Burton’s Microbiology
for the Health Sciences
Section VI.
Microbiology within Healthcare
Facilities
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Burton’s Microbiology
for the Health Sciences
Chapter 12.
Healthcare Epidemiology
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Chapter 12 Outline
• Introduction
• Healthcare-Associated
Infections
• Infection Control
• Conclusions
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Introduction
• Healthcare epidemiology is the study of the occurrence,
determinants, and distribution of health and disease
within healthcare settings
• The primary focus of healthcare epidemiology is on
infection control and the prevention of healthcare-
associated infections.
• Healthcare epidemiology includes any activities
designed to study and improve patient care outcomes.
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Healthcare-Associated Infections
• Infectious diseases can be divided into two categories:
1. Those acquired within healthcare facilities (called
healthcare-associated infections [HAIs])
2. Those acquired outside of healthcare facilities (called
community-acquired infections)
• Frequency of HAIs
– Of approximately 40 million hospitalizations per year
in the United States, an estimated 2 million patients
(~5% of the total) acquire HAIs.
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Pathogens Most Often Involved in HAIs
• The most common bacterial causes of HAIs in the United
States:
– Gram-positive cocci: Staphylococcus aureus,
coagulase-negative staphylococci, and Enterococcus
spp.
– Gram-negative bacilli: Escherichia coli,
Pseudomonas aeruginosa, Enterobacter spp., and
Klebsiella spp.
• The sources of these pathogens are healthcare
professionals, other healthcare workers, visitors, and the
patients themselves.
• Approximately 70% of HAIs involve drug-resistant
bacteria.
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Most Common Types of HAIs
• The four most common types of HAIs, in descending
order of frequency, are
1. Urinary tract infections (UTIs)
2. Surgical site infections (also referred to as
postsurgical wound infections)
3. Lower respiratory tract infections (primarily
pneumonia)
4. Bloodstream infections (septicemia)
• Other types: gastrointestinal diseases caused by
Clostridium difficile (referred to as Clostridium difficile–
associated diseases)
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Patients Most Likely to Develop HAIs
• Elderly patients
• Women in labor and delivery
• Premature infants and newborns
• Surgical and burn patients
• Diabetic, cancer, and transplant patients
• Patients receiving treatment with steroids, anticancer
drugs, antilymphocyte serum, and radiation
• Immunosuppressed patients
• Patients who are paralyzed or are undergoing renal
dialysis or catheterization
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Major Factors Contributing to HAIs
• The three major factors that combine to cause HAIs are
– An ever-increasing number of drug-resistant
pathogens
– The failure of healthcare personnel to follow infection
control guidelines
– An increased number of immunocompromised
patients
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The Three Major Contributing Factors in
HAIs
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Additional Factors Contributing to HAIs
• Overcrowding of hospitals and shortages of healthcare
staff
• The indiscriminate use of antimicrobial agents
• A false sense of security about antimicrobial agents
• Lengthy and more complicated types of surgery
• Increased use of less highly trained healthcare workers
• Increased use of anti-inflammatory and
immunosuppressant agents
• Overuse and improper use of indwelling devices
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What Can Be Done to Reduce the
Number of HAIs?
• Strict compliance with infection control guidelines
• Handwashing is the single most important measure
to reduce the risks of transmitting pathogens from
one patient to another or from one anatomic site to
another on the same patient!
• Other means of reducing the incidence of HAIs include
• disinfection and sterilization techniques,
• air filtration,
• use of ultraviolet lights,
• isolation of especially infectious patients,
• wearing gloves, masks, and gowns whenever appropriate.
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Proper Handwashing Technique
The most
important and
most basic
technique in
preventing and
controlling
infections and
preventing the
transmission of
pathogens is
handwashing.
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Proper Handwashing Technique (cont.)
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Infection Control
• Infection control⎯the numerous measures taken to
prevent infections from occurring in healthcare settings.
• Asepsis means “without infection”; there are two
types:
– Medical asepsis
• Precautionary measures necessary to prevent
direct transfer of pathogens from person to person
and indirect transfer of pathogens through the air
or on instruments, bedding, equipment, and other
inanimate objects (fomites)
– Surgical asepsis or sterile technique
• Practices used to render and keep objects and
areas sterile
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Infection Control (cont.)
• Surgical aseptic techniques are practiced in
operating rooms, in labor and delivery areas, and
during invasive procedures (e.g., drawing blood,
injecting medications, urinary and cardiac
catheterization, lumbar punctures).
• Differences between medical and surgical asepsis:
1. Medical asepsis is a clean technique,
whereas surgical asepsis is a sterile
technique
2. The goal of medical asepsis is to exclude
pathogens, whereas the goal of surgical
asepsis is to exclude all microbes.
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Infections Control (cont.)
• Standard Precautions – are to be applied to the
care of ALL patients in ALL healthcare settings,
regardless of the suspected or confirmed
presence of an infectious agent.
– They provide infection control guidelines regarding
hand hygiene; wearing of gloves, masks, eye
protection, and gowns; respiratory hygiene/cough
etiquette; safe injection practices; lumbar
puncture; cleaning of patient-care equipment;
environmental control; handling of soiled linens;
resuscitation devices; patient placement; and
disposal of used needles and other sharps.
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Standard
Precautions
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Healthcare Professional Donning Personal
Protective Equipment (PPE)
(A) sterile gown, (B) mask, and (C) gloves
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Proper Procedure for Glove Removal
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Transmission-Based Precautions
• 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 Standard
Precautions are required to interrupt transmission within
healthcare settings
• The three types of Transmission-Based
Precautions are
1. Contact Precautions
2. Droplet Precautions
3. Airborne Precautions
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Contact Precautions
Contact transmission
is divided into two
subgroups:
• (1) direct
contact (i.e., transfer
of microorganisms
from body surface to
body surface) and
• (2) indirect contact
(i.e., transfer of
microbes through a
contaminated
intermediate object).
