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.
After completing this course, the learner will be able to:
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 these responsibilities 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 training during the process of renewal of hospital privileges.1, 2 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.1, 2 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 infection control practices and Standard Precautions. 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. Scientifically accepted infection control techniques include but are not limited to3:
A chain of events is required for infection to occur. These events are a causative organism, a 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:
The organism and its reservoir are the sources of infection. The organism must have a means to exit the reservoir. In an infected host, the organisms exit 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.
The following table outlines the organism, mode of transmission and incubation period for most common microorganisms and parasites.
|Disease/Condition||Organism||Mode of Transmission||Incubation Period|
|Acquired immunodeficiency syndrome (AIDS)||Human immunodeficiency virus||
HIV is passed from one person to another. The virus travels through the bloodstream to many different places in the body.
|Median of 10 years4|
|2-4 weeks occasionally longer.5|
|Chancroid||Haemophilus ducreyi||Sexual||4-7 days6|
|Cholera||Vibrio cholerae||Ingestion of water contaminated with human waste||A few hours-5 days8|
|Creutzfeldt-Jacob disease||Prion protein||Unknown in most cases||12 months to 30 years9|
|Cryptococcosis||Cryptococcus neoformans, Cryptococcus gatti||Inhalation, tissue inoculation, gastrointestinal. No person-to-person spread10||Unknown|
|Cyptosporidiosis||Cryptosporidium species||Ingestion of contaminated water
Direct contact with carrier
|2-10 days, an average of 7 days11|
Newborn:3-12 weeks after delivery12
|Diarrheal diseases||Campylobacter species||
Ingestion of contaminated food or water
Efficient transfer by healthcare professionals to patients
|Variable, in part related to the influence of antibiotics14|
|Salmonella species||Ingestion of contaminated food or drink||12-72 hours15|
|Shigella species||Ingestion of contaminated food or drink
Direct contact with carrier
Ingestion of contaminated food or drink
The risk of acquiring Giardia infection from your pet is small. However, there are some steps you can take to lower your risk.18
|Hand, foot, and mouth disease||Viruses of the Enterovirus genus||Direct contact with nose and throat secretions, and with feces of infected persons||Not known, estimates vary widely20|
|Ingestion of contaminated food or drink contaminated with infected fecal material, Direct contact with carrier
Raw or uncooked meat, contact with infected feces
|A: 2-6 weeks22
E: 2-6 weeks22
|Bloodborne hepatitis||Hepatitis B
|Blood, seman, and other body fluids, and perinatally
Blood, sexual contact, and perinatally
Only occurs in people infected with hepatitis B. Percutaneous
|B: 6 weeks to 6 months23
C: Acute infection, 6-7 weeks24
|Herpangina||Coxsackie virus||Direct contact with nose and throat secretions and with feces of infected persons||4-14 days25|
|Herpes simplex||Human herpes virus 1 and 2||Contact with mucous membrane secretions during sexual activity||2 days to 2 weeks26|
|Histoplasmosis||Histoplasma capsulatum||Inhalation of airborne spores||3-17 days27|
Contact with soil contaminated with feces
|Impetigo||Staphylococcus aureus (most common), Streptococcus pyogenes||
Contact with carrier
|Influenza||Influenza virus A, B, or C||Droplet spread||
1- 4 days31
|Legionnaires’ disease||Legionella pneumonphila||Airborne from water source||2-12 days, occasionally longer32|
|Unclear, probably 3-70 days|
|Lyme disease||Borrelia burgdorferi||
Relative sizes of several ticks at different life stages. In general, adult ticks are approximately the size of a sesame seed and nymphal ticks are approximately the size of a poppy seed.34
|Lymphogranuloma venereum||Chlamydia trachomatis||Sexual||3-30 days36|
Bite from genus Anopheles mosquito
Droplet spread and Airborne
|Meningococcal meningitis or bacteremia||Neisseria meningitidis||Contact with pharyngeal secretions, perhaps airborne||1-14 days40|
|Mononucleosis||Epstein Barr virus||
Usually by contact with oral and pharyngeal secretions, also by blood and semen during sexual contact, and contact with infected blood or organs.41
|Mycobacterial diseases (non-tuberculosis) Mycobacterium species||Mycobacterium avium
Other Mycobacterium species
|Variable: probably contact with soil, water, or other environmental sources. Not transmissible person-to-person||Variable|
pulmonary tract infections
|Mycoplasma pneumonia||Droplet inhalation||1-4 weeks42|
|Pediculosis||Pediculus humanus capitus (head louse)
Pediculus humanus corporis (body louse)
|Approximately 2 weeks43|
|Phthirus pubis (crab louse)||
|Approximately 2-3 weeks45|
Direct contact with egg-contaminated articles - Usually fecal-oral
|Pneumocystis pneumonia||Pneumocystis jiroveci||
|Pneumococcal pneumonia||Streptococcus pneumoniae||Droplet spread||Probably 1-3 days50|
Direct contact of virus-laden saliva of a rabid animal into a bite or scratch. Transmission by aerosol and organ transplantation has been reported.
|weeks to months51|
|Respiratory syncytial disease||Respiratory syncytial virus||Self-inoculation by touching mouth or nose after contact with infectious respiratory secretions||2/8 days52|
Direct and indirect contact with lesions
|Rocky Mountain Spotted fever||Rickettsia rickettsii||
|Rotavirus gastroenteritis||Rota virus||Fecal, oral||About 48 hours55|
|Rubella||Rubella virus||Droplet spread
1-4 days if there was a previous exposure, 4-6 weeks for a first-time exposure57
|Direct contact with draining lesions
Auto-infection from colonized nares
pyogenes groups A with about 80 serologically distinct types
|Large respiratory droplets
Direct contact with secretions
Ingestion of contaminated food
Variable, e.g., 2-5 days for group A strep pharyngitis58
|2-4 weeks59, 60|
|Tetanus||Clostridium tetani||Entry through broken skin||
1 day to several months, usually 3 – 21 days62
|Trichinosis||Trichinella spiralis||Ingestion of insufficiently cooked food, especially pork and beef||1-2 days63|
2-10 weeks for an immune response, weeks to years for symptoms to occur64
|Typhoid fever||Salmonella typhi||
Ingestion of contaminated food or water
Usually 8-14 days, the range is 3 days to 2 months65
The host must be susceptible to the infection for infection to occur. Factors influencing susceptibility are:
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).
All of the microorganisms that can cause disease are capable of developing resistance to antibiotics and other drugs that are used to treat infections caused by these pathogens. Antibiotic-resistant organisms have become an increasingly serious problem, and some of the more common ones are discussed.
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 is 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 do not 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 perirectal cultures, and wound cultures when appropriate; 3) strict adherence to handwashing protocol; 4) environmental cleaning; 5) patient and staff cohorting; 6) staff education, and; 7) using contact precautions.67, 68
Staphylococcus aureus is transmitted primarily via the hands of healthcare professionals and by direct contact with contaminated equipment and surfaces. Transmission is very efficient, and S 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 S aureus (MRSA, ORSA) are common causes of nosocomial infections in hospitals and extended care facilities. Methicillin- and oxacillin-resistant colonization are rarely recognized and MRSA colonization is quite common, so every patient must be assumed to have been exposed to and/or colonized with MRSA/ORSA. In addition, MRSA often contaminates medical equipment such as stethoscopes and environmental surfaces like computer keyboards. Methicillin- and oxacillin-resistant S aureus can produce toxins and invade body tissues. The only effective antibiotic for treating these infections is vancomycin. The Centers for Disease Control and Prevention (CDC) recommends strict adherence to Standard Precautions, correct and appropriate use of personal protective equipment PPE, appropriate handling of medical devices and laundry, and Contact Precautions should be used if the facility has decided that MRSA is of special clinical or epidemiological significance.69
Vancomycin intermediate S aureus (VISA) and vancomycin-resistant S 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.70 These infections must be reported to the CDC and the state department of health. Patients who are infected with VISA or VRSA should be in a single room; Contact Precautions and Standard Precautions are required; staff education is recommended; minimize the number of staff caring for the patient; and flag the chart to alert staff of the situation.70
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 if the patient is infected with vancomycin-resistant enterococcus (VRE), treatment options for these infections 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.71 Vancomycin-resistant enterococcus is transmitted primarily via the hands of healthcare professionals and by direct contact with contaminated equipment and surfaces. There have been many approaches used to control VRE in healthcare settings, and the methods used should be tailored to the clinical setting, the specific patient/patients involved, and the epidemiological characteristics of the situation. Contact precautions and Standard precautions should be used to prevent transmission of VRE.71, 72
Tuberculosis (TB) is caused by the Mycobacterium tuberculosis bacteria, and it is one of the oldest recognized infectious diseases. Multidrug-resistant tuberculosis is resistant to isoniazid, rifampin, the fluoroquinolones, 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 with prescribed drug regimens, inappropriate/incorrect prescribing, patient risk factors, and characteristics of specific TB strains. Infection control measures should include separation of the infected patient/patients, using Standard Precautions, Respiratory Hygiene/Cough Etiquette, minimal hospitalization time, proper ventilation, and staff use of particulate respirators.73, 74 Airborne Precautions are required.73
Streptococcus pneumoniae is a pathogen that is commonly found in the upper respiratory tract. Infections with this pathogen are a common cause of pneumonia, meningitis, sepsis, bacteremia, and otitis media 75 and a leading cause of morbidity and mortality.76 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 of this pathogen have begun to emerge and are widespread in some communities.75, 76 A vaccine for the most common serotypes of S pneumoniae is available but underutilized. Contact Precautions, Droplet Precautions, and Respiratory hygiene/Cough Etiquette should be used when caring for patients who are infected with this pathogen.73
Acinetobacter is a bacterium that is usually found in the soil and water, and on the skin of healthy people. People who are susceptible to infections with drug-resistant Acinetobacter are usually immunocompromised and/or have chronic lung disease or diabetes. Outbreaks of pneumonia, urinary tract infections, wound infections, and blood infections from Acinetobacter occur in areas of healthcare facilities where very sick patients are cared for like intensive care units.77-79 People on ventilators, patients who have prolonged hospital stays, patients who have had an invasive procedure (e.g., insertion of a central IV line) and patients who have open wounds are at greater risk.77-79 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.80 Contact transmission is the primary way that Acinetobacter is spread, so Contact Precautions and Standard Precautions with special attention to hand washing are integral parts of controlling and preventing these infections. 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.81
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 are likely to occur in a healthcare setting, and it 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 to injury and/or infection.73, 82, 83 Work practice controls change practices and procedures to reduce or eliminate risks.
