Ghid pentru controlul infectiilor in spital
A Guide To
Infection Control
in the Hospital
Fifth Edition
Bearman
Stevens
Edmond
Wenzel
A Guide to
Infection Control
in the Hospital
An official publication of the
International Society for Infectious Diseases (ISID)
Fifth Edition
Bearman
Stevens
Edmond
Wenzel
2014
International Society for Infectious Diseases
Boston, MA • USA
International Society for Infectious Diseases
9 Babcock Street, Unit 3
Brookline, MA 02446 • USA
Phone: (617) 277-0551
Fax: (617) 278-9113
E-mail: info@isid.org
Web site: http://www.isid.org
© 2014 The International Society for Infectious Diseases.
Previous edition copyright 1998, 2002, 2004, 2008.
All rights reserved. Without limiting the rights under copyright reserved above, no part
of this publication may be reproduced, stored in or introduced into a retrieval system,
or transmitted, in any form or by any means (electronic, mechanical, photocopying,
recording, or otherwise), without prior written permission from the publisher.
Isbn 0-9749031-0-8
Printed in the United States of America
Sales and Distribution
Worldwide
International Society for Infectious Diseases
9 Babcock Street, Unit 3
Brookline, MA 02446 • USA
Phone: (617) 277-0551
Fax: (617) 278-9113
E-mail: info@isid.org
Web site: http://www.isid.org
Notice: The authors and publisher have made every effort to ensure that the patient care
recommended herein, including choice of drugs and drug dosages, is in accord with the
accepted standard and practice at the time of publication. However, since research and
regulation constantly change clinical standards, the reader is urged to check the product
information sheet included in the package of each drug, which includes recommended
doses, warnings, and contraindications. This is particularly important with new or infre-
quently used drugs. Any treatment regimen, particularly one involving medication,
involves inherent risk that must be weighed on a case-by-case basis against the
benefits anticipated. The reader is cautioned that the purpose of this book is to inform
and enlighten; the information contained herein is not intended as, and should not be
employed as, a substitute for individual diagnosis and treatment.
ii A Guide to Infection Control in the Hospital
Editors
Gonzalo M.L. Bearman, MD, MPH
Professor of Medicine
Associate Hospital Epidemiologist
Department of Medicine
Virginia Commonwealth University
School of Medicine
Richmond, Virginia, USA
Michael Stevens, MD, MPH
Assistant Professor of Medicine/
Division of Infectious Diseases
Associate Hospital Epidemiologist
Director, Antimicrobial
Stewardship Program
Director, Travel & Tropical
Medicine Clinic
Virginia Commonwealth University
Health System
Richmond, Virginia, USA
Michael B. Edmond, MD, MPH, MPA
Professor of Internal Medicine
Chief Quality Officer
University of Iowa
Iowa City, Iowa, USA
Richard P. Wenzel, MD, MSc
Professor and Former Chairman
Department of Internal Medicine
Medical College of Virginia Campus
Virginia Commonwealth University
Richmond, Virginia, USA
A Guide to Infection Control in the Hospital iii
iv A Guide to Infection Control in the Hospital
List of Contributors
Awa Aidara Kane, PhD Timothy F. Brewer, MD,
Department of Food Safety MPH, FACP
and Zoonoses Vice Provost, Interdisciplinary
WHO and Cross-Campus Affairs
Geneva, Switzerland Professor of Medicine
University of California,
Paul R. Allyn, MD Los Angeles
Fellow, Division of Infectious Los Angeles, California, USA
Diseases
University of California, Melanie Brown, MD
Los Angeles Division of Infectious Diseases
Los Angeles, California, USA Virginia Commonwealth University
Health System
Susan Assanasen, MD Richmond, Virginia, USA
Division of Infectious Diseases,
Department of Medicine, Anne Dediste, MD
Siriraj Hospital University Hospitals St. Pierre
Mahidol University Brugmann, and Queen Fabiola
Bangkok, Thailand Brussels, Belgium
Gonzalo M.L. Bearman, MD, MPH Patrick De Mol, MD, PhD
Professor of Medicine Department of Microbiology, Sart
Associate Hospital Epidemiologist Tilman University Hospital
Department of Medicine Liège, Belgium
Virginia Commonwealth University
School of Medicine Summer Donovan, DO
Richmond, Virginia, USA Pediatric Infectious Diseases Fellow
Virginia Commonwealth University
Mohamed Benbachir, PhD Health System
Quality Consultant Richmond, Virginia, USA
Casablanca, Morocco
Herbert L. DuPont, MD
Frederick James Bolton, PhD, University of Texas
FRCPath School of Public Health
Regional Health Protection Agency Baylor St. Luke’s Medical Center
Laboratory Houston, Texas, USA
Manchester Royal Infirmary
Manchester, United Kingdom
A Guide to Infection Control in the Hospital v
Adriano G. Duse, MT, MBBCh (Rand), Michèle Gerard, MD
DTM&H, MMed (Microbiology), Department of Infectiology
FCPath SA (Microbiology) Saint-Pierre University Hospital
Chief Specialist, Chair and Academic Brussels, Belgium
Head, Department of Clinical
Microbiology and Infectious Helen Giamarellou, MD
Diseases (CMID) Professor Internal Medicine
School of Pathology of the NHLS Infectious Disease Department
and Faculty of Health Sciences, Athens University Medical School
University of the Witwatersrand Athens, Greece
Johannesburg, South Africa Ravindra Gopaul, MD, MPH, MBA
Michael B. Edmond, MD, VCU Combined EM/IM
MPH, MPA Residency Program
Professor of Internal Medicine Department of Emergency Medicine
Chief Quality Officer Virginia Commonwealth University
University of Iowa Medical Center
Iowa City, Iowa, USA Richmond, Virginia, USA
Javier Ena, MD, MPH Bart Gordts, MD, MBA
Consultant Clinical Microbiology and
Department of Internal Medicine Infection Control
Hospital Marina Baixa Hospital Network Antwerp (ZNA)
Alicante, Spain Antwerp, Belgium
Betty A. Forbes, PhD Imma Grau, MD
Professor of Pathology Hospital Bellvitge
Director of Clinical Microbiology University of Barcelona
Department of Pathology Barcelona, Spain
Virginia Commonwealth University Jonathan Grein, MD
Richmond, Virginia, USA Associate Director,
Patricia Pecora Fulco, PharmD, Hospital Epidemiology
BCPS, FASHP, AAHIVP Cedars-Sinai Medical Center
Clinical Pharmacy Specialist Los Angeles, California, USA
Internal Medicine/HIV T. D. Healing, MSc, PhD
Clinical Associate Professor London, United Kingdom
of Pharmacy
Clinical Assistant Professor Peter Hoffman, BSc, Hon DipHIC
Internal Medicine/ Consultant Clinical Scientist
Division of Infectious Diseases Antimicrobial Resistance and
Virginia Commonwealth University Healthcare Associated Infection
Medical Center Reference Unit
Richmond, Virginia, USA Public Health England
London, United Kingdom
vi A Guide to Infection Control in the Hospital
Claudia D. Jarrin Tejada, MD Philippe Lepage, MD, PhD
Infectious Disease Fellow Head, Department of Pediatrics
Virginia Commonwealth University Hôpital Universitaire des Enfants
Health System Reine Fabiola
Richmond, Virginia, USA Université Libre de Bruxelles
Brussels, Belgium
Jan Kluytmans, MD, PhD
Consultant Microbiologist Jack Levy MD, PhD
Amphia Hospital Breda/Oosterhout, Head, Department of Pediatrics
Sint Elisabeth Hospital and Twee CHU Saint-Pierre
Steden Hospital, Tilburg Professor of Pediatrics
Professor of Medical Microbiology Université Libre de Bruxelles
and Infection Control Brussels, Belgium
VU University Medical Center, Denise K. Lowe, PharmD, BCPS
Amsterdam Director, Drug Information Services
Amsterdam, The Netherlands Virginia Commonwealth University
Health System
Eva-Birgitta Kruse, MD
Clinical Associate Professor
Laboratoriumsmedzin Köln Virginia Commonwealth University
Cologne, Germany School of Pharmacy
Caroline Landelle, PharmD, PhD Richmond, Virginia, USA
Infection Control Program Alejandro Macias, MD, MSc
and WHO Collaborating Centre Specialist in Internal Medicine
on Patient Safety and Infectious Diseases
University of Geneva Hospitals Professor and Head,
and Faculty of Medicine Infection Control
Geneva, Switzerland University of Guanajuato and
National Institute of Medical
Surbhi Leekha, MBBS, MPH Sciences and Nutrition
Assistant Professor, Departments of Mexico City, Mexico
Epidemiology and Public Health
and Medicine J. Daniel Markley, DO
University of Maryland School Virginia Commonwealth University
of Medicine Medical Center
Associate Hospital Epidemiologist Richmond, Virginia, USA
University of Maryland Alexandre R. Marra, MD
Medical Center Hospital Israelita Albert Einstein
Baltimore, Maryland, USA São Paulo, Brazil
Sebastiano Leone, MD Tawana McNair, MD
Division of Infectious Diseases Clinical Infectious Diseases Fellow
San Gerardo Hospital Department of Medicine
Monza, Italy Division of Infectious Diseases
Virginia Commonwealth University
Richmond, Virginia, USA
A Guide to Infection Control in the Hospital vii
Véronique Y. Miendje Deyi, Tara Palmore, MD, FACP
PharmD, PhD Deputy Hospital Epidemiologist
Brugmann University Hospital National Institutes of Health
Microbiology Lab Clinical Center
Brussels, Belgium National Institutes of Health
Bethesda, Maryland, USA
Rebekah W. Moehring, MD, MPH
Assistant Professor of Medicine Didier Pittet, MD, MS
Division of Infectious Diseases Infection Control Program and
Duke University Medical Center WHO Collaborating Centre
Durham, North Carolina, USA on Patient Safety
University of Geneva Hospitals
Rekha Murthy, MD and Faculty of Medicine
Director, Hospital Epidemiology, Geneva, Switzerland
Professor of Medicine,
Cedars-Sinai Medical Center Samuel R. Ponce de León, MD, MSc
Professor of Clinical Medicine, Division of Hospital Epidemiology
UCLA David Geffen School and Quality Care
of Medicine Instiuto Nacional de la Nutrición
Los Angeles, California, USA Salvador Zubirán
Mexico City, Mexico
Emanuele Nicastri, MD, PhD
Epidemiologist M. Sigfrido Rangel-Frausto,
National Institute for MD, MSc, MQ
Infectious Diseases Infectious Diseases Department
L. Spallanzani IRCCS Hospital Medica Sur
Rome, Italy Mexico City, Mexico
Belinda Ostrowsky, MD, MPH Marie-Claude Roy, MD, MSc
Director Antimicrobial Stewardship Microbiology and
and Associate Professor Infectious Diseases
Montefiore Medical Center & Albert Hôpital de l’Enfant-Jésus
Einstein College of Medicine Québec City, Québec, Canada
Bronx, USA
William A. Rutala, MS, MPH, PhD
Amy L. Pakyz, PharmD, MS Professor of Medicine,
Assistant Professor UNC School of Medicine
Virginia Commonwealth University Director, Statewide Program
School of Pharmacy for Infection Control and
Medical College of Virginia Campus Epidemiology
Richmond, Virginia, USA Director, Hospital Epidemiology,
Occupational Health and Safety
Roman Pallares, MD Program, UNC Health Care
Hospital Bellvitge Chapel Hill, North Carolina, USA
University of Barcelona
Barcelona, Spain
viii A Guide to Infection Control in the Hospital
Harald Seifert, MD Made Sutjita, MD, PhD
Professor of Medical Microbiology Loma Linda University
and Hygiene Infectious Disease Section
Institute for Medical Microbiology, Riverside County Regional
Immunology and Hygiene Medical Center
University of Cologne Moreno Valley, California, USA
Cologne, Germany
C.M.A. Swanink, MD, PhD
Michael Stevens, MD, MPH Rijnstate Hospital
Assistant Professor of Medicine / Department of Medical
Division of Infectious Diseases Microbiology and Immunology
Associate Hospital Epidemiologist Arnhem, The Netherlands
Director, Antimicrobial
Stewardship Program Antoni Trilla, MD, MSc
Director, Travel & Tropical Chief, Preventive Medicine and
Medicine Clinic Hospital Epidemiology Unit
Virginia Commonwealth University Professor of Public Health
Health System Hospital Clinic-University of
Richmond, Virginia, USA Barcelona
Barcelona, Spain
Andrew J. Stewardson, MBBS
Infection Control Program and Philippe Van de Perre, MD, PhD
WHO Collaborating Centre Professor of Virology,
on Patient Safety University Montpellier 1
University of Geneva Hospitals Head of Dept Bacteriology-Virology,
and Faculty of Medicine University Teaching Hospital
Geneva, Switzerland Director of INSERM U 1058,
Université Montpellier 1
Marc Struelens, MD, PhD Montpellier, France
Department of Microbiology
Erasme University Hospital Olivier Vandenberg, MD, PhD
Brussels, Belgium Infectious Disease
Epidemiological Unit
Pawan Suri, MD Department of Environmental Health
Chair, Division of Observation Public Health School
Medicine, Department of Université Libre de Bruxelles
Emergency Medicine Brussels, Belgium
Program Director, Combined Em/Im
Residency Program Jacobien Veenemans, MD, PhD
VCU School of Medicine Medical Microbiologist in Training
Assistant Professor in Emergency Laboratory for Microbiology and
Medicine and Internal Medicine Infection Control
Virginia Commonwealth University Amphia Hospital, Breda
Medical Center Breda, The Netherlands
Richmond, Virginia, USA
A Guide to Infection Control in the Hospital ix
Heike von Baum, MD Richard P. Wenzel, MD, MSc
Division of Clinical Hygiene Professor and Former Chairman
Institute for Microbiology and Department of Internal Medicine
Hygiene Medical College of Virginia Campus
Ulm, Germany Virginia Commonwealth University
Richmond, Virginia, USA
Margreet C. Vos, MD, PhD
Professor in Health Care Related Sergio B. Wey, MD, PhD.
Infections Infectious Diseases Division
Medical Microbiologist Federal University of São Paulo
Dept of Medical Microbiology and São Paulo, Brazil
Infectious Diseases,
Erasmus MC Andreas F. Widmer, MD, MS
Rotterdam, The Netherlands Professor of Medicine and
Infectious Diseases
Andreas Voss, MD. PhD Division of Infectious Diseases and
Professor of Medical Microbiology Hospital Epidemiology
and Infection Control Head, Division of Hospital
Radboud University Medical Center Epidemiology
Departement of Medical University Hospitals
Microbiology Basel, Switerland
Nijmegen, The Netherlands
Hilmar Wisplinghoff, MD
Constanze Wendt, MD, MS Institute for Medical Microbiology,
Dr. Limbach and Colleagues Immunology and Hygiene
Medical Diagnostic Laboratory Cologne, Germany
Heidelberg, Germany
Mireille Wulf, MD, PhD
Joshua A. White, MD Viecuri Medical Center
Clinical Infectious Disease Fellow Dept. Clinical microbiology
Virginia Commonwealth University Venlo, The Netherlands
Richmond, Virginia, USA
S.E.J. Young, FRCP
David J. Weber, MD, MPH Retired
Professor of Medicine, London, United Kingdom
Pediatrics and Epidemiology
UNC Schools of Medicine and
Public Health
Medical Director, Hospital
Epidemiology and Occupational
Health, UNC Health Care
Chapel Hill, North Carolina, USA
x A Guide to Infection Control in the Hospital
Introduction
The field of infection prevention has grown in importance over the
last 30 years. The science of infection prevention, like others, is in
constant evolution. With the collaboration of international leaders
and front line practitioners in infection prevention, we summarize
the most up to date principles, interventions, and strategies for
maximizing the reduction of healthcare associated infections. The
chapters herein are intended to improve quality of care, minimize
risk, save lives, and reduce costs.
As our intention is to publish an up-to-date guide every 5 years, we
welcome your comments and thoughts as we proceed with future
editions.
Remarks may be sent to:
Dr. Gonzalo Bearman
International Society for Infectious Diseases
9 Babcock Street, Unit 3
Brookline, MA 02446 USA
Fax: (617) 278-9113
E-mail: info@isid.org
We wish to thank all our colleagues and friends for their contributions.
A Guide to Infection Control in the Hospital xi
Table of Contents
Chapter 1 Importance of Infection Control…………………………….. 1
Chapter 2 Organization………………………………………………………….. 6
Chapter 3 Role of the Microbiology Laboratory…………………… 10
in Infection Control
Chapter 4 Antibiotic Resistance Challenges………………………… 14
Chapter 5 Waste Management……………………………………………… 17
Chapter 6 Hand Hygiene……………………………………………………… 22
Chapter 7 Isolation of Communicable Diseases…………………… 31
Chapter 8 Patient Areas, Disinfection and……………………………. 39
Environmental Cleaning
Chapter 9 Reuse of Disposable Devices……………………………….. 45
Chapter 10 Disinfection…………………………………………………………. 49
Chapter 11 The Healthcare Worker as a…………………………………. 57
Source of Transmission
Chapter 12 Managing Antibiotic Resistance:…………………………. 68
What Works in the Hospital
Chapter 13 Organizing and Recording Problems……………………. 77
Including Epidemics
Chapter 14 Horizontal vs Vertical………………………………………….. 83
Infection Control Strategies
Chapter 15 Positive Deviance in Infection Prevention…………… 85
Chapter 16 Bundles in Infection Prevention and Safety…………. 89
Chapter 17 The Hospital Environment…………………………………… 95
Chapter 18 Food: Considerations for……………………………………. 103
Hospital Infection Control
xii A Guide to Infection Control in the Hospital
Chapter 19 Hospital Water…………………………………………………… 114
Chapter 20 Laboratory Areas ……………………………………………….. 119
Chapter 21 The Pharmacy……………………………………………………. 132
Chapter 22 The Operating Room………………………………………….. 137
Chapter 23 Keeping the Environment Safe in………………………. 146
Infection Prevention and Control: Focus
on Countries with Limited Resources
Chapter 24 The Emergency Department and…………………………. 156
Receiving Areas
Chapter 25 HIV Infection and AIDS in Low- and………………… 159
Middle-Income Countries
Chapter 26 Tuberculosis………………………………………………………… 171
Chapter 27 Diarrhea…………………………………………………………….. 179
Chapter 28 Skin and Soft Tissue Infections………………………….. 186
Chapter 29 Bloodstream Infections………………………………………. 193
Chapter 30 Managing Vascular Catheters…………………………….. 197
Chapter 31 Hospital Acquired Urinary Tract Infection…………. 203
Chapter 32 Pneumonia…………………………………………………………. 212
Chapter 33 Mechanical Ventilation………………………………………. 217
Chapter 34 Diphtheria, Tetanus, Pertussis……………………………. 225
Chapter 35 Measles……………………………………………………………… 230
Chapter 36 Herpes Zoster Vaccine……………………………………….. 235
Chapter 37 Human Papillomavirus………………………………………. 237
Chapter 38 Transfusions ………………………………………………………. 244
Chapter 39 Preparing the Patient for Surgery……………………….. 254
A Guide to Infection Control in the Hospital xiii
Chapter 40 Infection Control in Obstetrics…………………………… 260
Chapter 41 The Infection Hazards of Human Cadavers………… 266
Chapter 42 Streptococcus pyogenes……………………………………… 277
(Group A Streptococcal Infections)
Chapter 43 Staphylococcus aureus……………………………………….. 287
Chapter 44 Enterococcal Species…………………………………………. 293
Chapter 45 Pneumococcus……………………………………………………. 298
Chapter 46 Legionella………………………………………………………….. 305
Chapter 47 Carbapenem-resistant Enterobacteriaceae…………. 309
Chapter 48 Bacterial Enteric Pathogens:………………………………. 314
Clostridium difficile, Salmonella,
Campylobacter, Shigella,
Escherichia coli and others
Chapter 49 Other Enterobacteriaceae…………………………………… 319
Chapter 50 Pseudomonas aeruginosa …………………………………… 323
Chapter 51 Helicobacter pylori……………………………………………. 327
Chapter 52 Fungi…………………………………………………………………. 333
Chapter 53 Viruses………………………………………………………………. 338
Chapter 54 MERS and Lessons from SARS …………………………. 346
Chapter 55 Parasites…………………………………………………………….. 350
Chapter 56 New Technologies in Infection Prevention…………. 359
Chapter 57 Left Ventricular Assist Device—……………………….. 367
Related Infections
Chapter 58 Hand Hygiene Monitoring…………………………………. 369
Chapter 59 Healthcare Personnel Attire in……………………………. 376
Non-Operating Room Settings
Chapter 60 Ebola Virus Disease…………………………………………… 382
Index …………………………………………………………………………… 388
xiv A Guide to Infection Control in the Hospital
Chapter 1
Importance of Infection Control
Richard P. Wenzel, MD, MSc
Health is a high priority for any society, and infections remain a
leading cause of disease globally. Those infections which occur
among patients in hospitals and become manifest only after
48 hours of stay are called “nosocomial.” Some prefer the term
“health care associated” infections. Such nosocomial or hospital
acquired infections lead to significant morbidity, mortality and
economic burden beyond those expected from the patients’
underlying diseases alone. In this text we will use the term
health care associated most of the time
In the Western world the health care associated infection rate
is 5–10% or 5–10 infections per 100 patient admissions. In the
developing world the rate can be 25% or more. Some hospitals
prefer to measure the number of infected people per 100 admis-
sions. Others prefer to add up the total hospital stay in days
for all patients over a period of time and report the number of
infections per 1000 patient days.
