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WHO/CDS/CSR/EPH/2002.12
DISTR:
GENERAL
ORIGINAL:
ENGLISH
Prevention of
hospital-acquired
infections
A PRACTICAL
GUIDE
2nd edition
Editors
G. Ducel, Fondation Hygie, Geneva, Switzerland
J. Fabry, Université Claude-Bernard, Lyon, France
L. Nicolle, University of Manitoba, Winnipeg, Canada
Contributors
R. Girard, Centre Hospitalier Lyon-Sud, Lyon, France
M. Perraud, Hôpital Edouard Herriot, Lyon, France
A. Prüss,World Health Organization, Geneva, Switzerland
A. Savey, Centre Hospitalier Lyon-Sud, Lyon, France
E. Tikhomirov, World Health Organization, Geneva, Switzerland
M. Thuriaux, World Health Organization, Geneva, Switzerland
P. Vanhems, Université Claude Bernard, Lyon, France
WORLD HEALTH
ORGANIZATION
Acknowledgements
The World Health Organization (WHO) wishes to acknowledge the significant support for this work from the
United States Agency for International Development (USAID).
This document was developed following informal meetings of the editorial working group in Lyon and Ge-
neva from 1997 to 2001.
The editors wish to acknowledge colleagues whose suggestions and remarks have been greatly appreciated:
Professor Franz Daschner (Institute of Environmental Medicine and Hospital Epidemiology, Freiburg, Ger-
many), Dr Scott Fridkin (Centers for Disease Control and Prevention, Atlanta, USA), Dr Bernardus Ganter
(WHO Regional Office for Europe, Copenhagen, Denmark), Dr Yvan Hutin (Blood Safety and Clinical Technol-
ogy, WHO, Geneva, Switzerland), Dr Sudarshan Kumari (WHO Regional Office for South-East Asia, New Delhi,
India), Dr Lionel Pineau (Laboratoire Biotech-Germande, Marseille, France).
The editors would like to thank Brenda Desrosiers, Georges-Pierre Ducel and Penny Ward for their help in
manuscript preparation.
Introduction 1
3
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
4
CONTENTS
5
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
6
Introduction
affect the host defences will provide continuing disease, and diagnostic and therapeutic interventions.
pressure on nosocomial infections in the future. The extremes of life — infancy and old age — are
Organisms causing nosocomial infections can be as- sociated with a decreased resistance to
transmitted to the community through discharged infection. Patients with chronic disease such as
patients, staff, and visitors. If organisms are multire- malignant tu- mours, leukaemia, diabetes mellitus,
sistant, they may cause significant disease in the renal failure, or the acquired immunodeficiency
community. syndrome (AIDS) have an increased susceptibility to
infections with opportunistic pathogens. The latter
are infections with organism(s) that are normally
Factors influencing the development of innocuous, e.g. part of the normal bacterial flora in
nosocomial infections the human, but may become pathogenic when the
The microbial agent body’s immuno- logical defences are compromised.
Immunosuppres- sive drugs or irradiation may
The patient is exposed to a variety of microorgan- lower resistance to infection. Injuries to skin or
isms during hospitalization. Contact between the mucous membranes bypass natural defence
patient and a microorganism does not by itself nec- mechanisms. Malnutrition is also a risk. Many
essarily result in the development of clinical modern diagnostic and therapeu- tic procedures,
disease such as biopsies, endoscopic exami- nations,
— other factors influence the nature and frequency catheterization, intubation/ventilation and suction
of nosocomial infections. The likelihood of expo- and surgical procedures increase the risk of
sure leading to infection depends partly on the char- infection. Contaminated objects or substances may
acteristics of the microorganisms, including be introduced directly into tissues or normally ster-
resistance to antimicrobial agents, intrinsic ile sites such as the urinary tract and the lower res-
virulence, and amount (inoculum) of infective piratory tract.
material.
2
INTRODUCTION
Nosocomial infections are widespread. They are im- 6. Plowman R et al. The socio-economic burden of hospi-
portant contributors to morbidity and mortality.They tal-acquired infection. London, Public Health Labo-
will become even more important as a public health ratory Service and the London School of Hygiene
problem with increasing economic and human impact and Tropical Medicine, 1999.
because of: 7. Wenzel RP. The economics of nosocomial infec-
● Increasing numbers and crowding of people. tions. J Hosp Infect 1995, 31:79–87.
● More frequent impaired immunity (age, illness, 8. Pittet D, Taraara D, Wenzel RP. Nosocomial blood-
treatments). stream infections in critically ill patients. Excess
length of stay, extra costs, and attributable mor-
● New microorganisms. tality. JAMA, 1994, 271:1598–1601.
● Increasing bacterial resistance to antibiotics (13). 9. Kirkland KB et al. The impact of surgical-site in-
fections in the 1990’s: attributable mortality, ex-
cess length of hospitalization and extra costs.
Purpose of this manual Infect Contr Hosp Epidemiol, 1999, 20:725–730.
This manual has been developed to be a practical, 10. Wakefield DS et al. Cost of nosocomial infection:
basic, resource which may be used by individuals relative contributions of laboratory, antibiotic,
with an interest in nosocomial infections and their and per diem cost in serious Staphylococcus aureus
control, as well as those who work in nosocomial infections. Amer J Infect Control, 1988, 16:185–192.
infection control in health care facilities. It is appli-
11. Coella R et al. The cost of infection in surgical
cable to all facilities, but attempts to provide rational
patients: a case study. J Hosp Infect, 1993, 25:239–
and attainable recommendations for facilities with
250.
relatively limited resources. The information should
assist administrators, infection control personnel, 12. Resources. In: Proceedings of the 3rd Decennial Inter-
and patient care workers in such facilities in the national Conference on Nosocomial Infections,
initial development of a nosocomial infection Preventing Nosocomial Infections. Progress in the 80’s.
control pro- gramme, including specific Plans for the 90’s, Atlanta, Georgia, July 31–August
components of such pro- grammes. Additional 3, 1990:30 (abstract 63).
reading in specific areas is provided in the list of 13. Ducel G. Les nouveaux risques infectieux.
WHO relevant documents and infection control Futuribles, 1995, 203:5–32.
texts at the end of the manual (An- nex 1), as well
as relevant references in each chapter.
3
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
CHAPTER
I
Epidemiology of
nosocomial infections
4
CHAPTER I. EPIDEMIOLOGY OF NOSOCOMIAL
INFECTIONS
1.2 Nosocomial infection sites organ spaces are identified separately. The infection
is usually acquired during the operation itself;
An example of the distribution of sites of nosoco-
either exogenously (e.g. from the air, medical equip-
mial infections is shown in Figure 1.
ment, surgeons and other staff), endogenously from
the flora on the skin or in the operative site or,
FIGURE 1. Sites of the most comon nosocomial rarely, from blood used in surgery. The infecting
infections: distribution according to the microor- ganisms are variable, depending on the
French national prevalence survey (1996)* type and location of surgery, and antimicrobials
received by the patient. The main risk factor is the
Other
sites O extent of contamination during the procedure
Catheter site C
(clean, clean- contaminated, contaminated, dirty),
ENT/Eye O Urinary tract U
C which is to a large part dependent on the length of
E/E E/
Bacteraemia B E the operation, and the patient’s general condition
B U (25). Other fac- tors include the quality of surgical
Respiratory tract technique, the presence of foreign bodies including
R2
(other) R2 drains, the viru- lence of the microorganisms,
SS
T
concomitant infection at other sites, the use of
Skin and RI
soft tissue SST S preoperative shaving, and the experience of the
Lower respiratory surgical team.
Surgica tract R1
l site
S
1.2.3 Nosocomial pneumonia
* Adapted fom Enquête nationale de prévalence des infections
nosocomiales, 1996. BEH, 1997, 36:161–163. Nosocomial pneumonia occurs in several different
patient groups. The most important are patients on
ventilators in intensive care units, where the rate of
1.2.1 Urinary infections pneumonia is 3% per day. There is a high case-
This is the most common nosocomial infection; 80% fatality rate associated with ventilator-associated
of infections are associated with the use of an ind- pneumonia, although the attributable risk is diffi-
welling bladder catheter (1,2,3). Urinary infections cult to determine because patient comorbidity is so
are associated with less morbidity than other noso- high. Microorganisms colonize the stomach, upper
comial infections, but can occasionally lead to airway and bronchi, and cause infection in the lungs
bacter- aemia and death. Infections are usually (pneumonia): they are often endogenous (digestive
defined by microbiological criteria: positive system or nose and throat), but may be exogenous,
quantitative urine culture (105 microorganisms/ml, often from contaminated respiratory equipment.
with a maximum of 2 isolated microbial species). The definition of pneumonia may be based on clini-
The bacteria respon- sible arise from the gut flora, cal and radiological criteria which are readily avail-
either normal (Escherichia coli) or acquired in hospital able but non-specific: recent and progressive
(multiresistant Klebsiella). radiological opacities of the pulmonary parenchyma,
purulent sputum, and recent onset of fever.
1.2.2 Surgical site infections Diagno- sis is more specific when quantitative
Surgical site infections are also frequent: the inci- microbiologi- cal samples are obtained using
dence varies from 0.5 to 15% depending on the type specialized protected bronchoscopy methods.
of operation and underlying patient status Known risk factors for infection include the type
(18,19,20). These are a significant problem which and duration of ventila- tion, the quality of
limit the po- tential benefits of surgical respiratory care, severity of the patient’s condition
interventions. The impact on hospital costs and (organ failure), and previous use of antibiotics.
postoperative length of stay (between 3 and 20 Apart from ventilator-associated pneumonia,
additional days) (21,22,23,24) is considerable. patients with seizures or decreased level of con-
The definition is mainly clinical: purulent discharge sciousness are at risk for nosocomial infection, even
around the wound or the insertion site of the drain, if not intubated. Viral bronchiolitis (respiratory syn-
or spreading cellulitis from the wound. Infections of cytial virus, RSV) is common in children’s units, and
the surgical wound (whether above or below the influenza and secondary bacterial pneumonia may
aponeurosis), and deep infections of organs or occur in institutions for the elderly. With highly
5
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
These are the four most frequent and important — Gram-negative bacteria: Enterobacteriacae (e.g.
nosocomial infections, but there are many other Escherichia coli, Proteus, Klebsiella, Enterobacter,
potential sites of infection. For example: Serratia marcescens), may colonize sites when the
host defences are compromised (catheter in-
● Skin and soft tissue infections: open sores (ulcers,
sertion, bladder catheter, cannula insertion)
burns and bedsores) encourage bacterial coloni-
and cause serious infections (surgical site, lung,
zation and may lead to systemic infection.
bacteraemia, peritoneum infection). They
● Gastroenteritis is the most common nosocomial may also be highly resistant.
infection in children, where rotavirus is a chief
— Gram-negative organisms such as Pseudomonas
pathogen: Clostridium difficile is the major cause of
spp. are often isolated in water and damp
nosocomial gastroenteritis in adults in developed
areas. They may colonize the digestive tract of
countries.
hospitalized patients.
● Sinusitis and other enteric infections, infections
— Selected other bacteria are a unique risk in
of the eye and conjunctiva.
hospitals. For instance, Legionella species may
● Endometritis and other infections of the repro- cause pneumonia (sporadic or endemic)
ductive organs following childbirth. through inhalation of aerosols containing con-
taminated water (air conditioning, showers,
therapeutic aerosols).
