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Infection Control and Barrier Precautions

4.00 Contact Hours:
New York Provider ID# IC 145, as Mandated by Chapter 786 of the New York Laws of 1992.
  • 0% complete
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Authors:    Dana Bartlett (BS, MS, MA) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Purpose/Goals

The purpose of this course is to prepare healthcare professionals to adhere to scientifically accepted principles and practices of infection control, understand modes and mechanisms of transmission, understand the use of engineering and work practice controls, select and use appropriate barrier protections, create and maintain a safe environment, and prevent and manage infectious and communicable diseases.

Objectives

After completing this course, the learner will be able to:

  1. Discuss the responsibility to adhere to scientifically accepted infection control standards and to monitor subordinates,
  2. Identify disease transmission mechanisms and strategies for prevention,
  3. Discuss the use of engineering and work practice controls to minimize exposure to potentially infectious blood borne pathogens,
  4. Discuss the selection and use of personal protective equipment (PPE) and other preventive barriers,
  5. Identify cleaning, disinfection and sterilization standards for creating and maintaining a safe environment, and
  6. Discuss prevention and management of infectious or communicable diseases in healthcare professionals.

New York Requirements for Adherence to Infection Control Standards

Healthcare professionals have an obligation to adhere to scientifically accepted standards for infection control to prevent disease transmission amongst patients or between patients and healthcare professionals. The healthcare professional also has a responsibility to monitor the infection control practices of subordinates. The state of New York takes this very seriously. In fact New York rules and regulations require healthcare professionals to participate in infection control and barrier precautions education at least every four years. Evidence of completion of this training must be submitted to the State Department of Health or the Education Department. Physicians with hospital privileges will present the training documentation to the hospital in lieu of the Department of Health during the process of renewal of hospital privileges (NY, 2008).

New York professions required to obtain this education are dental hygienists, dentists, licensed practical nurses, optometrists, physicians, physician assistants, podiatrists, registered professional nurses and specialist assistants, medical students, medical residents, and physician assistant students Exemptions may be granted because the professional has completed equivalent course work or because the nature of his or her practice does not require the use of infection control techniques or barrier precautions (NY, 2008). A written application for exemption from completion of this course work must be presented to the Department of Health for approval.

In New York, state rules and regulations define responsibility for compliance and consequences for non-compliance with infection control practices. All licensed healthcare facilities are responsible for monitoring and enforcing proper use of infections control practices and standard precaution. Failure to comply can result in a citation, potential fines, and other disciplinary action against the facility. Licensed healthcare professionals who fail to use appropriate infection control techniques may be charged with professional misconduct and disciplinary action. Patient or employee complaints about lax infection control practices in private offices will cause an investigation by the Department of Health and/or Education. Substantiated lapses may result in charges of professional misconduct against licensed healthcare professionals who were directly involved, who were aware of the violations, or who were responsible for ensuring staff education and compliance (NY, 2008). Scientifically accepted infection control techniques include but are not limited to (NY, 1992, p D):

  • wearing appropriate protective gloves at all times when touching blood, saliva, other body fluids or secretions, mucous membranes, non-intact skin, blood-soiled items or bodily fluid-soiled items, contaminated surfaces, sterile body areas, and during instrument cleaning and decontamination procedures;
  • discarding gloves used following treatment of a patient and changing to new gloves if torn or damaged during treatment of a patient; washing hands and donning new gloves prior to performing services for another patient; and washing hands and other skin surfaces immediately if contaminated with blood or other body fluids;
  • wearing of appropriate masks, gowns or aprons, and protective eyewear or chin length plastic face shields whenever splashing or spattering of blood or other body fluids is likely to occur;
  • sterilizing equipment and devices that enter the patient’s vascular system or other normally sterile areas of the body;
  • sterilizing equipment and devices that touch intact mucous membranes but do not penetrate the patient’s body or using high-level disinfection for equipment and devices which cannot be sterilized prior to use for a patient;
  • using appropriate agents including but not limited to detergents for cleaning all equipment and devices prior to sterilization or disinfection;
  • cleaning, by use of appropriate agents including but not limited to detergents, equipment and devices which do not touch the patient or that only touch the intact skin of the patient;
  • maintaining equipment and devices used for sterilization according to the manufacturer’s instructions;
  • adequately monitoring the performance of all personnel, licensed or unlicensed, for whom the licensee is responsible regarding infection control techniques;
  • placing disposable used syringes, needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers for disposal; and placing reusable needles, scalpel blades, and other sharp instruments in appropriate puncture resistant containers until appropriately cleaned and sterilized;
  • maintaining appropriate ventilation devices to minimize the need for emergency mouth-to-mouth resuscitation;
  • refraining from all direct patient care and handling of patient care equipment when the healthcare professional has exudative lesions or weeping dermatitis and the condition had not been medically evaluated and determined to be safe or capable of being safely protected against in providing direct patient care or in handling patient care equipment; and
  • placing all specimens of blood and body fluids in well-constructed containers with secure lids to prevent leaking; and cleaning any spill of blood or other body fluid with an appropriate detergent and appropriate chemical germicide.

Transmission

Definitions

  • Pathogen or infectious agent is a biological agent capable of causing disease.
  • Transmission is any mechanism by which a pathogen is spread by a source of reservoir to a person.
  • Reservoir is any person, animal, plant, soil, substance, or any combination of these in which an infectious agent normally lives and multiplies. The agent depends on the reservoir for survival and the reservoir must provide a place where the agent can reproduce itself in such a manner that it can be transmitted to a susceptible host.
  • Susceptible host is a person or animal lacking effective resistance to a particular infectious agent.
  • Common vehicle is contaminated material, product, or substance that serves as an intermediate means by which an infectious agent is transported to two or more susceptible hosts.
  • Colonization is when an organism is present without host interference or interaction, like normal skin flora.
  • Infection is when the host resists and organism, like redness or swelling, around a skin tear.
  • Infectious disease is when the infected host shows a decline in wellness due to an infection.
  • Incubation period is the time between contact and when the first symptom is recognized.
  • Latency is the time after primary infection during which the microorganism lives within the host without producing clinical evidence.

Overview of Transmission

A chain of events is required for infection to occur. These events are a causative organism, reservoir for the organism, a means to exit the reservoir, a mode of transmission, a susceptible host, and a mode of entry into the host. Causative organisms may be bacteria, rickettsiae, viruses, protozoa, fungi, or parasites. The characteristics of causative organisms are: 

  • Pathogenicity: ability to cause disease
  • Virulence: disease severity and invasiveness (ability to enter and move through tissue)
  • Infectious dose: number of organisms needed to initiate infection
  • Organism specificity: host preference
  • Antigen variations: viral genetic recombinations
  • Toxogenicity: capacity to produce toxins
  • Ability to develop resistance to antimicrobial agents

The organism and its reservoir are the source of infection. The organism must have a means to exit the reservoir. In an infected host the organisms exits through the respiratory tract, gastrointestinal tract, genitourinary tract, or drainage from a wound. A route of transmission is necessary to connect the source of infection to its new host. Routes of transmission are contact or airborne.

Contact transmission

  • Direct contact: person-to-person
  • Indirect contact: usually an inanimate object
  • Droplet contact: large particles from coughing, sneezing, or talking

Airborne transmission

  • Droplet nuclei: residue of evaporated droplets that remain suspended in the air
  • Dust particles in the air containing the infectious agents

The following table outlines the organism, mode of transmission and incubation period for most common microorganisms and parasites (Kennamer, 2007).

Disease/Condition Organism Mode of Transmission Incubation Period
Acquired immunodeficiency syndrome (AIDS) Human immunodeficiency virus Sexual
Percutaneous
Prenatal Median of 10 years
Amebiasis Entamoeba histolytica Contaminated water
Contact with raw vegetables
2-4 weeks
Chancroid Haemophilus ducreyi Sexual 3-5 days
Chickenpox Varicella zoster Airborne 14 days
Cholera Vivrio cholera Ingestion of water contaminated with human waste A few hours-5days
Creutzfeldt-Jacob disease Prion proteinaceous Unknown in most cases 15 months to 30 years
Cryptococcosis Cryptococcus neoformans Probably by inhalation
No person-to-person spread
Unknown
Cyptosporidiosis Cryptosporidium species Ingestion of contaminated water
Direct contact with carrier
Probably 1-2 days
Cytomegalovirus (CMV) Cytomegalovirus Transfusion
Transplant
Sexual
Perinatal
Contact with mucus membranes
Highly variable: 3-8 weeks after transmission
Newborn: 3-12 weeks after delivery
Diarrheal diseases Campylobacter species Ingestion of contaminated food 3-5 days
  Clostridium difficile Fecal-oral
Efficient transfer by healthcare
professionals to patients
Variable, in part related to the influence of antibiotics
  Salmonella species Ingestion of contaminated food or drink 12-36 hours
  Shigella species Ingestion of contaminated food or drink
Direct contact with carrier
1-3days
  Yersinia species Ingestion of contaminated food or drink
Direct contact with carrier
3-7 days
Giardiasis Giardia lamblia Fecal-oral transmission
Ingestion of contaminated water or food
1-4 weeks
Gonorrhea Neisseria gonorrhea Sexual 2-7 days
Hand, foot, and mouth disease Coxsackie virus Direct contact with nose and throat secretions, and with feces of infected persons 3-5 days
Foodborne hepatitis Hepatitis A
Hepatitis E
Ingestion of contaminated food or drink

Direct contact with carrier
A: 15-50 days
E: unclear
Bloodborne hepatitis Hepatitis B
Hepatitis C
Hepatitis D
Sexual
Perinatal
Percutaneous
B: 45-160 days
C: 6-9 months
D: Unclear
Herpangina Coxsackie virus Direct contact with nose and throat secretions, and with feces of infected persons 3-5 days
Herpes simplex Human herpesvirus 1 and 2 Contact with mucous membrane secretions 2-12 days
Histoplasmosis Histoplasma capsulatum Inhalation of airborne spores 5-18 days
Hookworms Necator americanus
Ancyclostoma deodenale
Contact with soil contaminated with feces A few week to many months
Impetigo Staphylococcus aureus Contact with carrier 4-10 days
Influenza Influenza virus A, B, or C Droplet spread 27-72 hours
Legionnaires’ disease Legionella pneumonphila Airborne from water source 2-10 days
Listeriosis Listeria monocytogenes Perinatal
Sexual
Unclear, probably 3-70 days
Lyme disease Borrelia burgdorferi Tick bite 14-23 days
Lymphogranuloma venereum Chlamydia inguinale Sexual Weeks to years
Malaria Plasmodium vivax
Plasmodium malariae
Plasmodium falciparum
Plasmodium ovale
Bite from Anopheles mosquito 12-30 days
Measles Measles virus Droplet spread 8-13 days
Meningococcal meningitis or bacteremia Neisseria meningitidis Contact with pharyngeal secretions, perhaps airborne 2-10 days
Mononucleosis Epstein Barr virus Contact with pharyngeal secretions 4-6 weeks
Mycobacterial diseases (non-tuberculosis) Mycobacterium species Mycobacterium avium
Mycobacterium kansaii
Mycobacterium fortuitum
Mycobacterium gordonae
Other Mycobacterium species
 Variable: probably contact with soil, water, or other environmental sources. Not transmissible person-to-person Variable
Mycoplasma
pneumonia
Mycoplasma pneumonia Droplet inhalation 14-21 days
Pediculosis Pediculus humanus capitus (head louse)
Pediculus humanus corporis (body louse)
Direct contact 1-2 weeks
  Phthirus pubis (crab louse) Sexual 1-2 weeks
Pinworm Enterobius vermicularis Direct contact with egg-contaminated articles 4-6 week life cycle
Often months of infection before recognition
Pneumocystis pneumonia Pneumocystis carinii Unknown
Not transmitted person-to-person
Infants 1-2 months
Adults unclear
Pneumococcal pneumonia Streptococcus pneumoniae Droplet spread Probably 1-3 days
Rabies Rabies virus Direct contact of virus-laden saliva of a rabid animal into a bite or scratch 2-8 weeks
Respiratory syncytial disease Respiratory syncytial virus Self inoculation by touching mouth or nose after contact with infectious respiratory secretions 3-7 days
Ringworm Microsporum species
Trychophton species
Epidermophyton floccosum
Direct and indirect contact with lesions 4-10 days
Rocky Mountain Spotted fever Rickettsia ricketsii Tick bite 3-14 days
Rotavirus gastroenteritis Rota virus Fecal, oral About 48 hours
Rubella Rubella virus Droplet spread
Direct contact
14-21 days
Scabies Sarcoptes scabiei Direct skin contact 2-6 weeks
Staphylococci Staphylococcus aureus
Coagulase-negative:
S. epidermdidis
S. haemolyticus
Direct contact with draining lesions
Auto-infection from colonized nares
Variable, usually 4-10 days
Streptococci Streptococcus
pyogenes groups A with about 80 serologically distinct types
Large respiratory droplets
Direct contact with secretions
Ingestion of contaminated food
1-3 days
Syphilis Treponema pallidum Sexual 2-6 weeks
Tetanus Clostridium tetani Puncture wound 4-21 days
Trichinosis Trichinella spiralis Ingestion of insufficiently cooked food, especially pork and beef 10-14 days
Tuberculosis Mycobacterium tuberculosis Airborne 4-12 weeks
Typhoid fever Salmonella typhi Ingestion of contaminated food or water 3 days to 3 months

The host must be susceptible to the infection for infection to occur. Factors influencing susceptibility are:

  • Number of organisms to which host is exposed and the duration of exposure
  • Age, genetic constitution of host, and general physical, mental, and emotional health and nutritional status of the host
  • Status of hematopoietic systems; efficacy of reticuloendothelial system
  • Absent or abnormal immuglobulins
  • The number of T lymphocytes and their ability to function

Pregnant healthcare professionals are not known to be at greater risk of contracting bloodborne infections; however, during pregnancy, the infant is at risk of perinatal transmission.

The organism must have a portal of entry into the host for infection to occur. Portals of entry are the mucous membranes, non-intact skin, respiratory tract, gastrointestinal tract, genitourinary tracts, or a mechanism of introduction (percutaneous injury or invasive devices).

Antibiotic-Resistant Organisms

Carbapenem-resistant enterobacteriaceae

Enterobacteriaceae are gram-negative bacilli that are commonly found in the gastrointestinal tract. Common species of this family that cause infections include Enterobacter, Escherichia coli, and Klebsiella. Carbapenem-resistant enterobacteriaceae (CRE) are resistant to treatment with the carbapenem family of antibiotics (Doripenem, ertapenem, imipenem, and meropenem), the antibiotics that have traditionally been used to treat pathogens that are resistant to broad-spectrum antimicrobials. The CRE are spread through contact with infected surfaces (e.g., hands or contaminated medical equipment), and infections with CRE are particularly dangerous: they can spread rapidly, the mortality rate can exceed 40%, and antibiotics that are effective against multi-drug resistant gram-negative bacilli are still being developed. CRE infections usually don’t occur in healthy people; they are more likely to occur in hospitalized patients who have a compromised immune system, patients who are mechanically ventilated, or those who have received multiple antibiotics. The incidence of CRE infections is increasing. Control and prevention of CRE infections should focus on: 1) identifying colonized patients; 2) screening by taking stool, rectal, and peri-rectal cultures, and wound cultures when appropriate; 3) strict adherence to handwashing protocol, and;4) using contact precautions. (CDC, March 5, 2013; Morbidity and Mortality Weekly, March 9, 2013).

Drug Resistant Staphylococcus Aureus

Staphylococcus aureus is transmissted primarily via the hands of healthcare professional and by direct contact with contaminated equipment and surfaces. Transmission is very efficient and Staphylococcus aureus colonizes the skin and nares easily. Once colonized, the person faces the likelihood of infection when invasive procedures are performed.

Methicillin and Oxacillin-Resistant Staphylococcus aureus (MRSA, ORSA) are a common nosocomial infection in hospitals and extended care facilities. MRSA/ORSA colonization is rarely recognized, so every patient must be assumed to have been exposed to MRSA/ORSA. MRSA/ORSA can produce toxins and invade body tissues. The only effective antibiotic is vancomycin. Contact precautions are not recommended by the Centers for Disease Control and Prevention (CDC), but the CDC does note that contact precautions should be used if the facility has decided that MRSA is of special clinical or epidemiological significance (CDC, August, 9, 2010).

