Microbiology and Parasitology

Monette O. Bato
 Table of Contents

Module 5: Chain of Infection 74

Introduction 74
Learning Outcomes 75
Lesson 1. Pathogenicity and Chain of Infection 75
Lesson 2. Infection and Host Resistance 87
Lesson 3. Vaccines in the Elimination of Disease 94
Assessment Task 96
Summary 98
References 99

Module 2: Nosocomial Infections ad their Prevention and Control 103

Introduction 103
Learning Outcomes 104
Lesson 1. Nosocomial Infections 104
Lesson 2. Infection Prevention and Control 112
Assessment Task 123
Summary 125
References 126

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 MODULE 5
Chain of Infection

Introduction

As future health professionals, it is of utmost importance that you understand disease

causation and how spread of diseases can be prevented. This can be done through
understanding the “Chain of Infection” which refers to a series of events that has to take place in
order to cause an infection. We can think of each single event as being a separate link in the
chain, without which, infection will not occur.

Figure 5.1. Chain of infection (McKesson, n.d.)

In this module, we will study with the different links in the chain of infection and the role
each one plays in causing an infection. In gaining familiarity with infection transmission,
prevention control can be properly planned and implemented.
 Learning Outcomes

At the end of this module, students should be able to:

1. Demonstrate familiarity with the mechanisms of pathogens and the chain of infection;
2. Identify the mechanisms of the chain of infection and disease causation and clinical
management; and
3. Distinguish the different pathogenic microorganisms and how they penetrate their host with
emphasis on mode of transmission, signs and clinical manifestations.

Lesson 1. Pathogenicity and Chain of Infection

Infectious Agent

One of the links in the chain of infection is the infectious agent or pathogen. These

pathogens may either be viruses - such as Influenza, shingles and Hepatitis; bacteria – such as

Vibrio, E. coli and Staphylococcus; fungi – such as ringworm; protozoan – for example
Enatamoeba sp. and Giardia sp.; prions - which are the cause of rare progressive
neurodegenerative disorders such as Creutzfeldt-Jakob disease (CJD) (Fentiman, 2019).

As discussed in the previous sections, these infectious agents which we previously

referred to as microorganisms, are all around us and within us, and many plays very important

roles in keeping us healthy. The problem comes when it leaves its normal place to go elsewhere
in the body – for example, those that normally reside on your skin and which usually cause no

harm getting into a cut could then cause infection. There are also microorganisms that are not
helpful to health and which cause disease (Royal College of Nursing, n.d.).

There is no difference between an opportunistic pathogen and any other kind of pathogen.
Both are microbes and both have the potential to cause damage or disease in a host. As

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mentioned earlier, the definition that is often used for opportunistic pathogens is that these
microbes cause disease in people with impaired immunity but not in normal individuals. However,

this definition is purely operational because it can pertain to the same microbe. For example,
Candida albicans and Staphylococcus epidermidis can cause disease in one individual but live
harmlessly in others, which means that the same microbe would be called an opportunist in one
individual and a commensal in another. Indeed, the identification of certain microbes as a cause

of disease in certain hosts can unmask or be a sentinel for an underlying immunodeficiency

(Pirofski & Casadevall, 2012).

However, the determinants of pathogenicity and virulence for these microbes depend on
host and microbial factors, as is the case for all microbes. In order to survive and multiply in a

host, a successful pathogen must be able to: (1) colonize the host; (2) find a nutritionally
compatible niche in the host body; (3) avoid, subvert, or circumvent the host innate and adaptive

immune responses; (4) replicate, using host resources; and (5) exit and spread to a new host.
Under severe selective pressure to induce only the correct host cell responses to accomplish this
complex set of tasks, pathogens have evolved mechanisms that maximally exploit the biology of
their host organisms (Alberts, et al., 2002).

The variety of diseases that pathogens can differ in terms of severity. Some infections
may be mild, while others can be life threatening. For example, the common cold is a mild viral

infection compared with the lethal Ebola virus disease.

Commonly encountered terms when studying infectious agents, particularly bacteria and

virus are pathogenicity and virulence. Oftentimes, they are used interchangeably but are actually

different from each other with the latter being defined as the capacity of a microbe to cause

damage in a (susceptible) host. Virulence, on the other hand, is defined as the relative capacity

of a microbe to cause damage in a host. Although both pathogenicity and virulence can only
manifest in a susceptible host, pathogenicity is a discontinuous variable, that is, there is or is not

pathogenicity, whereas virulence is a continuous variable, that is, it is defined by the amount of

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damage or disease that is manifest. Virulence is a relative term for there is no absolute measure
of virulence and virulence is always measured relative to another microorganism (for example, an

attenuated strain, or a different species). Although they differ as delineated here, pathogenicity
and virulence are both microbial variables that can only be expressed in a susceptible host,

underscoring that each is dependent on host variables (Pirofski & Casadevall, 2012).

With the occurrence of the recent pandemic caused by the coronavirus COVID-19 that is

the defining global crisis of our time, we are made aware that novel pathogens continue to emerge

in human, domestic animal, wildlife and plant populations. In fact, this phenomenon is not a new
occurrence as every infectious disease has emerged at some time in the past. Smallpox most
likely jumped from a rodent host to humans and was maintained by human-to-human transmission

when agriculture and urban centers supported large enough populations to sustain continuous
spread without exhausting susceptible hosts. Mycobacterium tuberculosis may have evolved from

M. bovis, causing human infections after the domestication of cattle (Dong, Olano, McBride, &
Walker, 2008).

Emerging pathogens are those that have newly appeared in a population or have existed

but are rapidly increasing in incidence or geographic range with the greatest concern being the

pathogenic viruses. How long these viruses last on surfaces can play a role in the disease
transmission. SARS-CoV-2, the coronavirus that causes COVID-19, is an example of this.

Reservoir

A reservoir is any person, animal, arthropod, plant, soil or substance (or combination of

these) in which an infectious agent normally lives and multiplies, on which it depends primarily for
survival, and where it reproduces itself in such manner that it can be transmitted to a susceptible

host (A Train Education.com, n.d.).

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 There are two types of reservoir - animate which includes people, insects, birds, and other
animals and inanimate which includes soil, water, food, feces, intravenous fluid and equipment.

Human reservoirs

Many common infectious diseases have human reservoirs. Diseases that are transmitted

from person to person without intermediaries include the sexually transmitted diseases, measles,

mumps, streptococcal infection, and many respiratory pathogens. Because humans were the only

reservoir for the smallpox virus, naturally occurring smallpox was eradicated after the last human
case was identified and isolated (cdc.gov, n.d.).

There are two types of human reservoirs: clinical cases and carriers. Clinical cases are
people who are infected with the disease agent and become ill. Because they are ill, their contacts

and activities may be limited. They are also more likely to be diagnosed and treated than carriers.
Carriers, on the other hand, are people who harbor infectious agents but are not ill. Carriers may
present more risk for disease transmission than clinical cases, because their contacts are
unaware of their infection, and their activities are not restricted by illness. Depending on the

disease, there may be different types of carriers: incubatory carriers, inapparent infections,

convalescent carriers, chronic carriers (Cityandguilds.com, 2004).

Incubatory carriers are people who are going to become ill, but begin transmitting
their infection before their symptoms start. For example, in the case of measles, a person infected

with measles can pass the virus to others via nasal and throat secretions a day or two before any

symptoms are noticeable (Cityandguilds.com, 2004).

Inapparent carriers are those with subclinical infection where an immune response can

occur without overt clinical disease. The individual is 7asymptomatic but is carrying the infectious
agent (Cityandguilds.com, 2004).

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 Convalescent carriers, on the other hand, are people who continue to be infectious during
and even after their recovery from illness. This happens with many diseases. For example, with

salmonella, individuals may excrete the bacteria in feces for several weeks and (rarely) even for
a year or more. This is most common in infants and young children (Cityandguilds.com, 2004).

Lastly, chronic carriers are people who continue to harbor infections for a year or longer

after their recovery. For example, the chronic carrier state is not uncommon following hepatitis B

infection, whether or not the person became ill, and may be lifelong. Contaminated food may also

act as a reservoir of infection. A common example of this is the presence of salmonella. If food
contaminated with salmonella is not thoroughly cooked, individuals who consume it can become
infected (Cityandguilds.com, 2004).

Carriers commonly transmit disease because they do not realize they are infected, and

consequently take no special precautions to prevent transmission. Symptomatic persons who are
aware of their illness, on the other hand, may be less likely to transmit infection because they are
either too sick to be out and about, take precautions to reduce transmission, or receive treatment
that limits the disease (cdc.gov.nd.).

Table 5.1. Human reservoirs and transmission of infectious agents

Reservoir Transmission vehicle Infectious agent

Blood Blood, needle stick, other Hepatitis B and C; HIV/AIDS, Staphylococcus

contaminated equipment aureus,S. epidermis

Tissue Drainage from a wound or S. aureus, E. coli, Proteus species

incision

Gastrointestinal Vomitus, feces, bile, saliva Hepatitis A virus, Shigella species,

tract Salmonella species

Urinary tract Urine E. coli enterococci, Pseudomonas

aeruginosa

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 Reservoir Transmission vehicle Infectious agent

Reproductive tract Urine and semen Neisseria gonorrhoeae, Treponema pallidum,

and genitalia Herpes simplex virus type 2, Hepatitis B virus

Source: A Train Education.com

Animal reservoirs

Humans are also subject to diseases that have animal reservoirs. Many of these diseases

are transmitted from animal to animal, with humans as incidental hosts. The term zoonosis refers

to an infectious disease that is transmissible under natural conditions from vertebrate animals to

humans. Long recognized zoonotic diseases include brucellosis (cows and pigs), anthrax (sheep),
plague (rodents), trichinellosis/trichinosis (swine), tularemia (rabbits), and rabies (bats, raccoons,
dogs, and other mammals). Zoonoses newly emergent in North America include West Nile

encephalitis (birds), and monkeypox (prairie dogs). Many newly recognized infectious diseases

in humans, including HIV/AIDS, Ebola infection and SARS, are thought to have emerged from
animal hosts, although those hosts have not yet been identified (cdc.gov).