1.3 Microorganisms
Many different pathogens may cause nosocomial
infections. The infecting organisms vary among dif- 1.3.2 Viruses
ferent patient populations, different health care set- There is the possibility of nosocomial transmission
tings, different facilities, and different countries. of many viruses, including the hepatitis B and C
viruses (transfusions, dialysis, injections, endoscopy),
respiratory syncytial virus (RSV), rotavirus, and
6
CHAPTER I. EPIDEMIOLOGY OF NOSOCOMIAL
INFECTIONS
enteroviruses (transmitted by hand-to-mouth con- 3. Flora from the health care environment (endemic
tact and via the faecal-oral route). Other viruses such or epidemic exogenous environmental infections).
as cytomegalovirus, HIV, Ebola, influenza viruses, Several types of microorganisms survive well in
herpes simplex virus, and varicella-zoster virus, may the hos- pital environment:
also be transmitted. — in water, damp areas, and occasionally in
sterile products or disinfectants
(Pseudomonas, Acinetobacter, Mycobacterium)
1.3.3 Parasites and fungi
— in items such as linen, equipment and sup-
Some parasites (e.g. Giardia lamblia) are transmitted
plies used in care; appropriate housekeeping
easily among adults or children. Many fungi and
normally limits the risk of bacteria surviving
other parasites are opportunistic organisms and
as most microorganisms require humid or hot
cause infections during extended antibiotic treatment
conditions and nutrients to survive
and severe immunosuppression (Candida albicans,
Aspergillus spp., Cryptococcus neoformans, Cryptosporidium). — in food
These are a major cause of systemic infections among — in fine dust and droplet nuclei generated by
immunocompromised patients. Environmental con-
coughing or speaking (bacteria smaller than
tamination by airborne organisms such as Aspergil-
10 m in diameter remain in the air for sev-
lus spp. which originate in dust and soil is also a
eral hours and can be inhaled in the same way
concern, especially during hospital construction.
as fine dust).
Sarcoptes scabies (scabies) is an ectoparasite which has
repeatedly caused outbreaks in health care facilities.
People are at the centre of the phenomenon:
● as main reservoir and source of microorganisms
1.4 Reservoirs and transmission
● as main transmitter, notably during treatment
Bacteria that cause nosocomial infections can be
acquired in several ways: ● as receptor for microorganisms, thus becoming a
new reservoir.
1. The permanent or transient flora of the patient
(endogenous infection). Bacteria present in the nor-
mal flora cause infection because of transmission
to sites outside the natural habitat (urinary tract),
damage to tissue (wound) or inappropriate anti- References
biotic therapy that allows overgrowth (C. difficile, 1. Mayon-White R et al. An international survey of
yeast spp.). For example, Gram-negative bacteria the prevalence of hospital-acquired infection. J
in the digestive tract frequently cause surgical site Hosp Infect, 1988, 11 (suppl A):43–48.
infections after abdominal surgery or urinary
2. Emmerson AM et al. The second national preva-
tract infection in catheterized patients.
lence survey of infection in hospitals —
2. Flora from another patient or member of staff overview of the results. J Hosp Infect, 1996,
(exogenous cross-infection). Bacteria are transmitted 32:175–190.
between patients: (a) through direct contact be-
3. Enquête nationale de prévalence des infections
tween patients (hands, saliva droplets or other
nosocomiales. Mai–Juin 1996. Comité technique
body fluids), (b) in the air (droplets or dust con-
national des infections nosocomiales. Bulletin
taminated by a patient’s bacteria), (c) via staff
Èpidémiologique Hebdomadaire, 1997, No 36.
contaminated through patient care (hands, clothes,
nose and throat) who become transient or per- 4. Gastmeier P et al. Prevalence of nosocomial in-
manent carriers, subsequently transmitting bac- fections in representative German hospitals. J
teria to other patients by direct contact during Hosp Infect, 1998, 38:37–49.
care, (d) via objects contaminated by the patient
5. Vasque J, Rossello J, Arribas JL. Prevalence of
(including equipment), the staff’s hands, visitors
nosocomial infections in Spain: EPINE study
or other environmental sources (e.g. water, other
1990–1997. EPINE Working Group. J Hosp Infect,
fluids, food).
1999, 43 Suppl:S105–S111.
7
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
6. Danchaivijitr S, Tangtrakool T, Chokloikaew S. 16. McGeer A et al. Definitions of infection for sur-
The second Thai national prevalence study on veillance in long-term care facilities. Am J Infect
noso- comial infections 1992. J Med Assoc Thai, Control, 1991, 19:1–7.
1995, 78 Suppl 2:S67–S72.
17. Girard R. Guide technique d’hygiène hospitalière. Alger,
7. Kim JM et al. Multicentre surveillance study for Institut de la Santé publique et Lyon, Fondation
nosocomial infections in major hospitals in Marace Mérieux, 1990.
Korea. Am J Infect Control, 2000, 28:454–458.
18. Cruse PJE, Ford R. The epidemiology of wound
8. Raymond J, Aujard Y, European Study Group. infection. A 10 year prospective study of 62,939
Nosocomial Infections in Pediatric Patients: A wounds. Surg Clin North Am, 1980, 60:27–40.
European, Multicenter Prospective Study. Infect
19. Horan TC et al. Nosocomial infections in surgical
Control Hosp Epidemiol, 2000, 21:260–263.
patients in the United States, 1986–1992 (NNIS).
9. Pittet D et al. Prevalence and risk factors for no- Infect Control Hosp Epidemiol, 1993, 14:73–80.
socomial infections in four university hospitals
20. Hajjar J et al. Réseau ISO Sud-Est: un an de sur-
in Switzerland. Infect Control Hosp Epidemiol, 1999,
veillance des infections du site opératoire. Bulle-
20:37–42.
tin Èpidémiologique Hebdomadaire, 1996, No 42.
10. Gikas A et al. Repeated multi-centre prevalence
21. Brachman PS et al. Nosocomial surgical infec-
surveys of hospital-acquired infection in Greek
tions: incidence and cost. Surg Clin North Am,
hospitals. J Hosp Infect, 1999, 41:11–18.
1980, 60:15–25.
11. Scheel O, Stormark M. National prevalence sur-
22. Fabry J et al. Cost of nosocomial infections: analy-
vey in hospital infections in Norway. J Hosp Infect,
sis of 512 digestive surgery patients. World J Surg,
1999, 41:331–335.
1982, 6:362–365.
12. Valinteliene R, Jurkuvenas V, Jepsen OB. Preva-
23. Prabhakar P et al. Nosocomial surgical infections:
lence of hospital-acquired infection in a Lithua-
incidence and cost in a developing country. Am J
nian hospital. J Hosp Infect, 1996, 34:321–329.
Infect Control, 1983, 11:51–56.
13. Orrett FA, Brooks PJ, Richardson EG. Nosocomial
24. Kirkland KB et al. The impact of surgical-site in-
infections in a rural regional hospital in a devel-
fections in the 1990’s: attributable mortality, ex-
oping country: infection rates by site, service,
cess length of hospitalization and extra costs.
cost, and infection control practices. Infect Control
Infect Control Hosp Epidemiol, 1999, 20:725–730.
Hosp Epidemiol, 1998, 19:136–140.
25. Nosocomial infections rates for interhospital com-
14. Garner JS et al. CDC definitions for nosocomial
parison: limitations and possible solutions — A
infections, 1988. Am J Infect Control, 1988, 16:128–
report from NNIS System. Infect Control Hosp
140.
Epidemiol, 1991, 12:609–621.
15. Horan TC et al. CDC definitions of nosocomial
surgical site infections, 1992: a modification of
CDC definition of surgical wound infections. Am
J Infect Control, 1992, 13:606–608.
8
CHAPTER
II
Infection control programmes
9
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
● to review risks associated with new technologies, It must be made readily available for patient care
and monitor infectious risks of new devices and staff, and updated in a timely fashion.
products, prior to their approval for use
● to review and provide input into investigation of
3. Infection control responsibility
epidemics
1. Role of hospital management
● to communicate and cooperate with other com-
mittees of the hospital with common interests such The administration and/or medical management of
as Pharmacy and Therapeutics or Antimicrobial the hospital must provide leadership by supporting
Use Committee, Biosafety or Health and Safety the hospital infection programme. They are respon-
Committees, and Blood Transfusion Committee. sible for:
● establishing a multidisciplinary Infection Control
Committee
2.2.2 Infection control professionals (infection
control team) ● identifying appropriate resources for a programme
to monitor infections and apply the most appro-
Health care establishments must have access to spe-
priate methods for preventing infection
cialists in infection control, epidemiology, and
infectious disease including infection control physi- ● ensuring education and training of all staff
cians and infection control practitioners (usually through support of programmes on the preven-
nurses) (2). In some countries, these professionals are tion of infection in disinfection and sterilization
specialized teams working for a hospital or a group techniques
of health care establishments; they may be admin- ● delegating technical aspects of hospital hygiene
istratively part of another unit, (e.g. microbiology to appropriate staff, such as:
laboratory, medical or nursing administration, pub-
lic health services). The optimal structure will vary — nursing
with the type, needs, and resources of the facility. — housekeeping
The reporting structure must, however, ensure the
— maintenance
infection control team has appropriate authority to
manage an effective infection control programme. — clinical microbiology laboratory
In large facilities, this will usually mean a direct re-
● periodically reviewing the status of nosocomial
porting relationship with senior administration.
infections and effectiveness of interventions to
The infection control team or individual is respon- contain them
sible for the day-to-day functions of infection con-
● reviewing, approving, and implementing policies
trol, as well as preparing the yearly work plan for
approved by the Infection Control Committee
review by the infection control committee and ad-
ministration. These individuals have a scientific and ● ensuring the infection control team has authority
technical support role: e.g. surveillance and to facilitate appropriate programme function
research, developing and assessing policies and ● participating in outbreak investigation.
practical supervision, evaluation of material and
products, control of sterilization and disinfection,
implemen- tation of training programmes. They 2.3.2 Role of the physician
should also support and participate in research and
assessment programmes at the national and Physicians have unique responsibilities for the pre-
international levels. vention and control of hospital infections:
● by providing direct patient care using practices
which minimize infection
2.2.3 Infection control manual
● by following appropriate practice of hygiene
A nosocomial infection prevention manual (3), (e.g. handwashing, isolation)
com- piling recommended instructions and
● serving on the Infection Control Committee
practices for patient care, is an important tool. The
manual should be developed and updated by the ● supporting the infection control team.
infection control team, with review and approval
by the committee.
10
CHAPTER II. INFECTION CONTROL
PROGRAMMES
Specifically, physicians are responsible for: 2.3.4 Role of the hospital pharmacist (5)
● protecting their own patients from other infected The hospital pharmacist is responsible for:
patients and from hospital staff who may be in- ● obtaining, storing and distributing pharmaceuti-
fected
cal preparations using practices which limit
● complying with the practices approved by the potential transmission of infectious agents to
Infection Control Committee patients
● obtaining appropriate microbiological specimens ● dispensing anti-infectious drugs and maintain-
when an infection is present or suspected ing relevant records (potency, incompatibility,
conditions of storage and deterioration)
● notifying cases of hospital-acquired infection to
the team, as well as the admission of infected pa- ● obtaining and storing vaccines or sera, and mak-
tients ing them available as appropriate
● complying with the recommendations of the An- ● maintaining records of antibiotics distributed to
timicrobial Use Committee regarding the use of the medical departments
antibiotics ● providing the Antimicrobial Use Committee and
● advising patients, visitors and staff on techniques Infection Control Committee with summary re-
to prevent the transmission of infection ports and trends of antimicrobial use
● instituting appropriate treatment for any infec- ● having available the following information on
tions they themselves have, and taking steps to disinfectants, antiseptics and other anti-infectious
prevent such infections being transmitted to agents:
other individuals, especially patients.
