Prevention of Hospital-Acquired Infections: A Practical Guide PDF

WHO/CDS/CSR/EPH/2002.12 Prevention of hospital-acquired infections A practical guide 2nd edition World Health Organization Department of Communicable Disease, Surveillance and Response This document has been downloaded from the WHO/CSR Web site. The original cover pages and lists of participants...

WHO/CDS/CSR/EPH/2002.12 Prevention of hospital-acquired infections A practical guide 2nd edition World Health Organization Department of Communicable Disease, Surveillance and Response This document has been downloaded from the WHO/CSR Web site. The original cover pages and lists of participants are not included. See http://www.who.int/emc for more information. © World Health Organization This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors. The mention of specific companies or specific manufacturers' products does no imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.  WHO/CDS/CSR/EPH/2002.12 DISTR: GENERAL ORIGINAL: ENGLISH Prevention of hospital-acquired infections A PRACTICAL GUIDE 2nd edition Editors G. Ducel, Fondation Hygie, Geneva, Switzerland J. Fabry, Université Claude-Bernard, Lyon, France L. Nicolle, University of Manitoba, Winnipeg, Canada Contributors R. Girard, Centre Hospitalier Lyon-Sud, Lyon, France M. Perraud, Hôpital Edouard Herriot, Lyon, France A. Prüss, World Health Organization, Geneva, Switzerland A. Savey, Centre Hospitalier Lyon-Sud, Lyon, France E. Tikhomirov, World Health Organization, Geneva, Switzerland M. Thuriaux, World Health Organization, Geneva, Switzerland P. Vanhems, Université Claude Bernard, Lyon, France WORLD HEALTH ORGANIZATION Acknowledgements The World Health Organization (WHO) wishes to acknowledge the significant support for this work from the United States Agency for International Development (USAID). This document was developed following informal meetings of the editorial working group in Lyon and Ge- neva from 1997 to 2001. The editors wish to acknowledge colleagues whose suggestions and remarks have been greatly appreciated: Professor Franz Daschner (Institute of Environmental Medicine and Hospital Epidemiology, Freiburg, Ger- many), Dr Scott Fridkin (Centers for Disease Control and Prevention, Atlanta, USA), Dr Bernardus Ganter (WHO Regional Office for Europe, Copenhagen, Denmark), Dr Yvan Hutin (Blood Safety and Clinical Technol- ogy, WHO, Geneva, Switzerland), Dr Sudarshan Kumari (WHO Regional Office for South-East Asia, New Delhi, India), Dr Lionel Pineau (Laboratoire Biotech-Germande, Marseille, France). The editors would like to thank Brenda Desrosiers, Georges-Pierre Ducel and Penny Ward for their help in manuscript preparation. © World Health Organization 2002 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors. The designations employed and the presentation of the material in this document, including tables and maps, do not imply the expression of any opinion whatsoever on the part of the secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recom- mended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. Designed by minimum graphics Printed in Malta  Contents Introduction 1 Chapter I. Epidemiology of nosocomial infections 4 1.1 Definitions of nosocomial infections 4 1.2 Nosocomial infection sites 5 1.2.1 Urinary infections 5 1.2.2 Surgical site infections 5 1.2.3 Nosocomial pneumonia 5 1.2.4 Nosocomial bacteraemia 6 1.2.5 Other nosocomial infections 6 1.3 Microorganisms 6 1.3.1 Bacteria 6 1.3.2 Viruses 6 1.3.3 Parasites and fungi 7 1.4 Reservoirs and transmission 7 Chapter II. Infection control programmes 9 2.1 National or regional programmes 9 2.2 Hospital programmes 9 2.2.1 Infection Control Committee 9 2.2.2 Infection control professionals (infection control team) 10 2.2.3 Infection control manual 10 2.3 Infection control responsibility 10 2.3.1 Role of hospital management 10 2.3.2 Role of the physician 10 2.3.3 Role of the microbiologist 11 2.3.4 Role of the hospital pharmacist 11 2.3.5 Role of the nursing staff 12 2.3.6 Role of the central sterilization service 12 2.3.7 Role of the food service 13 2.3.8 Role of the laundry service 13 2.3.9 Role of the housekeeping service 13 2.3.10 Role of maintenance 14 2.3.11 Role of the infection control team (hospital hygiene service) 14 iii  PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE — WHO/CDS/CSR/EPH/2002.12 Chapter III. Nosocomial infection surveillance 16 3.1 Objectives 16 3.2 Strategy 16 3.2.1 Implementation at the hospital level 17 3.2.2 Implementation at the network (regional or national) level 17 3.3 Methods 17 3.3.1 Prevalence study 18 3.3.2 Incidence study 18 3.3.3 Calculating rates 19 3.4 Organization for efficient surveillance 19 3.4.1 Data collection and analysis 20 3.4.2 Feedback/dissemination 23 3.4.3 Prevention and evaluation 23 3.5 Evaluation of the surveillance system 23 3.5.1 Evaluation of the surveillance strategy 23 3.5.2 Feedback evaluation 24 3.5.3 Validity/data quality 24 Chapter IV. Dealing with outbreaks 26 4.1 Identifying an outbreak 26 4.2 Investigating an outbreak 26 4.2.1 Planning the investigation 26 4.2.2 Case definition 26 4.2.3 Describing the outbreak 27 4.2.4 Suggesting and testing a hypothesis 27 4.2.5 Control measures and follow-up 28 4.2.6 Communication 28 Chapter V. Prevention of nosocomial infection 30 5.1 Risk stratification 30 5.2 Reducing person-to-person transmission 30 5.2.1 Hand decontamination 30 5.2.2 Personal hygiene 32 5.2.3 Clothing 32 5.2.4 Masks 33 5.2.5 Gloves 33 5.2.6 Safe injection practices 33 5.3 Preventing transmission from the environment 33 5.3.1 Cleaning of the hospital environment 33 5.3.2 Use of hot/superheated water 34 5.3.3 Disinfection of patient equipment 34 5.3.4 Sterilization 34 Chapter VI. Prevention of common endemic nosocomial infections 38 6.1 Urinary tract infections (UTI) 38 6.2 Surgical wound infections (surgical site infections) 39 iv  CONTENTS 6.2.1 Operating room environment 40 6.2.2 Operating room staff 40 6.2.3 Pre-intervention preparation of the patient 40 6.2.4 Antimicrobial prophylaxis 41 6.2.5 Surgical wound surveillance 41 6.3 Nosocomial respiratory infections 41 6.3.1 Ventilator-associated pneumonia in the intensive care unit 41 6.3.2 Medical units 41 6.3.3 Surgical units 41 6.3.4 Neurological patients with tracheostomy 41 6.4 Infections associated with intravascular lines 41 6.4.1 Peripheral vascular catheters 42 6.4.2 Central vascular catheters 42 6.4.3 Central vascular totally implanted catheters 42 Chapter VII. Infection control precautions in patient care 44 7.1 Practical aspects 44 7.1.1 Standard (routine) precautions 44 7.1.2 Additional precautions for specific modes of transmission 44 7.2 Antimicrobial-resistant microorganisms 45 Chapter VIII. Environment 47 8.1 Buildings 47 8.1.1 Planning for construction or renovation 47 8.1.2 Architectural segregation 47 8.1.3 Traffic flow 47 8.1.4 Materials 48 8.2 Air 48 8.2.1 Airborne contamination and transmission 48 8.2.2 Ventilation 48 8.2.3 Operating theatres 49 8.2.4 Ultra-clean air 49 8.3 Water 50 8.3.1 Drinking-water 50 8.3.2 Baths 50 8.3.3 Pharmaceutical (medical) water 51 8.3.4 Microbiological monitoring 51 8.4 Food 51 8.4.1 Agents of food poisoning and foodborne infections 52 8.4.2 Factors contributing to food poisoning 52 8.4.3 Prevention of food poisoning 52 8.5 Waste 53 8.5.1 Definition and classification 53 8.5.2 Handling, storage and transportation of health care waste 54 v  PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE — WHO/CDS/CSR/EPH/2002.12 Chapter lX. Antimicrobial use and antimicrobial resistance 56 9.1 Appropriate antimicrobial use 57 9.1.1 Therapy 57 9.1.2 Chemoprophylaxis 57 9.2 Antimicrobial resistance 57 9.2.1 