MICROBIOLOGY FOR RT

Epidemiology disease is defined as a communicable disease that

is easily transmitted from one person to another.

Epidemiology
Zoonotic Diseases
− is the study of factors that determine the
− infectious diseases that humans acquire from
frequency, distribution, and determinants of
animal sources are called zoonotic diseases or
diseases in human populations, and ways to
zoonoses (sing., zoonosis).
prevent, control, or eradicate diseases in
populations.
Incidence and Morbidity Rate
• Both pathology and epidemiology can be loosely • The incidence of a particular disease is defined as the
defined as the study of disease, but they involve different number of new cases of that disease in a defined
aspects of disease. population during a specific time period, for example, the
number of new cases of hantavirus pulmonary syndrome
• Whereas a pathologist studies the structural and
(HPS) in the United States during 2009.
functional manifestations of disease and is involved in
diagnosing diseases in individuals, an epidemiologist • The incidence of a disease is similar to the morbidity rate
studies the factors that determine the frequency, for that disease, which is usually expressed as the number
distribution, and determinants of diseases in human of new cases of a particular disease that occurred during a
populations. specified time period per a specifically defined population
(usually per 1,000, 10,000, or 100,000 population), for
example, the number of new cases of a particular disease
Epidemiologists in 2009 per 100,000 U.S. population.
− are scientists who specialize in the study of
disease and injury patterns (incidence and
Prevalence
distribution patterns) in populations, and ways to
prevent or control diseases and injuries • There are two types of prevalence: period prevalence
and point prevalence.
Epidemiologic Terminology 1. Period Prevalence
− is the number of cases of the disease existing in a
− it sometimes seems like epidemiologists speak a given population during a specific time period
language all their own. They frequently use terms (e.g., the total number of cases of gonorrhea that
such as communicable, contagious, and zoonotic existed in the U.S. population during 2009).
diseases the incidence, morbidity rate,
2. Point Prevalence
prevalence, and mortality rate of a particular
− is the number of cases of the disease existing in a
disease and adjectives such as sporadic, endemic,
given population at a particular moment in time.
epidemic, and pandemic to describe the status of
a particular infectious disease in a given
population. Mortality Rate
• Mortality refers to death. The mortality rate (also known
Communicable and Contagious Diseases as the death rate) is the ratio of the number of people who
died of a particular disease during a specified time period
− is a disease that is caused by a pathogen. If the per a specified population (usually per 1,000, 10,000, or
infectious disease is transmissible from one 100,000 population).
human to another (i.e., person to person), it is
called a communicable disease. Although it Sporadic Diseases
might seem like splitting hairs, a contagious
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− is a disease that occurs only occasionally which had gained entrance to the homes of villagers.
(sporadically) within the population of a Aerosols of the virus were produced when residents swept
particular geographic area, whereas an endemic up house dust containing the rodent droppings. The
disease is a disease that is always present within pathogen was then inhaled by individuals in those homes.
that population.

• An epidemic of West Nile virus (WNV) infections

Endemic Diseases
occurred throughout the United States. More than 4,100
− are diseases that are always present within the human cases occurred that year, resulting in 284 deaths. In
population of a particular geographic area. The addition, more than 16,000 birds died as a result of WNV
number of cases of the disease may fluctuate over infections, and more than 14,500 horses were infected
time, but the disease never dies out completely. with WNV during 2002. The 2002 WNV epidemic was
the largest recognized arboviral meningoencephalitis
epidemic in the Western Hemisphere and the largest WNV
Epidemic Diseases meningoencephalitis epidemic ever recorded. However,
− are diseases that occur in a greater than usual the 2003 WNV epidemic was even worse, with a total of
number of cases in a particular region, and 9,862 cases and 264 deaths. WNV epidemics occur each
usually occur within a relatively short period of year in the United States.
time.
Waterborne Disease Outbreaks
• An epidemic of a respiratory disease (Legionnaires’ • Such outbreaks occur annually in the United States,
disease or legionellosis) occurred during an American associated both with drinking water and water that is not
Legion convention in Philadelphia, Pennsylvania. It intended for drinking. The CDC have presented data
resulted in approximately 220 hospitalizations and 34 associated with 28 waterborne disease outbreaks
deaths. The pathogen (a Gram-negative bacillus named (WBDOs) that occurred during 2005 and 2006.a Of these,
Legionella pneumophila) was present in the water being 20 were associated with drinking water that caused illness
circulated through the air-conditioning system of the hotel among an estimated 612 persons and four death.
where the affected Legionnaires were staying
• An epidemic involving Escherichia coli O157:H7- Foodborne Disease Outbreaks
contaminated hamburger meat occurred in the Pacific
northwest. It resulted in approximately 500 diarrheal • Over 200 known diseases can be transmitted through
cases, 45 cases of kidney failure as a result of hemolytic food, caused by microbes (viruses, bacteria, parasites,
uremic syndrome (HUS), and the death of several young prions) or toxins and metals.
children. E. coli O157:H7 is a particularly virulent
serotype of E. coli; it is also known as enterohemorrhagic
E. coli. In this epidemic, the source of the E. coli was cattle Pandemic Diseases
feces. The ground beef used to make the hamburgers had
been contaminated with cattle feces during the − is a disease that is occurring in epidemic
slaughtering process. The hamburgers had not been proportions in many countries simultaneously
cooked long enough, sometimes worldwide.

• An epidemic of hantavirus pulmonary syndrome • According to the World Health Organization (WHO),
(HPS) occurred on Native American reservations in the infectious diseases are responsible for approximately half
Four Corners region (where the borders of Colorado, New the deaths that occur in developing countries
Mexico, Arizona, and Utah all meet). It resulted in approximately half of those are caused by three infectious
approximately 50 to 60 cases, including 28 deaths. The diseases human immunodeficiency virus/ acquired
particular hantavirus strain (now called Sin Nombre virus) immunodeficiency syndrome (HIV/AIDS) tuberculosis,
was present in the urine and feces of deer mice, some of and malaria each of which is currently occurring in
 MICROBIOLOGY FOR RT

pandemic proportions. Collectively, these three diseases • Another current pandemic is TB. To complicate matters,
cause more than 300 million illnesses and more than 5 many strains of Mycobacterium tuberculosis (the
million deaths per year. bacterium that causes TB) have developed resistance to
the drugs that are used to treat TB.
HIV/AIDS • TB caused by these strains is known as multidrug-
resistant tuberculosis (MDR-TB), or in some cases,
• Although the first documented evidence of HIV infection
extensively drug-resistant tuberculosis (XDR-TB). Some
in humans can be traced to an African serum sample
strains of M. tuberculosis have developed resistance to
collected in 1959, it is possible that humans were infected
every drug and every combination of drugs that has ever
with HIV before that date.
been used to treat TB. MDR-TB and XDR-TB are present
• The AIDS epidemic began in the United States around in virtually all regions of the world, including the United
1979, but the epidemic was not detected until 1981. It was States. According to the WHO, China and the countries of
not until 1983 that the virus that causes AIDS was the former Soviet Union have the highest occurrence rates
discovered. HIV is thought to have been transferred to of MDR-TB.
humans from other primates (chimpanzees in the case of
HIV-1, and sooty mangabeys [a type of Old World
Malaria
monkey] in the case of HIV-2). Common modes of HIV
transmission are shown in Figure 11-2. • The world’s most important tropical parasitic disease,
killing more people than any other communicable disease,
except TB.

Interactions Among Pathogens, Hosts, and

Environments

Whether or not an infectious disease occurs depends on

many factors, some of which are listed here:
• Factors pertaining to the pathogen
• Factors pertaining to the host (i.e., the person
who may become infected)
• Factors pertaining to the environment

Chain of Infection
The six components in the chain of infection are:
(a) a pathogen,
(b) a reservoir of infection,
(c) a portal of exit,
(d) a mode of transmission,
(e) a portal of entry, and
(f) a susceptible host.

