Infection Prevention and Control PDF

Omar Abdelrazig Abdalla Medical microbiologist objectives  By the end of this course the student should be able to :  Describe infections and chain of infection and nosocomial infections.  Define contact, droplet, and airborne transmission.  Outline the control program and campaign (i...

Omar Abdelrazig Abdalla Medical microbiologist objectives  By the end of this course the student should be able to :  Describe infections and chain of infection and nosocomial infections.  Define contact, droplet, and airborne transmission.  Outline the control program and campaign (infection control committee and team)  Outline routine practice and additional precautions in all health care settings.  Enlist the criteria for perceptional health and hazards.  Describe occupational immunization and its impotence.  Describe types of nosocomial infections and strategies of surveillance.  Describe the main points of hospital constructions.  Describe the application of infection control in medical laboratories.  Introduction & historical background.  Definition of Terminology & Concepts objectives  IPC objectives.  Causes of infections.  Cycles of infections.  Universal precautions for infection prevention.  Hands hygiene.  Isolation.  Immunization.  Environmental hygiene.  Use of personal protective equipment (PPE).  Safe practice regarding (IPC).  Identification Means of Transmission  Identification of Risk Factors  Discussing Infection Control Policies and Procedures  Implementing infection control measures at work place  The very first requirement in a hospital is that it should do the sick no harm History of infection control and hospital epidemiology  Pre 1800: Early efforts at wound prophylaxis  1800-1940: Nightingale, Semmelweis, Lister, Pasteur  1940-1960: Antibiotic era begins, Staph. aureus nursery outbreaks, hygiene focus  1960-1970’s: Documenting need for infection control programs, surveillance begins  1980’s: focus on patient care practices, intensive care units, resistant organisms, HIV  1990’s: Hospital Epidemiology = Infection control, quality improvement and economics  2000’s: ??Healthcare system epidemiology 6 Florence Nightingale  The first infection prevention and control champion  Research into hospital sanitary problems made her a firm believer in pure air, pure water, efficient drainage, cleanliness, and light  Nightingale’s firm belief in preventive medicine led to an established standard of formalized cleanliness and sanitation in hospitals and the military 7 Infection Prevention and Control Programs  The earliest formal programs were in the 1950s  Began as an effort to address issues like staphylococcal epidemics  The first Infection Control Nurses were appointed at this time; they often had a background in bacteriology  Surveillance of hospital infections was instituted and policies and procedures developed  Early infection control programs focused on environmental cleanliness  Antimicrobial resistant pathogens became a concern in the 1970s 8 Healthcare-Associated Infections  HAIs include urinary tract infections, pneumonia, bloodstream infections and surgical site infections  The WHO states urinary tract infection is the most frequent HAI in high-income countries; surgical site infections in settings with limited resources* 9 Healthcare-Associated Infections (HAI)  30% of patients in intensive care units (ICU) are affected by at least one HAI in high-income countries  In low- and middle-income countries the frequency of ICU-acquired infection is at least 23 fold higher*  Newborns are at higher risk of acquiring HAI in developing countries, with infection rates three to 20 times higher than in high-income countries* 10 Goals of IP&C  To prevent the spread of infections from  patient-to-patient  patients to health care providers  health care providers to patients  health care providers to health care providers and to visitors and others in the health care environment CONSEQUENTLY  To protect patients from HAIs, resulting in  improved survival rates  reduced morbidity associated with infections  shorter length of hospital stay  a quicker return to good health 11 Functions of IP&C  To obtain and manage critical data and information  To implement evidence-based practice, standards and guidelines through setting-specific policies and procedures  To intervene directly to prevent infections  To provide effective occupational health programs  To educate and train healthcare workers, patients, and non-medical caregivers  To provide communication of infection-related issues and relevant practices to leaders and staff to facilitate improvements  To evaluate the program and improve it as necessary 12 Practice of IP&C Today  Surveillance  Outbreak investigations  Prevention through practices/guidelines hand hygiene, use of barriers, isolation/precautions, construction/renovation, sterilisation/disinfection, antibiotic resistance, blood-borne pathogens, food/water/air safety, cleaning  Antibiotic use  Education  Occupational health  Audits 13 The risk of infection is always present.  