MRSA (methicillin-resistant Staphylococcus aureus) 58 9.2.2 Enterococci 59 9.3 Antibiotic control policy 59 9.3.1 Antimicrobial Use Committee 59 9.3.2 Role of the microbiology laboratory 59 9.3.3 Monitoring antimicrobial use 60 Chapter X. Preventing infections of staff 61 10.1 Exposure to human immunodeficiency virus (HIV) 61 10.2 Exposure to hepatitis B virus 62 10.3 Exposure to hepatitis C virus 62 10.4 Neisseria meningitidis infection 62 10.5 Mycobacterium tuberculosis 62 10.6 Other infections 62 Annex 1. Suggested further reading 63 Annex 2. Internet resources 64 vi  Introduction A nosocomial infection — also called “hospital- acquired infection” can be defined as: Eastern Mediterranean and South-East Asia Regions (11.8 and 10.0% respectively), with a prevalence of 7.7 and 9.0% respectively in the European and West- An infection acquired in hospital by a patient who was ern Pacific Regions (4). admitted for a reason other than that infection (1). An in- fection occurring in a patient in a hospital or other health The most frequent nosocomial infections are infec- care facility in whom the infection was not present or incu- tions of surgical wounds, urinary tract infections and bating at the time of admission. This includes infections lower respiratory tract infections. The WHO study, acquired in the hospital but appearing after discharge, and and others, have also shown that the highest preva- also occupational infections among staff of the facility (2). lence of nosocomial infections occurs in intensive care units and in acute surgical and orthopaedic Patient care is provided in facilities which range from wards. Infection rates are higher among patients with highly equipped clinics and technologically ad- increased susceptibility because of old age, under- vanced university hospitals to front-line units with lying disease, or chemotherapy. only basic facilities. Despite progress in public health and hospital care, infections continue to develop in hospitalized patients, and may also affect hospital Impact of nosocomial infections staff. Many factors promote infection among hospi- talized patients: decreased immunity among patients; Hospital-acquired infections add to functional dis- the increasing variety of medical procedures and ability and emotional stress of the patient and may, invasive techniques creating potential routes of in some cases, lead to disabling conditions that re- infection; and the transmission of drug-resistant duce the quality of life. Nosocomial infections are bacteria among crowded hospital populations, where also one of the leading causes of death (5). The eco- poor infection control practices may facilitate trans- nomic costs are considerable (6,7). The increased mission. length of stay for infected patients is the greatest contributor to cost (8,9,10). One study (11) showed that the overall increase in the duration of hospi- Frequency of infection talization for patients with surgical wound infections was 8.2 days, ranging from 3 days for gynaecology Nosocomial infections occur worldwide and affect to 9.9 for general surgery and 19.8 for orthopaedic both developed and resource-poor countries. Infec- surgery. Prolonged stay not only increases direct costs tions acquired in health care settings are among the to patients or payers but also indirect costs due to major causes of death and increased morbidity lost work. The increased use of drugs, the need for among hospitalized patients. They are a significant isolation, and the use of additional laboratory and burden both for the patient and for public health. A other diagnostic studies also contribute to costs. prevalence survey conducted under the auspices of Hospital-acquired infections add to the imbalance WHO in 55 hospitals of 14 countries representing between resource allocation for primary and sec- 4 WHO Regions (Europe, Eastern Mediterranean, ondary health care by diverting scarce funds to the South-East Asia and Western Pacific) showed an management of potentially preventable conditions. average of 8.7% of hospital patients had nosocomial infections. At any time, over 1.4 million people world- The advancing age of patients admitted to health wide suffer from infectious complications acquired care settings, the greater prevalence of chronic dis- in hospital (3). The highest frequencies of nosoco- eases among admitted patients, and the increased mial infections were reported from hospitals in the use of diagnostic and therapeutic procedures which 1  PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE — WHO/CDS/CSR/EPH/2002.12 affect the host defences will provide continuing disease, and diagnostic and therapeutic interventions. pressure on nosocomial infections in the future. The extremes of life — infancy and old age — are as- Organisms causing nosocomial infections can be sociated with a decreased resistance to infection. transmitted to the community through discharged Patients with chronic disease such as malignant tu- patients, staff, and visitors. If organisms are multire- mours, leukaemia, diabetes mellitus, renal failure, sistant, they may cause significant disease in the or the acquired immunodeficiency syndrome (AIDS) community. have an increased susceptibility to infections with opportunistic pathogens. The latter are infections with organism(s) that are normally innocuous, e.g. Factors influencing the development of part of the normal bacterial flora in the human, but nosocomial infections may become pathogenic when the body’s immuno- The microbial agent logical defences are compromised. Immunosuppres- sive drugs or irradiation may lower resistance to The patient is exposed to a variety of microorgan- infection. Injuries to skin or mucous membranes isms during hospitalization. Contact between the bypass natural defence mechanisms. Malnutrition is patient and a microorganism does not by itself nec- also a risk. Many modern diagnostic and therapeu- essarily result in the development of clinical disease tic procedures, such as biopsies, endoscopic exami- — other factors influence the nature and frequency nations, catheterization, intubation/ventilation and of nosocomial infections. The likelihood of expo- suction and surgical procedures increase the risk of sure leading to infection depends partly on the char- infection. Contaminated objects or substances may acteristics of the microorganisms, including resistance be introduced directly into tissues or normally ster- to antimicrobial agents, intrinsic virulence, and ile sites such as the urinary tract and the lower res- amount (inoculum) of infective material. piratory tract. Many different bacteria, viruses, fungi and parasites may cause nosocomial infections. Infections may be caused by a microorganism acquired from another Environmental factors person in the hospital (cross-infection) or may be Health care settings are an environment where both caused by the patient’s own flora (endogenous in- infected persons and persons at increased risk of fection). Some organisms may be acquired from an infection congregate. Patients with infections or car- inanimate object or substances recently contami- riers of pathogenic microorganisms admitted to nated from another human source (environmental hospital are potential sources of infection for pa- infection). tients and staff. Patients who become infected in the Before the introduction of basic hygienic practices hospital are a further source of infection. Crowded and antibiotics into medical practice, most hospital conditions within the hospital, frequent transfers of infections were due to pathogens of external origin patients from one unit to another, and concentra- (foodborne and airborne