Vancomycin Intermediate Staphylococcus aureus (VISA) and Vancomycin Resistant Staphylococcus aureus (VRSA) are classified based on a lab test. The result of the test is called minimum inhibitory concentration (MIC), which is the measure of the minimum amount of antimicrobial agent that inhibits bacterial growth in a test tube. Staph bacteria are classified as VISA if the MIC for vancomycin is 4-8µg/ml, and classified as VRSA if the vancomycin MIC is >16µg/ml (CDC, August 6, 2012). This infection must be reported to the CDC and the state department of health. Contact precautions are required.

Vancomycin-Resistant Enterococcus (VRE)

Enterococcus is a gram-positive bacterium that is normal flora of the gastrointestinal tract and female genital tract. It is a relatively weak pathogen, but it is capable of producing significant infections and treatment options are limited. People at risk for VRE infections include patients previously treated with vancomycin, patients in intensive care, patients who are immunocompromised, patients who have had abdominal or chest surgery, and patients with in-dwelling IV or urinary catheters (CDC, May 10, 2011). VRE is transmitted primary via the hands of healthcare professionals and direct contact with contaminated equipment and surfaces. Contact precautions are required. Some facilities are requiring a special isolation where a gown and glove are worn even if contact with the patient is not expected. This is not recommended by CDC (CDC, May 10, 2011).

Multidrug-Resistant Tuberculosis (MDR-TB)

TB is caused by the bacteria, mycobacterium tuberculosis. It is one of the oldest recognized infectious diseases. MDR-TB is resistant to isoniazid, rifampin, the fluoroqunilones, and at least one of the three second-line injectable drugs used to treat TB. The incidence of MDR-TB has increased in recent years due to poor compliance or incomplete therapy regimen. Airborne precautions are required (CDC, June 28, 2012).

Drug-Resistant Streptococcus pneumoniae

Streptococcus pneumoniae is a leading cause of morbidity and mortality in the United States. It is a pathogen that is commonly found in the upper respiratory tract. Infections are community-acquired and manifested in meningitis, bacteremia, pneumonia, and otitis media. The elderly and the very young are the most susceptible. Transmission is from infected respiratory droplets, and it can be spread by coughing, sneezing, close contact, or contact with infected droplets. Penicillin-resistant and multidrug-resistant strains have begun to emerge and are widespread in some communities (Jenkins, et al, 2012). A vaccine for the most common serotypes of S. pneumoniae is available, but underutilized. Droplet precautions and cough etiquette should be used.

Drug-Resistant Acinetobacter

Acinetobacter is bacteria usually found in the soil, water, and on the skin of healthy people. Susceptible people are immunocompromised, have chronic lung disease, or diabetes. Outbreaks of pneumonia, urinary tract infections, wound infections, and blood infections from Acinetobacter occur in healthcare facilities where very sick patients are housed, like intensive care units. People on ventilators, patients who have prolonged hospital stays, and patients who have open wounds are at greater risk (CDC November 24, 2010). The morbidity and mortality rates associated with drug-resistant Acinetobacter infections are very high, and outbreaks of these infections in healthcare facilities are very difficult to control (Kuo, et al, 2012). Contact transmission is the primary way that Acinetobacter is spread, so standard precautions with special attention to handwashing are sufficient. Because of the danger of these infections and the difficulty in containing outbreaks, patients who have an infection with drug-resistant Acinetobacter may need to be isolated or their placement in the facility should be carefully considered (APIC, 2010).

Prevention of Exposure

Controls are incorporated into the healthcare work setting to avoid or reduce exposure to potentially infectious materials. Healthcare associated transmission is the transmission of microorganisms that is likely to occur in a healthcare setting that can be reduced by using engineered controls, safe injection practices, and safe work practices. Engineering controls are equipment, devices, or instruments that remove or isolate a hazard. Safe injection practices are equipment and practices that allow the performance of injections in an optimally safe manner for patients, healthcare providers, and others that reduce exposure (CDC, 2008). Work practice controls change practices and procedures to reduce or eliminate risks.

Standard Precautions

Standard precautions are strategies for protecting healthcare professionals from occupational transmission of organisms. The premise is that all pre-existing patient infections cannot be identified; therefore, barrier precautions should be used routinely to protect from all sources of potential infection. Standard precautions apply to nonintact skin and mucous membranes, blood, all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood. Additional precautions are based on highly transmissible or epidemiologically important pathogens. Transmission Based Precautions (isolation) are airborne, droplet, and contact.

New elements of standard precautions have been added to focus on patient protection. These elements are respiratory hygiene/cough etiquette, safe injection practices, and the use of masks for insertion of catheters or injections into spinal or epidural spaces via lumbar puncture CDC, 2007).

Respiratory Hygiene/Cough Etiquette

Respiratory hygiene/cough etiquette is a strategy to reduce transmission of respiratory infections at the first point of entry into a healthcare setting. Signs educating patients and families should be posted at entry areas. The instructions are that persons with cough, congestion, rhinorrhea, or increased respiratory secretions should (CDC, 2007):

  • Cover the mouth and nose when coughing or sneezing
  • Dispose of used tissues promptly
  • Use a surgical mask if coughing and if tolerated
  • Wash hands after contact with respiratory secretions
  • Separate at least three feet from persons with respiratory infections in common areas when possible.

Healthcare personnel should observe Droplet Precautions when caring for patients with signs and symptoms of a respiratory infection. Healthcare personnel who have a respiratory infection are advised to avoid direct patient contact, especially with high risk patients. If this is not possible, then a mask should be worn while providing patient care (CDC, 2007).

Safe Injection Practice

Needlestick and sharps injuries are major occupational hazards for nurses (Cho, et al, 2012). Nurses sustain a large proportion of the needlestick and sharps injuries sustained by healthcare professionals, but laboratory staff, physicians, housekeepers, and other healthcare professionals are also injured (Himmelreich, et al, 2012). Some of these injuries expose professionals to bloodborne pathogens that can cause infection. The most important of these pathogens are hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Infections with each of these pathogens are potentially life threatening and preventable.

One serious bloodborne infection can cost more than a million dollars for medications, follow up laboratory testing, clinical evaluation, lost wages, and disability payments. The human costs after an exposure are immeasurable. Employees may experience anger, depression, fear, anxiety, difficulty with sexual relations, difficulty sleeping, problems concentrating, and doubts regarding their career choice. The emotional effect can be long lasting, even in a low risk exposure that does not result in infection (Zhang, et al, 2013).

Percutaneous injuries can be avoided by eliminating the unnecessary use of needles, using devices with safety features, and promoting education and safe work practices for handling needles and related systems. Since 1993, the use of safety-engineered sharps devices has increased while the use of conventional sharps devices has decreased. Vigorous efforts to prevent needlestick and sharps injuries (e.g., the Needlestick Prevention and Safety Act of 2000) and increased awareness have helped to decrease the number of these injuries: several authors noted that needlestick injuries have decreased 38% in recent years (Phillips, et al, 2012; Trossman, 2012). A number of sources have identified the desirable characteristics of safety devices. These characteristics include the following (NIOSH, 1999):

  • The device is needleless.
  • The safety feature is an integral part of the device.
  • The device preferably works passively (i.e., it requires no activation by the user). If user activation is necessary, the safety feature can be engaged with a single-handed technique and allows the professional's hands to remain behind the exposed sharp.
  • The user can easily tell whether the safety feature is activated.
  • The safety feature cannot be deactivated and remains protective through disposal.
  • The device performs reliably.
  • The device is easy to use and practical.
  • The device is safe and effective for patient care.

Although each of these characteristics is desirable, some are not feasible, applicable, or available for certain healthcare situations. For example, needles will always be necessary where alternatives for skin penetration are not available. Also, a safety feature that requires activation by the user might be preferable to one that is passive in some cases. Each device must be considered on its own merit and ultimately on its ability to reduce workplace injuries. The desirable characteristics listed here should serve only as a guideline for device design and selection.

Needles should NEVER be recapped, bent, broken, or removed from contaminated syringes. Recapping by hand is prohibited under the OSHA bloodborne pathogens standard [29 CFR 1910.1030] unless no alternative exists. Sharps should be disposed into a puncture-proof container.

There is exposure to percutaneous injuries during procedures where there is opportunity for percutaneous exposure, especially where there is poor visualization, blind suturing, non-dominant hand opposing or next to a sharp, and exposure to bone spicules and metal fragments. Sharp equipment should be disassembled using forceps or other devices. Suturing should always be done with a needle holder, forceps, or other tool. Do not use fingers to hold tissue when suturing or cutting. Never leave sharps on a work field. If used needles or other sharps are left in the work area or are discarded in a sharps container that is not puncture resistant, a needlestick injury may result. Injury may occur when a healthcare professional attempts to transfer blood or other body fluids from a syringe to a specimen container (such as a vacuum tube) and misses the target.

Safe injection practice in hospitals is well established. However, outbreaks of HBV and HCV amongst patients were traced back to ambulatory care facilities, which identified the need to define and reinforce safe injection practices in outpatient care setting. The reuse of needles, multidose vials, and work areas containing both sterile and contaminated injection supplies contributed to the problem. There was a lack of understanding of aseptic technique, a lack of oversight, and failure to follow up on infection control breeches (Kuehn, 2012).. The following are safe injection practices recommended by CDC (CDC, April 1, 2011) that apply to the use of needles, cannulas that replace needles and, where applicable, intravenous delivery systems.

  • Use aseptic technique to avoid contamination of sterile injection equipment.
    • Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed.
    • Needles, cannula and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient.
  • Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use.
    • Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set.
  • Use single-dose vials for parenteral medications whenever possible.
    • Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use.
  • If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile.
    • Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable.
  • Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.
  • Infection control practices for special lumbar puncture procedures
    • Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture and spinal or epidural anesthesia.
  • Employee safety
    • Adhere to federal and state requirements for protection of healthcare personnel from exposure to bloodborne pathogens.

Handwashing

Handwashing is the most important measure to reduce the transmission of microorganisms. Hands should be washed or alcohol-based rubs should be used between patient contacts and after gloves are removed. Hands should be washed after contact with blood, body fluids, secretions, excretions, and contaminated equipment. It may be necessary to wash hands between tasks on the same patient to prevent cross-contamination of different body sites. CDC and Prevention Guideline for Hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force (Morbidity and Mortality Weekly Report, October 25, 2002; WHO, 2009)

  • Improved adherence to hand hygiene (i.e. hand washing or use of alcohol-based hand rubs) has been shown to terminate outbreaks in healthcare facilities, to reduce transmission of antimicrobial resistant organisms (e.g. methicillin resistant staphylococcus aureus) and reduce overall infection rates (Marra, et al, 2013).
  • CDC is releasing guidelines to improve adherence to hand hygiene in healthcare settings. In addition to traditional handwashing with soap and water, CDC is recommending the use of alcohol-based hand cleansers by healthcare personnel for patient care because they address some of the obstacles that healthcare professionals face when taking care of patients and frequently washing their hands.
  • Handwashing with soap and water remains a sensible strategy for hand hygiene in non-healthcare settings and is recommended by CDC and other experts.
  • When healthcare personnel's hands are visibly soiled, they should wash with soap and water.
  • The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70% to 80 %, prevent cross contamination and protect patients and healthcare personnel from infection. Alcohol-based hand rubs should be used before and after caring for each patient just as gloves should be changed before and after each patient.
  • When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product.
  • Alcohol-based hand rubs significantly reduce the number of microorganisms on skin, are fast acting, and cause less skin irritation than soap and water.
  • Healthcare personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long if they care for patients at high risk of acquiring infections (e.g. Patients in intensive care units or in transplant units).
  • When evaluating hand hygiene products for potential use in healthcare facilities, administrators or product selection committees should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of a product that can affect acceptance and therefore usage include its smell, consistency, color and the effect of dryness on hands.
  • As part of these recommendations, CDC is asking healthcare facilities to develop and implement a system for measuring improvements in adherence to these hand hygiene recommendations. Some of the suggested performance indicators include periodic monitoring of hand hygiene adherence and providing feedback to personnel regarding their performance, monitoring the volume of alcohol-based hand rub used/1000 patient days, monitoring adherence to policies dealing with wearing artificial nails, and focused assessment of the adequacy of healthcare personnel hand hygiene when outbreaks of infection occur.
  • Allergic contact dermatitis due to alcohol hand rubs is very uncommon. However, with increasing use of such products by healthcare personnel, it is likely that true allergic reactions to such products will occasionally be encountered.
  • Alcohol-based hand rubs take less time to use than traditional hand washing. In an eight-hour shift, an estimated one hour of an ICU nurse's time will be saved by using an alcohol-based hand rub.

Personal Protective Equipment

The appropriate use of personal protective equipment (PPE) is an important element of standard precautions. Gloves provide a protective barrier between the patient and the healthcare professional and prevent gross contamination of the hands. Gloves do not replace the need for handwashing because the gloves may have small defects, may be torn during use, and hands may become contaminated during glove removal.

Masks, goggles, or face shields should be used to protect the mucous membranes of the eyes, nose, and mouth during situations where there is a likelihood of splashes or sprays. A surgical mask is worn by healthcare professionals to provide protection against large-particle droplets during close patient contact. When tuberculosis is known or suspected, healthcare professionals should wear an N95 respirator, a high-efficiency particulate air (HEPA) filter respirator or a powered air-purifying respirator (PAPR).

Gowns are worn to prevent contamination of clothing and protect the healthcare professional’s skin from blood and body fluid exposure. Impermeable gowns, leg coverings, boots, or shoe covers provide more protection when large quantities of blood or body fluids may be splashed. Gowns are also worn as a part of some transmission based precautions. Mouthpieces, resuscitation bags, or other ventilation devices should be used instead of mouth-to-mouth resuscitation.

Transmission Based Precautions

Transmission based precautions and protective environment (PE) are terms used to describe protective measures that need to be employed for specific groups of patients. An older term for this was isolation. Patients requiring transmission based precautions require a private room. A negative pressure air handling system that exhausts to the outside is required for airborne precautions. Movement of these patients should be limited. When transport is necessary, appropriate barriers should be used. Masks should be used for patients who are on airborne precautions. Patients infected with the same organism can share a room. This is called cohorting.

Airborne Precautions

Airborne Precautions are implemented for diseases that are transmitted by microorganisms in airborne droplet nuclei. Droplet nuclei are tiny particle residues left when droplets evaporate. Droplet nuclei remain suspended in the air and can be widely dispersed by air currents. Early identification and triage of suspected cases of airborne transmitted diseases should be done and possibly infectious patients should be separated from others and asked to wear a surgical mask.

DISEASES REQUIRING AIRBORNE PRECAUTIONS
(CDC, 2007)
DISEASE PRECAUTIONARY PERIOD
Chickenpox (varicella) Until lesions are crusted and no new lesions appear
Herpes zoster (disseminated) Duration of illness
Herpes zoster (localized in immunocompromised patient) Duration of illness
Measles (rubeola) Duration of illness
Smallpox Duration of illness
Tuberculosis (pulmonary or laryngeal, confirmed or suspected) Depends upon clinical response; patient must be on effective therapy, be improving clinically (decreased cough and fever and improved findings on chest radiograph), and have three consecutive negative sputum smears collected on different days, or TB must be ruled out.

Airborne precautions require a specially ventilated room with at least 6 air changes per hour; negative air pressure relative to the hallway; and outside exhaust or HEPA-filtered recirculation. The door to the room must be kept closed. The negative air pressure should be monitored. An N-95 mask or a PAPR is used in airborne precautions.

  • These masks and respirators should be labeled and stored in a paper bag between uses.
  • These mask and respirators should be discarded if soiled or if it no longer maintains its structural or functional integrity.
  • The N-95 mask should also be discarded at the end of each work shift.
  • The disposable respirator should be discarded at the end of 2 weeks.

When the patient in airborne precautions has to be moved or transported, the patient should wear a surgical mask from the time he leaves the isolation room, until he returns.

Droplet Precautions

Droplet precautions are used for patients known or suspected to be infected with microorganisms transmitted by droplets generated during coughing, sneezing, talking, or performance of procedures.

