are skin flora and spores.
• Cleaning should be done in a way that minimizes the scattering of dust and
dirt. A damp cloth or wet mop should be used for walls, floors, and surfaces
instead of dry dusting or sweeping. As an alternative to the dry mop, a
vacuum cleaner can be used for dust removal. If possible, hospital vacuum
cleaners should have filters in order to reduce dissemination of bacteria from
the vacuum exhaust.
• Cleaning should begin from the least soiled area to the most soiled area,
which is usually the toilets and soiled storage areas. Surfaces should be
washed from top to bottom so that debris falls to the floor and is cleaned up
last. The highest fixtures should be cleaned first, working downward to the
floor (e.g. ceiling lamps, shelves, tables, and lastly, the floor).
• The use of friction or scrubbing action is the most effective way to remove dirt
and microorganisms in every cleaning procedure.
• The floors should be mopped with warm water and detergent and dried.
Cleaning solutions should be changed frequently. If a disinfectant is used, the
disinfectant solution is less likely to kill infectious microorganisms if it is
heavily soiled.
• Cleaning of environmental surfaces should be performed by using separate
buckets. One container should contain detergent and the other one should
contain plain water. The procedure starts by wiping or scrubbing with
detergent, followed by rinsing with water, and drying at the end.
• Cleaning procedures for environmental surfaces must not be applied to
patient care equipment/instruments (e.g., dental instruments, thermometer).
The cleaning methods and products may differ significantly. Reusable
equipment (e.g., bed, chairs) is not used for the care of another patient until it
has been cleaned appropriately.
• Buckets should be washed and rinsed out after use and stored dry.
121
• Mops should be laundered daily in very hot water and detergent or in a

washing machine (if available) and dried thoroughly. Wet mops should not be
left standing in a bucket.
• Ward surfaces, rails, bedsteads, etc. should be damp-dusted with a detergent
cleaner.
• Bathtubs should be washed with warm water and detergent and then should
be dried.
• Toilets must be cleaned regularly and surfaces dried. Toilet room floors must
be dried thoroughly.
• If there is a reason to use a disinfectant in addition to the detergent cleaner,
make up the solution and use as directed by the label.
Note:
Disinfectants are NOT recommended for routine use.
Cleaning Staff
• An adequate number of cleaning staff should be available to enable the
healthcare facility to maintain a clean environment. 9, 11, 68, 73
• Personnel who clean patient-care equipment must receive special training on
the proper procedures. Written cleaning instructions should be available for
each piece of equipment.
• Cleaning personnel should have their work inspected on completion in order
to ensure that the cleaning has been done properly.
Common Methods for Cleaning

Dry Cleaning Method
The dry cleaning method relies on mechanical action to loosen and to remove
large objects and particulate soil but does not remove stains.
Dry cleaning is not suitable for wet or greasy areas. 73
Sweeping
The use of dry brooms, dry mops and dry dusters should be avoided in patient
treatment and food preparation areas as it is not efficient and it is potentially
hazardous. It leads to the dissemination of bacteria carrying particles and
increases the air-borne bacterial count nearly tenfold.
If sweeping is unavoidable, it should not be permitted in the immediate vicinity of
patients with exposed wounds and other sites where patients are at high risk for
infection, e.g., ICU. Enough time should be allowed for disseminated bacteria-
carrying particles to settle. 73
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Wet Cleaning Method

Wet cleaning is accomplished manually by a
damp cloth, damp mop, or deck scrubber using
water with or without detergent and with or without
disinfectant. In addition to water, mechanical
action (i.e., scrubbing) is used. Routine use of
chemical disinfectants is not necessary.
If a detergent cleaner is used, rinsing is recommended, since detergents become
concentrated, leading to a build-up of a detergent film.
Drying is essential. Moist surfaces are considered potentially contaminated
because moisture encourages bacterial growth. Direct patient care and food
preparation areas should not be used until completely dry. 73
Types of cleaning solutions used during housekeeping:

Plain detergent and water (i.e., detergent solution).
Detergent cleaners are used for general cleaning tasks. Detergents, e.g., soap,
remove dirt and organic material and dissolve or suspend grease, oil, and other
matter for easy removal by scrubbing. 68
Disinfectant
Disinfectants rapidly kill or inactivate infectious microorganisms during the
cleaning process. In most settings a chlorine solution made from locally available
bleach is the cheapest and most accessible disinfectant. 72
68
Disinfectants are also used to clean up spills of blood or other body fluids and
body fluids and to decontaminate items of infected patients.
Disinfectants rapidly kill or inactivate infectious microorganisms during the
cleaning process while detergents remove dirt and organic material. Removal of
dirt and organic material cannot be done by water or disinfectants alone. 68
Note:
Chlorine (bleach) solutions should never be mixed with cleaning products that
contain ammonia or phosphoric acid. Combining these chemicals will result in the
release of a chlorine gas, which can cause nausea, eye irritation, tearing,
headache, and shortness of breath. These symptoms may last for several hours.
If you are exposed to an unpleasantly strong odor following the mixing of a
chlorine solution with a cleaning product, leave the room or area immediately
until the fumes have cleared completely. 68 Accidents can be avoided by ensuring
all solutions are clearly labeled and only one type of disinfectant solution is
available in the cleaning supplies storage area.
123
Environmental Disinfection
Disinfectants
• The term disinfectant should be reserved for chemicals used on
environmental surfaces. The term antiseptic is used for chemicals used on
skin (alcoholic handrubs) for hand hygiene or cleansing patient skin. (See
“Operating Theatre”)
• Are most efficient if used according to instruction and at the correct dilution.
• Differ in their properties depending on the circumstances.
• May be rapidly inactivated by organic matter, e.g. blood. Any object that is to
be disinfected must therefore be cleaned thoroughly with warm water and
detergent prior to disinfection.
Hard Surfaces
Hard surfaces do not usually require disinfectants for effective cleaning. Warm
water with detergent is usually sufficient to remove all organic contamination. A
disinfectant may be used with a high degree of contamination such as a large
blood spill that may involve blood-borne pathogens.
Rules for Disinfectants

• Read the label and follow the manufacturer’s instructions.
• Check the expiration date of the solution.
• Ensure that the correct dilution is used– more is not more effective.
• Always wash and clean articles before disinfection.
• Do not refill disinfectant containers without cleaning and drying the container
between each use – topping off a partially filled container is not permitted.
• Disinfectants should be supplied in a ready-for-use dilution from the
pharmacy.
• Empty containers should be returned to the pharmacy. Do not use empty
containers to store any other solutions – this is dangerous as the wrong
solution might be used in the wrong situation.
• Open containers of disinfectant should not be tolerated in any hospital
environment as there is a serious risk of contamination with multiply-
antimicrobial-resistant bacteria, such as Pseudomonas species and spores.
• Where disinfectants are indicated for use on surfaces allow the disinfectant to
remain on the surface for a sufficient amount of time to inactivate microbes.
The instructions for use on the label of the disinfectant usually specify the
contact time.
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Table 19: Commonly Used Disinfectants

Chlorine-based
Alcohol Hydrogen peroxide
disinfectants
Antimicrobial Alcohol does not They are fast acting and Hydrogen peroxide
activity penetrate well have a broad spectrum and peroxygen
into organic of antimicrobial activity. compounds have a
matter, especially Diluted solutions are broad spectrum of
protein-based unstable and should be antimicrobial activity.
(e.g., blood), and freshly prepared daily This activity depends
should therefore unless prepared in an on use concentration;
be used only on opaque container, in for hydrogen peroxide,
physically clean which case the solution this needs to be >6%
surfaces. remains stable for >1 for semicritical
week. They are devices. At lower
inactivated by organic concentrations this
matter e.g., blood chemical has limited
particularly if used in low capabilities for surface
concentrations. They are disinfection.
incompatible with
cationic detergents.
Uses Mainly as an It is very active against Can be used for
antiseptic: viruses and is the semicritical items such
disinfectant of choice for as endoscopes;
Can also be used
environmental Peroxygens are
for disinfecting
decontamination of blood effective in
physically clean
and body fluids. It can penetration of organic
equipment or
also be used for matter but can cause
hard surfaces
environmental damage to devices.
such as
disinfection on hard
stethoscopes.
surfaces, e.g. baths or
sinks.
Precautions Alcohol should be They should not be used Manufacturer’s

stored in cool in the presence of approval should be
places as it is formaldehyde as some of obtained before using
flammable. the reaction products are on equipment where
Bottles should carcinogenic. Skin and corrosion may present
always be eyes should be protected problems. Wear eye
capped. when using undiluted protection when
hypochlorite solutions. pouring high
Do not mix with concentration
ammonium. hydrogen peroxide
(>6%); splash into the
eye can cause
irreversible damage.
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Preparation of different concentrations of Hypochlorite

Solution
Chlorine solutions are supplied by manufactures in Egypt by different
concentrations, mostly as 5%. However, there are variable concentrations as
5.25% or others are available. Therefore, for ensuring appropriate
concentrations, part per millions will be used instead of percentages. Different
parts per millions are used for different purposes as cleaning, disinfection (low,
intermediate, high) and sterilization (see table below).
Chlorine-containing compounds are described as having a certain percentage

of “active” chlorine. The amount of active chlorine is usually described as a
percentage. It is important to know the concentration of chlorine so that a
solution with the appropriate percentage of active chlorine can be prepared.
With liquid bleach, this information is often noted on the bottle. Any
concentration of bleach can be used to make the required part per million
solution by using the following formula: 74
Number of parts of
( [% active chlorine in liquid bleach]
p.p.m. Chlorine desired ) –1 =
water added to
one part of bleach
Example: To make a 100 p.p.m. chlorine solution from 5% active chlorine
[5% / 100 ppm] – 1 = (5 / 100) / (100 / 1000000) – 1 = 500 – 1 = 499 parts of

water for each part of bleach
So to prepare 100 ppm chlorine solution from 5% chlorine we should add
499 parts of water (499cc-or approximately ½ liter) to each part (1cc) of the
concentrated (5%) chlorine.
Table 20: Classification of Chlorine Concentrations

Disinfection
Cleaning Sterilization*
Low Intermediate High *
100 PPM 200 PPM 500 PPM 1000 PPM 52000 PPM
* Chlorine in these concentrations is very corrosive and not practically used.
126
Cleaning Techniques
Double-Bucket and Triple-Bucket Technique
The double-bucket technique is the most common and preferred method for
cleaning floors. Using two buckets minimizes recontamination of mopped areas.
Double- and triple bucket systems can extend the useful life of the detergent
solution. Fewer changes of the detergent solution are required. In triple-bucket
technique, the third bucket is used for wringing out the mop before rinsing with
water. Triple-bucket technique extends the life of the rinse water.
One bucket contains the detergent (or disinfectant detergent) solution and the
other one water. The mop is always rinsed and wrung out before it is dipped into
the detergent bucket. The efficacy of the disinfectant decreases with increased
soil or microbial load. 59
Cleaning Levels for Different Clinic Areas

Low-Risk Areas: Waiting Rooms, Administrative Areas
These areas are usually not contaminated with blood or body fluids or with
associated infectious microorganisms so the risk of infection is minimal. Routine
cleaning- the kind of cleaning you would do in your home – is usually good
enough for these areas. In general, clean these areas with a cloth or mop
dampened with detergent and water. 72
Intermediate Risk Areas: Patient Wards

These are areas used for the care of patients who are not obviously infectious
and not highly susceptible. These areas are usually cleaned by procedures that
control dust, such as damp mopping with detergent cleaners. Dry sweeping or
vacuum cleaners are not recommended. The use of detergent solution improves
the quality of cleaning. Spills of blood and body fluids are cleaned up with a
disinfectant solution. 75
High Risk Areas

These are special care areas (e.g., isolation wards, intensive therapy units,
operating room, dialysis unit).
In these areas there is a greater potential pathogen contamination with infectious
materials and more of a concern about potential infection transmission to both
patient and clinic staff. These areas must be cleaned with care using a cleaning
solution and separate cleaning equipment; disinfectant-detergent solutions are
used as needed, according to hospital policy. 72
127
Cleaning Supplies/Equipment
Cleaning supplies must be kept dry and stored properly. Reusable cleaning
supplies should be washed and disinfected after use.
Cleaning supplies/equipment include:
• Dry sweeper
• Mop with long handles
• Heavy duty gloves
• Damp cloth
• Mop bucket
• Detergent (e.g., liquid soap)
• Disinfectant (chlorine solution)
• Water
• Closed plastic shoes
Reprocessing, Washing of Cleaning Equipment

Dry sweeper
Dry, dust attracting
• Reprocess or wash if overloaded with dust or after max. 1-2 days.
• Alternatively a single-use disposable cover may be used and disposed
of after each use.
• Non-disposable dust mop covers must be vacuumed after each use.
• Use single-use covers impregnated with mineral oil to enhance dust
attracting properties.
Mop with long handles