— active properties in relation to concentration,
temperature, length of action, antibiotic spec-
trum
2.3.3 Role of the microbiologist (4)
— toxic properties including sensitization or
The microbiologist is responsible for:
irritation of the skin and mucosa
● handling patient and staff specimens to maximize
— substances that are incompatible with anti-
the likelihood of a microbiological diagnosis
biotics or reduce their potency
● developing guidelines for appropriate collection,
— physical conditions which unfavourably affect
transport, and handling of specimens
potency during storage: temperature, light,
● ensuring laboratory practices meet appropriate humidity
standards
— harmful effects on materials.
● ensuring safe laboratory practice to prevent in-
The hospital pharmacist may also participate in the
fections in staff
hospital sterilization and disinfection practices
● performing antimicrobial susceptibility testing through:
following internationally recognized methods, and
● participation in development of guidelines for
providing summary reports of prevalence of re-
antiseptics, disinfectants, and products used for
sistance
washing and disinfecting the hands
● monitoring sterilization, disinfection and the
● participation in guideline development for reuse
environment where necessary
of equipment and patient materials
● timely communication of results to the Infection
● participation in quality control of techniques used
Control Committee or the hygiene officer
to sterilize equipment in the hospital including
● epidemiological typing of hospital microorgan- selection of sterilization equipment (type of
isms where necessary. appliances) and monitoring.
11
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
Implementation of patient care practices for infec- ● development of infection control policy and
tion control is the role of the nursing staff. Nurses review and approval of patient care policies
should be familiar with practices to prevent the relevant to infection control
occurrence and spread of infection, and maintain ● ensuring compliance with local and national regu-
appropriate practices for all patients throughout the
lations
duration of their hospital stay.
● liaison with public health and with other facili-
The senior nursing administrator is responsible for:
ties where appropriate
● participating in the Infection Control Committee ● providing expert consultative advice to staff health
● promoting the development and improvement of and other appropriate hospital programmes in
nursing techniques, and ongoing review of matters relating to transmission of infections.
asep- tic nursing policies, with approval by the
Infec- tion Control Committee
2.3.6 Role of the central sterilization service
● developing training programmes for members of
the nursing staff A central sterilization department serves all hospital
areas, including the operating suite. An appropri-
● supervising the implementation of techniques for
ately qualified individual must be responsible for
the prevention of infections in specialized areas
management of the programme. Responsibility for
such as the operating suite, the intensive care unit,
day-to-day management may be delegated to a nurse
the maternity unit and newborns
or other individual with appropriate qualifications,
● monitoring of nursing adherence to policies. experience, and knowledge of medical devices.
The nurse in charge of a ward is responsible for: The responsibilities of the central sterilization service
are to clean, decontaminate, test, prepare for use,
● maintaining hygiene, consistent with hospital
steri- lize, and store aseptically all sterile hospital
policies and good nursing practice on the ward
equip- ment. It works in collaboration with the
● monitoring aseptic techniques, including hand- Infection Control Committee and other hospital
washing and use of isolation programmes to develop and monitor policies on
● reporting promptly to the attending physician any cleaning and decontamination of:
evidence of infection in patients under the ● reusable equipment
nurse’s care
● contaminated equipment
● initiating patient isolation and ordering culture
including
specimens from any patient showing signs of a
communicable disease, when the physician is not — wrapping procedures, according to the type
immediately available of sterilization
● limiting patient exposure to infections from visi- — sterilization methods, according to the type of
tors, hospital staff, other patients, or equipment equipment
used for diagnosis or treatment
— sterilization conditions (e.g. temperature, du-
● maintaining a safe and adequate supply of ward ration, pressure, humidity) (see Chapter V).
equipment, drugs and patient care supplies.
The director of this service must:
The nurse in charge of infection control is a member of the
● oversee the use of different methods — physical,
infection control team and responsible for :
chemical, and bacteriological — to monitor the
● identifying nosocomial infections sterilization process
● investigation of the type of infection and infect- ● ensure technical maintenance of the equipment
ing organism according to national standards and manufactur-
● participating in training of personnel ers’ recommendations
12
CHAPTER II. INFECTION CONTROL
PROGRAMMES
● maintain complete records of each autoclave run, ● distribution of working clothes and, if necessary,
and ensure long-term availability of records managing changing rooms
● collect or have collected, at regular intervals, all ● developing policies for the collection and trans-
outdated sterile units port of dirty linen
● communicate, as needed, with the Infection ● defining, where necessary, the method for disin-
Control Committee, the nursing service, the op- fecting infected linen, either before it is taken to
erating suite, the hospital transport service, the laundry or in the laundry itself
pharmacy service, maintenance, and other appro- ● developing policies for the protection of clean
priate services.
linen from contamination during transport from
the laundry to the area of use
2.3.7 Role of the food service (see Chapter VIII) ● developing criteria for selection of site of laundry
services:
The director of food services must be knowledgeable in
food safety, staff training, storage and preparation — ensuring appropriate flow of linen, separation
of foodstuffs, job analysis, and use of equipment. of “clean” and “dirty” areas
The head of catering services is responsible for: — recommending washing conditions (e.g. tem-
perature, duration)
● defining the criteria for the purchase of foodstuffs,
equipment use, and cleaning procedures to — ensuring safety of laundry staff through
main- tain a high level of food safety prevention of exposure to sharps or laundry
contaminated with potential pathogens.
● ensuring that the equipment used and all work-
ing and storage areas are kept clean
● issuing written policies and instructions for 2.3.9 Role of the housekeeping service (see 5.3)
handwashing, clothing, staff responsibilities and
The housekeeping service is responsible for the regu-
daily disinfection duties
lar and routine cleaning of all surfaces and main-
● ensuring that the methods used for storing, pre- taining a high level of hygiene in the facility. In
paring and distributing food will avoid contami- collaboration with the Infection Control Committee
nation by microorganisms it is responsible for :
● issuing written instructions for the cleaning of ● classifying the different hospital areas by varying
dishes after use, including special considerations need for cleaning
for infected or isolated patients where appropri- ● developing policies for appropriate cleaning tech-
ate
niques
● ensuring appropriate handling and disposal of
— procedure, frequency, agents used, etc., for
wastes
each type of room, from highly contaminated
● establishing programmes for training staff in food to the most clean, and ensuring that these
preparation, cleanliness, and food safety prac- tices are followed
● establishing a Hazard Analysis of Critical Control ● developing policies for collection, transport and
Points (HACCP) programme, if required. disposal of different types of waste (e.g. contain-
ers, frequency)
● ensuring that liquid soap and paper towel dis-
2.3.8 Role of the laundry service (see Chapter VIII)
pensers are replenished regularly
The laundry is responsible for:
● informing the maintenance service of any build-
● selecting fabrics for use in different hospital ing problems requiring repair: cracks, defects in
areas, developing policies for working clothes in the sanitary or electrical equipment, etc.
each area and group of staff, and maintaining
● caring for flowers and plants in public areas
appropriate supplies
● pest control (insects, rodents)
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● providing appropriate training for all new staff — testing autoclaves (temperature, pressure,
members and, periodically, for other employees, vacuum, recording mechanism) and regular
and specific training when a new technique is maintenance (cleaning the inner chamber,
introduced emptying the tubes)
● establishing methods for the cleaning and disin- — monitoring the recording thermometers of
fection of bedding (e.g. mattresses, pillows) refrigerators in pharmacy stores, laboratories,
the blood bank and kitchens
● determining the frequency for the washing of
curtains, screening curtains between beds, etc. — regularly inspecting all surfaces — walls,
floors, ceilings — to ensure they are kept
● reviewing plans for renovations or new furniture,
smooth and washable
including special patient beds, to determine fea-
sibility of cleaning. — repairing any opening or crack in partition
walls or window frames
There should be a continuing programme for staff
training.This programme should stress personal — maintaining hydrotherapy appliances
hygiene, the importance of frequent and careful — notifying infection control of any anticipated
washing of hands, and cleaning methods (e.g.
interruption of services such as plumbing or
sequence of rooms, correct use of equipment, dilu-
air conditioning.
tion of cleaning agents, etc.). Staff must also under-
stand causes of contamination of premises, and how
to limit this, including the method of action of dis-
2.3.11 Role of the infection control team
infectants. Cleaning staff must know to contact staff
(hospital hygiene service)
health if they have a personal infection, especially
infections of the skin, digestive tract and respiratory The infection control programme is responsible for
tract. oversight and coordination of all infection control
activities to ensure an effective programme.
14
CHAPTER II. INFECTION CONTROL
PROGRAMMES
References
1. Haley RW et al. The efficacy of infection surveil-
lance and control programs in preventing noso-
comial infections in US hospitals. Am J. Epidem,
1985, 121:182–205.
15
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CHAPTER
III
Nosocomial infection surveillance
3.2 Strategy
● improvements in health care with increased A surveillance system must meet the following
quality and safety criteria (Table 1):
16
CHAPTER III. NOSOCOMIAL INFECTION
SURVEILLANCE
The extent to which these characteristics are met will The surveillance programme must report to hospi-
vary among different institutions. tal administration, usually through the Infection
Control Committee (ICC), and must have a dedicated
budget to support its operation.
3.2.1 Implementation at the hospital level
Ensuring a valid surveillance system is an impor-
3.2.2 Implementation at the network (regional or
tant hospital function. There must be specific objec-
national) level
tives (for units, services, patients, specific care areas)
and defined time periods of surveillance for all Hospitals should share nosocomial infection data,
partners: e.g. clinical units and laboratory staff, on a confidential basis, with a network of similar
infection control practitioner (ICP)/nurse, and direc- facilities to support standards development for in-
tor, administration. ter-facility comparisons (5), and to detect trends.
Local, regional, national or international networks
Initially, discussion should identify the information
may be developed. The advantages include:
needs, and the potential for the chosen indicators to
support implementation of corrective measures ● technical and methodological assistance
(what or who is going to be influenced by the data). ● reinforcing compliance to existing guidelines and
This discussion will include:
clinical practices
● the patients and units to be monitored (defined
● evaluating the importance of surveillance (more
population)
legitimacy) to encourage participation
● the type of infections and relevant information ● facilitating the exchange of experiences and
to be collected for each case (with precise defini-
solutions
tions)
● promoting epidemiological research, including
● the frequency and duration of monitoring
analysis of the impact of interventions
● methods for data collection ● assisting nation/states in scope and magnitude
● methods for data analysis, feedback, and dissemi- estimates to help with resource allocation nation-
nation ally and internationally
● confidentiality and anonymity. ● the key advantage: possibility of developing valid
inter-hospital comparisons using standardized
methods and adjusted rates.
FIGURE 1. “Surveillance is a circular process”
1. 3.3 Methods
Implementation of surveillance:
goals definition, surveillance
protocol data collection
Simply counting infected patients (numerator) pro-
vides only limited information which may be diffi-
4. 2. cult to interpret. Further data are necessary to fully
Evaluation of the Feedback and
impact on dissemination: data describe the problem on a population basis, to quan-
nosocomial analysis,
infections by interpretation, tify its importance, to interpret variations, and to
surveillance comparisons, permit comparisons. Risk factor analysis requires
(trends) or other discussion
studies information for both infected and non-infected
3. patients. Infection rates, as well as risk-adjusted rates,
Prevention: decisions and
corrective actions can then be calculated.
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TABLE 2. Keypoints in the process of surveillance for surveillance provides attack rates, infection ratio and
nosocomial infection rates
incidence rates (Table 3). It is more effective in
• Active surveillance (prevalence and incidence studies) detecting differences in infection rates, to follow
• Targeted surveillance (site-, unit-, priority-oriented) trends, to link infections to risk factors, and for
inter-hospital and inter-unit comparisons (6).
• Appropriately trained investigators
• Standardized methodology This surveillance is more labour-intensive than a
prevalence survey, more time-consuming, and costly.