Patient may acquire infection before admission to the hospital = Community acquired infection.  Patient may get infected inside the hospital = Nosocomial infection.  It includes infections  not present nor incubating at admission,  infections that appear more than 48 hours after admission,  those acquired in the hospital but appear after discharge  also occupational infections among staff. INFECTION  Definition: Injurious contamination of body or parts of the body by bacteria, viruses, fungi, protozoa and rickettsia or by the toxin that they may produce.  Infection may be local or generalized and spread throughout the body.  Once the infectious agent enters the host it begins to proliferate and reacts with the defense mechanisms of the body producing infection symptoms and signs: pain, swelling, redness, functional disorders, rise in temperature and pulse rate and leucocytosis. Frequency of Nosocomial Infection  Nosocomial infections occur worldwide.  The incidence is about 5-8% of hospitalized patients, 1/3 of which is preventable.  The highest frequencies are in East Mediterranean and South-East Asia.  A high frequency of N.I. is evidence of poor quality health service delivered. Impact of Nosocomial Infections  They lead to functional disability and emotional stress to the patient.  They lead to disabling conditions that reduce the quality of life.  They are one of the leading causes of death.  The increased economic costs are high: Increased length of hospital stay , extra investigations, extra use of drugs and extra health care by doctors and nurses. Nosocomial Infections Cost  The cost varies according to the type and severity of these infections.  An estimated 1 to 4 extra days for a urinary tract infection, 7 – 8 days for a surgical site infection, 7 – 21 days for a blood stream infection, and 7 – 30 days for pneumonia.  The CDC has recently reported that US$5 billion are added to US health costs every year as a result of NI.  In Egypt one LE spent for infection control saves LE 60 spent on NI. Nosocomial Infection Sites  Urinary tract infection: most common type of N I (30-40% of reported cases), associated with an indwelling urinary catheter or instrumentation.  Lower respiratory and surgical wound infections are the next ( each about 15%).  Less frequent include bacteraemia (5%), intravenous site infection, gastrointestinal tract and skin infections.  Criteria of Nosocomial Infections Surgical site infection Any purulent discharge, abscess or spreading cellulitis at the surgical site during the month after operation Urinary infection Positive urine culture (1 or 2 species) with at least 100000 bacteria/ml, with or without clinical symptoms Respiratory infection Respiratory symptoms with at least 2 signs: cough; purulent sputum; new infiltrate on chest, appearing during hospitalization Vascular catheter Inflammation, lymphangitis or infection purulent discharge at the insertion site Septicaemia Fever or rigours and at least one positive blood culture Factors Influencing N.I.  The microbial agent  Patient susceptibility  Environmental factors  Chain of Infection + Quantity of Virulence Routes of Portal of Susceptible pathogen transmission entry into host host Microbial Agent  Many sick people are treated in a closed area; micro- organisms, frequent contact between carriers & susceptible, contaminated waste, equipment and supplies to be handled.  Developing of clinical disease depends on organism s virulence, infective dose and patient resistance Bacteria are the most common pathogens. 1. Commensal bacteria: found in normal flora of healthy humans, prevent pathogenic bacterial colonization eg skin, colon, vagina 2. Pathogenic bacteria: have great virulence and cause infection as : - Anaerobic gram +ve rods e.g Clostridium causing gangrene. - Gram +ve bacteria: Staph. aureus found on skin &nose. - Beta -hemolytic Strep. - Gram -ve bacteria as E.coli, Proteus, Klebsiella. - legionella species.  Viruses: HIV, HBV, HCV can be also be transmitted through blood & B F (transfusion, injections, dialysis)  respiratory syncytial virus, rota virus, ebola, infleunza, herpes simplex viruses.  Parasites & Fungi: e.g. Giardia lamblia is easily transmitted between adults or children, Aspergillus sp. affecting imunocompromised.  Scabies an ectoparasite causing outbreak. Patient Susceptibility  Age: infants and old age have decreased resistance to infection.  Immune status: Patients with chronic diseases as malignancy, leukaemia, diabetes mellitus, renal failure or AIDS have increased susceptibility to infection.  Immunosuppressive drugs or irradiation Environmental Factors  Healthcare settings are environment where both infected persons and persons at high risk of infection congregate.  