The distribution of infections by anatomic site in acute care
hospitals in the developed world is shown below:
Proportion of all health care associated infections by anatomic area
In developing countries the distribution may be different,
with fewer bloodstream infections since fewer devices are used,
more gastrointestinal infections, and a higher proportion of
post-operative wound infections.
Importance of Infection Control 1
Mortality
Bloodstream and pulmonary infections carry the highest mortal-
ity rates, approximately 25–30% in developed countries. It has
been shown that health care associated infections are equivalent
to the 8th leading cause of death in the U.S., even if one examines
only health care associated bloodstream infections. There should
be low mortality rates or no deaths following urinary tract or post-
operative wound infections. These rates might be expected to
be higher for developing nations because of limited resources to
manage them, including limited critical care availability.
Importantly, when a patient with a health care associated
infection dies prematurely, there are also years of life lost
(YLL) directly due to the infection. For example, if a 40 year
old woman whose life expectancy is 60 years dies from a health
care associated infection, her death contributes 20 years of
life lost. If 100 similar patients died over a period of one year,
then there would be 20 years x 100 patients or 2000 YLL lost
due to health care associated infections that year. In the U.S. it
has been estimated that health care associated bloodstream
infections each year lead to 260,000 YLL.
Morbidity
Few studies have examined morbidity directly related to health
care associated infections. However, one thinks of pain, stress,
depression or “suffering” when one considers morbidity. With
psychological instruments one could systematically measure
the days of each, even consider giving a score for each parame-
ter such as scoring pain on a 1–5 scale.
One could also imagine measuring the quality of life, days
before return to school or job, or number of doses of pain med-
ication as measures of morbidity. However, little has been done
in this area.
Costs
Almost all studies of the economic burden of health care associ-
ated infections have examined only the direct costs of additional
hospital stay. For example, in developed countries, patients
with health care associated bloodstream infections stay an extra
10–14 days, presumably for additional therapy. From a hospital
administrator’s perspective, there are fixed and variable costs.
The fixed costs include those for heat, air conditioning, lighting,
2 A Guide to Infection Control in the Hospital
etc. The variable costs are those that increase for each addi-
tional day of hospitalization. For example, additional nursing
care may be required as the census increases. If the incremental
cost of stay—the variable cost above the expected fixed cost
of stay—averages $500/day, the additional economic burden is
$5,000 to $7,000 for each infection.
Patients with post operative wound infections stay in the
hospital twice as long as matched controls without a wound
infection. This leads to considerably additional costs. It is gen-
erally thought that health care associated urinary tract infections
add 1–3 additional days in the hospital, and health care associ-
ated pneumonias add approximately 9 days to the expected stay
compared to matched controls without a health care associated
pneumonia.
There are also “indirect” costs, such as the costs of rehabili-
tation after hospitalization, the costs of outpatient medications,
and costs of followup appointments. Depending on a country’s
healthcare reimbursement system, a great deal of the indirect
costs might be borne by the patients themselves.
Table 1.1 below summarizes the ways to measure the impact
of health care associated infections:
Table 1.1 Measures of the Impact of Health Care Associated Infections
Impact of Health Care Associated Infections:
Mortality — Number of Deaths per 100 infected
Years of Life Lost (YLL) from health care associated infections
per 100 admissions
Morbidity — Pain and suffering days resulting from an infection
Costs — Direct costs of extra hospital days per 100 admissions
Number of extra hospital days from health care associated infections
A Quality Issue
An important point is that many view infection control as a key
issue in quality of care. In fact, in the developed countries it
is the first “success” story in the use of intervention measures
to improve patient care in hospitals. Thus, those who espouse
quality care should begin with infection control, in part because
the outcomes are so serious without control and in part because
successful interventions have been developed.
Importance of Infection Control 3
Individual Commitment
In the developed world, it is likely that at least 20% of all health
care associated infections can be prevented. More could be
prevented in the developing world. Most of the interventions
are simple and behavioral and relate to the individual healthcare
worker: careful hand washing, appropriate isolation and use
of gloves where appropriate, and proper use of devices such
as the insertion and care of foley bladder catheters. Thus, the
link between individual commitment to quality and improved
outcomes can be demonstrated for infection control.
System Issues
There are also system issues that need to be addressed for infec-
tion control. For example, soap and water have to be available at
all times for healthcare workers and placed in convenient loca-
tions for easy access. There needs to be a system by which sur-
gical patients receive preoperative antibiotics in the 1–2 hours
before the incision, not greater than two hours and never delayed
to one after the incision. A system has to be in place to isolate
some patients with communicable disease. Very recently the
importance of team-based prevention of health care associated
infections has been shown to be valuable when the team utilized
evidence-based interventions such as proper hand hygiene, bar-
rier precautions and subclavian site as the preferred one for a
central line. The implication of the team approach is that any
member of the team of healthcare professionals—physicians or
nurses—can ask the physician to restart a bedside procedures if
there is a break in sterile technique.
A Societal Issue
Lastly, I would return to the beginning to emphasize that a
healthier community can contribute more to its citizens. With
fewer infections and their complications, a well society is better
able to work, to educate, to contribute to the arts, and to provide
a myriad of services that are unavailable to a more ill society.
Infection control is a key ingredient to and an essential com-
ponent of a better functioning and happier society. In the end,
proper infection control can make a significant contribution to
improving the human condition.
4 A Guide to Infection Control in the Hospital
References
Book
Prevention and Control of Nosocomial Infections (4th Edition), Wenzel
RP (Ed). Baltimore: Lippincott Williams & Wilkins, 2003.
On Line Resources.
Decision Support In Medicine.Com: Program—Hospital Infection Con-
trol. Wenzel RP, Bearman G (Eds) 2013. Available at: http://www.
decisionsupportinmedicine.com
Manuscripts
Wenzel RP, Edmond MB. The Impact of Hospital Acquired Blood-
stream Infections. Emerg Infect Dis. 2001. 7:174 –7.
Pronovost P, Needham D, Berenholtz S, et al. An Intervention to
Decrease Catheter-Related Bloodstream Infections in the ICU.
N Engl J Med. 2006. 355:2725–2732.
Wenzel RP. Healthcare Associated Infections: Major Issues in the Early
Years of the 21st Century. Clin Infect Dis. 2007. 45(Suppl 1):585–8.
Wenzel RP, Edmond MB. Team-Based Prevention of Catheter-Related
Infections. N Engl J Med. 2006. 355:2781–3.
Wenzel RP. Minimizing Surgical Site Infections. N Engl J Med. 2009.
326:75–7.
Wenzel RP. Infection Control: The Case for Horizontal Rather than
Vertical Interventional Programs. Internat J Infect Dis. 2010. 14,
Supp 4:53–5.
Edmond MB, Wenzel RP. Screening Inpatients for MRSA—Case
Closed. N Engl J Med. 2013. 368:2314–5.
Importance of Infection Control 5
Chapter 2
Organization
Richard P. Wenzel, MD, MSc
A necessary feature for a successful program in infection con-
trol is dedicated leadership that creates a culture for excellence.
Without leaders, there are no followers among the manage-
ment team. Some important attributes of the management team
that support the culture for excellence include a knowledge of
microbiology, excellent communication skills, and an under-
standing of the key discipline of epidemiology. Some ability to
gather data and perform basic analyses is extremely useful.
Ideally, a trained infectious diseases specialist with some
training in infection control would lead the hospital’s program.
Such individuals have complementary clinical, microbiological,
and epidemiological skills useful in providing the vision and
oversight of a high performance team. Since energy and com-
mitment are so critical to success, a hospital may begin with
candidates that have these two attributes and select someone
with most but not all of the other skills listed above.
Leadership and management are distinct but overlapping
skills, useful for any program. The leader is charged with creat-
ing the vision, the day-to-day culture, the energy, the ideals and
the ethics of a program. The manager is charged with carrying
out the vision, making the components of a complex organi-
zation function well while meeting all financial budget restric-
tions. Some leaders have management skills, but the key role of
the hospital epidemiologist is to lead!
The team members supporting the hospital epidemiologist
may in fact be leaders in their respective fields of nursing epi-
demiology, microbiology, pharmacy, employee health, biosta-
tistics and epidemiology, and computer support. However, each
has a responsibility as a manager in their area of expertise and
oversight. They are charged with making the system work. In
small hospitals and those with limited resources, a single indi-
vidual may be charged with more than one of these tasks.
6 A Guide to Infection Control in the Hospital
Table 2.1 The Infection Control Team
Role Team Member Ideal Skills
Leader Hospital Epidemiologist Infectious Diseases, microbiology,
and infection control communication
Manager(s) Microbiologist Microbiology, interpretation
of antibiotic resistance
Nurse Epidemiologist Nursing & Epidemiology including
(infection control practitioner) surveillance skills, communication
Pharmacist Pharmacokinetics and
Pharmacodynamics of drugs,
especially antibiotics. Education
Employee Health Director Infection Control, Vaccine Use
Biostatistician Inference statistics and modeling skills
Computer Technician Design data base and search features
Functions
The starting point of a good program for infection control is
basic surveillance by which rates of infection can be calculated
after valid case finding. Most experts prefer prospective surveil-
lance rather than retrospective surveys because of the greater
accuracy of the former. Although hospital-wide surveillance is
the ideal, with limited resources a program may wish to focus
only on health care associated bloodstream infections because
of the high associated mortality and the relative ease with which
to identify nonpathogens from pathogens in blood cultures. One
could begin surveillance in the microbiology laboratory, and
after ruling out all of the contaminants, the physician or nurse
epidemiologist could gather clinical data from the infected
patients’ charts to be used later in epidemiological analyses.
Alternatively, with limited resources a decision could be
made to survey only post-operative (incisional) wound infec-
tions because of their high frequency, significant morbidity,
and high costs. One could survey all surgical patients only for
a fixed period of time after the operation, seeking evidence of
infection (pus at the incision site).
The number of infections or infected patients is included in
the numerator, and one has various options for the denominator.
Organization 7
Thus, various rates can be calculated:
The number of infections/100 admissions.
The number of infected patients/100 admissions.
The number of infections/1000 patient-days.
The critical point is that for calculation of a rate, the denom-
inator must include the total number of patients at risk. If one is
surveying only for post operative wound infections, each month
the population at risk, the denominator, would be all patients
undergoing operations during that time.
Some of the key functions of an effective infection control
Program Are Shown In The Table 2.2 Below:
Table 2.2 Functions of an Infection Control Program
Surveillance
Education and feedback to clinicians using surveillance data and antibiogram
data by anatomic site
Management of proper isolation techniques
Provision of either hand washing materials or alcohol-based (waterless)
hand cleansing materials
Development of standards for management of proper insertion and
maintenance of medical devices
Monthly meeting of the infection control team
Most of the roles indicated in Table 2.2 rely on excellent
education of various members of the healthcare team. Thus,
communication skills, and teaching skills specifically, greatly
enhance the value of the infection control team.
A key function of the organization that is necessary for its
optimal functioning is the monthly infection control meeting.
The goals of the monthly meeting are few in number but very
important:
Brief review of surveillance data.
Summary of any epidemic workup.
Review of antibiogram data, listing resistance rates for
important antibiotics such as methicillin resistant S. aureus,
vancomycin-resistant E. faecium, and third generation
cephalosporin antibiotic-resistant gram-negative rods.
8 A Guide to Infection Control in the Hospital
Review and passage of one new policy or procedure each
month. This may sound simple and easy to perform, but it
is the most difficult goal for any team, requiring homework,
background political work and bold decision making.
Summary
The effective infection control program needs a designated
leader supported by a team with special skills. Although ideal
leadership and management skills are listed above, a hospital
with limited resources will need to accommodate the program
with interested and dedicated personnel possessing most of the
desired skills. The role of surveillance is to provide local data,
especially important in education. A monthly infection control
meeting for the continued review and development of policies
is especially important.
References
Book
Katzenbach JR, Smith DK. The Wisdom of Teams. New York: Harper
Business, 1994.
Manuscripts
Wenzel RP. Leadership, Management and Politics: Issues for Healthcare
Epidemiology in Decision Support In Medicine.Com: Programs—
Hospital Infection Control. Wenzel RP, Bearman G (Eds) 2013.
Wenzel RP. Leadership and Management for Healthcare Epidemiology
in Prevention and Control of Nosocomial Infections (4th Edition),
Wenzel RP (Ed). Baltimore: Lippincott Williams & Wilkins, 2003.
Pgs. 609–16.
Wenzel RP. The Hospital Epidemiologist: Practical Ideas. Infect Control
Hosp Epidemiol. 1995.
Organization 9
Chapter 3
R ole of the Microbiology
Laboratory in Infection Control
Mohamed Benbachir, PhD
Key Issue
The microbiology laboratory plays an important role in the sur-
veillance, treatment options, control and prevention of health
care associated infections. The microbiologist is a permanent
member of the infection control committee (ICC).
Known Facts
The first task of the microbiology laboratory is accurately, con-
sistently and rapidly to identify the responsible agents to species
level and identify their antimicrobial resistance patterns. This
has been made easier because of the important progress made
in the fields of instruments, reagents and techniques. The qual-
ity of the microbiology results is directly linked to the quality
of the specimens. Specimens that are not collected and trans-
ported properly may lead to misleading results. Since the ICC
programms rely on microbiological results, quality assurance is
an important issue.
The microbiology laboratory is a surveillance and early
warning system. Laboratory based surveillance is an essential
part of the hospital wide surveillance in concert with surveil-
lance based on patient units (e.g., ICU, haematology) and on
specific sites of infection (e.g., blood, surgical site). Routine
surveillance of health care associated infections is based both on
daily review and on periodic reports of microbiology records.
The microbiology laboratory is also a sentinel system. Prompt
notification to clinical wards and to ICC initiate epidemiologi-
cal investigation which may lead to preventive measures to halt
the spread of causative microorganisms.
The microbiology laboratory is also involved in the detec-
tion and investigation of outbreaks. Comparison (“typing” or
“fingerprinting”) of epidemiologically related isolates helps to
10 A Guide to Infection Control in the Hospital
determine whether these organisms are related or not and thus
essential to confirm the existence of an outbreak. The laboratory
must collaborate with the ICC in the investigation of outbreaks.
Typing of isolates is also useful during outbreaks to determine
the prevalence and mode of spread of strains and to identify
reservoirs and carriers.
Antibiotic resistance levels vary widely depending on geo-
graphic location and even among hospitals from the same coun-
try. Hospital antibiotic policies can be generated only when
local information is available. Monitoring the antibiotic sus-
ceptibilities of bacteria generates a database which is consulted
when writing hospital antibiotic policies. On the other hand the
evolution of antibiotic resistance levels is a marker of the qual-
ity of infection control in a hospital.
Controversial Issues
Laboratory based surveillance is efficient but incomplete
because of the lack of clinical and epidemiological data avail-
able in the laboratory and because specimens are not always
collected from all cases of health care associated infections.
The counterpart to the improvement of laboratory perfor-
mances (detection and typing) is the extra investment needed. A
special budget to participate in infection control activities is not
always available, especially in developing countries.
Reference typing techniques (e.g., PFGE) are costly,
labor-intensive and require interpretation skills. Alternative
methods (e.g., Arbitrarily Primed-PCR) lack reproducibility
and standardized interpretative criteria. Whether to fingerprint
the isolates locally or to send the strains to reference labora-
tories depends on laboratory staffing and skills, the number of
isolates and available budget.
Suggested Practice
A representative of the microbiology laboratory staff must be
an active member of the ICC. In many hospitals, the ICC is
chaired by a microbiologist, and a key function is to improve
collaboration between clinical, laboratory and ICC personnel.
If necessary, the microbiologist gives training in basic microbi-
ology to ICC members and provides expertise (e.g., ready to use
microbiological strategies to deal with each specific infection
control situation, evaluation of resources needed, interpretation
of culture results).
Role of the Microbiology Laboratory in Infection Control 11
The microbiology laboratory staff should implement exter-
nal and internal quality controls, and participate in continuous
education and training to detect recognized, unusual and new
phenotypes of resistance. The quality of specimens collection
and transport should be maintained in collaboration with clini-
cians and nursing staff through seminars and procedure books.
On the other hand a minimum of epidemiological (e.g., date of
hospitalization) and clinical data should accompany the culture
orders.
Laboratory records are an important source of informa-
tion for the ICC. Storage and analysis of information are usu-
ally computerized. For laboratories with limited resources,
the WHONET software from WHO is a powerful tool which
is free of charge, user friendly and can be customized to each
laboratory needs.
The microbiology laboratory is responsible for dissemina-
tion of this information. All significant laboratory results should
be reported as quickly as possible to the clinicians and to the
ICC. Some of these results (isolation of Salmonella, Shigella
or Neisseria meningitidis, smears showing acid fast bacilli,
cultures with multi-resistant bacteria) have a high priority and
should be notified immediately by phone.