diseases, gas gangrene, teta- tion of patients highly susceptible to infection in one nus, etc.) or were caused by microorganisms not area (e.g. newborn infants, burn patients, intensive present in the normal flora of the patients (e.g. diph- care ) all contribute to the development of nosoco- theria, tuberculosis). Progress in the antibiotic treat- mial infections. Microbial flora may contaminate ment of bacterial infections has considerably reduced objects, devices, and materials which subsequently mortality from many infectious diseases. Most in- contact susceptible body sites of patients. In addi- fections acquired in hospital today are caused by tion, new infections associated with bacteria such as microorganisms which are common in the general waterborne bacteria (atypical mycobacteria) and/or population, in whom they cause no or milder dis- viruses and parasites continue to be identified. ease than among hospital patients (Staphylococcus aureus, coagulase-negative staphylococci, enterococci, Enterobacteriaceae). Bacterial resistance Many patients receive antimicrobial drugs. Through selection and exchange of genetic resistance elements, Patient susceptibility antibiotics promote the emergence of multidrug- Important patient factors influencing acquisition of resistant strains of bacteria; microorganisms in the infection include age, immune status, underlying normal human flora sensitive to the given drug are 2  INTRODUCTION suppressed, while resistant strains persist and may References become endemic in the hospital. The widespread use 1. Ducel G et al. Guide pratique pour la lutte contre of antimicrobials for therapy or prophylaxis (includ- l’infection hospitalière. WHO/BAC/79.1. ing topical) is the major determinant of resistance. Antimicrobial agents are, in some cases, becoming 2. Benenson AS. Control of communicable diseases less effective because of resistance. As an antimicro- manual, 16th edition. Washington, American Pub- bial agent becomes widely used, bacteria resistant lic Health Association, 1995. to this drug eventually emerge and may spread in 3. Tikhomirov E. WHO Programme for the Control the health care setting. Many strains of pneumo- of Hospital Infections. Chemiotherapia, 1987, 3:148– cocci, staphylococci, enterococci, and tuberculosis are 151. currently resistant to most or all antimicrobials which were once effective. Multiresistant Klebsiella and Pseu- 4. Mayon-White RT et al. An international survey domonas aeruginosa are prevalent in many hospitals. of the prevalence of hospital-acquired infection. This problem is particularly critical in developing J Hosp Infect, 1988, 11 (Supplement A):43–48. countries where more expensive second-line anti- 5. Ponce-de-Leon S. The needs of developing coun- biotics may not be available or affordable (12). tries and the resources required. J Hosp Infect, 1991, 18 (Supplement):376–381. Nosocomial infections are widespread. They are im- 6. Plowman R et al. The socio-economic burden of hospi- portant contributors to morbidity and mortality.They tal-acquired infection. London, Public Health Labo- will become even more important as a public health ratory Service and the London School of Hygiene problem with increasing economic and human impact and Tropical Medicine, 1999. because of: 7. Wenzel RP. The economics of nosocomial infec- Increasing numbers and crowding of people. tions. J Hosp Infect 1995, 31:79–87. More frequent impaired immunity (age, illness, 8. Pittet D, Taraara D, Wenzel RP. Nosocomial blood- treatments). stream infections in critically ill patients. Excess length of stay, extra costs, and attributable mor- New microorganisms. tality. JAMA, 1994, 271:1598–1601. Increasing bacterial resistance to antibiotics (13). 9. Kirkland KB et al. The impact of surgical-site in- fections in the 1990’s: attributable mortality, ex- cess length of hospitalization and extra costs. Infect Purpose of this manual Contr Hosp Epidemiol, 1999, 20:725–730. This manual has been developed to be a practical, 10. Wakefield DS et al. Cost of nosocomial infection: basic, resource which may be used by individuals relative contributions of laboratory, antibiotic, with an interest in nosocomial infections and their and per diem cost in serious Staphylococcus aureus control, as well as those who work in nosocomial infections. Amer J Infect Control, 1988, 16:185–192. infection control in health care facilities. It is appli- 11. Coella R et al. The cost of infection in surgical cable to all facilities, but attempts to provide rational patients: a case study. J Hosp Infect, 1993, 25:239– and attainable recommendations for facilities with 250. relatively limited resources. The information should assist administrators, infection control personnel, and 12. Resources. In: Proceedings of the 3rd Decennial Inter- patient care workers in such facilities in the initial national Conference on Nosocomial Infections, Preventing development of a nosocomial infection control pro- Nosocomial Infections. Progress in the 80’s. Plans for the gramme, including specific components of such pro- 90’s, Atlanta, Georgia, July 31–August 3, 1990:30 grammes. Additional reading in specific areas is (abstract 63). provided in the list of WHO relevant documents and 13. Ducel G. Les nouveaux risques infectieux. infection control texts at the end of the manual (An- Futuribles, 1995, 203:5–32. nex 1), as well as relevant references in each chapter. 3  PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE — WHO/CDS/CSR/EPH/2002.12 CHAPTER I Epidemiology of nosocomial infections S tudies throughout the world document that nosocomial infections are a major cause of morbidity and mortality (1–13). A high frequency of Changes in health care delivery have resulted in shorter hospital stays and increased outpatient care. It has been suggested the term nosocomial infec- nosocomial infections is evidence of a poor quality tions should encompass infections occurring in of health service delivery, and leads to avoidable patients receiving treatment in any health care set- costs. Many factors contribute to the frequency of ting. Infections acquired by staff or visitors to the nosocomial infections: hospitalized patients are hospital or other health care setting may also be often immunocompromised, they undergo invasive considered nosocomial infections. examinations and treatments, and patient care prac- Simplified definitions may be helpful for some tices and the hospital environment may facilitate the facilities without access to full diagnostic techniques transmission of microorganisms among patients. The (17). The following table (Table 1) provides defini- selective pressure of intense antibiotic use promotes tions for common infections that could be used for antibiotic resistance. While progress in the preven- surveys in facilities with limited access to sophisti- tion of nosocomial infections has been made, changes cated diagnostic techniques. in medical practice continually present new oppor- tunities for development of infection. This chapter summarizes the main characteristics of nosocomial TABLE 1. Simplified criteria for surveillance of infections, based on our current understanding. nosocomial infections Type of nosocomial Simplified criteria infection 1.1 Definitions of nosocomial infections Surgical site infection Any purulent discharge, abscess, or Nosocomial infections, also called “hospital-acquired spreading cellulitis at the surgical infections”, are infections acquired during hospital site during the month after the care which are not present or incubating at admis- operation sion. Infections occurring more than 48 hours after Urinary infection Positive urine