Wet
• Mop heads must be changed daily.
• Reprocess by machine washing in hot water (80 °C) (i.e., thermal
disinfection) and tumble dry.
Mop bucket
Buckets should be washed with detergent (e.g. soap), rinsed with water, dried,
and stored inverted.
128
Frequency of Cleaning
• Low-risk clinical areas: Once daily and whenever needed.
• Intermediate-risk areas: At least once daily, and whenever needed, e.g. after
visits. Immediate removal of organic material.
• High-risk areas: These areas must be cleaned between each patient and
thoroughly at the end of the day.
A cleaning policy developed should take into consideration immediate cleaning

after any organic contamination e.g. blood spills, vomitus, urine, stool, body
fluids, etc.
Cleaning Up Spills
Clean up spills of potentially infectious fluids immediately. Besides preventing the
spread of infection, prompt removal also prevents accidents.
When cleaning up spills:
• Always wear gloves, such as disposable or heavy duty gloves.
• If the spill is small, wipe it with a disposable cloth and then disinfect the
surface area of the spill with another disposable cloth that has been saturated
with a disinfectant (100 PPM chlorine solution) ) .
• If the spill is large, place a disposable paper or cloth towel over the spill to
soak up the fluid. Still wearing gloves, pick up the towel, dispose into a bag to
be disposed as biological waste and then soak the area with non-diluted
chlorine ). Leave it for considerable time then dry the surface.
• Do not simply place a cloth over the spill for cleaning up later; someone could
easily slip and fall on it and be injured.
• Remember, contaminated equipment spreads, rather than reduces,
microorganisms in the environment. Supplies and equipment used for
cleaning also need to be cleaned (see under cleaning of equipment). 72
Ineffective Practices
Two housekeeping practices – fumigation and the use of ultraviolet (UV) light –
are common in many facilities but should be eliminated. These practices are
time-consuming, waste valuable resources, and do not decrease the risk of
infection in your facility. 76
129
Fumigation
Fumigation with formalin, formaldehyde, or paraformaldehyde is an ineffective
method of reducing the risk of infection. It is a perfect example of a practice that
is not based on scientific findings.
Besides being ineffective, these agents are toxic and irritating to the eyes and
mucous membranes. Fumigation is time-consuming and makes rooms
unavailable for use, often leading to disruption of services or unnecessary
inconvenience to clients and staff. Thorough cleaning with a disinfectant cleaning
solution and scrubbing should be used instead of fumigation. 76
Ultraviolet (UV) light

In general, this is neither a practical nor cost-effective. In the largest and best-
designed scientific study on this topic, no decrease was shown in the surgical-
site infection rate when UV light was used. Although UV light does have some
uses in specialized sites (such as tissue culture laboratories), UV light is
unsatisfactory for general use in health cares facilities because:
• The killing ability of UV light decreases sharply: 1) if relative humidity is
greater than 60% - 70%; 2) if dust is present (in the air, on surfaces, or
on the bulb itself) and 3) with increasing distance from the lamp.
• UV light does not penetrate most substances (including fluids and
organic matter, such as mucous) and will therefore only kill
microorganisms directly on the surface that are exposed to the UV
light.
• The intensity of UV light needed to effectively kill microorganisms is
damaging to humans. Prolonged exposure can lead to eye or skin
irritation.
• UV lighting fixtures are expensive to install and maintain. Regular
servicing, including removing dust from the bulbs, is required.
• Cleaning by scrubbing is the most efficient and cost-effective way to
clean potentially contaminated areas in your facility. 76
130
Cleaning of equipments and patient care

articles
Table 21: Cleaning of Equipment and Patient-Care Articles
Equipment, Acceptable alternative
Routine or preferred Cleaning
patient-care or additional
method schedule
articles recommendations
Bathtub Non-infected patients: Infected patients: After each
Scrub with detergent Disinfect after cleaning use
Bath water usually
solution. Rinse and dry with a chlorine solution.
contaminates the
after cleaning.
inner bath surface Patients with open
with large numbers wounds: Disinfection
of microorganisms after cleaning with a 200
including potential PPM chlorine solution is
pathogens that can recommended in all
be transferred to departments where
the next patient patients have open
using the bath. wounds and/or are
immunocompromised.
Beds and bed Wash with detergent Infected patients: Daily and
frames solution, rinse, and dry. Disinfect after cleaning after
with a 200 PPM discharge
hypochlorite solution.
Bedpans and Wearing gloves, wash They should be After each

urinals thoroughly with warm disinfected after patient use.
water using a brush and discharge.
A bedpan or urinal
detergent to remove all
should be specified - After each use, low
visible signs of organic
for each patient level disinfection should
contamination. Dry or
be performed for high
leave them to dry and
risk patients (200 PPM
store them in a special
chlorine solution)
place away from patient
care areas and clean
areas.
131
Table 21: Cleaning of Equipment and Patient-Care Articles (Continued)

method schedule
Bowls (washing) Wash with detergent Infected patients: After each
solution, rinse, and dry. Disinfect after cleaning use
An individual
Store inverted and tilted with a 200 PPM
washbowl should
forward to avoid trapping hypochlorite solution.
be available for
of water, which may
each patient.
harbormicroorganisms
Bowls Clean with detergent and After each

autoclave. use
(surgical, sterile)
Bowls Wearing gloves, empty, Infected patients: After each
rinse and wash with Disinfect after cleaning use
(emesis)
detergent and hot water, with a 200 PPM
rinse and dry. hypochlorite solution.
Ceilings Wash with detergent Keep in good repair. Clean if
solution Physical integrity of visibly soiled
ceiling is important
because fungi and mold
can grow on moist/water-
damaged surfaces.
Carpets Vacuum and clean with Carpets are not allowed
detergent as needed. in patient care areas.
Commodes Using heavy-duty utility If fecal contamination Daily and
gloves, wash seats with a has occurred, remove the seats
hot detergent solution and soil with tissue, wash after each
dry with a disposable with a hot detergent use
paper towel. After each solution, then wipe with
use the seat of the disinfectant, (200 PPM
commode should be Chlorine or alcohol
cleaned with a large soaked wipe; rinse and
alcohol soaked wipe or dry).
chlorine solution and
dried.
132
Equipment, Acceptable alternative or Cleaning

Routine or preferred
patient-care additional schedule
method
Crockery and 1. Machine wash with Each patient should have After each
cutlery rinse temperature an individual set, either meal.
above 80° C and dry. provided by the hospital or
brought from home.
2. Handwashings are
preferably performed
in two sinks, the first
for washing with a hot
detergent solution (as
hot as possible:
approx. 60° C) and the
second for rinse with
hot water (77-82° C or
higher) for at least one
minute and allow
drying. Heavy utility
gloves will be required
at this temperature.
Drains Wearing heavy utility Regular maintenance is a On a regular
gloves, clean the area must. Cover with insect basis.
around the drain. screen. When blockage
Wash hands after occurs, contact
removal of gloves. Maintenance Department.
Chemical disinfection
is not required.
Floors Wash with a hot If contaminated, clean and At the
detergent solution. disinfect using a chlorine beginning of
Disinfection is not solution. the day, and
routinely required whenever
except in high-risk necessary.
areas.
133

method schedule
Furnishings Clean cloths are used Each day,
for each room, soaked and whenever
with detergent or necessary
disinfectant-detergent
solutions contained in
a basin. Double-basin
system minimizes the
recontamination
inherent in a single-
basin technique.
Alternatively, spray the
surface with the
disinfectant-detergent
solution. Vigorously
wipe the sprayed
surface with a clean
cloth saturated with the
solution.
Mattresses and Wash water They should have plastic After each
pillows impermeable cover waterproof covers that can patient and if
with a hot detergent be easily cleaned and soiled.
solution, rinse and dry. dried. Damaged pillows
must be replaced
immediately.
Infected patients: Disinfect
cover with a disinfectant
solution. Allow a two-
minute contact time then
rinse and dry. Do not
disinfect unnecessarily as
this damages mattress
cover.
134

Equipment, Acceptable alternative or
Routine or Cleaning
patient-care additional
preferred method schedule
Patient partition Clean partitions with - Should be disinfected if Each week
a detergent solution. contaminated with blood or and if dirty
body fluids.
Thermometers Wash in warm water Never leave soaking in
(not hot!) and disinfectants for long time
( Always separate
detergent and dry. or till been reused.
rectal from orally
Thermometers should be
used thermometers Soak in 70%
stored dry in a clean place
at all stages ) alcohol for 10 min.
till reused.
Toilet bowl and Using heavy-duty Infected patients or if Daily, and
seat utility gloves, wash grossly contaminated: whenever
bowl and seat with a necessary
After cleaning, disinfect
hot detergent
with 200 PPM chlorine
solution and dry the
solution, rinse and dry.
seat with a
This is important in an
disposable paper
area where soiling is more
towel. Wash your
likely, e.g. Gynecology,
hands after removal
Maternity, Urology
of gloves.
Department, etc.
This area should not be
cleaned with the same
supplies used for cleaning
patient care areas!
Trolleys Wipe with warm - Disinfect if contaminated Daily. Trolley
water and detergent with blood or body fluids. tops before
to remove dust. Dry. and after use.
Wash Scrub with Disinfection may be Each day,
basins/sinks detergent; use required if contaminated. and whenever
cleaner for stains, necessary
etc. Disinfection is
normally not
required.
135

Equipment, Acceptable alternative or
Routine or Cleaning
patient-care additional
preferred method schedule
Waste container Wash waste At the end of
container with a the day, and
disinfectant cleaning whenever
solution, rinse, and necessary
dry with a
disposable paper
towel.
Walls Walls must be spot - Disinfect if contaminated In high-risk
cleaned of spills and with blood or body fluids. areas , and
splashes and whenever
completely cleaned necessary.
when they are
soiled.
Working Clean with a If there is visible spillage of Several times
surfaces detergent solution, blood or organic material, during the day,
rinse and dry. first remove spill and and whenever
disinfect using a chlorine they are
solution. soiled.
136
Cleaning, Disinfection, and Sterilization of Medical Equipment
Cleaning, Disinfection, and

Sterilization of Medical
Equipment
Introduction
Medical equipments and surgical instruments are examples of devices that
are essential to the care of patients; however, because they typically are
designed for reuse, they also can transmit pathogens if any of the steps
involved in reprocessing, cleaning, disinfection, or sterilization are inadequate
or experience failures. Because the vast majority of pathogens are present in
organic matter, e.g. visible soil, the first step in reprocessing, cleaning, is the
most important. Any failure to remove soil at this point creates the potential for
transmission of infection as the efficacy of subsequent disinfection or
sterilization will be compromised. Decontamination is the process by which
microorganisms are removed or destroyed in order to render an object safe. It
includes: 31
• Cleaning,
• Disinfection, and
• Sterilization.
All hospitals and health care facilities should have a decontamination policy
and help staff to decide what decontamination process should be used for
which item of equipment. 11
Processing Instruments
Definition of Terms
Antimicrobial agent: Any agent that kills or suppresses the growth of
microorganisms.
Biocide: A chemical or physical agent that kills all living organisms,

pathogenic and nonpathogenic.
Biologic indicator (BI): A standardized preparation of bacterial spores on or

in a carrier serving to demonstrate whether sterilizing conditions have been
met. The type of spore varies by type of sterilization.
137
Cleaning: Cleaning is a process, usually involving detergent or enzymatic

presoak that removes foreign material (e.g. dirt or microorganisms) from an
object. Cleaning is the most essential step in reprocessing instruments and
equipment.
Decontamination: The use of physical or chemical means to remove,

inactivate, or destroy pathogens on a surface or item to the point where they
are no longer capable of transmitting infectious particles and the surface or
item is rendered safe for handling, for use, or for disposal. Decontamination
could comprise cleaning, disinfection or sterilization as appropriate.
Disinfection: Any process, chemical or physical, that destroys pathogens

such that an item is safe to handle for its intended use.
Disinfectant: A disinfectant is a chemical agent that destroys most pathogens

but may not kill bacterial spores. Chemical disinfection should only be used if
heat treatment is impractical or if it may cause damage to the equipment.
There is a broad spectrum of chemical disinfectants that have different anti-
microbial activities. Most of them do not necessarily kill all microorganisms or
spores that are present on an inanimate object but instead reduce the number
of microorganisms to a level that is not harmful to health. Disinfectants are
used on inanimate objects only and not on living tissue. Chemicals used to kill
microorganisms on skin or living tissue are known as antiseptics.
The broad category of disinfection may be subdivided into high-level,
intermediate-level, and low-level disinfection according to the anti-microbial
activity of the disinfectant.
Low level disinfectant (LLD): LLD is an agent that destroys all vegetative
bacteria (except tubercle bacilli), lipid viruses, some nonlipid viruses, and
some fungus, but not bacterial spores.
Intermediate-level disinfectant (ILD): ILD is an agent that destroys all

vegetative bacteria, including tubercle bacilli, lipid enveloped and some
nonlipid enveloped viruses, and fungus spores, but not bacterial spores.
High-level disinfectant (HLD): A high-level disinfectant is a chemical or

physical agent or process that is capable of killing some bacterial spores
when used in sufficient concentration, temperature, and under suitable
conditions. It is therefore expected to be effective against vegetative bacteria,
fungi, viruses and other microorganisms. It does not kill high numbers of
bacterial spores.
Note:
Some of the chemicals used for disinfection can also be used as chemical
sterilants which can kill bacterial spores. Contact with the heat-sensitive items
normally requires prolonged exposure times. For more details about chemical
sterilants see the sterilization section in this chapter.
138
Lipid virus: A virus whose core is surrounded by a coat of lipoprotein whose

disruption renders the virus non-infectious. Viruses included in this structural
category are generally easily inactivated by many types of disinfectants,
including low level disinfectants. Also referred to as enveloped viruses.
Examples are HIV, herpes, HCV, HBV and myxoviruses.
Nonlipid virus: A virus whose nucleic acid core is not surrounded by a lipid
envelope. These viruses are generally more resistant to inactivation by
disinfectants. These are also referred to as hydrophilic viruses as coxackie,
enteroviruses, etc.
Pasteurization: A process developed by Louis Pasteur of heating milk, wine,

or other liquids to 60 C to 100 C for approximately 30 minutes to reduce or to
significantly kill the number of pathogenic and spoilage organisms. The higher
the temperature, the shorter the time needed. Also termed as “heat
disinfection”.
Pyrogens: Fever producing agents or substances, e.g., endotoxins from the

outer membranes of gram negative bacteria.
Spaulding classification: A strategy developed by Dr. Earle H. Spaulding

for reprocessing contaminated medical devices. The system classifies devices
as critical, semicritical, or noncritical based on the risk from contamination of a
device to a patient. Three different levels of disinfection are applied based on
this risk scheme. For example a needle used for entry into tissue is critical
and needs to be sterile. A speculum (endoscopes) has contact with mucous
membranes and therefore needs to be cleaned and then undergo high-level
disinfection. A blood pressure cuff has contact with intact skin and only needs
cleaning.
Sterilant. An agent that destroys all viable forms of microbial life to achieve
sterilization.
Sterilization methods remove or destroy all forms of microbial life including
bacterial spores by either physical or chemical processes. It is recommended
that any instrument or equipment classified as critical that comes in contact
with the blood stream or with subdermal tissues be cleaned and sterilized in
between each use. 78 Sterilization is accomplished principally by steam under
pressure, by dry heat, and by chemical sterilants.
The choice of the method for sterilization depends on a number of factors
including the type of material that the object to be sterilized is made of, the
number and type of microorganisms involved, the classification of the item,
and availability of sterilization methods.
139
Table 22: Decreasing order of resistance of microorganisms to disinfection

and sterilization and the level of disinfection or sterilization. 79
Types of organisms Level
Prions (e.g., Creutzfeldt-Jakob - Sodium Hydroxide
Disease) soap for one hour
Resistant - 18 min prevacuum
steam sterilization
(134-137C)
Bacterial spores (e.g. Clostridium
teteni, Clostridium difficile) Sterilization
Coccidia (Cryptosporidium)
Some spores generated by spore
forming bacteria High Disinfection
Mycobacterium tuberculosis Intermediate