The microbiology laboratory must issue daily reports of
significant microbiology results. This report includes patient’s
identification, date of hospitalization, type and date of col-
lection of specimen and culture results. Reports that focus on
selected pathogens (e.g., methicillin resistant Staphylococcus
aureus, vancomycine resistant Enterococcus, extended spec-
trum ß-lactamase producing Enterobacteriaceae, carbapenem
resistant Acinetobacter baumannii can also be issued. The list
of selected pathogens which include bacteria with known epi-
demic potential and multi-resistant bacteria is established by the
ICC and is revised periodically following the epidemiological
situation at the institution.
Periodic reports are also useful in that they monitor trends.
Data from various time periods should be analysed to study the
patterns of infections.
The microbiology laboratory is responsible for the early
detection of clusters of microorganisms with the same pheno-
typic characteristics. Laboratory and epidemiological studies
12 A Guide to Infection Control in the Hospital
of suspected outbreaks should be conducted in parallel. During
outbreaks the microbiology laboratory collaborates with the
ICC to choose the specimens to collect, the isolates to finger-
print, and the relevant isolates to store. In some situations, cul-
tures of samples from carriers, from healthcare workers and the
environment will be considered. All this work should be done
timely.
Surveys of hospital personnel and environment should not
be conducted routinely but only to address specific situations.
Biotyping and antibiotic resistance phenotypes are not reli-
able epidemiological markers. Molecular biology techniques
are more discriminatory than phenotypic methods. The use of
chromosomal restriction patterns by pulsed field gel electro-
phoresis is considered the reference technique for typing most
bacterial species.
Data on antimicrobial resistance should be periodically
available to the medical staff, at least annually. The data
should be summarized for each ward or clinical specialty and
by anatomic site of infection or type of pathogen. These data
are helpful for generating hospital treatment guidelines, which
are useful in situations where empirical therapy is often given
before the microbiology results are available.
References
McGowan JE, Weinstein RA. The role of the laboratory in control of
nosocomial infection in Hospital infections (4th Edition). Bennett
JV, Brachman PS (Eds). Philadelphia. Lippincott-Raven, 1998. Pgs.
143–164.
Pfaller MA, Herwalt LA. The clinical microbiology laboratory and
infection control: Emerging pathogens, antimicrobial resistance and
new technology. Clin Infect Dis. 1997. 25:858–870.
Tenover FC, Arbeit RD, Goering RV and the Molecular Typing Work-
ing Group of the Society for Healthcare Epidemiology of America.
How to select and interpret molecular strain typing methods for epi-
demiological studies of bacterial infections: A review for healthcare
epidemiologists. Infect Control Hosp Epidemiol. 1997. 18:426–439.
Wilson MP, Spencer RC. Laboratory role in the management of hospital
acquired infections. J Hosp Infect. 1999. 42:1–6.
Espy MJ, Uhl JR, Sloan LM, et al. Real Time PCR in Clinical Micro-
biology: Applications for Routine Laboratory Tests. Clin Microbiol.
Role of the Microbiology Laboratory in Infection Control 13
- 2006. 19:165–256.
Chapter 4
Antibiotic Resistance Challenges
Richard P. Wenzel, MD, MSc
Key Issue
Begun in the 1940s, the antibiotic era is under 80 years’ dura-
tion, yet now is challenged by the worldwide increase in the
incidence of resistance by microorganisms.
Known Facts
In the community, penicillin-resistant pneumococci and
multidrug-resistant tuberculosis are major public health
problems. These organisms also have become significant
health care associated pathogens. A more recent issue is
the emergence of community-acquired methicillin resistant
S. aureus (CA-MRSA). A more virulent strain of C. difficile
with higher than usual toxin production has caused epidem-
ics in Canada and the U.S.
In hospitals throughout the world, there are special prob-
lems with methicillin resistant Staphylococcus aureus—both
health care associated and the new strains of CA-MRSA.
The explosion of infections with vancomycin-resistant
Enterococcus faecium in hospitals in the United States has
been remarkable. Much lower rates have been reported from
Europe.
Resistance of gram-negative rods to quinolones and third
generation cephalosporins continues to increase.
Those strains resistant to Ceftriaxone are called ESBLs
because they carry extended spectrum βeta Lactamases
enabling the bacteria to resist most βeta Lactam antibiotics.
Such strains are usually susceptible to carbapenems such as
imipenem and meropenem.
With increasing use of carbapenems there has been the
emergence of bacteria harboring carbapenemases, βeta Lac-
tamases that inactivate imipenem and meropenem. Some
such strains are susceptible only to colistin.
14 A Guide to Infection Control in the Hospital
The emergence of strains of S.aureus with intermediate lev-
els of resistance to vancomycin (VISA) has been noted in
several countries. These have MICs of 4 or 8 μg/ml, making
therapy a challenge with vancomycin. Furthermore, strains
with full resistance to vancomycin have been recovered
(VRSA). In 2002, two strains of S.aureus with high levels
of resistance to vancomycin (VRSA) were reported in the
United States. These strains have MICs ≥16μg/ml. As of
November 2013, 13 patients in the U.S. have been identified
with infections due to VRSA.
Unless we pay attention to the problem of antibiotic resis-
tance, we will quickly run out of effective therapy. Unfortu-
nately, the problem of resistance comes at a time when fewer
pharmaceutical companies are in the business of developing
new antimicrobials. Thus, the pipeline of new drugs is limited.
Controversial Issues
The causes of antibiotic resistance are not clearly known, but
surely unnecessary use of antibiotics is important. Such
high use leads to the selection of resistant organisms. Once
a patient has a resistant organism, then the possibility exists
for transmission to other patients. The initiating problem is
the selection of a resistant isolate under the “pressure” of
antibiotic usage.
A second issue is excellent infection control—isolation and
hand washing—to minimize spread of antibiotic resistant
isolates. Exactly what proportion of the level of resistance
stems from poor infection control is unclear, but is thought to
be higher for Gram positive than Gram negative organisms.
The third issue relates to the influx of patients harboring
resistant strains on admission to the hospital. Thus, the issue
is a need for quickly identifying patients and isolating them
on admission. This requires labeling the charts of patients
previously known to be infected with or carriers of antibi-
otic-resistant pathogen. When the patient enters the hospi-
tal, he or she should be automatically placed in appropriate
isolation. It remains unclear at what level of resistance it is
no longer cost effective to maintain a program of isolation
on admission. However, there are some data suggesting its
usefulness in controlling the rates of MRSA.
Antibiotic Resistance Challenges 15
The level of resistance in hospitals to antibiotics can be con-
sidered to be influenced by three major parameters: how much
enters in institution, how much is selected de novo or afterwards,
and how much spread as a result of poor infection control.
Imagine that one wanted to know what contributed to the cur-
rent rate of MRSA: It is mostly related to infection control,
influenced by the incoming burden of MRSA positive cases,
but less so by the quantity of methicillin used. In contrast, the
level of resistant gram-negative rods is very much influenced by
antibiotic pressure and the incoming burden of resistant gram-
negative rods.
Suggested Practice
Three areas for control of this problem are as follows:
emergence of a resistant clone.
limit transmission of any antibiotic-resistant organisms that
may emerge in the hospital to enter with a new patient.
all new patients who might be carrying an important antibi-
otic-resistant pathogen. This may be accomplished by mark-
ing the charts of patients previously known to be carriers or
by isolating all patients coming from another facility known
to have a high number of antibiotic-resistant organisms.
apy and perioperative prophylaxis should health care associ-
ated strains of CA-MRSA become more prevalent.
References
Wenzel RP, Edmond, MB. Managing Antibiotic Resistance. N Engl
J Med. 2000. 343:1961–3.
Wenzel RP, The antibiotic pipeline: challenges, costs and values. N Engl
J Med. 2004. 351:523–5.
Wenzel RP, Bearman G, Edmond MB. Community Acquired MRSA:
New issues for infection control. Int J Antimicrob Agents. 2007.
30:210–2.
Bouchet HW, Talbot GH, Benjamin DK, Jr., et al. 10x’20 Progress—
Development of New Drugs Active Against Gram-Negative Bacilli:
An Update From the Infectious Diseases Society of America. Clin
Infec Dis. 2013. 56:1685–94.
16 A Guide to Infection Control in the Hospital
Chapter 5
Waste Management
Tawana McNair, MD and Gonzalo Bearman MD, MPH
Key Issue
Waste is generated in the health care setting. The key step in
waste management is to distinguish between infectious and
noninfectious waste. Infectious waste has the potential to trans-
mit disease and should be collected, transferred, and disposed of
in a manner that decreases the risk of injury to healthcare work-
ers, waste management workers, patients, and the community.
Known Facts
There are many materials/equipment components used in
hospitals for the diagnosis and treatment of patients. These
materials have come in contact with blood, bodily fluids, and
tissues of patients and may contain infectious microorgan-
isms. These materials have the potential to transmit disease
and thus require proper management and disposal following
use. Prior to disposal, these materials need to be classified
into infectious and noninfectious waste.
The definition of infectious waste is not concrete or uni-
versal. However, the general idea is that infectious medical
waste has the potential to transmit microorganisms. There
are many factors which facilitate the progression of an infec-
tious exposure to an infectious disease. These factors include
the size of the inoculum, the virulence of the microorganism,
and the susceptibility of the person in contact with the infec-
tious waste. Currently, there is no method to determine the
risk of disease as these factors are usually unknown prior
to exposure. This limitation and the ambiguous definition
of infectious waste, highlight the need to correctly iden-
tify infectious waste from noninfectious waste in order to
decrease the risk of disease transmission. Strict protocols
should be in place to ensure compliance.
Waste Management 17
Exposure to infectious wastes can occur in many settings,
including outpatient/clinic settings, however, the majority of
accidents and exposures to infectious waste occur in the hos-
pital setting. The waste products from sharps (e.g. needles,
vials, surgical equipment) and cultures concentrated with
microorganisms have the highest potential for disease trans-
mission; however, disease transmission has also resulted
from exposure to blood, bodily fluids, tissue from infected
patients or laboratory animals, and material from microbiol-
ogy and pathology laboratories.
Controversial Issues
There is no set protocol or strict criteria to determine which
type of medical waste has the potential to cause disease in
susceptible hosts. However, there are categories of medical
waste that have a greater potential for transmitting disease.
Three questions should be considered when deciding if med-
ical waste has the potential to transmit pathogens. An infec-
tion control practitioner should be consulted for questions
and guidance.
or tissue with pathogenic microorganisms in sufficient
- 1. Minimize the use of antibiotics to limit the selection and
- 2. Maximize good hand washing and isolation practices to
- 3. Develop systems to identify quickly and isolate immediately
- 4. Begin to develop policies for changes in both empiral ther-
- 1. Does the medical waste contain blood, body fluids,
Quantity To Produce Disease?
Patients with known infections are likely to generate waste
containing a large amount of microorganisms. The super-
saturated gauze covering a draining wound, the sputum
of a patient with known TB, the syringe used on a patient
with known HIV or Hepatitis, a diaper with the stool of a
baby admitted with diarrhea, are all examples of infectious
waste with the potential to transmit disease. All blood and
body fluids, organs, and microbiology laboratory speci-
mens should be considered infectious waste regardless of
the patient’s diagnosis.
- 2. Does the waste contain viable and pathogenic
Microorganisms?
Clinical microbiology laboratories handle a large number
of microorganisms daily. These organisms are cultured
from blood, sputum, stool, and other body fluids and
18 A Guide to Infection Control in the Hospital
should therefore be treated as infectious while in the lab-
oratory and once disposed. Infectious waste in the clinical
microbiologic laboratory also includes material used for
isolation and identification of the microorganisms (e.g.
slides, pipettes, and tubes).
Consideration should also be made outside of the micro-
biology laboratory pertaining to blood and body fluid
samples sent for general evaluation such as the clinical
chemistry laboratory. These samples should also be con-
sidered infectious waste given their potential to contain
pathogenic organisms.
- 3. Can the waste create a portal of entry for pathogenic
Organisms Into A Susceptible Host?
Sharps are the single most frequent cause of occupation-
ally acquired blood-borne disease in health care workers
and should always be considered infectious waste. Sharps
include needles, scalpel blades or other sharp instruments,
IV catheters, broken glass (vials), and razor blades (no lon-
ger used for trimming hair given significant risk for infec-
tion). The health status of a patient is not always readily
available, therefore, sharps containing blood should be
classified as infectious because they provide a portal of
entry for microorganisms.
Sharps that do not contain blood (e.g., broken glass) are
still dangerous because they may cause puncture injuries to
healthcare workers and waste management workers that can
produce a portal of entry for pathogenic microorganisms.
Suggested Practice
The key step in waste management is to distinguish between
infectious and non-infectious waste. The definition and reg-
ulation of “infectious waste” varies by state. Each hospital
should develop written procedures for waste management
on the basis of national and regional regulations, the preva-
lence of infectious diseases that can potentially contaminate
medical waste and the local infrastructure for processing
infectious waste. Hospital staff should receive training for
correctly segregating all medical waste and regulation of the
written procedure must be strictly enforced.
Waste Management 19
In a waste management program, biologic waste should first
be separated from non-biologic waste (paper, glass, plastic).
Biologic waste should then be separated into infectious and
non-infectious waste. Non-infectious waste can be collected
in regular black bags and treated as residential waste.
Sharp infectious waste must be placed in rigid, puncture
proof and impermeable containers that bear the universal
biologic hazard symbol and should be removed from use
and discarded when the container is ¾ full. Incineration is
the preferred treatment method for sharps as it eliminates
microorganisms and any possibility of puncture wounds.
Other methods for treatment of infectious waste include
steam sterilization and chemical treatment.
Non-sharp infectious waste should be collected in leak-resis-
tant biohazard bags and sent for incineration. Alternatively,
it can be decontaminated on site and subsequently discarded
as non-infectious waste. On-site decontamination of micro-
biology laboratory waste is preferred, as this reduces the
potential of exposure during the handling and transportation
of infectious materials. Identification of live cultures and
stocks should be made in efforts to avoid aerosolization of
infectious microorganisms.
Disposal equipment including sharps containers, garbage
bags and bins should be readily available and easily accessi-
ble throughout all patient areas. Infectious waste should be
transported within the hospital in wheeled trolleys or carts
through specially designed routes and at low volume times
of the day. These routes should avoid patient care areas as
well as areas where food is prepared, stored, or transported
whenever possible.
Infectious waste should be treated soon after discarding.
If transport for off-site incineration is required, it should
be temporarily stored in a secure and completely closed
storage room.
20 A Guide to Infection Control in the Hospital
Summary
Although the risk of acquiring disease from infectious waste
is low, the consequences can be significant. As a result, all
hospitals need to develop a waste management program. The
Program Should Be Jointly Designed And Coordinated By The
infection control department, the hospital engineering staff, and
municipal authorities. Medical waste should be classified as
infectious when it contains a sufficient quantity of pathogenic
microorganisms to produce disease and there is a potential
within the waste management setting to create a portal of entry
into a susceptible host.
References
Hedrick Er. Infectious Waste Management—Will Science Prevail?
Agency for Toxic Substances and Disease Registry. The public
health implications of medical waste: A report to Congress. Atlanta,
GA: U.S. Department of Health and Human Services, Public Health
Service. Infect Control Hosp Epidemiol. 1988. 9:488–90.
Pruess A, Giroult E, Rushbrook P. Safe Management of Wastes from
Healthcare Activities. World Health Organization. Geneva. 1999.
Rutala WA, Mayhall CG. SHEA position paper: Medical Waste. Infect
Control Hosp Epidemiol. 1992. 13:38–48.
Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R,
Ashford D, Besser R, Fields B, McNeil MM, Whitney C, Wong
S, Juranek D, Cleveland J. Guidelines for Environmental Infection
Control in Healthcare Facilities. Recommendations from CDC and
the Healthcare Infection Control Practices Advisory Committee
(HICPAC). Chicago IL. American Society for Healthcare Engineer-
ing/American Hospital Association. 2004.
Zaidi M, Wenzel RP. Disinfection, Sterilization, and Control of Hospital
Waste in Principles and Practice of Infectious Diseases (5th Edition),
Mandell GL, Bennett JE, Dolin R. (Eds). Philadelphia: Churchill
Livingstone, 2000. Pgs. 2995–3005.
Zaidi, M. Waste Management. A Guide to Infection Control in the Hos-
pital. An Official Publication of the International Society for Infec-
tious Diseases (ISID) (4th Edition), Wenzel RP, Bearman G, Brewer
T, and Butzler J-P. (Eds). Boston, 2008. 5:22–25.
Waste Management 21
Chapter 6
Hand Hygiene
Andrew J. Stewardson, MBBS, and Didier Pittet, MD, MS
Keywords
Hand hygiene, hand washing, hand antisepsis, hand disinfec-
tion, alcohol-based handrub, epidemiology, healthcare workers,
patient safety.
Key Issues
Hand hygiene is the cornerstone of infection prevention.
Multimodal promotion can improve healthcare worker hand
hygiene compliance.
Enhanced compliance is associated with decreased cross-
transmission and reduced infection rates.
Known Facts
Appropriate hand hygiene is considered the leading measure
to reduce the transmission of health care associated patho-
gens in healthcare settings. Its impact on infectious and
resistant organisms’ cross-transmission risk is recognized in
hospitals, schools, and day care centers, as well as in com-
munity settings.
Inappropriate hand hygiene practice has been identified as a
significant contributor to numerous outbreaks.
Several studies have shown the impact of improved hand
hygiene on the risk of health care associated infection and
multiresistant pathogen cross-transmission. To date, most
studies have focused on methicillin resistant Staphylococcus
aureus.
Bacteria present on human skin can be considered as belong-
ing to one of two groups: resident and transient flora. Tran-
sient flora colonizes the superficial layers of the skin. It has a
short-term persistence on skin, but a high pathogenic poten-
tial. It is usually acquired by healthcare workers during direct
contact with patients or contaminated environmental surfaces
adjacent to the patient, and is responsible for most health care
22 A Guide to Infection Control in the Hospital
associated infections and spread of antimicrobial resistance
resulting from cross-transmission. Resident flora is attached
to deeper skin layers and has a low pathogenic potential unless
introduced into the body by invasive devices. It is also more
difficult to remove mechanically. Hand hygiene decreases
colonization with transient flora and can be achieved either
through handwashing or hand antisepsis.
Hand hygiene is a general term that includes the appropriate
use of handwashing, antiseptic handwashing, and antiseptic
handrubbing. Handwashing refers to the action of washing
hands with plain (non-antimicrobial) soap and water. Anti-
septic handwashing refers to washing hands with water and
soap or other detergents containing an antiseptic agent. Anti-
septic handrubbing refers to the application of an antiseptic
handrub (usually an alcohol-based formulation) to the hands
to reduce or inhibit the growth of microorganisms.
Hand antisepsis refers to either antiseptic handwashing or
antiseptic handrubbing. Hand disinfection is a similar con-
cept, but may cause confusion because disinfection usually
refers to environmental decontamination. Surgical hand
preparation refers to the procedure recommended to clean
hands performing surgery; it is, however, not discussed in
this chapter.
The WHO ‘My Five Moments for Hand Hygiene’ is based
on a conceptual model of microbial transmission and can be
used for teaching, monitoring and reporting hand hygiene
compliance. It defines five indications for hand hygiene in
healthcare (see Table 6.1). A period of time during which
one or more of these indications for hand hygiene exists is
called an opportunity. Hand hygiene compliance is calcu-
lated by dividing the number of hand hygiene actions per-
formed when an opportunity exists by the total number of
hand hygiene opportunities.