The new COVID-19 which is caused by the virus SARS-CoV-2 is thought to be most likely

have bats as their ecological reservoirs. It is believed further that the virus jumped the species
barrier to humans from another intermediate animal host. This intermediate animal host could be
a domestic food animal, a wild animal, or a domesticated wild animal which has not yet been

identified (World Health Organization, 2020).

Environmental reservoirs

Plants, soil, and water in the environment are also reservoirs for some infectious agents.
Many fungal agents, such as those that cause histoplasmosis, live and multiply in the soil.

Outbreaks of Legionnaires disease are often traced to water supplies in cooling towers and

evaporative condensers, reservoirs for the causative organism Legionella pneumophila

(cdc.gov).

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 Portal of Exit

The portal of exit is the path by which a pathogen leaves its host. It usually corresponds
to the site where the pathogen is localized. For example, influenza viruses and Mycobacterium
tuberculosis exit the respiratory tract, schistosomes through urine, cholera vibrios in feces ,
Sarcoptes scabiei in scabies skin lesions, and enterovirus 70, a cause of hemorrhagic
conjunctivitis, in conjunctival secretions. Some bloodborne agents can exit by crossing the

placenta from mother to fetus (rubella, syphilis, toxoplasmosis), while others exit through cuts or

needles in the skin (hepatitis B) or blood-sucking arthropods (malaria) (cdc.gov).

Mode of Transmission

The mode of transmission refers to how the pathogens move or transfer itself into a host.

The two main ways that an infection can be transmitted from its reservoir to a susceptible host via
direct transmission or indirect transmission. Direct transmission tends to be instantaneous and
occurs when there is direct contact with the infectious agent. Indirect transmission, on the other
hand, can occur through animate, inanimate mechanisms, or can also be airborne (Fentiman,

2019).

Direct transmission

In direct transmission, an infectious agent is transferred from a reservoir to a susceptible

host by direct contact or droplet spread (cdc.gov).

Direct contact occurs through skin-to-skin contact, kissing, and sexual intercourse. Hence,
infectious mononucleosis (“kissing disease”) and gonorrhea are classified as being directly

transmitted infections as they are spread from person to person by direct contact. Direct contact
can also refer to contact with soil or vegetation harboring infectious organisms. A specific example

is hookworm infection which is spread by direct contact with contaminated soil (cdc.gov).

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 Droplet spread refers to spray with relatively large, short-short range aerosols produced
by sneezing, coughing, and talking. It is classified as direct transmission because it occurs by

direct spray over a few feet (cdc.gov).

Transmission of respiratory infections such as COVID-19 is primarily via virus-laden fluid

particles (i.e., droplets and aerosols) that are formed in the respiratory tract of an infected person

and expelled from the mouth and nose during breathing. Talking, singing, coughing, and

sneezing. The competing effects of inertia, gravity, and evaporation determine the fate of these

droplets (A Train Education.com, n.d.).

Indirect transmission

Indirect transmission refers to the transfer of an infectious agent from a reservoir to a host

by suspended air particles, inanimate objects(vehicles), or animate intermediaries (vectors)

(cdc.gov).

Airborne transmission, according to the World Health Organization, “refers to the

transmission of disease caused by dissemination of droplet nuclei that remain suspended in air

over long distance and time”. Airborne dust includes material that has settled on surfaces and
become resuspended by air currents as well as infectious particles blown from the soil by the wind

(cdc.gov).

The microorganisms transmitted by an airborne route may be spread via fine mist, dust,

aerosols, or liquids. The aerosolized particles are generated from a source of infection such as

an infected patient or animal. In addition, aerosols may be generated from biological waste

products that accumulate in garbage cans, caves, and dry arid containers. In aerosolization, the

microorganisms that are less than 5 micrometers in size float in the air. Although a majority of the
particles will drop off within the vicinity, the infected aerosolized particles often remain suspended

in air and may even travel considerable distances (Bather, Mirza, & Edemekong, 2020).

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 Common vehicle transmission refers to transmission through a contaminated source.
Examples include food, water, biologic products such as blood, and fomites or inanimate objects.

A vehicle may passively carry a pathogen — as food and water may carry hepatitis A virus.
Alternatively, the vehicle may provide an environment in which the agent grows, multiplies, or

produces toxin— as improperly canned foods provide an environment that supports production of
botulinum toxin by Clostridium botulinum (cdc.gov).

Vector transmission occurs when a living organism carries an infectious agent on its body

(mechanical) or as an infection host itself (biological) to a new host (Lumenlearning.com, n.d.).

Examples of mechanical transmission are flies carrying Shigella on their appendages and fleas
carrying Yersinia pestis, the causative agent of plague, in their gut. Biological transmission

example, on the other hand, includes mosquitoes that are intermediate hosts of the causative
agents of malaria before it can be transmitted to humans (cdc.gov).

Vertical Transmission

Vertical transmission refers to the transfer of virus from parent to offspring, and may occur

via the ovum, across the placenta, during birth, or via the mother's milk. Viruses that cross the

placenta include rubella virus and cytomegaloviruses, which may cause congenital defects or
severe neonatal disease, and HIV (Baron, 1996).

Vertical transmission of cytomegalovirus may occur through the mother's milk, and both

cytomegalovirus and herpes simplex virus type 1 can be transmitted from parents to infants by

salivary contamination. Then, because of its long latency and the periodic recurrence of lesions,

the same virus may be transferred to the next generation. In small, isolated human populations,

infections with zoster-chickenpox may be maintained by a similar cycle, zoster in the grandmother

causing chickenpox in the grandchild by horizontal transmission. Perinatal transmission of

hepatitis B virus is important in much of Africa and Asia because it is common and often produces

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a persistent infection that may lead to cirrhosis of the liver or primary hepatocellular carcinoma.
(Baron, 1996).

Portal of Entry

Infectious agents get into the body through various portals of entry, including the mucous

membranes, non-intact skin, and the respiratory, gastrointestinal and genitourinary tracts (A Train

Education.com, n.d.).The portal of entry refers to the manner in which a pathogen enters a

susceptible host. The portal of entry must provide access to tissues in which the pathogen can
multiply or a toxin can act. Often, infectious agents use the same portal to enter a new host that
they used to exit the source host. For example, influenza virus exits the respiratory tract of the

source host and enters the respiratory tract of the new host. In contrast, many pathogens that
cause gastroenteritis follow a so-called “fecal-oral” route because they exit the source host in

feces, are carried on inadequately washed hands to a vehicle such as food, water, or utensil, and
enter a new host through the mouth. Other portals of entry include the skin (hookworm), mucous
membranes (syphilis), and blood (hepatitis B, human immunodeficiency virus) (cdc.gov).

The skin normally serves as a barrier to infection. However, any break in the skin,

intentional or unintentional, invites the entrance of pathogens. Percutaneous injury, surgical

incision, vascular access, and use of invasive devices all afford a portal of entry. (A Train

Education.com, n.d.)

The human body presents three large epithelial surfaces to the environment—the skin,

the respiratory mucosa, and the alimentary tract, and two lesser surfaces—the genital tract and

the conjunctiva. To gain entry to the body, viruses must either (1) infect cells in one of these

surfaces, (2) otherwise breach the surface (by trauma, the bite of an arthropod or animal, or

injection, transfusion or transplantation), or (3) be transmitted congenitally. Viruses escape from

the body via the same surfaces, often but not necessarily by the route used as a portal of entry

(Baron, 1996).

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 To simplify, examples of portals of entry include mouth, nose, eyes, and other anatomic
openings. It also includes breaks in the integrity of the skin brought about by rash or dermatitis,

insect bites, injuries, from microscopic to major surgical wounds, intravenous sites and any
location, whether anatomic or created, with a tube in place like needle-puncture injuries (Baron,

1996).

Susceptible Host

The final link in the chain of infection is a susceptible host. Susceptibility of a host depends
on genetic or constitutional factors, specific immunity, and nonspecific factors that affect an
individual’s ability to resist infection or to limit pathogenicity. An individual’s genetic makeup may

either increase or decrease susceptibility. For example, persons with sickle cell trait seem to be
at least partially protected from a particular type of malaria. (cdc.gov).

Infection does not occur automatically when the pathogen enters the body of a person
whose immune system is functioning normally. When a virulent pathogen enters an immune-
compromised person, however, infection is sure to follow. Host factors that influence the outcome

of an exposure include the presence or absence of natural barriers, the functional state of the

immune system, and the presence or absence of an invasive device (A Train Education.com,
n.d.).

A person with normal immune system function is described as immunocompetent.

Someone whose immune system is impaired by illness or age-related factors is said to be

immune-compromised. For example, a person with HIV/AIDS is immune-compromised (A Train

Education.com, n.d.).

The very young and the very old are also at risk for compromised immune function.
Infections are a major cause of death among newborns. Although babies receive certain

temporary immunities from their mothers through the placenta and in breast milk, their immune

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systems are still developing, making them vulnerable to infection. Aging also compromises
immune function, particularly in those who are hospitalized or in nursing homes.

Socioeconomic factors may also determine how likely it is that someone can become a

susceptible host for an infectious disease (Zoppi, n.d.). This may be associated to the fact that
socioeconomic status and nutritional status are related and the latter being a key factor in immune

function.