Standard Precautions are strategies for protecting healthcare professionals from occupational transmission of organisms; Standard Precautions also prevent patient-to-patient transmission and staff-to-patient transmission. Standard Precautions assume that all pre-existing patient infections cannot be identified. The primary underpinning of Standard Precautions is that all body fluids and secretions should be considered potentially infectious, and barrier precautions should be used routinely to protect from all sources of potential infection. Standard Precautions apply to nonintact skin and mucous membranes, blood, and all body fluids, secretions, and excretions, except sweat (And in certain circumstances sweat can be considered infectious). In some cases, e.g., with certain pathogens such as HIV, some body fluids such as vomit are only considered to be a risk for disease transmission if they contain visible blood. Additional precautions are based on highly transmissible or epidemiologically important pathogens. Transmission based precautions (isolation) are Airborne, Droplet, and Contact Precautions.
Standard Precautions has six basic elements: Hand washing, the use of personal protective equipment, safe and proper disposal of contaminated material and equipment, safe injection practices, Respiratory Hygiene/Cough Etiquette practices, and the use of masks for insertion of catheters or injections into spinal or epidural spaces via lumbar puncture. The new elements of Standard Precautions that have been added since they were formulated were designed 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.73
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 about Respiratory Hygiene/Cough Etiquette protocol should be posted at entry areas. The instructions are that persons with cough, congestion, rhinorrhea, or increased respiratory secretions should84:
The effectiveness of Cough Etiquette techniques has been questioned,85 but it is still considered to be a mandatory part of infection control and its use among the lay public can be increased by education.86
Healthcare personnel should observe Droplet Precautions (These will be discussed later in the module) when caring for patients who have signs and symptoms of a respiratory infection and for whom Respiratory Hygiene/Cough Etiquette is needed. Healthcare personnel who have a respiratory infection are advised to avoid direct patient contact, especially contact with high-risk patients. If this is not possible, then a mask should be worn while providing patient care.73, 84
Needle stick and sharps injuries are a common occurrence in healthcare. The CDC estimates that 350,000 sharps injuries occur each year, and these injuries are a potential cause for transmission of, and infection with hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and more than 20 other pathogens.87 Infections with each of these pathogens are potentially life threatening but they are also preventable. Literature reviews and individual studies have shown that compared to other health care workers, nurses are especially at risk for needle stick injuries,88-90 but housekeepers, physicians, laboratory staff, and other people who work in healthcare suffer these injuries, as well.91
BD SafetyGlide™ Shielding Hypodermic Needle
Hypodermic Needle-Pro® 18G - 25G
One serious bloodborne infection can cost more than a million dollars for medications, follow up laboratory testing, clinical evaluation, lost wages, and disability payments, and the human costs after an exposure are immeasurable. Employees who have been exposed to a dangerous pathogen such as HIV may experience anger, depression, fear, anxiety,92, 93 difficulty with sexual relations, difficulty sleeping, problems concentrating, and doubts regarding their career choice. The emotional effect can be long lasting, even after a low-risk exposure that does not result in infection.94
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 needle stick and sharps injuries (e.g., the Needle Stick Prevention and Safety Act of 2000) increased awareness of and use of safe injection practices, and improved equipment have helped to decrease the number of these injuries.91, 95
A number of sources have identified the desirable characteristics of needle and sharp safety devices. These characteristics include the following96:
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:
Safe injection practice in hospitals is well established. However, needle stick and sharp injuries continue to occur, and occur frequently; they are often not reported, and; failure to use safe injection practices has led to several serious outbreaks of HBV and HCV infection.97-101 Dolan et al. write:
“More than 50 outbreaks of viral and bacterial infections occurred in the United States during the period 1998-2014 because of these unsafe medical practices. These outbreaks resulted in the transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), and bacterial pathogens to more than 700 patients. The unsafe practices used by HCP in these outbreaks can be categorized as syringe reuse between patients during parenteral medication administration to multiple patients, contamination of medication vials or intravenous (IV) bags after having been accessed with a used syringe and/or needle, failure to follow basic injection safety practices when preparing and administering parenteral medications to multiple patients, and inappropriate use and maintenance of finger stick devices and glucometer equipment used on multiple patients.101”
The following are examples of safe injection practices recommended by the CDC and other professional organizations. These apply to the use of needles, cannulas that replace needles and where applicable, intravenous delivery systems.82, 101, 102
Handwashing is one of the most effective methods for preventing patient-to-patient, patient to staff, and staff-to-patient transmission of microorganisms, and it is one the foundations of infection control.103-105
Hands should be washed, or alcohol-based rubs should be used: 1) before and after patient contact; 2) between patient contacts; 3) after gloves are removed; 4) after contact with blood, body fluids, secretions, mucous membranes, excretions, and contaminated equipment; 5) after contact with inanimate objects and medical equipment in the immediate vicinity of a patient; 6) after using the bathroom; 7) before eating; and 8) in certain situations, e.g., between tasks on the same patient to prevent cross contamination.106
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. MRSA) and reduce overall infection rates.105, 107, 108
However, despite unequivocal evidence of the effectiveness of hand hygiene and mandatory hand hygiene education, healthcare professionals’ compliance with hand hygiene protocols is often very low, at times < 30%.103, 109, 110 There are many reasons why healthcare professionals are non-compliant with hand hygiene protocols, such as perceived lack of time, perceived inconvenience, high work load, and poor staffing.103, 111 Interventions for improving compliance with hand hygiene protocol can increase compliance,112, 113 and both the CDC and the World Health Organization (WHO) have published advice and guidelines for improving hand hygiene compliance.114, 115 As part of these recommendations, the CDC is asking healthcare facilities to develop and implement a system for measuring improvements in adherence to 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.
In addition to traditional handwashing with soap and water, the CDC recommends the use of alcohol-based hand cleansers by healthcare personnel who perform patient care because they address some of the obstacles that healthcare professionals face when taking care of patients and frequently washing their hands.106 Alcohol-based hand rubs have been shown to be very effective, in most cases as effective as soap and water. They significantly reduce the number of microorganisms on skin, they are fast acting, and they cause less skin irritation than soap and water. When using an alcohol-based hand rub, apply the product to the palm of one hand and rub your hands together, covering all surfaces of the hands and fingers until the hands are dry, approximately 20 seconds.106 Note that the volume needed to reduce the number of bacteria on hands varies by product and using the appropriate volume for each specific product is crucial for effectiveness.116, 117 Allergic contact dermatitis due to alcohol hand rubs is uncommon.118 However, with increasing use of such products by healthcare personnel, it is likely that true allergic reactions to these products will occasionally be encountered. Alcohol-based hand rubs take less time to use than traditional hand washing, 20 seconds versus 40-80 seconds.119 In addition hand rub dispensers can be mounted almost anywhere, unlike a sink and a water tap.
Soap and water (not an alcohol-based hand rub) should be used when: 1) hands are visibly dirty/soiled; 2) after known exposure to C. difficile if the endemic rates are high or the healthcare facility is experiencing an outbreak; 3) after known or suspected exposure to patients with infectious diarrhea during norovirus outbreaks; 4) if exposure to Bacillus anthracis is suspected or proven, and; after using the bathroom and before eating.106 For all other situations, an alcohol-based hand rub can be used.
The use of hand hygiene does not eliminate the need for gloves. Gloves can significantly reduce hand contamination, prevent cross contamination, and protect patients and healthcare personnel from infection.120 However, improper use of gloves can greatly increase hand contamination.121 Gloves must be removed after patient contact and a new pair put on for each new patient contact, and they should be replaced if they are torn, damaged, or grossly soiled.
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 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 drying effect on hands.
Handwashing with soap and water remains a sensible strategy for hand hygiene in non-healthcare settings and its use in these situations is recommended by the CDC and other experts.