culture admission are usually considered nosocomial. Defi- (1 or 2 species) with at least nitions to identify nosocomial infections have been 105 bacteria/ml, with or without clinical symptoms developed for specific infection sites (e.g. urinary, pulmonary). These are derived from those published Respiratory infection Respiratory symptoms with at by the Centers for Diseases Control and Prevention least two of the following signs appearing during hospitalization: (CDC) in the United States of America (14,15) or dur- — cough ing international conferences (16) and are used for — purulent sputum surveillance of nosocomial infections. They are based — new infiltrate on chest on clinical and biological criteria, and include ap- radiograph consistent with proximately 50 potential infection sites. infection Nosocomial infections may also be considered either Vascular catheter Inflammation, lymphangitis or endemic or epidemic. Endemic infections are most infection purulent discharge at the insertion site of the catheter common. Epidemic infections occur during out- breaks, defined as an unusual increase above the Septicaemia Fever or rigours and at least one positive blood culture baseline of a specific infection or infecting organ- ism. 4  CHAPTER I. EPIDEMIOLOGY OF NOSOCOMIAL INFECTIONS 1.2 Nosocomial infection sites organ spaces are identified separately. The infection is usually acquired during the operation itself; An example of the distribution of sites of nosoco- either exogenously (e.g. from the air, medical equip- mial infections is shown in Figure 1. ment, surgeons and other staff), endogenously from the flora on the skin or in the operative site or, rarely, FIGURE 1. Sites of the most comon nosocomial from blood used in surgery. The infecting microor- infections: distribution according to the ganisms are variable, depending on the type and French national prevalence survey (1996)* location of surgery, and antimicrobials received by the patient. The main risk factor is the extent of Other sites O contamination during the procedure (clean, clean- Catheter site C contaminated, contaminated, dirty), which is to a ENT/Eye E/E O Urinary tract U C large part dependent on the length of the operation, E/E Bacteraemia B and the patient’s general condition (25). Other fac- B U tors include the quality of surgical technique, the Respiratory tract R2 presence of foreign bodies including drains, the viru- (other) R2 lence of the microorganisms, concomitant infection SST at other sites, the use of preoperative shaving, and Skin and RI soft tissue SST S the experience of the surgical team. Lower respiratory Surgical tract R1 site S 1.2.3 Nosocomial pneumonia * Adapted fom Enquête nationale de prévalence des infections nosocomiales, 1996. BEH, 1997, 36:161–163. Nosocomial pneumonia occurs in several different patient groups. The most important are patients on ventilators in intensive care units, where the rate 1.2.1 Urinary infections of pneumonia is 3% per day. There is a high case- This is the most common nosocomial infection; 80% fatality rate associated with ventilator-associated of infections are associated with the use of an ind- pneumonia, although the attributable risk is diffi- welling bladder catheter (1,2,3). Urinary infections cult to determine because patient comorbidity is so are associated with less morbidity than other noso- high. Microorganisms colonize the stomach, upper comial infections, but can occasionally lead to bacter- airway and bronchi, and cause infection in the lungs aemia and death. Infections are usually defined by (pneumonia): they are often endogenous (digestive microbiological criteria: positive quantitative urine system or nose and throat), but may be exogenous, culture (≥105 microorganisms/ml, with a maximum often from contaminated respiratory equipment. of 2 isolated microbial species). The bacteria respon- The definition of pneumonia may be based on clini- sible arise from the gut flora, either normal (Escherichia cal and radiological criteria which are readily avail- coli) or acquired in hospital (multiresistant Klebsiella). able but non-specific: recent and progressive radiological opacities of the pulmonary parenchyma, purulent sputum, and recent onset of fever. Diagno- 1.2.2 Surgical site infections sis is more specific when quantitative microbiologi- Surgical site infections are also frequent: the inci- cal samples are obtained using specialized protected dence varies from 0.5 to 15% depending on the type bronchoscopy methods. Known risk factors for of operation and underlying patient status (18,19,20). infection include the type and duration of ventila- These are a significant problem which limit the po- tion, the quality of respiratory care, severity of the tential benefits of surgical interventions. The impact patient’s condition (organ failure), and previous use on hospital costs and postoperative length of stay of antibiotics. (between 3 and 20 additional days) (21,22,23,24) is Apart from ventilator-associated pneumonia, considerable. patients with seizures or decreased level of con- The definition is mainly clinical: purulent discharge sciousness are at risk for nosocomial infection, even around the wound or the insertion site of the drain, if not intubated. Viral bronchiolitis (respiratory syn- or spreading cellulitis from the wound. Infections of cytial virus, RSV) is common in children’s units, and the surgical wound (whether above or below the influenza and secondary bacterial pneumonia may aponeurosis), and deep infections of organs or occur in institutions for the elderly. With highly 5  PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE — WHO/CDS/CSR/EPH/2002.12 immunocompromised patients, Legionella spp. and 1.3.1 Bacteria Aspergillus pneumonia may occur. In countries with These are the most common nosocomial pathogens. a high prevalence of tuberculosis, particularly A distinction may be made between: multiresistant strains, transmission in health care settings may be an important problem. Commensal bacteria found in normal flora of healthy humans. These have a significant protec- tive role by preventing colonization by patho- 1.2.4 Nosocomial bacteraemia genic microorganisms. Some commensal bacteria may cause infection if the natural host is com- These infections represent a small proportion of promised. For example, cutaneous coagulase- nosocomial infections (approximately 5%) but case- negative staphylococci cause intravascular line fatality rates are high — more than 50% for some infection and intestinal Escherichia coli are the most microorganisms. The incidence is increasing, particu- common cause of urinary infection. larly for certain organisms such as multiresistant coagulase-negative Staphylococcus and Candida spp. Pathogenic bacteria have greater virulence, and Infection may occur at the skin entry site of the cause infections (sporadic or epidemic) regardless intravascular device, or in the subcutaneous path of of host status. For example: the catheter (tunnel infection). Organisms coloniz- — Anaerobic Gram-positive rods (e.g. Clostridium) ing the catheter within the vessel may produce cause gangrene. bacteraemia without visible external infection. The resident or transient cutaneous flora is the source of — Gram-positive bacteria: Staphylococcus aureus infection. The main risk factors are the length of (cutaneous bacteria that colonize the skin and catheterization, level of asepsis at insertion, and nose of both hospital staff and patients) cause continuing catheter care. a wide variety of lung, bone, heart and blood- stream infections and are frequently resistant to antibiotics; beta-haemolytic streptococci are 1.2.5 