Disinfection
Nonlipid or small viruses (polio,
coxsackie)
Susceptible Fungi (e.g., Aspergillus, Candida)
Vegetative bacteria (S. aureus, P. Low Disinfection
aeruginosa)
Lipid viruses (HIV, HBV, HCV,
herpes, myxoviruses)
The Instrument Processing (Decontamination Steps)

There are two steps to processing items that are used during clinical and
surgical procedures. Cleaning is the first and the most important step.
Cleaning is followed by either sterilization or disinfection and by immediate
use or proper storage of the item.
Fig. 21: Decontamination Steps
140
Risks of Infection from Equipment

The risks of infection from equipment may be classified into three categories.
Placing instruments and equipment into one of the following categories can be
helpful in choosing the proper level of disinfection or sterilization needed in
order to protect the patients and the health care personnel. 11
Low risk (noncritical items)

Noncritical items are items that come into contact with normal and intact skin
as stethoscopes or with the inanimate environment (e.g. walls, floors, ceilings,
furniture, sinks, etc.). Cleaning with a detergent and drying is usually
adequate. Stethoscopes are usually cleaned and in rare cases they should be
disinfected if used on infectious patient or highly susceptible patient.
Intermediate risk (semi-critical items)

Semi-critical items are items that do not penetrate the skin or enter sterile
areas of the body but that are in close contact with mucous membranes or
with non-intact skin. Cleaning followed by HLD is usually adequate. Examples
include respiratory equipment, flexible endoscopes, laryngoscopes, specula,
endotracheal tubes, thermometers, and other similar instruments.
High risk (critical items)

High risk items are items that penetrate sterile tissues such as body cavities
and the vascular system. These items are called critical items because of the
high risk of infection if such an item is contaminated with any microorganism
before penetrating the tissue. Cleaning followed by sterilization is required.
High-level disinfection may sometimes be appropriate if sterilization is not
possible, e.g., flexible endoscopes. Examples of high-risk items include
surgical instruments, intra-uterine devices, vascular catheters, implants, etc.
Single Use Items

These items may be used in critical, semi-critical, or noncritical areas;
however, they are single use items that are prepackaged with the appropriate
level of disinfection or sterilization and are disposed of after a single use.
Examples include gloves, needles, syringes, and tongue depressors.
The figure below shows the relationship between types of items and the
sterilization or disinfection that they must undergo.
141
Fig. 22: Relation between type of item & its decontamination
Cleaning
Cleaning is the removal of all foreign material (dirt and organic matter) from
the object being reprocessed. Two key components of cleaning are friction to
remove foreign matter and fluids to remove or rinse away contamination.
Thorough cleaning will remove most organisms from a surface and should
always precede disinfection and sterilization procedures. If instruments and
other items have not been cleaned, sterilization and disinfection may not be
effective because microorganisms trapped in organic material may survive
sterilization or disinfection. 80
Cleaning is normally accomplished by the use of water, detergents and
mechanical actions. Detergent is essential to dissolve proteins and oil that can
reside on instruments and equipment after use.
Cleaning may be manual or mechanical. Mechanical cleaning includes
ultrasonic cleaners or washer/disinfectors that may facilitate cleaning and
decontamination of some items and may reduce the need for handling. 31
The solution used most often to clean is an enzymatic presoak (protease
formula that dissolves protein). Alternatively a detergent can be used.
Detergents lower surface tension and lift dirt or oil away from the device.
Studies have shown that thorough cleaning alone can provide a 10 000 fold
reduction in contaminant microbes from endoscopes. 79, 81, 82 Cleaning can be
very effective in removing microbial contaminants from surgical devices.
Mechanical Cleaning
Most modern sterilization units are automated and there is minimal handling
of dirty equipment by staff. The equipment is placed in trays ready for
washing:
• Washing machine. The washing machine gives a cold rinse
followed by a hot wash at 71 °C for 2 minutes. This is followed by a
10-second hot water rinse at 80-90 °C and then by drying by a
heater or a fan at 50-75 °C.
142
• Washer/disinfector. The washer/disinfector is used for anesthetic

equipment. It runs a 45-minute cycle of washing and cleaning plus a
2-minutes cycle with water at 80-100 °C and with a detergent
solution.
• Ultrasonicator. The ultrasonicator is a sophisticated and expensive
but extremely efficient piece of equipment. It uses high-power
output of 0.44 W/cm3 and dislodges all organic matter.
Manual Cleaning
All items requiring disinfection or sterilization should be dismantled before
cleaning. Cold water is preferred; it will remove most of the protein materials
(blood, sputum, etc.) that would be coagulated by heat and would
subsequently be difficult to remove. The most simple, cost-effective method is
to thoroughly brush the item while keeping the brush below the surface of the
water in order to prevent the release of aerosols. The brush should be
decontaminated after use and should be dried.
Finally, items should be rinsed in clean water and then should be dried. Items
are then ready for use (noncritical items) or for disinfection (semi-critical
items) or for sterilization (critical items).
Manual cleaning is necessary when:
• Mechanical cleaning facilities are not available;
• Delicate instruments have to be cleaned;
• Complex instruments need to be taken apart to be cleaned;
• Items with narrow lumens need to be cleaned (endoscopes).
Manual or hand-cleaning must be done with extreme caution. The staff should
follow the set procedure:
143
Steps for cleaning
1. Wear heavy-duty rubber gloves, a Fig. 23: Steps for cleaning

plastic apron, eye protection, and
mask during cleaning.
2. Soak the instruments in normal tab

water containing a detergent.
3. Scrub instruments and other items

vigorously to completely remove all
foreign material using a soft brush or
old toothbrush, detergent, and water.
Hold items under the surface of the
water while scrubbing and cleaning to
avoid splashing. Disassemble
instruments and other items with
multiple parts, and be sure to brush in
the grooves, teeth, and joints to items
where organic material can collect
and stick.
4. Flush through lumens with an adapted

water jet.
5. Rinse items thoroughly with clean

water to remove all detergent. Any
detergent left on the items can reduce
the effectiveness of further
processing.
6. Inspect items to confirm that they are

clean.
7. Allow items to air dry or dry them with
a clean towel if chemical disinfection
is going to be used. This is to avoid
diluting the chemical solutions used
after cleaning. Items that will be high-
level disinfected by boiling or
steaming do not need to be dried.80
144
Remember when cleaning:

• Do not use hand soap to clean instruments because fatty acids in the soap
react with hard water to leave a soap scum on the instruments.
• Always wear utility gloves, a mask, and eye protection when cleaning
instruments.
• Do not use abrasive materials that scratch or pit instruments. Scratches,
pits, or grooves can harbor microorganisms and promote corrosion.
Automatic washing machines are preferable to washing by hand.
Soaking of Instruments Prior to Cleaning

Sometimes the level of contamination of the instrument makes it necessary to
soak items prior to cleaning (e.g. instruments in operating theatres). A deep
container, e.g. a bucket, containing a wire-mesh basket can be filled with
water and detergent. The instruments are placed in the wire basket, agitated
for 3-5 minutes, and then lifted out. The basket is overturned onto a table or
tray in order to separate the instruments prior to cleaning, packing and
autoclaving.
Disinfection
Disinfection can be carried out either by thermal or chemical processes.
Thermal disinfection is preferred whenever possible. It is generally more
reliable than chemical processes, leaves no residues, is more easily
controlled, and is non-toxic. Heat sensitive items have to be reprocessed with
a chemical disinfectant.
Organic matter (serum, blood, pus or fecal material) interferes with the
antimicrobial efficiency of either method. The larger the number of microbes
present, the longer it takes to disinfect. Thus scrupulous cleaning before
disinfection is of greatest importance.
High Level Disinfection (HLD) - Semi-critical Items

There are three types of HLD:
• Disinfection by boiling
• Moist heat at 70-100°C
• Chemical disinfection
Note:
When sterilization is not available, HLD is the only acceptable alternative for
instruments and other items (=semi-critical items) that will come into contact
with the bloodstream or tissues under the skin.
Boiling is HLD, not sterilization. Flaming is not an effective method of HLD
because it doesn’t effectively kill all microorganisms.
HLD by Boiling
High-level disinfection is best achieved by moist heat such as boiling in water
(100°C for one minute holding time), which kills all organisms except for a few
145
bacterial spores. It is important to note that boiling equipment items in water

will not achieve sterilization.
Steps of boiling: Fig. 24: Steps for boiling
1. Clean all items to be high-level

disinfected.
2. Open all hinged instruments and

disassemble those with sliding or multiple
parts. Place bowls and containers upright so
they fill with water. Make sure that all items
are completely submerged because water
must touch all surfaces for HLD to be
achieved.
3. Cover the pot or close the lid on the boiler

and bring the water to a gentle, rolling boil.
4. Once the water is in a rolling boil, start

timing for at least 1 minute. Use a timer or
make sure to record when the boiling
begins. From this point on do not add or
remove any water or items.
5. Lower the heat to keep the water at a

gentle, rolling boil. Too vigorous boiling may
damage items and will speed the
evaporation of the water.
6. After 1 minute holding time, remove items

using dry, high-level disinfected pickups.
Place items to air-dry on a high-level
disinfected tray or on a high-level
disinfected container that is away from dust
and insects and in a low-traffic area. Never
leave boiled instruments and other items in
water that has stopped boiling; they can
become contaminated as the water cools.
7. Store the dry items in a high-level

disinfected and covered container and use
items immediately or keep in a covered, dry,
high level disinfected container and use
within one week. 92
8. The boiler should be emptied and dried

daily.
146
Note:
Addition of a 2% solution of sodium bicarbonate elevates the temperature and
helps to prevent corrosion of the instruments and utensils.
Tips for HLD by boiling:

• Instruments and other items must be completely covered with water. Open
all hinged instruments and other items and disassemble those with sliding
or multiple parts.
• Always boil for 1 minute. Start counting the one minute when the water
reaches a rolling boil. If you forget to start timing the HLD procedure, start
timing at the point at which you realize that you did not begin timing.
• Do not add anything to or remove anything from the pot/boiler once boiling
begins. 92
• A white, scaly deposit may be left on instruments and other items that
have been boiled frequently and on the pot/boiler itself. These are lime
deposits caused by lime salts in the water.
• To minimize lime deposits:
• Add some vinegar to the water to remove deposits from instruments, other
items, and the inside of the pot/boiler.
• Boil the water for 10 minutes at the beginning of each day that the
pot/boiler is used; this will precipitate the lime (make it come out of the
water and settle on the bottom or sides of the pot/boiler instead of on the
instruments or other items) before the instruments or other items are
added.
• Use the same water throughout the day, adding only enough to keep the
instruments and other items below the surface.
• Drain and clean out the pot/boiler at the end of each day that it is used. 92.
• A high-level disinfected tray or container can be prepared either by:
- Boiling it for 1 minute and drying thoroughly, or
- Filling it with a 0.5% chlorine solution and letting it soak for 20 minutes,
draining the chlorine solution, and rinsing thoroughly with boiled water.
• Stainless steel containers are preferred as containers for HLD.
HLD by mechanical or thermal disinfection