• Risk-adjusted rates for comparisons
Therefore, it is usually undertaken only for selected
high-risk units on an ongoing basis (i.e. in
intensive care units), or for a limited period,
3.3.1 Prevalence study (cross-sectional/ focusing on selected infections and specialties (i.e.
transverse) 3 months in surgery) (7,8,9,10).
Infections in all patients hospitalized at a given point Recent trends in “targeted surveillance” include:
in time are identified (point prevalence) in the en-
● Site-oriented surveillance: priorities will be to
tire hospital, or on selected units. Typically, a team
monitor frequent infections with significant im-
of trained investigators visits every patient of the
pact in mortality, morbidity, costs (e.g. extra-
hospital on a single day, reviewing medical and
hospital days, treatment costs), and which may
nurs- ing charts, interviewing the clinical staff to
be avoidable.
identify infected patients, and collecting risk factor
data. The outcome measure is a prevalence rate. Common priority areas are:
Prevalence rates are influenced by duration of the — ventilator-associated pneumonia (a high mor-
patient’s stay (infected patients stay longer, leading tality rate)
to an overestimation of patient’s risk of acquiring
— surgical site infections (first for extra-hospital
an infection) and duration of infections.
days and cost)
Another problem is determining whether an infec-
— primary (intravascular line) bloodstream in-
tion is still “active” on the day of the study.
fections (high mortality)
In small hospitals, or small units, the number of
— multiple-drug resistant bacteria (e.g. methicil-
patients may be too few to develop reliable rates, or
lin-resistant Staphylococcus aureus, Klebsiella spp.
to allow comparisons with statistical significance.
with extended-spectrum beta-lactamase).
A prevalence study is simple, fast, and relatively in-
This surveillance is primarily laboratory-based.
expensive. The hospital-wide activity increases
The laboratory also provides units with regular
awareness of nosocomial infection problems among
reports on distribution of microorganisms isolated,
clinical staff, and increases the visibility of the in-
and antibiotic susceptibility profiles for the most
fection control team. It is useful when initiating a
frequent pathogens.
surveillance programme to assess current issues for
all units, for all kinds of infections, and in all pa- ● Unit-oriented surveillance: efforts can focus on
tients, before proceeding to a more focused continu- high-risk units such as intensive care units, sur-
ing active surveillance programme. Repeated gical units, oncology/haematology, burn units,
prevalence surveys can be useful to monitor trends neonatalogy, etc.
by comparing rates in a unit, or in a hospital, over ● Priority-oriented surveillance: surveillance un-
time.
dertaken for a specific issue of concern to the
facility (i.e. urinary tract infections in patients
with urinary catheters in long-term care
3.3.2 Incidence study (continuous/longitudinal)
facilities).
Prospective identification of new infections (incidence
While surveillance is focused in high-risk sectors,
surveillance) requires monitoring of all patients
some surveillance activity should occur for the
within a defined population for a specified time pe-
rest of the hospital. This may be most efficiently
riod. Patients are followed throughout their stay,
performed on a rotating basis (laboratory-based
and sometimes after discharge (e.g. post-discharge
or repeated prevalence studies).
sur- veillance for surgical site infections). This type
of
18
CHAPTER III. NOSOCOMIAL INFECTION
SURVEILLANCE
Number of infected patients* at the time of study / Prevalence (%) of nosocomial infections
Number of patients observed at the same time X100 (NI) for 100 hospitalized patients
(*or number of infections) Prevalence (%) of urinary tract infections
(UTI) for 100 hospitalized patients
Number of infected patients at the time of the study / Prevalence (%) of UTI for 100 patients
Number of patients exposed at the same time with
X100 a urinary catheter
Number of new infections acquired in a period / Attack rate (%) of UTI for 100 hospitalized
Number of patients observed in the same period patients
X100
Number of new infections acquired in a period / Attack rate (%) of surgical site infections
Number of patients exposed in the same period (SSI) for 100 operated patients
X100
Incidence rate
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the unit under surveillance, or from the Infection Continuing collaboration among infection control
Control Committee) must be a trained professional staff, the laboratory, and clinical units will facilitate
specifically responsible for surveillance, including an exchange of information and improve data qual-
training of personnel for data collection. A written ity (14). The patient is monitored throughout the
protocol must describe the methods to be used, the hospital stay, and in some cases (e.g. for surgical site
data to be collected (e.g. patient inclusion criteria, infections), surveillance includes the post-discharge
definitions), the analysis that can be expected, and period (15). The progressive reduction of the aver-
preparation and timing of reports (13). age length of stay with recent changes in health care
delivery increases the importance of identifying
post- discharge infections.
1. Data collection and analysis
1. Sources
3.4.1.2 Data elements
Data collection requires multiple sources of infor-
Some examples of data collection forms for a preva-
mation as no method, by itself, is sensitive enough
lence study and for surgical site infection surveil-
to ensure data quality. Trained data extractors (train-
lance are given in Figures 2 and 3. One form is
ing should be organized by the infection control
completed for each patient. Simple, validated, and
team or the supervisor) performing active
standardized definitions (16,17) are essential for cred-
surveillance will increase the sensitivity for
ibility of the surveillance system and to ensure data
identifying infections. Techniques for case-finding
quality. A complete guide for data collection should
include:
include:
Ward
— the activity:
● looking for clues such as:
presence of devices or procedures known ● patient inclusion criteria
to be a risk for infection (indwelling urinary
● precise definitions for each variable to be collected
and intravascular catheters, mechanical ven-
(not only definitions for infections)
tilation, surgical procedures)
— record of fever or other clinical signs consist-
● lists of codes for each variable, including specific
codes for missing data.
ent with infection
— antimicrobial therapy This data collection guide is also useful in training
data extractors.
— laboratory tests
The information to be collected should include:
— medical and nursing chart review.
● administrative data (e.g. hospital number, admis-
● Laboratory reports: isolation of microorgan- sion date)
isms potentially associated with infection, anti-
● additional information describing demographic
microbial resistance patterns, serological tests.
risk factors (e.g. age, gender, severity of underly-
Microbiology laboratory reports have low sensi-
ing illness, primary diagnosis, immunological
tivity because cultures are not obtained for all
status) and interventions (e.g. device exposure,
infections, specimens may not be appropriate,
surgical procedure, treatments) for infected and
some infectious pathogens may not be isolated
for non-infected patients
(e.g. virus), and the isolation of a potential patho-
gen may represent colonization rather than ● presence or absence of infection: date of onset,
infection (e.g. for surgical site infections, pneu- site of infection, microorganisms isolated, and
monia). Laboratory reports are, however, reliable antimicrobial susceptibility.
for urinary tract infection, bloodstream infections,
Data validation is essential to ensure correct inter-
and multiple-drug resistant bacteria
pretation and meaningful comparisons. Validation
surveillance, because the definitions for these
is a continuous process which may incorporate vari-
are essentially microbiological.
ous methods:
● Other diagnostic tests: e.g. white blood counts, ● before data input, information validated by a
diagnostic imaging, autopsy data.
second extractor
● Discussion of cases with the clinical staff dur- ● if computerized data collection is used, the soft-
ing periodic ward visits.
ware should include input checks (each variable
20
CHAPTER III. NOSOCOMIAL INFECTION
SURVEILLANCE
Date (dd/mm/yy)
Hospital
Unit
Unit specialty
Patient
Patient identification
Age (years)
Patient exposure
Surgical procedure (during the last month) ■ Yes ■ No
Urinary catheter ■ Yes ■ No
Mechanical ventilation ■ Yes ■ No
Intravascular catheter ■ Yes ■ No
Antibiotic ■ Yes ■ No
If yes, prescription for
■ Prophylaxis ■ Therapy ■ Other/unknown
Nosocomial infection
■ Yes ■ No
If yes, fill the following items
Surgical site infection ■ Yes ■ No
Urinary tract infection ■ Yes ■ No
Bloodstream infection ■ Yes ■ No
Pneumonia ■ Yes ■ No
Other respiratory infection ■ Yes ■ No
Line-related infection ■ Yes ■ No
Other nosocomial infection ■ Yes ■ No
21
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FIGURE 3. Example of a data collection form for surgical site infection surveillance
Hospital
Unit
Patient
Patient identification
Age (years)
Operation
Date of operation (dd/mm/yy)
Main procedure (code)
Wound class ■ Clean ■ Contaminated
■ Clean-contaminated ■ Dirty/infected
ASA score ■ 1 ■ 2 ■ 3 ■ 4 ■ 5
Duration of operation (minutes)
Urgent ■ Yes ■ No
Prosthesis/implant ■ Yes ■ No
Multiple procedures
■ Yes ■ No
Coeliosurgery
■ Yes ■ No
Antibiotics
Antimicrobial prophylaxis ■ Yes ■ No
Starting date (dd/mm/yy)
Duration (days)
Microorganism 2
22
CHAPTER III. NOSOCOMIAL INFECTION
SURVEILLANCE
collected must be coded according to the proto- biological review, and summary or graphic presen-
col) tations on a notice board in the unit. Dissemination
of information is also organized through the Infec-
● before analysis, a retrospective data validation
tion Control Committee to other units, management,
performed to identify missing values, inconsist-
and laboratories.
encies, outliers/possible errors, unexpected val-
ues or codes. Reports should not identify individual patients.
Codes must also be assigned to hospitals, units and
responsible physicians, to ensure anonymity. Reports
3.4.1.3 Analysis must be returned or disposed of confidentially fol-
Information should be collected only if it will be lowing established procedures.
used in the analysis.
Analysis includes the description of the population, 3.4.3 Prevention and evaluation
frequency of risk exposure and infections, calcula-
An effective surveillance system must identify pri-
tion of rates, comparisons of patient groups (with
orities for preventive interventions and improvement
significance testing), comparisons of rates over time,
in quality of care (18).
etc.
By providing quality indicators, surveillance enables
For adequate sample size, and monitoring long-term
the infection control programme, in collaboration
trends, continuous surveillance or surveillance
with patient care units, to improve practice, and to
undertaken at periodic intervals of sufficient length
define and monitor new prevention policies. The
is recommended.
final aim of surveillance is to decrease nosocomial
Inclusion of risk factors allows stratification of pa- infections and reduce costs.
tients by risk, and risk-adjusted rates for accurate
Surveillance is a continuous process which needs to
comparisons. A single overall nosocomial infection
evaluate the impact of interventions to validate the
rate is not useful for inter-hospital comparisons.
prevention strategy, and determine if initial objec-
Adjusted rates will enable the unit or the hospital to
tives are attained.
compare its performance over time with its own
previous results, and with other similar units/hos-
pitals, or with populations of patients with similar
3.5 Evaluation of the surveillance system
risk levels.
A surveillance system must be continuing if it is to
Computerization of data collection and analysis
be credible. Periodic contacts with staff will also help
should be considered, if possible, as it will ensure
to maintain a high level of compliance. Once the
rapid feedback and better data quality. Low-cost
surveillance system is functioning, a validation of
computers and different types of software are now
the surveillance methods and data should be un-
widely available to facilitate analysis for the epide-
dertaken at regular intervals, considering the
miologist. Information already collected and acces-
following criteria:
sible through the hospital computer system should
be used, wherever possible. Integration of nosoco-
mial infection surveillance into routine data han-
3.5.1 Evaluation of the surveillance strategy
dling should be encouraged by defining specific
requirements for hospital information systems. Review whether the surveillance system meets the
required characteristics (19,20):
● simplicity/flexibility/acceptance
3.4.2 Feedback/dissemination
● timeliness (is the feedback prompt enough to be
To be effective, feedback must be prompt, relevant useful?)
to the target group, i.e. the people directly involved
in patient care, and with the potential for maximal
● utility (in terms of priorities, impact, etc.)
influence on infection prevention (i.e. surgeons for ● efficacy/efficiency
surgical site infection, physicians and nurses in in-
Evaluation can be undertaken, for example,
tensive care units). Reporting may include meetings
through a questionnaire study exploring how
for sharing of information and discussion, micro-
feedback is
23
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
perceived and how results are used by different — completeness (missing data)
groups. — correctness (wrong data).