DISEASES REQUIRING DROPLET PRECAUTIONS
(CDC, 2007)
DISEASE PRECAUTIONARY PERIOD
Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, and sepsis Until 24 hours after initiation of effective therapy
Invasive Neisseria meningitidis disease, including meningitis, pneumonia, epiglottis, and sepsis Until 24 hours after initiation of effective therapy
Diphtheria (pharyngeal) Until off antibiotics and two cultures taken at least 24 hours apart are negative
Mycoplasma pneumoniae infection Duration of illness
Pertussis Until five days after initiation of effective therapy
Pneumonic plague Until 72 hours after initiation of effective therapy
Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children Until 24 hours after initiation of effective therapy
Adenovirus infection in infants and young children Duration of illness
Influenza Duration of illness
Mumps For 9 days after onset of swelling
Parvovirus B19 Maintain precautions for duration of hospitalization when chronic disease occurs in an immunodeficient patient. For patients with transient aplastic crisis or red-cell crisis, maintain precautions for 7 days.
Rubella (German measles) Until 7 days after onset of rash

Droplet precautions require a private room, but no special ventilation is necessary and the door may remain open. Masks should be worn if working within three feet of the patient. The patient should be masked if transported.

Contact Precautions

Contact precautions are used for patients with known or suspected infections or colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact.

DISEASES REQUIRING CONTACT PRECAUTIONS
(CDC, 2007)
DISEASE PRECAUTIONARY PERIOD
Infection or colonization with multidrug-resistant bacteria Until off antibiotics and culture negative
Clostridium difficile enteric infection Duration of illness
Escherichia coli disease, in diapered or incontinent patient Duration of illness
Shigellosis, in diapered or incontinent patient Duration of illness
Hepatitis A, in diapered or incontinent patient Duration of illness
Rotavirus infection, in diapered or incontinent patient Duration of illness
Respiratory syncytial virus infection, in infants and young children Duration of illness
Parainfluenza virus infection, in diapered or incontinent patient Duration of illness
Enteroviral infection, in diapered or incontinent patient Duration of illness
Scabies Until 24 hours after initiation of effective therapy
Diphtheria (cutaneous) Duration of illness
Herpes simplex virus infection (neonatal or mucutaneous) Duration of illness
Impetigo Until 24 hours after initiation of effective therapy
Major abscesses, cellulitis, or decubiti Until 24 hours after initiation of effective therapy
Pediculosis (lice) Until 24 hours after initiation of effective therapy
Rubella, congenital syndrome Place infant on precautions during any admission until 1 year of age, unless nasopharyngeal and urine culture are negative for virus after age 3 months
Staphylococcal furunculosis in infants and young children Duration of illness
Acute viral (acute hemorrhagic) conjunctivitis Duration of illness
Viral hemorrhagic infections (Ebola, Lassa, Marburg) Duration of illness
Zoster (chickenpox, disseminated zoster, or localized zoster in immunodeficient patient) Until all lesions are crusted
Requires airborne precautions
Smallpox Duration of illness
Requires airborne precautions

The patient should be in a private room. Standard precautions should be used, and a gown should be worn if there is likely to be contact with the patient or environmental surfaces.

Some facilities may be implementing special isolation for VRE. This is an exaggerated form of contact precautions requiring the use of gowns and gloves anytime the room is entered, even if you do not anticipate patient contact. The rational is that VRE survives in the environment for a long time and contact with any surface may lead to transmission. This isolation is not recommended by CDC.

Neutropenic Precautions

Neutropenic precautions (reverse isolation) are implemented to protect immunocompromised patients.

CONDITIONS AND TREATMENTS REQUIRING NEUTROPENIC PRECAUTIONS
(CDC, 2007)
CONDITION OR TREATMENT PRECAUTIONARY PERIOD
Acquired immunodeficiency syndrome Until white blood cell count reaches 1,000/µl or more or according to facility guidelines
Agranulocytosis Until remission
Burns, extensive noninfected Until skin surface heals substantially
Dermatitis, noninfected vesicular, bullous, or eczematous disease (when severe and extensive) Until skin surface heals substantially
Immunosuppressive therapy Until patient’s immunity is adequate
Lymphomas and leukemia, especially late stages of Hodgkin’s disease or acute leukemia Until clinical improvement is substantial

Neutropenic precautions require a private room with positive air pressure. Other precautions may range from standard precautions and limitation of traffic to extensive precautions using gloves, gowns, and masks. This varies depending on the reason for the precautions and the degree of the patient’s immunosuppression.

Immunization

Immunization Schedule 0-18 Years
Vaccine Birth 1 mo 2 mos 4 mos 6 mos 9 mos 12 mos 15 mos 18 mos 19-23 mos 2-3 yrs 4-6 yrs 7-10 yrs 11-12 yrs 13-15 yrs 16-18 yrs
Hepatitis B1(HepB) 1st dose 2nd dose 2nd dose   3rd dose 3rd dose 3rd dose 3rd dose 3rd dose              
Rotavirus(RV) RV-1 (2-dose series); RV-5 (3-dose series)     1st dose 2nd dose                        
Diphtheria, tetanus, & acellular pertussis (DTaP: <7 yrs)     1st dose 2nd dose 3rd dose     4th dose 4th dose     5th dose        
Tetanus, diphtheria, tetanus, & acellular pertussis (Tdap: > 7 yrs)                           (Tdap)    
Haemophilus influenzae type b (Hib)     1st dose 2nd dose 3rd dose   3rd or 4th dose 3rd or 4th dose                
Pneumococcal conjugate (PCV13)     1st dose 2nd dose 3rd dose   4th dose 4th dose                
Pneumococcal polysaccharide (PPSV23)                                
Inactivated poliovirus (IPV) (<18years)     1st dose 2nd dose 3rd dose 3rd dose 3rd dose 3rd dose 3rd dose     4th dose        
Influenza (IIV; LAIV) 2 doses for some         p.a. vacc. (IIV only) p.a. vacc. (IIV only) p.a. vacc. (IIV only) p.a. vacc. (IIV only) p.a. vacc. (IIV only) p.a. vacc. (IIV only) p.a. vacc. (IIV or LAIV) p.a. vacc. (IIV or LAIV) p.a. vacc. (IIV or LAIV) p.a. vacc. (IIV or LAIV) p.a. vacc. (IIV or LAIV) p.a. vacc. (IIV or LAIV)
Measles, Mumps, Rubella (MMR)             1st dose 1st dose       2nd dose        
Varicella (VAR)             1st dose 1st dose       2nd dose        
Hepatitis A (HepA)             2 dose series 2 dose series 2 dose series 2 dose series            
Human papillomavirus (HPV2: females only; HPV4: males and females)                           3 dose series    
Meningococcal (Hib-MenCY > 6 wks; MCV4-< 9mos;                           1st dose   booster
Range of recommended ages for all children Range of recommended ages for catch-up immunization Range of recommended ages for certain high-risk groups Range of recommended ages during which catch-up is encouraged and for certain high-risk groups Not routinely recommended
Healthcare Personnel Vaccination Recommendations
Vaccine
Hepatitis B HepB (3 doses)
Influenza TIV or LAIV annually
MMR MMR if born 1957 or later if no serologic evidence of immunity or prior vacciniation
Varicella varicella vaccine (3 doses) if no serologic evidence of immunity
Tetanus, Diphtheria, Pertussis Tdap one time if younger than 65, Td every 10 years
Meningococcal 1 dose to microbiologist who are routinely exposed to N. meningitidis

Development and Maintenance of a Safe Environment

Although the environment is a reservoir for a variety of microorganisms, it is rarely implicated in disease transmission except in the immunocompromised population. Consistently applied infection-control strategies and engineering controls are effective in preventing opportunistic, environmentally-related infections in immunocompromised populations (CDC, June 6, 2003).

Definitions

  • Contamination is the presence of microorganisms on inanimate objects or substances.
  • Decontamination is the process of removing disease-producing microorganisms and rendering the object safe for handling.
  • Cleaning is the removal of visible soil.
  • Disinfection is the process that results in the elimination of many or all pathogenic microorganisms on inanimate objects with the exception of bacterial endospores.
  • High level disinfection kills bacteria, mycobacteria (TB), fungi, viruses, and some bacterial spores.
  • Intermediate level disinfection kills bacteria, mycobacteria, most fungi, and most viruses. It does not kill resistant bacterial spores.
  • Low level disinfection kills most bacteria, some fungi, and some viruses. It will not kill bacterial spores and is less active against some gram negative rods like pseudomonas and mycobacteria.
  • Sterilization is a process that completely eliminates or destroys all forms of microbial life.

Environmental Recommendations

The following discussion of environmental recommendations is a synopsis of the most recent CDC recommendations (CDC, 2008).

Recommendations for disinfection and sterilization in healthcare facilities

Occupational Health and Exposure

(OSHA, 29 CFR 1910.1030; OSHA, CFR 1910.132: OSHA, CFR 1910.134)

  • Inform each professional of the possible health effects of his or her exposure to infectious agents (e.g., HBV, HCV, HIV, and/or chemicals (e.g., ethylene oxide [EtO], formaldehyde). The information should be consistent with Occupational Safety and Health Administration (OSHA) requirements and identify the areas and tasks in which potential exists for exposure.
  • Educate health-care professionals in the selection and proper use of PPE.
  • Ensure that professionals wear appropriate PPE to preclude exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE can include gloves, gowns, masks, and eye protection. The exact type of PPE depends on the infectious or chemical agent and the anticipated duration of exposure. The employer is responsible for making such equipment and training available.
  • Establish a program for monitoring occupational exposure to regulated chemicals (e.g., formaldehyde, EtO) that adheres to state and federal regulations.
  • Exclude healthcare professionals with weeping dermatitis of hands from direct contact with patient-care equipment.

Cleaning of Patient-Care Devices

(CDC, 2007)

  • In hospitals, perform most cleaning, disinfection, and sterilization of patient-care devices in a central processing department in order to more easily control quality.
  • Meticulously clean patient-care items with water and detergent, or with water and enzymatic cleaners before high-level disinfection or sterilization procedures.
  • Remove visible organic residue (e.g., residue of blood and tissue) and inorganic salts with cleaning. Use cleaning agents that are capable of removing visible organic and inorganic residues.
    • Clean medical devices as soon as practical after use (e.g., at the point of use) because soiled materials become dried onto the instruments. Dried or baked materials on the instrument make the removal process more difficult and the disinfection or sterilization process less effective or ineffective.
  • Perform either manual cleaning (i.e., using friction) or mechanical cleaning (e.g., with ultrasonic cleaners, washer-disinfector, washer-sterilizers).
  • If using an automatic washer/disinfector, ensure that the unit is used in accordance with the manufacturer’s recommendations.
  • Ensure that the detergents or enzymatic cleaners selected are compatible with the metals and other materials used in medical instruments. Ensure that the rinse step is adequate for removing cleaning residues to levels that will not interfere with subsequent disinfection/sterilization processes.
  • Inspect equipment surfaces for breaks in integrity that would impair either cleaning or disinfection/sterilization. Discard or repair equipment that no longer functions as intended or cannot be properly cleaned, and disinfected or sterilized.

Indications for Sterilization, High-Level Disinfection, and Low-Level Disinfection

(CDC, 2007)

  • Before use on each patient, sterilize critical medical and surgical devices and instruments that enter normally sterile tissue or the vascular system or through which a sterile body fluid flows (e.g., blood). Provide, at a minimum, high-level disinfection for semicritical patient-care equipment (e.g., gastrointestinal endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment) that touches either mucous membranes or nonintact skin.
  • Perform low-level disinfection for noncritical patient-care surfaces (e.g., bedrails, over-the-bed table) and equipment (e.g., blood pressure cuff) that touch intact skin

Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices

(CDC 2007)

  • Process noncritical patient-care devices using a disinfectant and the concentration of germicide
  • Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label’s safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. However, multiple scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least 1 minute. By law, all applicable label instructions on EPA-registered products must be followed. If the user selects exposure conditions that differ from those on the EPA-registered product label, the user assumes liability from any injuries resulting from off-label use and is potentially subject to enforcement action.
  • Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly).
  • If dedicated, disposable devices are not available, disinfect noncritical patient-care equipment after using it on a patient who is on contact precautions before using this equipment on another patient.

Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities

  • Clean housekeeping surfaces (e.g., floors, tabletops) on a regular basis, when spills occur, and when these surfaces are visibly soiled.
  • Disinfect (or clean) environmental surfaces on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled.
  • Follow manufacturers’ instructions for proper use of disinfecting (or detergent) products, such as recommended use-dilution, material compatibility, storage, shelf-life, and safe use and disposal.
  • Clean walls, blinds, and window curtains in patient-care areas when these surfaces are visibly contaminated or soiled.
  • Prepare disinfecting (or detergent) solutions as needed and replace these with fresh solution frequently (e.g., replace floor mopping solution every three patient rooms, change no less often than at 60-minute intervals), according to the facility’s policy.
  • Decontaminate mop heads and cleaning cloths regularly to prevent contamination (e.g., launder and dry at least daily).
  • Use a one-step process and an EPA-registered hospital disinfectant designed for housekeeping purposes in patient care areas where 1) uncertainty exists about the nature of the soil on the surfaces (e.g., blood or body fluid contamination versus routine dust or dirt); or 2) uncertainty exists about the presence of multidrug resistant organisms on such surfaces. See 5n for recommendations requiring cleaning and disinfecting blood-contaminated surfaces.
  • Detergent and water are adequate for cleaning surfaces in nonpatient-care areas (e.g., administrative offices).
  • Do not use high-level disinfectants/liquid chemical sterilants for disinfection of non-critical surfaces.
  • Wet-dust horizontal surfaces regularly (e.g., daily, three times per week) using clean cloths moistened with an EPA-registered hospital disinfectant (or detergent). Prepare the disinfectant (or detergent) as recommended by the manufacturer.
  • Disinfect noncritical surfaces with an EPA-registered hospital disinfectant according to the label’s safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. However, many scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least 1 minute. By law, the user must follow all applicable label instructions on EPA-registered products. If the user selects exposure conditions that differ from those on the EPA-registered product label, the user assumes liability for any injuries resulting from off-label use and is potentially subject to enforcement action. Do not use disinfectants to clean infant bassinets and incubators while these items are occupied. If disinfectants (e.g., phenolics) are used for the terminal cleaning of infant bassinets and incubators, thoroughly rinse the surfaces of these items with water and dry them before these items are reused. Promptly clean and decontaminate spills of blood and other potentially infectious materials. Discard blood-contaminated items in compliance with federal regulations.
  • For site decontamination of spills of blood or other potentially infectious materials (OPIM), implement the following procedures. Use protective gloves and other PPE (e.g., when sharps are involved use forceps to pick up sharps, and discard these items in a puncture-resistant container) appropriate for this task. Disinfect areas contaminated with blood spills using an EPA-registered tuberculocidal agent, a registered germicide on the EPA Lists D and E (i.e., products with specific label claims for HIV or HBV or freshly diluted hypochlorite solution.
  • If sodium hypochlorite solutions are selected use a 1:100 dilution (e.g., 1:100 dilution of a 5.25-6.15% sodium hypochlorite provides 525-615 ppm available chlorine) to decontaminate nonporous surfaces after a small spill (e.g., <10 mL) of either blood or OPIM. If a spill involves large amounts (e.g., >10 mL) of blood or OPIM, or involves a culture spill in the laboratory, use a 1:10 dilution for the first application of hypochlorite solution before cleaning in order to reduce the risk of infection during the cleaning process in the event of a sharp injury. Follow this decontamination process with a terminal disinfection, using a 1:100 dilution of sodium hypochlorite.
  • If the spill contains large amounts of blood or body fluids, clean the visible matter with disposable absorbent material, and discard the contaminated materials in appropriate, labeled containment.
  • Use protective gloves and other PPE appropriate for this task.
  • In units with high rates of endemic Clostridium difficile infection or in an outbreak setting, use dilute solutions of 5.25%–6.15% sodium hypochlorite (e.g., 1:10 dilution of household bleach) for routine environmental disinfection. Currently, no products are EPA-registered specifically for inactivating C. difficile spores.
  • If chlorine solution is not prepared fresh daily, it can be stored at room temperature for up to 30 days in a capped, opaque plastic bottle with a 50% reduction in chlorine concentration after 30 days of storage (e.g., 1000 ppm chlorine [approximately a 1:50 dilution] at day 0 decreases to 500 ppm chlorine by day 30).
  • An EPA-registered sodium hypochlorite product is preferred, but if such products are not available, generic versions of sodium hypochlorite solutions (e.g., household chlorine bleach) can be used.

Disinfectant Fogging

  • Do not perform disinfectant fogging for routine purposes in patient-care areas.