People with chronic disease may also be immune-compromised. People with diabetes
mellitus or peripheral vascular disease are at high risk for infection because of impaired
circulation. Medications can also impair immunity. For example, cancer drugs, anti-inflammatory

medications such as corticosteroids, and certain antibiotics can interfere with normal immune
function (Zoppi, n.d.)..

A person who underwent any surgical procedure carries the risk of infection because any
procedure that involves lymph node removal, such as modified radical mastectomy (removal of
the breast and axillary lymph nodes), carries a long-term risk of infection and lymphedema

(swelling) (A Train Education.com, n.d.).

Diagnostic or therapeutic procedures that involve an invasive device such as a urinary

catheter or a chest tube also increase the risk of infection. Caring for patients with these devices
demands strict attention to infection control standards and continuous monitoring for any sign of

infection or inflammation (A Train Education.com, n.d.).

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Lesson 2. Infection and Host Resistance

When a pathogenic microorganism invades the body for the first time, the clinical
(observable) response may range from nothing at all, through various degrees of nonspecific
reactions, to specific infectious disease. Immunologically, however, there is always a response,
the purpose of which is defense. If the defense is completely successful, there is no obvious bodily
reaction; if it is partially successful, the affected person exhibits symptoms but recovers from an
infectious disease; if unsuccessful, the person may be overwhelmed by the infectious process
and die (Infectious disease: Britanica.com, n.d.).

The immune system protects the body from possibly harmful substances by recognizing
and responding to antigens. Antigens are substances (usually proteins) on the surface of cells,
viruses, fungi, or bacteria. Nonliving substances such as toxins, chemicals, drugs, and foreign
particles (such as a splinter) can also be antigens. Furthermore, it recognizes and destroys, or
tries to destroy, substances that contain antigens (immune response: medlineplus.gov, n.d.).

Other examples of antigens include the proteins on the surfaces of bacteria, fungi and
viruses. When these antigens attach to special receptors on the immune cells (immune system
cells), a whole series of processes are triggered in the body. Once the body has come into contact
with a disease-causing germ for the first time, it usually stores information about the germ and
how to fight it. Then, if it comes into contact with the germ again, it recognizes the germ straight
away and can start fighting it faster (InformedHealth.org, 2020).

There are two subsystems within the immune system, known as the innate (non-specific)
immune system and the adaptive (specific) immune system. Both of these subsystems are closely
linked and work together whenever a germ or harmful substance triggers an immune response
(InformedHealth.org, 2020).

Innate Immunity

Innate, or nonspecific, immunity is the defense system with which you were born. It
protects you against all antigens. Innate immunity involves barriers that keep harmful materials
from entering your body. These barriers form the first line of defense in the immune response.

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Examples of innate immunity include cough reflex, enzymes in tears and skin oils, mucus, which
traps bacteria and small particles, skin, and stomach acid.

Innate immunity also comes in a protein chemical form, called innate humoral immunity.
Examples include the body's complement system and substances called interferon and
interleukin-1 (which causes fever).

If an antigen gets past these barriers, it is attacked and destroyed by other parts of the
immune system (medlineplus.gov, n.d.).

The innate immune system provides a general defense against harmful germs and
substances, so it’s also called the non-specific immune system. It mostly fights using immune
cells such as natural killer cells and phagocytes (“eating cells”). The main job of the innate immune
system is to fight harmful substances and germs that enter the body, for instance through the skin
or digestive system (medlineplus.gov, n.d.).

Furthermore, innate immune system responds to all pathogens which is made up of

physical barriers and internal defense. Before any immune factors are triggered, the skin functions
as a continuous, impassable barrier to potentially infectious pathogens. Pathogens are killed or
inactivated on the skin by desiccation (drying out) and by the skin’s acidity. In addition, beneficial
microorganisms that coexist on the skin compete with invading pathogens, preventing infection.
Regions of the body that are not protected by skin (such as the eyes and mucus membranes)
have alternative methods of defense, such as tears and mucus secretions that trap and rinse
away pathogens, and cilia in the nasal passages and respiratory tract that push the mucus with
the pathogens out of the body. Throughout the body are other defenses, such as the low pH of
the stomach (which inhibits the growth of pathogens), blood proteins that bind and disrupt
bacterial cell membranes, and the process of urination (which flushes pathogens from the urinary
tract) (opentextbc.ca, n.d.).

Despite these barriers, however, pathogens may enter the body through skin abrasions
or punctures, or by collecting on mucosal surfaces in large numbers that overcome the mucus or
cilia. Some pathogens have evolved specific mechanisms that allow them to overcome physical
and chemical barriers. When pathogens do enter the body, the innate immune system responds

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with inflammation, pathogen engulfment, and secretion of immune factors and proteins
(opentextbc.ca, n.d.).

The inflammatory response (inflammation) occurs when tissues are injured by bacteria,
trauma, toxins, heat, or any other cause. The damaged cells release chemicals including
histamine, bradykinin, and prostaglandins. These chemicals cause blood vessels to leak fluid into
the tissues, causing swelling. This helps isolate the foreign substance from further contact with
body tissues (medlineplus.gov, n.d.).

The chemicals also attract white blood cells called phagocytes that "eat" germs and
dead or damaged cells. This process is called phagocytosis. Phagocytes eventually die. Pus is
formed from a collection of dead tissue, dead bacteria, and live and dead phagocytes
(medlineplus.gov, n.d.).

Adaptive Immunity

The adaptive (specific) immune system makes antibodies and uses them to specifically
fight certain germs that the body has previously come into contact with. This is also known as an
“acquired” (learned) or specific immune response (medlineplus.gov, n.d.). The adaptive immune
system mounts a stronger, antigen-specific immune response after the innate immune response
fails to prevent a pathogen from causing an infection. There are two subdivisions of the adaptive
immune system: cell-mediated immunity and humoral immunity (med.libretxts.org, 2020).

Cell-Mediated Immunity

Cell mediated immunity is controlled by type 1 helper T cells (Th1) and cytotoxic T cells.
These cells are activated by antigen-presenting cells, which causes them to rapidly mature into
forms specific to that antigen. T cells then circulate through the body to destroy pathogens in
several ways. Helper T cells facilitate the immune response by guiding cytotoxic T cells to
pathogens or pathogen-infected cells, which they will then destroy (med.libretxts.org, 2020).

Cytotoxic T cells kill pathogens in several ways, including the release of granules that
contain the cytotoxins perforin and granzyme, which lyse small pores in the membrane of a
pathogen. Then T-cell produced proteases enter the pathogen and induce an apoptosis response

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within the cell. Helper T cells secrete cytokines such as interferon-gamma, which can activate
cytotoxic T cells and macrophages (med.libretxts.org, 2020).

Humoral Immunity

Humoral immunity refers to the component of the adaptive immune response that is
caused by B cells, antibodies, and type 2 helper T cells (Th2), as well as circulating mast cells
and eosinophils to a lesser extent. Its name comes from the idea that blood is one of the humors
of the body, since antibodies provide passive or active immunity through circulation in the
bloodstream (med.libretxts.org, 2020).

Type 2 helper T cells are included in the humoral immune system because they present
antigens to immature B-cells, which undergo proliferation to become specific to the presented
antigen. The B cells then rapidly produce a large number of antibodies that circulate through the
body’s plasma (med.libretxts.org, 2020) (med.libretxts.org, 2020).

Antibodies provide a number of functions in humoral immunity. Six different classes of

antibodies provide distinct functions and interact with different cells in the immune system. All
antibodies bind to pathogens to opsonize them, which makes it easier for phagocytic cells to bind
to and destroy the pathogen. They also neutralize the toxins produced by certain pathogens and
provide complement pathway activation, in which circulating proteins are combined in a complex
cascade that forms a membrane attack complex on a pathogen cell membrane, which lyses the
cell (med.libretxts.org, 2020).

Mast cells and eosinophils are considered part of the humoral immune system because
they can be sensitized towards certain antigens through circulating immunoglobin E (IgE), a
specific type of antibody produced by B cells. IgE binds to the mast cells and eosinophils when
an antigen is detected, using a type of Fc receptor on the mast cell or eosinophil that has a high-
binding affinity with IgE. This binding will cause degranulation and release of inflammatory
mediators that start an immune response against the antigen. This process is the reason why
memory B cells can cause hypersensitivity (allergy) formation, as circulating IgE from those
memory cells will activate a rapid inflammatory and immune response (med.libretxts.org, 2020).

Because the adaptive immune system is constantly learning and adapting, the body can
also fight bacteria or viruses that change over time (InformedHealth.org, 2020).

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 In many cases, acquired immunity is lifelong, as with measles or rubella. In other
instances, it can be short-lived, lasting not more than a few months. The persistence of acquired
immunity is related not only to the level of circulating antibody but also to sensitized T cells (cell-
mediated immunity). Although both cell-mediated immunity and humoral (B-cell) immunity are
important, their relative significance in protecting a person against disease varies with particular
microorganisms. For example, antibody is of great importance in protection against common
bacterial infections such as pneumococcal pneumonia or streptococcal disease and against
bacterial toxins, whereas cell-mediated immunity is of greater importance in protection against
viruses such as measles or against the bacteria that cause tuberculosis. (Infectious disease:
Britanica.com, n.d.)

Figure 5.1. Components of innate and adaptive immunity. Innate immunity mechanisms represent
the first barrier against infection (glycopedia.eu, n.d.).

Immunity may be passive or active. During passive immunity, antibodies made in another
person or animal enter the body and the immunity is short-lived. In the case of active immunity,
antigens enter the body and the body responds by making its own antibodies and B-memory cells.
In this case, immunity is longer lived although duration depends on the persistence of the antigen

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and the memory cells in the body. Both passive and active immunity can be either naturally or
artificially acquired (Kaiser, 2020).