Respiratory Hygiene/Cough Etiquette should be used when a patient, staff, or visitors have signs/symptoms of a respiratory infection. This infection control technique includes: 1) covering the nose and mouth when coughing or sneezing; 2) using tissues to contain respiratory secretions and properly disposing of them; 3) washing hand after using a tissue; 4) offering a surgical mask to anyone who is coughing; and 5) turning the head and maintaining at least 3 feet of separation when coughing.73
Personal protective equipment (PPE) provides a physical barrier between the patient and the healthcare professional. Personal protective equipment includes face shields, gloves, goggles, gowns, hair covers, masks, respirators, and shoe covers. The appropriate use of PPE is an important element of Standard Precautions. The choice of what PPE to use and when to use it depends on the patient-provider interaction and the mode of transmission, e.g., blood-borne, airborne.73 In most circumstances this decision is based on the professional judgment of the healthcare personnel.
Face shields, gowns, goggles, hair covers, masks, and shoe covers should be used if there is a risk for splash contact from blood or other potentially infectious body fluids/secretions to the eyes, mouth, mucous membranes, nose, or skin. Masks and respirators are used in certain situations to protect healthcare personnel, patients, and the public.
Gloves should be used: 1) if contact is anticipated (or is possible) with blood, other potentially infectious body fluids/secretions, or mucous membranes; 2) if there will be skin contact with patients who have, or may have skin colonization with certain pathogens such as MRSA;and 3) if there will be contact with contaminated or potentially contaminated medical equipment or environmental surfaces.73 Double gloving is often used during surgical procedures, but there is no information about the protective effectiveness of this technique during routine patient care, and in those situations, single gloving is generally considered to be adequate.73 Latex, nitrile, and vinyl gloves are available. Studies have shown that vinyl gloves are more likely to fail during patient care situations,73 and latex gloves are superior in terms of bacterial passage if the glove is perforated.122
Proper use of gloves73, 123:
Masks - often called surgical masks - are single use items. Surgical masks can protect healthcare workers, their use is part of Standard Precautions, Droplet Precautions, and Respiratory Hygiene/Cough Etiquette (The last two will be explained later),73 and their use and the conditions for which they should be used are mandated by the Occupational Health and Safety Administration (OSHA).123 Masks should be used73, 123:
Paper masks are not interchangeable with respirators, and they have limits.124, 125 They are primarily intended to protect the patient and the public (in the situations described above) and to protect healthcare workers from direct contact with infectious pathogens.73, 123-126 Respirators (Discussed in the following section of the module) are used to prevent the airborne transmission of selected and specific pathogens such as M. tuberculosis.73
Standard Precautions and the OSHA Blood-borne pathogen standard dictate that face shields, goggles, or other types of eye and face protection should be used if there is a risk for eye, mucous membrane, or skin contact with blood or potentially infectious body fluids/secretions.73, 123 These devices have been shown to protect healthcare workers against the transmission of infectious pathogens.73 The choice of which type of protection to use, e.g., goggles versus face shield, is determined by the clinical situation; there are no direct comparisons of one type of eye/face protective device with others.127 Studies of their effectiveness in preventing pathogens contacting the users have produced mixed results,128 and they should never be used as a substitute for respiratory protection devices.129 Personal eyeglasses and contact lenses are not considered as adequate protective equipment and should not be used as a substitute for face shields, goggles, etc.73
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 additional protection when large quantities of blood or body fluids may be splashed. The use of isolation gowns are part of Standard Precautions and Transmission Precautions, and their use is mandated by the OSHA Bloodborne Pathogens standard.73, 123 Isolation gowns are intended “ to protect the HCW’s arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material.73” Isolation gowns (sometimes referred to as surgical gowns, procedures gowns, or protective gowns) are disposable, single-use items made of materials that prevent movement of blood and other potentially infectious body/fluids/secretions through the gown and onto the user’s skin.130
There are several types of gowns that offer differing levels of performance131; for example, a Level 1 gown is for minimal risk situations such as basic patient care, standard isolations precautions and a Level 3 gown is for moderate risk situations such as inserting an IV catheter while working in the ER.131 Isolation gowns should provide full coverage of the arms, the front of the torso, and from the neck to the middle of the thighs, and they should always be used with gloves and with other PPE, if needed.73 Evidence for the effectiveness of gowns for preventing transmission of infectious material has been described as mixed.132 Laboratory jackets or coats are not an acceptable substitute for an isolation gown.73
The proper sequence for putting on PPE is:
The proper sequence for removing PPE is:
When removing PPE, it is important only to touch areas of the PPE that are not contaminated or potentially contaminated, e.g., the front of the gown would be considered to be potentially contaminated, the ties in the back of the gown would not.
Transmission Precautions and protective environment (PE) are terms used to describe protective measures that need to be employed for specific groups of patients. These measures address the three conditions needed for transmission of an infectious pathogen: a source, a susceptible host, and a method of transmission. An older term for Transmission Precautions was isolation. Patients requiring Transmission Precautions require a private room and a negative pressure air handling system that exhausts to the outside is required for Airborne Precautions. Movement of these patients should be limited, and when transport outside the room 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 are implemented for diseases that are transmitted by microorganisms carried by airborne droplet nuclei. Droplet nuclei are tiny particle residues left when droplets evaporate, and droplet nuclei remain suspended in the air, travel comparatively long distances, and can be widely dispersed by air currents. Airborne Precautions are needed if the infectious pathogen is < 5 microns; the infectious particles are found in aerosol form, and; the infectious particles travel a specific distance and remain airborne for a time that places those exposed at risk.133 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. Most respiratory illnesses are spread by droplets, not aerosols, and the specific diseases that require Airborne Precautions are listed below.73
|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.|
Respirators are required to be worn by healthcare personnel if Airborne Precautions are in place or during certain procedures such as endotracheal intubation in which aerosols are formed.73 In some high-risk situations, a powered air purifying respirator (PAPR) may be needed.
A surgical N95 respirator is recommended if Airborne Precautions are required.73 These respirators will block at least 95% of infectious particles 3 microns or larger in size.134 The N95 is a single user, disposable item that must be fit tested to be effective. Fit testing should be done when first using an N95, and after the correct size and model have been chosen, the user should perform a user seal check each time the N95 is used.73, 134
The N95 respirator is a disposable device (it cannot be cleaned or disinfected), but the N95 is different than a simple surgical mask that is discarded after one use as the N95 can be used more than once. There are guidelines for what has been termed extended use and reuse of the N95.135 These are somewhat lengthy and complex and the reader can view them on the CDC website by using the link provided below. Fortunately, most healthcare providers do not need to be highly familiar with these guidelines or memorize them; the infection control department of each healthcare facility will, if needed, provide case-by-case instructions for N95 basic use, extended use, and reuse.
Airborne Precautions also require the use of an airborne infection isolation room (AIIR) that has specially engineered airflow and ventilation systems, e.g., a specially ventilated room with at least 12 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, and the negative air pressure should be monitored.
When the patient in airborne precautions has to be moved or transported, the patient should wear a surgical mask from the time he/she leaves the isolation room until she/he returns.
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, e.g., the influenza virus. These droplets are larger than the aerosolized infectious particles that require the use of Airborne Precautions,136 and they do not travel as far, usually 6 feet or less.137 The diseases that require the use of Droplet Precautions are listed below.73
|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|
Until antibiotic therapy has finished and two cultures taken at least 24 hours apart are negative
|Mycoplasma pneumoniae infection||Duration of illness|
Until five days after effective therapy has been started
|Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children, streptococcal pneumonia||Until 24 hours after initiation of effective therapy|
|Adenovirus infection in infants and young children||Duration of illness|
For pandemic influenza, 5 days from onset of symptoms In a healthcare setting, for 7 days after illness onset or until 24 hours after fever and respiratory symptoms have resolved, whichever is longer
|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|
Meningococcal disease, including meningitis, pneumonia, and sepsis
Until 24 hours after initiation of effective therapy.
Duration of illness
Severe acute respiratory syndrome (SARS)
Duration of the illness plus 10 days after resolution of the fever, if respiratory symptoms are absent or improving. Airborne Precautions and Contact Precautions, as well
Streptococcal diseases, major burn
Until 24 hours after initiation of effective therapy
Viral hemorrhagic fevers
Duration of illness
Until five days after initiation of effective therapy
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, and she/he should observe Respiratory Hygiene/Cough Etiquette.
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.
Disease requiring the use of Contact Precaution are listed below.73
|Infection or colonization with multidrug-resistant bacteria||Until off antibiotics and culture negative|
|Clostridium difficile enteric infection||Duration of illness|
Gastroenteritis/ multiple different organisms, eg., E.coli, Shigella, 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, respiratory, in infants or young children||Duration of illness|
|Enteroviral infection, in diapered or incontinent patient||Duration of illness|
|Scabies||Until 24 hours after initiation of effective therapy|
Until two cultures taken 24 hours apart are negative
|Herpes simplex virus infection (neonatal or mucutaneous)||
Until lesions are dry and crusted
|Impetigo||Until 24 hours after initiation of effective therapy|
|Major abscesses, cellulitis, or decubiti, or wound infections||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
Duration of illness
Duration of illness
Duration of illness
Until lesions are crusted. Airborne Precautions, as well
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. Droplet Precautions, as well
Duration of illness
Duration of illness
Respiratory infectious disease, acute, infants and young children
Duration of illness
Ritter’s disease (Staphylococcal scalded skin syndrome)
Duration of illness
Severe acute respiratory syndrome (SARS)
Duration of illness. Airborne Precautions and Droplet Precautions, as well
Until the patient is improved, the drainage has stopped, and there are three consecutive negative cultures of the drainage
If Contact Precautions are indicated, the patient should be in a private room. Standard Precautions should be used, and a gown and gloves should be worn if there is likely to be contact with the patient or environmental surfaces.