Crowded conditions within hospital, frequent transfers of patients between units.  Microbial flora may contaminate objects, devices and materials which subsequently contact susceptible body sites of patients.  Transmission  Where do nosocomial infection come from?  Endogenous infection: When normal patient flora change to pathogenic bacteria because of change of normal habitat, damage of skin and inappropriate antibiotic use. About 50% of N.I. Are caused by this way.  Exogenous cross-infection: Mainly through hands of healthcare workers, visitors, patients. Exogenous environmental infections: several types of micro-organisms survive well in the hospital environment (hospital flora): * In water, damp areas and occasionally in sterile products or disinfectants eg pseudomonas, Acinetobacter, Mycobacterium. * On items such as linen, equipment and supplies * In food. * In fine dust and droplet nuclei Some procedures that save life may increase risk of infection e.g urinary catheters, I.V.L inhalation therapy, surgery. Inappropriate use of antibiotics. Basics of Infection Control  Prevention of nosocomial infection is the responsibility of all individuals and services provided by healthcare setting.  To practice good asepsis, one should always know: what is dirty, what is clean, what is sterile and keep them separate.  Hospital policies & procedures are applied to prevent spread of infection in hospital. Infection Control Program  A comprehensive, effective and supported program is essential for reducing infection risk and increasing hospital safety.  It should include surveillance, preventive activities and staff training.  I. National program developed by Ministry of Health: to support hospital programs. It sets national objectives, develops and updates guidelines recommended for health care. II. Hospital programs including: 1) major preventive efforts; keeping in mind patients and staff. 2) It must be supported by senior management and provided with sufficient resources. 3) It must develop a yearly work plan to assess and promote all good health care activities.  Hospital Program InfectionConrtol Team Infectioncontrol committee Infectioncontrol manual  Infection Control Team  The optimal structure varies with hospitals types, needs and resources.  Hospital can appoint epidemiologist or infectious disease specialist, microbiologist to work as infection control physician.  Infection control nurse who is interested and has experience in infection control issues.  Team should have authority to manage an effective control program.  Team should have a direct reporting with senior administration.  Infection control team members or are responsible for day-to-day functions of IC and preparing the yearly work plan.  They should be expert and creative in their job.  Infection Control Committee  It includes representatives from different concerned hospital departments & management. They meet bimonthly.  It establishes standards for patient care, it reviews and assesses IC reports and identifies areas of intervention.  It is a multidisciplinary committee responsible for monitoring program policies implementation and recommend corrective actions. Infection Control Manual  Every Hospital should have a nosocomial infection prevention manual compiling recommended instructions and practices for patient care.  This manual should be developed and updated in a timely manner by the infection control team.  It is to be reviewed and accepted by infection control committee. Infection Control Responsibility  Role of every hospital department and service units must be identified, documented as manuals kept in accessible place.  Job description of every hospital staff; defining details of his duties must be discussed before employment. Infection control precautions should be part of the routine work and stressed for that.  Program Components Surveillance Preventive Activities Staff Training NOSOCOMIAL INFECTION SURVEILLANCE  Nosocomial infection rate in a hospital is an indicator of quality and safety of care.  Surveillance to monitor this rate is essential to identify problems and evaluate control activities  The ultimate aim is the reduction of infection rate and their costs.  