Basic concepts of infection

prevention and control

By:
Dr Rania [Link]
Assist. prof. of microbiology and immunology
Infection Prevention and Control Consultant
Pretest
 Health care associated infections
or Community Acquired infection
1- Infections appear after 24 h of admission.
2- Patient admitted with pneumonia caused by
klebsiella, 3 days after admission he develops
blood stream infection caused by Klebsiella.
3- Patient admitted with skin abscess.
4- signs of infections appear during 48 h after
hospital discharge
 Health care associated infections
or Community Acquired infection
5- Day 1: Patient admitted to ICU, no signs of
infection
• Day 3: patient transported to internal
medicine department
• Day 4: signs of pneumonia
 Health care associated infections
or Community Acquired infection
6- neonate with group B strept infection 4 h
after delivery.
7- neonate born with rubella
8- neoborn with signs of CMV infection 6 h after
delivary
9- HBV infection due to unsafe injection
10- HCV transmitted to patient in the endoscopy
unit due to sharing of single dose vial
 Team or committee
1- develop an annual IC plan with clearly defined
objective
2- review and approve the infection control
policies
3- prepare an action plan for implementation
4- organize an epidemiological surveillance
program for HAIs
5- implement the infection control training
activities
 Team or committee
6- ensure availability of appropriate supplies
7- review and approve the annual plan for infection
control
8- develop written policies and procedures,
including regular evaluation and update
9- review epidemiological surveillance data and
identify areas for intervention
10- scientific and technical support role in
purchasing & monitoring of equipment and supplies
 Team or committee
11- communicate and cooperate with other
committees of the hospital
12- supervise and to monitor daily practices of
patient care
13- review infectious risks associated with new
technologies, new devices and new products
14- develop an annual training plan for the
health care workers
15- Participate in the audit activity
 Why infection control?
We have:
 Infection: HAI- MDROs- Outbreak - Emerging and
re-emerging infections
 Misbehaviours: Carelessness, bad attitudes, non
compliance
 Misconceptions:
✓ Incidence of infection in the facility.
✓ Prevalence of infection in the community.
✓ The mode of transmission of infections.
✓ The cost of IC practices
Introduction
 Why infection control?
Is it optional? MUST
1. Professionally: at most care – quality -
accreditation.
2. Ethically: the role of HCW is to combat not to
spread infection
3. Financially: an extra day of hospital stay costs 500
dollars
4. Religiously.: first do no harm = ‫ال ضرر وال ضرار‬
Possible cross contamination between
Patient A and Patient B
What will be our mission?
 To protect or to identify and reduce risks of acquiring &
transmitting infection among patients, staff & others (relatives,
visitors, environment…)

 WHO can carry on this mission?

 Together.
 Everyone
 Achieve
 More
How to organize & make it sustainable?

Be system wise:

 Organizational structure should be established.

 Current status is the starting point

What is the Current Status of infection

control?
 We might have:
1. Lack of organizational structure.
2. Lack of written policies and procedures.
3. Lack of resources.
4. Lack of knowledge.
5. Lack of communication.
6. Lack of top management commitment.
7. Lack of concepts (misconceptions)
8. Lack of compliance.
9. Lack of rewarding system.
10. Lack of control.
Definition of HAIs
 Infection: Entry and multiplication of an infectious
agent in the tissues of the host

1. Inapparent (asymptomatic, subclinical) infection:

an infectious process running a course similar to
that of clinical disease but below the threshold of
clinical symptoms
2. Apparent (symptomatic, clinical) infection:
one resulting in clinical signs and symptoms
(disease)
Healthcare Associated Infections
(Nosocomial infections)
 HAI is an infection that is acquired in a medical setting in the
course of medical treatment

 HAI is an infection meeting the following criteria:

➢ Infections that can be acquired during receiving medical treatment in a
healthcare facility
➢ Infections occurring more than 48 hours after admission are usually
considered HAIs
➢ An infection acquired in hospital by a patient who was admitted for a
reason other than that infection
➢ An infection occurring in a patient in a hospital or other health care
facility in whom the infection was not present or incubating at the time
of admission.
 Community-acquired infection

1. An infection present on admission

2. An infection incubating at the time of admission
to a health-care facility with no association to
previous hospitalization at the same facility
Sources of HAIs
 HAIs can come from either endogenous or exogenous sources

(I) Endogenous infections

 Endogenous infections are ones caused by
opportunistic pathogens that come from a patient's
own normal flora
 Endogenous infections may be acquired due to : -
(i) Patients being immunologically depressed
(ii) In the course of an invasive procedure
(iii) Due to injury
Sources of HAIs
 Exogenous infections
 Exogenous infections come from sources outside of the patient's own
body
 An important factor in exogenous infections is the presence within
hospitals of pathogens that are particularly capable of infecting
individuals in presence of the above risk factors (i.e., compromised
hosts)
 Many of these pathogens possess antibiotic resistance
 Such hospital-specific pathogens can be found incorporated among the
normal flora of staff or on fomites
Other important principles upon which HAIs
definitions are based:
First (available information)
 The information used to determine the presence and classification
of an infection should be a combination of:-
1. clinical findings,
2. Laboratory evidence, and.
3. Supportive data
4. Clinical evidence is derived from direct observation of the
infection site or review of other pertinent sources of data, such
as the patient’s chart
 Second, (a physician’s or surgeon’s diagnosis)
1. a physician’s or surgeon’s diagnosis of infection derived
from direct observation during a surgical operation,
endoscopic examination, or other diagnostic studies or
from clinical judgment is an acceptable criterion for an
infection, unless there is compelling evidence to the
contrary
2. For certain sites of infection, however, a physician’s clinical
diagnosis in the absence of supportive data must be
accompanied by initiation of appropriate antimicrobial
therapy to satisfy the criterion.
HCAI
 There are two special situations in which
an infection is considered HAI:
1. infection that is acquired in the hospital but
does not become evidence until after hospital
discharge
2. infection in a neonate that results from passage
through the birth canal.
HCAI
 There are two special situations in which an
infection is not considered HCAI:
1. infection that is associated with a complication or extension
of infection already present on admission, unless a change
in pathogen or symptoms strongly suggests the acquisition
of a new infection
2. in an infant, an infection that is known or proved to have
been acquired transplacentally (e.g., toxoplasmosis,
rubella, cytomegalovirus, or syphilis) and becomes evident
at or before 48 hours after birth.
 There are two conditions that are not
infections
1) Colonization, which is the presence of
microorganisms (on skin, mucous membranes, in
open wounds, or in excretions or secretions) that
are not causing adverse clinical signs or symptoms.

2) Inflammation, which is a condition that results

from tissue response to injury or stimulation by
noninfectious agents, such as chemicals.
Colonization vs. contamination

 Colonization
 Presence of microorganisms in or on a host with growth
and multiplication but without tissue invasion or damage

 Contamination
 The presence of microorganisms on inanimate objects
(e.g., clothing, surgical instruments) or in substances
(e.g., water, food, milk)
 Colonization vs. infection

 Colonization
 No cellular injury results

 Infection
 The entry and multiplication of an infectious agent
in the tissues of the host
Chain of infection
 HCAI
 Infected patients:
1. have longer hospital stays
2. are treated with less effective drugs that are
more toxic and/or more expensive
3. some patients will not recover and others
may develop long-term complications.
 HCAI
 Hundreds of millions of patients are affected by HCAI
worldwide each year, leading to significant mortality
and financial losses for health systems and patients.
 In developed countries, HCAI affects 5-15% of
hospitalized patients and 9-37% of intensive care units
(ICU) patients.
 Approximately 5 million HCAIs are estimated to
occur in acute care hospitals in Europe annually,
resulting in 25 million extra days in hospital.
 HCAI
 The risk of surgical site infections (SSI) in developing
countries is significantly higher than in the developed
world. Pooled cumulative incidence of SSI was 5.6
per 100 surgical procedures, which was the leading
infection in hospitals.
 In Europe HCAI represents an economic burden of
13–24 billion Euros annually.
 The annual economic cost of HCAI in the USA in
2004 was approximately US$ 6.5 billion
Basic infection control measures
 hand hygiene is the most effective overall
infection control measure