Some facilities may implement 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.138, 139 The rationale is that VRE survives in the environment for a long time and contact with any surface may lead to transmission.
Neutropenic precautions (also called protective isolation or reverse isolation) are implemented to protect immunocompromised patients. Guidelines for neutropenic precautions have been published.140 However, these are specific for certain clinical situations, and there is no standard universally accepted protocol that dictates how, when, and for whom neutropenic precautions should be used.141, 142 There are conditions and treatments, e.g., hematopoietic stem cell transplant, patients receiving chemotherapy, patients who have suffered a serious burn (A more detailed list is provided below), in which a patient is particularly at risk for infection. In these cases, special precautions should be taken, and in their 2007 Guideline for Isolation Precautions, the CDC does mention the need for, and use of a PE for immunocompromised patients. Some of the conditions of the PE include a private, well-sealed room with positive air pressure, HEPA filtered air, frequent air changes, and minimizing the amount of time the patient is outside the room.123 The exact methods used for neutropenic precautions vary depending on the reason for the precautions and the degree of the patient’s immunosuppression and level of risk.
Conditions/Diseases that may require neutropenic precautions:
Immunization is one method to reduce the transmission of communicable diseases. The following are recommendations for immunization based on age and exposure risk. Specifics and schedules for high- risk populations and catch-up immunizations are available from the CDC.
Immunization schedules for adults are available from the CDC.
Recommended immunization schedule for children and adolescents aged 18 years or younger, United States 2017
|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|
These recommendations for the immunization of healthcare personnel are from the Advisory Committee on Immunization Practices and the CDC.143
Hepatitis B - Three doses of hepatitis B vaccine, the second given 1 month after the first, the third at approximately 5 months after the second.
Influenza - Two influenza vaccines are available, live attenuated influenza vaccine (LAIV) which is given intranasally and trivalent inactivated influenza vaccine (TIV), which is given as an intramuscular injection. Live attenuated influenza vaccine is licensed for use in healthy nonpregnant persons aged 2--49 years. The TIV can be given to anyone ≥6 months of age. Live attenuated influenza vaccine can be used for healthcare personnel except anyone who is caring for patients who are severely immunocompromised and require a PE. If the healthcare worker has a pre-existing condition that confers high risk for influenza complications, is pregnant, or is ≥50 years of age, that person should not receive LAIV; use TIV.
Meningococcal – A 2-dose meningococcal vaccine series is recommended for: 1) healthcare personnel who have asplenia or persistent complement component deficiencies; 2) healthcare personnel traveling to countries in which meningococcal disease is hyperendemic or epidemic and who have asplenia or persistent complement component deficiencies; these people should receive a 2-dose vaccine series. Other healthcare personnel traveling to high-risk area should be given a single dose of meningococcal conjugate vaccine quadrivalent (MCV4) before travel if they have never received it or if they received it >5 years previously. Clinical microbiologists and research microbiologists who might be exposed routinely to isolates of N. meningitides should receive a single dose of MCV4 and receive a booster dose every 5 years if they remain at increased risk. Health-care personnel aged >55 years who have any of the above risk factors for meningococcal disease should be vaccinated with MPSV4, i.e., meningococcal quadrivalent polysaccharide vaccine.
MMR – Vaccination with mumps, measles and rubella (MMR) vaccine, two doses, 4 weeks apart if the healthcare worker was born later than 1957 or if there is no serologic evidence of immunity.
Poliomyelitis - Vaccination against poliovirus is recommended for healthcare personnel who have a high risk of exposure, laboratory personnel who work with the virus, clinicians who have close contact with patients who might be excreting wild polioviruses, and healthcare personnel who are traveling to an area where the virus is endemic. Unvaccinated individuals should be given 3 doses of polio vaccine, dose 2 to be given 4-8 weeks after the first, dose 3 at 6-12 months after the second dose. Previously vaccinated individuals can receive a booster dose.
Tetanus, diphtheria, pertussis – Tdap once if never vaccinated, and a Td booster every 10 years.
Typhoid - Microbiologists and anyone who frequently works with S typhi should be vaccinated and booster vaccinations given as indicated.
Varicella – Healthcare personnel who have no evidence of immunity to varicella should be given 2 doses of varicella vaccine, 4-8 weeks apart.
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.144
Infection control strategies include: 1) education of the staff; 2) policies and procedures for cleaning, disinfection, and sterilization, and; 3) engineering and environmental controls. General principles of engineering and environmental controls will be discussed; more information will be provided as specific clinical situations are covered.
Basic education has been briefly discussed in previous sections of the module, and its application to other parts of the infection control process will be covered below. Both the CDC and OSHA recommend that the healthcare facility/employer must inform the staff of potential risks for exposure to infectious materials and provide them with the education and equipment they need to prevent contamination of medical equipment and the environment; to protect themselves against contamination and infection; and to protect patients against contamination and infections.
Cleaning, disinfection, and sterilization are essential for infection control and maintaining a safe environment. These processes can be used singly or in combination, they are done using different tools and techniques, and they produce different results. In simple terms, sterilization is intended to kill all microorganisms, disinfection will kill/remove the majority of microorganisms, and cleaning will physically remove surface contamination and debris.
General Principles of Cleaning, Disinfection, and Sterilization145
Cleaning and Disinfecting
Cleaning is the process of removing visible contamination and surface contamination from an object and can be completed mechanically or with cleaners. Cleaning can also help disinfect but the two processes are not the same, and cleaning is not intended to kill bacteria or other microorganisms. Disinfection is the process of destroying pathogenic organisms; disinfection cannot and does not destroy all organisms.
The following information is from the CDC Guideline for Sterilization and Disinfection in Healthcare facilities.145
Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities145
Indications for Sterilization, High-Level Disinfection, and Low-Level Disinfection
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).146 Provide, at a minimum, high-level disinfection for semi-critical patient-care equipment (e.g., gastrointestinal endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment) that touches either mucous membranes or nonintact skin.145, 146
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.146
Selection and Use of Low-Level Disinfectants for Non-critical Patient-Care Devices 145
Do not perform disinfectant fogging for routine purposes in patient-care areas.
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), Selected EPA-Registered Disinfectants (EPA) (703) 308-6411, on-line link https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants, or email: email@example.com.
High-Level Disinfection of Endoscopes
Endoscopes are fragile, expensive, difficult to clean, much used, and susceptible to contamination.145 There are millions of endoscopic procedures done each year and iatrogenic infections caused by contamination of endoscopes are rare.145, 146 However, endoscopes have been linked to more infectious outbreaks than any other reusable medical device146 and failure to properly clean and disinfect endoscopes is a primary reason why these outbreaks happen.145 In addition, studies have shown that even cleaned and processed endoscopes are often contaminated.148-150
The recommendations for the disinfection and sterilization of endoscopes listed below are from the CDC.145, 151 The American Society for Gastrointestinal Endoscopy has also published guidelines for cleaning endoscopes; there are also multi- medical society and the Society of Gastroenterology Nurses guidelines for this procedure, as well.152-154
Disinfection Strategies for Other Semi-Critical Devices
Other medical devices aside from endoscopes that contact mucous membranes and are considered to be semi-critical include (but are not limited to) rectal and vaginal probes, flexible cystoscopes, tonometers, and ultrasound probes used for various procedures. The risk of contracting an infectious disease from one of these devices is very small but not impossible,155 and contamination with microorganisms such as cytomegalovirus, human papilloma virus, hepatitis C, herpes simplex, Klebsiella, and Pseudomonas have been found on these devices, even after cleaning and disinfection.156-160
Disinfection strategies vary widely for these semi-critical items devices, and the FDA requests the manufacturers to provide at least one validated cleaning and disinfection/sterilization protocol in the labeling for their devices. 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.
Steam is the preferred method for sterilizing critical medical and surgical instruments that are not damaged by heat, steam, pressure, or moisture.
Monitoring of Sterilizers145
|Indicator tapes provide a seal for sterilization packs and an immediate identification of processed items. Dispensers are available in all sizes|
|Internal CI's should be used within each pouch or package, tray , or container. Class 5 integrators should be used in conjunction with physical monitoring and biological indicator testing for verifying the efficacy a sterilization system. (See AAMI ST79:2006)|
Storage of Sterile Items145
Flash sterilization (immediate-use steam sterilization, IUSS) was traditionally used for items that were needed immediately, but a traditionally sterilized one was 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 Association of Perioperative Registered Nurses (AORN), and others that flash sterilization has become overused and can cause adverse events.161-163 The CDC and the Joint Commission have guidelines for the proper use of immediate use steam sterilization145, 164 and these guidelines are supported by the AORN.165
These guidelines for flash sterilization are from the CDC.145
The Joint Commission recommendations for immediate use of steam sterilization164:
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.166
Exceptional circumstances that require non-critical items to be either dedicated to one patient or patient cohort or subjected to low-level disinfection between patient uses are those involving73, 167, 168:
Disinfectants can be a source of microbial contamination,169-172 and hospital-acquired infections caused by contaminated disinfectants have been documented.169-172
These measures should be used to reduce the occurrence of contaminated disinfectants145:
The home environment should be as safe as 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.