Passive Immunity

Passive immunity is protection from a disease provided by antibodies created outside of

the body. It does not require previous exposure to a disease agent and takes effect immediately.
However, immunity acquired does not last long of only up to a few months (lumenlearning.com,
n.d.).

Naturally acquired passive immunity occurs during pregnancy, in which certain antibodies
are passed from the maternal blood into the fetal bloodstream in the form of IgG. Antibodies are
transferred from one person to another through natural means such as in prenatal and postnatal
relationships between mother and child. Some antibodies can cross the placenta and enter the
fetal blood. This provides some protection for the child for a short time after birth, but eventually
these deteriorate and the infant must rely on its own immune system. Antibodies may also be
transferred through breast milk. The transferred IgG from mother to fetus during pregnancy
generally lasts 4 to 6 months after birth. The immune responses reach full strength at about age
5 (lumenlearning.com, n.d.).

Passive immunity Lactobacillus bifidus can also be in the form of IgA and IgG found in
human colostrum and milk of babies who are nursed. In addition to the IgA and IgG, human milk
also contains: oligosaccharides and mucins that adhere to bacteria and viruses to interfere with
their attachment to host cells; lactoferrin to bind iron and make it unavailable to most bacteria;
B12 binding protein to deprive bacteria of needed vitamin B12; bifidus factor that promotes the
growth of, normal flora in the gastrointestinal tract of infants that crowds out harmful bacteria;
fibronectin that increases the antimicrobial activity of macrophages and helps repair tissue
damage from infection in the gastrointestinal tract; gamma-interferon, a cytokine that enhances
the activity of certain immune cells; hormones and growth factors that stimulate the baby’s
gastrointestinal tract to mature faster and be less susceptible to infection; and lysozyme to break
down peptidoglycan in bacterial cell walls (lumenlearning.com, n.d.).

Passive immunity can be induced artificially when antibodies are given as a medication to
a nonimmune individual. These antibodies may come from the pooled and purified blood products

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of immune people or from non-human immune animals, such as horses. In fact, the earliest
antibody-containing preparations used against infectious diseases came from horses, sheep, and
rabbits (historyofvaccines.org, 2018). These antibody-containing preparations are termed
antiserum. The rabies vaccine and snake antivenom are two examples of antiserums that yield
passive immunity (technologynetworks.com, 2020).

Convalescent plasma therapy is a passive immunization process used as a potential

therapy for COVID-19. It is simply the transfusion of plasma containing antibodies from immune
survivors of infectious diseases to the affected individuals. Plasma is a light yellowish fluid which
makes more than half of the blood’s volume. Since the transfer happens artificially it is classified
immunity acquired through this method is classified as artificial passive immunity
(technologynetworks.com, 2020).

Active Immunity

Active immunity results when exposure to a disease organism triggers the immune system
to produce antibodies to that disease. Unlike passive immunity, active immunity is long-lasting,
and sometimes life-long. However, immunity does not happen immediately upon disease
exposure but can take days or weeks after the first exposure for it to develop.

Active immunity is also classified as either natural or artificial.

Naturally acquired active immunity refers to the natural exposure to an infectious agent or
other antigen by the body and the body responds by making its own antibodies. Wild infection for
example with hepatitis A virus (HAV) and subsequent recovery gives rise to a natural active
immune response usually leading to lifelong protection (Baxter, 2007).

Artificial acquired active immunity is also called vaccine-induced immunity where a person
can build a resistance to a disease following an immunization. An immunization is defined as the
process by which someone becomes protected against a specific disease via the administration
of a vaccine (technologynetworks.com, 2020).

The process of acquiring artificial immunity through vaccination will be discussed in the
next section.

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Lesson 3. Vaccines in the Elimination of Disease
The terms ‘vaccination’ and ‘immunization’ are oftentimes used interchangeably.
However, they do not have the same meaning. Vaccination is the term used for getting a vaccine
– that is, actually getting the injection or taking an oral vaccine dose. Immunization, on the other
hand, refers to the process of both getting the vaccine and becoming immune to the disease
following vaccination (healthdirect.gov.au, n.d.).

Vaccination is a way to “teach” the immune system how to recognize and eliminate an
organism. That way, the body is prepared if it ever gets exposed. They are an important form of
primary prevention as they have allowed us to control diseases that once threatened many lives,
such as measles, polio, tetanus, and whooping cough among others. Vaccination teaches the
body to recognize new diseases. It stimulates the body to make antibodies against antigens of
pathogens. It also primes immune cells to remember the types of antigens that cause infection
which allows for a faster response to the disease in the future (healthline.com, n.d.).

Types

There are several different types of vaccines and each type is designed to teach the
immune system how to fight off certain kinds of germs — and the serious diseases they cause.
During the creation of vaccines, the following things are considered. These considerations are
how the immune system responds to the germ, who needs to be vaccinated against the germ,
and the best technology or approach to create the vaccine. Based on a number of these factors,
scientists decide which type of vaccine they will make. There are 4 main types of vaccines and
these are: live-attenuated vaccines, inactivated vaccines, subunit, recombinant, polysaccharide,
and conjugate vaccines, and toxoid vaccines (vaccines.gov, n.d.).

1. Live-attenuated vaccines

Live vaccines use a weakened (or attenuated) form of the germ that causes a disease.
Because these vaccines are so similar to the natural infection that they help prevent, they create
a strong and long-lasting immune response. Just 1 or 2 doses of most live vaccines can give you
a lifetime of protection against a germ and the disease it causes (vaccines.gov, n.d.).

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 An advantage of this type of vaccine is that because it introduces actual live pathogens
into the body, it is an excellent simulation for the immune system. So live attenuated vaccines can
result in lifelong immunity with just one or two doses (vaccines.gov, n.d.).

However, because they contain living pathogens, live attenuated vaccines are not given
to people with weakened immune systems, such as people undergoing chemotherapy or HIV
treatment, as there is a risk the pathogen could get stronger and cause sickness. Additionally,
these vaccines must be refrigerated at all times so the weakened pathogen doesn't die. Specific
vaccines of this type are those used to prevent measles, mumps, rubella (MMR combined
vaccine), varicella (chickenpox), influenza (nasal spray), and rotavirus (publichealth.org, n.d.)

2. Inactivated vaccines

Inactivated vaccines use the killed version of the germ that causes a disease. These
vaccines usually don’t provide immunity (protection) that’s as strong as live vaccines. There may
be a need for several doses over time (booster shots) in order to get ongoing immunity against
diseases. Some of the diseases that they provide protection are against hepatitis A, flu (shot only),
polio (shot only), and rabies (vaccines.gov, n.d.).

3. Subunit, recombinant, polysaccharide, and conjugate vaccines

Subunit, recombinant, polysaccharide, and conjugate vaccines use specific pieces of the
germ — like its protein, sugar, or capsid (a casing around the germ). Because these vaccines use
only specific pieces of the germ, they give a very strong immune response that’s targeted to key
parts of the germ. They can also be used on almost everyone who needs them, including people
with weakened immune systems and long-term health problems. One limitation of these vaccines
is that booster shots to may be needed get ongoing protection against diseases. These vaccines
are used to protect against Hib (Haemophilus influenzae type b) disease, hepatitis B, HPV
(Human papillomavirus), whooping cough (part of the DTaP combined vaccine), pneumococcal
disease, meningococcal disease, and shingles (vaccines.gov, n.d.).

4. Toxoid vaccines

Some bacterial diseases damage the body by secreting harmful chemicals or toxins. For
these bacteria, scientists are able to "deactivate" some of the toxins using a mixture of

95
formaldehyde and water. These dead toxins are then safely injected into the body. The immune
system learns well enough from the dead toxins to fight off living toxins, should they ever make
an appearance. Specific examples of this type of vaccine are those used to prevent diphtheria
and tetanus (publichealth.org, n.d.).

The future of vaccines

Scientists are still working to create new types of vaccines. Examples of this are DNA
vaccines which are easy and inexpensive to make which also produce strong, long-term immunity
and recombinant vector vaccines (platform-based vaccines), which act like a natural infection, so
they're especially good at teaching the immune system how to fight germs (vaccines.gov, n.d.).

Assessment Task 5-1

1. How does the immune system distinguish normal microflora from pathogens?

2. Can the emergence of new pathogens be predicted?

3. Think about your future work setting. What key factors can you identify that might make it
more likely that infection will occur, and how are those factors managed?

4. Discuss the chain of infection for the following infections. Furthermore, discuss the
various means by which the chain can be broken taking each link into consideration.

a. Ascariasis

b. Athletes foot

c. Malaria

d. COVID-19

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 Assessment Task 5-2

1. Differentiate the following and give specific examples

a. innate vs. acquired immunity
b. natural vs artificial immunity
c. passive and active immunity
2. Explain how having stress affect the immune system.
3. Explain the difference between the first and second lines of body defenses against
infection by pathogen
4. Explain herd immunity.

Assessment Task 5-3

1. Explain how vaccines work.

2. Are all vaccines 100% effective in preventing diseases? Why or why not?
3. Why do some vaccines require booster doses?
4. Why is there a new flu vaccine every year?

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 Summary

Infectious diseases can be transmitted from one person to another through the process

called the chain of infection. The chain is composed of a series of events or links as follows:

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible
host. This process will occur for as long as all six links in the chain are intact. It is therefore

important in infection control to know the measures that can be taken in order to break the links.

The immune system functions to prevent and retard the local establishment or systemic
dissemination of pathogens. It functions on two levels, innate and adaptive where the former
provides early but short -lasting protection and the latter developing more slowly but delivering
precise antigen-specific responses with immunological memory.