High-Level Disinfection of Endoscopes

Endoscopes are fragile, expensive, difficult to clean, much used, and susceptible to contamination (Hervé, et al, 2013). There are millions of endoscopic procedures done each year, but iatrogenic infections caused by contamination of endoscopes are rare (ASGE, 2011). The recommendations for the disinfection and sterilization of endoscopes listed below are from the CDC (CDC, 2008). The American Society of Gastrointestinal Endoscopy has also published guidelines for cleaning endoscopes (ASGE, 2011).

  • To detect damaged endoscopes, test each flexible endoscope for leaks as part of each reprocessing cycle. Remove from clinical use any instrument that fails the leak test, and repair this instrument.
  • Immediately after use, meticulously clean the endoscope with an enzymatic cleaner that is compatible with the endoscope. Cleaning is necessary before both automated and manual disinfection.
  • Disconnect and disassemble endoscopic components (e.g., suction valves) as completely as possible and completely immerse all components in the enzymatic cleaner. Steam sterilize these components if they are heat stable.
  • Flush and brush all accessible channels to remove all organic (e.g., blood, tissue) and other residue. Clean the external surfaces and accessories of the devices by using a soft cloth or sponge or brushes. Continue brushing until no debris appears on the brush.
  • Use cleaning brushes appropriate for the size of the endoscope channel or port (e.g., bristles should contact surfaces). Cleaning items (e.g., brushes, cloth) should be disposable or, if they are not disposable, they should be thoroughly cleaned and either high-level disinfected or sterilized after each use.
  • Discard enzymatic cleaners (or detergents) after each use because they are not microbicidal and, therefore, will not retard microbial growth.
  • Process endoscopes (e.g., arthroscopes, cystoscope, and laparoscopes) that pass through normally sterile tissues using a sterilization procedure before each use; if this is not feasible provide at least high-level disinfection. High-level disinfection of arthroscopes, laparoscopes, and cytoscopes should be followed by a sterile water rinse.
  • Phase out endoscopes that are critical items (e.g., arthroscopes, laparoscopes) but cannot be steam sterilized. Replace these endoscopes with steam sterilizable instruments when feasible.
  • Mechanically clean reusable accessories inserted into endoscopes (e.g., biopsy forceps or other cutting instruments) that break the mucosal barrier (e.g., ultrasonically clean biopsy forceps) and then sterilize these items between each patient.
  • Use ultrasonic cleaning of reusable endoscopic accessories to remove soil and organic material from hard-to-clean areas.
  • Process endoscopes and accessories that contact mucous membranes as semicritical items, and use at least high-level disinfection after use on each patient.
  • Use an FDA-cleared sterilant or high-level disinfectant for sterilization or high-level disinfection
  • After cleaning, use formulations containing glutaraldehyde, glutaraldehyde with phenol/phenate, ortho-phthalaldehyde, hydrogen peroxide, and both hydrogen peroxide and peracetic acid to achieve high-level disinfection followed by rinsing and drying (see Table 1 for recommended concentrations).
  • Extend exposure times beyond the minimum effective time for disinfecting semicritical patient-care equipment cautiously and conservatively because extended exposure to a high-level disinfectant is more likely to damage delicate and intricate instruments such as flexible endoscopes. The exposure times vary among the Food and Drug Administration (FDA)-cleared high-level disinfectants.
  • Federal regulations are to follow the FDA-cleared label claim for high-level disinfectants. The FDA-cleared labels for high-level disinfection with >2% glutaraldehyde at 25°C range from 20-90 minutes, depending upon the product based on three tier testing which includes AOAC sporicidal tests, simulated use testing with mycobacterial and in-use testing.
  • Several scientific studies and professional organizations support the efficacy of >2% glutaraldehyde for 20 minutes at 20ºC; that efficacy assumes adequate cleaning prior to disinfection, whereas the FDA-cleared label claim incorporates an added margin of safety to accommodate possible lapses in cleaning practices. Facilities that have chosen to apply the 20 minute duration at 20ºC have done so based on the IA recommendation in the July 2003 SHEA position paper, “Multi-society Guideline for Reprocessing Flexible Gastrointestinal Endoscopes
  • When using FDA-cleared high-level disinfectants, use manufacturers’ recommended exposure conditions. Certain products may require a shorter exposure time (e.g., 0.55% ortho-phthalaldehyde for 12 minutes at 20°C, 7.35% hydrogen peroxide plus 0.23% peracetic acid for 15 minutes at 20°C) than glutaraldehyde at room temperature because of their rapid inactivation of mycobacteria or reduced exposure time because of increased mycobactericidal activity at elevated temperature (e.g., 2.5% glutaraldehyde at 5 minutes at 35°C).
  • Select a disinfectant or chemical sterilant that is compatible with the device that is being reprocessed. Avoid using reprocessing chemicals on an endoscope if the endoscope manufacturer warns against using these chemicals because of functional damage (with or without cosmetic damage).
  • Completely immerse the endoscope in the high-level disinfectant, and ensure all channels are perfused. As soon as is feasible, phase out nonimmersible endoscopes.
  • After high-level disinfection, rinse endoscopes and flush channels with sterile water, filtered water, or tapwater to prevent adverse effects on patients associated with disinfectant retained in the endoscope (e.g., disinfectant-induced colitis). Follow this water rinse with a rinse with 70% - 90% ethyl or isopropyl alcohol.
  • After flushing all channels with alcohol, purge the channels using forced air to reduce the likelihood of contamination of the endoscope by waterborne pathogens and to facilitate drying.
  • Hang endoscopes in a vertical position to facilitate drying.
  • Store endoscopes in a manner that will protect them from damage or contamination.
  • Sterilize or high-level disinfect both the water bottle used to provide intraprocedural flush solution and its connecting tube at least once daily. After sterilizing or high-level disinfecting the water bottle, fill it with sterile water.
  • Maintain a log for each procedure and record the following: patient’s name and medical record number (if available), procedure, date, endoscopist, system used to reprocess the endoscope (if more than one system could be used in the reprocessing area), and serial number or other identifier of the endoscope used.
  • Design facilities where endoscopes are used and disinfected to provide a safe environment for healthcare professionals and patients. Use air-exchange equipment (e.g., the ventilation system, out-exhaust ducts) to minimize exposure of all persons to potentially toxic vapors (e.g., glutaraldehyde vapor). Do not exceed the allowable limits of the vapor concentration of the chemical sterilant or high-level disinfectant (e.g., those of ACGIH and OSHA).
  • Routinely test the liquid sterilant/high-level disinfectant to ensure minimal effective concentration of the active ingredient. Check the solution each day of use (or more frequently) using the appropriate chemical indicator (e.g., glutaraldehyde chemical indicator to test minimal effective concentration of glutaraldehyde) and document the results of this testing. Discard the solution if the chemical indicator shows the concentration is less than the minimum effective concentration. Do not use the liquid sterilant/high-level disinfectant beyond the reuse-life recommended by the manufacturer (e.g., 14 days for ortho-phthalaldehyde).
  • Provide personnel assigned to reprocess endoscopes with device-specific reprocessing instructions to ensure proper cleaning and high-level disinfection or sterilization. Require competency testing on a regular basis (e.g., beginning of employment, annually) of all personnel who reprocess endoscopes.
  • Educate all personnel who use chemicals about the possible biologic, chemical, and environmental hazards of performing procedures that require disinfectants.
  • Make PPE (e.g., gloves, gowns, eyewear, face mask or shields, respiratory protection devices) available and use these items appropriately to protect professionals from exposure to both chemicals and microorganisms (e.g., HBV).
  • If using an automated endoscope reprocessor (AER), place the endoscope in the reprocessor and attach all channel connectors according to the AER manufacturer’s instructions to ensure exposure of all internal surfaces to the high-level disinfectant/chemical sterilant.
  • If using an AER, ensure the endoscope can be effectively reprocessed in the AER. Also, ensure any required manual cleaning/disinfecting steps are performed (e.g., elevator wire channel of duodenoscopes might not be effectively disinfected by most AERs).
  • Review the FDA advisories and the scientific literature for reports of deficiencies that can lead to infection because design flaws and improper operation and practices have compromised the effectiveness of AERs.
  • Develop protocols to ensure that users can readily identify an endoscope that has been properly processed and is ready for patient use.
  • Do not use the carrying case designed to transport clean and reprocessed endoscopes outside of the healthcare environment, to store an endoscope, or to transport the instrument within the healthcare environment.
  • No recommendation is made about routinely performing microbiologic testing of either endoscopes or rinse water for quality assurance purposes.
  • If environmental microbiologic testing is conducted, use standard microbiologic techniques.
  • If a cluster of endoscopy-related infections occurs, investigate potential routes of transmission (e.g., person-to-person, common source) and reservoirs.
  • Report outbreaks of endoscope-related infections to persons responsible for institutional infection control and risk management and to FDA. Notify the local and the state health departments, CDC, and the manufacturer(s).
  • No recommendation is made regarding the reprocessing of an endoscope again immediately before use if that endoscope has been processed after use according to the recommendations in this guideline.
  • Compare the reprocessing instructions provided by both the endoscope’s and the AER’s manufacturer’s instructions and resolve any conflicting recommendations.

Management of Equipment and Surfaces in Dentistry

(CDC, 2008)
 
  • Dental instruments that penetrate soft tissue or bone (e.g., extraction forceps, scalpel blades, bone chisels, periodontal scalers, and surgical burs) are classified as critical and should be sterilized after each use or discarded. In addition, after each use, sterilize dental instruments that are not intended to penetrate oral soft tissue or bone (e.g., amalgam condensers, air-water syringes) but that might contact oral tissues and are heat-tolerant, although classified as semicritical. Clean and, at a minimum, high-level disinfect heat-sensitive semicritical items.
  • Noncritical clinical contact surfaces, such as uncovered operatory surfaces (e.g., countertops, switches, light handles), should be barrier-protected or disinfected between patients with an intermediate-disinfectant (i.e., EPA-registered hospital disinfectant with a tuberculocidal claim) or low-level disinfectant (i.e., EPA-registered hospital disinfectant with HIV and HBV claim).
  • Barrier protective coverings can be used for noncritical clinical contact surfaces that are touched frequently with gloved hands during the delivery of patient care, that are likely to become contaminated with blood or body substances, or that are difficult to clean. Change these coverings when they are visibly soiled, when they become damaged, and on a routine basis (e.g., between patients). Disinfect protected surfaces at the end of the day or if visibly soiled.
  • Processing Patient-Care Equipment Contaminated with Bloodborne Pathogens (HBV, HCV, HIV), Antibiotic-Resistant Bacteria (e.g., Vancomycin-Resistant Enterococci, Methicillin-Resistant Staphylococcus aureus, Multidrug Resistant Tuberculosis), or Emerging Pathogens (e.g., Cryptosporidium, Helicobacter pylori, Escherichia coli O157:H7, Clostridium difficile, Mycobacterium tuberculosis, Severe Acute Respiratory Syndrome Coronavirus), or Bioterrorist Agents
  • Use standard sterilization and disinfection procedures for patient-care equipment (as recommended in this guideline), because these procedures are adequate to sterilize or disinfect instruments or devices contaminated with blood or other body fluids from persons infected with bloodborne pathogens or emerging pathogens, with the exception of prions. No changes in these procedures for cleaning, disinfecting, or sterilizing are necessary for removing bloodborne and emerging pathogens other than prions.

Disinfection Strategies for Other Semicritical Devices

(CDC, 2008)

Other repeat-use invasive medical devices such as vaginal and rectal ultrasound transducers can be a source of contamination and disease transmission with pathogens such as human papilloma virus, CMV, HIV, and gram-negative pathogens (Leroy, 2013). Contamination of these instruments is not common, but although the rate of patients infected by the use of one of these types of devices is low (3.1% in one study) it is not negligible or acceptable (Leroy, 2013). The CDC guidelines are listed below; disinfection and sterilization with different forms of hydrogen peroxide or ultra violet light are also being evaluated for sterilizing these types of devices. 

  • Even if probe covers have been used, clean and high-level disinfect other semicritical devices such as rectal probes, vaginal probes, and cryosurgical probes with a product that is not toxic to staff, patients, probes, and retrieved germ cells (if applicable). Use a high-level disinfectant at the FDA-cleared exposure time.
  • When probe covers are available, use a probe cover or condom to reduce the level of microbial contamination. Do not use a lower category of disinfection or cease to follow the appropriate disinfectant recommendations when using probe covers because these sheaths and condoms can fail.
  • After high-level disinfection, rinse all items. Use sterile water, filtered water or tapwater followed by an alcohol rinse for semicritical equipment that will have contact with mucous membranes of the upper respiratory tract (e.g., nose, pharynx, and esophagus).
  • There is no recommendation to use sterile or filtered water rather than tapwater for rinsing semicritical equipment that contact the mucous membranes of the rectum (e.g., rectal probes, anoscope) or vagina (e.g., vaginal probes).
  • Wipe clean tonometer tips and then disinfect them by immersing for 5-10 minutes in either 5000 ppm chlorine or 70% ethyl alcohol. None of these listed disinfectant products are FDA-cleared high-level disinfectants.

Microbial Contamination of Disinfectants

(CDC, 2008)

Disinfectants can be a source of microbial contamination. A 2007 review of the literature found 7 outbreaks involving 622 patients who had developed a hospital-acquired infection caused by contaminated disinfectants (Vonberg, et al, 2007). 

  • Institute the following control measures to reduce the occurrence of contaminated disinfectants: 1) prepare the disinfectant correctly to achieve the manufacturer’s recommended use-dilution; and 2) prevent common sources of extrinsic contamination of germicides (e.g., container contamination or surface contamination of the healthcare environment where the germicide are prepared and/or used).
  • Federal law requires that all disinfectant label instructions such as shelf life, storage, dilution, proper use, disposal, and material compatibility must be followed, and the user is responsible for any harm caused by off-label use.

Flash Sterilization

Flash sterilization (immediate-use sterilization) was traditionally used for items that were needed immediately but were not available. Flash sterilization involves placing items in a gravity displacement sterilizer for 3 minutes, at 27-28 pounds of pressure and a temperature of 132°C. It is an effective technique, but it has limitations and it should only be used when necessary, not for convenience or to compensate for poor planning. Concerns have been raised by the CDC, the AORN and others that flash sterilization has become overused (Smart, et al, 2012), and it should not be used as a routine method of sterilization. The guidelines below are from the CDC (CDC, 2008). 

  • Do not flash sterilize implanted surgical devices unless doing so is unavoidable.
  • If flash sterilization is needed for an implantable device, recordkeeping is essential: the load identification, the patient’s name, and the biological indicator result must be carefully documented.
  • Do not use flash sterilization for convenience, as an alternative to purchasing additional instrument sets, or to save time.
  • When using flash sterilization, make sure the following parameters are met: 1) clean the item before placing it in the sterilizing container (that are FDA cleared for use with flash sterilization) or tray; 2) prevent exogenous contamination of the item during transport from the sterilizer to the patient; and 3) monitor sterilizer function with mechanical, chemical, and biologic monitors.
  • Do not use packaging materials and containers in flash sterilization cycles unless the sterilizer and the packaging material/container are designed for this use.
  • When necessary, use flash sterilization for patient-care items that will be used immediately (e.g., to reprocess an inadvertently dropped instrument).
  • When necessary, use flash sterilization for processing patient-care items that cannot be packaged, sterilized, and stored before use.

Methods of Sterilization

(CDC, 2008)

  • Steam is the preferred method for sterilizing critical medical and surgical instruments that are not damaged by heat, steam, pressure, or moisture.
  • Cool steam or heat-sterilized items before they are handled or used in the operative setting.
  • Follow the sterilization times, temperatures, and other operating parameters (e.g., gas concentration, humidity) recommended by the manufacturers of the instruments, the sterilizer, and the container or wrap used, and that are consistent with guidelines published by government agencies and professional organizations.
  • Use low-temperature sterilization technologies (e.g., ETO, hydrogen peroxide gas plasma) for reprocessing critical patient-care equipment that is heat or moisture sensitive.
  • Completely aerate surgical and medical items that have been sterilized in the EtO sterilizer (e.g., polyvinylchloride tubing requires 12 hours at 50oC, 8 hours at 60oC) before using these items in patient care.
  • Sterilization using the peracetic acid immersion system can be used to sterilize heat-sensitive immersible medical and surgical items.
  • Critical items that have been sterilized by the peracetic acid immersion process must be used immediately (i.e., items are not completely protected from contamination, making long-term storage unacceptable).
  • Dry-heat sterilization (e.g., 340oF for 60 minutes) can be used to sterilize items (e.g., powders, oils) that can sustain high temperatures.
  • Comply with the sterilizer manufacturer’s instructions regarding the sterilizer cycle parameters (e.g., time, temperature, concentration).
  • Because narrow-lumen devices provide a challenge to all low-temperature sterilization technologies and direct contact is necessary for the sterilant to be effective, ensure that the sterilant has direct contact with contaminated surfaces (e.g., scopes processed in peracetic acid must be connected to channel irrigators).