Construction activities in or near healthcare facilities cause increase disease risks for airborne and waterborne disease, and infections caused by construction activity have been well documented.173, 174 The increasing age of healthcare facilities is generating the ongoing need for repair and remediation work that can introduce or increase contamination of the air and water in patient-care environments. The CDC has further recommendations for construction activity in healthcare facilities that should be reviewed if applicable.175
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; e) direct air flow; f) manage outside air; g) provide reliable filtration, and; h) minimize the risk of transmission of airborne pathogens.175, 176 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 in healthcare facilities that should be reviewed if applicable.175
Dentists and dental office personnel are exposed to blood, body fluids, and aerosols, and the exposure can be by direct contact, indirect contact, or inhalation. Transmission of infectious agents from staff to patient or patient to staff is rare in dental settings, but it has occurred.177, 178 The mode of transmission in these cases has not always been established, but poor compliance with infection control practices has been reported and is the likely cause.177
Infection control in dental settings is in many ways identical to infection control in other healthcare settings, and the basic principles outlined here should be observed.145, 177-179
Administrative measures: A written infection control and infection prevention policy must be in place. Important aspects of this include having at least one person who is responsible for coordinating/overseeing the policy, and a plan for handling exposures.
Infection control and infection prevention training: Training/education in infection control and infection prevention must completed during the hiring period; annually; when employees are learning or performing new procedures; and according to local, state, and federal regulations.
Dental personnel safety: This would include (but is not limited to) proper immunizations, OSHA-approved training in the OSHA Bloodborne Pathogens standard, having knowledge of the proper post-exposure protocol, and rules/policies for dental personnel and patients who have a potentially infectious illness. This last point includes specific recommendations regarding the influenza virus.179
Program evaluation: There must be a policy in place for the evaluation of the infection control and infection prevention program.
Hand hygiene: Training in hand hygiene must be provided, and hand hygiene supplies must be available.
PPE: Training in the proper use of PPE should be provided, and PPE supplies must be available.
Respiratory Hygiene/Cough Etiquette: Training in Respiratory Hygiene/Cough Etiquette must be provided and supplies needed for observance of this infection control technique must be available.
Sharps safety and Safe Injection Practices: Personnel must be trained in sharps safety and Safe Injection Practices, and they must be provided the equipment needed to practice these infection control techniques.
Sterilization and disinfection: Policies and procedure for sterilization and disinfection must be in place and easily accessed, dental staff must be trained in these policies and procedures, and the appropriate equipment necessary for sterilization and disinfection must be available. Dental equipment, like medical equipment, should be divided into critical, semi-critic, and non-critical, and these classifications should be used as a guideline for choosing sterilization and disinfection techniques. Specific recommendations for dental setting sterilization and disinfection include145,177:
Environmental infection control and prevention144, 177, 178: Surfaces that are likely to be contaminated and with which patients or staff may have contact should be regularly cleaned or cleaned as needed using the proper disinfectant. Ordinary surfaces (e.g., walls) can be cleaned with soap and water; high-level disinfectants are not recommended for these surfaces as they can be corrosive and damaging. Spills of contaminated/potentially contaminated material should be correctly and promptly cleaned, and PPE should be used as needed during the cleanup.
Dental unit water quality: Water lines that are used for dental procedures can develop biofilm and growth of bacteria.177, 178 Most of the microorganisms that are typically found in dental unit water lines have limited pathogenic potential, but Legionella species, Pseudomonas aeruginosa, and non-tuberculous Mycobacterium have been found in these water systems. Dental units must have a water filtration system that allows for ≤ 500 colony-forming units (CFU) per mL of heterotrophic water bacteria. (Note: A heterotrophic organism requires carbon and nitrogen for its metabolic activity). If dental equipment is permanently attached to air and water lines, waterproof barriers must be used and changed after each use. Other equipment that uses water must be properly used, e.g., a patient should not close her/his lips tightly around a saliva ejector as this may reverse the flow, causing material from a previous patient to aspirate.
Hospital-acquired pneumonia is a significant cause of morbidity and mortality. This section will discuss risk factors for hospital-acquired pneumonia and methods/techniques for preventing hospital-acquired pneumonia (which is sometimes referred to as healthcare-associated pneumonia) in patients who are mechanically ventilated and those who are not.
The most important risk factor for hospital-acquired pneumonia is mechanical ventilation. Other risk factors include180:
Preventing Hospital-Acquired Pneumonia
For mechanically ventilated patients, measures that can prevent hospital- acquired pneumonia include avoiding intubation when possible, elevating the head of the bed, oral hygiene with an antiseptic, maintaining physical conditioning, minimizing the use of sedation, minimizing pooling of secretions above the endotracheal tube, proper maintenance of ventilator circuit, and staff education.180
There has been comparatively little research on the prevention of hospital acquired pneumonia in the non-ventilated patient, but proper positioning, early identification and treatment of dysphagia, good oral hygiene, using an antiseptic mouth rinse, and conscientious use of Standard Precautions and infection control techniques may be helpful.181
The following are the CDC and the American Thoracic Society recommendations for the prevention of hospital-acquired pneumonia.182, 183 Recommendations from the Institute for Healthcare Improvement are included, as well.184
Staff education: Staff knowledge of the risks of hospital-acquired pneumonia and their knowledge of, and compliance with prevention techniques are critical for reducing the incidence and severity of this disease.
Conduct surveillance in ICU patients: Do not routinely perform surveillance cultures of patient, equipment or devices
Sterilization and Disinfection:
Tracheostomy Care and Suctioning
Good tracheostomy care reduces morbidity, and it also reduces the amount of time to decannulation.185, 186 Principles of good tracheostomy care include:
Suctioning of respiratory tract secretions: Suctioning is an essential part of care for certain patients who are mechanically ventilated or have a tracheostomy, but it places them at risk for infection and hospital-acquired pneumonia. The following advice and recommendations can help prevent these complications.
Modifying Host Risk for Infection and Hospital-Acquired Pneumonia: Vaccination
Vaccination is an important part of protecting patients against hospital-acquired pneumonia and pneumonia. Patients at risk who should be given pneumococcal vaccination include191-195:
No recommendation can be made for the routine administration of preparations of granulocyte colony stimulating factor (GCSF) medications 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.196
Aspiration is a significant risk factor for hospital-acquired pneumonia and pneumonia. Measures that can prevent and decrease the risk for aspiration include180,181,197-199:
Prevention of aspiration associated with enteral feeding199-202:
Prevention or modulation of oropharyngeal colonization
Bacteria are present in the oral cavity, both normal flora and bacteria that are transmitted to the patient during hospitalization. Aerobic and facultatively anaerobic 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.203
Patients who are mechanically ventilated have an increase in oral biofilm, xerostomia, colonization of the oral cavity by pathogens, and no ability to self-clean, all of which increase the risk for ventilator-associated pneumonia.204
Oropharyngeal cleaning and decontamination with an antiseptic agent can help reduce the number of these pathogens and reduce the incidence of hospital-acquired pneumonia and ventilator-acquired pneumonia.203-207
Chlorhexidine is the most commonly used and studied oral antiseptic for the prevention of oral decolonization and prevention of hospital-acquired pneumonia, but it is not clear which antiseptic agent is the most effective, and the optimal oral hygiene protocol has not been determined.204, 208
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
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.209
Use an oral chlorhexidine gluconate (0.12%) rinse during the perioperative period in adult patients who had cardiovascular surgery was shown to reduce the incidence of ventilator-associated pneumonia.210
Prevention of gastric colonization
Mechanical ventilation for > 48 hours is considered a risk factor for stress ulcer and gastrointestinal bleeding,211 and stress ulcer prophylaxis is recommended for these patients.210
Oral proton pump inhibitors, oral or IV, are the drug of choice.211 Antacids, histamine-2 receptor blockers, and sucralfate can also be used.210 Evidence comparing the proton pump inhibitor, antacids, histamine-2 receptor blockers, and sucralfate in terms of efficacy and safety appear to favor the proton pump inhibitors, but studies are few and limited in scope.
There is evidence that stress ulcer prophylaxis decreases the incidence of stress ulcers and bleeding but that it increases the risk for nosocomial pneumonia.211 However, experts feel that this risk is preferable to the development of stress ulcer and bleeding and that the studies that have associated stress ulcer prophylaxis with nosocomial pneumonia had methodologic flaws and were poorly controlled for co-morbidities.211
Enteral nutrition may have a protective effect against stress ulcer. But unless it is contraindicated, patients who are receiving enteral nutrition and need stress ulcer prophylaxis should be treated with a proton pump inhibitor or another protective drug.211
Prevention of postoperative pneumonia
Patients who are at-risk for developing post-operative pneumonia include212:
Interventions for preventing post-operative pneumonia include213, 214:
Other prophylactic procedures for prevention of hospital-acquired pneumonia/pneumonia
Antimicrobials are not recommended for preventing pneumonia in critically ill patients or in patients who are mechanically ventilated.215
Selective decontamination of the digestive tract with antiseptics or antibiotics applied to the oropharynx has been shown to reduce the incidence of ventilator-associated pneumonia and hospital-associated pneumonia.180
There is insufficient evidence to recommend glucocorticoids, pro-biotics, or silver-coated endotracheal tubes as effective prophylactic measures.180
Routine turning of the patient or the use of automatically turning beds is not routinely recommended.181
Warm, stagnant water between 50°-122°F allows for the multiplication of Legionella pneumophila, and the organism grows in structures such as evaporative coolers, faucets, misters, showers, water heaters, and whirlpool baths.216
Legionella pneumophilia is aspirated, or the aerosolized bacteria is inhaled into the lungs. One case of person-to-person transmission has been reported, but Legionnaires’ disease is not generally considered to be a contagious disease.216 Standard Precautions are considered to be sufficient infection control technique when caring for a patient who has Legionnaires’ disease.73
Factors that increase the risk of developing Legionnaires’ disease include216-218:
Testing for Legionnaires’ disease should be done if219,220:
The Legionella bacteria grow in water systems, and there are multiple guidelines at the national, state, and local level for detecting, controlling and preventing Legionnaire’s disease in these systems.221 However, it is interesting to note that some authors feel that routine testing of water is not helpful and that efforts should focus on control and prevention.222 National guidelines for control and prevention of Legionnaire’s disease in healthcare facilities are available from the CDC,182 and some aspects of those guidelines are presented below.