Further classifications of adaptive immunity are active and passive immunity. Both can
also be further classified into being natural and artificial. In passive immunity, antibodies are given
to a person to prevent disease or to treat disease after the body is exposed to an antigen
(artificial). Passive immunity is also given from mother to child through the placenta before birth,
and through breast milk after birth (natural). This type of immunity is fast acting but lasts only a
few weeks or months. In active immunity, antibodies develop in a person's own immune system
after the body is exposed to an antigen through a disease (natural) or through immunization
(artificial). This type of immunity lasts for a long time.

Vaccines provide active immunity to disease. It protects the body from infection by tricking
it into believing it has a disease, so it can fight the disease. There are many approaches to vaccine
development, but vaccines can be broadly classified by how the antigen(s), the active
component(s) that generate a specific immune response against the disease-causing organism,
are prepared. Vaccines may be viral (live or inactivated), viral vector, subunit (protein or
polysaccharide) or nucleic acid (DNA or RNA). Combination vaccines may include inactivated,
protein-based and/or protein-conjugated polysaccharide vaccine components. Other ingredients
in vaccines vary depending on the manufacturing process and the nature of the antigen(s)
(immune.org.nz, 2020).

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https://www.atrainceu.com/content/1-examining-chain

Alberts, B., Johnson, A., Lewis, J., Raff, M., Roberts, K., & Walter, P. (2002). Molecular Biology
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Baron, S. (1996). Medical Microbiology 4th edition. The University of Texas Medical Branch at
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Bather, B., Mirza, T. M., & Edemekong, P. F. (2020). Airborne Precautions. Florida: StatPearls
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Baxter, D. (2007). Active and passive immunity, vaccine types, excipients and licensing.
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disease/Immunization

CDC.gov. (n.d.). Chain of infection

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CDCgov. (n.d.). Infection Control: cdc.gov. https://www.cdc.gov/infectioncontrol/basics/standard-

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Fentiman, R. (2019, June 11). What are the 6 links in the chain of infection: hygiene-solutions.co.
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Fentiman, R. (2019, June 11). What are the 6 links in the chain of infection? https://www-hygiene-
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Glycopedia.eu. (n.d.). Overview of the immune responses. http://www.glycopedia.eu/e-

chapters/Overview-of-Immune-Responses-A-Primer-72/Innate-Adaptative-Passive-
Active-Immunities

Healthdirect.gov.au. (n.d.). Immunization or vaccination what's the difference.

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the-difference

Healthline.com. (n.d.). Everything you need to know about vaccination: healthline.com .

https://www.healthline.com/health/vaccinations#schedule

Historyofvaccines.org. (2018, January 10). Passive immuniztion: historyofvaccines.org .

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Immune.org.nz. (2020, September). Vaccines: https://www.immune.org.nz/vaccines/vaccine-

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Lumenlearning.com. (n.d.). Boundless microbiology:

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resources/infection-prevention/break-chain-infection-hand-hygiene-best-practices/

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 MODULE 6

Nosocomial Infections and their Prevention and

Control

Introduction

Nosocomial infections which is also called healthcare associated infections (HAI) occur in
patients under medical care. As these infections occur during hospital stay, they cause prolonged
stay, disability, and economic burden. Transmission usually occurs via healthcare workers,
patients, hospital equipment, or procedures. The most common sites of infection are the urinary
tracts, lungs, bloodstreams, and surgical wounds.

Microbial control means the inhibition or prevention of microorganisms’ growth. This

control can be achieved through by either killing microorganisms or by inhibiting their growth. The
process of microbial control usually involves the use of physical or chemical agent that kill or
inhibit growth of microorganisms.

In this module, we will study with nosocomial infections, how they occur and their common
sites. We will also study ways of controlling microbial growth in order to control disease
transmission focusing on health settings.
 Learning Outcomes

At the end of this module, students should be able to:

1. Demonstrate familiarity with the principles of healthcare associated infections; and

2. Identify the processes of controlling the growth of microorganisms including the actions of
control agents.

Lesson 1. Nosocomial Infections

The term "nosocomial" comes from two Greek words: "nosus" meaning "disease" +
"komeion" meaning "to take care of." Hence, "nosocomial" should apply to any disease contracted
by a patient while under medical care. However, common usage of the term "nosocomial" is now
synonymous with hospital-acquired. Nosocomial infections are infections that have been caught
in a hospital and are potentially caused by organisms that are resistant to antibiotics. A
nosocomial infection is specifically one that was not present or incubating prior to the patient's
being admitted to the hospital, but occurring within 72 hours after admittance to the hospital (Shiek
Jr, n.d.).

Nosocomial pathogens include bacteria, viruses and fungal parasites. According to WHO
estimates, approximately 15% of all hospitalized patients suffer from these infections. During
hospitalization, patient is exposed to pathogens through different sources environment,
healthcare staff, and other infected patients. Transmission of these infections should be restricted
for prevention. Hospital waste serves as potential source of pathogens and about 20%–25% of
hospital waste is termed as hazardous (Khan, Baig, & Mehboob, 2017).

Nosocomial or ‘hospital’ infection were formerly so named to mark their hospital origin.
The term ‘health care-associated infection’ (HAI) is now used to take into account more
appropriately the patient care process in today’s complex health care systems, often involving
long-term, rehabilitation, ambulatory, and home care. HAI is one of the most common medical
complications affecting patients in intensive care units (ICUs) (Landelle & Pittet, 2016).

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 HAI is defined by the World Health Organization (WHO) as “an infection occurring in a
patient during the process of care in a hospital or other health care facility, which was not present
or incubating at the time of admission. This includes infections acquired in the health care facility,
but appearing after discharge, and also occupational infections among health care workers
(HCWs) of the facility” (who.int, 2010).

Types of nosocomial infections

There are four most frequent types of nosocomial infections and they are: central line-
associated bloodstream infections, catheter-associated urinary tract infections, surgical site
infections and ventilator-associated pneumonia.

Central line-associated bloodstream infections

A central line-associated bloodstream infection (CLABSI) is defined as a laboratory-

confirmed bloodstream infection not related to an infection at another site that develops at least
2 days following insertion of central venous catheter. Although the central venous catheter
facilitates patients’ treatment, it is associated with a variety of complications such as thrombosis,
embolism formation and infection. Of all the healthcare-associated infections, CLABSIs are
associated with high-cost burden (Aloush & Alsaraireh, 2018). Most cases however, are
preventable with proper aseptic techniques, surveillance, and management strategies.

Central lines are of two types: (1) Tunneled catheters are implanted surgically (by creating
a subcutaneous track before entering vein) into the internal jugular, subclavian, or femoral vein
for long-term (weeks to months) use such as chemotherapy or hemodialysis and (2) Non-tunneled
catheters, more commonly used. They are temporary central venous catheters that are inserted
percutaneously and account for most CLABSIs. Within 7 to 10 days of central venous catheter
placement, bacteria on the skin surface migrate along the external surface of the catheter from
the skin exit site towards the intravascular space. (Haddadin, Annamaraju, & Regunath, 2020).

There are many different ways that contamination can occur of the central line and cause
a central line-related infection (ausmed.com, 2020).

 Contamination on insertion;

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  The patient’s skin flora;
 The healthcare professional accessing the central venous access device;
 Central venous access devices (CVAD) hub colonization;
 Contaminated infusion or components of IV set;
 Hematogenous spread from other sites (e.g. through the bloodstream from another
infection); and
 Non-intact dressing.
 Patient-related risk factors for developing a CLABSI include:
 Immunosuppression;
 Increased age;
 Poor nutrition;
 Impaired skin integrity;
 Other infection;
 Multiple invasive procedures;
 Antibiotic therapy;
 Certain comorbidities such as diabetes and vascular disease;
 Parenteral nutrition;
 Position of central line can also increase the risk of infection if it is femoral or
internal jugular; and
 Lengthy hospitalization before venous catheterization.
 Other risk factors include:
 Poor patient hygiene;
 Healthcare workers using poor hand hygiene;
 Non-adherence to aseptic technique;
 Type of central line and number of lumens;
 If it was an emergency insertion;
 Non-compliance with central line maintenance, such as not using antiseptics or not
completing dressing changes; and
 Prolonged duration of the catheter

Symptoms of CLABSI includes fever, chills, fast heart rate, redness, swelling, or
tenderness at the catheter site, and drainage from catheter site (winchesterhospital.org, n.d.)

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 Catheter associated urinary tract infections (CAUTI)

A catheter-associated urinary tract infection (CAUTI) is one of the most common infections
a person can contract in the hospital. Indwelling catheters are the cause of this infection. An
indwelling catheter is a tube inserted into the urethra which drains urine from the bladder into a
collection bag. A catheter may be needed after surgery or if bladder function cannot be controlled,
and when there is a need to closely monitor how much urine the kidneys are producing
(Healthline.com, 2017).

The definition of CAUTI falls into two groups: symptomatic urinary tract infection and
asymptomatic bacteremia urinary tract infection. It includes those infections in which a patient had
an indwelling urinary catheter at the time or within 48 hours before onset of the event. There is no
minimum period of time that the catheter must be in place in order for the UTI to be considered
catheter-associated. Among urinary tract infections acquired in the hospital, approximately 75%
area associated with a urinary catheter. (idph.iowa.gov, n.d.).

A CAUTI has similar symptoms to a typical urinary tract infection (UTI). Symptoms include
cloudy urine, blood in the urine, strong urine odor, urine leakage around the catheter, pressure,
pain, or discomfort in the lower back or stomach, chills, fever, unexplained fatigue, and vomiting.
It can be difficult to diagnose if patient is already hospitalized because similar symptoms may be
part of the original illness. In elderly people, changes in mental status or confusion can be signs
of a CAUTI (Healthline.com, 2017).