Packaging

(CDC, 2008)

  • Ensure that packaging materials are compatible with the sterilization process and have received FDA 510[k] clearance.
  • Ensure that packaging is sufficiently strong to resist punctures and tears to provide a barrier to microorganisms and moisture.

Monitoring of Sterilizers

(CDC, 2008)

  • Use mechanical, chemical, and biologic monitors to ensure the effectiveness of the sterilization process.
  • Monitor each load with mechanical (e.g., time, temperature, pressure) and chemical (internal and external) indicators. If the internal chemical indicator is visible, an external indicator is not needed.
  • Do not use processed items if the mechanical (e.g., time, temperature, and pressure) or chemical (internal and/or external) indicators suggest inadequate processing.
  • Use biologic indicators to monitor the effectiveness of sterilizers at least weekly with an FDA-cleared commercial preparation of spores (e.g., Geobacillus stearothermophilus for steam) intended specifically for the type and cycle parameters of the sterilizer.
  • After a single positive biologic indicator used with a method other than steam sterilization, treat as nonsterile all items that have been processed in that sterilizer, dating from the sterilization cycle having the last negative biologic indicator to the next cycle showing satisfactory biologic indicator results. These nonsterile items should be retrieved if possible and reprocessed.
  • After a positive biologic indicator with steam sterilization, objects other than implantable objects do not need to be recalled because of a single positive spore test unless the sterilizer or the sterilization procedure is defective as determined by maintenance personnel or inappropriate cycle settings. If additional spore tests remain positive, consider the items nonsterile and recall and reprocess the items from the implicated load(s).
  • Use biologic indicators for every load containing implantable items and quarantine items, whenever possible, until the biologic indicator is negative.

Load Configuration

(CDC, 2008)

  • Place items correctly and loosely into the basket, shelf, or cart of the sterilizer so as not to impede the penetration of the sterilant.

Storage of Sterile Items

(CDC, 2008)

  • Ensure the sterile storage area is a well-ventilated area that provides protection against dust, moisture, insects, and temperature and humidity extremes.
  • Store sterile items so the packaging is not compromised (e.g., punctured, bent).
  • Label sterilized items with a load number that indicates the sterilizer used, the cycle or load number, the date of sterilization, and, if applicable, the expiration date.
  • The shelf life of a packaged sterile item depends on the quality of the wrapper, the storage conditions, the conditions during transport, the amount of handling, and other events (moisture) that compromise the integrity of the package. If event-related storage of sterile items is used, then packaged sterile items can be used indefinitely unless the packaging is compromised.
  • Evaluate packages before use for loss of integrity (e.g., torn, wet, or punctured). The pack can be used unless the integrity of the packaging is compromised.
  • If the integrity of the packaging is compromised (e.g., torn, wet, or punctured), repack and reprocess the pack before use.
  • If time-related storage of sterile items is used, label the pack at the time of sterilization with an expiration date. Once this date expires, reprocess the pack.

Quality Control

(CDC, 2008)

  • Provide comprehensive and intensive training for all staff assigned to reprocess semicritical and critical medical/surgical instruments to ensure they understand the importance of reprocessing these instruments.
  • Compare the reprocessing instructions (e.g., for the appropriate use of endoscope connectors, the capping/noncapping of specific lumens) provided by the instrument manufacturer and the sterilizer manufacturer and resolve any conflicting recommendations by communicating with both manufacturers.
  • Conduct infection control rounds periodically (e.g., annually) in high-risk reprocessing areas (e.g., the Gastroenterology Clinic, Central Processing); ensure reprocessing instructions are current and accurate and are correctly implemented. Document all deviations from policy. All stakeholders should identify what corrective actions will be implemented.
  • Include the following in a quality control program for sterilized items: a sterilizer maintenance contract with records of service; a system of process monitoring; air-removal testing for prevacuum steam sterilizers; visual inspection of packaging materials; and traceability of load contents.
  • For each sterilization cycle, record the type of sterilizer and cycle used; the load identification number; the load contents; the exposure parameters (e.g., time and temperature); the operator’s name or initials; and the results of mechanical, chemical, and biological monitoring.
  • Retain sterilization records (mechanical, chemical, and biological) for a time period that complies with standards (e.g., 3 years), statutes of limitations, and state and federal regulations.
  • Prepare and package items to be sterilized so that sterility can be achieved and maintained to the point of use. Consult the Association for the Advancement of Medical Instrumentation or the manufacturers of surgical instruments, sterilizers, and container systems for guidelines for the density of wrapped packages.
  • Periodically review policies and procedures for sterilization.
  • Perform preventive maintenance on sterilizers by qualified personnel who are guided by the manufacturer’s instruction.

Reuse of Single-Use Medical Devices

(CDC, 2008)

  • Adhere to the FDA enforcement document for single-use devices reprocessed by hospital. FDA requires hospitals to use the same standards by which it regulates the original equipment manufacturer (FDA, 2013).

Disinfection in Ambulatory Care, Home Care, and the Home

(CDC, 2008)

  • The home environment should be much safer than hospitals or ambulatory care. Epidemics should not be a problem and cross-infection should be rare. The healthcare provider is responsible for providing the responsible family member information about infection-control procedures to follow in the home, including hand hygiene, proper cleaning and disinfection of equipment, and safe storage of cleaned and disinfected devices.
  • Among the products recommended for home disinfection of reusable objects are bleach, alcohol, and hydrogen peroxide. APIC recommends that reusable objects (e.g., tracheostomy tubes) that touch mucous membranes be disinfected by immersion in 70% isopropyl alcohol for 5 minutes or in 3% hydrogen peroxide for 30 minutes. Additionally, a 1:50 dilution of 5.25%–6.15% sodium hypochlorite (household bleach) for 5 minutes should be effective.
  • Noncritical items (e.g., blood pressure cuffs, crutches) can be cleaned with a detergent. Blood spills should be handled according to OSHA regulations. In general, sterilization of critical items is not practical in homes but theoretically could be accomplished by chemical sterilants or boiling.
  • Single-use disposable items can be used or reusable items sterilized in a hospital.
  • Some environmental groups advocate “environmentally safe” products as alternatives to commercial germicides in the home-care setting. These alternatives (e.g., ammonia, baking soda, vinegar, Borax, liquid detergent) are not registered with EPA and should not be used for disinfecting because they are ineffective against S. aureus. Borax, baking soda, and detergents also are ineffective against Salmonella Typhi and E.coli; however, undiluted vinegar and ammonia are effective against S. Typhi and E.coli. Common commercial disinfectants designed for home use also are effective against selected antibiotic-resistant bacteria.
  • Public concerns have been raised that the use of antimicrobials in the home can promote development of antibiotic-resistant bacteria. This issue is unresolved and needs to be considered further through scientific and clinical investigations.
  • The public health benefits of using disinfectants in the home are unknown. However, some facts are known: many sites in the home kitchen and bathroom are microbially contaminated, use of hypochlorites markedly reduces bacteria, and good standards of hygiene (e.g., food hygiene, hand hygiene) can help reduce infections in the home. In addition, laboratory studies indicate that many commercially prepared household disinfectants are effective against common pathogens and can interrupt surface-to-human transmission of pathogens. The “targeted hygiene concept”—which means identifying situations and areas (e.g., food-preparation surfaces and bathroom) where risk exists for transmission of pathogens—may be a reasonable way to identify when disinfection might be appropriate.

Reprocessing of medical devices and equipment

Medical equipment should come with manufacturer instructions on how to provide care and maintenance. The instructions should include a) the equipments’ compatibility with chemical germicides, b) whether the equipment is water-resistant or can be safely immersed for cleaning, and c) how the equipment should be decontaminated if servicing is required (CDC, 2008). If manufacturers’ instructions are not available for non-critical medical equipment, like stethoscopes and blood pressure cuffs, they usually only require cleansing followed by low- to intermediate-level disinfection, depending on the nature and degree of contamination (CDC, 2008).

Cleaning disinfecting and sterilizing patient care items should be done in a central location to control the quality. If disinfecting and sterilizing is done in outside the central processing location, the same level of efficiency and safety should be maintained (CDC, 2008).

The following principles about sterilization or disinfection of patient-care equipment are put forth by CDC (CDC, 2008).

General Principles

  • In general, reusable medical devices or patient-care equipment that enters normally sterile tissue or the vascular system or through which blood flows should be sterilized before each use. Sterilization means the use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores. The major sterilizing agents used in hospitals are a) moist heat by steam autoclaving, b) ethylene oxide gas, and c) dry heat. However, there are a variety of chemical germicides (sterilants) that have been used for purposes of reprocessing reusable heat-sensitive medical devices and appear to be effective when used appropriately, i.e., according to manufacturer's instructions. These chemicals are rarely used for sterilization, but appear to be effective for high-level disinfection of medical devices that come into contact with mucous membranes during use (e.g., flexible fiberoptic endoscopes).
  • Heat stable reusable medical devices that enter the blood stream or enter normally sterile tissue should always be reprocessed using heat-based methods of sterilization (e.g., steam autoclave or dry heat oven).
  • Laparoscopic or arthroscopic telescopes (optic portions of the endoscopic set) should be subjected to a sterilization procedure before each use; if this is not feasible, they should receive high-level disinfection. Heat stable accessories to the endoscopic set (e.g., trocars, operative instruments) should be sterilized by heat-based methods (e.g., steam autoclave or dry heat oven).
  • Reusable devices or items that touch mucous membranes should, at a minimum, receive high-level disinfection between patients. These devices include reusable flexible endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment.
  • Medical devices that require sterilization or disinfection must be thoroughly cleaned to reduce organic material or bioburden before being exposed to the germicide and the germicide and the device manufacturer's instructions should be closely followed.
  • Except on rare and special instances (as mentioned below), items that do not ordinarily touch the patient or touch only intact skin are not involved in disease transmission, and generally do not necessitate disinfection between uses on different patients. These items include crutches, bedboards, blood pressure cuffs, and a variety of other medical accessories. Consequently, depending on the particular piece of equipment or item, washing with a detergent or using a low-level disinfectant may be sufficient when decontamination is needed. If noncritical items are grossly soiled with blood or other body fluids, a higher level of disinfections is required.

Exceptional circumstances that require noncritical items to be either dedicated to one patient or patient cohort or subjected to low-level disinfection between patient uses are those involving:

  • Patients infected or colonized with vancomycin-resistant enterococci or other drug-resistant microorganisms judged by the infection control program, based on current state, regional, or national recommendations, to be of special or clinical or epidemiologic significance

or

  • Patients infected with highly virulent microorganisms, e.g., viruses causing hemorrhagic fever (such as Ebola or Lassa).

The manufacturer should be contacted for questions about disinfectants. A source of information about low level or intermediate level disinfectants is the Antimicrobial Program Branch, Environmental Protection Agency (EPA) hotline (703) 308-0127 or email: info_antimicrobial@epa.gov. A source of information about high level disinfectants if the Food and Drug Administration (FDA) regional office or the FDA Center for Devices and Radiological Health at (301) 443-4690 (CDC, December 21, 2012).

Construction activities in or near healthcare facilities cause increase disease risks for airborne and waterborne disease Berger, et al, 2011). The increasing age of healthcare facilities is generating ongoing need for repair and remediation work that can introduce or increase contamination of the air and water in patient-care environments (CDC, June 6, 2003). The CDC has further recommendations for constructions that should be reviewed if applicable (CDC, June 6, 2003).

The purpose of heating, ventilation, and air conditioning (HVAC) systems in healthcare facilities is to a) maintain the indoor air temperature and humidity at comfortable levels; b) control odors; c) remove contaminated air; d) facilitate air-handling requirements to provide protection from airborne healthcare–related pathogens; and e) minimize the risk for transmission of airborne pathogens (CDC, June 6, 2003). Decreased performance of healthcare facility HVAC systems, filter inefficiencies, improper installation, and poor maintenance can contribute to the spread of healthcare–related airborne infections. The CDC has further recommendations for HVAC systems that should be reviewed if applicable (CDC, June 6, 2003).

Hospital Acquired Pneumonia

The following are risk factors for healthcare-associated bacterial pneumonia (Kollef, 2011).

Risk Factors Examples
Factors that enhance colonization of the oropharynx and/or stomach by microorganisms Administration of antimicrobial agents
Admission to the ICU
Presence of underlying chronic lung disease
Conditions favoring aspiration into the respiratory tract or reflux from the gastrointestinal tract Initial or repeat endotracheal intubation
Insertion of nasogastric tube
Supine position
Coma
Surgical procedures involving the head, neck, thorax, or upper abdomen
Immobilization due to trauma or illness
Conditions requiring prolonged use of mechanical ventilatory support with potential exposure to contaminated respiratory devices and/or contact with contaminated or colonized hands  
Host factors Extremes of age
Malnutrition
Severe underlying conditions
Immunosuppression

Recommendations for the prevention of healthcare associated pneumonia typically focus on: 1) educating staff of the risks; 2) preventing cross-infection; 3) increasing the host’s defenses; 4) optimizing nutrition while reducing the risk of aspiration; 5) reducing colonization, and; 6) correcting/minimizing co-morbid conditions (Morrow, 2009). The following are the CDC and the American Thoracic Society recommendations for the prevention of healthcare associated pneumonia (CDC, 2003; American Thoracic Society, 2005). Recommendations from the Institute for Health Improvement are included, as well (Institute for Health Improvement, 2012).

Primary Prevention of Healthcare Associated Bacterial Pneumonia

  • Staff Education
  • Conduct Surveillance in ICU Patients
    • Do not routinely perform surveillance cultures of patient, equipment or devices
  • Prevention of Transmission in a Healthcare Setting
    • Sterilization or disinfection:
      • Thoroughly clean all equipment. When possible use steam sterilization or high level disinfection by wet heat pasteurization
      • Use sterile water for rinsing reusable semicritical respiratory equipment after chemical disinfection. If this not feasible, rinse with filtered water.
      • Adhere to provisions in the FDA/s enforcement document for single use devices that are reprocess by third parties.
    • Do not routinely sterilize or disinfect the internal machinery of the mechanical ventilator
    • Do not routinely change the breathing circuits with humidifiers based on duration of use. Clean only when visibly soiled or malfunctioning.
    • Breathing-circuit- tubing condensate
      • Periodically drain and discard any condensate, making sure the condensate does not drain toward the patient.
      • Wear gloves during procedure or handling of condensate
      • Decontaminate hands with soap and water if visible soiled or with alcohol-based hand rub after procedure.
      • No recommendation can be made for placing a filter or trap at the distal end of the expiratory-phase tubing to collect condensate.
    • Use sterile water to fill bubbling humidifiers
    • No recommendation can be made for the preferential use of a close, continuous-feed humidification system.
    • Ventilator breathing circuits with heat moisture exchange (HME):
      • No recommendation can be made for the preferential use of either HMEs or heated humidifiers to prevent pneumonia in patients receiving mechanically assisted ventilation
      • Change an HME that is in use on a patient when it malfunctions mechanically or becomes visibly soiled.
      • Do not routinely change an HME that is in use on a patient more frequently than every 48 hours.
      • Do not routinely change the breathing circuit attached to an HME while it is in use on a patient
    • Oxygen humidifiers
      • Follow manufacturers' instructions for use of oxygen humidifiers
      • Change the humidifier-tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated.
    • Small-volume medication nebulizers: in-line and hand-held nebulizers
      • Between treatments on the same patient: clean, disinfect; rinse with sterile water (if rinsing is needed), and dry small-volume in-line or hand-held medication nebulizers
      • Use only sterile fluid for nebulization, and dispense the fluid into the nebulizer aseptically
      • Whenever possible, use aerosolized medications in single-dose vials. If multidose medication vials are used, follow manufacturers’ instructions for handling, storing, and dispensing the medications
    • Mist-tents
      • Between uses on different patients, replace mist tents and their nebulizers, reservoirs, and tubings with those that have been subjected to sterilization or high-level disinfection
      • No recommendation can be made about the frequency of routinely changing mist-tent nebulizers, reservoirs, and tubings while in use on one patient.
      • Subject mist-tent nebulizers, reservoirs and tubings that are used on the same patient to daily low-level disinfection (e.g., with 2% acetic acid) or pasteurization followed by air-drying
    • Other devices
      • Between uses on different patients, sterilize or subject to high level disinfection:
        • Portable respirometers and ventilator thermometers
        • Reusable hand-powered resuscitation bags
      • No recommendation can be made about the frequency of changing hydrophobic filters placed on the connection port of resuscitation bags.
    • Anesthesia machines and breathing systems or patient circuits:
      • Do not routinely sterilize or disinfect the internal machinery of anesthesia equipment
      • Between uses on different patients, clean reusable components of the breathing system or patient circuit and then sterilize or subject them to high-level liquid chemical disinfection or pasteurization in accordance with the device manufacturers’ instructions for their reprocessing
      • No recommendation can be made about the frequency of routinely cleaning and disinfecting unidirectional valves and carbon dioxide absorber chambers
      • Follow published guidelines and manufacturers' instructions about in use maintenance, cleaning, and disinfection or sterilization of other components or attachments of the breathing system or patient circuit of anesthesia equipment
      • No recommendation can be made for placing a bacterial filter in the breathing system or patient circuit of anesthesia equipment
    • Pulmonary-function testing equipment
      • Do not routinely sterilize or disinfect the internal machinery of pulmonary-function testing machines between uses on different patients
      • Change the mouthpiece of a peak flow meter or the mouthpiece and filter of a spirometer between uses on different patients
    • Room-air “humidifiers” and faucet aerators
      • Do not use large-volume room-air humidifiers that create aerosols (e.g., by venturi principle, ultrasound, or spinning disk, and thus actually are nebulizers) unless they can be sterilized or subjected to high-level disinfection at least daily and filled only with sterile water
      • No recommendation can be made about the removal of faucet aerators from areas for immunocompetent patients
      • If Legionella spp. are detected in the water of a transplant unit and until Legionella spp. are no longer detected by culture, remove faucet aerators in the unit