References
3.5.3 Validity/data quality 1. Gaynes RP. Surveillance of nosocomial infections.
A data quality evaluation should be periodically In: Hospital infections, fourth edition. Bennet and
undertaken, with criteria such as (19): Brachman, eds. Philadelphia, Lippincott-Raven,
1998:65–84.
● For the denominator:
2. Lee TB et al. Recommended practices for surveil-
— exhaustiveness (missing patients)
lance. Am J Infect Control, 1998, 26:277–288.
24
CHAPTER III. NOSOCOMIAL INFECTION
SURVEILLANCE
8. Sherertz RJ et al. Consensus paper on the sur- 15. Glenister H et al. An assessment of selective sur-
veillance of surgical wound infections. Am J Infect veillance methods for detecting hospital-acquired
Control, 1992, 20:263–270. infection. Am J Med, 1991, 91 (suppl. 3b):121S–
124S.
9. HELICS report. European recommendations for
nosocomial infection surveillance in intensive 16. Gardner JS et al. CDC definitions for nosocomial
care units. Hygiènes, 1999, 7:127–134. infections, 1988. Am J Infect Control, 1988, 16:128–
140.
10. HELICS report. European recommendations for
surgical site infection surveillance. Hygiènes, 1999, 17. Horan TC et al. CDC definitions of nosocomial
7:51–59. surgical site infections, 1992: a modification of
CDC definitions of surgical wound infections.
11. Freeman J. Modern quantitative epidemiology in
Infect Control Hosp Epidemiol, 1992, 13:606–608.
the hospital. In: Hospital epidemiology and infection
control. Mayhall CG, ed. Baltimore, Williams & 18. Emmerson AM. The impact of surveys on hospi-
Wilkins, 1996. tal infection. J Hosp Infect, 1995, 30:421–440.
12. National Nosocomial Infections Surveillance 19. Centers for Disease Control, Atlanta. Guidelines
(NNIS) System Report, Data summary from Janu- for evaluating surveillance systems. MMWR,
ary 1990–May 1999. Issued June 1999. Am J Infect 1988, 37 (suppl. n S5).
Control, 1999, 27:520–532.
20. Dettenkofer M, Daschner FD. Cost-effectiveness
13. Perl TM. Surveillance, reporting and the use of of surveillance methods. Baillère’s clinical infectious
computers. In: Prevention and control of nosocomial diseases, July 1996, Vol 3, No. 2. Emmerson and
infections, third edition. RP Wenzel, ed. Baltimore, Ayliffe, eds. London, Baillère Tindall.
Williams & Wilkins, 1997:127–161.
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CHAPTER
IV
Dealing with outbreaks
4.2 Investigating an outbreak The case definition can change with time as new
information becomes available, or with additional
Systematic planning and implementation of an out-
diagnostic information.
break investigation is necessary.
A data collection form for case-finding should be
developed, and include:
4.2.1 Planning the investigation ● demographic characteristics (e.g. age, sex, cause
● Notify the appropriate individuals and depart- of admission/leading diagnosis, date of admission,
ments in the institution of the problem; establish date of any surgery, prior antimicrobials)
terms of reference for the investigation. This must ● clinical data (e.g. onset of symptoms and signs,
include development of an outbreak team and
frequency and duration of clinical features asso-
clear delineation of authority.
ciated with the outbreak, treatments, devices)
● Infection control staff must be part of the out- ● any other potentially relevant data.
break team.
26
CHAPTER IV. DEALING WITH
OUTBREAKS
The form must be straightforward to use. It is com- FIGURE 2. Epidemic curve in case of ongoing
transmission*
pleted with information extracted from medical
9
charts, microbiology reports, pharmacy reports and
log books of affected wards. The data collected must 8
also be checked for validity.
7
The clinical diagnosis will usually be confirmed
microbiologically. Optimal diagnostic specimens to
6
be obtained from cases should be described. It may
Number of cases
be appropriate to store selected biological materials 5
for future analysis in anticipation that new diag-
nostic methods may become available. 4
FIGURE 1. Epidemic curve in case of single point Number of people at risk who are infected
source outbreak*
Total number of people at risk
16
10
At the end of the descriptive analysis, it should be
possible to:
Number of cases
27
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
4
Number of cases
0
1–2
3–4
4–5
5–6
7–8
8–9
14–15
20–21
24–25
2–3
6–7
9–10
12–13
13–14
15–16
16–17
17–18
18–19
19–20
21–22
22–23
23–24
10–11
11–12
Weeks (i.e. 1–2 : 3 cases between the 1st and the 2nd week)
* adapted from Astagneau P, Duneton P.Management of epidemics of nosocomial infections. Pathol Biol (Paris) 1998, 46:272–278.
rent literature may help identify possible routes of 4.2.5 Control measures and follow-up
infection for the suspected or known infecting
The aims are:
agents.
● to control the current outbreak by interrupting
A case-control study is the most common approach
the chain of transmission
to hypothesis testing. This compares the frequency
of a risk factor in a group of cases (i.e. individuals ● to prevent future occurrence of similar outbreaks.
with the nosocomial infection) and in a group of The selection of control measures (Table 1) is deter-
controls (i.e. individuals without the infection). Con- mined by results of the initial analysis in consulta-
trols must be carefully selected to limit bias. Two or tion with appropriate professionals (infection control
more controls for each case may be necessary to staff, epidemiologist, clinicians, microbiologists,
provide sufficient statistical power. By definition, the nurs- ing). This is also an opportunity to initiate or
controls are not-cases (individuals without the no- im- prove a surveillance system to facilitate
socomial infection or colonization). Further in-depth evaluation of the efficacy of the control procedures
discussion of the selection of controls is described instituted. Continuous surveillance may be
in several other sources (1,2,3). implemented in high-risk units (see Chapter III).
The strength of association between exposure and
disease is quantified by the odds ratio in case-
control studies (or the relative risk for cohort stud- 4.2.6 Communication
ies), with a 95% confidence interval. The role of During the investigation of an outbreak, timely, up-
chance, confounding, and bias should be considered to-date information must be communicated to the
in interpreting results.
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CHAPTER IV. DEALING WITH
OUTBREAKS
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CHAPTER
V
Prevention of nosocomial infection
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CHAPTER V. PREVENTION OF NOSOCOMIAL INFECTION
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5.2.2 Personal hygiene women. In other units, women may wear a short-
sleeved dress.
All staff must maintain good personal hygiene. Nails
must be clean and kept short. False nails should not The working outfit must be made of a material easy
be worn. Hair must be worn short or pinned up. to wash and decontaminate. If possible, a clean out-
Beard and moustaches must be kept trimmed short fit should be worn each day. An outfit must be
and clean. changed after exposure to blood or if it becomes
wet through excessive sweating or other fluid expo-
sure.
5.2.3 Clothing
Working clothes
Shoes
Staff can normally wear a personal uniform or street
In aseptic units and in operating rooms, staff must
clothes covered by a white coat. In special areas
wear dedicated shoes, which must be easy to
such as burn or intensive care units, uniform
clean.
trousers and a short-sleeved gown are required for
men and
32
CHAPTER V. PREVENTION OF NOSOCOMIAL INFECTION
33
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— Zone B: care of patients who are not infected, 5.3.3 Disinfection of patient equipment
and not highly susceptible, cleaned by a pro-
Disinfection removes microorganisms without com-
cedure that does not raise dust. Dry sweeping
plete sterilization to prevent transmission of organ-
or vacuum cleaners are not recommended. The
isms between patients. Disinfection procedures
use of a detergent solution improves the
must (5,9,10):
qual- ity of cleaning. Disinfect any areas
with visible contamination with blood or ● meet criteria for killing of organisms
body fluids prior to cleaning. ● have a detergent effect
— Zone C: infected patients (isolation wards). ● act independently of the number of bacteria
Clean with a detergent/disinfectant solution, present, the degree of hardness of the water, or
with separate cleaning equipment for each the presence of soap and proteins (that inhibit
room. some disinfectants).
— Zone D: highly-susceptible patients (protective
To be acceptable in the hospital environment, they
isolation) or protected areas such as must also be:
operating suites, delivery rooms, intensive
care units, premature baby units, casualty
● easy to use
departments and haemodialysis units. Clean ● non-volatile
using a deter- gent/disinfectant solution and
● not harmful to equipment, staff or patients
separate clean- ing equipment.
● free from unpleasant smells
All horizontal surfaces in zones B, C and D, and all
toilet areas should be cleaned daily. ● effective within a relatively short time.
● Bacteriological testing of the environment is not For further recommendations, see Tables 5 and 6. In
recommended except in selected circumstances using a disinfectant, manufacturers recommenda-
such as: tions must always be followed. Different products
— epidemic investigation where there is a sus- or processes achieve different levels of disinfection.
These are classified as high-, intermediate- or
pected environmental source
low-level disinfection (11); Table 5 provides charac-
— dialysis water monitoring for bacterial counts, teristics of the three levels, and Table 6 makes
as required by standards (see Chapter VIII) recommendations for the level of disinfection for dif-
— quality control when changing cleaning prac- ferent patient care activity.
tices. High-level disinfection (critical) — this will destroy
all microorganisms, with the exception of heavy con-
tamination by bacterial spores.
5.3.2 Use of hot/superheated water
Intermediate disinfection (semi-critical) — this
An alternative to disinfection for environmental inactivates Mycobacterium tuberculosis, vegetative
cleaning for some objects is hot water (Table 4). bacteria, most viruses and most fungi, but does not
necessarily kill bacterial spores.
TABLE 4. Disinfection with hot water Low-level disinfection (non-critical) — this can kill
most bacteria, some viruses and some fungi, but can-
Temperature
not be relied on for killing more resistant bacteria
Duration such as M. tuberculosis or bacterial spores.
1. Sanitary 80 C 45–60 seconds equipment These levels of disinfection are attained by using the
2. Cooking 80 C 1 minute appropriate chemical product in the manner
utensils
appro- priate for the desired level of disinfection.
3. Linen 70 C 25 minutes
95 C 10 minutes
5.3.4 Sterilization (5–13)
Sterilization is the destruction of all microorganisms.
Operationally this is defined as a decrease in the
34
CHAPTER V. PREVENTION OF NOSOCOMIAL INFECTION
TABLE 6. Level of disinfection for patient equipment in relation with type of care (11,12)
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CHAPTER V. PREVENTION OF NOSOCOMIAL INFECTION
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CHAPTER
VI
Prevention of common endemic
nosocomial infections
38
CHAPTER VI. PREVENTION OF COMMON ENDEMIC NOSOCOMIAL
INFECTIONS
FIGURE 1. Portalsof entry for microorganisms in urinary drainage systems: the urethral meatus-catheter
junction; the catheter-drainage tubing junction; the drainage tubing-bag junction; and
the outlet that drains urine from the bag
Urethral meatus–
catheter junction
Catheter–drainage
tubing junction
Drainage–
tubing bag
junction
● limiting the duration of drainage, if catheteriza- Generally, the smallest diameter catheter should be
tion is necessary used. Catheter material (latex, silicone) does not in-
fluence infection rates.