The term surveillance implies that observational data are regularly analyzed. Organization for surveillance Datacollectionandanalysis Ward activity Laboratoryreports Data elements &analysis devicesor procedures culture&sensitivity patient data&infection fever &inf. signs resistance patterns population &risks antibiotics &charts serologic tests computerizationof data Key points in Surveillance  Active surveillance (Prevalence and incidence studies)  Targeted surveillance (site, unit, priority-oriented)  Appropriately trained investigators  Standardized methodology  Risk- adjusted rates for comparisons Organization for surveillance Feedback&dissemenation prompt, releventtotarget group Meetings&disscussions Dissemenationbycommittee Scope of Infection Control Aiming at preventing spread of infection: Standard precautions: these measures must be applied during every patient care, during exposure to any potentially infected material or body fluids as blood and others. Components: A. Hand washing. B. Barrier precautions. C. Sharp disposal. D. Handling of contaminated material. Definition of Terminology & Concepts Infectious agent Anything that may be transmitted from one person to another, or from the environment to a person, and subsequently cause an infection or parasitic infestation. Infectious agents are most often micro-organisms such as bacteria or viruses. Pathogen A micro-organism that is capable of causing infection. Many micro- organisms are opportunistic pathogens; that is, they will cause infection in vulnerable individuals but not, normally, in healthy adults. Colonization When micro-organisms are present on or in a person but not currently causing any harm, that person is said to be colonized with those organisms. For example, human beings are normally colonized with huge numbers of several different species of bacteria. Definition of Terminology & Concepts Healthcare-associated infection (HCAI) Any infection acquired as a result of a healthcare-related intervention or an infection acquired during the course of healthcare that the patient may reasonably expect to be protected from. For example, a person may acquire viral gastroenteritis in many circumstances but if they acquire it in hospital from another patient, it should be regarded as healthcare associated. This has Replaced the term ‘hospital- acquired infection’. Cross-infection Cross-infection is one term given to the transmission of infectious agents between patients within the healthcare setting. It may be direct transmission from one person to another, or indirect, for example via an incorrectly cleaned piece of equipment. Definition of Terminology & Concepts Universal precautions Correctly called universal blood and body fluid precautions, these are the precautions that are taken with all blood and ‘high-risk’ body fluids. They are based on the principle that any individual may be infected with a blood borne virus, such as HIV or hepatitis B, and so pose a risk of infection; no individual can be regarded as completely ‘risk free’. They are incorporated within standard precautions. Standard precautions The phrase ‘standard precautions’ is sometimes used interchangeably with ‘universal precautions’ to describe the actions that should be taken in every care situation to protect patients and others from infection, regardless of what is known of the patient’s status with respect to infection.  Definition of Terminology & Concepts Standard precautions include: hand hygiene at the ‘5 moments’ described by the WHO (2009) , including before and after each patient contact care in the use and disposal of sharps the correct use of personal protective equipment for contact with all blood, body fluids, secretions and excretions (except sweat) providing care in a suitably clean environment with adequately decontaminated equipment the safe disposal of waste the safe management of used linen. Definition of Terminology & Concepts Transmission-based precautions Additional infection control precautions taken with patients known or strongly suspected to be infected or colonized with organisms that pose a significant risk to other patients. The precautions will vary depending on the route by which the organism travels from one individual to another, but there will be common elements. Transmission-based precautions can be divided into: contact enteric droplet airborne. Droplet precautions Additional infection control precautions taken with patients known or strongly suspected to be infected or colonized with pathogenic micro-organisms that are mainly transmitted via droplets of body fluid expelled by an infected person. These are most often respiratory secretions expelled during coughing and sneezing but can include droplets from other sources such as projectile vomiting or explosive diarrhea. The droplets are relatively large and do not remain suspended in the air for long so special ventilation is not normally required. Droplet precautions consist of isolation of the patient in a single room with the door closed and use of gloves and apron for any procedure involving contact with the patient or their immediate environment. Airborne precautions Additional infection control precautions taken with patients known or strongly suspected to be infected or colonized with pathogenic micro-organisms that are mainly transmitted through the airborne route. These organisms are present in smaller droplets expelled by an infected person and so remain suspended in the air. Droplet precautions consist of prompt isolation of the patient in a single room, if possible with negative pressure