Other nosocomial infections also important. These are the four most frequent and important — Gram-negative bacteria: Enterobacteriacae (e.g. nosocomial infections, but there are many other Escherichia coli, Proteus, Klebsiella, Enterobacter, potential sites of infection. For example: Serratia marcescens), may colonize sites when the host defences are compromised (catheter in- Skin and soft tissue infections: open sores (ulcers, sertion, bladder catheter, cannula insertion) burns and bedsores) encourage bacterial coloni- and cause serious infections (surgical site, lung, zation and may lead to systemic infection. bacteraemia, peritoneum infection). They may Gastroenteritis is the most common nosocomial also be highly resistant. infection in children, where rotavirus is a chief — Gram-negative organisms such as Pseudomonas pathogen: Clostridium difficile is the major cause of spp. are often isolated in water and damp nosocomial gastroenteritis in adults in developed areas. They may colonize the digestive tract of countries. hospitalized patients. Sinusitis and other enteric infections, infections — Selected other bacteria are a unique risk in of the eye and conjunctiva. hospitals. For instance, Legionella species may Endometritis and other infections of the repro- cause pneumonia (sporadic or endemic) ductive organs following childbirth. through inhalation of aerosols containing con- taminated water (air conditioning, showers, therapeutic aerosols). 1.3 Microorganisms Many different pathogens may cause nosocomial infections. The infecting organisms vary among dif- 1.3.2 Viruses ferent patient populations, different health care set- There is the possibility of nosocomial transmission tings, different facilities, and different countries. of many viruses, including the hepatitis B and C viruses (transfusions, dialysis, injections, endoscopy), respiratory syncytial virus (RSV), rotavirus, and 6  CHAPTER I. EPIDEMIOLOGY OF NOSOCOMIAL INFECTIONS enteroviruses (transmitted by hand-to-mouth con- 3. Flora from the health care environment (endemic tact and via the faecal-oral route). Other viruses such or epidemic exogenous environmental infections). Several as cytomegalovirus, HIV, Ebola, influenza viruses, types of microorganisms survive well in the hos- herpes simplex virus, and varicella-zoster virus, may pital environment: also be transmitted. — in water, damp areas, and occasionally in sterile pro ducts or disinfectants (Pseudomonas, Acinetobacter, Mycobacterium) 1.3.3 Parasites and fungi — in items such as linen, equipment and sup- Some parasites (e.g. Giardia lamblia) are transmitted plies used in care; appropriate housekeeping easily among adults or children. Many fungi and normally limits the risk of bacteria surviving other parasites are opportunistic organisms and as most microorganisms require humid or hot cause infections during extended antibiotic treatment conditions and nutrients to survive and severe immunosuppression (Candida albicans, Aspergillus spp., Cryptococcus neoformans, Cryptosporidium). — in food These are a major cause of systemic infections among — in fine dust and droplet nuclei generated by immunocompromised patients. Environmental con- coughing or speaking (bacteria smaller than tamination by airborne organisms such as Aspergil- 10 µm in diameter remain in the air for sev- lus spp. which originate in dust and soil is also a eral hours and can be inhaled in the same way concern, especially during hospital construction. as fine dust). Sarcoptes scabies (scabies) is an ectoparasite which has repeatedly caused outbreaks in health care facilities. People are at the centre of the phenomenon: as main reservoir and source of microorganisms 1.4 Reservoirs and transmission as main transmitter, notably during treatment Bacteria that cause nosocomial infections can be acquired in several ways: as receptor for microorganisms, thus becoming a new reservoir. 1. The permanent or transient flora of the patient (endogenous infection). Bacteria present in the nor- mal flora cause infection because of transmission to sites outside the natural habitat (urinary tract), damage to tissue (wound) or inappropriate anti- References biotic therapy that allows overgrowth (C. difficile, 1. Mayon-White R et al. An international survey of yeast spp.). For example, Gram-negative bacteria the prevalence of hospital-acquired infection. in the digestive tract frequently cause surgical site J Hosp Infect, 1988, 11 (suppl A):43–48. infections after abdominal surgery or urinary tract 2. Emmerson AM et al. The second national preva- infection in catheterized patients. lence survey of infection in hospitals — overview 2. Flora from another patient or member of staff of the results. J Hosp Infect, 1996, 32:175–190. (exogenous cross-infection). Bacteria are transmitted 3. Enquête nationale de prévalence des infections between patients: (a) through direct contact be- nosocomiales. Mai–Juin 1996. Comité technique tween patients (hands, saliva droplets or other national des infections nosocomiales. Bulletin body fluids), (b) in the air (droplets or dust con- Èpidémiologique Hebdomadaire, 1997, No 36. taminated by a patient’s bacteria), (c) via staff contaminated through patient care (hands, clothes, 4. Gastmeier P et al. Prevalence of nosocomial in- nose and throat) who become transient or per- fections in representative German hospitals. J Hosp manent carriers, subsequently transmitting bac- Infect, 1998, 38:37–49. teria to other patients by direct contact during 5. Vasque J, Rossello J, Arribas JL. Prevalence of care, (d) via objects contaminated by the patient nosocomial infections in Spain: EPINE study (including equipment), the staff’s hands, visitors 1990–1997. EPINE Working Group. J Hosp Infect, or other environmental sources (e.g. water, other 1999, 43 Suppl:S105–S111. fluids, food). 7  PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE — WHO/CDS/CSR/EPH/2002.12 6. Danchaivijitr S, Tangtrakool T, Chokloikaew S. The 16. McGeer A et al. Definitions of infection for sur- second Thai national prevalence study on noso- veillance in long-term care facilities. Am J Infect comial infections 1992. J Med Assoc Thai, 1995, 78 Control, 1991, 19:1–7. Suppl 2:S67–S72. 17. Girard R. Guide technique d’hygiène hospitalière. Alger, 7. Kim JM et al. Multicentre surveillance study for Institut de la Santé publique et Lyon, Fondation nosocomial infections in major hospitals in Marace Mérieux, 1990. Korea. Am J Infect Control, 2000, 28:454–458. 18. Cruse PJE, Ford R. The epidemiology of wound 8. Raymond J, Aujard Y, European Study Group. infection. A 10 year prospective study of 62,939 Nosocomial Infections in Pediatric Patients: A wounds. Surg Clin North Am, 1980, 60:27–40. European, Multicenter Prospective Study. Infect 19. Horan TC et al. Nosocomial infections in surgical Control Hosp Epidemiol, 2000, 21:260–263. patients in the United States, 1986–1992 (NNIS). 9. Pittet D et al. Prevalence and risk factors for no- Infect Control Hosp Epidemiol, 1993, 14:73–80. socomial infections in four university hospitals 20. Hajjar J et al. Réseau ISO Sud-Est: un an de sur- in Switzerland. Infect Control Hosp Epidemiol, 1999, veillance des infections du site opératoire. Bulle- 20:37–42. tin Èpidémiologique Hebdomadaire, 1996, No 42. 10. Gikas A et al. Repeated multi-centre prevalence 21. Brachman PS et al. Nosocomial surgical infec- surveys of hospital-acquired infection in Greek tions: incidence and cost. Surg Clin North Am, 1980, hospitals. J Hosp Infect, 1999, 41:11–18. 60:15–25. 11. Scheel O, Stormark M. National prevalence sur- 22. Fabry J et al. Cost of nosocomial infections: analy- vey in hospital infections in Norway. J Hosp Infect, sis of 512 digestive surgery patients. World J Surg, 1999, 41:331–335. 