Disinfection by hot water can also be performed in specially constructed
washing machines (e.g., for linen, dishes and cutlery). In these machines the
processes of cleaning, of hot water disinfection, and of drying are combined in
a very effective procedure, providing some items ready for use (e.g.,
respiratory circuits) or safe to handle (e.g. surgical instruments). The thorough
initial rinsing and washing removes most of the microorganisms and shorter
disinfection times. If machines are used they should be regularly maintained
and checked for efficacy.
147
Low to high-level disinfection is achieved depending on type of machine and

complexity of the items. 31
Chemical HLD
Before deciding to use a chemical disinfectant, consider whether a more
appropriate method is available. Chemical disinfection is used most
commonly for heat-labile equipment (e.g. endoscopes) where single use is not
cost effective.
A limited number of disinfectants can be used for this purpose. e.g.:
• Glutaraldehyde 2% for 20 min.,
• Hydrogen peroxide 6% - 7.5% for 20 – 30 min.,
• Peracetic acid 0.2-0.35% for 5 min.
• Ortho-phthalaldehyde (OPA) for 5-12 min.
The object must be thoroughly rinsed with sterile water after disinfection. If
sterile water is not available, freshly boiled water can be used. After rinsing,
items must be kept dry and stored properly.
Steps:
1. Clean and dry all items to be high-level disinfected. Water from wet
instruments and from other items dilutes the chemical solution, thereby
reducing its effectiveness.
2. When using a glutaraldehyde solution: Preparations of glutaraldehyde
are non-corrosive to metals and other materials and inactivation by
organic matter is very low. Alkaline solutions require activation; once
activated they remain active for at least 2 weeks depending on the
frequency of use. If the solution is not activated prepare it in a sterile
container by following the manufacturer’s instructions. Fresh solution
should be made each day (or sooner, if the solution becomes cloudy).
3. If using a previously prepared solution, use an indicator strip to
determine if the solution is still effective. If preparing a new solution, put
it in a clean container with a lid and mark the container with the
preparation date and expiration date.
4. Open all hinged instruments and other items and disassemble those
with sliding or multiple parts; the solution must contact all surfaces in
order for HLD to be achieved.
5. Place all items in the solution so that they are completely submerged.
Place bowls and containers upright, not upside-down, so that they fill
with the solution.
6. Cover the container and allow items to soak for 20 minutes. During this
period, do not add or remove any items from the container. Monitor the
time.
148
7. Remove the items from the container using, dry, high-level disinfected
pickups (e.g., forceps).
8. Rinse thoroughly with boiled water to remove the chemical residue that
is left on items. This residue is toxic to skin and to tissues.
9. Place items to air-dry on a high-level disinfected tray or in a high-level
disinfected container before use or storage. Use instruments and other
items immediately or keep them in a covered, dry, high-level disinfected
container and use within one week. 92
Notes on Disinfectants:
• There is no all purpose disinfectant. The best housekeeping disinfectants
are not the best instrument disinfections. Example, 2% gluteraldehyde is a
good instrument and equipment disinfectant but it is inappropriate for the
floors and walls.
• Environmental sampling to verify the effectiveness of disinfectants is of no
value.
• For selection of a disinfectant, the level of disinfection required should be
determined according to the contamination likely to be present.
• Antiseptics should never be used for HLD. They are for use on the skin
and mucous membranes, not on inanimate objects.Disinfectants should
always be stored in a cool, dark place; they should never be stored in
direct light or excessive heat.
149
Table 23: Comparison of the characteristics of chemical sterilants used primarily as

high–level disinfectants.
OPA HP/PA (7.35%
HP(6%-7.5%) PA (0.2%) Glut (≥2.0%)
(0.55%) 0.23%)
20-30m @ 5m@40°C 20m 12m 15m
HLD Claim
20°C
Sterilization 6h @20° 10 m@40°C 10 h None 3h@20°C
Claim
(sporicidal
effect)
Activation No No Yes (alkaline glut) No No
21 days Single use 14-30days (acid 14 d 14 d
Reuse Life1
glut-1yr)
Shelf Life 2y 6 mo 2y 2y 2y
Stability2
Disposal None None Local3 Local3 None
Restrictions
Materials Good Fair Excellent Excellent No data
Compatibility
Yes (6%) No Yes (1.5% or Yes (0.3% No
Monitor MEC4
higher) OPA)
Serious eye Serious eye Respiratory Eye Eye damage
damage & skin irritant,
Safety
(safely damage stains skin
glasses) (conc soln) 5
Manual or Automated Manual or Manual or Manual
Processing
automated automated automated
Organic material Yes Yes Yes Yes Yes
resistance
Abbreviations: HLD= high-level disinfectant; HP= hydrogen peroxide; PA= peracetic

acid; glut=glutaraldehyde; HP/PA= hydrogen peroxide and paracetic acid; OPA=
ortho-phthaladehyde; m=minutes; h=hours; NA=not applicable; TWA=time-weighted
average for a conventional 8-hours workday.
1
number of days a product can be reused as determined by re-use protocol
2
time a product can remain in storage (unused)
3
no U.S. EPA regulations but some states and local authorities have additional
restrictions
4
MEC= minimum effective concentration is the lowest concentrated of active
ingredients at which the product is still effective
5
Conc soln=concentrated solution.
Note :
Concentration of used disinfectant and contact time should be revised
because different companies provide different concentrations for a single
disinfectant, so manufacture’s instructions should be carefully read before use
of any disinfectant.
150
Table 24: Disinfectant properties (High level disinfection)
Properties * Antimicrobial activity

Inactivation Viruses
Corrosive/ Irritant/Sen Myco- Other
Disinfectant Stability Organic Spores
Damaging -sitizing bacterial Bacteria E NE
matter
Moderately
Glutaraldehyde 2% No Good Good ****** Good Good Good
(14-28 No Yes ***
(20 min.) (fixative) ** 3h 20 min. 5-10 min. 5-10 min. 5-10 min.
days)
Peracetic acid 0.2- No
No Slight Slight Good Good Good Good Good
0.35% (5-10 min.) (< 1 day)
Alcohol **** 60-90%
Yes
(ethanol or Yes
(in closed Slight No None Good Good Good Moderate
isopropanol) (fixative) **
container)
(10 min.)
Peroxygen
Moderately
compounds 6-7.5% Yes Slight No Variable Variable Good Good Variable
(7 days)
(20-30 min.)
Chlorine releasing
No
agents Yes Yes Yes ***** Good Good Good Good Good
(< 1 day)
200-1000 PPM
Clear soluble Good to
Yes No Slight Yes None Good Moderate Poor
phenolics ******* moderate
Quaternary
ammonia Yes Yes No No None Variable Moderate Moderate Poor
compounds ********
* Use protective clothing when handling disinfectants

** Poor penetration
*** Should only be used in a well ventilated room
**** Flammable
***** In high concentration
****** Less active against M. avium intracellulare
******* Potentially toxic
******** Diluted solutions may allow the growth of Gram-negative bacilli
E = enveloped
NE = non enveloped
151
Sterilization
Sterilization is a process which achieves the complete destruction or killing of all
microorganisms, including bacterial spores.
Sterilization is principally accomplished by: 31
• Steam under pressure (Autoclaving)
• Dry heat (Hot Air Oven)
• The use of chemicals such as ethylene oxide gas (which is mainly used in
industry) or other low temperature methods (e.g. hydrogen peroxide gas
plasma).
Note:
• Boiling and flaming are not effective sterilization techniques because they do
not effectively kill all microorganisms.
• Large health care facilities should have more than one type of sterilization
system in case of power outage, equipment failure, or shortage of supplies. 78
Pressure Steam Sterilization (Autoclaving)

Steam sterilization is the most common and most preferred method employed for
sterilization of all items that penetrate the skin and mucosa if they are heat
stable. Steam sterilization is dependable, non toxic, inexpensive, sporicidal, and
has rapid heating and good penetration of fabrics.
Method
The steam must be applied for a specified time so that the items reach a
specified temperature. For unwrapped items:
• 121 °C for 20 min. at 1.036 Bar (15.03 psi) above atmospheric pressure.
• 134 °C for 3-4 minutes at 2.026 Bar (29.41 psi) above atmospheric pressure.
• (See next table)
Types of steam sterilizers

1. Small table-top sterilizers
• Sometimes used in physicians’ and dentists’ offices and clinics.
• Are essentially horizontal pressure cookers.
• Holding temperature for unwrapped items:
• 121ºC for 20 minutes or 134 °C for 3-4 minutes. 87
152
2. Portable steam sterilizer

These can be adapted for processing critical devices in low resource settings. 88
In addition, pressure cookers can provide adequate steam sterilization in
situations where conditions and resources are severely limited. 89
3. Gravity downward-displacement sterilizers
• Larger than tabletop sterilizers with addition of more automatic controls.
• The chamber fills with steam, displacing the air downward and forcing it out of
the drain valve.
• Holding temperature for unwrapped items: 121ºC for 20 minutes or 134 °C for
3-4 minutes. 87
4. Emergency (flash) sterilizers (these are a form of gravity-displacement

sterilizer):
• Normally located in operating room suite.
• Quick sterilization cycle at 134ºC for 3-4
minutes.
• Should be used only when there is
insufficient time to sterilize an item by the
preferred prepackaged method. 87
• Only for unwrapped items.
5. High-speed prevacuum vacuum sterilizers (Porous load autoclaves)

• Similar to downward-displacement sterilizers, with the addition of a vacuum
pump system.
• Vacuum pump removes the air from the chamber before the steam is
admitted, reducing the penetration time and total cycle time.
• Holding temperature 134ºC for 3-4 minutes for wrapped items. 87
• Ideally used for wrapped items and porous loads (fabrics, swabs, instruments
with lumens).
153
Table 25: Sterilization times 90

Type of instruments to be Sterilization
sterilized time
Gravity sterilizer:
Unwrapped 121 ºC (1.036 Bar) 20 min.
Unwrapped: 134 ºC (2.026 Bar) 3 min.

(metal and glass only)
Unwrapped: 134 ºC 10 min.

(2.026 Bar) (e.g., rubber)
Wrapped 121 ºC (1.036 Bar) 30 min.
Wrapped 134 ºC (2.026 Bar) 15 min.
High-speed vacuum sterilizer
wrapped: 134 ºC (2.026 Bar) 4 min.
Note:
Sterilization time does not include the time it takes to reach the required
temperature or the time for exhaust and drying; therefore, it is shorter than the
total cycle time.
The temperatures required for steam sterilization are lower than those for dry-
heat sterilization because moist heat under pressure allows for more efficient
destruction of microorganisms. 90
154
Steps for pressure steam sterilization:

1. Clean all items to be sterilized.
2. Open or unlock all hinged items and disassemble
items with multiple parts. Do not arrange items close
together.
3. Arrange all labeled packs, drums, or unwrapped
items in the chamber of the
autoclave in a way that allows
the steam to circulate freely. DO
NOT STACK.
4. Follow the manufacturer
instruction for operating the
X
autoclave. Adjust time, temperature and pressure
according to the table before. It is best to use a timer, which helps ensure that
the appropriate timing is achieved.
5. Do not begin timing until the autoclave reaches the desired temperature and
pressure
- If the timing process is forgotten, start the cycle again. If the autoclave is
automatic, the heat will shut off and the pressure will begin to fall off once
the sterilization cycle is complete.
- If the autoclave is not automatic, turn off the autoclave after achieving the
required time.
6. Wait until the pressure gauge reads “0” to open the autoclave. Open the lid or
door to allow remaining steam to escape. Leave all items in the autoclave
until they dry completely. It may take up to 30 minutes.
7. Remove packs, drums, or unwrapped items from the autoclave using sterile
pick-ups to handle unwrapped items. The packs of equipment should come
out of the autoclave dry. Wet packs must be considered non-sterile. Do
not store packs, drums or unwrapped items until they cool to room
temperature. This may take several hours.
8. Store items using the following guidelines:
- Wrapped items – The length of time (=shelf life) that a wrapped, sterile item
is considered sterile depends on whether or not a contaminating event
occurs not necessarily on how long an item has been stored. Store items in
a closed, dry, cabinet with moderate temperature and low humidity in an
area that is not heavily trafficked. A wrapped pack can be considered
sterile as long as it remains intact and dry. When in doubt about the sterility
of a pack, consider it contaminated and re-sterilize the items.
155
- Unwrapped items – use immediately after removal from the autoclave or

keep them in a covered, dry, sterile container for up to one week. 87
9. Label accurately with contents, date of processing and expiration date and
store wrapped materials in storage cabinet.
Advantages and disadvantages of steam sterilization

Advantages:
• Highly effective;
• Rapid heating and rapid penetration of instruments;
• Nontoxic;
• Inexpensive;
• Can be used to sterilize liquids. 90
•
Disadvantages:
• Items must be heat and moisture resistant;
• Will not sterilize powders, ointments or oils. 90
• Needs good maintenance.
Wrapping instruments and other items for steam sterilization

• Wrapping instruments and other items
before steam sterilization helps to
decrease the likelihood that, after
sterilization, they will be contaminated
before use.
• To wrap instruments and other items for
steam sterilization, use two layers of
material such as paper, newsprint, or
muslin or cotton fabric. Do not use canvas
because it is difficult for steam to go
through canvas. Make points while
wrapping the instruments and other items
so that the packs can be easily opened
without contaminating their contents. 90
Fig. 25: Wrapping instruments
and other items for steam
sterilization
156
Fig. 26: Steps for wrapping instruments and other items
Step 1 Step 2 Step 3 Step 4

Place the instrument or Fold the bottom section Fold the left section to Fold the right section to
other item in the center of the top wrapper to the the center, and fold the center, and fold back
of the top wrapper center, and fold back the back the point. the point.
should be positioned so point.
that the points –not the
flat edges- are at the
top, bottom, and sides.
Step 5 Step 6 Step 7 Step 8

Fold the top section to Fold the bottom Fold the left section to Fold the right
the center, and fold section of the bottom the center, and fold section to the
back the point. wrapper to the center, back the point. center, and fold
and fold back the back the point.
point.
Step 9 Step 10 Step 11

Fold the top section Tuck the point under the Fasten the folds securely,
to the center, and right left sections. using autoclave tape, if
fold back the point. available.
157
Autoclave maintenance
The autoclave should be checked each time it is used in order to make sure that
it is functioning properly. An equipment log should be used to monitor
performance including temperature, timing, and cycle.
•
• The autoclave is not working correctly if:

• Steam comes out of the safety valve instead of the pressure valve. In
such a case, the pressure valve must be cleaned and inspected.
• Steam comes out from under the lid or around the door. If this
happens, the gasket must be cleaned and dried or replaced. 87
To ensure that the autoclave is properly maintained

• Routine maintenance should become standard procedure. Someone should
be assigned to be responsible for this task.
• Follow the manufacturer’s instructions whenever possible since autoclave
maintenance varies depending on the type of autoclave.
Dry-heat Sterilization
Dry heat sterilization (Hot Air Oven):
For dry heat-sterilization to be achieved, a constant supply of electricity is
necessary. Dry heat is preferred for reusable glass, metal instruments, oil,
ointments and powders. Do not use this method of sterilization for other items,
which may melt or burn. 87
Dry heat ovens should have fans to give even temperature distribution and faster
equilibrium of load to sterilization temperatures.
Steps of dry-heat sterilization:
1. Clean and dry all items to be sterilized.
2. Either (1) wrap with foil or (2) place unwrapped items on a tray or shelf, or (3)
put them in a closed metal container.
3. Place items in the oven and heat to the holding temperature.
Table 26: Dry heat sterilization temperatures & times
Holding Sterilization Time
Temperature (After reaching the holding
temperature)
180 ºC 30 minutes
170ºC 1 hour
160ºC 2 hours
149ºC 2.5 hours
141ºC 3 hours
158
4. Leave items in the oven to cool to room temperature before removing. When
items are cool, remove instruments and other items (using sterile pickups for
unwrapped items) and use immediately or store.
5. Proper storage is as important as the sterilization process itself.
Store items using the following guidelines:
• Wrapped items – store in a closed, dry, cabinet with moderate temperature
and low humidity in an area that is not heavily trafficked.
• Unwrapped items – use immediately after removal from the autoclave or
hot oven, keep them in a covered, dry, and sterile container for up to one
week. 87
Note:
• The oven must have a thermometer or temperature gauge to make sure that
the designated temperature is reached.
• Do not begin timing until the oven reaches the desired temperature.
• If the timing process is forgotten, start it when the oversight is realized.
Advantages and disadvantages of dry-heat sterilization

Advantages
• Can be used for powders, anhydrous oils, and glass.
• Reaches surfaces of instruments that cannot be disassembled.
• No corrosive or rusting effect on instruments.
• Low cost.
Disadvantages
• Penetrates materials slowly and unevenly.
• Long exposure time’s necessary.
• High temperatures damage rubber goods and some fabrics.
• Limited package materials. 90
Maintenance of dry-heat ovens

Dry heat ovens should be checked to make sure that they are functioning
properly. Staff should:
• Keep the oven clean.
• Check that the temperature gauge is working correctly on a regular
basis – every few weeks is sufficient. To check the temperature gauge,
159
put a thermometer in the oven and compare the temperature reading

with the one on the gauge. 87
Low Temperature Sterilization
Low temperature sterilization is used for heat- and moisture- sensitive medical
devices. Since the 1950s ethylene oxide has been the most common method of
low temperature gas sterilization. Other methods have emerged that include
hydrogen peroxide + gas plasma and immersion in a dilute liquid peracetic acid.
Ethylene oxide gas

Uses: Ethylene oxide can be used to sterilize most articles that can withstand
temperatures of 50-60 °C. However, it should be used under carefully controlled
conditions because it is extremely toxic and explosive. Although it is very
versatile and can be used for heat-labile equipment, fluids, and rubber, etc., a
long period of aeration (to remove all traces of the gas) is required before the
equipment can be distributed. The operating cycle ranges from 2-24 hours and it
is a relatively expensive process. 87 Sterilization with ethylene oxide should be
monitored by using bacterial spore tests.
Hydrogen peroxide gas plasma

Uses: Gas plasma is generated in a chamber under deep vacuum and acted on
by radiofrequency radiation wherein free radical particles which disrupt microbial
cellular components. The plasma is combined with hydrogen peroxide. The cycle
time is approximately 75 minutes. Diffusion of the vapor and plasma into long,
narrow lumens can be enhance withuse of additional devices to assure flow of
gas through the device’s lumen. Diffusion into long lumens even with H2O2
injection is of poor quality assurance.
Chemical Sterilization
Before deciding to use a chemical sterilant, consider whether a more appropriate
method is available. Chemical sterilants are primarily used for heat- labile
equipment where single use is not cost effective. Instruments and other items
can be sterilized by soaking in a chemical solution followed by rinsing in sterile
water. 87 The immersion time to achieve sterilization or sporicidal activity is
specific for each type of chemical sterilant. The difficulty lies in the fact that
immersion for the appropriate time, rinsing with sterile water, and then
transferring the device to a sterile field for use is challenging. Also, in contrast
with steam sterilization methods, a biological indicator is not available for most
chemical sterilants. Given these limitations most liquid chemical sterilants are
instead used for high-level disinfection. If an item is sterilized chemically, it
should be used immediately after sterilization, to be sure that it is sterile.
160
Types of chemical sterilants:

Glutaraldehyde is a commonly available solution that can be used for
sterilization. Other chemical sterilants may be locally available, such as peracetic
acid, 7.5% hydrogen peroxide, or hydrogen peroxide (1%) plus peracetic acid
(0.08%).87 Formaldehyde is obsolete and toxic.
Glutaraldehyde
Uses: A 2% glutaraldehyde solution for at least 10 hours that can be used to
sterilize heat labile items. Glutaraldehyde solution is irritating to the skin, to the
eyes, and to the respiratory tract. There are two types of glutaraldehyde available
in Egypt. One alkaline solution that requires activation (e.g., Cidex®) and one
acidic solution that is stable and does not require activation but is slower in
activity than the activated alkaline buffered solution.
Precautions: Glutaraldehyde is an eye and nasal irritant and may cause

respiratory illness (asthma) and allergic dermatitis. Glutaraldehyde should not be
used in an area with little or no ventilation. Eye protection, a plastic apron, and
gloves must be worn when glutaraldehyde liquid is made up, disposed of, and
used for sterilization. Latex gloves may be worn and discarded after use if the
duration of contact with glutaraldehyde is brief, e.g. less than 5 minutes. For
longer duration, nitrile gloves must be worn. Glutaraldehyde should be stored
away from heat sources and in containers with close-fitting lids. The length of
time that glutaraldehyde solutions can be used varies but they are usually good
for up to 14 days. Solutions should be replaced any time they become cloudy. 87
Peracetic acid
Uses: A 0.2 – 0.35% peracetic solution for 10 minutes can be used to sterilize
heat-labile items (e.g. arthroscopes, dental instruments). A special advantage of
peracetic acid is that it has harmless decomposition products and leaves little
residue on sterilized items. It remains effective in the presence of organic matter
and is sporicidal even at low temperatures. Peracetic acid can corrode copper,
brass, bronze, plain steel, and galvanized iron, but additives and pH modification
can reduce these effects. It is considered unstable, particularly when diluted. It is
more effective than glutaraldehyde at penetrating organic matter, e.g. biofilms. It
is known to be highly corrosive and its use as a disinfectant in its natural state is
therefore limited unless there is a corrosion inhibitor in the formulation. Nu-
Cidex® is stabilized peracetic acid solution with a corrosion inhibitor. The solution
is activated to provide the appropriate in-use strength. Once prepared the current
manufacturer’s recommendations is that it should be used within 24 hours.
Sterilization using peracetic acid can be done through an automated reprocessor
that dilutes the 35% peracetic acid to a use concentration of 0.2%. This system
can only be used if the device being reprocessed is immersible as endoscopes.
Filtered water is used to rinse the device. Connectors to assure free flow of the
liquid chemical sterilant are important and the connectors are very specific to
161
each model of device being reprocessed. This system is used to chemically

sterilize both flexible and rigid endoscopes.
Steps for chemical sterilization:

• Wear protective clothing.
• Clean, and dry all items to be sterilized.
• Prepare the chemical sterilization solution following the manufacturer’s
instructions.
• If using a previously prepared solution, use an indicator strip to determine if
the solution is still effective.
• If preparing a new solution, put it in a sterile container with a lid and mark the
container with the preparation date and expiration date.
• Open all hinged instruments and other items. Disassemble those instruments
with sliding or multiple parts because the solution must contact all surfaces for
sterilization to be achieved.
• Place all items in the solution so that they are completely submerged. Place
bowls and containers upright so that they are filled with the solution.
• Cover the container and follow the manufacturer’s instructions regarding the
time necessary for sterilization. During this period, do not add or remove any
items from the container.
• Remove the items from the container using large sterile pickups.
• Rinse thoroughly with sterilized water to remove the residue that chemical
sterilants leave on items.
• Place items on a sterile tray or in a sterile container and allow to air dry before
use or storage.
• When items are dry, use or store immediately.
• If items are to be stored, keep them in a covered, dry, sterile container for up
to one week. 87
Monitoring the Effectiveness of Sterilization

To ensure that sterilization has been successful the process of sterilization (and
not the end product) is tested. Indicators have been developed to monitor the
effectiveness of sterilization by measuring various aspects of the process through
different indicators.
162
Mechanical indicators
These indicators, which are part of the autoclave or dry-heat oven itself, record
and allow you to observe time, temperature, and/or pressure readings during the
sterilization cycle. 87
Chemical indicators
• Tape with lines that change color when the intended temperature has
been reached.
• Pellets in glass tubes that melt, indicating that the intended
temperature and time have been reached.
• Indicator strips that show that the intended combination of
temperature, time, and pressure has been achieved.
• Indicator strips that show that the chemicals and/or gas are still
effective. 87
• Chemical indicators are available for testing ethylene oxide, dry heat,
and steam processes. These indicators are used internally, placed
where steam or temperature take longest to reach, or put on the
outside of the wrapped packs to distinguish processed from
nonprocessed packages. 11
Biological indicators
These indicators use heat-resistant bacterial endospores to demonstrate whether
or not sterilization has been achieved. If the bacterial endospores have been
killed after sterilization, you can assume that all microorganisms have been killed
as well. After the sterilization process the strips are placed in a broth that
supports aerobic growth and incubated for 7 days. The advantage of this method
is that it directly measures the effectiveness of sterilization. The disadvantage is
that this indicator is not immediate, as are mechanical and chemical indicators.
Bacterial culture results are needed before sterilization effectiveness can be
determined. 87
Recommended ideal monitoring system

Perform the following monitoring activities whenever possible.
For steam sterilization

• If the autoclave has recording chart, review it after each load. If not,
record the temperature, time and pressure information in a log book
that is reviewed after each load.
163
• Place heat-and steam-sensitive chemical indicators, if available, on the

outside of each pack.
• Perform testing with biological indicators weekly (or monthly, if testing
weekly is not possible).
• Indicators should be in the middle of the item reprocessed (the most
difficult part of the load).
• A thermometer could be put in the most difficult part of the load.
For dry-heat sterilization
• If the oven has a recording chart, review it after each load. If not,
record the temperature and time information in a log that is reviewed
after each load.
• Place heat-sensitive chemical indicators, if available, on the outside of
each pack.
• Perform testing with biological indicators weekly (or monthly, if testing
weekly is not possible). 87
• A thermometer could be put in the most difficult part of the load.
For chemical sterilization

• Record the time information in a log that is reviewed after each load.
• Use an indicator strip, if available, to determine if the solution is still
effective. 87
Correcting sterilization failure
• If monitoring indicates a failure in sterilization, attempt to determine the cause
of the failure and arrange for corrective steps, as follows:
- Immediately check that the autoclave or dry-heat oven is being used
correctly or replace the chemical solution.
- If correct use of the unit has been documented and monitoring still indicates
a failure in sterilization, discontinue using the unit and have it serviced.
- Any instruments or other items that have been processed in the faulty
autoclave or dry-heat oven must be considered nonsterile and must be
processed again with the unit is functioning properly.
Sterile Services Department (SSD)

The sterile services department (SSD) is vital for an effective Infection Control
and Prevention program. The expertise and knowledge of SSD personnel is
164
important to ensure high standards of decontamination; an effective SSD always

results in long-term savings.
Not all hospitals can afford to have an SSD and a separate surgical services unit
to deal with the operating theatres and associated departments. At the least, they
should have a single department covering all areas.
Preparing an Area for Processing Instruments and Other

Items
One goal of a comprehensive infection control program is to minimize the level of
contamination in areas in which “clean” activities take place. 86 Examples of
areas where “clean” activities take place are operating theaters, procedure
rooms, and working areas for sterilizing, high-level disinfecting, and storing
instruments and other items. Areas in which “dirty” activities take place include
rooms where soiled instruments and other items are washed. 86 It is ideal to have
separate rooms – one for receiving and cleaning instruments and other items and
another room for final processing (sterilization or high-level disinfection) and
storage. However, in many settings in Egypt this is not possible. When only one
room is available, it should be arranged so that activities and objects flow in an
organized way. It is necessary to have at least one sink (two are preferable),
sufficient counter top space for receiving dirty items and for drying and packaging
clean items, and for storage space (preferably closed cabinets). 86 It is key to
have good spatial separation between soiled handling area and the clean,
packaging area.
Establishing an SSD
Soiled, used, and recyclable equipment should be collected from the wards and
then should be transferred to the SSD where it is washed, inspected, disinfected
or packaged and sterilized, and dispatched back to the wards.
Fig. 27: Flow diagram of items processed in SSD
Delivery of
items to
Ward/Operating Receiving dirty