There are a number of ways infection can occur during catheterization. For example, the
catheter may become contaminated upon insertion, the drainage bag may not be emptied often
enough, bacteria from a bowel movement may get on the catheter, urine in the catheter bag may
flow backward into the bladder, the catheter may not be regularly cleaned (Healthline.com, 2017).

A CAUTI is diagnosed using a urine test. Urinalysis can detect blood cells in the urine.
Their presence may signal an infection. Another useful test is a urine culture. This test identifies
any bacteria or fungi in the urine (Healthline.com, 2017).

Prompt treatment of a CAUTI is essential. An untreated UTI can lead to a more serious
kidney infection. There are an estimated 13,000 annual death attributed to CAUTI. In addition,

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people with catheters may already have conditions that compromise their immune systems.
Fighting off a CAUTI can cause further immune system stress.

CAUTI can be prevented by things such as hand washing, not using urine drain tubes and
if they must be used, inserting them properly and keeping them clean. Catheters should be put in
only when necessary, and removed as soon as possible. Core prevention strategies include
insertion of catheters only for appropriate indications, leaving catheters in place only as long as
needed, ensuring that only properly trained persons insert and maintain catheters, insertion of
catheters using aseptic technique and sterile equipment (acute care setting), following aseptic
insertion, maintaining a closed drainage system, maintaining unobstructed urine flow, and hand
hygiene as well as using standard precautions (idph.iowa.gov, n.d.).

Surgical site infections (SSI)

A surgical site infection (SSI) is an infection that occurs after surgery in the part of the
body where the surgery took place. Surgical site infections can sometimes be superficial
infections involving the skin only. Other surgical site infections are more serious and can involve
tissues under the skin, organs, or implanted material (cdc.gov, n.d.). SSIs are nosocomial
infections be fall in 2%–5% of patients subjected to surgery. These are the second most common
type of nosocomial infections mainly caused by Staphylococcus aureus resulting in prolonged
hospitalization and risk of death. The pathogens causing SSI arise from endogenous microflora
of the patient. The incidence may be as high as 20% depending upon procedure and surveillance
criteria used (Khan, Baig, & Mehboob, 2017).

An SSI typically occurs within 30 days after surgery. The CDC describes 3 types of surgical
site infections:

1. Superficial incisional SSI. This infection occurs just in the area of the skin where the
incision was made.
2. Deep incisional SSI. This infection occurs beneath the incision area in muscle and the
tissues surrounding the muscles.
3. Organ or space SSI. This type of infection can be in any area of the body other than
skin, muscle, and surrounding tissue that was involved in the surgery. This includes a
body organ or a space between organs (Johns Hopkins Medicine, n.d.).

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 Signs and symptoms of surgical site infections include redness, delayed healing, fever,
pain, tenderness, warmth, or swelling. These are the other signs and symptoms for specific types
of SSI (Johns Hopkins Medicine, n.d.):

1. A superficial incisional SSI may produce pus from the wound site. Samples of the pus
may be grown in a culture to find out the types of germs that are causing the infection.
2. A deep incisional SSI may also produce pus. The wound site may reopen on its own,
or a surgeon may reopen the wound and find pus inside the wound.
3. An organ or space SSI may show a discharge of pus coming from a drain placed
through the skin into a body space or organ. A collection of pus, called an abscess, is
an enclosed area of pus and disintegrating tissue surrounded by inflammation. An
abscess may be seen when the surgeon reopens the wound or by special X-ray
studies (Johns Hopkins Medicine, n.d.).

Infections after surgery are caused by germs. The most common of these include the
bacteria Staphylococcus, Streptococcus, and Pseudomonas . Germs can infect a surgical wound
through various forms of contact, such as from the touch of a contaminated caregiver or surgical
instrument, through germs in the air, or through germs that are already on or in the body and then
spread into the wound (Johns Hopkins Medicine, n.d.).

Important patient-related factors for SSI include existing infection, low serum albumin
concentration, older age, obesity, smoking, diabetes mellitus, and ischemia secondary to vascular
disease or irradiation. Surgical risk factors include prolonged procedures and inadequacies in
either the surgical scrub or the antiseptic preparation of the skin. Physiological states that increase
the risk of SSI include trauma, shock, blood transfusion, hypothermia, hypoxia, and
hyperglycemia. Parameters that may be associated independently with an increased risk of SSI,
and that may predict infection, include abdominal surgery, a contaminated or dirty operation, and
more than three diagnoses at the time of discharge. The major sources of infection are
microorganisms on the patient's skin and, less often, the alimentary tract or female genital tract.
The organism most often isolated is Staphylococcus aureus, which often is resistant to methicillin.
Antibiotic-resistant bacteria are a continuing and increasing problem (Cheadle, 2006).

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 To prevent SSIs, doctors, nurses, and other healthcare providers should follow CDC
infection prevention guidelines including cleaning their hands and arms up to their elbows with an
antiseptic agent just before the surgery, cleaning their hands with soap and water or an alcohol-
based hand rub before and after caring for each patient. If indicated, removing some of the
patient’s hair immediately before your surgery using electric clippers if the hair is in the same area
where the procedure will occur. Wearing special hair covers, masks, gowns, and gloves during
surgery to keep the surgery area clean is also done to reduce the risk of SSIs. When indicated,
antibiotics may also be given before your surgery starts. In most cases, the antibiotics are given
within 60 minutes before the surgery starts and they should be stopped within 24 hours after
surgery. Cleaning the skin at the site of surgery with a special soap that kills germs can also
prevent SSI (cdc.gov, n.d.).

Ventilator associated pneumonia (VAP)

VAP is nosocomial pneumonia found in 9–27% of patients on mechanically assisted

ventilator. It usually occurs within 48 hours after tracheal incubation. 86% of nosocomial
pneumonia is associated with ventilation (Khan, Baig, & Mehboob, 2017). Ventilator-associated
pneumonia (VAP) results from the invasion of the lower respiratory tract and lung parenchyma by
microorganisms. Intubation compromises the integrity of the oropharynx and trachea and allows
oral and gastric secretions to enter the lower airways.

Endotracheal intubation is the major risk factor for ventilator-associated pneumonia.

Endotracheal intubation breaches airway defenses, impairs cough and mucociliary clearance,
and facilitates microaspiration of bacteria-laden secretions that pool above the inflated
endotracheal tube cuff. In addition, bacteria form a biofilm on and within the endotracheal tube
that protects them from antibiotics and host defenses. The highest risk of VAP occurs during the
first 10 days after intubation. Ventilator-associated pneumonia occurs in 9 to 27% of mechanically
ventilated patients (Sethi, 2019).

Many risk factors for the development of VAP have been identified. They can be
differentiated into modifiable and nonmodifiable risk factors and into patient-related and
treatment-related risk factors. Nonmodifiable patient-related risk factors include male sex,
preexisting pulmonary disease, coma, AIDS, head trauma, and multiple-organ system failure.

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Nonmodifiable treatment-related risk factors include the necessity of neurosurgery, monitoring of
intracranial pressure, reintubation, or transportation out of ICU. Pathogens and antibiotic
resistance patterns vary significantly among institutions and can vary within institutions over short
periods (eg, month to month). Local antibiograms at the institutional level that are updated on a
regular basis are essential in determining appropriate empiric antibiotic therapy. In general, the
most important pathogens are Pseudomonas aeruginosa, methicillin-sensitive Staphylococcus
aureus, and methicillin-resistant S. aureus (MRSA) (Weinstein, Bonten, Kollef, & Hall, 2004).

Patient-related risk factors for VAP are intubation, duration of mechanical ventilation,
aspiration of gastric or oropharyngeal contents that are contaminated with colonizing flora, enteral
nutrition, use of antacids, and ventilator circuit-related factors (Weinstein, Bonten, Kollef, & Hall,
2004).

The symptoms are like the symptoms of other types of pneumonia and includes fever and
chills, cough, shortness of breath, chest pain, and coughing up mucus (Summit Medical Group,
n.d.).

VAP can be accurately diagnosed by any one of several standard criteria: histopathologic
examination of lung tissue obtained by open lung biopsy, rapid cavitation of a pulmonary infiltrate
in the absence of cancer or tuberculosis, positive pleural fluid culture, same species with same
antibiogram isolated from blood and respiratory secretions without another identifiable source of
bacteremia, and histopathologic examination of lung tissue at autopsy (Mayhall, 2001).

Control of Nosocomial Infection

Being a significant cause of illness and death, nosocomial infections need to be prevented
from the base line so that their spread can be controlled.

Since unhygienic environment serves as the best source for the pathogenic organism to
prevail, there must be policies to ensure the cleaning and use of cleaning agents on walls, floor,
windows, beds, baths, toilets and other medical devices. Proper ventilated and fresh filtered air
should be in place to eliminate airborne bacterial contamination. Regular check of filters and
ventilation systems of general wards, operating theatres and ICUs must be maintained and
documented. Microbiological monitoring methods should be used for water analysis. Infected
patients must be given separate baths.

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 Infections can be transferred from healthcare staff. Therefore, it is the duty of healthcare
professionals to take role in infection control. This is where personal hygiene and wearing of
personal protective equipment (PPE) becomes important. Infectious healthcare waste should be
stored in restricted areas as they serve as reservoirs of pathogens.

Healthcare Institutes should devise control programs against these infections.

Administration, workers and individuals admitted or visiting hospital must take into account such
programs to play their role in prevention of infections. (Khan, Baig, & Mehboob, 2017).

Lesson 2. Infection Prevention and Control

Infection prevention and control (IPC) is a scientific approach and practical solution
designed to prevent harm caused by infection to patients and health workers. It is grounded in
infectious diseases, epidemiology, social science and health system strengthening. IPC occupies
a unique position in the field of patient safety and quality universal health coverage since it is
relevant to health workers and patients at every single health-care encounter (World Health
Organization, n.d.).