1982, 6:362–365. 12. Valinteliene R, Jurkuvenas V, Jepsen OB. Preva- 23. Prabhakar P et al. Nosocomial surgical infections: lence of hospital-acquired infection in a Lithua- incidence and cost in a developing country. Am J nian hospital. J Hosp Infect, 1996, 34:321–329. Infect Control, 1983, 11:51–56. 13. Orrett FA, Brooks PJ, Richardson EG. Nosocomial 24. Kirkland KB et al. The impact of surgical-site in- infections in a rural regional hospital in a devel- fections in the 1990’s: attributable mortality, ex- oping country: infection rates by site, service, cost, cess length of hospitalization and extra costs. Infect and infection control practices. Infect Control Hosp Control Hosp Epidemiol, 1999, 20:725–730. Epidemiol, 1998, 19:136–140. 25. Nosocomial infections rates for interhospital com- 14. Garner JS et al. CDC definitions for nosocomial parison: limitations and possible solutions — A infections, 1988. Am J Infect Control, 1988, 16:128– report from NNIS System. Infect Control Hosp 140. Epidemiol, 1991, 12:609–621. 15. Horan TC et al. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definition of surgical wound infections. Am J Infect Control, 1992, 13:606–608. 8  CHAPTER II Infection control programmes P revention of nosocomial infections is the respon- sibility of all individuals and services providing health care. Everyone must work cooperatively to Professional and academic organizations must also be involved in this programme. reduce the risk of infection for patients and staff. This includes personnel providing direct patient care, 2.2 Hospital programmes management, physical plant, provision of materials The major preventive effort should be focused in and products, and training of health workers. Infec- hospitals and other health care facilities (2). Risk pre- tion control programmes (1) are effective provided vention for patients and staff is a concern of every- they are comprehensive and include surveillance and one in the facility, and must be supported at the prevention activities, as well as staff training. There level of senior administration. A yearly work plan to must also be effective support at the national and assess and promote good health care, appropriate regional levels. isolation, sterilization, and other practices, staff train- ing, and epidemiological surveillance should be de- veloped. Hospitals must provide sufficient resources 2.1 National or regional programmes to support this programme. The responsible health authority should develop a national (or regional) programme to support hospi- tals in reducing the risk of nosocomial infections. 2.2.1 Infection Control Committee Such programmes must: An Infection Control Committee provides a forum set relevant national objectives consistent with for multidisciplinary input and cooperation, and other national health care objectives information sharing. This committee should include wide representation from relevant programmes: e.g. develop and continually update guidelines for management, physicians, other health care workers, recommended health care surveillance, preven- clinical microbiology, pharmacy, central supply, tion, and practice maintenance, housekeeping, training services. The develop a national system to monitor selected committee must have a reporting relationship infections and assess the effectiveness of inter- directly to either administration or the medical staff ventions to promote programme visibility and effectiveness. In an emergency (such as an outbreak), this com- harmonize initial and continuing training pro- mittee must be able to meet promptly. It has the grammes for health care professionals following tasks: facilitate access to materials and products essen- to review and approve a yearly programme of tial for hygiene and safety activity for surveillance and prevention encourage health care establishments to monitor to review epidemiological surveillance data and nosocomial infections, with feedback to the pro- identify areas for intervention fessionals concerned. to assess and promote improved practice at all The health authority should designate an agency to levels of the health facility oversee the programme (a ministerial department, institution or other body), and plan national activi- to ensure appropriate staff training in infection ties with the help of a national expert committee. control and safety 9  PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE — WHO/CDS/CSR/EPH/2002.12 to review risks associated with new technologies, It must be made readily available for patient care and monitor infectious risks of new devices and staff, and updated in a timely fashion. products, prior to their approval for use to review and provide input into investigation of 2.3 Infection control responsibility epidemics 2.3.1 Role of hospital management to communicate and cooperate with other com- mittees of the hospital with common interests such The administration and/or medical management of as Pharmacy and Therapeutics or Antimicrobial the hospital must provide leadership by supporting Use Committee, Biosafety or Health and Safety the hospital infection programme. They are respon- Committees, and Blood Transfusion Committee. sible for: establishing a multidisciplinary Infection Control Committee 2.2.2 Infection control professionals (infection control team) identifying appropriate resources for a programme to monitor infections and apply the most appro- Health care establishments must have access to spe- priate methods for preventing infection cialists in infection control, epidemiology, and infectious disease including infection control physi- ensuring education and training of all staff cians and infection control practitioners (usually through support of programmes on the preven- nurses) (2). In some countries, these professionals are tion of infection in disinfection and sterilization specialized teams working for a hospital or a group techniques of health care establishments; they may be admin- delegating technical aspects of hospital hygiene istratively part of another unit, (e.g. microbiology to appropriate staff, such as: laboratory, medical or nursing administration, pub- lic health services). The optimal structure will vary — nursing with the type, needs, and resources of the facility. — housekeeping The reporting structure must, however, ensure the — maintenance infection control team has appropriate authority to manage an effective infection control programme. — clinical microbiology laboratory In large facilities, this will usually mean a direct re- periodically reviewing the status of nosocomial porting relationship with senior administration. infections and effectiveness of interventions to The infection control team or individual is respon- contain them sible for the day-to-day functions of infection con- reviewing, approving, and implementing policies trol, as well as preparing the yearly work plan for approved by the Infection Control Committee review by the infection control committee and ad- ministration. These individuals have a scientific and ensuring the infection control team has authority technical support role: e.g. surveillance and research, to facilitate appropriate programme function developing and assessing policies and practical participating in outbreak investigation. supervision, evaluation of material and products, control of sterilization and disinfection, implemen- tation of training programmes. They should also 2.3.2 Role of the physician support and participate in research and assessment Physicians have unique responsibilities for the pre- programmes at the national and international vention and control of hospital infections: levels. by providing direct patient care using practices which minimize infection 2.2.3 Infection control manual by following appropriate practice of hygiene A nosocomial infection prevention manual (3), com- (e.g. handwashing, isolation) piling recommended instructions and practices for serving on the Infection Control Committee patient care, is an important tool. The manual should be developed and updated by the infection control supporting the infection control team. team, with review and approval by the committee. 