Major risk factors for noncompliance are healthcare worker
profession (physicians are usually less compliant than
nurses), workload (compliance is inversely related to work-
load), indication (compliance is worse before patient contact
than after), poor access to hand hygiene materials (sinks,
dispensers), and the absence of multimodal hand hygiene
promotion (see page 25, first bullet).
Hand Hygiene 23
Among all identified risk factors for noncompliance, time
constraint is the most important. In other words, the higher
the demand for hand hygiene, the lower the compliance.
Thus, access to hand hygiene products at the point of care
and the use of a fast-acting agent both facilitate improved
compliance.
The ideal technique for hand hygiene should be quick to per-
form at the point of care, reduce hand contamination to the
lowest possible level, and be free from significant side-ef-
fects on the HCWs’ skin.
Alcohols are currently the preferred agent for routine hand
hygiene. They have excellent activity and the most rapid
bactericidal action of all antiseptics. Of importance from a
workflow perspective, alcohols dry very rapidly, allowing
for fast antisepsis at the point of care. In addition, alcohols
are more convenient for hygienic handrub than aqueous
solutions given their excellent spreading quality and rapid
evaporation. Furthermore, there is no antibacterial resistance
to alcohols. Importantly, however, visibly-soiled hands
should be washed with soap and water.
When evaluating hand hygiene products for use in the health-
care setting, important factors include their relative efficacy
against pathogens, rapidity of action, acceptance and toler-
ance by HCWs, convenience of use, accessibility, and cost.
With alcohol-based agents, the time required for drying may
affect efficacy and user acceptance. Alcohol-based antisep-
tics intended for hand hygiene in healthcare are available
in rinse, gel, and foam formulations. At equal concentra-
tions, n-propanol is the most effective alcohol, and ethanol
the least.
Alcohol-based handrubs (whether isopropyl, ethyl, or n-pro-
panol, in 60–90% vol/vol), when containing appropriate
emollients such as glycerol (1 to 3%) or other skin-condi-
tioning agents, are less irritant to healthcare workers’ hands
than soap and water. Soaps and detergents are damaging
substances when applied to the skin on a regular basis by
increasing skin pH, reducing lipid content, increasing
transepidermal water loss, and even enhancing microbial
shedding.
24 A Guide to Infection Control in the Hospital
Multimodal promotion strategies are the most effective
means of improving hand hygiene compliance. The WHO
multimodal hand hygiene strategy includes: 1) system
change, including alcohol-based handrub at the point of
care; 2) education and training; 3) observation and per-
formance feedback; 4) reminders in the workplace; and 5)
patient safety climate (an implementation guide and suite
of tools are available at www.who.int/gpsc/5may/en/). The
WHO Hand Hygiene Self-Assessment Framework is a
self-administered questionnaire that can be used to provide
a situation analysis of hand hygiene resources, promotion,
and practices within healthcare facilities, and to develop an
action plan for future interventions.
The cost-effectiveness of hand hygiene promotion has been
demonstrated in several studies.
Controversial Issues
The central challenge for hand hygiene in healthcare involves
translating recommendations into HCW behavior change.
The most widely implemented and successful model is the
multimodal promotion strategy recommended by WHO,
which has been used and adapted to various healthcare sys-
tems, cultures and resources worldwide. However, the most
influential components of multimodal intervention strategies
for hand hygiene promotion remain to be determined.
While multimodal promotion is known to be the most effec-
tive way to improve hand hygiene compliance, the key
determinants of long-lasting improvement requires further
investigation. In addition, there is a need for effective strat-
egies to improve hand hygiene compliance amongst phy-
sicians, a group that is generally less sensitive to standard
multimodal promotion.
Direct observation using the WHO ‘My Five Moments for
Hand Hygiene’ technique is currently considered the opti-
mal method to monitor hand hygiene compliance. Advan-
tages include provision of a meaningful denominator (e.g.
when hand hygiene is indicated), capacity to stratify results
(e.g. by profession or indication), and the behavior change
Hand Hygiene 25
benefit of immediate performance feedback. Key limita-
tions, however, are the relatively small proportion of total
actions that are monitored, and the resource-intensive nature
of this activity. Other options include monitoring product
consumption (such as alcohol-based handrub), self-report-
ing, patient observers, and automated systems. These alter-
natives are likely to be the focus of intensive research given
the increasing focus on hand hygiene compliance as a qual-
ity/performance indicator.
Some encouraging data exist to support a role for patient
participation in hand hygiene promotion. In its most active
form, this involves inviting patients to remind healthcare
workers to perform hand hygiene. But this strategy remains
challenging to implement and should be introduced cau-
tiously and only with the support of all stakeholders. A grad-
ual change in culture should be expected. Generally more
acceptable is education of patients and their visitors about
when they themselves should perform hand hygiene. The
impact of this latter strategy in terms of infection rate reduc-
tion remains, however, to be determined.
Most antiseptics, including alcohols, have very poor or no
activity against bacterial spores. Handwashing is preferred
over hand rubbing when spore contact is likely because of
the mechanical action involved. However, initial concern
that widespread use of alcohol-based handrubs could result
in increased transmission of Clostridium difficile has not
been borne out in practice.
Methods used to assess the antimicrobial efficacy of products
differ among studies and countries, including whether or not
the efficacy of the agent is to be tested against viral patho-
gens. The correlation between laboratory-based standards
and effectiveness in clinical practice has been questioned.
Further studies should be conducted at the bedside using
standardized protocols to obtain more realistic views of
microbial colonization and the risk of bacterial transfer and
cross-transmission. Moreover, further evidence is required
regarding the relative efficacy of foam formulations.
26 A Guide to Infection Control in the Hospital
The role of gloves in healthcare is in evolution, with recent
evidence indicating that gloves can be associated both
with lower hand hygiene compliance and reductions in
cross-transmission under certain circumstances.
Suggested Practice
Guidelines for hand hygiene in healthcare settings have been
developed by the CDC/HICPAC, SHEA, APIC, and IDSA in
2002 (available at www.cdc.gov/ncidod/hip/hhguide.htm),
and WHO in 2009 (available at www.who.int/gpsc/5may/
tools/9789241597906/en/). Each recommendation was classi-
fied in 4 categories. The guidelines include indications for hand
hygiene (see Table 6.1), surgical hand preparation, selection of
hand hygiene agents, healthcare worker skin care and educa-
tion, strategies for motivational programs, administrative mea-
sures, and recommended outcome or process measurements.
Table 6.1 Indications for Hand Hygiene Actions
A. Wash hands with soap and water when hands are visibly
dirty or visibly soiled with blood or other body fluids (IB)
or after using the toilet (II).
B. If exposure to potential spore-forming pathogens is
strongly suspected or proven, including outbreaks of
Clostridium difficile, hand washing with soap and water
is the preferred means (IB).
C. Use an alcohol-based handrub as the preferred means
for routine hand antisepsis in all other clinical situations
described below, if hands are not visibly soiled (IA).
If alcohol-based handrub is not available, wash hands
with soap and water (IB).
D. Perform hand hygiene:
the patient during the same care sequence).
Hand Hygiene 27
Footnote to Table 6.1
The system for categorizing recommendations is adapted
from the CDC/HICPAC system as follows:
Category IA. Strongly recommended for implementation
and strongly supported by well-designed experimental,
clinical, or epidemiologic studies.
Category IB. Strongly recommended for implementation and
supported by some experimental, clinical, or epidemiolog-
ic studies and a strong theoretical rationale.
Category IC. Required for implementation, as mandated by
federal and/or state regulation or standard.
Category II. Suggested for implementation and supported by
suggestive clinical or epidemiologic studies or a theoreti-
cal rationale.
Among indications for hand hygiene (see Table 6.1), it is
worth noting that unless hands are visibly soiled, the use of
an alcohol-based handrub agent is recommended for routine
hand hygiene in all clinical situations (IA). Availability of an
alcohol-based handrub at the point of care is recommended
to improve compliance.
Wearing of gloves should not be considered as an alternative to
hand hygiene. Hand hygiene is required regardless of whether
gloves are used or changed. Recommendations for glove use
are: 1) to wear gloves when contact with blood or other poten-
tially infectious materials, mucous membranes, and non-intact
skin can be reasonably anticipated; 2) to remove gloves after
caring for a patient; 3) to not wear the same gloves for the
care of more than one patient; 4) to not wash gloves between
patients; and 5) to change gloves during patient care if moving
from a contaminated body site to a clean body site.
Summary
Hand hygiene is the cornerstone of infection prevention. How-
ever, HCW compliance remains low unless subjected to suc-
cessful promotion strategies. Improving hand hygiene practices
28 A Guide to Infection Control in the Hospital
it is, however, associated with decreased cross-transmission
and reduced infection rates and antimicrobial resistance trans-
fer. Factors adversely affecting HCW compliance with recom-
mended practices include poor access to sinks and hand hygiene
materials, time required to perform conventional handwashing
with soap and water, time constraint associated with a high
intensity of patient care, and a high number of opportunities for
hand hygiene per hour of care on a single patient in critical care.
Availability of an alcohol-based handrub at the point of
care is recommended to improve compliance. Alcohol-based
handrubbing is currently recommended as the primary tool for
hand hygiene action and promotion because it reduces bacte-
rial counts on hands more effectively than plain or antimicro-
bial soaps, can be made more accessible than sinks and other
handwashing facilities, requires less time to use, and causes less
skin irritation and dryness than washing hands with soap and
water. Rubbing the hands together until the agent has dried is
the essential part of the technique. Both easy access to hand
hygiene facilities and the availability of skin care lotion appear
to be necessary prerequisites for appropriate hand hygiene
behavior. The promotion of alcohol-based handrubs at the point
of care contributed significantly to an increase in compliance
both in several clinical studies and in nationwide hand hygiene
promotion campaigns. The availability of a handrub alone how-
ever, is insufficient to obtain sustained improvement in hand
hygiene practices. Multimodal strategies are indicated and
include: 1) system change, including alcohol-based handrub at
the point of care; 2) education and training; 3) observation and
performance feedback; 4) reminders in the workplace; and 5)
patient safety climate. This approach involves a system change
to make hand hygiene a priority, with alcohol-based hand rub as
standard of care.
References
Pittet D, Mourouga P, Perneger TV, and Members of the Infection Con-
trol Program. Compliance with hand washing in a teaching hospital.
Ann Intern Med. 1999. 130:126–130.
Pittet D, Boyce JM. Hand hygiene and patient care: Pursuing the Sem-
melweis legacy. Lancet Infect Dis. 2001. April:9–20.
Hand Hygiene 29
Boyce JM, Pittet D. Guideline for hand hygiene in healthcare set-
tings: Recommendations of the Healthcare Infection Control Prac-
tices Advisory Committee and HICPAC/SHEA/APIC/IDSA Hand
Hygiene Task Force. MMWR. 2002. 51[RR16]:1–44.
Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide
programme to improve compliance with hand hygiene. Lancet. 2000.
356:1307–1312.
Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. My five
moments for hand hygiene: A user-centred design approach to under-
stand, train, monitor and report hand hygiene. J Hosp Infect. 2007.
67:9–21.
World Health Organization. WHO Guidelines on Hand Hygiene in
Healthcare. World Health Organization Press. Geneva. 2009.
Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D.
Patient participation: Current knowledge and applicability to patient
safety. Mayo Clin Proc. 2010. 85:53–62.
Stewardson AJ, Allegranzi B, Perneger TV, Attar H, Pittet D. Testing the
WHO Hand Hygiene Self-Assessment Framework for Usability and
Reliability. J Hosp Infect. 2013. 83:30–35.
Allegranzi B, Gayet-Ageron A, Damani N, et al. Global implementation
of WHO’s multimodal strategy for improvement of hand hygiene: A
quasi-experimental study. Lancet Infect Dis. 2013. 13:843–851.
30 A Guide to Infection Control in the Hospital
Chapter 7
Isolation of Communicable Diseases
Bart Gordts, MD, MBA
Key Issue
The combination of standard precautions and isolation proce-
dures represents an effective strategy in the fight against health
care associated transmission of infectious agents. Current CDC-
HICPAC proposed guidelines1 describing the updated methods
and indications for these precautions are straightforward, but
effective barriers at the bedside are sometimes still lacking
today. Key factors in achieving effective interruption of health
care associated transmission in all hospitals are the availabil-
ity of the necessary financial and logistic resources as well as
the increase in compliance of healthcare professionals (HCPs)
with the guidelines. Preventing transmission of infections by
means of isolation procedures in a scientific and cost-effective
manner represents a challenge to every healthcare institution. In
2007, the indications and methods for isolation as described in
19962 were updated taking into account the changing patterns in
healthcare delivery, emerging pathogens and most importantly,
additions to the recommendations for standard precautions.
Moreover, the increasing prevalence of multi-drug resistant
health care associated pathogens necessitated specific strategic
approaches,3 which cannot be considered separately from other
isolation policies.
Known Facts
Isolation and barrier precautions aim to reduce or eliminate
direct or indirect patient to patient transmission of health care
associated infections that can occur through 3 mechanisms:
tact and the direct physical transfer of microorganisms from
one patient to another or via hands of a HCP. Transmission
can be direct (skin to skin) or indirect (via a contaminated
surface).
Isolation of Communicable Diseases 31
pended for long in the air and usually travel a short distance
of less than 1 meter.
suspended in the air longer and therefore can travel long dis-
tances and infect susceptible hosts several meters away from
the source.
Besides patient to patient transmission, health care asso-
ciated infections can be endogenous (patient is the source of
pathogen causing his infection) or acquired from environmental
sources like contaminated water supplies, medical equipment,
IV solutions, etc. These infections are not prevented by isolation
precautions.
The most cost-effective, simple and feasible way to prevent
transmission of pathogens consists in a two-tier approach as
described in the CDC-HICPAC guidelines1:
patients. They represent a basic list of hygiene precau-
tions designed to reduce the risk of transmission of blood-
borne pathogens and those from contact with moist body
substances.
precautions are necessary during the care of patients with
highly transmissible or epidemiologically important patho-
gens. These practices are designed to interrupt airborne-,
droplet- and direct or indirect contact transmission.
Isolation and barrier precautions have also proven successful
in limiting the epidemic spread of multiply resistant gram nega-
tive bacilli, methicillin resistant Staphylococcus aureus (MRSA),
vancomycin resistant enterococci4 (VRE). Isolation precau-
tions can also be assumed effective in the fight against health
care associated epidemics caused by vancomycin intermediate
or resistant Staphylococcus aureus5 (VISA, VRSA), extended
spectrum beta-lactamase (ESBL) producing enterobacteriaceae
(like Enterobacter spp.), quinolone- or carbapenem resistant
Pseudomonas aeruginosa and enterobacteriaceae, and multi-
resistant Stenotrophomonas maltophilia and Acinetobacter spp.6
32 A Guide to Infection Control in the Hospital
Suggested Practice
All patients receiving care in hospitals or doctor offices, irre-
spective of their diagnoses, must be treated in such a manner as
to minimize the risk of transmission of any kind of microorgan-
isms from patient to HCP, from HCP to patient, and from patient
to HCP to patient.
Standard Precautions
Standard precautions apply whenever there is contact with rup-
tured skin or mucous membranes, blood, all body fluids, secre-
tions or excretions except sweat. They are designed to reduce
the risk of transmission from both recognized and unrecognized
sources of infection. Among these ‘standard’ precautions, hand
hygiene among HCPs constitutes the single most important pre-
vention of nosocomially transmitted infections. Standard Pre-
cautions combine the major features of universal precautions7
and body substance isolation8 and are based on the principle
that all blood, body fluids, secretions, excretions except sweat,
nonintact skin, and mucous membranes may contain transmis-
sible infectious agents. HCP’s should wash hands when soiled
and disinfect hands when possibly contaminated, irrespective
of whether gloves were worn. Hand hygiene should take place
immediately after gloves are removed, before and between
patient contacts, and any time one handles blood, body fluids,
secretions or excretions, or potentially contaminated items or
equipment.
Gloves should be worn if touching blood, body fluids, secre-
tions, excretions, mucous membranes, broken skin or contam-
inated objects. Gloves must be changed between patients and
before touching clean sites on the same patient.
A mask and eye protection as well as a gown should be worn
to protect mucous membranes, skin and clothing during proce-
dures that are likely to result in splashing of blood, body fluids,
secretions, or excretions.
Patients, HCPs or visitors must not be exposed to contam-
inated materials or equipment. Reusable equipment should be
cleaned and sterilized before reuse. Soiled linen should be trans-
ported in a (double) bag.
HCPs must protect themselves against bloodborne contam-
ination by carefully handling sharp instruments like needles.
Needles should not be recapped. All used sharps instruments
must be placed in designated puncture-resistant containers.
Isolation of Communicable Diseases 33
No special precautions are needed for eating utensils and
plates since hot water and detergents in hospitals are sufficient
to decontaminate these articles. Rooms, cubicles, and bedside
equipment should be appropriately cleaned.
In addition to these standard precautions, ‘transmission-based
precautions’ must be used for patients known or suspected to be
infected with highly transmissible or epidemiologically import-
ant pathogens which can spread by airborne or droplet trans-
mission or by contact with dry skin or contaminated surfaces.
Examples of conditions necessitating isolation precautions
and a summary of measures to be taken are shown in Table 7.1
and Table 7.2.
Table 7.1 Indications for Standard and Isolation Precautions
Precaution category Condition
Standard All patients
Contact Hemorrhagic fever such as Ebola, Lassa, and Marburg,
(risk for) colonization or infection with multiresistant bacteria,
C. difficile infection, acute diarrhea in incontinent patient,
RSV infection, croup or bronchiolitis in young infants, skin
infections like impetigo, major abcess, cellulitis or decubiti,
staphylococcal furonculosis, pediculosis, scabies or cutaneous
infections with C. diphtheriae, Herpes simplex virus, zoster.
Droplet Meningitis, (suspected) invasive infection with
H. influenzae type B or N. meningitidis, diphtheria,
M. pneumoniae, pertussis, influenza, adenovirus, mumps,
Parvovirus B19, rubella, streptococcal pharyngitis,
pneumonia, scarlet fever in young children.
Airborne Pulmonary or laryngeal (suspected) tuberculosis, measles,
varicella; disseminated zoster.
Contact Precautions
Contact precautions must be taken when transmission can occur
by skin to skin contact and the direct physical transfer of micro-
organisms as shown in Table 7.1.
Provide a private room, if possible. When not available,
cohort patients infected with the same microorganism but with
no other infection. Nonsterile gloves should be worn before
entering the room. Apply hand washing and hand antisepsis as
34 A Guide to Infection Control in the Hospital
in standard precautions. Be sure not to touch potentially con-
taminated surfaces or equipment. Wear a clean, nonsterile gown
when entering and remove it before leaving the room. Limit
patient transport to the unavoidable situation and maintain iso-
lation precautions during transport. When possible, limit the use
of patient-care equipment to a single patient.
Droplet Precautions
Apply droplet precautions for patients infected with pathogens
that spread by respiratory droplets larger than 5 μm produced
during coughing, sneezing, talking, or during invasive proce-
dures such as bronchoscopy (see Conditions in Table 7.1).
Private room as in contact precautions. If unachievable,
maintain spatial separation of at least 1 m between the infected
patient and other patients and visitors. Special ventilation is
unnecessary and the door may remain open. Masks are worn if
within less than 1 meter of the patient. Limit patient transport
to the unavoidable and maintain isolation precautions during
transport. When possible, limit the use of patient-care equip-
ment to a single patient.