 Recent recommendations include two

levels of precautions:
1. Standard precautions.
2. Transmission based precautions
Standard precautions
 Standard precautions can be applied to all patients
in all health-care settings, regardless of a suspected
or confirmed infectious agent.

 These precautions constitute the primary strategy

for infection prevention. They are based on the
principle that ALL blood and other bodily fluids,
secretions and excretions, excluding perspiration,
may contain transmissible infectious agents.
Standard precautions
 These precautions include:
1. Hand hygiene
2. Barrier technique (PPE)
3. Respiratory Hygiene and Cough Etiquette
4. Safe injection practices.
5. Patient care equipment
6. Cleaning and disinfection.
7. Waste management
Transmission based precautions
 Transmission-based precautions should be used
when treating patients who are known or suspected
of being infected or colonized with infectious
agents.

 Precautions are applied according to the clinical

syndrome and the likely etiologic agents, and then
modified based on test results.

 There are three categories: contact precautions;

droplet precautions; and airborne precautions.
The global response

 WHO Clean Care is Safer Care and the

campaign SAVE LIVES: Clean Your Hands focus on
engaging government commitment to addressing
HCAI and improving hand hygiene at the point of care.

 The WHO Guidelines on Hand Hygiene in Health Care

recommend the 'Five Moments for Hand
Hygiene.
Hand washing is still the most effective
way to clean hands, especially when
visibly soiled.
Organizational Structure
 Infection control programmes

National or regional programmes

The responsible health authority should develop a national (or
regional) programme to support hospitals in reducing the risk of
nosocomial infections. Such programmes must:

 set relevant national objectives consistent with other national health

care objectives
 develop and continually update guidelines for recommended health
care surveillance, prevention, and practice
 National or regional programmes
 develop a national system to monitor selected infections and
assess the effectiveness of interventions
 harmonize initial and continuing training programmes for
health care professionals
 facilitate access to materials and products essential for hygiene
and safety
 encourage health care establishments to monitor nosocomial
infections, with feedback to the professionals concerned.
Team and Committee?
 Infection Control Team ; ICT
 It comprises the ICD and ICN(s).
 The ICT is responsible for the day-to-day running of
ICPs. It is important that all hospitals should have an
ICT.
 In cases where the provision of an ICT is not practical,
arrangements for the provision of and access to the
infection control service should be arranged with a
nearby hospital.
 The optimal structure will vary with the type, needs,
and resources of the facility.
 ICT
 The ICT must have appropriate authority to manage an effective
ICP.
 In large-facilities, this will usually mean a direct reporting
relationship with senior administration.
 The role of the ICT is ; to ensure that an effective ICP has been
planned, to co-ordinate its implementation, and to evaluate the
impact of such measures.
 It is important to ensure that there is a 24 hour access to the ICT
for advice on infection prevention and control , which would
include both medical and nursing advice.
 Role of ICT
 To develop an annual IC plan with clearly defined
objective
 To develop written policies and procedures,
including regular evaluation and update.
 To prepare an action plan for implementation of the
ICP and to get approval from the ICC.
 To supervise and to monitor daily practices of patient
care designed to prevent infection.
 Role of ICT
 To identify problems in the implementation of infection control
activities which need to be solved or transferred to the hospital
ICC.
 To organize an epidemiological surveillance program for HAIs
(particularly in high risk areas to detect outbreaks early).
 To report outbreaks to the ICC and to investigate outbreaks and
provide data (and expert advice) that should be evaluated to
allow for any change in practice or allocation of resources.
 To educate all grades of staff in infection control policy, practice
and procedures relevant to their own area of practice.
Role of ICT
 To Provide advice to all grades of staff on all aspects of
infection prevention and control on a day-to-day basis.
 To develop an annual training plan for the health care
workers and to get an approval from ICC.
 To implement the infection control training activities within
the health care facility.
 To ensure availability of supplies and equipment needed for
infection control.
Role of ICT
 To have a scientific and technical support role in purchasing
& monitoring of equipment and supplies, and in evaluation
&checking the efficacy of sterilization and disinfection
measures.
 To participate with the pharmacy and antibiotic committee in
developing a program for supervising the use of antibiotics.
 To support and participate in research and assessment
programs .
 To Participate in the audit activity.
 To submit monthly reports on activities to the ICC.
 Infection control committee
As a minimum, the committee should include:
 Chief executive or hospital administrator or his nominated authorized
representative
 ICD or Hospital Microbiologist who may act as a chairperson.
 Infection Control Nurse.
 Infectious Diseases Physician (if available).
 Director of Nursing ( or his/her representative ).
 Occupational Health Physician (if available).
 Representatives from the major clinical specialties.
 Additionally, representatives of any other department (pharmacy,
central supply, maintenance, housekeeping, training services, etc) may
be invited as necessary.
 Role of the committee
1. To review and approve the annual plan for infection
control
2. To review and approve the infection control policies
3. To support the IC-teams and to direct resources to
address problems as identified.
4. To ensure availability of appropriate supplies needed
for ICT
5. To review epidemiological surveillance data and
identify areas for intervention;
 Role of the committee
6- To ensure appropriate staff training in infection control and
safety
7. To review infectious risks associated with new technologies,
new devices and new products, prior to their approval for
use
8 .To assess and promote improved practices
[Link] review and provide input into an outbreak investigation;
10. To communicate and cooperate with other committees of
the hospital with common interests such as Antibiotic
Committee, Occupational health Committee… etc
 Meetings

 The ICC should meet regularly (?monthly) according to

local need.

 ICT:
 The team should meet regularly (weekly) to discuss
relevant issues.
 There must be a standing agenda including updates on:
surveillance, observations of IC practice, policy review,
educational & training efforts, and follow-up on
identified problems.
Conclusion
Change your mind set
To improve is to change
To be perfect is to change often
Post test
 Health care associated infections
or Community Acquired infection
1- Infections appear after 24 h of admission.
2- Patient admitted with pneumonia caused by
klebsiella, 3 days after admission he develops blood
stream infection caused by Klebsiella.
3- Patient admitted with skin abscess.
4- signs of infections appear during 48 h after hospital
discharge
Health care associated infections
or Community Acquired infection
5- Day 1: Patient admitted to ICU, no signs of infection
 Day 3: patient transported to internal medicine department
 Day 4: signs of pneumonia
Health care associated infections
or Community Acquired infection
6- neonate with group B strept infection 4 h after delivery.
7- neonate born with rubella
8- neoborn with signs of CMV infection 6 h after delivary
9- HBV infection due to unsafe injection
10- HCV transmitted to patient in the endoscopy unit due to
sharing of single dose vial
Team or committee
1- develop an annual IC plan with clearly defined objective
2- review and approve the infection control policies
3- prepare an action plan for implementation
4- organize an epidemiological surveillance program for HAIs
5- implement the infection control training activities
Team or committee
6- ensure availability of appropriate supplies
7- review and approve the annual plan for infection control
8- develop written policies and procedures, including regular
evaluation and update
9- review epidemiological surveillance data and identify areas
for intervention
10- scientific and technical support role in purchasing &
monitoring of equipment and supplies
Team or committee
11- communicate and cooperate with other committees of the
hospital
12- supervise and to monitor daily practices of patient care
13- review infectious risks associated with new technologies,
new devices and new products
14- develop an annual training plan for the health care workers
15- Participate in the audit activity