Prevention of Person-to-Person Transmission of Bacteria

  • Standard Precautions
  • Care of patients with tracheostomy
    • Good tracheostomy care reduces morbidity and it also reduces the amount of time to decannulation (Mitchell, et al, 2013).
    • All supplies to replace a tracheostomy tube should be at the bedside or within easy reach.
    • Humidification should be used if the patient is mechanically ventilated or has thick secretions.
    • Perform tracheostomy under aseptic conditions.
    • When changing a tracheostomy tube, wear a gown, use aseptic technique, and replace the tube with one that has undergone sterilization or high-level disinfection
    • No recommendation can be made for the daily application of topical antimicrobial agent(s) at the tracheostoma
  • Suctioning of respiratory tract secretions
    • No recommendation can be made for the preferential use of either the multiuse closed-system suction catheter or the single-use open system suction catheter for prevention of pneumonia (Morrow, et al, 2012)
    • No recommendation can be made about wearing sterile rather than clean gloves when performing endotracheal suctioning.
    • No recommendation can be made about the frequency of routinely changing the in-line suction catheter of a closed-suction system in use on one patient
    • If the open-system suction is employed, use a sterile single-use catheter.
    • Use only sterile fluid to remove secretions from the suction catheter if the catheter is to be used for re-entry into the patient's lower respiratory tract.

Modifying Host Risk for Infection

  • Increasing Host Defense Against Infection: Administration of Immune Modulators
    • Pneumococcal vaccination. Vaccinate patients at high risk for severe pneumococcal infections: (Morbidity and Mortality Weekly Report , 2011; Morbidity and Mortality Weekly Report, 2010; )
      • persons aged >65 years;
      • persons aged 5-64 years who have chronic cardiovascular disease, chronic pulmonary disease, diabetes mellitus, alcoholism, chronic liver disease (cirrhosis), or cerebro-spinal fluid (CSF) leaks;
      • persons aged 5-64 years who have functional or anatomic asplenia;
      • persons aged 5-64 years who are living in special environments or social settings;
      • immunocompromised persons aged >5 years with HIV infection, leukemia, lymphoma, Hodgkin’s disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, or other conditions associated with immunosuppression and persons in long-term care facilities
    • Administer the vaccine to all children aged <2 years and to children aged 24-59 months who are at increased risk for pneumococcal disease.
    • Consider administering the vaccine to all children aged 24-59 months, with priority given to children aged 24-35 months, children who are American Indians/Alaska Natives or black, and children who attend group child-care centers
    • In long-term care facilities (LTCFs), establish a standard procedure for the administration of vaccine to persons at high risk of acquiring severe pneumococcal infections, including pneumococcal pneumonia
    • No recommendation can be made for the routine administration of preparations of GCSF or intravenous gamma globulin for prophylaxis against healthcare-associated pneumonia
    • No recommendation can be made for the routine administration of glutamine for prevention of healthcare-associated pneumonia
  • Precautions for Prevention of Aspiration
    • As soon as the clinical indications for their use are resolved, remove devices such as endotracheal, tracheostomy, or enteral (i.e., oro- or nasogastric, or jejunal) tubes from patients
    • Prevention of aspiration associated with endotracheal intubation
      • If possible, limit the use of sedating or paralytic agents that depress cough and other host-protective mechanisms.
      • Maintain endotracheal tube cuff pressure at > 20 ccm H2O.
      • Condensation in the ventilator circuit can become contaminated. Care should be taken to prevent condensation from reaching the lower airway or the nebulizer chamber.
      • Use of non-invasive ventilation (NIV) to reduce the need for and duration of endotracheal intubation
      • When feasible and not medically contraindicated, use noninvasive positive-pressure ventilation delivered continuously by face or nose mask, instead of performing endotracheal intubation in patients who are in respiratory failure and are not needing immediate intubation
      • When feasible and not medically contraindicated, use NIV as part of the weaning process in order to shorten the period of endotracheal intubation
      • As much as possible, avoid repeat endotracheal intubation in patients who have received mechanically assisted ventilation
      • Unless contraindicated by the patient’s condition, perform orotracheal rather than nasotracheal intubation on patients
      • If feasible, use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow drainage (by continuous or frequent intermittent suctioning) of tracheal secretions that accumulate in the patient's subglottic area
      • Before deflating the cuff of an endotracheal tube in preparation for tube removal, or before moving the tube, ensure that secretions are cleared from above the tube cuff.
  • Prevention of aspiration associated with enteral feeding:
    • In the absence of medical contraindication(s), elevate the head of the bed at an angle of 30-45 degrees if the patient is at high risk for aspiration pneumonia (e.g., a person receiving mechanically assisted ventilation or who has an enteral tube in place)
    • Try and limit the use of medications that affect the cough and gag reflexes or impair swallowing.
    • Routinely verify appropriate placement of the feeding tube. There are many methods for doing this (e.g., auscultation, observing the aspirate contents, checking the pH of the aspirate), but they all have limitations and there is no consensus as to the best method for verifying appropriate placement of a feeding tube (Guy, et al, 2009).
    • Maintain head elevation for one hour after the feeding has finished.
    • Check residuals prior to feeding; if the residual is > 200 mL, the rate and volume of the feeding may need to be adjusted.
    • No recommendation can be made for the preferential use of small bore tubes for enteral feeding
    • No recommendation can be made for preferentially administering enteral feedings continuously or intermittently
    • No recommendation can be made for preferentially placing the feeding tubes (e.g., jejunal tubes) distal to the pylorus
  • Prevention or modulation of oropharyngeal colonization
    • Aerobic and facultatively anerobic gram-negative bacilli frequently colonize the oral cavities in patients who are hospitalized and/or immunocompromised. These pathogens are a significant cause of hospital-acquired pneumonia
    • Oropharyngeal cleaning and decontamination with an antiseptic agent can help reduce the number of these pathogens
    • It is not clear which antiseptic agent is the most effective, and the optimal oral hygiene protocol has not been determined (Lam, et al, 2012).
    • Develop and implement a comprehensive oral-hygiene program (that might include the use of an antiseptic agent) for patients in acute-care settings or residents in long-term care facilities who are at high risk of developing healthcare-associated pneumonia
    • Chlorhexidine oral rinse
      • No recommendation can be made for the routine use of an oral chlorhexidine rinse for the prevention of healthcare associated pneumonia in all postoperative or critically ill patients or other patients at high risk for pneumonia (Kusahara, 2012)
      • Use an oral chlorhexidine gluconate (0.12%) rinse during the perioperative period on adult patients who undergo cardiac surgery
    • No recommendation can be made for the routine use of topical antimicrobial agents for oral decontamination to prevent ventilator associated pneumonia (VAP)
  • Prevention of gastric colonization
    • Patients who are mechanically ventilated are at risk for stress-related gastric ulcers and bleeding
    • No recommendation can be made for the preferential use of sucralfate, H2-antagonists, or antacids for stress-bleeding prophylaxis in patients receiving mechanically assisted ventilation (Huang, et al, 2010)
    • No recommendation can be made for the routine administration of selective digestive decontamination (SDD) to all critically ill, mechanically ventilated, or ICU patients as there is no conclusive evidence for or against its use (Walden, 2012)
    • No recommendation can be made for routine acidification of gastric feeding

Prevention of Postoperative Pneumonia

  • Instruct preoperative patients, especially those at high risk for contracting pneumonia, about taking deep breaths and ambulating as soon as medically indicated in the postoperative period. Patients at high-risk include:
    • those who will have abdominal aortic aneurysm repair, thoracic surgery, or emergency surgery;
    • those who will receive general anesthesia;
    • those who are aged >60 years;
    • those with totally dependent functional status;
    • those who have had a weight loss >10%;
    • those using steroids for chronic conditions;
    • those with recent history of alcohol use,
    • history of COPD, or smoking during the preceding year;
    • those with impaired sensorium,
    • a history of cerebrovascular accident with residual neurologic deficit, or low (<8mg/dL) or high (>22 mg/dL) blood urea nitrogen level;
    • and those who will have received more than 4 units of blood before surgery
  • Encourage all postoperative patients to take deep breaths, move about the bed, and ambulate unless these are medically contraindicated
  • Head of the bed should be elevated at least 30° while eating
  • Oral hygiene with chlorhexidine should be considered
  • Use coughing exercises and incentive spirometry on postoperative patients who are at high risk for developing pneumonia
  • No recommendation can be made about the routine use of chest physiotherapy on all postoperative patients at high risk for pneumonia

Other Prophylactic Procedures for Pneumonia

  • Administration of antimicrobial agents other than in SDD
    • No recommendation can be made about the routine administration of systemic antimicrobial agent(s) to prevent pneumonia in critically ill patients and/or in those receiving mechanically-assisted ventilation
    • No recommendation can be made for scheduled changes in the class of antimicrobial agents used routinely for empiric treatment of suspected infections in a particular group of patients
  • No recommendation can be made for the routine use of turning or rotational therapy, either by "kinetic" therapy or by continuous lateral rotational therapy (i.e., placing patients on beds that turn on their longitudinal axes intermittently or continuously) for prevention of healthcare-associated pneumonia in critically ill or immobilized patients

Primary Prevention and Control of Healthcare Associated Legionnaires Disease

  • Staff Education
  • Infection and Environmental Surveillance (OSHA. Legionnaire’s Disease: Facts and Frequently Asked Questions; OSHA. Legionnaire’s Disease: Water Sampling Guidelines; OSHA Technical Manual: Legionnaire’s Disease)
    • Maintain a high index of suspicion for the diagnosis of healthcare associated Legionnaires disease and perform laboratory diagnostic tests (both culture of appropriate respiratory specimen and the urine antigen test) for legionellosis on suspected cases, especially in patients who are at high risk of acquiring the disease (CDC. February 5, 2013; Sabria, et al, 2012)
      • patients who are immunosuppressed, including hematopoietic stem cell transplantation (HSCT) or solid-organ-transplant recipients;
      • cigarette smoking;
      • alcohol history;
      • CVA history
      • patients receiving systemic steroids;
      • patients aged >65 years;
      • or patients who have chronic underlying disease such as diabetes mellitus, congestive heart failure, and COPD)
    • Periodically review the availability and clinicians’ use of laboratory diagnostic tests for Legionnaires disease in the facility, and if clinicians do not routinely use the tests on patients with diagnosed or suspected pneumonia, implement measures to enhance clinicians’ use of the tests (e.g., by conducting educational programs)
    • Routine culturing of water systems for Legionella spp.
    • No recommendation can be made about routinely culturing water systems for Legionella spp. in healthcare facilities that do not have patient-care areas (i.e., transplant units) for persons at high risk for Legionella infection
    • In facilities with hematopoietic stem-cell- or solid-organ transplantation programs, periodic culturing for legionellae in water samples from the transplant unit(s) can be performed as part of a comprehensive strategy to prevent Legionnaires disease in transplant recipients
    • No recommendation can be made about the optimal methods (i.e., frequency, number of sites) for environmental surveillance cultures in transplant units.
    • Perform corrective measures aimed at maintaining undetectable levels of Legionella spp. in the unit’s water system.
    • Maintain a high index of suspicion for legionellosis in transplant patients with healthcare-associated pneumonia even when environmental surveillance cultures do not yield legionellae
  • Use and Care of Medical Devices, Equipment, and Environment
    • If Legionella spp. are detected in the water of a transplant unit and until Legionella spp. are no longer detected by culture, remove faucet aerators in areas for severely immunocompromised patients
    • Cooling towers
      • When a new building is constructed, place cooling towers in such a way that the tower drift is directed away from the facility's air intake system and design the cooling towers such that the volume of aerosol drift is minimized
      • For cooling towers, install drift eliminators, regularly use an effective biocide, maintain the tower according to manufacturers' recommendations, and keep adequate maintenance records
  • Water-distribution system
    • Where practical and allowed by state law, maintain potable water at the outlet at >51oC (>124oF) or <20oC (<68oF), especially in facilities housing organ-transplant recipients or other patients at high risk.
    • If water is maintained at >51oC, use thermostatic mixing valves to prevent scalding
    • No recommendation can be made about the treatment of water with chlorine dioxide, heavy-metal ions, ozone, or ultraviolet light. Hospitals served by municipalities with monochloramine-treated water have had success in controlling legionellae
    • Healthcare facilities with hemopoietic stem-cell or solid-organ transplantation programs
      • If legionellae are detected in the potable water supply of a transplant unit, and until Legionellae are no longer detected by culture:
      • Decontaminate the water supply
      • Restrict severely immunocompromised patients from taking showers
      • Use water that is not contaminated with Legionella spp. for HSCT patients’ sponge baths
      • Provide HSCT patients with sterile water for tooth brushing or drinking, or for flushing nasogastric tubes
      • Do not use water from faucets with Legionella-contaminated water in patients rooms to avoid creating infectious aerosols