Clinical laboratory testing: Periodically review the availability and clinicians’ use of laboratory diagnostic tests for Legionnaires disease. If clinicians do not routinely use the tests on patients with diagnosed or suspected pneumonia, implement measures to enhance clinicians’ use of the tests.
Water cultures: 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
Transplant units: 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.
Maintain a high index of suspicion for Legionellosis in transplant patients with healthcare-associated pneumonia even when environmental surveillance cultures do not yield Legionellae.
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
Transplant units/positive cultures: If Legionellae are detected in the potable water supply of a transplant unit, and until Legionellae are no longer detected by culture:
Healthcare facilities that do not house and/or treat severely immunocompromised patients (e.g., hematopoietic stem cell transplant or solid-organ transplant recipients):
Engineering/construction concerns: 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.
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.
Review of Disease Transmission, the Required Precautions, and Infection Control Techniques
Pertussis is transmitted by infected respiratory secretions that become airborne when someone coughs or sneezes. It is typically a mild, self-limiting disease but serious complications are possible. The incidence of pertussis had declined for many years but more and more cases are being reported each year, and given the fact that effective vaccination is available, this is a very unfortunate and preventable public health development.
Pertussis is a reportable disease, and the local and/or state health department should be notified about 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. A close contact is considered to be182, 223:
Preventing Pertussis Transmission/Vaccination
Droplet Precautions, Respiratory Hygiene/Cough Etiquette, and Standard Precautions should be used when caring for a patient who has pertussis.73 Droplet Precautions should be used for up to 5 days after initiation of effective therapy.73
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 when entering the room of a patient with confirmed or suspected pertussis.182
A single room is preferable, but cohorting is an option if needed.73
Patients with confirmed pertussis should be 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.182
Limit the movement and transport of a patient with diagnosed or suspected pertussis to essential purposes only. If a patient is transported out of the room, ensure that precautions are maintained.
Restrict symptomatic pertussis-infected healthcare professionals from work during the first 5 days of after beginning antimicrobial prophylaxis.182
For symptomatic healthcare personnel, do diagnostic laboratory tests if they have signs/symptoms that are suggestive of pertussis (i.e., unexplained cough illness of >1 week duration, paroxysmal cough).182
The following are the current recommendations for pertussis vaccination182, 224-226:
In LTCFs for children and children with prolonged stay in acute-care facilities, follow the recommendations of the ACIP for vaccinating children according to their chronologic age.
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:
The primary objective of post-exposure antimicrobial prophylaxis (PEP) is to protect at-risk individuals from death and serious complications from pertussis.227 The CDC’s recommendation for PEP for pertussis are73, 227:
Post-exposure prophylaxis should be offered to close contacts and to healthcare workers who have had prolonged exposure to respiratory secretions.73
Symptomatic healthcare personnel who are proven to have pertussis or personnel who are highly suspected of having pertussis should be given chemoprophylaxis.182
Restrict symptomatic pertussis-infected healthcare professionals from work during the first 5 days of after beginning antimicrobial prophylaxis.182
Review the process of disease transmission and infection control techniques.
Maintain a high index of suspicion for healthcare-associated pulmonary aspergillosis in severely immunocompromised patients. Establish a surveillance system for cases of healthcare-associated pulmonary aspergillosis. Promptly inform infection-control personnel Aspergillus sp. is isolated from cultures of specimens from patient’s respiratory tract. Periodically review the hospital's microbiologic, histopathologic, and postmortem data.
Do not perform routine, periodic cultures of the nasopharynx of asymptomatic patients at high-risk for aspergillosis.p;
Do not perform routine, periodic cultures of equipment or devices used for respiratory therapy, pulmonary function testing, or delivery of inhalation anesthesia in the hematopoietic stem cell transplant unit or of dust in rooms of hematopoietic stem cell transplant 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.
Prevention of Transmission of Aspergillus Spores
Aspergillus is a fungus, and Aspergillus spores are very common in the environment. Aspergillus is not a contagious disease, and aspergillosis is primarily a disease contracted by people who have a compromised immune system or chronic lung disease.Standard Precautions are considered sufficient when caring a patient who has an infection with Aspergillus.73 Use Contact Precautions and Airborne Precautions if there is a massive soft tissue infection with copious drainage and repeated irrigations are needed.73
There are numerous methods of preventing transmission of Aspergillus. The following recommendations are from the CDC and the Infectious Disease Society of America181, 228:
Construction is a well-known and well-documented risk factor for the development of aspergillosis,229-232 construction activity is a serious threat to patients who are immunocompromised, and preventive measures during construction are essential. When constructing specialized-care units with a PE for hematopoietic stem cell transplant, the patient rooms must be designed to minimize accumulation of fungal spores: 1) HEPA filtration of incoming air is recommended. 2) there must be directed room airflow, 3) there must be positive air pressure in patient's room in relation to the corridor, 4) the room must be well-sealed, and 5) there should be >12 air changes per hour.181
Other recommendations include229-231:
Patients who have prolonged neutropenia and who are at high risk for invasive aspergillosis should be given prophylactic treatment with one of these antifungal drugs: posaconazole, voriconazole, and/or micafungin.228
Adenovirus, parainfluenza virus, and respiratory syncytial virus (RSV) are common causes of self-limited respiratory infections in infants and children,233 and they can also cause diarrhea, keratoconjunctivitis, and pneumonia. In adolescents and adults, infections with these viruses are typically less severe than in infants and children.233 However, patients who are elderly, immunocompromised, those who have cardiopulmonary disease, or who have had hematopoietic stem cell transplants, and solid-organ transplant recipients may develop severe illnesses when infected,233, 234 and the respiratory syncytial virus is a very common nosocomial pathogen that can infect up to 50% of patients and staff.233
Prevention of Transmission and Infection Control
Staff knowledge and use of infection control techniques for the prevention of influenza transmission are very important.240 However, there is ample evidence that for nurses knowledge of and perhaps more importantly, compliance with these techniques is less than ideal.240-243 The CDC includes staff education in its recommendations for preventing seasonal influenza in healthcare settings,244 and staff education on this topic can make a positive difference.242
Healthcare facilities should have mechanisms in place to which healthcare personnel can be promptly notified about increased influenza activity in the community or if there is an in-house influenza outbreak.244 There should be a member of the staff who is specifically assigned for communicating with public health officials and the health care personnel.
Ensure that laboratory tests are made available to clinicians for prompt diagnosis of influenza.
Vaccination is one of the most effective methods for preventing transmission of influenza.241, 244
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 influenza 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 include244, 245:
Influenza vaccination is also recommended for244, 245:
Vaccination should be offered before influenza activity in the community begins. Health care personnel should be offered vaccination by the end of October, if possible. Children aged 6 months through 8 years who require 2 doses should be given the first dose as soon as possible after vaccine becomes available, and the second dose ≥4 weeks later.245
In LCTFs, establish an SOP for timely administration of the inactivated influenza vaccine to high-risk persons.182, 245
In other settings where healthcare is given (e.g., home healthcare agencies), vaccinate patients for whom vaccination is indicated, and refer patient’s household members and care givers for vaccination.182
Preventing Person-to-Person Transmission
Preventing person-to-person transmission of influenza involves educating the public and the staff, identifying members of the public and patients who are likely to have influenza, and observing the proper infection control techniques.244 For the public and patients244:
For healthcare personnel244:
Infection control techniques are vitally important in preventing person-to-person transmission of influenza. In order to prevent the spread/transmission of influenza, healthcare personnel should strictly adhere to Standard Precautions, handwashing protocol, Respiratory Hygiene/Cough Etiquette, Droplet Precautions, and the proper use of PPE.244 Don a face mask when entering the room. Droplet precautions should be used if the patient has suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility.244If a patient under Droplet Precautions requires movement or transport outside of the room, have the patient wear a face mask, if possible; use Respiratory Hygiene/Cough Etiquette; and hand hygiene. Be sure that the personnel who will be caring for/receiving these patients are aware of the clinical situation.244
Use caution when performing aerosol-generating procedures
Precautions for aerosol-generating procedures include performing these procedures only if they are medically necessary and cannot be postponed, limiting the number of personnel present,performing the procedures in an airborne infection isolation room if feasible, room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized; healthcare personnel should wear respiratory protection equivalent to a fitted N95 filtering facepiece respirator or equivalent N95 respirator and perform surface cleaning after the procedures.244
Perform environmental infection control
Environmental infection control includes cleaning and disinfection and engineering controls, e.g., air filtration systems, physical barriers.244
Control of Influenza Outbreaks – Vaccination and Chemoprophylaxis
Determine the outbreak strain. Vaccinate unvaccinated patients and healthcare personnel.