10  CHAPTER II. INFECTION CONTROL PROGRAMMES Specifically, physicians are responsible for: 2.3.4 Role of the hospital pharmacist (5) protecting their own patients from other infected The hospital pharmacist is responsible for: patients and from hospital staff who may be in- obtaining, storing and distributing pharmaceuti- fected cal preparations using practices which limit complying with the practices approved by the potential transmission of infectious agents to Infection Control Committee patients obtaining appropriate microbiological specimens dispensing anti-infectious drugs and maintain- when an infection is present or suspected ing relevant records (potency, incompatibility, conditions of storage and deterioration) notifying cases of hospital-acquired infection to the team, as well as the admission of infected pa- obtaining and storing vaccines or sera, and mak- tients ing them available as appropriate complying with the recommendations of the An- maintaining records of antibiotics distributed to timicrobial Use Committee regarding the use of the medical departments antibiotics providing the Antimicrobial Use Committee and advising patients, visitors and staff on techniques Infection Control Committee with summary re- to prevent the transmission of infection ports and trends of antimicrobial use instituting appropriate treatment for any infec- having available the following information on tions they themselves have, and taking steps to disinfectants, antiseptics and other anti-infectious prevent such infections being transmitted to other agents: individuals, especially patients. — active properties in relation to concentration, temperature, length of action, antibiotic spec- trum 2.3.3 Role of the microbiologist (4) — toxic properties including sensitization or The microbiologist is responsible for: irritation of the skin and mucosa handling patient and staff specimens to maximize — substances that are incompatible with anti- the likelihood of a microbiological diagnosis biotics or reduce their potency developing guidelines for appropriate collection, — physical conditions which unfavourably affect transport, and handling of specimens potency during storage: temperature, light, ensuring laboratory practices meet appropriate humidity standards — harmful effects on materials. ensuring safe laboratory practice to prevent in- The hospital pharmacist may also participate in the fections in staff hospital sterilization and disinfection practices performing antimicrobial susceptibility testing through: following internationally recognized methods, and participation in development of guidelines for providing summary reports of prevalence of re- antiseptics, disinfectants, and products used for sistance washing and disinfecting the hands monitoring sterilization, disinfection and the participation in guideline development for reuse environment where necessary of equipment and patient materials timely communication of results to the Infection participation in quality control of techniques used Control Committee or the hygiene officer to sterilize equipment in the hospital including epidemiological typing of hospital microorgan- selection of sterilization equipment (type of isms where necessary. appliances) and monitoring. 11  PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE — WHO/CDS/CSR/EPH/2002.12 2.3.5 Role of the nursing staff participating in outbreak investigation Implementation of patient care practices for infec- development of infection control policy and tion control is the role of the nursing staff. Nurses review and approval of patient care policies should be familiar with practices to prevent the relevant to infection control occurrence and spread of infection, and maintain ensuring compliance with local and national regu- appropriate practices for all patients throughout the lations duration of their hospital stay. liaison with public health and with other facili- The senior nursing administrator is responsible for: ties where appropriate participating in the Infection Control Committee providing expert consultative advice to staff health promoting the development and improvement of and other appropriate hospital programmes in nursing techniques, and ongoing review of asep- matters relating to transmission of infections. tic nursing policies, with approval by the Infec- tion Control Committee 2.3.6 Role of the central sterilization service developing training programmes for members of the nursing staff A central sterilization department serves all hospital areas, including the operating suite. An appropri- supervising the implementation of techniques for ately qualified individual must be responsible for the prevention of infections in specialized areas management of the programme. Responsibility for such as the operating suite, the intensive care unit, day-to-day management may be delegated to a nurse the maternity unit and newborns or other individual with appropriate qualifications, monitoring of nursing adherence to policies. experience, and knowledge of medical devices. The nurse in charge of a ward is responsible for: The responsibilities of the central sterilization service are to clean, decontaminate, test, prepare for use, steri- maintaining hygiene, consistent with hospital lize, and store aseptically all sterile hospital equip- policies and good nursing practice on the ward ment. It works in collaboration with the Infection monitoring aseptic techniques, including hand- Control Committee and other hospital programmes washing and use of isolation to develop and monitor policies on cleaning and reporting promptly to the attending physician any decontamination of: evidence of infection in patients under the nurse’s reusable equipment care contaminated equipment initiating patient isolation and ordering culture including specimens from any patient showing signs of a communicable disease, when the physician is not — wrapping procedures, according to the type immediately available of sterilization limiting patient exposure to infections from visi- — sterilization methods, according to the type of tors, hospital staff, other patients, or equipment equipment used for diagnosis or treatment — sterilization conditions (e.g. temperature, du- maintaining a safe and adequate supply of ward ration, pressure, humidity) (see Chapter V). equipment, drugs and patient care supplies. The director of this service must: The nurse in charge of infection control is a member of the oversee the use of different methods — physical, infection control team and responsible for : chemical, and bacteriological — to monitor the identifying nosocomial infections sterilization process investigation of the type of infection and infect- ensure technical maintenance of the equipment ing organism according to national standards and manufactur- ers’ recommendations participating in training of personnel report any defect to administration, maintenance, surveillance of hospital infections infection control and other appropriate personnel 12  CHAPTER II. INFECTION CONTROL PROGRAMMES maintain complete records