● maintaining appropriate aseptic practice during
urinary catheter insertion and other invasive For patients with a neurogenic bladder:
urological procedures (e.g. cystoscopy, urodynamic ● avoid an indwelling catheter if possible
testing, cystography)
● if assisted bladder drainage is necessary, clean
● hygienic handwash or rub prior to insertion and
intermittent urinary catheterization should be
following catheter or drainage bag manipulation
used.
(Chapter V)
● sterile gloves for insertion
6.2 Surgical wound infections (surgical site
● perineal cleaning with an antiseptic solution prior
infections)
to insertion
Factors which influence the frequency of surgical
● non-traumatic urethral insertion using an appro-
wound infection include (5,6,7,8):
priate lubricant
● surgical technique
● maintaining a closed drainage system.
● extent of endogenous contamination of the
Other practices which are recommended, but not
wound at surgery (e.g. clean, clean-contaminated)
proven to decrease infection include:
● duration of operation
● maintaining good patient hydration
● underlying patient status
● appropriate perineal hygiene for patients with
catheters ● operating room environment
● appropriate staff training in catheter insertion ● organisms shed by the operating room team.
and care A systematic programme for prevention of surgical
● maintaining unobstructed drainage of the blad- wound infections (5) includes the practice of opti-
der to the collection bag, with the bag below the mal surgical technique, a clean operating room en-
level of the bladder. vironment with restricted staff entry and appropriate
39
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
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staff attire, sterile equipment, adequate preoperative puncture, such as total joint arthroplasty. Double
preparation of the patient, appropriate use of gloving is also recommended when operating on
preoperative antimicrobial prophylaxis, and a sur- patients known to be infected with bloodborne
gical wound surveillance programme. Surgical pathogens such as the human immunodeficiency
wound infection rates are decreased by standard- virus (HIV), hepatitis B, or hepatitis C (10). Gloves
ized surveillance for infection with reporting of rates should be changed immediately after any acciden-
back to individual surgeons. tal puncture.
All items used within a sterile field must be sterile. 6.2.2.3 Operating room activitiy
Sterile drapes must be placed on the patient and on
● The number of persons entering the theatre dur-
any equipment included in the sterile field; these
ing an operation should be minimized.
drapes must be handled as little as possible. Once a
sterile drape is in position, it must not be moved; ● Unnecessary movement or conversation should
shifting or moving the sterile drape compromises be avoided.
the sterile field.
40
CHAPTER VI. PREVENTION OF COMMON ENDEMIC NOSOCOMIAL
INFECTIONS
the surgeon to work without contacting unprepared ● Position comatose patients to limit the potential
skin. for aspiration.
The patient must be covered with sterile drapes; no ● Avoid oral feeds in patients with swallowing ab-
part is uncovered except the operating field and normalities.
areas needed for the administration and maintenance ● Prevent exposure of neutropenic or transplant
of anaesthesia.
patients to fungal spores during construction or
renovation (Chapter VIII).
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FIGURE 2. Portals of entry for microorganisms in IV ● Mask, cap, and sterile gloves and gown must be
systems
worn for insertion.
● The introduction of the catheter and the subse-
During quent catheter dressings require a surgical hand
manufacture wash or rub.
Additives
Hairline cracks
● Follow appropriate aseptic care in accessing the
or punctures system, including disinfecting external surfaces of
hub and ports.
● Change of lines should normally not occur more
Bottle (bag)–
often than once every three days. A change of
tubing line is necessary, however, after the transfusion of
junction
blood, blood products, or intralipids, and for
dis- continuous perfusions.
Medicatio
n port ● Change dressing at the time of the change of lines,
Stopcock following surgical asepsis.
Insertion
site ● Use a sterile gauze or transparent dressing to
Secondary
infection from cover the catheter site.
other side
● Do not replace over a guide wire if infection is
suspected.
● An increased number of catheter lumens may
increase the risk of infection. A single lumen cath-
Reproduced by permission of Wiley&Sons, Inc. from Hospital Infec-
tion Control: Principles and Practice, M. Castle, Copyright© 1980 eter is preferred wherever possible.
by John Wiley & Sons , Inc.
● Antimicrobial impregnated catheters may decrease
infection in high-risk patients with short-term
(<10 days) catheterization.
● Use the subclavion site in preference to jugular
6.4.1 Peripheral vascular catheters or femoral sites.
● If local infection or phlebitis occurs, the catheter ● a preoperative shower and implantation under
should be removed immediately. surgical conditions in an operating room
● local preparation includes washing and antisep-
sis with major antiseptic solution as for other sur-
6.4.2 Central vascular catheters
gical procedures
● Clean the insertion site with an antiseptic solu- ● mask, hat, and sterile gloves and gown must be
tion.
worn; the introduction of a catheter and the
● Do not apply solvents or antimicrobial ointment dress- ing require a surgical handwash or rub
to the insertion site. ● maintain a closed system during the use of the
42
CHAPTER VI. PREVENTION OF COMMON ENDEMIC NOSOCOMIAL
INFECTIONS
device; a change of lines should normally occur 8. Garibaldi R et al. The impact of preoperative skin
every 5 days for continuous use, and at each in- disinfection of preventing intraoperative wound
tervention for intermittent use; a change of line is contamination. Infect Control Hosp Epidemiol, 1988,
necessary after the transfusion of blood, and for 9:109–113.
discontinuous perfusions.
9. Dodds RDA et al. Surgical glove perforation. Brit
J Surg, 1988, 75:966–968.
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CHAPTER
VII
Infection control precautions
in patient care
● Infection by direct or indirect contact: infection • Clean up spills of infective material promptly
occurs through direct contact between the source • Ensure that patient-care equipment, supplies and
of infection and the recipient or indirectly
linen contaminated with infective material is
through contaminated objects.
either discarded, or disinfected or sterilized be-
tween each patient use
Isolation and other barrier precautions must be • If no washing machine is available for linen
clearly written policies which are standardized, and soiled with infective material, the linen can be
adaptable to the infectious agent and the patients. boiled.
These include:
– standard or routine precautions to be followed
for all patients Considerations for protective clothing include:
– additional precautions for selected patients. – gown: should be of washable material, but-
toned or tied at the back and protected, if
nec- essary, by a plastic apron
7.1.1 Standard (routine) precautions (1,2) – gloves: inexpensive plastic gloves are avail-
To be applied to the care of all patients. This in- able and usually sufficient
cludes limiting health care worker contact with all – mask: surgical masks made of cloth or paper
secretions or biological fluids, skin lesions, mucous
may be used to protect from splashes.
membranes, and blood or body fluids. Health care
workers must wear gloves for each contact which
may lead to contamination, and gowns, mask and 7.1.2 Additional precautions for specific modes of
eye protection where contamination of clothes or transmission (1,2)
the face is anticipated.
The following precautions are used for selected
patients in addition to those described above:
44
CHAPTER VII. INFECTION CONTROL PRECAUTIONS IN PATIENT
CARE
Airborne precautions (droplet nuclei <5 m) (e.g. ● incineration of needles, syringes
tuberculosis, chickenpox, measles) (5,6) ● disinfection of medical instruments
The following is required: ● incineration of excreta, body fluids, nasopharyn-
● individual room with adequate ventilation; this geal secretions
includes, where possible, negative pressure; door ● disinfection of linen
closed; at least six air exchanges per hour; ex-
haust to outside away from intake ducts ● restrict visitors and staff
● staff wearing high-efficiency masks in room ● daily disinfection and terminal disinfection at the
end of the stay
● patient to stay in room.
● use of disposable (single-use) equipment
Droplet precautions (droplet nuclei >5 m) (e.g. bac- ● appropriate transport and laboratory manage-
terial meningitis, diphtheria, respiratory syncytial
ment of patient specimens.
virus)
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46
CHAPTER
VIII
Environment
47
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
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the flow of air, liquids and wastes. Other traffic pat- of water droplets from air conditioning cooling tow-
terns may also be identified. Building or rebuilding ers or with aerosolization in patient showers, and
a hospital requires consideration of all physical subsequently may be inhaled by patients at risk of
movements and communications, and where con- infection.
tamination may occur.
The number of organisms present in room air will
In this context, rather than considering a “clean” and depend on the number of people occupying the
a “dirty” circuit, consider only circuits where the room, the amount of activity, and the rate of air ex-
different flows can cross without risk provided ma- change. Bacteria recovered from air samples usually
terial is properly protected. An elevator can accom- consist of Gram-positive cocci originating from the
modate hospital staff, sterile equipment, visitors and skin. They can reach large numbers if dispersed from
waste, as long as each of these is treated appropri- an infected lesion, particularly an infected exfolia-
ately. Both sterile products and waste must be sealed tive skin lesion. However, since the contaminated
in safe containers, and the outside of those contain- skin scales are relatively heavy, they do not remain
ers must present no risk of biological contamina- suspended in the air for long. Gram-negative bacte-
tion. ria are usually found in the air only when associ-
ated with aerosols from contaminated fluids, and
tend to die on drying.
8.1.4 Materials
Droplets projected from the infected upper respira-
The choice of construction materials — especially tory tract may conta in a wide variety of
those considered in the covering of internal surfaces microrganisms, including viruses, and many infec-
— is very important. Floor coverings must be easy tions can be spread by this route (i.e. respiratory vi-
to clean and resistant to disinfection procedures. ruses, influenza, measles, chickenpox, tuberculosis).
This also applies to all items in the patient In most cases, these are spread by large droplets,
environment. and an infective dose will rarely move more than a
few feet from the source patient. Varicella-zoster
All of this calls for: (chickenpox), tuberculosis, and a few other agents,
1. Definition of needs (planning) however, may be transmitted over large distances in
droplet nuclei.
2. Definition of the level of risk (segregation)
48
CHAPTER VIII.
ENVIRONMENT
areas where high-risk patients receive care, and move bacteria larger than 0.5 to 5 m in diameter
in areas subject to heavy contamination. and are used to obtain downstream bacteria-free
air. The operating room is usually under positive
● Filters used in the ventilation systems must meet
pres- sure relative to the surrounding corridors, to
standards for the patient care activity of the area.
mini- mize inflow of air into the room.
High-efficiency filters must be provided in sys-
tems serving areas where patients are particularly
susceptible to infection (haematology/oncology TABLE 1. Factors influencing airborne contamina-
units) or where some clinical procedures subject tion in operating theatres
patients to unusual hazard (for instance surgical
procedure, particularly transplantation). 1. Type of surgery
2. Quality of air provided
● Regular inspection and maintenance of filters,
3. Rate of air exchange
humidifiers, and grills in the ventilation system
must be performed and documented. 4. Number of persons present in operating theatre
5. Movement of operating room personnel
● Cooling towers and humidifiers should be regu-
larly inspected and cleaned to prevent aerosoli- 6. Level of compliance with infection control practices
zation of Legionella spp. 7. Quality of staff clothing
● Zoning of air systems may confine the air of a 8. Quality of cleaning process
department to that department alone. A design
that enables air pressure to control air movement
into or out of a specific room or area will control 8.2.4 Ultra-clean air
the spread of contamination. Positive air ● For minimizing airborne particles, air must be cir-
pressure is recommended for areas which must culated into the room with a velocity of at
be as clean as possible. It is achieved by least
supplying more air into an area than can be 0.25 m/sec through a high-efficiency particulate
removed by the exhaust ventilation system. air (HEPA) filter, which excludes particulate mat-
This produces an outflow around doors and ter of defined size. If particles 0.3 microns in
other openings, and decreases entry of air from diameter and larger are removed, the air entering
more contaminated areas. Nega- tive air the room will be essentially clean and free of
pressure is recommended for contami- nated bac- terial contaminants.
areas, and is required for isolation of patients
with infections spread by the airborne route. It is
● This principle has been applied to microbiology
achieved by supplying less air to the area than laboratories, pharmacies, special intensive care
can be removed by the ventilation sys- tem. units, and operating rooms.