Theater instruments
Storage of Processing:
clean items Cleaning, Disinfection,
Sterilization, Packing
165
In the ward:
• Collect instruments that are to be re-used in a clearly labeled
container.
• Arrange for dirty instruments to be delivered to the SSD – DO NOT
ATTEMPT TO WASH THEM ON THE WARD.
• Discard cotton wool balls and dressings into regular waste disposal
containers (for more details see chapter on Waste Disposal I).
In the SSD:
• Receive instruments in the dirty area.
• Wash all instruments in water and detergent or enzymatic presoak
either mechanically or manually using appropriate protective barriers.
• Inspect all equipment for cleanliness and damage.
• Send damaged instruments for repair after appropriate
decontamination or discard them if necessary.
• Pack cleaned instruments on a tray.
• Autoclave trays at recommended temperature and/or disinfect as
required.
• Ensure that the packaged trays are dry – inspect tapes.
• Sort the packaged trays for ward collection.
• Return equipment to the ward or store in the clean treatment room.
The layout of the SSD

Ideally, physical barriers should separate dirty and clean areas in the
reprocessing room. However, if this is not possible (perhaps because of shortage
of space or of funds) the same room can be used, provided that:
• The air moves from the clean area to the dirty area.
• Both areas have separate storage facilities.
• There are adequate hand disinfection facilities.
• Activity patterns are established in which soiled objects never cross
paths with clean, sterilized, or high-level disinfected instruments and
other items.
• The doors are kept closed in the reprocessing rooms in order to
minimize dust contamination and to eliminate flies.
• There is separate equipment for each area.
• The staff work in either area– never in both.
166
Storage in the SSD

After items have been reprocessed, the sterile packs should be stored in well-
ventilated, clean stores ready for dispatch to the wards. Collection should be
regular and there should be a written record of receipt and delivery. This helps to
monitor the use and the loss of instruments.
Note!
Do not store instruments or other items such as scalpel blades and suture
needles in solutions-always store them in a dry container. Microorganisms can
live and multiply in both antiseptic and disinfectant solutions which can
contaminate instruments and other items and which can lead to infections.
SSD staff facilities

• All SSD staff should be provided with adequate protective clothing (e.g.
heavy duty gloves, plastic aprons, and eye protection if manual
cleaning is undertaken). Overshoes are not necessary.
• SSD staff should be immunized against hepatitis B. (See chapter
“Occupational Safety and Employee Health”
Fig. 28: Single room for processing instruments and other items
Receiving
Waste Waste
Sink
Cleaned
Instruments
Work area
Door
Work area Boiler
Auto-
Sterile storage cabinet clave Sterile pack work area
The flow of work in a single room for reprocessing of instruments should be

designed to minimize the likelihood of contamination. Activity patterns should be
established in which soiled objects never cross paths with clean, sterilized, or
high-level disinfected instruments and other items.
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Waste Management I
Waste Management I
Introduction
Health-care medical waste is a by-product of health care that includes sharps,
non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices, and
radioactive materials. Poor management of health care waste may expose health
care personnel, waste handlers, and the community to infectious agents, to toxic
materials, and to an increased risk of injury. It may also damage the environment
(e.g., contamination of water, air, and food). In addition, if waste is not disposed
of properly, members of the community may have an opportunity to collect
disposable medical equipment (particularly syringes) and to resell these
materials. Medical waste can potentially be reused without sterilization. This
reuse of unsterilized waste material causes a large portion of the diseases that
develop due to poor waste management. 93 An extensive survey of medical
waste generated at a Saudi Arabian hospital found that a comprehensive waste
program was able to reduce the amount of waste being discarded as medical
from 1163 kg/day to 407 kg/day or a 65% reduction. 61 A substantial portion of
items that were being discarded as medical waste were plastics such as IV bags
and tubing, disposable, uncontaminated paper wraps used for instruments which
did not meet this country’s definitions of medical waste.
Magnitude of Medical Waste in Egypt

Although there are no accurate figures on the magnitude of medical waste
generated from health care facilities in Egypt, some limited reports describe the
amount of medical waste generated per bed per day to be on the average of 1
kg. There are approximately 123,000 beds distributed in governmental and
private health care facilities (excluding military and police hospitals). This means
that the total hospital waste is estimated to be on average 123 tons/day. 94
Almost 80% of the total waste generated by health care activities is general
waste (comparable to domestic waste), while the remaining 20% of waste is
considered to be hazardous and may be infectious, toxic, or radioactive. 95 In
other words, Egypt generates an average of 24,600 tons of hazardous or
infectious waste daily.
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Waste Management I
Legislation for Egypt

Law No. 4 for the protection of the environment was issued in 1994. Its
implementation policy was issued by a decree from the board of ministers,
number 338 for year 1995. Law No. 4 is concerned with the protection of the
environment (protection of air, water, and ground) from all aspects of pollution,
including pollution with dangerous waste.
Dangerous waste was defined as all material which harms the health of human
beings or which has a negative impact on the environment as infectious, toxic, or
radioactive material.
Law No. 4 includes 100 elements. Element no. 29 stresses the prevention of
handling of dangerous waste without a license from the responsible
administrative area. Those who do not comply with element no. 29 could be
punished by prison for a period of not less than 5 years and by being fined an
amount of money not less than 20000 L.E.
General Principles of Waste Management

• A clear facility policy for waste management should be available for
proper implementation of a waste management system. The policy
should describe in detail the methods of waste segregation, collection,
storage, and disposal, according to the resources available in each
health facility.
• Roles and responsibilities of the different team members responsible
for waste management should be clarified. One main person should be
assigned to be responsible for waste management in each facility.
• All used sharps must be discarded without re-sheathing in a puncture-
resistant container that is readily accessible.
• All clinical waste, e.g., waste contaminated with blood and/or bloody
fluids, should be discarded into a colored bag (e.g. red or yellow).
Segregation of waste should take place at its source of origin.
The Different Types of Waste

Wastes and by-products cover a diverse range of materials and can be divided
into two categories:
Non-medical waste (or non-hazardous waste)

General or non-medical waste poses no risk of injury or infection to staff, to
patients, to visitors, or to the community at large. It is similar in composition to
household trash.
169
Waste Management I
Note:
General waste represents 80% of the total waste from health care activities.
Examples include:
Kitchen waste, paper, boxes, packaging materials, bottles, plastic containers,
hand towels, tissues, food related trash, and similar materials that are not
contaminated with body fluids.76
Medical waste (component of hazardous waste)

Medical waste consists of several different subcategories that should all be dealt
with in the same way:
Infectious waste
Potentially infectious waste includes all waste items that are contaminated
with or suspected of being contaminated with body fluids.
Examples include:
Blood and blood products, used catheters and gloves, cultures and
stocks of infectious agents, waste from dialysis and dentistry units,
wastes from isolation units, wound dressings, nappies, wastes
contaminated with blood and its derivatives, discarded diagnostic
samples, infected animals from laboratories, and contaminated
materials (swabs, bandages, and gauze) and equipment
(disposable medical devices, e.g., IV fluid lines, and disposable
spatulas). 95, 96
Anatomic wastes
Anatomic wastes consist of recognizable body parts and tissues (e.g., placenta),
extracted tumors, waste from microbiology labs, and animal carcasses.
Note:
Infectious and anatomic wastes make up the majority of hazardous waste and
account for up to 20% of the total waste from health care activities.
Sharps waste
Sharps waste consists of used syringes, needles, disposable scalpels and
blades, etc.
Note:
Sharps waste represents about 1% of the total waste from health-care activities.
170
Waste Management I
Chemical waste
Waste containing chemical substances e.g., laboratory chemicals, empty bottles
of lab or pharmacy chemicals, disinfectants that have expired or are no longer
needed; solvents, diagnostic kits, poisonous and corrosive materials, and
cleaning agents and others. 95
Pharmaceutical waste
Waste containing pharmaceutical substances.
Examples include:
Expired, unused, and contaminated pharmaceuticals, e.g., expired drugs,
vaccines and sera. 95
Note:
Chemical and pharmaceutical waste account for about 3% of waste from health-
care activities.
Genotoxic waste
Genotoxic waste consists of highly hazardous, mutagenic, teratogenic, or
carcinogenic waste containing substances with genotoxic properties.
Examples include:
Cytotoxic and neoplastic drugs (used in cancer treatment) and their
metabolites and genotoxic chemicals. 95
Radioactive materials
Examples include:
Unused liquids from radiotherapy or laboratory research; contaminated
glassware, packages, or absorbent paper; urine and excreta from patients
treated or tested with unsealed radionucleotides; sealed sources. 95
Heavy metals
Heavy metal waste consists of both materials and equipment with metals and
derivatives.
Examples include:
Batteries, broken mercury thermometers, manometers. 95-96
Note:
Genotoxic waste, radioactive matter and heavy metal content represent about
1% of the total waste from health care activities.
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Waste Management I
Sorting, Handling, Interim Storage, and

Disposal of Medical Waste
Establishing a Medical-Waste Management Plan
Since disposal of medical waste is frequently a problem, it is useful to develop a
medical waste management plan and to designate a staff member to coordinate
the management of medical waste. The management plan should include
training all personnel handling medical waste and orienting the entire staff to the
overall plan. 76
A waste management plan should address four components of waste
management:
Definitions:
• Sorting: Sorting is separating
waste by type (e.g., infectious
Fig. 29: Steps of Medical-
waste, pharmaceutical waste) Waste Management
into color coded bags at the
place where it is generated.
• Handling: Handling is collecting

and transporting waste within
the facility.
• Interim storage: Interim storage

is storing waste within the facility
until it can be transported for
final disposal.
• Final disposal: Final disposal is

the elimination of solid medical
waste, liquid medical waste,
sharps, and hazardous chemical
waste from the health facility. 76
Sorting
Only a small percentage of the waste generated by a health care facility is
medical waste that must be specially handled to reduce the risk of infections or of
injury. Therefore, sorting the waste at the point at which it is generated can
greatly reduce the amount that needs special handling. 97
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Waste Management I
Separate containers should be used for disposing of general and medical waste.
The person who generates it should segregate the waste by type.
Colored plastic bags should be used to help distinguish between general- and
medical-waste containers.
A three-bin system for waste sorting should be established as follows: 97
• Red bags are used for infectious and pathologic waste that needs to be
incinerated.
• Yellow bags are used for radioactive waste that is to be dealt with by
atomic energy institutions.
• Black bags are for general waste that is to be disposed with the normal
general waste and is to be transferred by the municipals.
Waste sorting tips

• Sort waste at the point where it is generated;
• Always keep separate containers in convenient places wherever both
general and medical waste are generated;
• Use colored plastic bags to help distinguish between general and medical
waste containers;
• Place sharps containers in convenient places to minimize the distance that
staff need to carry sharps;
• Sharps containers should be puncture-resistant and leak proof on three
sides, e.g., tin cans with lids, or plastic bottles;
• Medical waste containers should be cleaned with a disinfectant solution at
least once per day. Housekeepers should wear heavy utility gloves and
eye protection during cleaning of the containers. 76
Fig. 30: Waste transportation

Handling
Medical waste should be handled as little as
possible before disposal. Medical waste should
not be collected from patient-care areas by
emptying it into open carts; this may lead to
contamination of the surroundings and to
scavenging of waste as well as to an increase
in the risk of injury to staff, clients and visitors.
76
Bag filling
Waste and sharps containers should be discarded when they become three
quarters full and at least once daily or after each shift. The reason for this is to
173
Waste Management I
reduce the risk of plastic bags splitting open and of an injury from a protruding
sharp item in sharps containers. 97
Waste handling tips

• Handle medical waste as little as possible;
• Medical waste and sharps containers should be discarded when they are
three quarters full or at least once per day;
• Never put hands into a container that holds medical waste;
• Do not empty medical waste into open carts because this increases the
risk of injury to staff, patients, and visitors, and may lead to spills and to
environmental contamination. 76
Interim Storage
• Waste should be transported at the end of every shift.
• To reduce the risk of infection and of injury, minimize the amount of time
waste is stored at the health care facility. Waste should be stored in an area
of controlled access that is minimally trafficked by staff, clients, and visitors.
Interim storage time should not exceed two days. 97 It is preferable to have a
room to store waste in on each floor of the facility, but, if this is difficult, one
central storage room should be designated.
• The storage area should be included in a cleaning schedule.
Interim storage tips

• Since medical waste poses a serious health threat to the community:
• Never store medical waste in open containers
• Never throw waste into an open pile.
• Waste should be stored in containers with lids to minimize the potential for
insect, rodent, or other animal infestation, and to minimize the smell. 97
Final Disposal of Solid Medical and General Waste

There are two different ways of final disposal at a facility: Burn and non-burn
techniques.
1. Non-burn techniques:
• Community waste collecting system.
• Disposal of general or non-hazardous waste. 97
• Burying solid medical waste.
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Waste Management I
To use the burial method of waste disposal there must be enough space
available to dig a burial pit and to enclose it in a fence or a wall. 97
Fig. 31: Burial pit
When burying solid medical waste, adhere to the following guidelines:

• Burial should be at least 50 meters from the nearest water source,
located downhill from any wells, free of standing water, and in an area
that does not flood.
• Burial pit should be 1-2 meters wide and 2-5 meters deep. The bottom
of the pit should be at least 1.8 meters above the water table.
• Erect a fence or a wall around the site to keep out animals.
• Every time solid medical waste is added to the pit, cover it with 10-30
cm of dirt.
• When the level of waste reaches to within 30-50 cm of ground level, fill
the pit with dirt, seal it with concrete, and dig a new pit. 97
In order to bury medical waste in Egypt, a facility must apply for a license.
Transporting solid medical waste

Transporting solid medical waste is an option for final disposal if a facility is
unable to use burn or non-burn techniques. It is the least desirable option for
disposal because it is likely that non-medical personnel will put themselves at risk
by being involved in the disposal process. If this option is used, facility staff must
educate the waste transport and disposal personnel to the risks involved in the
disposal process and must teach them how to dispose of solid medical waste
safely. 76
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Waste Management I
2. Burn technique
Incineration of solid medical waste