Airborne Precautions
Apply airborne precautions for patients infected with patho-
gens spread by respiratory droplets smaller than 5 μm produced
during coughing, sneezing, talking, or during invasive proce-
dures such as bronchoscopy (see Conditions in Table 7.1).
As for the other infections requiring airborne precautions,
patients suspected or known to be infected by M. tuberculosis
should be nursed in a private room where the air flows in the
direction from the hall into the room (negative air pressure), with
6 (minimum) to 12 (optimal) changes per hour and appropriate
discharge of air outdoors. Negative air pressure can be created by
placing a fan in the window and exhausting the air to the outside.
High-efficiency filtration is necessary if the air is circulated in
other areas of the hospital. Keep the door closed. Cohorting can
be done in rare circumstances for patients infected with strains
presenting with an identical antimicrobial susceptibility.
Respiratory protection should be worn both by HCPs and
visitors when entering the room. The technical requirements
for respiratory protection devices remain controversial: CDC
guidelines9 advocate masks with face-seal leakage of ≤10%
and filter 1μm particles for > 95% efficiency (N95). However, a
Isolation of Communicable Diseases 35
molded surgical mask may be as effective in dealing with health
care associated outbreaks and better complied with because
of cost. Avoid transporting patients through other areas of the
facility. If transport is unavoidable, the patient should wear a
surgical mask that covers mouth and nose.
It is mandatory to maintain isolation until the diagnosis
of tuberculosis is ruled out or, when confirmed, the patient is
on effective therapy, improving clinically and has three con-
secutive negative sputum smears excluding the presence of
acid fast bacilli. Patients infected with multidrug resistant M.
tuberculosis should stay in airborne isolation throughout the
hospitalization.
Table 7.2 Summary of Transmission-based Precautions
Precaution Contact Droplet Airborne
Patient room Private Private Private with specific
ventilation requirements
Gloves Before entering room As in standard
Hand hygiene ———— As in standard, with hand antisepsis ————
Gown If direct contact
with patient or ———— As in standard ————
environment
Masks Standard Within Before entering room
1 meter special requirements
of patient
Other ————— Limit patient transport —————
Protective Environment
A set of prevention measures termed ‘Protective Environment’ has
been described in the CDC-HICPAC guidelines comprising engi-
neering and design interventions that decrease the risk of expo-
sure to environmental fungi for severely immunocompromised
allogeneic hematopoietic stem cell transplant patients during their
highest risk phase.10 Specific air quality requirements include
HEPA filtration of incoming air, directed room air flow, positive
room air pressure, well-sealed rooms, ventilation to provide >12
air changes per hour, strategies to minimize dust, routinely clean-
ing crevices and sprinkler heads, and prohibiting dried and fresh
36 A Guide to Infection Control in the Hospital
flowers and potted plants in the rooms. Protective environment
does not include the use of barrier precautions beyond those indi-
cated for standard and transmission-based precautions.
Implementation of Isolation Precautions
Hospitals are encouraged to review the recommendations and to
modify them according to what is feasible and achievable. The
success of transmission prevention in each institution relies on
three keystones:
continuous improvement program.
Since clear indications and advised practices for isolation
procedures are available to date, the further success of transmis-
sion prevention further relies upon:
Accurate and early identification of patients at risk requiring
isolation by:
– availability of unambiguous written criteria for starting
– initiation of isolation procedure as soon as the infectious
– active surveillance of risk factors among patients upon
– early laboratory diagnosis.
Effective discharge planning for patients in isolation to be
transferred to other healthcare facilities and effective admis-
sion planning for patients at risk of carrying infectious
agents from other hospitals or nursing homes.
Increased compliance of patients with the precautions
through supportive efforts to facilitate adherence and
through education about the mechanism of transmission and
the reason for being placed in isolation.
Instruction and information of visitors about infection pre-
vention measures.
Clear endorsement by hospital management and department
heads.
Isolation of Communicable Diseases 37
References
1
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare
Infection Control Practices Advisory Committee. 2007 Guideline for
Isolation Precautions: Preventing Transmission of Infectious Agents
in Healthcare Settings. Available at: http://www.cdc.gov/niosh/
docket/archive/pdfs/NIOSH-219/0219-010107-siegel.pdf
2
Garner JS. Guideline for isolation precautions in hospitals. The Hos-
pital Infection Control Practices Advisory Committee. Infect Control
Hosp Epidemiol. 1996. 17(1):53–80.(s).
3
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare
Infection Control Practices Advisory Committee. Management
of Multidrug-Resistant Organisms in Healthcare Settings. 2006.
Available at: http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuide-
line2006.pdf
4
Hospital Infection Control Practices Advisory Committee. Recommen-
dations for Preventing the Spread of Vancomycin Resistance. Infect
Control Hosp Epidemiol. 1995. 16:105 13.
5
Edmond MB, Wenzel RP, Pasculle AW. Vancomycin-resistant Staphy-
lococcus aureus: Perspectives on Measures Needed for Control. Ann
Intern Med. 1996. 124:329–34.
6
Flaherty JP, Weinstein RA. Nosocomial Infection Caused by Antibi-
otic-resistant Organisms in the Intensive Care Unit. Infect Control
Hosp Epidemiol. 1996. 17:236–248.
7
CDC. Update: Universal precautions for prevention of transmission of
human immunodeficiency virus, hepatitis B virus, and other blood-
borne pathogens in health-care settings. MMWR. 1988. 37(24):377–
82, 87–8.
8
Lynch P, Cummings MJ, Roberts PL, Herriott MJ, Yates B, Stamm
WE. Implementing and evaluating a system of generic infection
precautions: Body substance isolation. Am J Infect Control. 1990.
18(1):1–12.
9
CDC. Guidelines for preventing the transmission of Mycobacterium
tuberculosis in health-care settings, 2005. MMWR Recomm Rep.
10
CDC. Guidelines for preventing opportunistic infections among
hematopoietic stem cell transplant recipients. Recommendations of
CDC, the Infectious Disease Society of America, and the Ameri-
can Society of Blood and Marrow Transplantation. MMWR. 2000.
49(RR-10):1–125.
38 A Guide to Infection Control in the Hospital
Chapter 8
Patient Areas, Disinfection
and E nvironmental C leaning
Constance Wendt, MD
Key Issue
The patient environment harbors a number of potential
reservoirs for pathogens.
Known Facts
Patients need a clean environment for their uncomplicated
recovery.
Controversial Issues
The extent to which environmental reservoirs contribute to
health care associated infections remains unclear.
The extent to which germicidal solutions should be used
on environmental surfaces as opposed to non-germicidal
cleaning methods remains unclear.
Suggested Practice:
Patient areas should be cleaned periodically and after
contamination.
Patient areas should be protected from heavy dust.
Since the writings of Florence Nightingale in the 19th century
the need for a clean patient care environment is unquestioned.
However, uncertainty remains about the extent to which environ-
mental reservoirs contribute to health care associated infections.
Environment reservoirs have been linked with outbreaks
of health care associated infections, e. g. air filters, insulation
materials, or surfaces. Other objects and surfaces known to har-
bor bacteria, such as flowers, toilets, and medical waste may
also pose a risk for health care associated infections.
Patient Areas, Disinfection and Environmental Cleaning 39
Housekeeping Surfaces
Housekeeping surfaces (floors, walls tabletops) have been
associated with outbreaks of vancomycin-resistant Enterococci
and methicillin resistant Staphylococcus aureus (MRSA) and
more recently with Clostridium difficile and Noroviruses. The
increasing incidence of resistant organisms has prompted
further discussion on the need for routine surface disinfection.
However, these special problems do not justify routine disinfec-
tion of all hospital floors and furnishings. It has been demon-
strated that the rate of health care associated infections are not
significantly different between units cleaned with disinfectants
and those units cleaned with detergents.
Routine cleaning of housekeeping surfaces with deter-
gents is sufficient in most circumstances. In case of outbreaks,
especially when due to resistant microorganisms known to be
harbored in the environment, additional cleaning with a dis-
infection solution may be indicated. A common reason given
for environmental contamination with microorganisms may be
the lack of adherence to facility procedures for cleaning and
disinfection. Monitoring for adherence to recommended envi-
ronmental cleaning practices is an important component for
success in controlling cross-transmission by fomites. However,
surface disinfection is not a substitute for standard infection
control measures.
Spills of blood and body substances should be promptly
cleaned and decontaminated.
Carpeting and Cloth Furnishings
Carpeting and cloth furnishings may be a source of dust contain-
ing microorganisms. These types of surfaces should be avoided
were spills are likely, in patient rooms and in areas housing
immunosuppressed patients. Routine cleaning of carpeting and
cloth furnishings should be performed with well-maintained
equipment designed to minimize dust dispersion. Wet cleaning
should be performed using a method that minimizes the produc-
tion of aerosols and leaves little or no residues. Carpeting that
remains wet for more than 72 hours should be replaced.
40 A Guide to Infection Control in the Hospital
Hospital Toilets
Cultures of hospital toilets have demonstrated that frequency
and level of contamination is usually low, making the toilets
an uncommon source of hospital infections. However, on units
for mentally impaired adults, young children, or neurologically
impaired patients heavy soiling with feces may occur resulting
in cross-infections between patients.
Hospital toilets should be cleaned with a disinfecting solu-
tion. The bowl should be cleaned with a scouring powder and a
brush, but disinfectants should not be poured in the bowl.
Flowers and Plants
The water containing cut flowers may yield high numbers of
microorganisms including Acinetobacter, Klebsiella spp.,
Enterobacter spp., Pseudomonas spp., Serratia marcescens,
and Flavobacterium. Although it has not been demonstrated
that microorganisms from cut flowers or potted plants were
linked with health care associated infections, cut flowers and
potted plants should be avoided in rooms of immunocompro-
mised and intensive care unit patients. On other units flowers
should be handled by support staff with no patient contact or
gloves should be worn for flower handling. Antibacterial agents,
e. g. 0.01%–0.02% chlorhexidine or 10ml of 1% hypochlorite
can be added to the vase water.
Contaminated Laundry
Patients should have clean, freshly laundered bed linens. As it
has been demonstrated that the handling of used bed linen may
increase the concentration of airborne microorganisms, the dis-
infection of blankets has been suggested. However, there are
no data to justify the additional cost and workload needed to
disinfect blankets.
Soiled linen should be handled as little as possible and with
minimum agitation. Soiled linens should not be sorted or pre-
rinsed in patient care areas. Linens soiled with blood or body
fluids should be deposited and transported in bags that prevent
leakage.
Patient Areas, Disinfection and Environmental Cleaning 41
Construction Projects
Construction projects have been linked to health care associated
fungal infections. As a result, careful control measures should
be implemented during hospital construction projects. These
measures should include erection of physical barriers and tem-
porary shut down of ventilation systems. If possible, air flow of
ventilation systems should re-routed to protect sensitive areas.
Traffic flow patterns for construction personal should be defined
and separated from those of patients and health care workers.
Infective Solid Waste
Infective solid waste may come from patients under isola-
tion precautions, laboratories and from the pathology. Sharp
items and blood and blood products should also be considered
infective.
Personnel handling infectious waste should be informed of
the potential health and safety hazard. If necessary, the waste
should be transported in sealed impervious containers and
stored in areas accessible only to personnel involved in the
disposal process.
Other Reservoirs
Other possible reservoirs of health care associated pathogens
are summarized in Table 8.1.
Table 8.1 Possible Reservoirs of Infectious Agents
in the Environment and Modes of Control
Reservoir Associated Control
Pathogen
Patient Rooms
Air Filters Aspergillus Replace soiled filters periodically
False Ceilings
Rhizopus Barrier protection during
reconstruction
Fireproof Material Aspergillus Add fungicide to moist material
Air-Fluidized Beds – Follow manufacturer’s recommendation
Mattresses Pseudomonas, Use intact plastic cover; disinfect
Acinetobacter between patients
42 A Guide to Infection Control in the Hospital
Table 8.1 Possible Reservoirs of Infectious Agents
in the Environment and Modes of Control (continued)
Reservoir Associated Control
Pathogen
Bathroom
Faucet Aerators Pseudomonas Clean regularly
Sinks Pseudomonas Use separate sinks for handwashing
and disposal of contaminated fluids
Tub Immersion Pseudomonas Add germicide to water, drain and
disinfect after each use
Urine-Measuring Serratia Disinfect between patients,
Device good handwashing
Routinely Used Medical Equipment
ECG Electrodes S. aureus, Disinfect after use or use
Gram-negative rods disposable leads
Stethoscopes Staphylococci Prudent to clean periodically
with alcohol
Electronic thermometers C. difficile Probe cover, disinfect each day
and when visibly contaminated
Thermometers (glass) Salmonella Disinfect between use
Plaster Pseudomonas, Use judiciously in immunocompromised
Bacillus, Clostridia, patients or over nonintact skin
Cunninghamella
Elasticized Bandages Zygomycetes Avoid in immunocompromised patients
or over nonintact skin
Other Possible Sources
Chutes Pseudomonas, Proper design and placement
Staphylococci
Contaminated Pseudomonas Avoid extrinsic contamination and seek
Germicides manufacturer’s microbicidal efficiency
verification of claims
Ice Baths Staphylococcus, Avoid direct contact with ice to cool
Ewingella IV solutions/syringes; use closed
system for thermodilution
Patient Areas, Disinfection and Environmental Cleaning 43
Table 8.1 Possible Reservoirs of Infectious Agents
in the Environment and Modes of Control (continued)
Reservoir Associated Control
Pathogen
Other Possible Sources
Water Baths Pseudomonas, Add germicide to water bath or use
Acinetobacter plastic overwrap
maintain filter efficiency
Pets Salmonella Prudent to avoid in hospital setting
(except seeing-eye dogs)
Adapted from Weber, DJ, and Rutala WA: Environmental issues and nosocomial infection. in
Wenzel RP (Ed): Prevention and control of nosocomial infections; 3rd edition. Baltimore, MD:
Williams and Wilkins; 1997. 491–514.
References
Weber, DJ, Rutala WA. Environmental issues and hospital acquired
infections in Prevention and Control of Hospital Acquired Infection
(3rd Edition), Wenzel, RP (Ed). Baltimore: Williams and Wilkins,
Streifel AJ. in Hospital Epidemiology and Infection Control (4th Edi-
tion), Mayhall, CG (Ed). Baltimore: Williams and Wilkins, 2012.
Pgs. 1051–1058.
Centers for Disease Control and Prevention: Guidelines for environ-
mental infection control in health care facilities: recommendations of
CDC and the Healthcare Infection Control Practices Advisory Com-
mittee (HICPAC). MMWR. 2003. 52 (No. RR-10):1–42.
Siegel, JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare
Infection Control Practices Advisory Committee: Management
of Multidrug-Resistant Organisms In Healthcare Settings, 2006.
Available at: http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuide-
line2006.pdf (Accessed 14 October 2013).
Siegel, JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare
Infection Control Practices Advisory Committee, 2007 Guideline for
Isolation Precautions: Preventing Transmission of Infectious Agents
in Healthcare Settings, June 2007. Available at: http://www.cdc.gov/
hicpac/2007IP/2007isolationPrecautions.html (Accessed 14 October
2013).
44 A Guide to Infection Control in the Hospital
- 1. Before touching a patient.
- 2. Before aseptic/clean procedure.
- 3. After body fluid exposure risk.
- 4. After touching a patient.
- 5. After touching patient surroundings (without touching
- constitutes one of the major challenges of infection control;
- 1. via contact, which involves skin (or mucosa) to skin con-
- 2. via respiratory droplets larger than 5 μm that are not sus-
- 3. airborne transmission: particles less than 5 μm that remain
- 1. Standard precautions must be taken while caring for all
- 2. In addition to standard precautions, extra barrier or isolation
- 1. Availability to all HCPs an unambiguous written document
- describing the indications and procedures for isolation;
- 2. Successful implementation of the procedures through clear
- objectives and education off all HCPs;
- 3. Monitoring of the compliance with isolation procedures in a
- and discontinuing isolation;
- disease is suspected;
- admission to the hospital or ward;
- 2005. 54(17):1–141.
- Pigeon Droppings Aspergillus Filter all hospital air;
- 1997. Pgs. 491–514.
Chapter 9
Reuse of Disposable Devices
Samuel R. Ponce de León, MD, MSc
It seems to me that reusing disposable devices
has an element of poetic justice ingrained, if
one can become poetic about economics.
—V.W. Greene
Key Issue
Reutilization of disposable devices is a common practice in
most hospitals but there are no well-founded standard guide-
lines to assure the quality and the safety of this practice.
Known Facts
Most disposable devices can be reused.
Economic benefits can be obtained by reusing disposables.
Sterilization is a well known and common practice in
hospitals.
Infections and malfunction are higher risks if the device is
damaged in the re-sterilization process.
There are diverse studies showing the security of reprocess-
ing a variety of cardiac and urinary catheters, balloon-tipped
catheters, guide-wires, implants, needles, surgical instru-
ments, hemodialysers, laparoscopic instruments and
pacemakers.
There is evidence against the reuse of specific items with
particular methods, such as Transducer Domes and Esopha-
geal Stethoscopes with ethylene oxide sterilization.
Risks associated with the reuse of disposable catheters
include: infection, pyrogenic reaction, toxicity, particulate
contamination, breakage-catheter integrity, catheter biocom-
patibility, risk for personnel, and risk for the environment.
Patients should know that a reused item is is going to be
utilized.
Reuse of Disposable Devices 45
Controversial Issues
The selection of the patients to utilize a re-sterilized-device
implies an ethical issue that should be resolved in every
facility.
There is a relationship between complexity of disposables
and difficulties of sterilization.
– A clear limit should be established regarding the number of
times an item can be reused.
– The burden of complications due to reutilization is not
known.
– FDA consider those hospitals reusing disposable devices
as manufacturers. The device should comply just as though
it was a new one.
Reuse of disposables increases the risk of exposure of HCW
to body fluids and chemicals used for sterilization.
It is impossible for every single facility to evaluate each item
to be reused. In most cases decisions will be made based in
published experience.
Specialized sterilization companies maybe an option.
Ethical, regulatory and legal implications should be
considered.
The reuse of disposable masks (N95 respirators) during epi-
demics or pandemics should be clearly regulated; the Amer-
ican Institute of Medicine does not recommend its reuse, but
in the case of a pandemic there will a short supply.
There are many questions and few answers (to many dispos-
ables and very few studies), and funding for this research is
scarce.
Suggested Practice
Reuse of disposables should not be an ad hoc practice or treated
casually. A facility committed to the reuse of single-use devices
should have an institution-specific policy and work with clear
guidelines to ensure the safety of patients.
The American Society for Hospital Service Personnel has
published the following guidelines:
guidelines for use and reprocessing the device.
46 A Guide to Infection Control in the Hospital
parameters, obtain information about the material properties
(steel, rubber, latex, PVC, etc). Ask the manufacturers if the
product can be reprocessed; and if so, ask for recommendations.
reprocessed device will be expected to meet.
These include:
A.– Physical appearance (color, shape, size, etc.), and
B.– Function (moving parts, tensile strength, flexibility,
etc.).
device can be adequately cleaned according to the material
properties and cleaning methods available.
device can be adequately sterilized according to material
properties and sterilizing methods available.
The quantity of items which must be tested to get an
adequate study sample.
The number of times the device can be reprocessed and
still meet the form and function criteria.