Early antiviral treatment is recognized as a safe and effective therapy that can shorten the duration of the illness and prevent complications.246Chemoprophylaxis should be given as soon as possible, and it is not advisable to wait for laboratory confirmation.246
At-risk patients who should receive prophylactic antiviral therapy include246:
Antiviral treatment is also recommended as early as possible for any patient with confirmed or suspected influenza who is hospitalized, a patient who has a severe, complicated, or progressive illness, or one who has a high risk for complications from influenza.246 The available antivirals are amantadine, oseltamivir, peramivir, rimantadine, and zanamivir and depending on the drug, oral, inhaled, and IV forms are available. The specific drug that should be used depends on the age of the patient, the clinical setting, and the strain of influenza.244 The CDC has published guidelines that can help clinicians make the proper choice of antivirals: Influenza (Flu). Influenza Antiviral Medications: Summary for Clinician, March 8, 2017; these can be viewed by using these links: the second link pertains to LTCFs.
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 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.
Occupational Exposure to Infectious Pathogens: Hepatitis B, Hepatitis C, HIV
Healthcare personnel who perform patient care are at risk for exposure to potentially dangerous pathogens, and the most common of these are hepatitis B (HBV), hepatitis C (HCV), and HIV. Fortunately, transmission of one of these highly virulent microorganisms from patient to provider and the development of an infection are rare occurrences. However, occupational exposures to pathogens such as HBV, HCV, and HIV are a common everyday experience in healthcare facilities and during patient care, and nurses and other healthcare professionals must understand the risks of exposure and how to protect themselves.
Hepatitis B, HCV, and HIV are (in the healthcare setting) primarily transmitted by exposure to contaminated blood, and this can occur by a percutaneous injury, i.e., a needle stick or a sharps exposure, or by contact with a mucous membrane or non-intact skin. The risk that a healthcare professional will acquire HBV, HCV, or HIV and develop an infection because of an occupational exposure depends on these factors248, 249:
Blood is the most important source of HBV, HCV, and HIV transmission to healthcare professionals. Other body fluids, such as cerebrospinal fluid, synovial fluid, pericardial fluid, pleural fluid, peritoneal fluid, and amniotic fluid are considered potentially infectious.248-250 Semen and vaginal secretions can be a source of sexual transmission of these viruses, but there are no documented cases of transmission of HBV, HCV, or HIV in the occupational setting from exposure to semen or vaginal secretions.250 Other body fluids, e.g., feces, gastric secretions, nasal secretions, saliva, sputum, sweat, tears, and urine may contain low amounts of HBV, HCV, and HIV but unless these fluids are visibly contaminated with blood, they are not considered infectious.248-250
An occupational exposure to HBV, HCV, or HIV is defined by Weber et al. as “contact with potentially infectious blood, tissue, or body fluids in a manner that allows for possible transmission of HIV and therefore requires consideration of post-exposure prophylaxis (PEP).” Exposure then would include needle stick or sharps injuries, puncture wounds, mucosal contact, or exposure of the non-intact skin, i.e., skin that is abraded.
Risk of Occupational Transmission/ Infection of HBV, HCV, and HIV
In descending order, the risk of transmission and development of infection after an occupational exposure is: HBV, HIV, and HCV.
Hepatitis B is highly infectious. The risk for transmission depends on the HBV surface antigen and HBV e antigen status of the source (and the previously mentioned factors), and this risk has been estimated to be 18%-62%.248, 251 The risk of developing hepatitis from an occupational exposure to HBV has been estimated to be from 1%-31%.248
Hepatitis C is less infectious than HBV. The CDC has estimated that the risk for seroconversion after an occupational exposure to HCV is 1.8%, with a range of 0-7%.252 However, Egro et al.(2017) noted that the data used by the CDC to develop these numbers was from old sources, some of it was from non-US medical centers where universal precautions are not used as they should be, and that only needle stick injuries were assessed.253 These authors examined 1361 exposures over a 13 year period (mucous membrane exposures and percutaneous exposures) and found a seroconversion rate of 0.1%; the two cases of seroconversion happened after percutaneous exposure.253
Transmission of HIV from a patient to a healthcare professional is uncommon. The risk of seroconversion has been estimated to be 0.3% for percutaneous exposure and 0.09% per mucous membrane exposure254 but as with risk estimations for HCV, these estimates have been criticized as possibly being too high and based on conditions that don’t reflect current exposure circumstances and the availability and effectiveness of post-exposure prophylaxis.255 Fortunately, confirmed cases of occupational transmission of HIV and subsequent HIV infection are rare, with 58 cases reported to the CDC between 1985 and 2013.249
By calling 1-888-448-4911 from anywhere in the United States from 9:00 am to 9:00 pm, seven days a week, 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 needle stick injuries and other serious occupational exposures to blood borne microorganisms that lead to such serious infections or diseases as HIV or hepatitis.
Other helpful resources are:
HIV Antiretroviral Pregnancy Registry. Address: Research Park, 1011 Ashes Drive, Wilmington, NC 28405. Telephone: 800-258-4263; fax: 800-800-1052. Email: firstname.lastname@example.org.
FDA (for reporting unusual or severe toxicity to antiretroviral agents) at http://www.fda.gov/medwatch. Address: U.S. Food and Drug Administration, 10903 New Hampshire Avenue Silver Spring, MD 20993. Telephone: 800-332-1088.
U.S. Department of Health and Human Services. AIDS Info. Address: AIDSinfo, P.O. Box 4780, Rockville, MD 20849-6303. Telephone: 1-800-4448-0440; fax, 1-302-315-2818; TTY, 1-888-480-3739. Email: ContactUs@aidsinfo.nih.gov
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. Hepatitis B immune globulin, HBV 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.
Healthcare professionals should be well versed in the use of Standard Precautions and use them conscientiously. Anyone who may be exposed to blood or body fluids should be offered hepatitis B vaccination at no charge. There are no vaccines for the prevention of HCV of HIV infection.
Sepsis is a potentially fatal condition of organ dysfunction that is primarily caused by a dysfunctional inflammatory response to an infection.258, 259 Sepsis can be usefully viewed as a continuum, and the definitions and conditions associated with sepsis have evolved. Sepsis is now defined as life-threatening organ dysfunction caused a dysregulated host response to infection259; septic shock is defined as a subset of sepsis characterized by circulatory, cellular, and metabolic dysfunction that is associated with a high risk of mortality.259 The definition of septic shock is consistent with the basic definition of shock: a condition of cellular and tissue hypoxia that is caused by reduced oxygen delivery, increased oxygen consumption, or inadequate utilization of delivered oxygen. Shock, regardless of its origin, essentially represents a mismatch between demand and supply of oxygen to the tissues.
The clinical view of sepsis has changed over time, and terms such as systemic inflammatory response syndrome (SIRS), early sepsis, severe sepsis, and septicemia are no longer included in the definition of sepsis.
The pathogenesis of sepsis is very complex and full discussion of the process will not be included here. In brief, sepsis begins with infection, and infection is defined an invasion and multiplication of microorganisms; it is important to remember that infection is not synonymous with harm or damage, it simply indicates the presence of a microorganism. The normal response to infection is to destroy and/or contain the microorganisms by way of the immune response, e.g., the activity of macrophages and by the activation and production of inflammatory mediators that direct and control the immune response. In sepsis, however, the inflammatory response is both exaggerated and generalized and healthy tissue and organs - and not only those of the initial location of the infection - become damaged and dysfunctional.260
The diagnosis of sepsis depends on the presence of a pathogen, a clear source/site of infection and for septic shock, a clinical picture of organ dysfunction. Patients who have sepsis typically present with signs and symptoms that are consistent with the source of the infection (e.g., cough, hypoxia, and respiratory distress with a pulmonary infection); fever, hypotension, and tachycardia, and; evidence of hypoperfusion such as mental status changes, cyanosis, and decreased urinary output.258 The mortality rate of sepsis is variable and depend on many factors like age, the presence of medical co-morbidities, and if sepsis progresses to septic shock, but it has been estimated to be 10%-52%.258
Sepsis is a very serious public health problem. It has been estimated that globally there are 30 million cases of sepsis each year and sepsis is responsible for 6 million deaths every year261, and the problem of sepsis is no less serious in the United States. Rhee et al. performed a retrospective review of adult patients admitted to 409 hospitals in the period of 209-2014.262 The authors located 173,690 cases of sepsis; this was an incidence of 6% of all hospitalizations, 15% of these patients died while in the hospital, and sepsis was present in 35% of all hospitalizations that ended in death.262 Sepsis is not only a potentially deadly condition, but there is some evidence that suggests that in recent years the severity of sepsis has been increasing, the proportion of patients with sepsis who developed severe organ dysfunction increasing from 26% to 44%. (Envier, 2018) In New York State it has been estimated sepsis affects 50,000 people each year and the mortality rate is ~ 30%.264
The New York State Sepsis Improvement Initiative and Rory’s Law
In 2014, New York state began to require every hospital in the state that provides care for patients who have sepsis to develop and implement evidence-based protocols and to provide the Department of Health with clinical information that could be used to evaluate the hospital’s performance and to determine the risk-adjusted mortality of patients treated for sepsis at each hospital. These requirements were initiated in response to the death of in 2012 of 12-year-old Rory Staunton. Staunton developed sepsis after suffering an abrasion, and despite being hospitalized, he died five days after the injury. The opinion is that Staunton’s case was mismanaged and that although he had clear clinical and laboratory indications of sepsis, the diagnosis was not made. His parents began a movement for public awareness of sepsis and changes in hospital care of sepsis, eventually culminating in the passage of the regulations that are informally known as Rory’s Law.