Prevention and Control of Healthcare Associated Pertussis

  • Staff Education
  • Case-Reporting, Disease Surveillance, and Case-Contact Notification
    • Report to the local and/or state health department all confirmed and suspected cases of pertussis
    • Conduct active surveillance for cases of pertussis until 42 days after the onset of the last pertussis case
    • Notify persons who have had close contact with a case of pertussis in the healthcare setting so that they can be monitored for symptoms of pertussis or administered appropriate chemoprophylaxis. Close contact includes
      • face-to-face contact with a patient who is symptomatic (e.g., in the catarrhal or paroxysmal period of illness);
      • sharing a confined space in close proximity for a prolonged period of time (e.g., >1 hour) with a symptomatic patient;
      • or direct contact with respiratory, oral, or nasal secretions from a symptomatic patient (e.g., an explosive cough or sneeze on the face, sharing food, sharing eating utensils during a meal, kissing, mouth-to-mouth resuscitation, or performing a full medical examination of the nose and throat)
  • Prevention of Pertussis Transmission (CDC, February 27, 2013)
    • Vaccination for Primary Prevention (MMWR, 2013)
      • No recommendation can be made for routinely vaccinating adults, including healthcare professionals, with the acellular pertussis vaccine at regular intervals (e.g., every 10 years)
      • In LTCFs for children and for children with prolonged stay in acute-care facilities, follow the recommendations of ACIP for vaccinating children according to their chronologic age
    • Vaccination for Secondary Prevention
      • No recommendation can be made for vaccinating adults, including healthcare professionals, during an institutional outbreak of pertussis
      • For routine use, adolescents 11- 18 years who have completed the DTP/DTaP vaccine series, and adults 19- 64 should receive a single dose of TDAp.
      • Adults 65 years or older who anticipate having close contact with an infant that is < 12 months should receive a single dose of Tdap. (MMWR, 2011)
      • During an institutional outbreak of pertussis, accelerate scheduled vaccinations to infants and children aged <7 years who have not completed their primary vaccinations, as follows:
        • Infants aged <2 months who are receiving their initial vaccination: Administer the first dose of the DTaP vaccine as early as age 6 weeks and the second and third doses at a minimum of 4-week intervals between doses. Give the fourth dose on or after age 1 year and >6 months after the third dose
        • Other children aged <7 years: Administer DTaP vaccine to all patients who are aged <7 years and are not up-to-date with their pertussis vaccinations, as follows: administer a fourth dose of DtaP vaccine if the child has had 3 doses of DTaP or diphtheria, tetanus and pertussis (DTP) vaccine, is >12 months old, and >6 months have passed since the third dose of DTaP or DTP vaccine; administer a fifth dose of DTaP vaccine if the child has had four doses of DTaP or DTP vaccine, is aged 4-6 years, and received the fourth vaccine dose before the fourth birthday
    • Vaccination of children with a history of well-documented pertussis disease
      • No recommendation can be made for administering additional dose(s) of pertussis vaccine to children who have a history of well-documented pertussis disease (i.e., pertussis illness with either a B. pertussis-positive culture or epidemiologic linkage to a culture-positive case)
  • Patient Placement and Management
    • Patients with confirmed pertussis
      • Place a patient with diagnosed pertussis in a private room, or if known not to have any other respiratory infection, in a room with other patient(s) with pertussis until after the first 5 days of a full course of antimicrobial treatment or 21 days after the onset of cough if unable to take antimicrobial treatment for pertussis
    • Patients with suspected pertussis
      • Place a patient with suspected pertussis in a private room. After pertussis and no other infection is confirmed, the patient may be placed in a room with other patient(s) who have pertussis until after the first 5 days of a full course of antimicrobial treatment or 21 days after the onset of cough if unable to take antimicrobial treatment for pertussis
      • Perform diagnostic laboratory tests (for confirmation or exclusion of pertussis) on patients who are admitted with or who develop signs and symptoms of pertussis to allow for the earliest possible downgrading of infection-control precautions to the minimum required for each patient’s specific infection(s)
  • Management of Symptomatic Healthcare Personnel
    • Perform diagnostic laboratory tests for pertussis in healthcare personnel with illness suggestive of pertussis (i.e., unexplained cough illness of >1week duration, paroxysmal cough)
    • Treat symptomatic healthcare personnel who are proven to have pertussis or personnel who are highly suspected of having pertussis with the same antimicrobial regimen, as detailed for chemoprophylaxis of case-contacts
    • Restrict symptomatic pertussis-infected healthcare professionals from work during the first 5 days of their receipt of antimicrobial therapy
  • Masking
    • In addition to observing standard precautions, wear a surgical mask when within three feet of a patient with confirmed or suspected pertussis, when performing procedures or patient-care activities that are likely to generate sprays of respiratory secretions, or on entering the room of a patient with confirmed or suspected pertussis
  • Prophylactic Antibiotic Regimen for Contacts of Persons with Pertussis are recommended (CDC, February 19, 2013)
  • Work Exclusion of Asymptomatic Healthcare Professionals Exposed to Pertussis
    • Do not exclude from patient care a healthcare professional who remains asymptomatic and is receiving chemoprophylaxis after an exposure to a case of pertussis
    • If mandated by state law or where feasible, exclude an exposed, asymptomatic healthcare professional who is unable to receive chemoprophylaxis, from providing care to a child aged <4 years during the period starting 7 days after the professional’s first possible exposure until 14 days after his last possible exposure to a case of pertussis
  • Other measures
    • Limit the movement and transport of a patient with diagnosed or suspected pertussis from his room to those for essential purposes only. If the patient is transported out of the room, ensure that precautions are maintained to minimize the risk for disease transmission to other patients and contamination of environmental surfaces or equipment
    • Do not allow persons who have symptoms of respiratory infection to visit pediatric, immunosuppressed, or cardiac patients

Prevention and Control of Healthcare Associated Pulmonary Aspergillosis

  • Staff Education
  • Surveillance
    • Maintain a high index of suspicion for healthcare-associated pulmonary aspergillosis in severely immunocompromised patients
    • Maintain surveillance for cases of healthcare-associated pulmonary aspergillosis by establishing a system by which the facility’s infection-control personnel are promptly informed when Aspergillus sp. is isolated from cultures of specimens from patient’s respiratory tract and by periodically reviewing the hospital's microbiologic, histopathologic, and postmortem data.
    • Do not perform routine, periodic cultures of the nasopharynx of asymptomatic patients at high risk
    • Do not perform routine, periodic cultures of equipment or devices used for respiratory therapy, pulmonary function testing, or delivery of inhalation anesthesia in the HSCT unit, nor of dust in rooms of HSCT recipients
    • No recommendation can be made about routine microbiologic air sampling before, during, or after facility construction or renovation, or before or during occupancy of areas housing immunocompromised patients
    • In facilities with PEs, perform surveillance of the ventilation status of these areas either by continuous monitoring or periodic analysis of the following parameters: room air exchanges, pressure relations and filtration efficacy to ensure that appropriate levels are
  • Prevention of Transmission of Aspergillus spp. Spores
    • Planning New Specialized-Care Units for High-Risk Patients
      • When constructing new specialized-care units with PE for HSCT recipients, ensure that patient rooms have adequate capacity to minimize accumulation of fungal spores via 1) HEPA filtration of incoming air, 2) directed room airflow, 3) positive air pressure in patient's room in relation to the corridor, 4) well-sealed room, and 5) high (>12) air changes per hour
      • Do not use laminar air flow (LAF) routinely in PE
      • Units for autologous HSCT and solid-organ transplant recipients
      • No recommendation can be made for constructing PE for recipients of autologous HSCTs or solid-organ-transplants (e.g., heart, liver, lung, kidney)
    • In Existing Facilities with HSCT Units and No Cases of Healthcare-Associated Aspergillosis
      • No recommendation can be made for routinely placing a recipient of autologous HSCT or solid-organ transplant in PE.
      • Maintain air-handling systems in PE and other high-risk patient-care areas according to published recommendations
      • Maintain air-handling systems in PE and other high-risk patient-care areas according to published recommendations
      • Develop a water-damage response plan for immediate execution when water leaks, spills, and moisture accumulation occur to prevent fungal growth in the involved areas
      • Use proper dusting methods for patient-care areas designated for severely immunocompromised
      • Wet-dust horizontal surfaces daily using cloth that has been moistened with an EPA-registered hospital disinfectant
      • Avoid dusting methods that disperse dust (e.g., feather dusting)
      • Keep vacuums in good repair and equip them with HEPA filters for use in areas with patients at high risk
      • Do not use carpeting in hallways and rooms occupied by severely immunocompromised patients
      • Avoid using upholstered furniture or furnishings in rooms occupied by severely immunocompromised patients.
      • Minimize the length of time that immunocompromised patients in PEs are outside their rooms for diagnostic procedures and other activities.
      • Instruct severely immunocompromised patients to wear a high efficiency respiratory-protection device (e.g., an N95 respirator) when they leave the PE during periods when construction, renovation, and/or other dust-generating activities are ongoing in and around the healthcare facility
      • No recommendation can be made about the specific type of respiratory-protection device (e.g., surgical mask, N95 respirator) for use by a severely immunocompromised patient who leaves the PE during periods when there is no construction, renovation or other dust-generating activity in progress in or around the healthcare facility.
      • Systematically review and coordinate infection-control strategies with personnel in charge of the facility’s engineering, maintenance, central supply and distribution, and catering services
      • When planning construction, demolition, and renovation activities in and around the facility, assess whether patients at high-risk for aspergillosis are likely to be exposed to high ambient-air spore counts of Aspergillus spp. from construction, demolition, and renovation sites, and if so, develop a plan to prevent such exposures
      • During construction, demolition, or renovation activities, construct impermeable barriers between patient-care and construction areas to prevent dust from entering the patient-care areas
      • Direct pedestrian traffic that come from construction areas away from patient-care areas to limit the opening and closing of doors or other barriers that might cause dust dispersion, entry of contaminated air, or tracking of dust into patient-care areas
      • Do not allow fresh or dried flowers or potted plants in patient-care areas for severely immunocompromised patients
    • When a Case of Aspergillosis Occurs
      • Assess whether the infection is healthcare-related or community-acquired.
      • Determine, if any ventilation deficiency exists in the PEs
      • If no evidence exists that the patient’s aspergillosis is facility-acquired, continue routine maintenance procedures to prevent healthcare-associated aspergillosis
      • If evidence of possible facility-acquired infection with Aspergillus spp. exists, conduct an epidemiologic investigation and an environmental assessment to determine and eliminate the source of Aspergillus spp.
      • Use an antifungal biocide (e.g., copper-8-quinolinolate) that is registered with the Environmental Protection Agency for decontamination of structural materials
  • Chemoprophylaxis
    • No recommendation can be made for the routine administration of antifungal agents
    • No recommendation can be made for any specific strategy to prevent recurrence of pulmonary aspergillosis in patients undergoing hematopoietic stemcell transplantation who have a history of pulmonary aspergillosis

Prevention and Control of Healthcare Associated RSV, Parainfluenza Virus, and Adenovirus Infections

  • Staff Education
  • Surveillance
    • Establish mechanisms by which the appropriate healthcare personnel are promptly alerted to any increase in the activity of RSV, parainfluenza virus, adenovirus, or other respiratory viruses in the local community. Establish mechanisms by which the appropriate healthcare personnel can promptly inform the local and state health departments of any increase in the activity of the above-named viruses or of influenza-like illness in their facility.
    • In acute-care facilities during periods of increased prevalence of symptoms of viral respiratory illness in the community or healthcare facility, and/or during the RSV and influenza season (i.e., December-March), attempt prompt diagnosis of respiratory infections caused by RSV, influenza, parainfluenza, or other respiratory viruses. Use rapid diagnostic techniques as clinically indicated in patients who are admitted to the healthcare facility with respiratory illness and are at high risk for serious complications from viral respiratory infections (e.g., pediatric patients, especially infants, and those with compromised cardiac, pulmonary, or immune function)
    • No recommendation can be made for routinely conducting surveillance cultures for RSV or other respiratory viruses in respiratory secretions of patients
    • In LTCFs, establish mechanism(s) for continuing surveillance to allow rapid identification of a potential outbreak in the facility.
  • Prevention of Transmission of RSV, Parainfluenza Virus, or Adenovirus (CDC. RSV, October 17, 2008; CDC. Human Parainfluenza Viruses (HPIVs), November 5, 2012; CDC. Adenoviruses, December 27, 2011)
    • Prevention of Person-to-Person Transmission
      • Standard and contact precautions for RSV and parainfluenza virus; and standard, contact, and droplet precautions for adenovirus
      • Patient placement in acute-care facilities
        • Place a patient with diagnosed RSV, parainfluenza, adenovirus, or other viral respiratory tract infection in a private room when possible or in a room with other patients with the same infection and no other infection
        • Place a patient with suspected RSV, parainfluenza, adenovirus, or other viral respiratory tract infection in a private room.
        • Promptly perform rapid diagnostic laboratory tests on patients who are admitted with or who have symptoms of RSV infection after admission to the healthcare facility to facilitate early downgrading of infection-control precautions to the minimum required for each patient’s specific viral infection
        • Promptly perform rapid diagnostic laboratory tests on patients who are admitted with or who have symptoms of parainfluenza or adenovirus infection after admission to the healthcare facility to facilitate early downgrading of infection-control precautions to the minimum required for each patient’s specific viral infection and early initiation of treatment when indicated.
    • Limiting patient movement or transport in acute-care facilities
      • Limit to essential purposes only the movement or transport of patients from their rooms when they are diagnosed or suspected to be infected with RSV, parainfluenza virus, or
      • If transport or movement from the room is necessary
      • For a patient with diagnosed or suspected RSV or parainfluenza virus infection, ensure that precautions are maintained to minimize the risk for transmission of the virus to other patients and contamination of environmental surfaces or equipment by ensuring that the patient does not touch other persons’ hands or environmental surfaces with hands that have been contaminated with his/her respiratory secretions
      • For a patient with diagnosed or suspected adenovirus infection, minimize patient dispersal of droplets by having the patient wear a surgical mask, and ensure that contact precautions are maintained to minimize the risk of transmission of the virus to other patients and contamination of environmental surfaces or equipment
    • Other measures in acute-care facilities
      • Staffing
      • Restrict healthcare personnel in the acute stages of an upper respiratory tract infection from caring for infants and other patients at high risk for complications from viral respiratory tract infections
      • When feasible, perform rapid diagnostic testing on healthcare personnel with symptoms of respiratory tract infection, especially those who provide care to patients at high-risk for acquiring and/or developing severe complications from RSV, parainfluenza, or adenovirus infection, so that their work status can be determined promptly.
      • Limiting visitors
      • Do not allow persons who have symptoms of respiratory infection to visit pediatric, immunocompromised, or cardiac patients
      • Follow the recommendations of the American Academy of Pediatrics to consider monthly administration of palivizumab, an RSV monoclonal-antibody preparation
  • Control of outbreaks in acute-care facilities
    • Perform rapid screening diagnostic tests for the particular virus (es) known or suspected to be causing the outbreak on patients who are admitted with symptoms of viral respiratory illness. Promptly cohort the patients (according to their specific infections) as soon as the results of the screening tests are available. In the interim, when possible, admit patients with symptoms of viral respiratory infections to private rooms.
    • Personnel cohorting
    • During an outbreak of healthcare-associated RSV infection, cohort personnel as much as practical (e.g., restrict personnel who give care to infected patients from giving care to uninfected patients)
    • No recommendation can be made for routinely cohorting personnel during an outbreak of healthcare-associated adenovirus or parainfluenza virus infection.
    • No recommendation can be made for the use of RSV immune globulin or monoclonal antibody to control outbreaks of RSV infection in the healthcare setting