• Collectively, HIV/AIDS, TB, and malaria cause more • There must first be a pathogen
than 300 million illnesses and more than 5 million deaths • There must be a source of the pathogen
per year. • There must be a portal of exit
• There must be a mode of transmission
Tuberculosis • There must be a portal of entry
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• There must be a susceptible host

Reservoirs of Infection
• The sources of microbes that cause infectious diseases
are many and varied. They are known as reservoirs of
infection or simply reservoirs. A reservoir is any site
where the pathogen can multiply or merely survive until it
is transferred to a host. Reservoirs may be living hosts or
inanimate objects or materials.

Living Reservoirs
• Include humans, household pets, farm animals, wild
Strategies for Breaking the Chain of Infection animals, certain insects, and certain arachnids (ticks and
mites). The human and animal reservoirs may or may not
To prevent infections from occurring, measures must be be experiencing illness caused by the pathogens they are
taken to break the chain of infection at some point (link) harboring.
in the chain.
• Eliminate or contain the reservoirs of
pathogens or curtail the persistence of a
pathogen at the source.
• Prevent contact with infectious substances
from exit pathways.
• Eliminate means of transmission.
• Block exposure to entry pathways.
• Reduce or eliminate the susceptibility of
potential hosts.

Some of the specific methods of breaking the chain of Animals

infection are: • As previously stated, infectious diseases that humans
acquire from animal sources are called zoonotic diseases
• Practice effective hand hygiene procedures
or zoonoses. Many pets and other animals are important
• Maintain good nutrition and adequate rest and
reservoirs of zoonoses.
reduce stress.
• Obtain immunizations against common • There are over 200 known zoonoses diseases that can be
pathogens. transmitted from animals to humans.
• Practice insect and rodent control measures.
• Practice proper patient isolation procedures.
• Ensure proper decontamination of surfaces Arthropods
and medical instruments. • Technically, arthropods are animals, but they are being
• Dispose of sharps and infectious waste discussed here separately from other animals because, as
properly a group, they are so commonly associated with human
• Use gloves, gowns, masks, respirators, and infections. Many different types of arthropods serve as
other personal protective equipment, reservoirs of infection, including insects (e.g., mosquitoes,
whenever appropriate to do so. biting flies, lice, fleas), and arachnids (e.g., mites, ticks)
• Use needle safety devices during blood
collection.
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Nonliving Reserviors
• Nonliving or inanimate reservoirs of infection include
air, soil, dust, food, milk, water, and fomites (defined later
in the chapter). Air can become contaminated by dust or
respiratory secretions of humans expelled into the air by
breathing, talking, sneezing, and coughing
• Air, soil, dust, food, milk, water, and fomites are
examples of nonliving or inanimate reservoirs of infection

Modes of Transmissions

• Healthcare professionals must be thoroughly familiar

with the sources (reservoirs) of potential pathogens and
pathways for their transfer. A hospital staphylococcal
epidemic may begin when aseptic conditions are relaxed
and a Staphylococcus aureus carrier transmits the
pathogen to susceptible patients.

• The five principal modes by which transmission of

pathogens occur are contact (either direct or indirect
contact), droplet, airborne, vehicular, and vector
transmission.
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• They also help by educating the public, explaining how

diseases are transmitted, explaining proper sanitation
procedures, identifying and attempting to eliminate
reservoirs of infection, carrying out measures to isolate
diseased persons, participating in immunization programs,
and helping to treat sick persons. Through measures such
as these, smallpox and poliomyelitis have been totally or
nearly eliminated in most parts of the world.

World Health Organization

• The WHO, a specialized agency of the United Nations,
was founded in 1948. Its missions are to promote technical
cooperation for health among nations, carry out programs
to control and eradicate diseases, and improve the quality
of human life.
• When an epidemic strikes, such as the 2000 Ebola
outbreak in Uganda, teams of epidemiologists are sent to
the site to investigate the situation and assist in bringing
the outbreak under control. Because of this assistance,
• Direct skin-to-skin contact. many countries have been successful in their fight to
• Direct mucous membrane-to-mucous control smallpox, diphtheria, malaria, trachoma, and
membrane contact by kissing or sexual numerous other diseases.
intercourse.
• Indirect contact via airborne droplets of
respiratory secretions, usually produced as a Centers for Disease Control and Prevention
result of sneezing or coughing. • In the United States, a federal agency called the U.S.
• Indirect contact via food and water Department of Health and Human Services administers
contaminated with fecal material. the Public Health Service and CDC, which assist state and
• Indirect contact via arthropod vectors. local health departments in the application of all aspects
• Indirect contact via fomites that become of epidemiology.
contaminated by respiratory secretions, blood,
urine, feces, vomitus, or exudates from • Many microbiologists and epidemiologists work at the
hospitalized patients. CDC headquarters in Atlanta, Georgia. Microbiologists at
• Indirect contact via transfusion of the CDC are able to work with the most dangerous
contaminated blood or blood products from an pathogens known to science because of the elaborate
ill person or by parenteral injection (injection containment facilities that are located there. CDC
directly into the bloodstream) using nonsterile epidemiologists travel to areas of the United States and
syringes and needles. elsewhere in the world, wherever and whenever an
epidemic is occurring, to investigate and attempt to control
Public Health Agencies the epidemic.
• Public health agencies at all levels constantly strive to
prevent epidemics and to identify and eliminate any that
do occur.
• One way in which healthcare personnel participate in this
massive program is by reporting cases of communicable
diseases to the proper agencies.
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• National Center for Immunization and

Respiratory Diseases
• National Center for Zoonotic, Vector-Borne,
and Enteric Diseases
• National Center for HIV/AIDS, Viral
Hepatitis, STD, and TB Prevention
• National Center for Preparedness, Detection,
and Control of Infectious Disease

Botulism
− is a potentially fatal microbial intoxication,
Bioterrorism and Biological Warfare Agents caused by botulinal toxin, a neurotoxin produced
• Pathogenic microorganisms sometimes wind up in the by C. botulinum.
hands of terrorists and extremists who want to use them to • C. botulinum is a spore-forming anaerobic Gram-
cause harm to others. In times of war, the use of positive bacillus.
microorganisms in this manner is called biological
warfare (BW), and the microbes are referred to as • Botulinal toxin may cause nerve damage, visual
biological warfare agents. However, the danger does not difficulty, respiratory failure, flaccid paralysis of
exist solely during times of war. The possibility that voluntary muscles, brain damage, coma, and death within
members of terrorist or radical hate groups might use a week if untreated. Respiratory failure is the usual cause
pathogens to create fear, chaos, illness, and death always of death.
exists. These people are referred to as biological terrorists
or bioterrorists, and the specific pathogens they use are
Smallpox
referred to as bioterrorism agents.
− is a serious, contagious, and sometimes fatal viral
• Four pathogens that are potential BW and bioterrorism
disease.
agents are B. anthracis, C. botulinum, V. major, and Y.
pestis. • Patients experience fever, malaise, headache,
prostration, severe backache, a characteristic skin rash
(Fig. 11-10), and occasional abdominal pain and vomiting.
Anthrax
Smallpox can become severe, with bleeding into the skin
− is caused by B. anthracis, a spore-forming, Gram and mucous membranes, followed by death.
positive bacillus.
• People can develop anthrax in several ways (Fig. 11-8),
resulting in three forms of the disease: cutaneous
anthrax, inhalation anthrax, and gastrointestinal
anthrax. Anthrax infections involve marked
hemorrhaging and serous effusions (fluid that has escaped
from blood or lymphatic vessels) in various organs and
body cavities and are frequently fatal.
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Plague
− is caused by Y. pestis, a Gram-negative
coccobacillus.
− is predominantly a zoonosis and is usually
transmitted to humans by flea bite.
• Plague can manifest itself in several ways: bubonic
plague, septicemic plague, pneumonic plague, and
plague meningitis.
1. Bubonic plague - is named for the swollen,
inflamed, and tender lymph nodes (buboes) that
develop.
2. Pneumonic plague - is highly communicable,
involves the lungs. It can result in localized
Water Supplies and Sewage Disposal
outbreaks or devastating epidemics.
3. Septicemic plague - may cause septic shock, • Water is the most essential resource necessary for the
meningitis, or death. survival of humanity. The main sources of community
water supplies are surface water from rivers, natural
• Patients with plague are depicted in Figure 11-12.
lakes, and reservoirs, as well as groundwater from
Bioterrorists could disseminate Y. pestis via aerosols,
wells. However, two general types of water pollution (i.e.,
resulting in numerous severe and potentially fatal
chemical pollution and biological pollution) are present in
pulmonary infections. Pneumonic plague can be
our society, making it increasingly difficult to provide safe
transmitted from person to person.
water supplies.
1. Chemical pollution - occurs when industrial
installations dump waste products into local
waters without proper pretreatment, when
pesticides are used indiscriminately, and when
chemicals are expelled in the air and carried to
earth by rain (“acid rain”).
2. Biological Pollution - the main source of this is
waste products of humans fecal material and
garbage that swarm with pathogens.
• The causative agents of cholera, typhoid fever,
bacterial and amebic dysentery, giardiasis,
cryptosporidiosis, infectious hepatitis, and poliomyelitis
can all be spread through contaminated water.
• Waterborne epidemics today are the result of failure to
make use of available existing knowledge and technology.
In those countries that have established safe sanitary
procedures for water purification and sewage disposal,
outbreaks of typhoid fever, cholera, and dysentery occur
only rarely.
• The largest waterborne epidemic to occur in the United
States was an outbreak of cryptosporidiosis in Milwaukee,
Wisconsin, in 1993, which affected more than 400,000
people.
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Sources of Water Contamination 1. Primary Sewage Treatment