of each autoclave run, distribution of working clothes and, if necessary, and ensure long-term availability of records managing changing rooms collect or have collected, at regular intervals, all developing policies for the collection and trans- outdated sterile units port of dirty linen communicate, as needed, with the Infection defining, where necessary, the method for disin- Control Committee, the nursing service, the op- fecting infected linen, either before it is taken to erating suite, the hospital transport service, the laundry or in the laundry itself pharmacy service, maintenance, and other appro- developing policies for the protection of clean priate services. linen from contamination during transport from the laundry to the area of use 2.3.7 Role of the food service (see Chapter VIII) developing criteria for selection of site of laundry services: The director of food services must be knowledgeable in food safety, staff training, storage and preparation — ensuring appropriate flow of linen, separation of foodstuffs, job analysis, and use of equipment. of “clean” and “dirty” areas The head of catering services is responsible for: — recommending washing conditions (e.g. tem- perature, duration) defining the criteria for the purchase of foodstuffs, equipment use, and cleaning procedures to main- — ensuring safety of laundry staff through tain a high level of food safety prevention of exposure to sharps or laundry contaminated with potential pathogens. ensuring that the equipment used and all work- ing and storage areas are kept clean issuing written policies and instructions for 2.3.9 Role of the housekeeping service (see 5.3) handwashing, clothing, staff responsibilities and The housekeeping service is responsible for the regu- daily disinfection duties lar and routine cleaning of all surfaces and main- ensuring that the methods used for storing, pre- taining a high level of hygiene in the facility. In paring and distributing food will avoid contami- collaboration with the Infection Control Committee nation by microorganisms it is responsible for : issuing written instructions for the cleaning of classifying the different hospital areas by varying dishes after use, including special considerations need for cleaning for infected or isolated patients where appropri- developing policies for appropriate cleaning tech- ate niques ensuring appropriate handling and disposal of — procedure, frequency, agents used, etc., for each wastes type of room, from highly contaminated to establishing programmes for training staff in food the most clean, and ensuring that these prac- preparation, cleanliness, and food safety tices are followed establishing a Hazard Analysis of Critical Control developing policies for collection, transport and Points (HACCP) programme, if required. disposal of different types of waste (e.g. contain- ers, frequency) ensuring that liquid soap and paper towel dis- 2.3.8 Role of the laundry service (see Chapter VIII) pensers are replenished regularly The laundry is responsible for: informing the maintenance service of any build- selecting fabrics for use in different hospital ing problems requiring repair: cracks, defects in areas, developing policies for working clothes in the sanitary or electrical equipment, etc. each area and group of staff, and maintaining caring for flowers and plants in public areas appropriate supplies pest control (insects, rodents) 13  PREVENTION OF HOSPITAL-ACQUIRED INFECTIONS: A PRACTICAL GUIDE — WHO/CDS/CSR/EPH/2002.12 providing appropriate training for all new staff — testing autoclaves (temperature, pressure, members and, periodically, for other employees, vacuum, recording mechanism) and regular and specific training when a new technique is maintenance (cleaning the inner chamber, introduced emptying the tubes) establishing methods for the cleaning and disin- — monitoring the recording thermometers of fection of bedding (e.g. mattresses, pillows) refrigerators in pharmacy stores, laboratories, the blood bank and kitchens determining the frequency for the washing of curtains, screening curtains between beds, etc. — regularly inspecting all surfaces — walls, floors, ceilings — to ensure they are kept smooth and reviewing plans for renovations or new furniture, washable including special patient beds, to determine fea- sibility of cleaning. — repairing any opening or crack in partition walls or window frames There should be a continuing programme for staff training.This programme should stress personal — maintaining hydrotherapy appliances hygiene, the importance of frequent and careful — notifying infection control of any anticipated washing of hands, and cleaning methods (e.g. interruption of services such as plumbing or sequence of rooms, correct use of equipment, dilu- air conditioning. tion of cleaning agents, etc.). Staff must also under- stand causes of contamination of premises, and how to limit this, including the method of action of dis- 2.3.11 Role of the infection control team infectants. Cleaning staff must know to contact staff (hospital hygiene service) health if they have a personal infection, especially infections of the skin, digestive tract and respiratory The infection control programme is responsible for tract. oversight and coordination of all infection control activities to ensure an effective programme. The hospital hygiene service is responsible for: 2.3.10 Role of maintenance organizing an epidemiological surveillance pro- Maintenance is responsible for: gramme for nosocomial infections collaborating with housekeeping, nursing staff or participating with pharmacy in developing a pro- other appropriate groups in selecting equipment gramme for supervising the use of anti-infective and ensuring early identification and prompt cor- drugs rection of any defect ensuring patient care practices are appropriate to inspections and regular maintenance of the the level of patient risk plumbing, heating, and refrigeration equipment, and electrical fittings and air conditioning; records checking the efficacy of the methods of disinfec- should be kept of this activity tion and sterilization and the efficacy of systems developed to improve hospital cleanliness developing procedures for emergency repairs in essential departments participating in development and provision of teaching programmes for the medical, nursing, ensuring environmental safety outside the hos- and allied health personnel, as well as all other pital, e.g. waste disposal, water sources. categories of staff Additional special duties include: providing expert advice, analysis, and leadership — participation in the choice of equipment if in outbreak investigation and control maintenance of the equipment requires tech- participating in the development and operation nical assistance of regional and national infection control initia- — inspection, cleaning and regular replacement tives of the filters of all appliances for ventilation the hospital hygiene service may also provide and humidifiers assistance for smaller institutions, and undertake research in hospital hygiene and infection con- 14  CHAPTER II. INFECTION CONTROL PROGRAMMES trol at the facility, local, national, or international level. References 1. Haley RW et al. The efficacy of infection surveil- lance and control programs in preventing noso- comial infections in US hospitals. Am J. Epidem, 1985, 121:182–205. 2. Schechler WE et al. Requirements for infrastruc- ture and essential activities of infection control and epidemiology in hospitals: a consensus panel report. Society of Healthcare Epidemiology of America. Infect Control Hosp Epidemiol, 1998, 19:114– 124. 3. Savey A, Troadec M. Le Manue