IPC practices are evidence-based procedures and practices that can prevent and reduce
disease transmission, and eliminate sources of potential infections (Provincial Infectious Diseases
Advisory Committee (PIDAC), 2012). When used consistently, IPAC practices will prevent the
transfer of health care associated infections (HAIs) in all health care settings.

Medical and Surgical Asepsis

Two types of techniques are used to prevent infection in the hospital setting. The first,
medical asepsis, or clean technique and second, surgical asepsis, also known as sterile
technique. The difference between the two is given below:

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Table 6.1. Differences between medical and surgical asepsis
Criteria Medical asepsis
Definition All of the procedures used to
protect the patient and his
environment from the spread
of infectious organisms.
Emphasis Cleanliness (freedom from
most pathogenic organisms).
Purpose To reduce the transmission of
pathogenic organisms from
patient to another person.
Isolation Patients with a communicable
disease are separated from
the rest of the patients by
room, ward, or unit.
Zone A zone about the isolation unit
is established as
contaminated. Everything
within the zone of isolation is
contaminated. Nothing goes
out of the zone without being
disinfected or wrapped in a
clean cover to permit handling
in a clean zone.
Handwashing Hands and forearms are
washed for 1 to 2 minutes to
remove surface contaminants
and soil. Hands and arms are
dried with paper towels.
Gowns Clean gowns are worn to
protect the worker. Inside of
gown is clean; outside of gown
Surgical asepsis
All of the procedures used to sterilize and to
keep sterile any objects or articles that are
to be introduced into a wound or body cavity
or that is to penetrate the skin.
Sterility (freedom from all microorganisms).
To prevent introduction of any organism into
an open wound on the patient or into a body
cavity.
Patients requiring surgery are taken to the
operating room of the hospital.
A zone about the site of operation or wound
is established as a sterile field. Once a
sterile article touches an unsterile article, it
is contaminated (unsterile). Only sterile
articles are brought into the sterile field.
Hands and forearms are scrubbed for 10
minutes to reduce the bacterial count on the
skin surface. Hands and arms are dried with
a sterile towel.
Sterile gowns are worn to protect the patient
from the worker. Outside of gown that is in
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 in contact with patient and his contact with the sterile field must be kept
environment is contaminated. sterile.
Status of Reservoir of infection. Potential host (other people and
patient environment are reservoirs of infection).

Goals Confine disease organisms Reduce number of organisms and prevent

and prevent spread to others. spread of infection to others.
Source: (Nursing411.org, n.d.)

Medical Asepsis

Medical asepsis also referred to as a clean technique, is the infection control principle and
practice that decreases the spread of infection. It reduces the number of pathogenic
microorganisms and also impairs the proliferation and growth of microorganisms (Registered
Nursing.org, 2020). It includes all practices that reduce the number, growth, transfer and spread
of pathogenic microorganisms. They include hand washing, bathing, cleaning environment,
gloving, gowning, wearing mask, hair and shoe covers, disinfecting articles and use of antiseptics.

Medical asepsis is practiced because when the body is penetrated, natural barriers such
as skin and mucous membranes are bypassed. This renders the patient susceptible to microbes
that might enter which makes it important to perform hand hygiene and put on gloves. When
invading sterile areas of the body, the sterility of the body system is maintained. In medical
asepsis, it is also important to make sure the item that is placed into a sterile area of the body
remains sterile (spice.unc.edu, n.d.)

Medical aseptic practices are involved in all nursing activities because microorganisms
are always present in the environment. An awareness of how microorganisms are transmitted is
essential for safe caregiving practices. Moreover, isolation procedures are used when a
healthcare worker (HCW) may have a disease that is easily spread from one person to another.

The types of isolation include:

1. Contact Isolation - for C-difficile, conjunctivitis, MRSA, etc.

2. Droplet Isolation - for influenza, pneumonia, streptococcal disease, etc.

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 3. Airborne Isolation - for tuberculosis

If a HCW is placed in strict isolation, he/she is placed in a separate room to prevent others
from becoming infected.

1. Care providers and visitors will be required to wear a gown, mask and gloves
before entering the resident’s room.
2. All linen and other items that come in contact with this resident will be given special
handling in order to avoid spreading germs.

It is also important for HCWs to review Handwashing/Standard Precautions whose

procedure includes:

1. Turn on faucet with a clean paper towel.

2. Adjust water to acceptable temperature.
3. Put soap on hands.
4. Lather all areas of hands and wrists, rubbing vigorously for at least 10 seconds.
5. Clean nails by rubbing them in palm of other hand.
6. Rinse thoroughly, running water down from wrists to fingertips.
7. Pat dry with paper towel.
8. Turn off faucet with paper towel and discard towel immediately (in.gov, n.d.).

Surgical Asepsis

Surgical asepsis is the absence of all microorganisms within any type of invasive
procedure. Sterile technique is a set of specific practices and procedures performed to make
equipment and areas free from all microorganisms and to maintain that sterility (opentextbc.ca,
n.d.).

Surgical aseptic technique is used when procedures are technically complex and invasive,
involve extended procedure time (more than 20 minutes) or a large, open key site and large or
numerous key parts. The main aseptic field needs to be managed as a critical aseptic field (a
controlled working space that ensures asepsis by providing protection from the procedure

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environment – typically by using a sterilized drape), using sterile gloves and often with full barrier
precautions to include sterile gown, mask and cap (Association of Safe Aseptic Practice, 2015).

There are safety protocols that must be considered in surgical asepsis and they are as
follows:

1. Hand hygiene is a priority before any aseptic procedure.

2. When performing a procedure, ensure the patient understands how to prevent
contamination of equipment and knows to refrain from sudden movements or touching,
laughing, sneezing, or talking over the sterile field.
3. Choose appropriate PPE to decrease the transmission of microorganisms from
patients to health care worker.
4. Review hospital procedures and requirements for sterile technique prior to initiating
any invasive procedure.
5. Health care providers who are ill should avoid invasive procedures or, if they can’t
avoid them, should double mask.

Moreover, there are several steps and information that must be taken into consideration
when doing surgical asepsis or sterile technique as follows:

1. All objects used in a sterile field must be sterile. Commercially packaged sterile
supplies are marked as sterile hence, packages should be checked for sterility by
assessing intactness, dryness, and expiry date prior to use. Any torn, previously
opened, or wet packaging, or packaging that has been dropped on the floor, is
considered non-sterile and may not be used in the sterile field.
2. A sterile object becomes non-sterile when touched by a non-sterile object. Sterile
objects must only be touched by sterile equipment or sterile gloves. Whenever the
sterility of an object is questionable, consider it non-sterile.

Fluid flows in the direction of gravity. Keep the tips of forceps down during a sterile
procedure to prevent fluid travelling over entire forceps and potentially contaminating
the sterile field.

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3. Sterile items that are below the waist level, or items held below waist level, are
considered to be non-sterile. Keep all sterile equipment and sterile gloves above waist
level. Table drapes are only sterile at waist level.
4. Sterile fields must always be kept in sight to be considered sterile. Sterile fields must
always be kept in sight throughout entire sterile procedure. Never turn your back on
the sterile field as sterility cannot be guaranteed.
5. When opening sterile equipment and adding supplies to a sterile field, take care to
avoid contamination. Set up sterile trays as close to the time of use as possible.
Sterile objects can become non-sterile by prolonged exposure to airborne
microorganisms.
6. Any puncture, moisture, or tear that passes through a sterile barrier must be
considered contaminated. Keep sterile surface dry and replace if wet or torn.
7. Once a sterile field is set up, the border of one inch at the edge of the sterile drape is
considered non-sterile. Place all objects inside the sterile field and away from the one-
inch border.
8. If there is any doubt about the sterility of an object, it is considered non-sterile. Known
sterility must be maintained throughout any procedure.
9. Sterile persons or sterile objects may only contact sterile areas; non-sterile persons or
items contact only non-sterile areas. The front of the sterile gown is sterile between
the shoulders and the waist, and from the sleeves to two inches below the elbow.
 Non-sterile items should not cross over the sterile field. For example, a non-sterile
person should not reach over a sterile field.
 When opening sterile equipment, follow best practice for adding supplies to a
sterile field to avoid contamination.
 Do not place non-sterile items in the sterile field.
10. Movement around and in the sterile field must not compromise or contaminate the
sterile field. Do not sneeze, cough, laugh, or talk over the sterile field.

Maintain a safe space or margin of safety between sterile and non-sterile objects and
areas.
Refrain from reaching over the sterile field.
Keep operating room (OR) traffic to a minimum, and keep doors closed.

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 Keep hair tied back.
When pouring sterile solutions, only the lip and inner cap of the pouring container is
considered sterile. The pouring container must not touch any part of the sterile field.
Avoid splashes.
Sources (Kennedy, 2013) (Pyrek, 2011)

Standard Precautions and Transmission-based Precautions

Standard and transmission-based precautions are the cornerstone for all infection
prevention activities to prevent healthcare-associated infections (HAI) and the transmission of
communicable diseases to patients, staff and visitors (Wyoming Department of Health, n.d.).

The two-tiered approach of standard and transmission-based precautions provides a high

level of protection to patients, healthcare workers and other people in healthcare settings.
Standard precautions are the work practices required to achieve a basic level of infection
prevention and control. They are the minimum infection prevention and control practices that must
be used at all times for all patients in all situations. Transmission-based precautions, on the other
hand, are used when standard precautions alone are not sufficient to prevent the spread of an
infectious agent. They are based upon the mode of transmission of the infectious agent
(health.vic, n.d.).