• In the sewage disposal plant, large debris is
• Rainwater falling over large areas collects in lakes and
first filtered out (called screening), skimmers
rivers and, thus, is subject to contamination by soil
remove floating grease and oil, and floating
microbes and raw fecal material.
debris is shredded or ground. Then, solid
material settles out in a primary sedimentation
Water Treatment tank. Flocculating substances can be added to
cause other solids to settle out. The material
• Water must be properly treated to make it safe for human that accumulates at the bottom of the tank is
consumption. It is interesting to trace the many steps called primary sludge.
involved in such treatment (Fig. 11-14).
• The water first is filtered to remove large pieces of debris 2. Secondary Sewage Treatment
such as twigs and leaves. Next, the water remains in a • The liquid (called primary effluent) then
holding tank, where additional debris settles to the bottom undergoes secondary treatment, which
of the tank; this phase of the process is known as includes aeration or trickling filtration. The
sedimentation or settling. Alum (aluminum potassium purpose of aeration is to encourage the growth
sulfate) is then added to coagulate smaller pieces of debris, of aerobic microbes, which oxidize the
which then settle to the bottom; this phase is known as dissolved organic matter to CO2 and H2O.
coagulation or flocculation. • Trickling filters accomplish the same thing
(i.e., conversion of dissolved organic matter to
CO2 and H2O by microbes), but in a different
manner. After either aeration or trickling
filtration, the activated sludge is transferred to
a settling tank, where any remaining solid
material settles out. The remaining liquid
(called secondary effluent) is filtered and
disinfected (usually by chlorination), so that
the effluent water can be returned to rivers or
oceans.
Water is considered potable (safe to drink) if it contains 1
coliform or less per 100 mL of water.
3. Tertiary Sewage Treatment
 In some desert cities, where water is in short
supply, the effluent water from the sewage
disposal plant is further treated (referred to as
tertiary sewage treatment), so that it can be
returned directly to the drinking water system;
this is a very expensive process.
 Tertiary sewage treatment involves the
addition of chemicals, filtration (using fine
sand or charcoal), chlorination, and sometimes
Sewage Treatment distillation. In other cities, effluent water is
used to irrigate lawns; however, it is expensive
• Raw sewage consists mainly of water, fecal material to install a separate water system for this
(including intestinal pathogens), and garbage and bacteria purpose. In some communities, the sludge is
from the drains of houses and other buildings. When heated to kill bacteria, then dried and used as
sewage is adequately treated in a disposal plant, the water fertilizer.
it contains can be returned to lakes and rivers to be
recycled.
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Bioterrorism and Biological Warfare Agent people—perhaps hundreds of millions. Huge plague
epidemics occurred in Asia and Europe, including the
European plague epidemic of 1348–1350, which killed
Introduction about 44% of the population (40 million of 90 million
• Terrorists and extremists who want to use pathogenic people). The last major plague epidemic in Europe
microorganisms to cause harm to others is called occurred in 1721. Plague still occurs, but the availability
biological warfare. of insecticides and antibiotics has greatly reduced the
incidence of this dreadful disease. Human plague is very
• The microbes are referred to as biological warfare agents. rare in the United States (only 7 cases in 2007).
• The possibility that members of terrorist or radical hate
groups might use pathogens to create fear, chaos, illness, The CDC has classified the etiologic agents of anthrax,
and death always exists. botulism, smallpox, and plague as category A
• These people are referred to as biological terrorists or bioterrorism agents.
bioterrorists, and the specific pathogens they use are Category A agents are those that:
referred to as bioterrorism agents.
• Pose the greatest possible threat for a bad
effect on public health.
Four pathogens that are potential BW and bioterrorism • May spread across a large area or need public
agents are: awareness.
• Need a great deal of planning to protect the
1. B. anthracis,
public’s health.
2. C. botulinum,
3. V. major (smallpox virus), and
4. Y. pestis. Other pathogens viewed as potential BW agents are the
(The causative agents of anthrax, botulism, smallpox, and causative agents of brucellosis, Q fever, tularemia,
plague.) viral encephalitis, and viral hemorrhagic fevers.
• To minimize the danger of potentially deadly
microorganisms falling into the wrong hands,
Biological Warfare Agents
the U.S. Antiterrorism and Effective Death Penalty Act of
• The use of pathogens as BW agents dates back thousands
1996 makes the CDC responsible for controlling shipment
of years. Ancient Romans threw carrion (decaying dead
of select agents—pathogens and toxins deemed most
bodies) into wells to contaminate the drinking water of
likely to be used as BW agents.
their enemies.
• Authorities must constantly be on the alert for possible
• In the Middle Ages, the bodies of plague victims were
theft of these pathogens from biological supply houses and
catapulted over city walls in an attempt to infect the
legitimate laboratories. In addition, vaccines, antitoxins,
inhabitants of the cities. Early North American explorers
and other antidotes must be available wherever the threat
provided Native Americans with blankets and
of the use of these biological agents is high, as in various
handkerchiefs that were contaminated with smallpox and
potential war zones.
measles viruses.
• The ASM has recommended that all clinical
microbiology laboratories be staffed with persons familiar
The Black Death
with the likely agents of bioterrorism and trained to detect,
• During the Middle Ages, plague was referred to as the identify, and safely handle these agents. What individuals
black death because of the darkened, bruised appearance can do to prepare for bioterrorist attacks is discussed in
of the corpses. The blackened skin and foul smell were the “Insight: Preparing for a Bioterrorist Attack” on the CD-
result of cell necrosis and hemorrhaging into the skin. ROM.
Plague probably dates back from 1000 or more years BC.
In the past 2,000 years, the disease has killed millions of
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Healthcare Epidemiology Healthcare-Associated Infections