Incinerating is the best option for solid waste
disposal, since the high temperature (1300 ˚C)
destroys microorganisms and reduces the
amount of waste. Burning in an incinerator or
oil drum is recommended. 97
Facilities that generate low levels of solid
medical waste should use an incinerator
appropriately sized for the facility’s demands.
Facilities that generate low levels of solid
Fig. 32: Incinerator
medical waste can use a small drum
incinerator. A drum incinerator can be made
from a 200 liter or 55 gallon oil drum. 97
Using a drum incinerator:
• The drum incinerator should be sited downwind from the facility.
• Put a fence around the incinerator or never leave the fire unattended in
order to ensure the safety of staff, patients, visitors, and the community
at large.
• Place the incinerator on hard earth to prevent grass or vegetation from
catching fire.
• The drum incinerator should have sufficient air inlet to allow for efficient
and complete burning of medical waste.
• Burn only medical waste to minimize the amount of waste to be
burned.
• Use kerosene as an accelerant. To avoid an explosion add kerosene
before ignition.
• Treat ash from incineration as general waste and dispose of it properly.
97
Tips for disposal of solid medical waste

• Always wear heavy utility gloves and shoes when
handling solid medical waste.
• The disposal site for solid medical waste should be on
the grounds of the medical facility. This allows staff who
are knowledgeable about the risks of medical waste to
supervise the disposal process.
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Waste Management I
Final Disposal of Liquid Medical Waste

Liquid medical waste can be poured down a sink, drain, and flushable toilet. If
none of these are available, liquid medical waste should be buried in a pit. Points
to remember when disposing of liquid medical waste:
• Always wear heavy utility gloves and shoes when handling or
transporting liquid medical waste. Afterwards, wash both gloves and
shoes.
• Consider where the sink, drain or toilet empties. It is hazardous to have
medical waste flowing through open gutters or emptying onto the
grounds of the facility.
• When carrying or disposing of liquid medical waste, avoid splashing
the waste on yourself, on others or on surfaces.
• After disposal rinse the sink, drain, or toilet to remove residual waste,
being careful to avoid splashing. Clean the fixture with a disinfectant
solution at the end of each day or more often if heavily soiled.
• Decontaminate the container that held the liquid medical waste by
filling it with a 0.5% chlorine solution and letting it sit for 10 minutes
before washing. 76
Final Disposal of Hazardous Chemical Waste

• Always wear heavy utility gloves and shoes when handling or
transporting hazardous chemical waste. Afterwards, wash both gloves
and shoes if they become contaminated.
• Cleaning solutions and disinfectants should be handled as liquid
medical waste.
• After disposal, rinse containers thoroughly with water, wash glass
containers with detergent and water. Do not reuse plastic containers.
Disposing of cytotoxic and radioactive waste should be done in accordance with
all local and national laws and regulations. 76
Note:
Final waste disposal should follow the Egyptian regulations published in “The
guidelines of final medical waste disposal” (MOHP and the WHO,1998).
177
Waste Management II: Safe Sharps Disposal
Waste Management II:

Safe Sharps Disposal
Introduction
The term “sharps” refers to any object that can cut or puncture the skin including,
but not limited to, needles (hypodermic and suture) scalpels, lancets, broken
vials or glass, broken capillary tubes, slides and coverslips, and exposed ends of
dental wires. The primary cause of occupational exposure to blood-borne
pathogens in all health care personnel (HCP) is injury from needlesticks or other
sharp objects. At least 20 pathogens have been known to be transmitted
following percutaneous exposure to blood. The most important of these
pathogens are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV.
Infections with each of these pathogens are potentially life threatening – and
preventable. 98
Risk from Needlestick Injuries

The estimated risk of infection following a needlestick injury varies from one virus
to another. The estimated risk of infection after exposure to an HBV infected
person from a needlestick injury ranges from 6%-30%. The risk of HCV infection
ranges from 0% to 7% with an average of 1.8% by injury while the average
transmission rate of HIV is estimated to be 0.3%. Most of this variability in risk of
infection is related to the concentration of virus in the source patient’s blood. 99
Frequency and Causes of Needlestick Injuries in Egypt

A survey conducted in Egypt revealed that almost 70% of all HCP have been
exposed over their lifetime to needlestick injuries. Overall, the average number of
needlestick injuries per year varied greatly among different job categories.
Estimated annual numbers of needlestick injuries were highest among laboratory
technicians. Injuries occurred while needles were two-hand recapped, when
patient or staff members made sudden movements, during collection of the
garbage, or during bending of the needle prior to final disposal. 100 Studies from
other countries reveal an overall needlestick and sharps injuries (NSSI) rate of 33
per 1000 HCP; the highest proportion of exposures was to nurses at the point of
use. 58
178
Most needlestick injuries occur during the following activities:

• Recapping, bending, or breaking needles;
• Inserting a needle into a test tube or specimen
container and missing the target;
• Injury from a person carrying unprotected sharps;
• Sharps that are present in unexpected places, like
linens;
• During complex surgical procedures;
• Handling or disposing of waste that contains used
sharps, and;
• Patients moving suddenly during injections
Note:
• 38% of sharp injuries occur during use, 42% occur after use before disposal.
• The most common cause of needlestick injuries in Egypt occurs during
recapping of needles after use.
One-hand Recapping (“Scoop”) Technique

Many accidental needlesticks occur when staff recap needles. Recapping is a
dangerous practice: If at all possible, dispose of needles immediately without
recapping them. If it is necessary to recap a needle (for example, to avoid
carrying an unprotected sharp when immediate disposal is not possible), do not
bend or break the needle or remove the needle from the syringe by hand.
To safely recap needles use “the one-hand” technique:

Step 1
Place the cap on a flat surface, then remove your hand from
the cap.
Step 2
With one hand, hold the syringe and use the needle to
“scoop up” the cap.
Step 3
When the cap covers the needle completely, use the other
hand to secure the cap on the needle hub. Be careful to
handle the cap at the bottom only (near the hub). 36
Fig. 33: One-hand Recapping Technique
179
Hands-free Technique for Passing Sharps

Health care personnel can accidentally stick each other when passing sharps
during a procedure. Always pass sharps in such a way that the surgeon and
assistant are never touching the item at the same time. This is known as the
“hands-free” technique.
To use the hands-free technique: Fig. 34: Hands-free Technique
for passing sharps
• The assistant puts the sharp in a sterile
kidney basin or other“safe zone” in the
sterile field.
• The assistant tells the service provider

that the sharp is in the safe zone.
• The provider picks up the sharp item,

uses it, and returns it to the safe zone. 36
Tips to prevent sharp injuries

• Do not bend, break, or cut sharps. Shearing or breaking of needles is
prohibited;
• Concentrate on what you are doing and don’t get distracted;
• Dispose of all sharps in an approved puncture-resistant container as soon
after use as possible. The location of this container should be close to the
area where sharps are used;
• Needle and syringe should be disposed as one unit if possible. If a needle
must be removed, it should not be done by hand;
• Do not recap needles unless absolutely necessary. If recapped, never use
two hands, instead use the one-hand “scoop” technique (see above);
• Do not overfill sharps disposal container. Seal the container and replace
when it is ¾ full;
• Do not empty sharps containers. Dispose of whole container as one unit.
• Wear utility gloves when disposing of medical waste including sharps
containers.
• Use the hands-free technique (see below) when passing sharps. 36
• To prevent sharp injuries during transport of medical waste, use a puncture
proof container that remain closed.
180
Management of Sharps Injuries

See Occupational Health, Management of Occupational Exposures
Sharps Disposal Containers (Safety Box)

Never discard needles and sharps in clinical waste bags, as the housekeeping
staff might get injured.
Fig. 35: Safety Boxes
Tips for performance criteria of sharps containers

There are four major criteria for sharps disposal container safety performance:
functionality, accessibility, visibility, and accommodation:
Functionality: Containers should remain in a good state during their
entire usage. They should be leak resistant on their sides and bottoms,
and puncture resistant until final disposal. Individual containers should
have adequate volume and safe access to the opening. 101
Accessibility: Containers should be accessible to all workers who use,
maintain, or dispose of sharp devices. Containers should be placed in all
areas where sharps are used and, if necessary, portable within the
workplace. 101
Visibility: Containers should be plainly visible to the workers who use
them. Workers should be able to see the degree to which the container is
full and proper warning labels. 101
Accommodation: Container designs should be convenient,
101
environmentally sound, and easy to store.
181
Glossary
Glossary
Antiseptic 102 A chemical agent used on the skin and on the mucous
membranes in order to remove or to kill microorganisms
without causing damage or irritation to the tissue. An
antiseptic may also prevent the growth and development of
microorganisms. Antiseptics are not meant to be used on
inanimate objects such as instruments and surfaces.
Antiseptic Hand An antiseptic hand wash is one that will destroy or remove
Wash resident as well as transient microorganisms from hands.
Aseptic techniques Practices that help reduce the risk of post-procedure

102
infections in clients by reducing the likelihood that during
clinical procedures microorganisms will enter areas of the
body where they can cause disease. While all infection
control practices contribute to this effort, aseptic technique
refers to those practices performed just before or during a
clinical procedure. These include proper handwashing,
surgical hand scrubs, the use of barriers such as gloves
and surgical attire, proper preparation of a client for clinical
procedures, the maintenance of a sterile field, the use of
good surgical technique, and the maintenance of a safe
environment in the surgical/procedure area.
Carriage The presence in an individual (host) of a pathogenic

microorganism without clinical symptoms of infection or
sometimes without signs of any immune response.
Case 11 A person with symptoms.
Cellular Immunity Certain types of white blood cells that coordinate and
memorize exposure to microorganisms foreign to the body.
It is a critical part of the body’s immunity. These cells have
the capacity to coordinate destruction of invading
pathogens by direct contact or by the activation of
substances (antibodies, interferon), which will inactivate
them. Cellular immunity is the component of the immune
system that memorizes antigens on microbes to activate a
protective response should there be subsequent exposure.
182
Glossary
Chemical sterilization See sterilization.

Chemoprophylaxis The administration of antimicrobial agents in order to
prevent the development of an infection or to prevent the
progression of an infection into active manifest disease.
Cleaning The first step in processing instruments and other items for
reuse. This process entails scrubbing instruments and
other items with a brush and using detergent and water
before they are sterilized or high-level disinfected. Cleaning
should remove blood and other body fluids, organic
material, tissue, and dirt. In addition, cleaning greatly
reduces the number of microorganisms (incl. bacterial
endospores) on instruments and on other items, making it
a crucial processing step. If instruments and items have not
first been cleaned, sterilization and high-level disinfection
(HLD) may not be effective because microorganisms
trapped in organic material may be protected and may
survive sterilization or HLD process and organic material
and dirt can make the chemicals used in chemical
sterilization and HLD less effective.
Cohort A group of patients infected or colonized with the same

microorganisms that are grouped together in a designated
area of a unit or ward.
Colonization Reproduction of microorganisms in the spaces or on the

surfaces of the host’s body without any tissue damage or
clinical symptoms of infection.
Commensal A microorganism resident in or on a body without causing

clinical infection.
Communicable The time in the natural history of an infection during which

Period transmission may take place.
Conditional Pathogens which cause disease other than trivial local

Pathogens infections only in persons with reduced resistance to
infection (incl. newborn infants) or when implanted directly
into tissue or in a normally sterile body area.
183
Glossary
Contact An exposed individual who might have been infected

through transmission from another host or from the
environment.
Contamination Entrance of infectious, organic, or chemical agents into

tissues and spaces that are normally sterile (clean) or that
have other permanent inhabitants.
Conventional Cause disease in healthy individuals in the absence of

Pathogens specific immunity.
Disinfectant A chemical agent used to kill microorganisms on inanimate

objects, such as instruments and surfaces. Disinfectants
are not meant to be used on skin or on mucous
membranes.
Dry-heat sterilization See sterilization.