Employee safety considerations.
The procedures, chemicals, and equipment to be used in
reprocessing.
Process controls, quality assurance monitoring, and docu-
mentation.
Testing of the reprocessed item in simulated use situations
The necessity of destructive auditing to identify unaccept-
able changes to the material properties or the presence of
residual toxicity.
Documentation of testing results.
A method for labeling the reprocessed device and
marking for successive reprocessing episodes.
groups (administration, infections-control, ethics
committee) and the manufacturer.
Reuse of Disposable Devices 47
patient consent, and documentation of the use of
reprocessed devices.
Other specific recommendations are:
possible.
balloon inflated and deflated before using it.
References
American Society of Anesthesiologists Committee on occupational
health of operating room personnel. http://sprojects.mmi.mcgill.ca/
hearth/cath-005.htlm.
National Academy of Sciences. Institute of Medicine. News April 27,
Green WW. Reuse of Disposable Medical Devices: Historical and Cur-
rent Aspects. Infect Control. 1986. 7:508–513.
Crow S. The Slings and Arrows of Outrageous Fortune. Infect Control.
Canadian Hospital Association. The Reuse of Single-Use Medical
Devices. October 3, 2003.
Rutala WA. Disinfection, Sterilization, and Waste Disposal in Preven-
tion and Control of Nosocomial Infections (3rd Edition), Wenzel RP
(Ed). Baltimore: Williams and Wilkins, 1997. Pgs. 491–514.
8:697–701.
Collier R. The ethics of reusing single-use devices. CMAJ. 2011.
183:1245.
Centers for Disease Control and Prevention. Reuse of single use medical
devices. Accessed from: http://www.cdc.gov/hicpac/pdf/guidelines/
Disinfection_Nov_2008.pdf
48 A Guide to Infection Control in the Hospital
Chapter 10
Disinfection
Summer Donovan, DO and
Gonzalo M.L. Bearman, MD, MPH
Key Issue
Proper sterilization and/or disinfection of medical devices, sur-
gical devices, and contaminated surfaces is crucial to the pre-
vention of pathogen transmission. The level of sterilization or
disinfection depends on the planned use of the device.
Known Facts
Definitions:
Cleaning is the removal of visible foreign material on
objects or surfaces, and is normally performed manually or
mechanically.
Disinfection is the thermal or chemical destruction of patho-
genic and other types of microorganisms. Disinfection does
not kill all microbial forms, such as bacterial spores.
Sterilization destroys or eliminates all microbial forms,
including bacterial spores.
Instruments that enter into normally sterile tissue or the
bloodstream require sterilization. Medical devices that con-
tact mucous membranes, such as flexible endoscopes and
endotracheal tubes, normally require disinfection.
About 51 million inpatient surgical procedures are per-
formed each year in the United States.
About 53 million ambulatory procedures are carried out
each year in the United States.
Suggested Practice
EH Spaulding Approach to Disinfection and Sterilization
In 1968, Spaulding formulated an approach to disinfection of
medical devices that is still used today. He classified items as
critical, semicritical, or noncritical based on their risk of trans-
mitting infection.
Disinfection 49
Critical items confer a high risk of infection if
contaminated with organisms.
– Examples: surgical instruments, urinary catheters,
biopsy forceps.
– The level of cleaning required is sterilization.
Semicritical items come into contact with mucous
membranes or intact skin.
– Examples: endoscopes, laryngoscope blades,
vaginal speculum.
– This category requires at least high-level disinfection.
Noncritical items come into contact with intact skin,
but not mucous membranes.
– Examples: examination table top, baby weight scales,
blood-pressure cuffs.
– Low-level disinfection should be used to prevent
secondary transmission of pathogens to patients.
Methods for Disinfection and Sterilization
Sterilization destroys all microorganisms, including
bacterial spores. Methods for sterilization include:
– High temperature: steam and dry heat.
– Low temperature: ethylene oxide (ETO) gas and
hydrogen peroxide.
– Liquid immersion: chemical sterilants.
High-level disinfection kills all organisms except for
high numbers of bacterial spores. Methods include:
– Heat automated: pasteurization.
– Liquid immersion: chemical sterilants or high-level
disinfectants.
Intermediate-level disinfection kills Mycobacteria,
most viruses, and bacteria. This method does not kill
bacterial spores.
– Liquid contact: EPA-registered hospital disinfectants
with tuberculocidal activity (e.g. chlorine-based
products and phenolics).
50 A Guide to Infection Control in the Hospital
Low-level disinfection kills some viruses and bacteria.
This method does not kill bacterial spores.
– Liquid contact: EPA-registered hospital disinfectants
with no tuberculocidal activity (e.g. chlorine-based
products, phenolics, quaternary ammonium compounds,
or 70%–90% alcohol).
Selection and Use of Method
The level of sterilization or disinfection depends upon the
desired microbicidal activity of the method (see Table 10.1).
Recommended Procedures for Disinfection
of Medical Devices
Prior to disinfection or sterilization:
– Clean all medical devices with water and detergent.
– Ensure that the devise is free of any irregularities that
could impair disinfection or sterilization (e.g. cracks in
the surface). Discard items that cannot be cleaned prop-
erly or no longer function properly.
Sterilize all critical items.
Employ high-level disinfection for all semicritical items.
Use low-level disinfection for all noncritical items.
Recommended Procedures for Disinfection
of Environmental Surfaces
Clean any surface in a patient care area when visibly soiled.
Clean floors, tabletops, and other surfaces regularly (daily
or three times per week), when spills occur, and when the
surface is visibly soiled.
Replace disinfectant solutions regularly (e.g. mopping solu-
tion every three patient rooms, and/or every hour).
Use a high-level disinfectant for disinfection of critical
surfaces.
Use a hospital disinfectant for noncritical surfaces.
If disinfectants are used to clean infant bassinets in between
patients, the surface must be thoroughly rinsed and dried
prior to reuse.
Disinfection 51
Table 10.1 Sterilization and Disinfection—Spectrum of Activity Against Pathogens.
Method Example(s) of Method Spectrum of Activity Against Pathogens
Bacterial Spores Mycobacteria Vegetative Bacteria Fungi Viruses
Sterilization
High Temperature Steam + + + + +
Low Temperature ETO gas, hydrogen peroxide, + + + + +
peracetic acid
Liquid Immersion + + + + +
High-level Disinfection
Heat Automated – + + + +
Liquid Immersion Glutaraldehyde, phenolics, – + + + +
hydrogen peroxide, peracetic acid
52 A Guide to Infection Control in the Hospital
Intermediate-level Disinfection
Liquid Contact Chlorine compounds, phenolics – + + ± ±
Low-level Disinfection
Liquid Contact Chlorine compounds, phenolics, – – + ± ±
quaternary ammonium
compound, 70–90% alcohol
Modified from Rutala WA and Weber DJ. Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to Know. Clinical Infectious Diseases 2004; 39:702–9
In the case of a blood spill, use protective gloves prior to
discarding any sharps and cleaning visible blood with absor-
bent material. Following cleaning, disinfect the area with an
EPA-registered agent, specifically a germicide that is labeled
for use with human immunodeficiency virus (HIV) or hepa-
titis B virus (HBV), or freshly diluted sodium hypochlorite
solution.
Several potential strategies exist for monitoring compliance
and assessing environmental hygiene.
– Adenosine triphosphate (ATP) bioluminescence is a fast
and sensitive way to monitor effectiveness of cleaning and/
or to implement a modified cleaning regimen. Less than
500 relative light units (RLU) suggest that a surface is
clean. Some studies advocate that a more stringent cutoff
of 250 RLU should be used.
– Fluorescent markers (UV light) are a useful means of
assessing and providing feedback about the frequency that
high-touch surfaces are wiped by housekeeping. Complete
or partial removal of fluorescent markers during terminal
cleaning is correlated with less surface contamination.
Hard surface disinfection techniques include, but are not
limited to:
– Copper and copper alloy cladding, silver, and triclosan
products incorporated into hard surfaces. Copper technol-
ogy has potent antimicrobial activity and has shown prom-
ise in the reduction of health care associated infections.
Silver is known to have intrinsic antimicrobial activity.
No evidence of benefit from silver-based products has yet
been published. Triclosan has limited spectrum of antimi-
crobial activity and induces resistance over the long term,
making this product of limited use in the clinical setting.
– Quaternary ammonium salt surfactant coating. This may
be another promising technology, but its utility has yet to
be proven.
Several approaches to whole-room disinfection exist.
– UV light reduces bioburden of a wide spectrum of organ-
isms, including C. difficile spores. An issue with this
approach is that it only provides “line-of-site” killing and
does not penetrate fabrics well.
Disinfection 53
– Hydrogen peroxide vapor achieves rapid bactericidal
activity via the production of oxygen free radicals and is
extremely effective when used following bleach disinfec-
tion. This approach has been shown to be less effective at
reducing MRSA infection rates, but may be more effective
overall than UV light in eliminating aerobic bacteria from
surfaces.
– Titanium dioxide spray can be used on hard surfaces, soft
surfaces, and fabrics to provide a long-lasting biocidal
coating.
Special Circumstances
Creutzfeldt-Jakob disease (CJD) is a neurodegenerative
disorder caused by transmissible prions. It is incurable, uni-
versally fatal, and is resistant to most conventional disinfec-
tion and sterilization methods. Therefore, it is necessary to
have in place special procedures for decontaminating items
that possess a high risk of transmitting the disease. These
include critical items and semicritical items contaminated
with brain, spinal cord or eye tissue from patients known or
suspected to have infection with CJD. The current recom-
mended procedure is cleaning of the device and sterilization
using a combination of sodium hydroxide and autoclaving.
– Immerse the device in 1N NaOH for 1 hour, remove and
rinse with water, then transfer to an open pan for autoclav-
ing (for 18 minutes at 134ºC in a prevacuum sterilizer or
for 1 hour at 132ºC in a gravity displacement sterilizer).
In units with high rates of Clostridium difficile infection,
use 5.25%–6.15% sodium hypochlorite solution for routine
environmental disinfection.
Controversial Issues
It is unclear whether certain critical items (e.g. laparoscopes
and arthroscopes) require sterilization or high-level disinfec-
tion. Heat stable scopes should be steam sterilized. How-
ever, for items that cannot tolerate steam, sterilization with
ETO can be too time-consuming to be practical. There is
no good evidence that sterilizing all scopes improves patient
outcome.
54 A Guide to Infection Control in the Hospital
Surfaces can become contaminated with organisms, leading
to transmission between patients, either directly or via an
intermediate health care worker. However, routine disinfec-
tion of surfaces is controversial because they are considered
noncritical items (they touch only intact skin), and therefore
carry a very low risk of infection. Although data show that
the use of disinfectants lowers the microbial load on sur-
faces, evidence that this practice reduces rates of health care
associated infections is lacking.
Reuse of single use medical devices continues to be an
evolving area. Although it may be safe to reuse certain sin-
gle use items, concern remains about the possible risk of
infection with such practices. Currently, the Food and Drug
Administration (FDA), issue regulations for proper handling
of these items.
Summary
Medical and surgical devices and environmental surfaces can
be categorized according to their ability to transmit infection
into critical, semicritical, and noncritical items. Use of this cat-
egorization scheme helps determine the level of sterilization or
disinfection needed. In order to make an informed decision, it
is important to understand the pros and cons of each method.
Patient safety, cost, and effectiveness should all be taken into
account. Each institution should have protocols for cleaning,
sterilization and disinfection that are devised in conjunction
with the infection control practitioner, medical staff, nursing,
and housekeeping staff.
References
Cullen KA, Hall MJ, Golosinskiy A, Division of Healthcare Statistics.
Ambulatory Surgery in the United States, 2006. National Health Sta-
tistics Reports. 2009. 11.
Rutala WA, Weber DJ, and the Healthcare Infection Control Practices
Advisory Committee (HICPAC). Guideline for Disinfection and
Sterilization in Healthcare Facilities, 2008. http://www.cdc.gov/
hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf (Accessed 7
October 2013).
Rutala WA and Weber DJ. Disinfection and Sterilization in Health Care
Facilities: What Clinicians Need to Know. Clin Infect Dis. 2004.
39:702–9.
Disinfection 55
Rutala WA and Weber DJ. Disinfection, Sterilization, and Control of
Hospital Waste. Mandell: Mandell, Douglas, and Bennett’s Princi-
ples and Practice of Infectious Diseases (7th Edition), Philadelphia:
Churchill Livingstone Elsevier, 2009. Pgs. 3677–3695.
- 1. Review the package labeling and the manufacturer’s
- 2. If the manufacturer has not determined reprocessing
- 3. Establish a list of form and function criteria which the
- 4. Determine if you have the capability to demonstrate that the
- 5. Determine if you have the capability to demonstrate that the
- 6. Determine if reprocessing of this device is cost justified.
- 7. For each device, establish a testing protocol that identifies:
- 8. Review testing protocols/results with appropriate review
- 9. Determine the need for policies for pricing, informed
- 10. Periodically review the use and methods.
- 1. Have a procedure to ensure the destruction of pyrogens.
- 2. Start the cleaning and sterilization process as soon as
- 3. For angioplasty catheters it is essential to inspect the
- 2006. (www.nationalacademies.org).
- 1986. 7:561–563.
- McGregor M. The Reuse of Cardiac Pacemakers. Can J Cardiol 1992;
Sherlock O, O’connell N, Creamer E, Humphreys H. Is It Really Clean?
An evaluation of the efficacy of four methods for determining hospi-
tal cleanliness. J Hosp Infect. 2009. 72:140e146.
Moore G, Smyth D, Singleton J, Wilson P. The use of adenosine triphos-
phate bioluminescence to assess the efficacy of a modified cleaning
Program Implemented Within An Intensive Care Setting. Am J Infect
Control. 2010. 38:617–22.
Boyce JM, Havill NL, Dumigan DG, Golebiewski M, Balogun O, Riz-
vani R. Monitoring the Effectiveness of Hospital Cleaning Practices
by Use of an Adenosine Triphosphate Bioluminescence Assay. Infect
Control Hosp Epidemiol. 2009. 30:7.
Currie B. Revisiting environmental hygiene and hospital-acquired
infections. Infectious Disease Special Edition. September 2013, Vol-
ume 1.
Boyce JM, Havill NL, Havill HL, et al. Comparison of Fluorescent
Marker Systems with 2 Quantitative Methods of Assessing Terminal
Cleaning Practices. Infect Control Hosp Epidemiol. 2011. 32:12.
Havill NL, Moore BA, Boyce JM. Comparison of the microbiological
efficacy of hydrogen peroxide vapor and ultraviolet light processes
for room decontamination. Infect Control Hosp Epidemiol. 2012.
33:507–512.
56 A Guide to Infection Control in the Hospital
Chapter 11
The Healthcare Worker as a
Source of Transmission
Margreet C. Vos, MD, PhD
Key Issue
Within the hospital, healthcare workers (HCWs) are often
exposed to infections. Any transmissible disease can occur
in the hospital setting and may affect HCWs. HCWs are not
only at risk of acquiring infections but also of being a source of
infection to patients. Therefore, both the patient and the HCW
need to be protected from contracting or transmitting health
care associated infections by using recommended infection
control measures.
Known Facts
The infection control objectives of a hospital should be
planned by the infection control committee and occupa-
tional health services. The focus of the committee and ser-
vices must be personal hygiene, monitoring of carriage of
specific micro-organisms, monitoring of infectious disease
outbreaks and exposures and, after identifying infection
risks, institution of preventive measures.
Prevention of infectious diseases in HCWs serves three pur-
poses: the health of the healthcare worker, the prevention of
work restrictions, and the reduction of health care associated
infections. The latter is discussed in this chapter.
Education is an important factor for improving compliance
with guidelines and prevention measures. All HCWs need to
know about the risk of infection and the route of transmis-
sion of pathogens. Hand hygiene and standard precautions
are the foundation for preventing transmission of infectious
diseases to patients.
The Health Care Worker as a Source of Transmission 57
Immunization should be used to protect HCWs from spe-
cific infectious agents. Preventing infections in HCWs will
also prevent transmission of infections from HCWs to
patients. Prompt evaluation of and institution of appropri-
ate control measures for patients with signs and symptoms
of transmissible infectious diseases will reduce the risk of
health care associated diseases.
In deciding the type of infection control procedures needed,
one must consider the HCW’s job, risk of exposure, and the
suspected infectious pathogen.
A short overview of some of the most important infectious
diseases transmitted by HCWs is presented below.
General
In a recent review, 152 health care associated infection out-
breaks with a HCW as a source were identified. These outbreaks
were mainly associated with surgery, neonatology, and gynecol-
ogy departments. The most frequently encountered pathogens
were Hepatitis B virus, S. aureus and S. pyogenes.
In general, the most important infection prevention measure
is adequate hand hygiene. Hand disinfection as defined by the
WHO guidelines specify 5 moments of hand hygiene. In short
the patient during the same care sequence).
Skin Infections
Scabies. Scabies is transmitted by direct contact. In case of Nor-
wegian (crusted) scabies, transmission is also through fomites,
such as bed linens, floors, walls, furniture, clothes and the air.
Symptoms of intense pruritius can develop 2 to 6 weeks after
initial infestation. To prevent infection and to prevent a hospital
outbreak, a HCW with skin exposure should receive prophylactic
therapy, and to prevent re-infestation, the household contacts
58 A Guide to Infection Control in the Hospital
should be treated too. In case of scabies crustosa, contact persons
should be identified and should receive prophylactic treatment.
Contact patients are those who shared the room or were other-
wise direct or indirect exposed to skin scales. Contact health
care workers are those having cared for the patient without tak-
ing precautions measures. Immunocompromised patients have
a high chance of developing scabies crustosa, which is harder
to recognize compared to “local” scabies and more infectious.
Staphylococcus aureus. About one-third of the population are
persistent nasal carriers of S. aureus (SA), one-third are inter-
mittent carriers, and one-third are unaffected. Other sites of
colonization are the throat, perineum, skin, axilla, or hair. Peo-
ple with dermal lesions, such as eczema, are more likely to be
carriers. Carriers may spread SA to patients, especially patients
with wounds, intravascular catheters and other indwelling cath-
eters. Dissemination of SA is by direct or indirect contact or,
less commonly, by skin scales. Healthcare workers with active
lesions caused by SA such as boils (even on an occult body
area) or other skin lesions are more likely to transmit infection
to others than nasal carriers. HCW’s who are carriers of methi-
cillin resistant Staphylococcus aureus (MRSA) are a high risk to
patients, by transmitting MRSA from their skin, hands or nose
to wounds or mucosal surfaces. MRSA seems to spread more
easily than MSSA, probably due to selection during antibiot-
ic use and probably not due to the presence of other virulence
mechanisms in mecA positive micro-organisms.
During periods of high incidence of staphylococcal dis-
ease or epidemics of MRSA, identifying carriers by culturing
patients and HCWs is useful. Carriers can be treated with 2%
mupirocin ointment and disinfective soap washing. The opti-
mal strategy for identifying and decolonizing HCWs who carry
MRSA is unknown.
Group A Streptococcus. Group A Streptococcus (GAS) is a
well-known pathogen of the skin and pharynx. Other reservoirs
include the rectum and the female genital tract. Major modes of
transmission are direct contact and large droplets. An increased
incidence of wound infections by GAS should be investigated.
Particular focus should be placed on carriage by HCWs.