Prevention and Control of Healthcare Associated Influenza

  • Staff Education
  • Surveillance
    • Establish mechanisms by which facility personnel are promptly alerted about increased influenza activity in the community.
    • Establish protocols for intensifying efforts to promptly diagnose cases of facility acquired influenza.
    • Arrange for laboratory tests to be available to clinicians for prompt diagnosis of influenza
  • Modifying Host Risk For Infection
    • Vaccination
      • In acute-care settings (including acute-care hospitals, emergency rooms, and walk-in clinics) or ongoing-care facilities (including physicians’ offices, public health clinics, employee health clinics, hemodialysis centers, hospital specialty-care clinics, outpatient rehabilitation programs, or mobile clinics), offer vaccine to inpatients and outpatients at high risk for complications from influenza beginning in September and throughout the influenza season
      • Groups at high risk for influenza-related complications include
        • those aged >65 years;
        • residents of LTCFs that house persons of any age who have chronic medical conditions;
        • adults and children aged >6 months who have chronic disorders of the pulmonary or cardiovascular system, including asthma;
        • adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies; or immunosuppression (including immunosuppression caused by medications or HIV);
        • children and adolescents (aged 6 months-18 years) who are receiving long-term aspirin therapy; and women who will be in the second or third trimester of pregnancy during the influenza season.
      • In addition, offer annual influenza vaccination to all persons aged 50-64 years, close contacts of children aged <24 months, and healthy children aged 6-23 months
      • In LCTFs, establish an SOP for timely administration of the inactivated influenza vaccine to high-risk persons
        • Obtain consent for influenza vaccination (if such is required by local or state law) from every resident (or his/her guardian) at the time the resident is admitted to the facility or anytime afterwards, before the next influenza season.
        • Routinely vaccinate all residents, except those with medical contraindication(s) to receipt of influenza vaccine, (under a standing operating procedure (SOP) or with the concurrence of the residents’ respective attending physicians) at one time, annually, before the influenza season. To residents who are admitted during the winter months after completion of the facility’s vaccination program, offer the vaccine at the time of their admission
      • In other settings where healthcare is given (e.g., in homes visited by personnel from home healthcare agencies), vaccinate patients for whom vaccination is indicated, as listed in section III-A-1, and refer patient’s household members and care givers for vaccination, before the influenza season
      • Personnel
        • Beginning in October each year, provide inactivated influenza vaccine for all personnel including night and weekend staff. Throughout the influenza season, continue to make the vaccine available to newly hired personnel and to those who initially refuse vaccination. If vaccine supply is limited, give highest priority to staff caring for patients at greatest risk for severe complications from influenza infection.
        • Educate healthcare personnel regarding the benefits of vaccination and the potential health consequences of influenza illness for themselves and their patients
        • Take measures to provide all healthcare personnel convenient access to inactivated influenza vaccine at the work site, free of charge, as part of employee health program
    • Prevention of Person to Person Transmission
      • Droplet Precautions
      • Personnel Restrictions
        • In acute-care facilities, utilize the facility’s employee health service or its equivalent to evaluate personnel with influenza-like illness and determine whether they should be removed from duties that involve direct patient contact. Use more stringent criteria for personnel who work in certain patient-care areas (e.g., ICUs, nurseries, and organ-transplant [especially HSCT] units) where patients who are most susceptible to influenza-related complications are located
    • Control of Influenza Outbreaks
      • Determine the Outbreak Strain
      • Vaccination of Patients and Personnel
        • Administer current inactivated influenza vaccine to unvaccinated patients and healthcare personnel
      • Antiviral Agent Administration
        • When a facility outbreak of influenza is suspected or recognized:
        • Administer amantadine, rimantadine, or oseltamivir as prophylaxis to all patients without influenza illness in the involved unit for whom the antiviral agent is not contraindicated (regardless of whether they received influenza vaccinations during the previous fall). Do not delay administration of the antiviral agent(s) for prophylaxis unless the results of diagnostic tests to identify the infecting strain(s) can be obtained within 12-24 hours after specimen collection
        • Administer amantadine, rimantadine, oseltamivir, or zanamivir to patients acutely ill with influenza, within 48 hours of illness onset.
        • Choose the agent appropriate for the type of influenza virus circulating in the community. Offer antiviral agent(s) (amantadine, rimantadine, or oseltamivir) for prophylaxis to unvaccinated personnel for whom the antiviral agent is not contraindicated and who are in the involved unit or taking care of patients at high-risk
        • Consider prophylaxis for all healthcare personnel, regardless of their vaccination status, if the outbreak is caused by a variant of influenza that is not well matched by the vaccine
        • No recommendation can be made about the prophylactic administration of zanamivir to patients or personnel
        • Discontinue the administration of influenza antiviral agents to patients or personnel if laboratory tests confirm or strongly suggest that influenza is not the cause of the facility outbreak
        • If the cause of the outbreak is confirmed or believed to be influenza and vaccine has been administered only recently to susceptible patients and personnel, continue prophylaxis with an antiviral agent until 2 weeks after the vaccination
        • To reduce the potential for transmission of drug-resistant virus, do not allow contact between persons at high risk for complications from influenza and patients or personnel who are taking an antiviral agent for treatment of confirmed or suspected influenza during and for 2 days after the latter discontinue treatment
    • Other Measures in Acute-Care Facilities:
      • When influenza outbreaks, especially those characterized by high attack rates and severe illness, occur in the community and/or facility:
        • Curtail or eliminate elective medical and surgical admissions
        • Restrict cardiovascular and pulmonary surgery to emergency cases only
        • Restrict persons with influenza or influenza-like illness from visiting patients in the healthcare facility
        • Restrict personnel with influenza or influenza-like illness from patient care

Outpatient Dental Facilities

Special attention in dental facilities is required. Back flow prevention devices are required to prevent cross contamination when using cuspidors, high speed hand piece and air or water syringes. Back-siphonage devices are required to prevent contamination of the public water. This is regulated by the health authority or plumbing code enforcement agencies in the community (CDC, October, 2008).

Infectious and Communicable Disease Control among Healthcare Professionals

Definitions

  • Infectious disease is a clinically manifest disease of man or animal resulting from an infection.
  • Communicable disease is an illness due to a specific infectious agent which arises through transmission of that agent from an infected person, animal, or inanimate reservoir to a susceptible host.
  • Occupational Health Strategies, as applied to infection control, are a set of activities intended to assess, prevent, and control infections and communicable diseases in healthcare professionals.

Safety and health issues can best be addressed in the setting of a comprehensive prevention program that considers all aspects of the work environment and that has employee involvement as well as management commitment. Implementing the use of improved engineering controls is one component of such a comprehensive program. Prevention strategy factors that must be addressed include implementation of needleless systems if possible, modification of hazardous work practices, administrative changes to address needle hazards in the environment (e.g., prompt removal of filled sharps disposal boxes), safety education and awareness, feedback on safety improvements, and action taken on continuing problems.

Post-Exposure Evaluation and Management

Employers are required to establish exposure control plans that include post-exposure follow up for their employees and to comply with incident reporting requirements mandated by the 1992 OSHA bloodborne pathogen standard. Access to clinicians who can provide post-exposure care should be available during all working hours, including nights and weekends. HBIG, hepatitis B vaccine, and antiretroviral agents for HIV post-exposure prophylaxis (PEP) should be available for timely administration, either by providing access on site or by creating linkages with other facilities or providers to make them available off-site (OSHA, 2011).

The following are recommendation by the Centers for Disease Control (CDC, July 2003) for immediate activity after exposure.

Provide immediate care to the exposure site.

  • Wash wounds and skin with soap and water.
  • Flush mucous membranes with water.
  • Irrigate eyes with clean water, saline or sterile irrigants.

No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended.

Report the exposure to the government agency responsible for managing exposures. Reporting is necessary because PEP treatment may be recommended.

Determine risk associated with exposure by:

  • type of fluid (e.g., blood, visibly bloody fluid, other potentially infectious fluid or tissue, and concentrated virus), and
  • type of exposure (i.e., percutaneous injury, mucous membrane or non-intact skin exposure, and bites resulting in blood exposure).

Evaluate exposure source.

  • Assess the risk of infection using available information.
  • Test known sources for HBsAg, anti-HCV, and HIV antibody (consider using rapid testing).
  • For unknown sources, assess risk of exposure to HBV, HCV, or HIV infection.
  • Do not test discarded needles or syringes for virus contamination.

Evaluate the exposed person.

  • Assess immune status for HBV infection (i.e., by history of hepatitis B vaccination and vaccine response).

Risk of Infection after Exposure

Comprehensive exposure prevention strategies have played a significant role in decreasing the probable risk of infection from bloodborne pathogens. The risks of exposure with appropriate precautions are low, but they are real. Understanding how an exposure occurs and the risks of exposure is imperative for both the occupational health clinician and the healthcare professional. After an occupational exposure to a bloodborne pathogen, the risk of infection depends on a number of factors including:

  • type of body substance involved
  • route of exposure,
  • volume of blood or body fluid involved
  • severity of exposure,
  • pathogen involved
  • degree of viremia
  • the immune status of the healthcare professional at the time of the injury
  • whether appropriate PEP was used

HBV: The number of occupational infections decreased by 95% after the HBV vaccine became available in 1982 (CDC, July 2003). Healthcare professionals who have received hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection. The risk of HBV infection is primarily related to the degree of contact with blood in the workplace and also to the hepatitis B e antigen (HBeAg) status of the source person. Individuals who are both hepatitis B surface antigen (HBsAg) positive and HBeAg positive have more virus in their blood and are more likely to transmit HBV. Amongst healthcare professionals who are susceptible, the risk of infection after one percutaneous exposure is 6%-30% (CDC, July 2003).

Although percutaneous injuries are among the most efficient modes of HBV transmission, these exposures probably account for only a minority of HBV infections among healthcare professionals. In several investigations of nosocomial hepatitis B outbreaks, most infected healthcare professionals could not recall an overt percutaneous injury, although in some studies, up to one third of the infected recalled caring for a patient who was HBsAg-positive. Additionally, HBV has been demonstrated to survive in dried blood at room temperature on environmental surfaces for approximately 4 days (CDC, October 22, 2012).

HBV infections that occur in healthcare professionals with no history of non-occupational exposure or occupational percutaneous injury might have resulted from direct or indirect blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces (CDC, June 29, 2001). HBsAg is also found in several other body fluids, including breast milk, bile, cerebrospinal fluid, feces, nasopharyngeal washings, saliva, semen, sweat, and synovial fluid. However, most body fluids are not efficient vehicles of transmission because they contain low quantities of infectious HBV, despite the presence of HBsAg (CDC, June 29, 2001).

HCV is not transmitted efficiently through occupational exposures to blood. Transmission has been reported rarely, but more than half the reported cases had other risk factors (Pearlman, 2004). The risk for HCV infection after a needlestick or sharps exposure to HCV-positive blood is approximately 1.8% (range: 0%–10%) (CDC, Nov., 2008; Tomkins, et al, 2012). Transmission rarely occurs from mucous membrane exposures to blood, and no transmission in healthcare professionals has been documented from intact or non-intact skin exposures to blood.

HIV: The average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3% (Gilman, 2012). The risk after a mucous membrane exposure is approximately 0.09% (Gilman, 2012). Although episodes of HIV transmission after non-intact skin exposure have been documented, the average risk for transmission by this route has not been precisely quantified but is estimated to be less than the risk for mucous membrane exposures. The risk for transmission after exposure to fluids or tissues other than HIV-infected blood also has not been quantified but is probably considerably lower than for blood exposures (Gilman, 2012).

Post-Exposure Prophylaxis (PEP)

By calling 1-888-448-4911 from anywhere in the United States 24 hours a day, clinicians can gain access to the National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline). The PEPline has trained physicians prepared to give clinicians information, counseling and treatment recommendations for professionals who have needlestick injuries and other serious occupational exposures to blood borne microorganisms that lead to such serious infections or diseases as HIV or hepatitis.

HBV: Recommendations for HBV post-exposure management include initiation of the hepatitis B vaccine series to any susceptible, unvaccinated person who sustains an occupational blood or body fluid exposure, regardless of the source person’s hepatitis B status. Postexposure Prophylaxis (PEP) with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series should be considered for occupational exposures after evaluation of the hepatitis B surface antigen status of the source and the vaccination and vaccine response status of the exposed person (Mathieu, 2012).

Women who are pregnant or breastfeeding can be vaccinated against HBV infection and/or get HBIG. Pregnant women who are exposed to blood should be vaccinated against HBV infection, because infection during pregnancy can cause severe illness in the mother and a chronic infection in the newborn. The vaccine does not harm the fetus.

Post-exposure treatment should begin as soon as possible after exposure, preferably within 24 hours, and no later than 7 days. Hepatitis B immune globulin (HBIG) is effective in preventing HBV infection after an exposure. The decision to begin treatment is based on several factors, such as (DHHS, 2003):

  • _ whether the source individual is positive for hepatitis B surface antigen,
  • _ whether the healthcare professional has been vaccinated, and
  • _ whether the vaccine provided immunity

HCV: There is no vaccine against hepatitis C and no treatment after an exposure that will prevent infection. Immune globulin and antiviral agents like, Interferon, with or without ribavirin, are not recommended for PEP of hepatitis C.

IG is not effective for postexposure prophylaxis of HCV. Antiviral agents (e.g., interferon) are not recommended to prevent HCV infection. The mechanisms of the effect of interferon in treating HCV are not understood, and an established infection might need to be present for interferon to be effective.

Limited data indicate that antiviral therapy might be beneficial when started early in the course of HCV infection, but no guidelines exist for administration of therapy during the acute phase of infection. When HCV infection is identified early, the individual should be referred for medical management to a specialist in this area.

HIV: There is no vaccine against HIV. PEP is not recommended for all occupational exposures to HIV because most exposures do not lead to HIV infection and because the drugs used to prevent infection may have serious side effects. Based on the level of risk of HIV transmission of the exposure, a two or more drug PEP may be recommended. A three or more drug regimen may be recommended for an exposure of high risk transmission, but potential toxicity many prevent completion of the regimen, making the regimen ineffective (Gilman, 2012; Mathieu, 2012). The PEP regimen should be started immediately. The optimal duration of PEP is not known.

The majority of HIV exposures warrant a two drug regime using two nucleoside reverse transcriptase inhibitors (NRTIs), or one NRTI and one nucleotide reverse transcriptase inhibitors (NtRTIs). Because of the complexity determining PEP, consultation should be sought. The following are resources for consultation (Panlilio, et.al, 2005, pg 10):

  • PEPline at UCSF; telephone 888-448-4911;
  • HIV Antiretroviral Pregnancy Registry at ; Address: Research Park, 1011 Ashes Drive, Wilmington, NC 28405. Telephone: 800-258-4263; Fax: 800-800-1052; E-mail: registry@nc.crl.com;
  • FDA (for reporting unusual or severe toxicity to antiretroviral agents) at ; telephone: 800-332-1088; address: MedWatch, HF-2, Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857;
  • CDC (for reporting HIV infections in HCP and failures of PEP) at telephone 800-893-0485; and
  • HIV/AIDS Treatment Information Service.

All of the antiviral drugs for HIV have been associated with side effects. The most common side effects include nausea, vomiting, diarrhea, tiredness, or headache. The few serious side effects that have been reported in healthcare professionals using combination PEP have included kidney stones, hepatitis, and suppressed blood cell production. Interaction with other medicines can cause serious side effects.

Pregnancy should not rule out the use of post-exposure treatment when it is warranted. However, what is known and not known regarding the potential benefits and risks associated with the use of antiviral drugs in order to make an informed decision about treatment. The effect of antiretroviral drugs on developing fetus may be teratogenic (Gilman, 2012).

If the source individual cannot be identified or tested, decisions regarding follow-up should be based on the exposure risk and whether the source is likely to be a person who is infected with a bloodborne pathogen. Follow-up testing should be available to all professionals who are concerned about possible infection through occupational exposure.

Follow-up after Exposure

HBV: If the HBV vaccine is given, a follow up test in 1-2 months will determine the response to the vaccine. Other routine follow-up after post-exposure treatment is not recommended, because the prevention is highly effective. Symptoms suggesting hepatitis should be reported (CDC, August 16, 2012).

HCV
Postexposure follow-up of healthcare, emergency medical and public safety professionals for HCV virus (CDC, Nov., 2008):  
For the source Perform baseline testing for anti-HCV
For the person exposed to an HCV-positive source Perform baseline and follow-up testing, including baseline testing for anti-HCV and ALT activity
AND
Follow-up testing for anti-HCV (e.g., at 4–6 months) and ALT activity. If earlier diagnosis of HCV infection is desired, testing for HCV RNA may be performed at 4–6 weeks
  Supplemental anti-HCV testing to confirm all anti-HCV results reported as positive by enzyme immunoassay

“CDC's recommendations for prevention and control of HCV infection specify that persons should not be excluded from work, school, play, child care, or other settings on the basis of their HCV infection status. There is no evidence of HCV transmission from food handlers, teachers, or other service providers in the absence of blood-to-blood contact” (CDC, 2008).

HIV: Follow up counseling, postexposure testing, and medical evaluation should be done regardless of whether PEP was used (Gilman, 2012). Perform HIV-antibody testing by enzyme immunoassay should be monitored at baseline, six weeks, 12 weeks, and six months. If the exposed person becomes infected with HCV, HIV testing should be done for 12 months (Gilman, 2012). People on PEP should be monitored closely for toxicity.

Post Exposure Precautions

HBV: If the exposed healthcare professional receives post-exposure treatment, it is unlikely that infection and exposure to others will occur. No precautions are recommended (DHHS, 2003).

HCV: Because the risk of becoming infected and passing the infection on to others after an exposure to HCV is low, no precautions are recommended.

HIV: During the follow-up period, especially the first 6-12 weeks when most infected persons are expected to show signs of infection, the exposed person should follow recommendations for preventing transmission of HIV. These include not donating blood, semen, or organs and not having sexual intercourse. If the healthcare professional chooses to have sexual intercourse, using a condom consistently and correctly may reduce the risk of HIV transmission. In addition, women should consider not breastfeeding infants during the follow-up period to prevent exposing their infants to HIV in breast milk.

Conclusion

Healthcare professionals have an obligation to adhere to scientifically accepted standards for infection control and responsibility to monitor the infection control practices of subordinates. The correct incorporation of work practice controls and engineering controls help to avoid or reduce exposure to potentially infectious materials and hazards. Compliance with environmental infection control measures will decrease the risk of healthcare related infections among patients, especially the immunocompromised and healthcare professionals (Sehulster et al., 2004).

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This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Dietetic Technicians, Registered (DTR), Dietitian/Nutritionalist (RDN), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Registered Nurse (RN), Respiratory Therapist (RT)

Topics:

CPD: Practice Effectively, CPD: Preserve Safety, Infection Control/Disease, Medical Surgical, New York Requirements


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