Infectious diseases (infections) can be divided into two
• Defined as the study of the occurrence, determinants, and categories depending on where the person became
distribution of health and disease within healthcare infected:
settings.
(a) infections that are acquired within hospitals or
• Infection control and preventing Healthcare-Associated other healthcare facilities (called healthcare-
Infections (HAIs) are its primary focus. associated infections or HAIs)
(b) infections that are acquired outside of healthcare
• Includes any activities designed to study and improve
facilities (called community-acquired infections).
patient care outcomes.
(A hospitalized patient could have either type of
infection.)
Healthcare Epidemiology
− includes any activities designed to study and • According to the Centers for Disease Control and
improve patient care outcomes. Prevention (CDC), community-acquired infections are
These activities include: those that are present or incubating at the time of hospital
admission.
• Surveillance measures,
• Risk reduction programs focused on device • All other infections are considered HAIs, including those
and procedure management, that erupt within 14 days of hospital discharge.
• Policy development and implementation, • The term “healthcare-associated infection” should not be
• Education of healthcare personnel in infection confused with the term “iatrogenic infection”
control practices and procedures,
(physicianinduced).
• Cost–benefit assessment of prevention and
control programs, and • An iatrogenic infection is an infection that results from
• Any measures designed to eliminate or medical or surgical treatment (i.e., an infection that is
contain reservoirs of infection, caused by a surgeon, another physician, or some other
• Interrupt the transmission of infection, and healthcare worker).
protect patients,
• Healthcare workers, and − examples of iatrogenic infections are surgical
site infections and urinary tract infections
• Visitors against infection and disease.
(UTIs) that result from urinary catheterization of
patients.
• Health and disease are the result of complex interactions
• Iatrogenic infections are a type of HAI, but not all HAIs
among pathogens, patients, and the healthcare
are iatrogenic infections.
environment.
• The importance of microbiology to those who work in
health-related occupations can never be overemphasized. Frequency of Healthcare-Associated Infections
• It is sad to think that a patient who enters a hospital for
• Whether working in a hospital, medical or dental clinic,
one problem could develop an infection while in the
long-term care facility, rehabilitation center, or hospice or
hospital and perhaps die of that infection. However, this is
caring for sick persons in their homes, all healthcare
an all-too-common occurrence.
professionals must follow standardized procedures to
prevent the spread of infectious diseases. • The CDC recommends the use of the term “healthcare-
associated infections” for infections acquired within any
• Thoughtless or careless actions when providing patient
type of healthcare facility. The term replaces the older
care can cause serious infections that otherwise could have
term “hospital-acquired infections,” and its synonym,
been prevented.
“nosocomial infections.”
 MICROBIOLOGY FOR RT

• In 2002, the estimated number of HAIs in U.S. hospitals • Although some of the pathogens that cause HAIs
was approximately 1.7 million (roughly 5% of originate in the external environment, many come from
hospitalized patients). The estimated number of deaths in the patients themselves—their own indigenous microflora
2002, associated with HAIs, was 98,987 (approximately that enter a surgical incision or otherwise gain entrance to
6% of the patients having HAIs). Of these, the greatest areas of the body other than those where they normally
number of deaths (35,967) was caused by pneumonia. reside.
• HAIs cause significant increases in excess hospital stays • Urinary catheters, for example, provide a
and costs for additional treatment. “superhighway” for indigenous microflora of the distal
urethra to gain access to the urinary bladder.
Pathogens Most Often Involved in Healthcare- • Approximately 70% of HAIs involve drug-resistant
Associated Infections bacteria as a result of the many antimicrobial agents in use
there.
• The hospital environment harbors many pathogens and
potential pathogens. • Which are common in hospitals, nursing homes, and
other healthcare settings
• Some live on and in healthcare professionals, other
hospital employees, visitors to the hospital, and patients • The drugs place selective pressure on the microbes,
themselves. meaning that only those that are resistant to the drugs will
survive. These resistant organisms then multiply and
• Others live in dust or wet or moist areas like sink drains,
predominate (refer back to Fig. 9-6).
showerheads, whirlpool baths, mop buckets, flowerpots,
and even food from the kitchen.
• To make matters worse, the bacterial pathogens that are Pseudomonas infections are especially difficult to treat, as
present in hospital settings are usually drug-resistant are infections caused by:
strains and, quite often, are multidrugresistant.
(a) multidrug-resistant Mycobacterium tuberculosis
(MDR-TB),
(b) Vancomycin-resistant Enterococcus spp. (VRE),
The following bacteria are the most common causes of
and
HAIs in the United States:
(c) MRSA and methicillin-resistant strains of
1. Gram-positive cocci: Staphylococcus epidermidis (MRSE).
• Staphylococcus aureus (including methicillin-
• Bacteria are not the only pathogens that have become
resistant strains of Staphylococcus aureus
drug resistant, however.
[MRSA])
• Coagulase-negative staphylococci • Viruses have also developed drug resistance. (such as
Enterococcus spp. (including human immunodeficiency virus [HIV]), fungi (such as
vancomycinresistant enterococci) various Candida spp.), and protozoa (such as malarial
parasites).
2. Gram-negative bacilli
• In 2001, the CDC launched a campaign to prevent
• Escherichia coli
antimicrobial resistance in healthcare settings. Table 12-1
• Pseudomonas aeruginosa
contains the 12 steps recommended by the CDC to prevent
• Enterobacter spp
antimicrobial resistance among hospitalized adults.
• Klebsiella spp

Table 12-1: Twelve Steps to Prevent Antimicrobial

Resistance among Hospitalized Adults:
 MICROBIOLOGY FOR RT

Most Common Types of Healthcare-Associated Infections

According to the CDC, the four most common types of
HAIs in U.S. hospitals are:
1. UTIs
− which represent about 32% of all HAIs and cause
about 13% of the deaths associated with HAIs
2. Surgical Site Infections
− which represent about 22% of all HAIs • cause
about 8% of the deaths associated with HAIs
According to the CDC, the four most common types of
HAIs in U.S. hospitals are:
1. Lower respiratory tract infections (primarily
pneumonia)
− which represent about 15% of HAIs
− cause about 36% of the deaths associated with
HAIs
2. Bloodstream infections (septicemia)
− which represent about 14% of HAIs
Modes of Transmission − cause about 31% of the deaths associated with
HAIs
The three principal routes by which pathogens involved in
3. Lower respiratory tract infections
HAIs are transmitted are contact, droplet, and airborne.
− (primarily pneumonia)
1. Contact Transmission − which represent about 15% of HAIs
There are two types of contact transmission: − Cause about 36% of the deaths associated with
• Direct contact transmission - pathogens are HAIs
transferred from one infected person to 4. Bloodstream infections
another person without a contaminated − (septicemia)
intermediate object or person. − which represent about 14% of HAIs
• Indirect contact transmission - pathogens − cause about 31% of the deaths associated with
are transferred via a contaminated HAIs
intermediate object or person.
Other common HAIs are the gastrointestinal diseases
2. Droplet Transmission
caused by Clostridium difficile, which are referred to as C.
− respiratory droplets carrying pathogens transmit
difficile-associated diseases.
infection when they travel from the respiratory
tract of an infectious individual (e.g., by sneezing C. difficile (often referred to as “C. diff”)
or coughing) to susceptible mucosal surfaces of a
recipient. - is an anaerobic, spore-forming, Grampositive
− droplets traditionally have been defined as being bacillus.
larger than 5 m in size. - It is a common member of the indigenous
3. Airborne Transmission microflora of the colon, where it exists in
− occurs with the dissemination of either airborne relatively small numbers.
droplet nuclei or small particles containing Although C. difficile produces two types of toxins
pathogens.
− airborne droplets are defined as being less than or 1. Enterotoxin
equal to 5 m in size. 2. Cytotoxin
 MICROBIOLOGY FOR RT