Standard Precautions

Standard Precautions are used for all patient care. They’re based on a risk assessment
and make use of common-sense practices and personal protective equipment use that protect
healthcare providers from infection and prevent the spread of infection from patient to patient
(cdc.gov, n.d.).

Hand hygiene is a major component of standard precautions and one of the most effective
methods to prevent transmission of pathogens associated with health care. In addition to hand
hygiene, the use of personal protective equipment should be guided by risk assessment and the
extent of contact anticipated with blood and body fluids, or pathogens. In addition to practices
carried out by health workers when providing care, all individuals (including patients and visitors)

118
should comply with infection control practices in health-care settings. The control of spread of
pathogens from the source is key to avoid transmission. Among source control measures,
respiratory hygiene/cough etiquette, developed during the severe acute respiratory syndrome
(SARS) outbreak, is now considered as part of standard precautions. Worldwide escalation of the
use of standard precautions would reduce unnecessary risks associated with health care.
Promotion of an institutional safety climate helps to improve conformity with recommended
measures and thus subsequent risk reduction. Provision of adequate staff and supplies, together
with leadership and education of health workers, patients, and visitors, is critical for an enhanced
safety climate in health-care settings (World Health Organization, 2007).

1. Hand Hygiene

Hand hygiene refers to both washing with plain or anti-bacterial soap and water and to the
use of alcohol gel to decontaminate hands. When hands are not visibly soiled, alcohol gel is the
preferred method of hand hygiene when providing health care to clients. It should be performed
before and after contact with a client, immediately after touching blood, body fluids, non-intact
skin, mucous membranes, or contaminated items (even when gloves are worn during contact),
immediately after removing gloves, when moving from contaminated body sites to clean body
sites during client care, after touching objects and medical equipment in the immediate client-care
vicinity, before eating, after using the restroom, and after coughing or sneezing into a tissue as
part of respiratory hygiene (cdc.gov, n.d.).

2. Personal Protective Equipment (PPE)

PPE includes items such as gloves, gowns, masks, respirators, and eyewear used to
create barriers that protect skin, clothing, mucous membranes, and the respiratory tract from
infectious agents. PPE is used as a last resort when work practices and engineering controls
alone cannot eliminate worker exposure. The items selected for use depend on the type of
interaction a public health worker will have with a client and the likely modes of disease
transmission. Gloves are worn when touching blood, body fluids, non-intact skin, mucous
membranes, and contaminated items. Gloves must always be worn during activities involving
vascular access, such as performing phlebotomies. A surgical mask and goggles or face shield
are worn if there is a reasonable chance that a splash or spray of blood or body fluids may occur

119
to the eyes, mouth, or nose. A gown is worn if skin or clothing is likely to be exposed to blood or
body fluids. PPE is removed immediately in order after use to prevent contamination of skin or
clothing. If PPE or other disposable items are saturated with blood or body fluids such that fluid
may be poured, squeezed, or dripped from the item, discard into a biohazard bag. PPE that is not
saturated may be placed directly in the trash. Saturated waste generated from the home should
be placed in sealable leak-proof plastic bags before placing in regular trash bags for disposal
(Wisconsin Department of Health Services, n.d.).

3. Needlesticks and Sharps Injury Prevention

Safe handling of needles and other sharp devices are components of standard
precautions that are implemented to prevent health care worker exposure to blood borne
pathogens. The safety devices on needles and other sharps should be activated immediately after
use. Used needles should be discarded immediately after use and not recapped, bent, cut,
removed from the syringe or tube holder, or otherwise manipulated. Any used needles, lancets,
or other contaminated sharps should be placed in a leak-proof, puncture-resistant sharps
container that is either red in color or labeled with a biohazard label. Do not overfill sharps
containers. Discard after 2/3 full or when contents are at the full line indicated on the containers.
Used sharps containers may be taken to a collection facility such as an area pharmacy, hospital,
or clinic that provides this service (Wisconsin Department of Health Services, n.d.).

4. Cleaning and Disinfection

Client care areas, common waiting areas, and other areas where clients may have
potentially contaminated surfaces or objects that are frequently touched by staff and clients
(doorknobs, sinks, toilets, other surfaces and items in close proximity to clients) should be cleaned
routinely with disinfectants, following the manufacturer’s instructions for amount, dilution, and
contact time. Most disinfectants are not effective in the presence of dirt and organic matter;
therefore, cleaning must occur first before disinfection. Wet a cloth with the disinfectant, wipe
away dirt and organic material, then with a clean cloth apply the disinfectant to the item and allow
to air dry for the time specified by the product manufacturer (Wisconsin Department of Health
Services, n.d.).

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 5. Respiratory hygiene and cough etiquette

Education of health workers, patients and visitors about covering mouth and nose when
coughing or sneezing is important in controlling spread of infection. Hand hygiene after contact
with respiratory secretions should be practiced. Spatial separation of persons with acute febrile
respiratory symptoms should be done (World Health Organization, 2007).

6. Waste Disposal

The World Health Organization recommends that safe waste management is ensured.
Waste contaminated with blood, body fluids, secretions and excretions as clinical waste, should
be treated in accordance with local regulations. Human tissues and laboratory waste that is
directly associated with specimen processing should also be treated as clinical waste and single
use items should be discarded properly (World Health Organization, 2007).

Transmission-based Precautions

Transmission-based precautions (TBP) are designed for patients with documented or

suspected infection with pathogens for which additional precautions beyond standard precautions
are needed to prevent transmission. The three categories of transmission-based precautions are:
contact, droplet, and airborne precautions, and are based on the likely routes of transmission of
specific infectious agents. They may be combined for infectious agents that have more than one
route of transmission. Whether used singly or in combination, they are always used in addition to
standard precautions. Transmission-based precautions are applied at the time of initial contact,
based on the clinical presentation and the most likely pathogens – so-called Empiric or Syndromic
Precautions. Single-patient rooms are always preferred for children needing Transmission-based
precautions. If unavailable, cohorting of patients, and preferably of staff, according to clinical
diagnosis is recommended (Siegel, 2012).

As mentioned, the three categories of transmission-based precautions are:

1. Airborne transmission precautions—These apply to situations in which pathogens can

be transmitted by the airborne route, that is, by small droplets of 5 µm or smaller (e.g.,
the organisms that cause tuberculosis, measles, and chickenpox and Aspergillus).

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 2. Droplet transmission precautions—These apply to situations in which pathogens can
be transmitted by large particle droplets, greater than 5 µm (e.g., the organisms that
cause mumps, rubella, and influenza).
3. Contact transmission precautions—These apply to situations in which pathogens can
be transmitted by direct or indirect contact (e.g., methicillin-resistant Staphylococcus
aureus [MRSA], herpes simplex virus, and hepatitis A virus).
Source: (Freedman, 2012).

Table 6.2 outlines the TBPs to be taken for infections with airborne, droplet or contact
transmission.

Table 6.2. Transmission-based precautions required according to route of transmission

Infection Control Route of transmission

Measure Airborne Droplet Contact
Gloves As per standard As per standard For all manual contact with patient,
precautions precautions associated devices and immediate
environmental surfaces
Impermeable As per standard As per standard When healthcare worker's clothing
apron/gown precautions precautions is in substantial contact with the
patient, items in contact with the
patient, and their immediate
environment
P2 Respirator Yes Not required Not required

Mask (surgical- No (P2 Yes As per standard precautions

style) respirator)

Goggles/face As per standard As per standard As per standard precautions

shields precautions precautions
Standard single No (negative Yes or cohort Yes or cohort patients with same
room with own pressure patients with infection
ensuite ventilation same infection
required)
Door closed

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 Negative Essential Not required Not required
pressure
ventilation room
Source: (health.vic, n.d.)

Assessment Task 6-1

1. Discuss the most common pathogens associated with each type of nosocomial infection.
2. Discuss the various ways of preventing each type of nosocomial infection.

123
 Assessment Task 6-2

1. When should a sterile field be opened (under normal circumstances)?

2. What part of the sterile field is considered non-sterile?
3. List the strengths and limitations for both alcohol-based hand rub and traditional soap and
water for performing hand hygiene.
4. Define and give examples of diseases transmitted by both direct contact and indirect
contact.
5. List the type of precaution used and the duration for the following infections/conditions:

a. Abscess- major, no dressing or dressing does not contain the drainage

b. antibiotic resistant organisms (eg. MRSA, VRE)

6. For each of the following Infections spread by the droplet route, list the type and duration
of precautions used to prevent transmission of each: Influenza, pertussis, RSV, SARS
COV.
7. For patients with the following various diseases, list the necessary precautions. Focus on
precautions required for immunized and non-immunized staff in relation to common
airborne organisms and the differences between them: TB, Measles, Varicella,
Disseminated Zoster, SARS COV.

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 Summary

Nosocomial infections, also known as healthcare-associated infections, are newly

acquired infections that are contracted within a hospital environment. Transmission usually occurs
via healthcare workers, patients, hospital equipment, or interventional procedures. There are four
most common types and they are catheter-associates urinary tract infection, ventilator-associate
pneumonia, surgical site infection, and central line-associated blood stream infections.

In modern medicine, infection prevention and control (IPC) measures in health-care

settings are of central importance to the safety of patients, health-care workers and the
environment, and to the management of communicable disease threats to the global and local
community. Application of basic IPC precautions, such as medical asepsis, surgical asepsis,
standard precautions, and transmission-based precautions, is a cornerstone for providing safe
health care. The programs include activities, procedures and policies designed to reduce the
spread of infections, usually within healthcare facilities. Its goals are to prevent susceptible
patients acquiring pathogenic micro-organisms and to limit the spread of antimicrobial resistant
infections.

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