Negative air pressure produces an inflow Workers in microbiology laboratories use special
around openings and reduces the movement of unidirectional airflow hoods to handle microbial
contaminated air out of the area. For effective air cultures. These are particularly useful for certain
pressurization all doors must be kept closed ex- highly infectious cultures. Hoods of this type pro-
cept for essential entrances and exits. tect the individual worker as well as the labora-
tory environment from contamination by the
8.2.3 Operating theatres airborne route.
Modern operating rooms which meet current air Similar hoods are used in pharmacies to prevent
standards are virtually free of particles larger than airborne contamination of sterile fluids when
0.5 m (including bacteria) when no people are in containers are opened. For example, when add-
the room. Activity of operating room personnel is ing an antibiotic to a container of sterile glucose
the main source of airborne bacteria, which origi- solution for intravenous use, or when preparing
nate primarily from the skin of individuals in the fluids for parenteral hyperalimentation.
room. The number of airborne bacteria depends on
In intensive care units, laminar flow units have
eight factors (Table 1). Conventional operating
been used in the treatment of immunosuppressed
rooms are ventilated with 20 to 25 changes per
patients.
hour of high-efficiency filtered air delivered in a
vertical flow. High-efficiency particulate air For operating theatres, a unidirectional clean air-
(HEPA) systems re- flow system with a minimum size of 9 m2 (3 m x
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50
CHAPTER VIII.
ENVIRONMENT
and adherence to these practices monitored. Infected requirements of users (including risk factors for
patients should be restricted from using communal patients).
baths. Potential entry points for organisms to cause
Methods used for monitoring must suit the use. Bac-
infection in patients, such as percutaneous devices,
teriological, medical and biochemical methods are
must be protected with waterproof occlusive dress-
not necessarily adapted to environmental analyses,
ings.
and may lead to falsely reassuring conclusions. Two
points which must be considered for water ecosys-
tems are: (1) biofilm, (2) level of stress for the micro-
8.3.3 Pharmaceutical (medical) water
organism (nutrients, exposure to physical or
There are physical, chemical, bacteriological, and chemical antibacterial agents).
biological parameters which must be met for water
Biofilm consists of microorganisms (dead or alive)
used for medical purposes.
and macromolecules of biological origin, and accu-
Pharmaceutical waters include (8): mulates as a complex gel on the surfaces of con-
● purified water — sterile water used for the duits and reservoirs. It is a dynamic ecosystem with
prepa- ration of drugs that normally do not a wide variety of organisms (bacteria, algae, yeasts,
need to be sterile, but must be pyrogen-free protozoa, nematodes, insect larvae, molluscs) start-
ing with the biodegradable organic matter of water.
● water used for injectable preparations, which This biofilm is a dynamic reservoir for microorgan-
must be sterile isms (including pathogenic agents such as Legionella
● dilution water for haemodyalisis. and Pseudomonas aeruginosa). Individual organisms
may be freed into circulation through shearing at
In the case of dialysis, contamination may induce
the surface of the biofilm or through the mechani-
infections (bacteria passing from the dialysate cal impact of vibrations (such as may occur during
into the blood) or febrile reactions due to construction).
pyrogenic endotoxins from the degradation of
the mem- branes of Gram-negative bacteria. The Bacteriological tests may not always give true esti-
CDC rec- ommends that the water for mates of contamination because of the presence of
haemodyalisis contain: agents such as disinfectants.
The levels of organisms in dialysate should be The use determines characteristics needed for the
monitored once a month. The coliform recom- water. These usually differ from those of tap water.
mendations may be revised downwards with
Infections attributable to water are usually due to
improvements in water production, use of dialy-
failure to meet water quality standards for the spe-
sis membranes with improved permeability, and
cific use.
increasing knowledge of the role of bacterial
prod- ucts in the complications of long-term Infection control/hygiene teams must have written,
dialysis. New techniques (haemofiltration, valid policies for water quality to minimize risk of
haemodialysis filtration on line) require stricter adverse outcomes attributable to water in health care
guidelines for water dilution and for settings.
haemodialysis solutions (9).
8.4 Food
8.3.4 Microbiological monitoring Quality and quantity of food are key factors for pa-
Regulations for water analysis (at the national level tient convalescence. Ensuring safe food is an impor-
for drinking-water, in the Pharmacopoeia for phar- tant service delivery in health care.
maceutical waters) define criteria, levels of impuri-
ties, and techniques for monitoring. For water use
for which regulations are not available, parameters
should be appropriate for the planned use and the
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CHAPTER VIII.
ENVIRONMENT
Infectious waste Waste suspected to contain pathogens, e.g. laboratory cultures; waste from
isolation wards; tissues (swabs), materials, or equipment that have been in
contact with infected patients; excreta
Pathological waste Human tissues or fluids, e.g. body parts; blood and other body fluids; fetuses
Sharps Sharp waste, e.g. needles; infusion sets; scalpels; knives; blades; broken
glass
Pharmaceutical waste Waste containing pharmaceuticals, e.g. pharmaceuticals that are expired or
no longer needed; items contaminated by or containing pharmaceuticals
(bottles, boxes)
Cytotoxic waste Waste containing substances with genotoxic properties, e.g. waste contain-
ing cytostatic drugs (often used in cancer therapy); genotoxic chemicals
Chemical waste Waste containing chemical substances, e.g. laboratory reagents; film devel-
oper; disinfectants that are expired or no longer needed; solvents
Wastes with high content of heavy metals Batteries; broken thermometers; blood pressure gauges; etc.
Pressurized containers Gas cylinders; gas cartridges; aerosol cans
Radioactive waste Waste containing radioactive substances, e.g. unused liquids from radio-
therapy or laboratory research; contaminated glassware, packages, or
absorbent paper; urine and excreta from patients treated or tested with
unsealed radionucleotides; sealed sources
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● waste from surgery and autopsies on patients with ● Microbiological laboratory waste should be steri-
infectious diseases (e.g. tissues, and materials or lized by autoclaving. It must be packaged in bags
equipment that have been in contact with blood compatible with the process: red bags, suitable
or other body fluids) for autoclaving, are recommended.
● waste from infected patients in isolation wards ● Cytotoxic waste, most of which is produced in
(e.g. excreta, dressings from infected or surgical major hospital or research facilities, must be col-
wounds, clothes heavily soiled with human blood lected in strong, leak-proof containers clearly
or other body fluids) labelled “Cytotoxic wastes”.
● waste that has been in contact with infected ● Small amounts of chemical or pharmaceutical
patients undergoing haemodialysis (e.g. dialysis waste may be collected together with infectious
equipment such as tubing and filters, disposable waste.
towels, gowns, aprons, gloves and laboratory coats) ● Large quantities of obsolete or expired pharma-
● infected animals from laboratories ceuticals stored in hospital wards or departments
must be returned to the pharmacy for disposal.
● any other instruments or materials that have been
Other pharmaceutical waste generated at the
contaminated by infected persons or animals.
wards, such as spilled or contaminated drugs, or
packaging containing drug residues must not be
returned because of the risk of contaminating the
8.5.2 Handling, storage and transportation of
pharmacy; it must be deposited in the correct
health care waste
container at the point of generation.
All waste disposal practices must meet local regula-
● Large quantities of chemical waste must be packed
tions. The following practices are recommended as a
in chemical-resistant containers and sent to spe-
general guide:
cialized treatment facilities (if available). The
● For safety and economic reasons, health care in- iden- tity of the chemicals must be clearly
stitutions must organize a selective collection of marked on the containers: hazardous chemical
hospital waste, differentiating between medical wastes of different types should never be
waste, general waste and some specific wastes mixed.
(sharp instruments, highly infectious waste, cytoxic
● Waste with a high content of heavy metals (e.g.
waste).
cadmium or mercury) must be collected and dis-
● General health care waste may be disposed in the posed of separately.
stream of domestic refuse.
● Pressurized containers may be collected with gen-
● Sharps should be collected at source of use in eral health care waste once they are completely
puncture-proof containers (usually made of metal empty, provided that the waste is not destined
or high-density plastic) with fitted covers. Con- for incineration.
tainers should be rigid, impermeable, and punc-
● Low-level radioactive infectious waste (e.g. swabs,
ture proof. To discourage abuse, containers should
syringes for diagnostic or therapeutic use) may
be tamper-proof (difficult to open or break).
be collected in yellow bags or containers for
Where plastic or metal containers are unavail-
infectious waste if these are destined for incin-
able or too costly, containers made of dense card-
eration.
board are recommended — these fold for ease of
transport and may be supplied with a plastic ● Health care personnel and other hospital work-
lining. ers should be informed about the hazards related
to health care waste and trained in appropriate
● Bags and other containers used for infectious
waste management practices.
waste must be marked with the international in-
fectious substance symbol. ● Additional information on collection, handling,
storage and disposal of health care wastes, as
● Infectious health care waste should be stored in a
well as personal protection and training issues is
secure place with restricted access.
pro- vided in a referenced document (10).
54
CHAPTER VIII.
ENVIRONMENT
5. Guide Uniclima — Traitement de l’air en milieu 10. Prüss A, Giroult B, Rushbrook P. Safe management
hospitalier. Paris, Editions SEPAR. ISBN 2.951 of wastes from health-care activities. Geneva, WHO,
117.0.3. 1999.
6. World Health Organization. Guidelines for drinking- 11. American Institute of Architects. Guidelines for
water quality, Vol. 1, Recommendations, 2nd edition. design and construction of hospital and health care facili-
Geneva, WHO, 1993. ties. Washington, American Institute of
Architects Press, 2001.
7. Pollack M. Pseudomonas aeruginosa in principles and
practices of infectious diseases, 4th ed. New York,
Churchill-Livingstone, 1995, chapter 197.
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CHAPTER
IX
Antimicrobial use and
antimicrobial resistance
F ollowing the discovery and widespread use of TABLE 1. Commonly used antimicrobials by class
sulfonamides and penicillin in the mid-20th
Class Antibiotics
tury, the years between 1950 and 1970 saw a “golden
cen-
age” of antimicrobial discovery (Table 1) . Many in- Aminoglycoside Streptomycin, kanamycin,
s tobramycin,
fections that were once serious and potentially fatal gentamicin, neomycin,
could now be treated and cured. However, these amikacin
Beta-lactams
successes encouraged the overuse and misuse of
antibiotics. Currently many microorganisms have
• Penicillins Benzylpenicillin (penicillin G),
procaine-benzyl penicillin,
become resistant to different antimicrobial agents, benzathine-benzyl
and in some cases to nearly all agents. Resistant bac- penicillin,
teria may cause increased morbidity and death, phenoxymethylpenicillin
(penicillin V), ampicillin,
particularly among patients with significant under- amoxycillin, methicillin,
lying diseases or who are immunocompromised. cloxacillin
Resistance to antimicrobial agents is a problem in • Penicillin/beta- amoxicillin/clavulanic
the community as well as health care facilities, but lactamase inhibitors acid,
in hospitals, transmission of bacteria is amplified be- • Cephalosporins piperacillin/tazobacta
cause of the highly susceptible population. m
1st generation: cephalexin,
Resistance and its spread among bacteria is gener- cephalothin
ally the result of selective antibiotic pressure (1,2). 2nd generation: cefuroxime,
Resistant bacteria are transmitted among patients, cefoxitin, cefaclor
3rd generation: cefotaxime,
and resistance factors are transferred between bac- Other beta-lactams ceftriaxone, ceftazidime
teria, both occurring more frequently in health care • Carbapenems
Aztreonam,
settings. The continuous use of antimicrobial agents • Glycopeptides
increases selection pressure favouring the Imipenem, meropenem
• Macrolides/azolides
emergence, multiplication, and spread of resistant Vancomycin, teicoplanin
strains. Inap- propriate and uncontrolled use of Erythromycin,
antimicrobial agents including overprescribing, • Tetracyclines oleandomycin,
administration of suboptimal doses, insufficient spiramycin, clarithromycin,
duration of treatment, and misdiagnosis leading to azithromycin
inappropriate choice of drug, contribute to this. In • Quinolones Tetracycline, chlortetracycline,
health care settings, the spread of resistant minocycline, doxycycline,
oxytetracycline
organisms is facilitated when handwashing, barrier
precautions, and equipment cleaning are not Nalidixic acid,
ciprofloxacin,
optimal. The emergence of resist- ance is also • Oxazolidinone norfloxacin, pefloxacin,
favoured by underdosing due to short- age of sparfloxacin, fleroxacin,
• Streptogramin
antibiotics, where lack of microbiological ofloxacin, levofloxacin,
• Others gatifloxacin,
laboratories results in empiric prescribing, and
moxifloxacin
where the lack of alternate agents compounds the
linezolid
risk of therapeutic failure.