• The concentrations of these toxins are too low to cause Listed here are the most vulnerable patients in a hospital
disease when only small numbers of C. difficile are setting:
present.
1. Elderly patients
• However, superinfections of C. difficile can occur when 2. Women in labor and delivery
a patient receives oral antibiotics that kill off susceptible 3. Premature infants and newborns
members of the gastrointestinal flora (superinfections are 4. Surgical and burn patients
described in Chapter 9). 5. Patients with diabetes or cancer
6. Patients with cystic fibrosis
• C. difficile, which is resistant to many orally
7. Patients having an organ transplant
administered antibiotics, then increases in number, leading
8. Patients receiving treatment with steroids,
to increased concentrations of the toxins.
anticancer drugs, antilymphocyte serum, or
radiation
Enterotoxin 9. Immunosuppressed patients (i.e., patients whose
immune systems are not functioning properly)
- causes a disease known as Antibiotic-Associated 10. Patients who are paralyzed or are undergoing
Diarrhea (AAD). renal dialysis or urinary catheterization
Cytotoxin 11. Patients with indwelling devices such as
endotracheal tubes, central venous and arterial
- causes a disease known as Pseudomembranous catheters, and synthetic implants.
Colitis (PMC), in which sections of the lining of
the colon slough off, resulting in bloody stools. (Immunosuppressed patients are especially likely to
develop HAIs)
(Both AAD and PMC are common in hospitalized
patients)
Major Factors Contributing to Healthcare-Associated
Infections
• Healthcare-associated zoonoses are a recently
recognized problem in hospitals (see “Insight: Healthcare 1. The three major factors that combine to cause
Associated Zoonoses” on the CD-ROM). Recall that HAIs (Fig. 12-1) are:
zoonoses are diseases that are transmissible from animals a. An ever-increasing number of drug-resistant
to humans. pathogens
b. The failure of healthcare personnel to follow
• Patients most likely to develop HAIs are infection control guidelines
immunosuppressed patients—patients whose immune c. An increased number of
systems have been weakened by age, underlying diseases, immunocompromised patients
Medical surgical treatments. Contributing factors include
aging population, increasingly aggressive medical and
therapeutic interventions, and an increase in the number of
implanted prosthetic devices, organ transplantations,
xenotransplantations (the transplantation of animal organs
or tissues into humans), and vascular and urinary
catheterizations.
• The highest infection rates are in intensive care unit
(ICU). patients.
• HAI rates are three times higher in adult and pediatric
ICUs than elsewhere in the hospital.
 MICROBIOLOGY FOR RT

Figure 12-1: The three major contributing factors in HAIs pathogens from one patient to another or from one
anatomic site to another on the same patient.
Handwashing, as it specifically pertains to
Additional contributing factors are:
healthcare personnel, is discussed later in the
1. The indiscriminate use of antimicrobial agents, chapter (“Standard Precautions”).
which has resulted in an increase in the number of
Presented here are common sense, everyday, handwashing
drug resistant and multidrug-resistant pathogens.
guidelines that pertain to everyone:
2. A false sense of security about antimicrobial
agents, leading to a neglect of aseptic techniques 1. Wash your hands before you:
and other infection control procedures. • Prepare or eat food
3. Lengthy, more complicated types of surgery • Treat a cut or wound or tend to someone who
4. Overcrowding of hospitals and other healthcare is sick
facilities, as well as shortages of staff • Insert or remove contact lenses
5. Increased use of less-highly trained healthcare 2. Wash your hands after you:
workers, who are often unaware of infection • Use the restroom
control procedures. • Handle uncooked foods, particularly raw
6. Increased use of anti-inflammatory and meat, poultry, or fish
immunosuppressant agents, such as radiation, • Change a diaper
steroids, anticancer chemotherapy, and • Cough, sneeze, or blow your nose
antilymphocyte serum • Touch a pet, particularly reptiles and exotic
7. Overuse and improper use of indwelling medical animals
devices. • Handle garbage
• End; to someone who is sick or injured
3. Wash your hands in the following manner:
• Medical devices that support or monitor basic body
• Use warm or hot running water.
functions contribute greatly to the success of modern
• Use soap (preferably an antibacterial soap).
medical treatment.
• Wash all surfaces thoroughly, including
- However, by bypassing normal defensive wrists, palms, back of hands, fingers, and
barriers, these devices provide microbes access to under fingernails (preferably with a nail
normally sterile body fluids and tissues. brush) Rub hands together for at least 10 to 15
- The risk of bacterial/fungal infection is related to seconds .
the degree of debilitation of the patient And the • When drying, begin with your forearms and
design and management of the device. work toward your hands and fingertips, and
- It is advisable to discontinue the use of urinary pat your skin rather than rubbing to avoid
catheters, vascular catheters, respirators, and chapping and cracking.
hemodialysis on individual patients as soon as
(These handwashing guidelines were originally published
medically feasible.
by the Bayer Corporation and the American Society for
Microbiology.)
• It is critical for all healthcare workers to be aware of the
• Other means of reducing the incidence of HAIs include
problem of HAIs and to take appropriate measures to
disinfection and sterilization techniques, air filtration, use
minimize the number of such infections that occur within
of ultraviolet lights, isolation of especially infectious
healthcare facilities.
patients, and wearing gloves, masks, and gowns whenever
- The primary way to reduce the number of HAIs is appropriate.
strict compliance with infection control guidelines
Note: Handwashing is the single most important measure
(these guidelines are described in a subsequent
to reduce the risks of transmitting pathogens from one
section).
patient to another or from one anatomic site to another on
- Handwashing is the single most important
the same patient.
measure to reduce the risks of transmitting
 MICROBIOLOGY FOR RT

Modes of Transmission Modes of Disease Transmission

Introduction
• Healthcare workers need to have a solid understanding
of the reservoirs and sources of possible infections.
• A hospital staphylococcal epidemic may start when
aseptic procedures are laxed and a Staphylococcus
aureus carrier exposes susceptible patients (such as
infants, patients undergoing surgery, and people who are
disabled) to the bacterium.
• This infection might quickly spread across the entire
hospital population. Communicable Disease
- infectious diseases that are transmitted from
5 Principles of Transmission person to person.

1. Contact Transmission (Indirect and Direct) 1. Direct skin-to-skin contact

• Direct contact - occurs when there is a • Within hospitals, this mode of transfer is
physical contact between an infected person particularly prevalent, which is why it is so
and a susceptible person. important for healthcare professional to wash
• Indirect contact - occurs when there is no their hands before and after every patient
direct human-to-human contact. It occurs contact.
from a reservoir to contaminated surfaces or • Frequent handwashing will prevent the
objects. transfer of pathogens.
2. Droplet Transmission 2. Direct mucous membrane-to-mucous
- may be generated by coughing, sneezing and membrane contact by kissing or sexual
even talking. The transfer of pathogens via intercourse
infectious droplets (particles 5 um in diameter • Most STDs are transmitted in this manner.
larger). • STDs: Syphilis, gonorrhea, and infections
3. Airborne Transmission caused by chlamydia, herpes, and HIV.
- involves the dispersal of droplet nuclei, which 3. Indirect contact via airborne droplets of
are the residue of evaporated droplets and are respiratory secretions, usually produced as a
smaller than 5 um in diameter. result of sneezing or coughing
4. Vehicular Transmission • Most contagious airborne diseases are caused
- involves contaminated inanimate objects by respiratory pathogens carried to
(“vehicles”), such as food, water, dust, and susceptible people in droplets of respiratory
fomites. secretions.
5. Vectors Transmission • Improperly cleaned inhalation therapy
- these are the living organisms that can equipment can easily transfer these pathogens
transmit infectious pathogens between from one patient to another.
humans, or from animals to humans, it • Diseases that may be transmitted in this
includes various types of biting insects and manner include colds, influenza, measles,
arachnids. mumps, chickenpox, smallpox, and
pneumonia.
4. Indirect contact via food and water
contaminated with fecal material.
 MICROBIOLOGY FOR RT