The Health Care Worker as a Source of Transmission 59
Healthcare workers with overt infection due to GAS should
be restricted from work until 24 hours after adequate therapy
has been given or until cultures are proven to be negative. Over-
all, the risk of transmission of GAS from HCW to patients is
considered low.
Herpes simplex. Herpes simplex type I can be transmitted from
HCWs to patients through primary or recurrent lesions. Most
infections are orofacial and transmitted by direct contact. Saliva
also can be infectious. Because the main route of transmission is
by contaminated hands after direct contact with the lesion, hand
washing and disinfection before and after patient contact are
the most important methods for preventing transmission to pa-
tients. Herpes simplex lesions of the fingers (herpetic whitlow)
are an occupational disease of HCWs due to direct exposure to
contaminated fluid such as vaginal secretions or skin lesions.
Healthcare workers with herpetic whitlow must use gloves to
prevent the spread of the herpes virus to patients. When caring
for patients at risk of severe infection, such as preterm neonates,
patients with severe malnutrition, severely burned, or immuno-
compromised patients, restriction of work of HCWs with herpes
infections should be considered.
Enteric Diseases
Accute Diarrhea. Transmission of most microorganisms caus-
ing diarrhea in HCWs is by direct or indirect contact. Careful
hand washing hygiene, especially after visiting the bathroom,
is the most important measure for preventing transmission of
these pathogens. Until symptoms are resolved, healthcare work-
ers with acute infectious diarrhea should not care for patients.
Even after resolution of the acute disease, HCWs may still carry
enteric pathogens.
HCWs can be asymptomatic carriers of Salmonella spp or
Campylobacter spp during the convalescent period or a pro-
tracted period thereafter. Testing for carriage may be unreliable
and is therefore usually limited to food handlers, who are more
likely to transmit disease to others. Careful hand washing after
using the bathroom and before patient contact will prevent the
transmission of enteric pathogens from most carriers. Antibiotic
treatment is rarely indicated.
60 A Guide to Infection Control in the Hospital
In case of norovirus, HCWs can be an important link in
hospital outbreaks: infected HCWs may be asymptomatic upon
arrival at work, get ill suddenly and consequently spread the
virus by vomiting. On the other hand, they can be infected by
patients. Patients should be isolated, HCWs should be sent
home in the event that they manifest active disease. The advent
of PCR testing makes the diagnosis of norovirus more feasible.
During an outbreak of norovirus, hand hygiene with soap and
water is preferable to alcohol based hand sanitizers.
Hepatitis A. Hepatitis A occurs rather infrequently as a health
care associated infection. Prevention of transmission is through
maintaining personal hygiene, especially through hand wash-
ing.
Respiratory Diseases
Common Cold. The common cold in adults is caused by the para-
influenza virus, adenovirus, rhinovirus, or respiratory syncytial
virus. Healthcare workers are important sources of these viruses
to patients. In general, to prevent health care associated trans-
mission from HCWs to patients, infected HCWs should wash or
disinfect their hands carefully before patient contact. The use of
masks is optional but may be helpful in preventing transmission
due to large droplets upon close contact. Routine use of gloves
has no additional benefit; even if gloves are used, hands should
be disinfected or washed after gloves are removed. In most peo-
ple, viral upper respiratory infections are self-limiting. Howev-
er, in immunocompromised patients, such as recipients of bone
marrow transplants, these infections may progress to severe
lower respiratory tract diseases with very high mortality rates.
Infection control strategies include identifying, cohorting, and
isolating of infected patients and limiting contact of symptomat-
ic HCWs and visitors with high risk patients. Work restrictions
for symptomatic HCWs may be considered, especially when
working with immunocompromised patients. HCWs with upper
respiratory infections and fever should generally consider stay-
ing home from work.
Influenza. Influenza epidemics are well known in hospitals.
Transmission occurs from HCWs to other HCWs and patients,
The Health Care Worker as a Source of Transmission 61
and from patients to HCWs and other patients. Hospital infection
control committees should implement an influenza vaccination
- this comprises;
- 1. Before touching a patient.
- 2. Before aseptic/clean procedure.
- 3. After body fluid exposure risk.
- 4. After touching a patient.
- 5. After touching patient surroundings (without touching
Program Each Year, Several Weeks Before The Influenza Season.
There is evidence that vaccination is associated with decreases
in mortality, the number of febrile respiratory illness days and
HCW absenteeism. During periods of influenza activity, person-
nel with acute febrile respiratory infections should not provide
care to high-risk patients. The incubation period is 1 day before
onset of symptoms and the period of communicability is from
1 day before until 7 day after onset of symptoms. Additional-
ly, prophylactic antiviral agents may be used. Hospitals should
have written guidelines for avian and pandemic influenza.
Pertussis. Vaccination of adults with whole-cell B. pertussis
vaccine is not recommended because of local and systemic reac-
tions. The acellular vaccine has been used for attempted control
of hospital pertussis outbreaks but clinical effectiveness has not
been proven. Active disease in HCWs should trigger a search
for potentially exposed patients. Infection prevention measures
should be taken. These include giving prophylactic antibiotic
treatment to exposed neonates with low or negative IgG levels
as these patients are at high risk for developing severe pertussis.
Varicella Zoster. Varicella zoster virus causes varicella or chick-
enpox in childhood. After years, due to reactivation, the virus
can manifest as skin lesions (zoster or shingles), which may be
widely disseminated in immunocompromised patients. Those
lesions can be infectious to others through direct contact and
cause varicella in susceptible persons.
Varicella is one of the most common health care associated
diseases among HCWs. It is a highly contagious disease, and
exposure to the virus is common in the healthcare setting. Most
persons with a clear history of chickenpox in childhood are prob-
ably immune. Persons with a negative history can be immune
but should be tested. Susceptible HCWs may acquire infec-
tion after exposure to infectious patients. Non-immune HCWs
exposed to varicella should be excluded from work from day
8 to 21 after contact, to ensure that infection has not occurred.
If the HCW develops disease, he/she should be excluded from
work until all lesions are dry and crusty. Since such a policy
62 A Guide to Infection Control in the Hospital
regarding work restriction is very expensive, vaccination of all
susceptible workers should be done. A live-attenuated varicella
vaccine was licensed for use in several, but not in all countries.
Vaccination provides approximately 70% protection against
infection and 95% protection against severe disease for 7 to 10
years after vaccination. Vaccination of HCW’s is proven to be
cost-effective.
Measles. Measles is transmitted by the airborne route. The same
strategy as has been recommended for varicella-susceptible
HCWs can be followed for susceptible HCWs exposed to mea-
sles. Prompt identification of HCWs and patients with rash and
fever will help prevent further spread of this virus.
Tuberculosis. The infection Control Committee should indicate
high-risk wards, were HCW’s are routinely screened on tuber-
culosis. After conversion of the Mantoux test, or positive other
newly developed screening tests (IGRA),prophylactic treatment
is indicated to prevent open tuberculosis which is contagious
for patients. Furthermore, all HCWs reporting symptoms sug-
gestive of tuberculosis should have a medical examination and
a chest radiograph. Suggestive symptoms are cough for more
than 3 weeks, persistent fever, and weight loss. After identifying
an HCW suffering from open tuberculosis, a prompt evaluation
of all contacts must be instituted. Stringent measures regarding
work restrictions are necessary. Healthcare workers should be
receiving effective treatment and have negative sputum smears
before returning to work. Bacille Calmette-Guérin (BCG) vac-
cination should be considered for all tuberculin skin test nega-
tive HCWs, unless previously vaccinated, in countries where
tuberculosis is endemic or in hospitals where exposure to infec-
tious TB cases is likely.
Bloodborne Pathogens
The management of HCWs infected with bloodborne pathogens
has been reviewed by the AIDS/TB committee of the Society
for Healthcare Epidemiology of America (SHEA). Recently, an
updated CDC recommendation for the management of hepatitis
B virus-infected Health-care providers and students was pub-
lished. In general, prevention of infection is based on appropriate
The Health Care Worker as a Source of Transmission 63
infection control procedures to avoid blood contact from patient
to HCW and from HCW to patient. The major emphasis is on
applying blood precautions, practicing hand washing, minimiz-
ing contact with blood or blood-contaminated excretions, and
handling all blood as potentially infectious. Education concern-
ing bloodborne pathogens for all healthcare workers is recom-
mended, not just those who are already infected.
Hepatitis B. Immunization with the hepatitis B virus (HBV)
vaccine is the most important measure to prevent infection of
the HCW by HBV. Each hospital must develop an immuniza-
tion strategy. Healthcare workers with active HBV or those who
are carriers of HBV are at risk for transmitting HBV to others.
The risk of transmission of HBV is higher than that of the hep-
atitis C virus or human immunodeficiency virus, as is reflected
in 38 outbreaks of HBV by HCW-to-patient transmission in the
past 22 years.
Vaginal hysterectomy, major pelvic surgery, and cardiac
surgery are associated with HBV transmission despite the use
of proper infection control measures. With these surgeries, the
chances of needle-stick injuries are presumably greater. Before
increased use of infection control interventions, the risk of HBV
transmission was also associated with dental procedures. The
presence of high numbers of HBV-DNA copies in source HCW
is almost always the case. Another route of transmission can
be by hepatitis B positive HCWs with exudative dermatitis on
body areas that may come in contact with patients.
Restricting HCWs from practice of gynecologic or (car-
diac) surgery or performing dental procedures should be not
be judged by the presence of a HBV infection only.The risk of
transmission should be carefully established and monitored.The
risk of transmission to patients, despite appropriate use of infec-
tion control measures, depends on the procedures performed
and the levels of HBV-DNA. Treatment of the HBV infection
can possibly decrease the number of copies of HBV-DNA
below critical levels. Defined critical levels of the HBV-DNA
varies between countries. For HBV positive HCWs who per-
form exposure-prone procedures, an expert panel should pro-
vide oversight of the HCWs practice and risk of transmission.
64 A Guide to Infection Control in the Hospital
Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV).
The risk of transmission of HIV is probably 100 times lower
than hepatitis B, with that of HCV being somewhere between
HIV and HBV. Healthcare workers known to be infected with
HIV or HCV are strongly recommended to follow universal
precautions as recommended in their hospital to minimize the
risk of infection to others. Using double gloves for procedures
is recommended. HIV- and HCV-infected HCWs should not be
prohibited from patient care activities solely on the basis of their
infection. Healthcare workers need not be screened routinely
for HIV or HCV infection, except in cases of significant expo-
sure of a patient to the blood or body fluid of an HCW.
AIDS. Healthcare workers infected with HIV can be infected
with HIV-associated pathogens. In turn, these pathogens can
be transmissible to patients. Examples are Mycobacterium
tuberculosis, varicella zoster, and measles by aerogenic spread
and Salmonella spp, Cryptosporidium spp, and all other enteric
pathogens via fecal-oral exposure. For prevention of transmis-
sion, see the relevant part of this chapter.
Vaccine-Preventable Diseases
Healthcare workers may be exposed to vaccine-preventable dis-
eases and then, after contracting the disease, be infectious to
patients. It is recommended that HCWs be vaccinated or have
demonstrated immunity to certain vaccine-preventable dis-
eases. The infection control committee of each hospital has to
develop policies requiring proof of immunity or, if needed, offer
vaccination. Herd immunity of the hospital community is not
reliable and unvaccinated HCWs are a potential risk to patients.
For HCW’s, the following diseases are vaccine-preventable and
can be transmitted to patients during healthcare work; varicella,
measles, pertussis, influenza A, hepatitis B, hepatitis A and to
some extent tuberculosis.
The Health Care Worker as a Source of Transmission 65
Table 11.1 Work Restrictions for Healthcare Workers with
Transmissible Infections
Immunization Work or Patient
Available Contact Restriction =
Scabies – Until cleared by medical evaluation
S. aureus – Actively draining lesion
Proven transmission
With search-and-destroy strategies,
MRSA carrier should be restricted
until successfully treated
Group A Streptococcus – Until 24 hours adequate therapy, or
proven negative cultures
Herpes simplex – In case of whitlow and caring for
immunocompromised patients
including neonates
Hepatitis A + Until 7 days after onset of jaundice
Common cold viruses – Consider contact restriction with high-risk
(see text) patients (e.g., bone marrow transplants)
Influenza + Consider contact restriction with high-risk
patients (e.g., bone marrow transplants)
Varicella + In case of active disease, postexposure
in susceptible persons: day 8–21
Pertussis + In case of active disease
Measles + In case of active diseases, postexposure
in susceptible persons: day 5–21
Tuberculosis + In case of active disease
HBV + Refer to local regulations: restriction
from high-risk procedures.
HCV – –
HIV – Refer to local regulations
66 A Guide to Infection Control in the Hospital
References
Bell D, Shapiro CN, Chamberland ME, Ciesielski CA. Prevent-
ing Bloodborne Pathogen Transmission from Healthcare Work-
ers to Patients: The CDC Perspective. Surg Clin North Am. 1995.
75:1189–1203.
Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN,
Deitchmann SD, et al. Guideline for Infection Control in Healthcare
Personnel, 1998. Infect Control Hosp Epidemiol. 1998. 189:407–463.
Centers for Disease Control and Prevention. Immunization of Health
care Workers: Recommendations of the Advisory Committee on
Immunization Practices (ACIP) and the Hospital Infections Con-
trol Practices Advisory Committee (HICPAC). MMWR. 1997.
46(RR-18):1–42.
Chandler RE, Lee LE, Townes JM, Taplitz RA.Transmission of Group
A Streptococcus Limited to Healthcare Workers with Exposure
in the Operating Room. Infect Control Hosp Epidemiol. November
Danzmann L, Gastmeier P, Schwab F, Vonberg R-P. Health care work-
ers causing large nosocomial outbreaks: A systematic review. BMC
Infectious Diseases. 2013. 13:98.
Kuehnert MJ, Cardo DM, Infections Associated with Healthcare Per-
sonnel: Vaccine-Preventable Diseases and Bloodborne Pathogens.
Curr Infect Dis Rep. December 2000. 2(6):475–483.
Ofner-Agostini M, Gravel D, McDonald LC, et al. A Cluster of Cases
of Severe Acute Respiratory Syndrome Among Toronto Healthcare
Workers After Implementation of Infection Control Precautions: A
Case Series. Infect Control Hosp Epidemiol. May 2006. 27(5):473–8.
Shefer L, Dales L, Nelson M, et al. Use and Safety of Acellular Pertussis
Vaccine Among Adult Hospital Staff During an Outbreak of Pertus-
sis. J Inf Dis. 1995. 171:1053–1056.
WHO Guidelines on Hand Hygiene in Health Care. http://whqlibdoc.
who.int/publications/2009/9789241597906_eng.pdf
Updated CDC Recommendations for the Management of Hepati-
tis B Virus–Infected Health-Care Providers and Students. MMWR
Recomm Rep. July 2012. 61(3).
The Health Care Worker as a Source of Transmission 67
- 2006. 27(11):1159–63.
Chapter 12
Managing Antibiotic Resistance:
What Works in the Hospital
Amy L. Pakyz, PharmD, MS and
Denise K. Lowe, PharmD, BCPS
Key Issue
Over the past several decades the incidence of antibiotic resis-
tance by microorganisms has increased and transmission of
these resistant microorganisms between hospitalized patients
has been reported. Antibiotic resistance in the hospital impacts
patient outcomes as well as healthcare-related costs.
Known Facts
Antibiotic resistance is more common in hospitalized set-
tings, primarily in intensive care units, although use of
antibiotics in the community setting is often the origin of
hospital antibiotic resistance.
Nearly all microorganisms have displayed clinically import-
ant resistance to antibiotics. Mechanisms for resistance
include genetic transmission (conjugation, transformation,
and transduction) and biological modalities (destruction,
transformation, active efflux, and receptor modification).
Resistance to antibiotics can be classified as intrinsic or
acquired, and can be transmitted vertically or horizontally,
with horizontal transmission being the most significant
means for emergence and spread.
Indiscriminate use of antibiotics is a major factor in promot-
ing antimicrobial resistance. Other factors that contribute
to the entry of resistant pathogens into hospitals include:
the transfer of patients with resistant pathogens from other
healthcare facilities; patient-to-patient transmission of
pathogens via the hands of healthcare workers; transfer of
resistant genes among organisms.
68 A Guide to Infection Control in the Hospital
In 2013, the Centers for Disease Control and Prevention
(CDC) categorized microorganisms that pose the greatest
antimicrobial resistance threats to public health into three
threat groups:
– Urgent: Clostridium difficile, Carbapenem-resistant
Enterobacteriaceae (CRE), Drug-resistant Neisseria
gonorrhoeae.
– Serious: Drug-resistant Acinetobacter, Drug-resistant
Campylobacter, Fluconazole-resistant Candida, Extend-
ed-spectrum, cephalosporin-resistant Enterobacteriaceae,
Vancomycin resistant Enterococcus (VRE), Drug-resistant
Pseudomonas aeruginosa, Drug-resistant nontyphoidal-
Salmonella, Drug-resistant Salmonella typhi, Drug-resis-
tant Shigella, Methicillin resistant Staphylococcus aureus
(MRSA), Drug-resistant Streptococcus pneumoniae,
Drug-resistant tuberculosis (multiple drug resistant and
extensively drug resistant).
– Concerning: Vancomycin-resistant Staphylococcus aureus
(VRSA), Erythromycin-resistant Streptococcus Group A,
Clindamycin-resistant Streptococcus Group B.
Worldwide, there are problems with methicillin resistant
Staphylococcus aureus—both health care associated MRSA
and Community-associated MRSA (CA-MRSA).
The explosion of infections with vancomycin-resistant
Enterococcus faecium in US hospitals has been remarkable.
Much lower rates have been reported from Europe.
Resistance of gram-negative rods to quinolones and third
generation cephalosporins continues to increase.
Micorbial strains resistant to Ceftriaxone are called ESBLs
because they carry extended spectrum βeta Lactamases
enabling the bacteria to resist most βeta Lactam antibiotics.
These bacteria are usually susceptible to carbapenems such
as imipenem and meropenem.
With the increased use of carbapenems has been the emer-
gence of bacteria harboring carbapenemases, βeta lact-
amases that inactivate imipenem and meropenem. These
strains are susceptible only to colistin.
The emergence of S.aureus with intermediate levels of resis-
tance to vancomycin (VISA) has been reported in several
Managing Antibiotic Resistance: What Works in the Hospital 69
countries. These strains have MICs of 8μg/mL. In 2002, two
strains of S.aureus with high levels of resistance to vanco-
mycin (VRSA) were reported in the U.S. These strains have
MICs ≥32 μg/mL. As of October 2013, 13 patients in the
U.S. have been identified with infections due to VRSA.
The burden of antimicrobial resistance includes increased
patient-related morbidity and mortality and higher health-
care costs.
Adoption of new strategies designed to delay or prevent
resistance is crucial since the introduction of new antimicro-
bial drugs into the market has substantially declined.
Antimicrobial stewardship and infection prevention and
control programs are the two key initiatives employed in
combating the emergence and transmission of antibiotic
resistance.
Controversial Issues
The causes of antibiotic resistance in the hospital setting
are not clearly known. The unnecessary use of antibiotics is
important. Such high antibiotic use leads to the selection of
resistant organisms. Once patients are colonized or infected
with a resistant organism, the risk of cross transmission to
other patients exists. The initiating problem is the selection
of a resistant isolate under the “pressure” of antibiotic usage.