(electric oven)
Endemic The usual level or presence of an agent or disease in a

defined population during a given period of time.
Endogenous The causative agent of the infection is present in the

infection patient at the time of admission to the hospital as part of
his/her normal flora but there are no signs of infection. The
infection develops during the stay in hospital as a result of
the patient’s altered resistance or of surgery.
Environmental The general cleaning and maintenance of cleanliness in a
cleaning or health care facility. In addition to cleanliness, the purpose
“housekeeping” of housekeeping is to reduce the number of
microorganisms in the facility (thus reducing risk of
infections to patients and staff members) and to provide an
appealing work and service-delivery space.
Epidemic An unusual higher than expected level of infection or
disease by a common agent in a defined population in a
given period.
Epidemic incidence Incidence rate that exceeds an ordinary level or the level
rate that is anticipated within the specific population during a
certain period of time.
184
Glossary
Epidemiological A system for collecting, analyzing, and interpreting data on

surveillance infectious diseases (nosocomial infections) including
periodic reporting.
Epidemiology The study of the occurrence and cause of disease in

populations.
Exogenous infection Infection occurs from an outside source (infection by

colonization following cross-infection). During the stay in
the hospital the patient comes into contact with new
infective agents either from contact with hands of staff or
from poorly sterilized equipment and may become
colonized and subsequently may develop an infection.
Flora Microorganisms resident in an environmental or body site.
General waste (= non- Non-hazardous waste that poses no risk of injury or

hazardous waste) infections. Similar in nature to household trash, general
waste includes uncontaminated paper, boxes, packaging
materials, bottles, plastic containers, and food-related
trash.
See also medical or hazardous waste.
Hemodialysis Hemodialysis removes toxins, electrolytes, and fluid by

circulating the patients’ blood through a hemodialyzer
(artificial kidney). Patients are usually scheduled to receive
hemodialysis for two to six hours three times per week.
High-level This step in processing instruments and other items for

disinfection (HLD) reuse is capable of killing bacterial spores when used in
sufficient concentration and time or, for a physical process,
sufficient temperature under suitable conditions. It is
therefore expected to be effective against vegetative
bacteria, fungi, viruses, parasites and other
microorganisms. It does not kill high numbers of bacterial
spores. HLD is suitable for instruments and other items that
will come in contact with broken skin or intact mucous
membranes. HLD can be performed by boiling, by the use
of chemicals, or by steaming.
185
Glossary
Humoral Immunity These are antibodies or proteins produced by certain cells

in the body which attack pathogens that enter the body and
try to stop them from spreading or from attaching
themselves to specific cells or sites.
Immunity The resistance of a host to a specific infectious agent.
Immunocompromised A state of reduced resistance to infection that results form

a malignant disease, drugs, radiation illness or congenital
defect.
Incidence The number of new cases of a disease (or event) occurring

in a specified time.
Incidence rate The ratio of the number of new infections or diseases in a

defined population in a given period to the number of
individuals at risk in the population.
Incubation period The time between contact with a pathogenic agent and
appearance of the first clinical symptoms of disease.
Index Case The first case to be recognized in a series of transmissions

of an agent in a host population.
Infection The process of interaction between a macroorganism and
a microorganism in which the latter enters the host’s body,
reproduces, and may affect tissues directly (invasion)
through processes that can include toxin secretion or
indirectly as a result of immune reactions.
Infection control A system of measures based on epidemiological diagnosis

directed at preventing development and spread of
infectious diseases in a health care facility.
Infection reservoir A long-term infection source that supports the existence of

a parasitic species in nature.
186
Glossary
Instruments and As used in the guidelines, this term includes:

other items Instruments used during surgery or other clinical
procedures such as pelvic examination, insertion of IUD,
childbirth, dental examinations, etc.
Other items that are reused during the delivery of health
services, such as pickups (lifters or cheatle forceps),
instrument pans and trays, linen, etc.
Intrinsic Contamination before use. This is usually due to

contamination contamination or faulty sterilization of fluids during
manufacture.
Isolation The physical separation of an infected or colonized host

from the remainder of the at risk population in an attempt to
prevent transmission of the specific agent to other
individuals and to patients.
Medical waste Medical waste consists of several different subcategories

of waste generated in the diagnosis, treatment, and/or
(= hazardous waste)
immunization of clients, including:
Infectious waste: Potentially infectious waste includes
all waste items that are contaminated with or
suspected of being contaminated with body fluids.
Examples include: Blood and blood products and other
body fluids, as well as waste from dialysis and
dentistry units, wastes from isolation units, wound
dressings, etc.
Anatomic waste: Anatomic wastes consist of recognizable
body parts and tissues (e.g., placenta), extracted tumors,
waste from microbiology labs, and animal carcasses.
Sharps waste: Sharps waste consists of used syringes,
needles, disposable scalpels and blades, etc.
Chemical waste: Waste containing chemical substances
e.g., laboratory chemicals, empty bottles of lab or
pharmacy chemicals, disinfectants that have expired or are
no longer needed, etc.
Pharmaceutical waste: Waste containing pharmaceutical
substances. Examples include: Expired, unused, and
contaminated pharmaceuticals, e.g., expired drugs,
vaccines and sera.
Genotoxic waste: Genotoxic waste consists of highly
187
Glossary
hazardous, mutagenic, teratogenic, or carcinogenic waste

containing substances with genotoxic properties. Examples
include: Cytotoxic and neoplastic drugs (used in cancer
treatment) and their metabolites and genotoxic chemicals.
Radioactive materials: Examples include: Unused liquids
from radiotherapy or laboratory research; contaminated
glassware, packages, or absorbent paper; urine and
excreta from patients treated or tested with unsealed
radionucleotides, etc.
Heavy metals: Heavy metal waste consists of both
materials and equipment with metals and derivatives.
Examples include: Batteries, broken mercury
thermometers, manometers.
Microbial flora of the The microbial flora of the skin can be divided into two
skin categories:
Resident microorganisms (“colonizing flora”) include
Staphylococcus species and diptheroids. These
microorganisms are considered permanent residents of the
skin and are not readily removed by mechanical friction.
Resident microorganisms in the deep layers may not be
removed by handwashing with plain soaps and detergents,
but they can usually be killed or inhibited by handwashing
with products that contain antimicrobial ingredients.
Transient non-colonizing flora include microorganisms that
come into contact with skin through interactions with
patients, with equipment, or with the environment. Non-
colonizing flora are not consistently present in the majority
of persons and survive only a limited period of time. These
organisms are primarily gram-negative bacilli and are often
acquired through activities that involve close contact with a
patient’s secretions or excreta. Non-colonizing flora are
easily removed by simple, efficient handwashing.
Microbiological The reduction of the number of pathogenic microorganisms

Clearance in a specimen below that detectable by conventional
means.
Microorganisms Organisms that can be seen only with the magnification of
a microscope. They exist everywhere in the environment -
in people, animals, plants, soil, air, and water and other
solutions.
188
Glossary
Minimal infective For every type of microorganism, the minimal infective

dose of a dose can be determined. This is the lowest number of
microorganism bacteria, viruses, or fungi that cause the first clinical signs
of infection in a healthy individual.
Nosocomial Nosocomial infections – known also as health care
infections (NI) associated infections, hospital-associated infections, and
=Health care hospital infections – are infections that are not present in
associated HAI the patient at the time of admission to the hospital but
develop during the course of the stay in the health care
facility. Hospital-acquired infections can appear after
discharge. Infections developed by personnel as a result of
working in a hospital are also considered to be nosocomial
infections.
Occupational The Occupational Safety and Health Administration

exposures (OSHA) in the United States defines occupational exposure
as any “reasonably anticipated skin, eye, mucous
membrane, or parenteral contact with blood or other
potentially infectious material(s) that may result from the
performance of an employee’s duties”.
Opportunistic Cause generalized disease only in patients with profoundly

Pathogens diminished resistance to infection.
Outbreak Two or more epidemiologically cases of infection linked in

place and/or time that are caused by the same
microorganism.
Pathogen A microorganism capable of producing disease.
Pathogenicity The ability of a microorganism to cause disease.
Peritoneal Dialysis Peritoneal dialysis removes toxins, electrolytes, and fluid

by diffusion through the peritoneal membrane. Peritoneal
dialysis requires placement of a catheter into the abdomen
for access and repeated infusion and drainage of dialysate.
Prevalence Rate The ratio of the total number of individuals who have a
disease at a particular time to the population at risk of
having the disease.
189
Glossary
Protective Isolation This type of isolation should be used for severely

or Environment immunocompromised patients who are highly susceptible
to and need protection from infection from both persons
and the environment and are not required in most facilities
unless there is a program for bone marrow transplantation.
See CDC Guidelines for HSCT .
Reservoir Any animate or inanimate focus in the environment in

which an infectious agent may survive and multiply and
which may act as a potential source of infection.
Routine Hand Wash Routine handwashing is the removal of dirt, organic

material, and transient microorganisms.
Scoop Technique One hand –recapping. This method is only recommended if

it is necessary, as recapping needles is dangerous.
Seroconversion The development of antibodies not previously present in a

host resulting from a primary infection.
Sharps-disposal A puncture-resistant container for disposal of used needles

container and syringes and other sharp objects, e.g., blades.
Source Isolation The aim of this isolation is to prevent the transfer of

microorganisms from infected patients who may act as a
source of infection to staff or to other patients. For certain
airborne transmissible infectious diseases the room should
be at negative pressure with respect to the corridor.
Source of The place in which a microorganism accumulates and from

nosocomial which a microorganism is directly transmitted to a
infections susceptible host.
Sporadic case A single case which has not been associated with other
cases, excreters, or carriers in the same period of time.
Standard Precautions A set of clinical practice recommendations to help minimize
the risk of exposure to infectious materials, such as blood
and other body fluids, by both clients and staff. Standard
precautions help break the disease-transmission cycle at
the mode of transmission step.
190
Glossary
Steam sterilization See Sterilization.

(autoclaving)
Sterile Free from all living microorganisms.
Sterile Service The sterile services department (SSD) is vital for an

Department (SSD) effective Infection Control program. Using its expertise and
knowledge of sterilization and of disinfection to ensure high
standards of cleanliness, an SSD always results in long-
term savings.
Sterilization The sterilization process eliminates all microorganisms
(bacteria, viruses, fungi, and parasites), including bacterial
endospores. Sterilization is recommended for instruments
and for other items that will come in contact with the
bloodstream or tissues under the skin. The three methods
of sterilization are:
Steam sterilization (autoclaving): This method requires
moist heat under pressure. For steam to be produced,
there must be sources of both water and heat. A heat
source is necessary to maintain the required temperature
and pressure.
Dry heat sterilization (electric oven): This method requires
heat for a specific period of time. For dry-heat sterilization
to be achieved, a constant supply of electricity is
necessary. Only glass or metal objects can be sterilized by
this method, because high temperatures are necessary for
sterilization to be achieved.
Chemical sterilization: This method is used for instruments
and other items that are heat-sensitive or when heat
sterilization is unavailable. Instruments and other items can
be sterilized by soaking them in a chemical solution, such
as a product containing glutaraldehyde, followed by rinsing
them in sterile water.
Surgical attire Attire such as gloves, caps, masks, and gowns that help
reduce the risk of post-procedure infections in clients by
reducing the likelihood that clients will be exposed to
potentially infectious microorganisms. In addition, this attire
– as well as protective eyewear, waterproof aprons, and
sturdy footwear – protects the service provider from
exposure to clients’ potentially infectious blood and other
body fluids.
191
Glossary
Surgical Scrub A surgical hand scrub is performed to remove transient

flora and to reduce resident flora for the duration of surgery
in case of glove tears.
Susceptible A person presumably not possessing sufficient resistance

(or immunity) against a pathogenic agent who contracts
infection when exposed to the agent.
Transmission The evolutionary formed ability of a pathogen to move from

mechanism one host individual to another. Under hospital conditions it
is realized only when the causative agents of traditional
infections are imported.
Transmission route The aggregate of transmission vectors operative under

specific conditions in a given infection.
Virulence Degree of pathogenicity (potential of a given

microorganism to cause disease in a definite host). The
concept includes infectivity, invasiveness, and toxicity.
Zoonosis An infectious disease transmissible from vertebrate

animals to humans.
192
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NATIONAL GUIDELINES

FOR INFECTION CONTROL

I encourage all health professionals providing health services to implement

I wish to express my sincere thanks to all colleagues that shared in the

Minister of Health and Population

The recommendations in this document originated from Egyptian and

Ms. Caroline Bodenschatz

Dr. Frank Mahoney

Dr. Maha Talaat

Dr. Amr Kandeel

Dr. Kenneth Earhart

Dr. Zoheir Hallaj

Dr. Khaled Abd El-Aziz Abulsaad

Dr. Ehab Attia

Dr. Ashraf El-Kilani

Dr. Mohamed Genedy

Infection Control Department - MOHP

High Nursing Institute

Dr. Shaheen Mehtar MBBS, FRC Path, Dept. of Community

World Health Organization

US Naval Medical Research Unit – No.3 (NAMRU-3)

List of Tables……………………….……………………….……………………. XIII

Importance of Infection Control in the Health Care Setting……………... 1

Functional Aspects of the Health Care Facility Infection Control

Types of Hand Hygiene……………………….……………………….………. 62

Personal Protective Equipment (PPE) ……………………….……………… 71

Isolation Precautions in Health Care Facilities (HCF) ……………………. 76

Occupational Safety and Employee Health…………………………………. 97

Control and Prevention of Antimicrobial Resistant Organisms in HCF.. 109

Linen Management……………………….……………………….…………...... 117

Environmental Cleaning……………………….……………………….………. 120

Cleaning, Disinfection, and Sterilization of Medical Equipment………... 137

Waste Management I……………………….……………………….…………... 168

Waste Management II: Safe Sharps Disposal………………………………. 178

Fig. 2 Hepatitis B transition 9

Fig. 3 Ways of infections transmission in Health Care Settings 15

Fig. 4 Organizational Structure 32

Fig. 5 Sites of the most common nosocomial infections 35

Fig. 6 Simplified example of steps in a surveillance system 35

Fig. 7 Intravenous Infusion System 43

Fig. 8 Sources and routes of transmission of infection from IV System 44

Fig. 11 Use of multi-dose vial 54

Fig. 12 Urinary Catheterization System 55

Fig. 13 Steps for Routine Hand Wash 64

Fig. 14 Handwashing Technique 65

Fig. 15 Frequently Missed Areas When Handwashing 66

Fig. 16 Sterile Gloves 71

Fig. 17 Non-sterile Gloves 72

Fig. 18 Utility Gloves 72

Fig. 19 Commonly used protective Barriers 75

Fig. 20 Sharps Injuries in Egypt 106

Fig. 21 Decontamination Steps 140

Fig. 22 Relation between type of item & its decontamination 142

Fig. 23 Steps for cleaning 144

Fig. 24 Steps for boiling 146

Fig. 26 Steps for wrapping instruments and other items 157

Fig. 27 Flow diagram of items processed in SSD 165

Fig. 29 Steps of Medical-Waste Management 172

Fig. 30 Waste transportation 173

Fig. 31 Burial pit 175

Fig. 32 Incinerator 176

Fig. 33 One Hand recapping technique 179

Fig. 34 Hands-free Technique 180

Fig. 35 Safety Boxes 181