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Examples of Diseases
Requiring Contact Precautions
• Acute viral (hemorrhagic) • Infection or colonization with
conjunctivitis; multidrug-resistant organisms;
• Acute respiratory infectious • Major draining abscesses or
diseases or aseptic meningitis wound infections;
in infants and young children;
• Severe mucocutaneous herpes
• Chickenpox; simplex infections;
• Cutaneous diphtheria; • Smallpox;
• Disseminated shingles; • Major staphylococcal or
streptococcal disease of skin,
• Gastroenteritis in diapered or wounds, or burns;
incontinent persons;
• Viral hemorrhagic fevers due to
• Impetigo; lassa, ebola, marburg, or
crimean-congo fever viruses
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Droplet
Precautions
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Examples of Diseases
Requiring Droplet Precautions
• Adenovirus infection in infants and • Mycoplasma pneumonia;
young children;
• Whooping cough;
• Adenovirus pneumonia;
• Pharyngeal diphtheria;
• Epiglottitis or meningitis caused by
Haemophilus influenzae type b; • Pneumonic plague;
• Major skin, wound, or burn • German measles;
infections due to group A
streptococcus; • Severe acute respiratory syndrome
(SARS);
• Scarlet fever in infants and young
children; • Strep throat in infants and young
children;
• Influenza;
• Rhinovirus infection;
• Meningitis or pneumonia caused by
Neisseria meningitidis; • Viral hemorrhagic fevers due to
lassa, Ebola, Marburg, or Crimean
• Mumps; Congo fever viruses
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Airborne
Precautions
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Examples of Diseases
Requiring Airborne Precautions
• Chickenpox;
• Confirmed or suspected pulmonary or laryngeal
tuberculosis;
• Extrapulmonary tuberculosis with draining lesions;
• Disseminated shingles in any patient;
• Localized shingles in immunocompromised patients;
• Measles;
• Monkeypox;
• SARS;
• Smallpox
• Note that some of these diseases also require Droplet
Precautions and/or Contact Precautions.
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Type N95 Respirator
Type N95 respirator
is used when Airborne
Precautions are
indicated.
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Airborne Infection Isolation Room
• The preferred placement for
patients who are infected
with pathogens that are
spread via airborne droplet
nuclei (5 μm or less in
diameter), and therefore
require Airborne Precautions,
is an airborne infection
isolation room (AIIR).
• An AIIR is under negative
pressure.
• The air evacuated from an
AIIR passes through a high-
efficiency particulate air
(HEPA) filter.
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Protective Environments
• Patients who are especially
vulnerable to infection are
placed in a Protective
Environment⎯patients with
severe burns or leukemia,
transplant or
immunosuppressed patients,
patients receiving radiation
treatment, leukopenic
patients, and premature
infants.
• The room is under positive
pressure and air entering the
room passes through HEPA
filters.
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Handling Food and Eating Utensils
• Some of the regulations for safe handling of food and
eating utensils include
– Using high-quality, fresh food
– Properly refrigerating and storing food
– Properly washing, preparing, and cooking food
– Properly disposing of uneaten food
– Covering hair and wearing clean clothes and aprons
– Thoroughly washing hands and nails before handling
foods
– Keeping all cutting boards and other surfaces
scrupulously clean
– Washing cooking and eating utensils in a dishwasher
with a water temperature of >80°C.
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Handling Fomites
• Fomites are nonliving, inanimate objects, other than
food, that may harbor and transmit microbes (e.g.,
patients’ gowns, bedding, towels, hospital equipment,
telephone, computer keyboard, etc.).
• Transmission of pathogens by fomites can be prevented
by observing certain rules:
– Use disposable equipment and supplies whenever
possible
– Disinfect or sterilize equipment soon after use
– Use individual equipment for each patient
– Use disposable thermometers or thermometer covers
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Medical Waste Disposal
• General regulations
– Follow OSHA standards
for disposal of medical
wastes
• Disposal of sharps
– Handle and dispose of
sharps properly.
– Dispose of sharps in
specifically designed
puncture-resistant
containers (“sharps
containers”).
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Infection Control Committees and
Infection Control Professionals
• All healthcare facilities should have some type of formal
infection control program in place.
• The Infection Control Committee (ICC) is composed of
representatives from most of the hospital’s departments,
including medical and surgical services, pathology,
nursing, hospital administration, risk management,
pharmacy, housekeeping, food services, and central
supply.
– The chairperson is usually an infection control
professional such as an epidemiologist or infectious
disease specialist, an infection control nurse, or a
microbiologist.
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Role of the Clinical Microbiology
Laboratory (CML) in Hospital
Epidemiology and Infection Control
• CML personnel participate in infection control by
– Monitoring the types and numbers of pathogens
isolated from hospitalized patients
– Notifying the appropriate infection control person
should an unusual pathogen or an unusually high
number of isolates of a common pathogen be
detected
– Processing environmental samples, including samples
from hospital employees that have been collected
from within the affected ward(s)
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Concluding Remarks
• HAIs can add several weeks to a patient’s hospital stay
and may lead to serious complications and even death.
• Insurance companies rarely reimburse healthcare
facilities for costs associated with HAIs.
• HAIs can be avoided through proper education and
disciplined compliance with infection control practices!
• All healthcare workers must fully comprehend the
problem of HAIs, must be completely
knowledgeable about infection control practices,
and must personally do everything in their power
to prevent HAIs from occurring!
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