Each hospital in the state of New York that provides care for patients who have sepsis is required to abide by and follow the Sections 405.2 and 405.4 of the New York State Codes, Rules and Regulations.264 Sections 405.2 and 405.4 are outlined below in a (very slightly) abbreviated form and italics have been added where it was deemed important; the full texts can be accessed by using this link.
Hospitals shall have in place evidence-based protocols for the early recognition and treatment of patients with severe sepsis and septic shock that are based on generally accepted standards of care as required by section 405.4(a) of this Part.
The medical staff shall adopt, implement, periodically update and submit to the department evidence-based protocols for the early recognition and treatment of patients with severe sepsis and septic shock (“sepsis protocols”) that are based on generally accepted standards of care. Sepsis protocols must include components specific to the identification, care and treatment of adults, and of children, and must clearly identify where and when components will differ for adults and for children. These protocols must include the following components:
(i) a process for the screening and early recognition of patients with sepsis, severe sepsis and septic shock;
(ii) a process to identify and document individuals appropriate for treatment through severe sepsis and septic shock protocols, including explicit criteria defining those patients who should be excluded from the protocols, such as patients with certain clinical conditions or who have elected palliative care;
(iii) guidelines for hemodynamic support with explicit physiologic and biomarker treatment goals, methodology for invasive or non-invasive hemodynamic monitoring, and timeframe goals;
(iv) for infants and children, guidelines for fluid resuscitation with explicit timeframes for vascular access and fluid delivery consistent with current, evidence-based guidelines for severe sepsis and septic shock with defined therapeutic goals for children;
(v) a procedure for identification of infectious source and delivery of early antibiotics with timeframe goals; and
(vi) criteria for use, where appropriate, of an invasive protocol and for use of vasoactive agents.
The medical staff shall ensure that staff with direct patient care responsibilities and, as appropriate, staff with indirect patient care responsibilities, including, but not limited to laboratory and pharmacy staff, are periodically trained to implement sepsis protocols required pursuant to paragraph (4) of this subdivision. Medical staff shall ensure updated training when the hospital initiates substantive changes to the protocols.
Hospitals shall submit sepsis protocols required pursuant to paragraph (4) of this subdivision to the department for review not later than September 3, 2013. Hospitals must implement these protocols after receipt of a letter from the department indicating that the proposed protocols have been reviewed and determined to be consistent with the criteria established in this Part. Hospitals must update protocols based on newly emerging evidence-based standards. Protocols are to be resubmitted at the request of the department, not more frequently than once every two years unless the department identifies hospital-specific performance concerns.
The medical staff shall be responsible for the collection, use, and reporting of quality measures related to the recognition and treatment of severe sepsis for purposes of internal quality improvement and hospital reporting to the department. Such measures shall include, but not be limited to, data enough to evaluate each hospital’s adherence rate to its own sepsis protocols, including adherence to timeframes and implementation of all protocol components for adults and children.
Hospitals shall submit data specified by the department to permit the department to develop risk-adjusted severe sepsis and septic shock mortality rates in consultation with appropriate national, hospital and expert stakeholders. Such data shall be reported annually, or more frequently at the request of the department, and shall be subject to audit at the discretion of the department.
For the purposes of this section, the following terms shall have the following meanings:
Sepsis shall mean a proven or suspected infection accompanied by a systemic inflammatory response;
Severe sepsis shall mean sepsis plus at least one sign of hypoperfusion or organ dysfunction; for pediatrics, severe sepsis shall mean sepsis plus one of the following: cardiovascular organ dysfunction or acute respiratory distress syndrome (ARDS) or two or more organ dysfunctions; and
For adults, septic shock shall mean severe sepsis with persistent hypotension or cardiovascular organ dysfunction despite adequate IV fluid resuscitation; for pediatrics, septic shock shall mean severe sepsis and cardiovascular dysfunction despite adequate IV fluid resuscitation.
Infection Control Training Requirements
Sepsis is caused by infection, and New York state has infection control education which is outlined in New York State Law 6505-B and Section 239 of the New York State Public Health Law.
New York State Law 6505-B mandates infection control education for dental hygienists, dentists, licensed practical nurses, optometrist, podiatrists, registered nurses practicing in the state.265
Section 239 of the New York State Public Health Law states, part:
(a) Every physician, physician assistant and specialist assistant practicing in the state shall, on or before July first, nineteen hundred ninety-four and every four years thereafter, complete coursework or training, appropriate to the professional's practice, approved by the department regarding infection control and barrier precautions, including engineering and work practice controls, in accordance with regulatory standards promulgated by the department in consultation with the department of education, to prevent the transmission of HIV, HBV or HCV in the course of professional practice. Such coursework or training must also be completed by every medical student, medical resident and physician assistant student in the state as part of the orientation programs conducted by medical schools, medical residency programs and physician assistant programs.
(b) Every physician, physician assistant, specialist assistant, medical student, medical resident and physician assistant student must provide to the department documentation demonstrating the completion of and competence in the coursework or training required under subdivision (a) of this section, provided however, that physicians subject to the provisions of paragraph (f) of subdivision one of section twenty-eight hundred five-k of this chapter shall not be required to provide such documentation to the department.
Implementation of these measures has been beneficial. The New York State Report on Sepsis Care Improvement Initiative: Hospital Quality Performance (2017) reported that hospitals had improved the rates of initiation of sepsis protocols and performing the early treatment protocols and mortality rates have improved as well. The adult mortality rate decreased to 25.4% from 30.2%; the pediatric mortality rate fluctuated, from a 6.8% in quarter two of 2014 to 5.3% in quarter one of 2015, to a low of 6.5% in quarter three of 2015.264
Coordinated efforts to improve sepsis detection and treatment clearly have a positive impact on patient survival259, and performance improvement programs like the New York state program improve compliance with sepsis care guidelines and decrease patient mortality.259
Early identification and thus early treatment of sepsis is critically important; this point is repeatedly stressed in the medical literature. A recent (2017) article that used data collected from 2014 – 2016 and that was reported to the New York State Department of Health reinforced this as early initiation of the three-hour bundle and of antibiotic therapy decreased the mortality rate.266 Many of the therapies for treating sepsis, particularly antibiotic therapy and fluid resuscitation, are recommended to be given within the first few hours of treatment259, and late administration increases the risk for mortality.258 Early identification of sepsis involves; (1) Knowing the risk factors for sepsis, and; (2) knowing the signs and symptoms of sepsis.
Risk Factors for Sepsis258,261:
Signs and Symptoms
The signs and symptoms of sepsis are essentially the same for adults and children.258,267 Common signs and symptoms include, but are not limited to:
Gram-negative and gram-positive bacteria and fungal infections can cause sepsis, but in many cases, the causative microorganism is not identified.258 Respiratory tract infections and abdominal infections are the most common causes of sepsis, followed by soft tissue infections and urinary tract infections.269
Sepsis often begins outside the hospital270, but public awareness of sepsis is very low.271 Given that early recognition and early treatment are critically important, educating patients, families, caregivers, and the public about sepsis has obvious importance.
The lay public will often not have the technical background to understand the complexities of sepsis, but that is not a hindrance to providing them with accurate information that is simple to use and has practical benefit. Any basic educational program about sepsis should include sections on the seriousness of sepsis, causes of sepsis, signs and symptoms, what to do if you suspect someone has sepsis, and sepsis prevention. The following information provides a framework for such a program
The Problem of Sepsis
Sepsis affects millions of people in the US every year, from infants to the elderly and seemingly healthy adults, and the risk of death from sepsis is very high. People who are most at risk are the elderly, people who have a chronic infection or are immunocompromised, people who have a chronic medical condition, or anyone who has recently had an invasive procedure. However, it is important to remember that sepsis can happen to anyone.
Causes of Sepsis
Sepsis is caused by an infection, an invasion of the body by bacteria; the infection can occur in the skin, the urinary bladder, the lungs, or in other areas.
Signs and Symptoms
Sepsis is characterized by a very high fever or a very low fever, a rapid heart rate, and a general sense of not feeling well, and these happen in the context of an infection.
The Sepsis Alliance uses the mnemonic TIME as an educational device to teach people about the signs and symptoms of sepsis.272
T = Temperature, high or low
I – Infection
M = Mental decline, the change in mental status that occurs with the decreased perfusion that occurs with severe sepsis
E = Extremely ill
What to Do if You Suspect Someone has Sepsis
Seek medical attention immediately; don’t wait. If someone has sepsis, there is nothing that can be done at home to improve the situation, and delaying treatment is dangerous.
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 among healthcare professionals.