Sulfonamides Quinupristin/dalfopristin
and
trimethoprim Bacitracin, cycloserine,
novobiocin,
spectinomycin,
clindamycin, nitrofurantoin
56 Trimethoprim, trimethoprim/
sulfamethoxazole
CHAPTER IX. ANTIMICROBIAL USE AND ANTIMICROBIAL
RESISTANCE
9.1 Appropriate antimicrobial use rowest spectrum possible. The choice of parenteral,
oral or topical antimicrobial formulations is made
Each health care facility should have an antimicro-
on the basis of clinical presentation (site and sever-
bial use programme (3,4). The goal is to ensure
ity of infection). Oral administration is preferred, if
effective economical prescribing to minimize the
possible. Combinations of antibiotics should be used
selection of resistant microorganisms. This policy
selectively and only for specific indications such as
must be implemented through the Antimicrobial Use
enterococcal endocarditis, tuberculosis, and mixed
Committee.
infections.
● Any antibiotic use must be justifiable on the ba-
The physician must decide whether antibiotic
sis of the clinical diagnosis and known or
therapy is really necessary. In patients with fever,
expected infecting microorganisms.
non-infectious diagnoses must be considered.
● Appropriate specimens for bacteriological exami-
nation must be obtained before initiating antibi-
otic treatment, to confirm the treatment is The aim of antimicrobial therapy is to choose a drug
appropriate. that is selectively active against the most likely
pathogen(s) and the least likely to cause adverse
● The selection of an antibiotic must be based not
effects or promote resistance.
only on the nature of the disease and that of the
pathogenic agent(s), but on the sensitivity pat-
tern, patient tolerance, and cost.
9.1.2 Chemoprophylaxis
● The physician should receive timely, relevant in-
formation of the prevalence of resistance in the Antibiotic prophylaxis is used only when it has been
facility. documented to have benefits which outweigh risks.
Some accepted indications include:
● An agent with as narrow a spectrum as possible
should be used.
● selected surgical prophylaxis (Table 2)
9.1.1 Therapy
Empirical antimicrobial therapy must be based on 9.2 Antimicrobial resistance
careful clinical evaluation and local epidemiologi- Nosocomial infections are often caused by antibi-
cal data regarding potential pathogens and antibi- otic-resistant organisms. Where transmission of
otic susceptibility. Appropriate specimens for Gram these organisms in the health care setting is
stain, culture and, if available, sensitivity testing must occurring, specific control measures are necessary
be obtained before starting therapy. Therapy (Table 3, Table 4). Antimicrobial restriction is also an
selected should be effective, limit toxicity, and be of impor- tant intervention.
the nar-
57
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
58
CHAPTER IX. ANTIMICROBIAL USE AND ANTIMICROBIAL
RESISTANCE
infections are most common in the intensive care formulary, prescribing policies, reviews and approves
and other high-risk units with highly-susceptible practice guidelines, audits antibiotic use, oversees
patients (e.g. burn and cardiothoracic units). Epidemic education, and interacts with pharmaceutical repre-
spread of MRSA may occur; highly-transmissible sentatives. The committee must be
strains tend to spread regionally and nationally to multidisciplinary, and should include: infectious
many hospitals. Factors increasing the likelihood of disease physicians, surgeons, infection control
acquisition of resistant organisms are shown in the nurses, pharmacists, microbiologists, and
following box (9). administration as well as other relevant
professionals.
59
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
One of the most important functions of the microbi- 2. Struelens MJ. The epidemiology of antimicrobial
ology laboratory is to determine the antibiotic resistance in hospital-acquired infections: prob-
susceptibility of organisms isolated from infected lems and possible solutions. BMJ, 1998, 317:652–
patients, in order to assist the physician in the choice 654.
of treatment.
3. Shlaes DM et al. Society for Healthcare Epidemi-
ology of America and Infectious Diseases Society
of America Joint Committee on the Prevention
9.3.3 Monitoring antimicrobial use
of Antimicrobial Resistance: Guidelines for the
Antimicrobial use in the facility must be monitored. prevention of antimicrobial resistance in hospi-
This is usually performed by the pharmacy depart- tals. Infect Control Hosp Epidemiol, 1997, 18:275–291.
ment, and should be reported in a timely manner to
4. Working Party of the British Society for Antimi-
the Antimicrobial Use Committee and the Medical
crobial Chemotherapy. Hospital antibiotic con-
Advisory Committee. Specific elements to be moni-
trol measures in the UK. J Antimicrob Chemother,
tored include the amount of different antimicrobials
1994, 34:21–42.
used during a given period and trends in antimi-
crobial use over time. In addition, the antimicrobial 5. Swedish-Norwegian Consensus Group. Antibiotic
use in specific patient areas such as the intensive prophylaxis in surgery: Summary of a Swedish-
care units or haematology/oncology units should Norwegian consensus conference. Scand J Infect
be analysed. Dis, 1998, 30:547–557.
In addition to monitoring antimicrobial use, inter- 6. Dellinger EP et al. Quality standard for antimi-
mittent audits should be undertaken to explore the crobial prophylaxis in surgical procedures. Clin
appropriateness of antimicrobial use. These audits Infect Dis 1994, 18:422–427.
should be undertaken under the auspices of the
7. Martin C, the French Study Group on Antimicro-
Antimicrobial Use Committee. The antimicrobial use
bial Prophylaxis in Surgery, the French Society
to be audited will be based on changes observed in
of Anesthesia and Intensive Care. Antimicrobial
antimicrobial use, antimicrobial resistance of organ-
prophylaxis in surgery: General concepts and
isms, or concerns about poor patient outcomes.
clinical guidelines. Infect Control Hosp Epidemiol,
Phy- sicians who are caring for patients must
1994,15:463–471.
participate in planning the audit and analysis of
data. Prior to undertaking the audit a series of 8. Page CP et al. Antimicrobial prophylaxis for sur-
appropriate guide- lines for antimicrobial use gical wounds: Guidelines for clinical care. Arch
should be developed and approved by the medical Surg 1993, 128:79–88.
staff. A chart audit to de- termine to what extent 9. Ayliffe GAJ. Recommendations for the control of methi-
the antimicrobials prescribed meet these criteria is cillin-resistant Staphylococcus aureus (MRSA).
then performed. If the criteria have not been met, WHO/EMC/LTS/96.1.
reasons for inappropriate use should be identified.
10. Weekes LM, Brooks C. Drugs and therapeutic
committees in Australia: Expected and actual per-
formance. Brit J Clin Pharmacol, 1996, 42:551–557.
60
CHAPTER
X
Preventing infections of staff
Employees’ health should be reviewed at recruit- ● injuring device used to enter a blood vessel
ment, including immunization history and previ- ● source patient with high viral load
ous exposures to communicable diseases (e.g.
tuberculosis) and immune status. Some previous
● hollow-bore needle
infections (e.g. varicella-zoster virus [VZV]) may be Information on preventive measures must be pro-
assessed by serological tests. vided to all staff with potential exposure to blood
Immunizations recommended for staff include: hepa- and blood products. Policies must include screening
titis A and B, yearly influenza, measles, mumps, of patients, disposal of sharps and wastes,
rubella, tetanus, diphtheria. Immunization against protective clothing, managing inoculation
varicella may be considered in specific cases. The accidents, steriliza- tion and disinfection.
Mantoux skin test will document a previous tuber- Hospital policy must include measures to promptly
culosis infection and must be obtained as a base- obtain serological testing of source patients where
line. necessary. Postexposure prophylaxis should be
Specific postexposure policies must be developed, started within four hours of exposure. The use of
and compliance ensured for: human immunodefi- postexposure antiretroviral drugs is recommended.
ciency virus (HIV), hepatitis A virus, hepatitis B virus, The combination of antiretroviral drugs, zidovudine
hepatitis C virus, Neisseria meningitidis, Mycobacterium (AZT), lamivudine (3TC), and indinavir is currently
tuberculosis, varicella-zoster virus, hepatitis E virus, recommended, but local or national guidelines
Corynebacterium diphtheriae, Bordetella pertussis, and rabies. should be followed, if available.
61
PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE —
WHO/CDS/CSR/EPH/2002.12
10.3 Exposure to hepatitis C virus (5) 1. CDC guidelines for infection control in hospital
personnel. Am J Infect Control, 1998, 26:289–354 or
The routes of infection are similar to hepatitis B in-
Infect Control Hosp Epidemiol 1996; 17:438–473.
fection. No postexposure therapy is available for
hepatitis C, but seroconversion (if any) must be 2. Bouvet E. Risk for health professionals of infec-
docu- mented. As for hepatitis B viral infection, the tion with human immunodeficiency virus.
source person must be tested for HCV infection. Current knowledge and developments in preven-
tive measures. Médecine et Maladies Infectieuses,
1993, 23:28–33.
For any occupational exposure to bloodborne patho-
3. Health Canada. An integrated protocol to man-
gens, counselling and appropriate clinical and sero-
age health care workers exposed to bloodborne
logical follow-up must be provided.
pathogens. Can Commun Dis Rep, 1997, 23 Suppl 2:
i–iii, 1–14; i–iii, 1–16.
62
ANNEX 1
World Health Organization Basic food safety for health workers, Adams M, Motarjemi
M. WHO/SDE/PHE/FOS/99.1. Order No. 1930166.
Indoor air quality: Biological contaminants. European
Series No. 31, 1990. ISBN 92 890 1122 X, Order Safe management of wastes from health-care activities, ed-
No. 1310031. ited by Prüss A, Giroult E, Rushbrook P, 1999.
ISBN 92 4 15425 9, Order No. 1150453.
Hazard Analysis Critical Control Point Evaluation. A guide
to identifying hazards and assessing risks associated Best infection control practices for skin-piercing intradermal,
with food preparation and storage, Bryan FL, 1992. subcutaneous, and intramuscular needle injection. 2001,
ISBN 92 4 154433 3, Order No. 1150370. WHO/BCT/DCT/01.02.
Sanitation promotion. WSSCC Working Group on Promotion Mayhall C Glen, ed. Hospital epidemiology and infection
of Sanitation, edited by Simpson-Hébert M, Wood control (2nd ed). Philadelphia, Lippincott, Williams
S. WHO/EOS/98.5. Order No. 1930147. & Wilkins, 1999.
Infection control for viral haemorrhagic fevers in the African Wenzel RP, ed. Prevention and control of hospital
health care setting. WHO/EMC/ESR/98.2. infections (3rd ed). Philadelphia, Lippincott,
Williams & Wilkins, 1997.
63
ANNEX 2
Internet resources
64