• Many infectious diseases are transmitted by Asepsis

restaurant food handlers who fail to wash their
- which literally means “without infection” ,
hands after using the restroom.
includes any actions (referred to as aseptic
5. Indirect contact via arthropod vectors
techniques) taken to prevent infection or
• Mosquitoes, flies, fleas, lice, ticks, and mites
break the chain of infection.
can transfer various pathogens from person to
person. • Aseptic techniques are actions taken to prevent infection
6. Indirect contact via fomites that become or break the chain of infection.
contaminated by respiratory secretions, blood,
urine, feces, vomitus, or exudates from There are two main types or categories of asepsis:
hospitalized patients 1. Medical asepsis
• Fomites such as stethoscopes and latex gloves 2. Surgical asepsis
are sometimes the vehicles by which
pathogens are transferred from one patient to
another. Contributions of Joseph Lister Joseph Lister (1827–
7. Indirect contact via transfusion of 1912)
contaminated blood or blood products from an
• A British surgeon, made significant contributions in the
ill person or by parenteral injection (injection
areas of antisepsis (against infection) and asepsis (without
directly into the bloodstream) using non sterile
infection). During the 1860s, he instituted the practice of
syringes and needles
using phenol (carbolic acid) as an antiseptic to reduce
• Individuals using illegal intravenous drugs
microbial contamination of open surgical wounds.
commonly transmit these diseases to each
other by sharing needles and syringes, which • Lister’s antiseptic and aseptic techniques greatly reduced
easily become contaminated with the blood of the incidence of surgical wound infections and surgical
an infected person. mortality. Because phenol is quite caustic and toxic, it was
• One reason why disposable and single-used later replaced by other antiseptics.
hospital equipments have become popular is
because they are effective in preventing
bloodborne infections. Medical Asepsis
- is a clean technique. Its goal is to exclude
pathogens.
Infection Control
Disinfection
• The term infection control pertains to the numerous
measures that are taken to prevent infections from - process that eliminates many or all pathogenic
occurring in healthcare settings. microorganisms, except bacterial spores, on
inanimate objects.
• Infection control measures are designed to break
various links in the chain of infection. Categories of Disinfectants

• It pertains to the numerous measures that are taken to • A few disinfectants will kill bacterial spores with
prevent infections from occurring in healthcare settings. prolonged exposure times (3–12 hours); these are referred
to as chemical sterilant.
• Ever since the discoveries and observations of Ignaz
Semmelweis and Joseph Lister in the 19th century, it has
been known that wound contamination is not inevitable Other disinfectants used within healthcare settings are
and that pathogens can be prevented from reaching categorized as high-level, intermediate-level, and low-
vulnerable areas, a concept referred to as asepsis. level disinfectants:
 MICROBIOLOGY FOR RT

1. High-level disinfectants - kill all microbes Surgical Asepsis

(including viruses),e except large numbers of
- is a sterile technique. Its goal is to exclude all
bacterial spores.
microbes.
2. Intermediate-level disinfectants - might kill
mycobacteria, vegetative bacteria, most viruses, • Note the differences between medical and surgical
and most fungi, but do not necessarily kill asepsis: Medical asepsis is a clean technique, whereas
bacterial spores. Surgical Asepsis is a sterile technique.
3. Low-level disinfectants - kill most vegetative
bacteria some fungi, and some viruses within 10 • The goal of medical asepsis is to exclude pathogens,
minutes of exposure. whereas the goal of surgical asepsis is to exclude all
microbes.

Spaulding System for Classification of Instruments • Surgical aseptic techniques are practiced in operating
and Items for Patient Care rooms, in labor and delivery areas, and during invasive
procedures. Ex. invasive procedures, such as drawing
• More than 30 years ago, Earle H. Spaulding devised a blood, injecting medications, urinary catheter insertion,
system of classifying instruments and items for patient cardiac catheterization, and lumbar punctures, must be
care according to the degree of risk for infection that was performed using strict surgical aseptic precautions.
involved.
• This system is still used to determine how these items are
to be disinfected or sterilized Spotlighting Perfusionists
• As stated in the American Medical Association’s Health
1. Critical Items - confer a high risk for infection if Care Careers Directory (2008–2009), “Perfusionists are
they are contaminated with any microbe. Thus, skilled allied health professionals, trained and educated
such objects must be sterile. specifically as members of an open-heart, surgical team
Ex. surgical instruments, cardiac and urinary responsible for the selection, setup, and operation of a
catheters, implants, and ultrasound probes used in mechanical device commonly referred to as the heart-lung
sterile body cavities. machine.”
2. Semi Critical Items - contact mucous membranes • “In addition to the operation of the heart-lung machine
or nonintact skin and require high-level during surgery, perfusionists often function in supportive
disinfection. roles for other medical specialties in operating mechanical
Ex. respiratory therapy and anesthesia equipment, devices to assist in the conservation of blood and blood
some endoscopes, laryngoscope blades, products during surgery, and provide extended, long-term
esophageal manometry probes, and diaphragm support of patients’ circulation outside of the operating
fitting rings. room environment.”
3. Noncritical Items - are those that come in contact
with intact skin, but not mucous membranes.
Such items are divided into two sub categories: Spotlighting Surgical Technologists
a. noncritical patient care items (e.g.,
• As stated in the American Medical Association’s Health
bedpans, blood pressure cuffs, crutches,
Care Careers Directory (2008–2009), “Surgical
computers).
technologists are an integral part of the team of medical
b. noncritical environmental surfaces (e.g.,
practitioners providing surgical care to patients in a variety
bed rails, some food utensils, bedside
of settings.”
tables, patient furniture, floors).
(Low-level disinfectants may be used for noncritical
items. Ex. 70% to 90% ethyl or isopropyl alcohol)
 MICROBIOLOGY FOR RT

Regulations Pertaining to Healthcare Epidemiology

and Infection Control
• One of the most important of these regulations was
published in 2001 by the Occupational Safety and Health
Administration (OSHA).
• It is entitled the Bloodborne Pathogen Standard (29 CFR
1910.1030). Standard Precautions
• This standard requires facilities having employees who • In a healthcare setting, one is not always aware of which
have occupational exposure to blood or other potentially patients are infected with HIV, HBV, HCV, or other
infectious materials to prepare and update a written plan communicable pathogens.
called the Exposure Control Plan.
• Thus, to prevent transmission of pathogens within
healthcare settings, two levels of safety precautions have
been developed by the CDC: Standard Precautions and
Transmission-Based Precautions.
a. Standard Precautions combine the major
features of Universal Precautions and Body
Substance Isolation Precautions, and are intended
to be applied to the care of all patients in all
healthcare settings, regardless of the suspected or
confirmed presence of an infectious agent.
b. Transmission-Based Precautions, on the other
hand, are enforced only for certain specific types
of infections.
• Implementation of Standard Precautions constitutes the
primary strategy for the prevention of healthcare-
associated transmission of infectious agents among
patients and healthcare personnel.
• Standard Precautions are based on the principle that all
blood, body fluids, secretions, excretions except sweat,
non- intact skin, and mucous membranes may contain
transmissible infectious agents.
CDC - Centers for Disease Control and Prevention

Vaccinations
Because healthcare personnel are at particular risk for
several vaccine-preventable infectious diseases, the CDC
Regulations Pertaining to Healthcare Epidemiology recommends that they receive the following vaccines
and Infection Control
• Hepatitis B recombinant vaccine
This plan is designed to eliminate or minimize employee
• Influenza vaccine
exposure to pathogens.
• Measles live-virus vaccine
• Mumps live-virus vaccine
• Rubella live-virus vaccine
• Varicella-zoster live-virus vaccine
 MICROBIOLOGY FOR RT

Hand Hygiene Personal Protective Equipment

• The most important and most basic technique in There are many components of personal protective
preventing and controlling infections and preventing the equipment (PPE). The most common are listed here.
transmission of pathogens is handwashing. Personal Protective Equipment
• A plain (nonantimicrobial) soap may be used for routine • gloves
handwashing, but an antimicrobial or antiseptic agent • gowns
should be used in certain circumstances. • masks
• eye protection
• respiratory protection
Father of Handwashing
• Ignaz Philipp Semmelweis (1818–1865) has been
Gloves
referred to as the “Father of Handwashing, ” the “Father
of Hand Disinfection, ” and the “Father of Hospital • Gloves can protect both patients and healthcare
Epidemiology.” personnel from exposure to infectious materials that may
be carried on hands.
• Semmelweis, a Hungarian physician, was employed in
the maternity department of a large Viennese hospital • Gloves must be changed between tasks and procedures
during the 1840s. on the same patient whenever there is risk of transferring
microorganisms from one body site to another.