ventilation or a positive pressure lobby, with the door closed, and use of gloves and apron for any procedure involving contact with the patient or their immediate environment. Staff entering the room should wear a fitted respirator. Definition of Terminology & Concepts Isolation Isolation is the practice of nursing a patient in a single- occupancy room to reduce the risk of spread of pathogens and to reinforce and facilitate additional infection control precautions. Source isolation The practice of isolating a patient for the main purpose of preventing the spread of organisms from that patient. Protective isolation The practice of isolating a patient for the main purpose of preventing the spread of organisms to that patient, normally used for patients with impaired immune systems.  Definition of Terminology & Concepts Cohorting When the number of patients with a particular infection or carrying a particular organism exceeds the single room capacity of a healthcare provider, they may be nursed together in a cohort. This is most often done for highly infectious conditions such as norovirus. Patients who require isolation but have different infections cannot be cohort nursed together because of the risk of cross-infection between them. Barrier nursing The practice of nursing a patient who is carrying an infectious agent that may be a risk to others in such a way as to minimize the risk of transmission of that agent to others. Reverse barrier nursing The practice of nursing an individual who is regarded as being particularly vulnerable to infection in such a way as to minimize the transmission of potential pathogens to that person. Objectives  Learn about the basic principles of infection and disease.  Understand how disease is transmitted.  Review infection control measures. 56 Disease Causation HOST Types of AGENTS ENVIRONMENTAL Characteristics Factors Age Biologic – bacteria, virus, Housing – crowding, noise molds Gender Chemical – poison, alcohol Air – temperature, humidity Occupation Physical - trauma, fire Water , food Race Marital status Genetic profile 57  Definition of Terms Host: living animal or plant Agent: something that produces or is capable of producing an effect, i.e. infection Vector: an organism (as an insect) that transmits an agent from one organism or source to another Vehicle: inanimate object (food, water, etc) that can carry an agent from one organism to another 58 58 Definition of Terms Disease: impairment of normal functioning, manifested by signs and symptoms Infection: the state produced by the establishment of an infective agent in or on a suitable host , host may or may not have signs or symptoms Carrier: individual harbors the agent but does not have symptoms. Person can infect others. Reservoir: habitat (man, animal, etc.) in which the agent normally lives, grows, and multiplies 59  Consequences of Nosocomial Infections  Additional morbidity  Prolonged hospitalization  Long-term physical, developmental and neurological sequelae  Increased cost of hospitalization  Death 60 Challenges to the hospital epidemiologist Make a hospital safe  Prevent harm to the patient and employees  initial focus on infectious diseases  increasingly all adverse (harmful) events are targets  Improve hospital efficiency  Eliminate unnecessary costs  Eliminate wasteful practices 61 Chain of Infection: Transmission Portal of Portal Exit of Entry Reservoir Host Susceptibility Infectious Agent Pathogens Pathogenic organisms can be:  Bacteria  Viruses  Fungi  Parasites  Protozoa. Vulnerable people  Some groups of people may be more vulnerable to infection, for example because of age or ill or general health  If these groups become infected the symptoms may be serious and life-threatening. Micro-organisms that are resistant to antibiotics can make it difficult to treat the illness. Chain of infection In order for the spread of infectious diseases to take place, the ‘chain of infection’ must be completed. Breaking the chain  Preventing infection means breaking the links in the chain so that an infection cannot spread  Not everybody who carries harmful micro-organisms will show symptoms  Examples of standard precautions taken in EVERY situation to reduce the risk of infection: Good hand hygiene Safe disposal of waste Safe management of laundry Correct use of Personal Protective Equipment (PPE). Your health and hygiene You have an important role to play in preventing the spread of infections  Vaccinations  Illness  Clothing  Personal hygiene  Skin health  Good hand habits. Disease Transmission 68  Mode of Transmission Route Example Disease Direct contact Kissing, sexual contact, skin-to-skin STDs, skin infections, scabies contact Droplet Organism on large respiratory droplets that Mumps, pertussis (whooping people sneeze, cough, drip, or exhale. cough), common cold, ‘strep Disease spread when people are close to throat’, meningitis each other (usually