• Many of the women whose babies were delivered in one

Isolation Gowns
of the hospital’s clinics became ill and died of a disease
known as puerperal fever (also known as childbed fever), • Isolation gowns are worn in conjunction with gloves and
the cause of which was unknown at the time. with other PPE when indicated. Gowns are usually the first
piece of PPE to be donned. They protect the healthcare
• Semmelweis observed that physicians and medical
worker’s arms and exposed body areas and prevent
students often went directly from an autopsy room to the
contamination of clothing with blood, body fluids, and
obstetrics clinic to assist in the delivery of a baby.
other potentially infectious material. Gloves must be
Although they washed their hands with soap and water
changed between tasks and procedures on the same patient
upon entering the clinic. Semmelweis noted that their
whenever there is risk of transferring microorganisms
hands still had a disagreeable odor.
from one body site to another.
• He concluded that the puerperal fever that the women
later developed was caused by “cadaverous particles”
Masks
present onthe hands of the physicians and students.
• Masks are used for three primary purposes in healthcare
• In May 1847, Semmelweis instituted a policy that stated
settings:
that “all students or doctors who enter the wards for the
purpose of making an examination must wash their hands 1. They are worn by healthcare personnel to protect
thoroughly in a solution of chlorinated lime that will be them from contact with infectious material from
placed in convenient basins near the entrance of the patients.
wards.” 2. They are worn by healthcare personnel when
engaged in procedures requiring sterile technique
• Thereafter, the maternal mortality rate dropped
to protect patients from exposure to pathogens
dramatically. This was the first evidence that cleansing
that may be present in a healthcare worker’s
contaminated hands with an antiseptic agent reduces HAIs
mouth or nose.
more effectively than handwashing with plain soap and
3. They are placed on coughing patients to limit
water.
potential dissemination of infectious respiratory
secretions from the patient to others.
 MICROBIOLOGY FOR RT

Eye Protection Disposal of Sharps

• Types of eye protection include goggles and disposable • Needlestick injuries and injuries resulting from broken
or non disposable face shields. Masks may be used in glass and other sharps are the primary manner in which
combination with goggles, or a face shield may be used healthcare workers become infected with pathogens such
instead of a mask and goggles. Eye protection and masks as HIV, HBV, and HCV. Thus, Standard Precautions
are removed after gloves are removed. include guidelines regarding the safe handling of such
items.
Respiratory Protection • Needles and other sharp devices must be handled in a
manner that prevents injury to the user and to others who
• Respiratory protection requires the use of a respirator
may encounter the device during or after a procedure.
with N95 of higher filtration to prevent inhalation of
infectious particles • Accidents can be prevented by employing safer
techniques (such as by not recapping needles), by
disposing of used needles in appropriate sharps disposal
containers, and by using safety-engineered sharp devices.

Transmission-Based Precautions

• Within a healthcare setting, pathogens are transmitted by

three major routes: contact, droplet, and airborne.
Transmission-based precautions are used for patients who
are known or suspected to be infected or colonized with
highly transmissible or epidemiologically important
pathogens for which additional safety precautions beyond
Patient-Care Equipment Standard Precautions are required to interrupt
transmission within hospitals.
• Organic material must be removed from medical
equipment, instruments, and devices prior to high level • There are three types of Transmission-Based
disinfection and sterilization. All such equipment and Precautions, which may be used either singly or in
devices must be handled in a manner that will prevent combination: Contact Precautions, Droplet
healthcare workers and the environment with potentially Precautions, and Airborne Precautions. It is very
infectious material. important to understand that Transmission-Based
Precautions are to be used in addition to the Standard
Precautions already being used.
Environmental Control
• The hospital must have, and employees must comply Contact Precautions
with, adequate procedures for the routine care, cleaning,
and disinfection of environmental surfaces such as - is the most important and frequent mode of
bedrails, bedside tables, commodes, doorknobs, sinks, and transmission of HAIs.
any other surfaces and equipment in close proximity to • Contact Precautions are used for patients known or
patients. suspected to be infected or colonized with
epidemiologically important pathogens that can be
Linens transmitted by direct or indirect contact. Examples include
multidrug-resistant bacteria, C. difficileassociated
• Textiles such as bedding, towels, and patient gowns that diseases, respiratory syncytial virus (RSV) infection in
have become soiled with blood, body fluids, secretions, or children, scabies, impetigo, chickenpox or shingles, and
excretions must be handled, transported, and laundered in viral hemorrhagic fevers.
a safe manner.
 MICROBIOLOGY FOR RT

Droplet Precautions a single-patient room that is equipped with special air

handling and ventilation systems. AIIRs are under
- is a form of contact transmission. However, in
negative pressure to prevent room air from entering the
droplet transmission, the mechanism of
corridor when the door is opened, and air that is evacuated
transfer is quite different than either direct or
from such rooms passes through High-Efficiency
indirect contact transmission.
Particulate Air (HEPA) filters to remove pathogens.
• Droplets are produced primarily as a result of coughing, Standard and Airborne Precautions are strictly enforced.
sneezing, and talking, as well as during hospital
procedures such as suctioning and bronchoscopy.
Protective Environments
Transmission occurs when droplets (larger than 5 μm in
diameter) containing microbes are propelled a short • Certain patients are especially vulnerable to infection,
distance through the air and become deposited on another particularly to invasive environmental fungal infections.
person’s conjunctiva, nasal mucosa, or mouth. Because of Examples of such are patients with severe burns, those
their size, droplets do not remain suspended in the air. who have leukemia, patients who have received a
Droplet Precautions must be used for patients known or transplant (such as a hematopoietic stem cell transplant),
suspected to be infected with microbes transmitted by immunosuppressed persons, those receiving radiation
droplets that can be generated in the ways previously treatments, leukopenic patients (those having abnormally
mentioned. low white blood cell counts), and premature infants.
• These patients can be protected by placing them in a
Protective Environment (sometimes referred to as
Airborne Precautions protective isolation or positive pressure isolation). The
- involves either airborne droplet nuclei or dust Protective Environment is a well-sealed singlepatient
particles containing a pathogen. room in which vented air entering the room is passed
through HEPA filters. Strategies to minimize dust include
• Airborne droplet nuclei are smallparticle residues (5 μm scrubbable surfaces rather than upholstery and carpet.
or less in diameter) of evaporated droplets containing Crevices and sprinkler heads are routinely cleaned.
microbes; because of their small size, they remain Appropriate Standard and Transmission-Based
suspended in air for long periods. Airborne Precautions Precautions are strictly enforced.
apply to patients known or suspected to be infected with
epidemiologically important pathogens that can be
transmitted by the airborne route. Handling Food and Eating Utensils
• Contaminated food provides an excellent environment
Patient Placement for the growth of pathogens. Most often, human
carelessness, especially neglecting the practice of
• Whenever possible, single-patient rooms are used for handwashing, is responsible for this contamination.
patients who might contaminate the hospital environment Foodborne pathogens and the diseases they cause are
or who do not (or cannot be expected to) assist in discussed in Chapter 11. Regulations for safe handling of
maintaining appropriate hygiene or environmental food and eating utensils are not difficult to follow.
control. Single rooms are always indicated for patients
placed on Airborne Precautions and are preferred for They include:
patients requiring Contact or Droplet Precautions
• Using high-quality, fresh food
• Properly refrigerating and storing food
Airborne Infection Isolation Rooms • Properly washing, preparing, and cooking
food
• The preferred placement for patients who are infected • Properly disposing of uneaten food
with pathogens that are spread via airborne droplet nuclei • Thoroughly washing hands and fingernails
and, therefore, require Airborne Precautions, is in an before handling food and after visiting a
Airborne Infection Isolation Room (AIIR). An AIIR is restroom
 MICROBIOLOGY FOR RT

• Properly disposing of nasal and oral Medical Waste Disposal

secretions in tissues and then thoroughly
• Materials or substances that are harmful to health are
washing hands and fingernails
referred to as biohazards (short for biologic hazards). They
• Covering hair and wearing clean clothes and
must be identified by a biohazard symbol, which was
aprons
shown in Figure 12-7. According to OSHA standards,
• Providing periodic health examinations for
medical wastes must be disposed of properly.
kitchen workers
• Prohibiting anyone with a respiratory or Medical Waste Disposal These standards include the
gastrointestinal disease from handling food or following:
eating utensils
• Keeping all cutting boards and other surfaces • Any receptacle used for decomposable solid
scrupulously clean or liquid waste or refuse must be constructed
• Rinsing and then washing cooking and eating so that it does not leak and must be maintained
utensils in a dishwasher in which the water in a sanitary condition. This receptacle must
temperature is greater than 80°C be equipped with a solid, tight-fitting cover,
unless it can be maintained in a sanitary
condition without a cover.
Handling Fomites • All sweepings, solid or liquid wastes, refuse,
and garbage shall be removed to avoid
• As previously described, fomites are any nonliving or
creating a menace to health and shall be
inanimate objects other than food that may harbor and
removed as often as necessary to maintain the
transmit microbes. Examples of fomites in healthcare
place of employment in a sanitary condition.
settings are patients’ gowns, bedding, towels, and eating
• The medical facility’s infection control
and drinking utensils; and hospital equipment such as
program must address the handling and
bedpans, stethoscopes, latex gloves, electronic
disposal of potentially contaminated items.
thermometers, and electrocardiographic electrodes that
Disposal of sharps was discussed earlier in the
become contaminated by pathogens from the respiratory
chapter.
tract, intestinal tract, or the skin of patients. Telephones
and computer keyboards in patient-care areas can also
serve as fomites. Infection Control Committees
Transmission of pathogens by fomites can be prevented by • Also known as Infection Prevention and Control (Ipc)
observing the following rules: committees, are multidisciplinary teams within healthcare
facilities or organizations dedicated to preventing and
• Use disposable equipment and supplies
managing healthcare-associated infections (HAIs). These
wherever possible
committees play a crucial role in ensuring the safety of
• Disinfect or sterilize equipment as soon as
patients, healthcare workers, and visitors by implementing
possible after use
measures to minimize the risk of infections spreading
• Use individual equipment for each patient
within healthcare settings.
• Use electronic or glass thermometers fitted
with one-time use, disposable covers or use
disposable, single-use thermometers; Spotlighting Infection
electronic and glass thermometers must be
cleaned or sterilized on a regular basis, - refer to various aspects related to the
following the manufacturer’s instructions detection, prevention, or management of
• Empty bedpans and urinals, wash them in hot infections.
water and store them in a clean cabinet
between uses
• Place bed linen and soiled clothing in bags to
be sent to the laundry
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Infection Prevention Public Health Measures

• Proper Hand Hygiene: Regular hand washing with soap • Public Awareness Campaigns: Educating the public
and water is one of the most effective ways to prevent the about the importance of vaccination, hygiene, and other
spread of infections. preventive measures can reduce infections.
• Vaccination: Immunizations can prevent many serious • Surveillance and Monitoring: Public health authorities
infections. monitor trends in infections to detect outbreaks and
implement control measures.
• Safe Food Handling: Ensuring food safety can prevent
foodborne infections.
Research and Development
• Safe Practices in Healthcare Settings: Healthcare
professionals must follow strict protocols to prevent • Ongoing research is essential for understanding new and
healthcare-associated infections. emerging infections, developing vaccines, and improving
treatment options.

Infection Detection
Technological Advancements
• Symptoms Recognition: Recognizing the signs and
• Telemedicine: Remote consultations can help in
symptoms of infections (fever, cough, unusual fatigue,
diagnosing and managing certain infections without direct
etc.) helps in early detection.
contact.
• Diagnostic Tests: Various tests, such as blood tests,
• Data Analytics: Analyzing health data can identify
cultures, and imaging, can help diagnose specific
patterns and trends, aiding in the early detection of
infections.
outbreaks.
• Contact Tracing: Identifying and monitoring people who
have been exposed to an infectious disease can prevent its
Microbiology Laboratories
further spread.
• It plays a critical role in various fields, including
healthcare, research, environmental science, and industry.
Management of Infections Here are some key aspects of their roles:
• Antibiotics and Antivirals: Depending on the type of
Disease Diagnosis and Monitoring
infection, doctors may prescribe antibiotics (for bacterial
infections) or antiviral medications (for viral infections). • Clinical Microbiology: Microbiology labs in hospitals
and clinics diagnose infectious diseases, identify
• Isolation and Quarantine: Isolating infected individuals
pathogens (bacteria, viruses, fungi), and determine their
and quarantining those exposed can prevent the spread of
antibiotic susceptibility, aiding doctors in prescribing
infections.
appropriate treatments.
• Supportive Care: Providing supportive care, such as
• Epidemiology: Microbiologists track disease outbreaks,
fluids, rest, and pain relief, can help the body fight off
analyze patterns, and develop preventive strategies,
many infections.
crucial for public health.
• Preventing Complications: Timely and appropriate
medical care can prevent complications associated with
Research and Development
infections
• Drug Development: Microbiology labs are involved in
the discovery and testing of new drugs, especially
antibiotics, antivirals, and vaccines, to combat evolving
pathogens.
 MICROBIOLOGY FOR RT

• Genetic Engineering: Microbiologists work on genetic Infectious Disease Surveillance

modification of microorganisms for various applications,
• Monitoring Antimicrobial Resistance: Labs track the
such as producing enzymes, proteins, or developing
emergence of drug resistant strains, guiding healthcare
genetically modified organisms (GMOs).
policies and antibiotic usage guidelines.
• Pandemic Preparedness: Microbiologists monitor
Food and Beverage Industry
potential pandemic threats, studying novel pathogens and
• Food Microbiology: Labs ensure food safety by testing developing preparedness plans.
for pathogens, spoilage organisms, and toxins. They also
Forensic Microbiology
monitor fermentation processes and develop new
preservation methods. • Criminal Investigations: Microbiologists analyze
microbial evidence in criminal cases, such as bioterrorism
• Quality Control: Microbiologists help maintain the
threats or food contamination incidents.
quality and safety of beverages, dairy products, and other
consumables

Environmental Microbiology
• Water and Soil Analysis: Microbiology labs analyze
water and soil samples for the presence of contaminants,
pollutants, and pathogens, ensuring environmental safety
and public health.
• Bioremediation: Microbiologists research and apply
microorganisms to remove pollutants from soil and water,
contributing to environmental cleanup efforts.

Industrial Microbiology
• Biotechnology: Labs develop biotechnological processes
involving microorganisms, such as producing biofuels,
enzymes, and other bio based products.
• Waste Management: Microbiologists design processes
that use microbes to break down organic waste in
industries, reducing environmental impact.

Education and Training

• Academic Research: Microbiology labs in universities
and research institutions conduct experiments, advancing
scientific knowledge and training future scientists.
• Training: Microbiology labs provide hands-on training
for students and professionals, teaching essential
techniques and protocols.