More research is needed to best define specific infection pre-
vention practices and strategies to limit or halt the transmis-
sion of multidrug-resistant organisms.
The optimal duration of contact precautions for patients
infected or colonized with multidrug-resistant organisms has
not been established.
The optimal circumstances and populations for the employ-
ment of active surveillance cultures as an infection preven-
tion strategy are unknown.
The adoption of a “bare below the elbows” (BBE) policy
has occurred in many hospitals in the UK and North Amer-
ica. Although these strategies are based on common sense, it
remains unknown if this practice reduces the transmission of
resistant microorganism.
70 A Guide to Infection Control in the Hospital
Formulary restrictions and pre-authorizations are methods
often applied to broad-spectrum antibiotics and those anti-
biotics associated with rapid resistance.
– Results of clinical trials have not demonstrated a reduction
in the overall emergence of antibiotic resistance among
bacteria when restrictions or pre-authorizations have been
utilized. Rather, the introduction of new or different anti-
biotic-resistant bacterial strains within the hospital setting
has been reported.
– Use of restrictions and pre-authorizations has been suc-
cessful in specific outbreaks of infection with antibiotic-re-
sistant bacteria, particularly in conjunction with infection
control practice and educational activities.
Suggested Practice
Judicious Use of Antimicrobials
The Infectious Diseases Society of America and the Society for
Healthcare Epidemiology of America developed a guideline
document entitled: Guidelines for Developing an Institutional
Program To Enhance Antimicrobial Stewardship.
Hospitals are encouraged to implement a multidisciplinary
antimicrobial stewardship team that includes among its core
members an infectious diseases physician and clinical pharma-
cist with infectious diseases training. Other important members
of this team include a hospital epidemiologist, a clinical micro-
biologist, an information system specialist, and infection con-
trol professional.
Key Strategies: Antimicrobial Selection and Utilization
The following are recommended core strategies:
Prospective audit with intervention and feedback
– Prospective evaluation of antimicrobial use with direct
feedback to the prescriber.
Antimicrobial formulary restriction/preauthorization
– Evaluate antimicrobials for inclusion on hospital
formulary and restrict their use through formulary
limitation or required preauthorization/justification.
Managing Antibiotic Resistance: What Works in the Hospital 71
The following are recommended elements of an antimicrobial
stewardship program depending on an institution’s resources,
local antimicrobial use, and antimicrobial resistance problems:
Education
Guidelines and clinical pathways
Antimicrobial order forms
Streamlining or de-escalation of therapy
Dose optimization
Parenteral to oral conversion
Infection Prevention and Control Program:
The transmission and endurance of a problem pathogen in a
healthcare institution depends on the patient base, selective
pressure from antimicrobial use, and the number of patients col-
onized or infected with the problem pathogen.
A combination of interventions may need to be employed to
prevent and control the spread of problem pathogens. Types of
interventions used by institutions may vary depending on the
types and significance of problem pathogens, the population of
the institution, and available resources.
The Healthcare Infection Control Practices Advisory Com-
mittee (HICPAC) developed a guideline document concerning
the management of multi-drug resistant organisms in healthcare
settings.
In addition to following Standard Precautions for all patient
encounters, the following are some recommended strategies:
Improvements in hand hygiene,
Use of Contact Precautions in patients with a multidrug-
resistant organism until patients are culture-negative,
Active surveillance cultures,
Education,
Enhanced environmental cleaning,
Cohorting of patients,
Decolonization, and
Improvements in communication regarding patients
with multidrug-resistant organisms between healthcare
institutions.
72 A Guide to Infection Control in the Hospital
Key components of every antimicrobial stewardship and
infection prevention and control programs include:
Administrative support
– Seek and acquire the support of hospital administration and
medical staff leadership for fiscal and human resources.
Ongoing surveillance on a regular interval
– Measure antimicrobial use and track use,
– Monitor and track antimicrobial resistance trends (anti-
biograms) and newly emerging problem pathogens,
– Measure the effectiveness of interventions.
Education/Feedback
– Provide educational interventions and training to medical
care providers,
– Disseminate information about program outcomes.
Additional Preventive Practices:
Guidelines for preventive practices are also included in the
Center for Disease Prevention and Control’s Campaign to
Reduce Antimicrobial Resistance in Healthcare Settings.
This evidence-based 12-step initiative focuses on four
overall strategies to guide clinicians in an effort to prevent the
emergence of drug resistance in hospitals:
Prevent infection
– vaccinate (protect)
– remove indwelling lines
Diagnose and treat infection effectively
– target the pathogen
– consult with the experts
Use antimicrobials wisely
– practice antimicrobial control
– use local data
– treat infection not colonization
– treat infection not contamination
– know when to say “no” to vancomycin
– stop treatment when infection is cured or unlikely
Prevent transmission
– isolate the pathogen
– break the chain of contagion
Managing Antibiotic Resistance: What Works in the Hospital 73
The 12 steps can be tailored to specific hospital populations,
e.g., dialysis, surgery, and emergency, critical and long-term care.
Promoting and practicing antibiotics stewardship can also
involve the use of biomarkers for infection to reduce unnec-
essary use of antibiotics, and selection of the optimal type,
dose and duration of therapy. Procalcitonin has been used suc-
cessfully as a diagnostic and prognostic tool in various patient
populations.Intravenous to oral switch reduces risk of cathe-
ter-associated infections and facilitates patient discharge. Inap-
propriate and unnecessary antibiotics use increases mortality
whereas shorter-term treatment may limit the occurrence of
negative patient outcomes.
Traditional techniques for the detection of pathogenic micro-
organisms that involve selective culturing and plating methods
are both time-consuming and labor-intensive. Newer techniques
provide rapid, selective and sensitive diagnostic tools, which
can also be employed to identify uncultivable pathogens. The
polymerase chain reaction (PCR) method is used for the selec-
tive and quantitative detection of single microbes, or simultane-
ous detection of multiple strains. Optical and electrochemical
biosensory methods also provide enhanced detection of patho-
gens, and current techniques are being developed for on-site
analysis. Other analytical detection methods include metabolic
footprinting—the analysis of a microorganism’s extracellular
metabolites, which discriminates between mutated strains based
on distinct metabolic phenotypes.
Other targeted interventions to minimize preventable infec-
tions include use of chlorhexidine-containing products for cath-
eter insertions, mechanical ventilation (MV) and (pre-surgical)
decolonization. These strategies have shown to significantly
reduce the risk for infections with non-resistant and resistant
pathogens.
Summary
Antibiotic resistance is increasing worldwide, and is associated
with severe morbidity, mortality, and increased healthcare-
related costs. A collaborative practice approach between
clinicians, public health practitioners, and administrators needs
to be implemented to help manage this serious infectious
disease issue.
74 A Guide to Infection Control in the Hospital
References
U.S. Department of Health and Human Services, Center for Disease
Control and Prevention: Antibiotic Resistance Threats in the United
States, 2013. http://www.cdc.gov/drugresistance/threat-report-2013/
pdf/ar-threats-2013-508.pdf (Accessed 3 October 2013).
Maki DG, Safdar N, et al. Antimicrobial resistance: Waking up to the
challenge supplement: prevalence, consequences, and solutions.
Pharmacotherapy. 2007. 27:121S–125S.
Wenzel RP, Edmond MB. Managing antibiotic resistance. N Engl J
Med. 2000. 343:1961–3.
Rybak MJ. Antimicrobial Resistance: Waking up to the challenge
supplement: antimicrobial stewardship. Pharmacotherapy. 2007.
27:131S–135S.
Dellit TH, Owens RC, et al. Infectious Diseases Society of America and
the Society for Healthcare Epidemiology of America Guidelines for
developing an institutional program to enhance antimicrobial stew-
ardship. Clin Infect Dis. 2007. 44(2):159–177.
Siegel, JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare
Infection Control Practices Advisory Committee: Management of
Multidrug-Resistant Organisms in Healthcare Settings. 2006. http://
www.cdc.gov/hicpac/mdro/mdro_0.html (Accessed 13 October 2013).
Spellberg B, Powers JH, et al. Trends in antimicrobial drug development:
Implications for the future. Clin Infect Dis. 2004. 38(9):1279–1286.
Stelfox HT, Bates DW, et al. Safety of patients isolated for infection
control. JAMA. 2002. 290:1899–1905.
Burger A, Wijewardena C, Clayson S, et al. Bare below the elbows:
Does this policy affect handwashing efficacy and reduce bacterial
colonization? Ann R. Coll Surg Engl. 2011. 93(1):13–16.
Centers for Diseases Control and Prevention. Get Smart for Healthcare.
http://www.cdc.gov/drugresistance/healthcare/ha/12steps_HA.htm
(Accessed 11 October 2013).
Schuetz P, Muller B, et al. Procalcitonin to guide initiation and duration
of antibiotic treatment in acute respiratory infections: an individual
patient data meta-Analysis. Clin Infect Dis. 2012. 55(5):651–62.
Magrini L, Travaglino F, et al. Procalcitonin variations after emergency
department admission are highly predictive of hospital mortality in
patients with acute infectious diseases. Eur Rev Med Pharmacol Sci.
Hohn A, Schroeder S, et al. Procalcitonin-guided algorithm to reduce
length of antibiotic therapy in patients with severe sepsis and septic
shock. BMC Infect Dis. 2013. 13:158–67.
Arnold HM, Micek ST, et al. Antibiotic stewardship in the intensive
care unit. Semin Respir Crit Care Med. 2011. 32(2):215–27.
Chastre J, Wolff M, et al. Comparison of 8 days versus 15 days of anti-
biotic therapy for ventilator-associated pneumonia in adults: A rand-
omized trial. JAMA. 2003. 290(19):2588–98.
Managing Antibiotic Resistance: What Works in the Hospital 75
Sandberg T, Skoog G, et al. Ciprofloxacin for 7 days versus 14 days
in women with acute pyelonephritis: A randomized, open-label and
double-blind,placebo-controlled, non-inferiority trial. Lancet. 2012.
380(9840):484–90.
Peltola H, Pääkkönen M, et al. Short- versus long-term antimicrobial
treatment for acute hematogenous osteomyelitis of childhood: Pro-
spective, randomized trial on 131 culture-positive cases. Pediatr
Infect Dis J. 2010. 29(12):1123–8.
el Moussaoui R, de Borgie CA, et al. Effectiveness of discontinuing
antibiotic treatment after three days versus eight days in mild to mod-
erate-severe community acquired pneumonia: Randomized, double
blind study. BMJ. 2006. 332(7554):1355.
Rodríguez-Lázaro D, D’Agostino M, et al. Real-time PCR-based meth-
ods for detection of Mycobacterium avium subsp. paratuberculosis in
water and milk. Int J Food Microbiol. 2005. 101(1):93–104.
Caliendo AM. Multiplex PCR and emerging technologies for the
detection of respiratory pathogens. Clin Infect Dis. 2011. 52(Suppl
4):S326–30.
Lazcka O, Del Campo FJ, et al. Pathogen detection: A perspective of
traditional methods and biosensors. Biosens Bioelectron. 2007.
22(7):1205–1217.
Skottrup PD, Nicolaisen M, et al. Towards on-site pathogen detec-
tion using antibody-based sensors. Biosens Bioelectron. 2008.
24(3):339–348.
Mapelli V, Olsson L, et al. Metabolic footprinting in microbiology:
Methods and applications in functional genomics and biotechnology.
Trends Biotechnol. 2008. 26(9):490–497.
Szeto SS, Reinke SN, et al. Mutations in the Saccharomyces cerevi-
siae succinate dehydrogenase result in distinct metabolic phenotypes
revealed through(1)H NMR-based metabolic footprinting. J Pro-
teome Res. 2010. 9(12):6729–6739.
Baran R, Bowen BP, et al. Metabolic footprinting of mutant libraries
to map metabolite utilization to genotype. ACS Chem Biol. 2013.
8(1):189–199.
U.S. Department of Health and Human Services. National Action
Plan to Prevent Healthcare-Associated Infections: Roadmap to Elim-
ination. http://www.hhs.gov/ash/initiatives/hai/exec_summary.html
(Accessed 13 October 2013).
Climo MW, Yokoe DS, et al. Effect of daily chlorhexidine bathing on
hospital-acquired infection. N Engl J Med. 2013. 368(6):533–542.
Zhang TT, Tang SS, et al. The effectiveness of different concentrations
of chlorhexidine for prevention of ventilator-associated pneumonia:
a meta-analysis. J Clin Nurs. 2013.
Afonso E, Llaurado M, et al. The value of chlorhexidinegluconate wipes
and prepacked washcloths to prevent the spread of pathogens—a sys-
tematic review. Aust Crit Care. 2013.
76 A Guide to Infection Control in the Hospital
- 2013. (Suppl 1):133–42.
Chapter 13
Organizing and Recording Problems
Including Epidemics
Samuel Ponce de León, MD, MSc and
Alejandro E. Macias, MD, MSc
Key Issue
Surveillance is the foundation for organizing and maintaining
an infection control program.
Known Facts
Reviewing patient records, interviewing nurses and physi-
cians, and reviewing microbiology results give the infection
control team an accurate view of the frequency and type of
infections associated with health care. At the same time, these
activities give the infection control team or nurse a highly
visible profile to all services and personnel, which helps to
promote continuous improvement. Recently, surveillance
monitors also the compliance with components of prevention
bundles, such as hand hygiene, proper insertion and opportune
withdrawal of devices, proper antisepsis, or bed inclination.
Surveillance is the central activity from which all other related
actions are sustained. Passive surveillance is not an accurate
or effective method of infection control; surveillance must be
active and continuous, in some cases focused on the highest
risk areas. The extent (focal or hospital-wide surveillance) of
this activity depends on hospital needs and resources.
There being no other way to detect an epidemic in the earli-
est stage, frequently visiting the clinical units and the clini-
cal laboratory allows for the early detection of outbreaks and
provides information necessary to maintain the functioning
of the overall program. The system ideally should detect two
or three associated cases as soon as they appear and not after
several cases or deaths have occurred.
Organizing and Recording Problems Including Epidemics 77
Reporting surveillance results is an essential element for an
effective infection control program. Reports to clinical ser-
vices must be regular, periodic, and presented in a non-an-
tagonistic way to encourage change. For infection control
activities to succeed, the program must include personnel
dedicated exclusively to surveillance.
For benchmarking against systems such as the National
Healthcare Safety Network (NHSN) or other networks, the
numerators of the rates focus usually on major device-as-
sociated infections (central line-associated blood stream
infection, ventilator-associated pneumonia, and catheter-as-
sociated urinary tract infection) and those associated with
procedures (wound infection and postoperative pneumonia).
Denominators constituted by the numbers of discharged
patients are inadequate to compare between institutions.
Proper denominators are one thousand days of device use or
one hundred procedures. Other surveillance reports can be
the rate of hand hygiene compliance, the bacterial resistance,
or the Clostridium difficile-associated diarrhea.
The frequency of health care associated epidemics in devel-
oping countries is higher than those reported in the United
States. This problem can be particularly severe in intensive
care units because:
sive devices used without organized procedures and
eters, hemodialysis filters, and even needles, a practice
attributed to financial limitations; and
care.
In developing countries, neonatal intensive care units have
the highest risk for epidemics, most commonly caused by
blood stream infections due to contamination of intravascu-
lar lines or infusates. These risks occur due to poor standards
of care that should be avoided, such as inappropriate han-
dling and storage of multiple vials for small doses of med-
ications, use of glucose infusions that remain open in use
during hours, and lack of hand hygiene in an overcrowded
78 A Guide to Infection Control in the Hospital
and badly designed unit with a shortage of personnel.
A common practice when confronting an epidemic is to
close the unit and fumigate the area instead of following
infection control recommendations. This approach is costly
and inefficient.
Hospitals without microbiology laboratory must make every
effort to have one to perform, at least, critical cultures such
as blood cultures.
When confronting an outbreak of health care associated
infection, reports in the literature are a valuable resource for
preparing investigation and control.
The organization of an infection control program in a hos-
pital with very limited resources requires determination and
good relations with the clinical staff.
Because cutting costs is a constant goal for most hospitals,
explaining the benefits of infection control procedures will
help gain support for the program. It is worthwhile to calcu-
late the savings and the implicit improvements in quality of
care derived from the program.
Maintain good channels of communication. The authorities
must feel and know that the program is solving problems
instead of creating them. The attitude of the infection control
group should be optimistic and creative; there is always the
possibility of improvement, even if the level that you reach
is not the same as the one reported by others.
Controversial Issues
Definitions of health care associated infections may be con-
troversial. Definitions must be understood as tools for sur-
veillance and will not always concur with the clinician’s
view. For example, a patient with fever for a few hours and
positive blood and catheter tip cultures for Staphylococcus
epidermidis should be recorded as an infection associated
with health care even if the clinician does not prescribe spe-
cific treatment and the fever disappears by withdrawing the
line. On the other hand, clinicians tend to diagnose pneumo-
nia more liberally than infection control personnel.
Definitions must be simple and meet hospital purposes. Hos-
pitals without microbiology support can develop definitions
Organizing and Recording Problems Including Epidemics 79
based exclusively on clinical data. The Pan-American
Health Organization (PAHO) has published a booklet with
clinical definitions. The definitions proposed by Wenzel may
be useful for hospitals with limited resources.
General Recommendations for Surveillance
Surveillance must be based on practical definitions.
Surveillance must be continuous on wards and the microbi-
ology laboratory.
For every instance of suspected health care associated infec-
tion forms should be filled out recording diagnosis, age,
ward, dates of admission and discharge, outcome, type of
infection, and etiologic agent.
Monthly results of surveillance should be reported to the
clinical services in a simple format and the results presented
at the infection control meeting. Decisions to improve infec-
tion control need to be discussed and implemented. For
benchmarking, denominators must be constituted by one
thousand days of device use or one hundred procedures.
General Recommendations in Epidemics
An epidemic is an infection control emergency; measures
should be taken as soon as an epidemic is suspected.
The first step in controlling an epidemic is to reinforce and
monitor general recommendations of infection control in
the ward where the cases are occurring. A case definition is
made (e.g., Enterobacter cloacae bacteremia in neonates in
the neonatal intensive care unit) and then current case rates
are compared against previous rates (pre-epidemic period).
After reviewing cases, additional recommendations
should be given to the staff in order to prevent new cases.
From evidence, sound hypothesis must be established
to avoid wrong conclusions and unnecessary closure of
medical wards. Table 13.1 shows some examples of these
hypotheses.
Maintain frequent communication with the clinical staff in
the unit or ward involved and give them all relevant infor-
mation from your analysis.
80 A Guide to Infection Control in the Hospital
Table 13.1 Evidence-based Working Hypothesis to
Study and Control Common Hospital Outbreaks
Outbreak Working hypothesis
Gram-negative bacteremia in neonates Contaminated intravenous lines or infusates
Candidemia Contaminated parenteral nutrition solutions
Ventilator-associated pneumonia Contaminated respiratory equipment
Streptococcal surgical site infection Healthcare worker carrier of
Group A streptoccoccus
Tuberculosis Exposure to TB patient without
effective respiratory protection
Diarrhea in children Exposure to rotavirus (or other viruses)
without effective contact precautions
Diarrhea in adults Prolonged use of antibiotics and absence
of adequate source control
Multidrug-resistant Antibiotics used without supervision
Gram-negative infection
Summary
Hospital-wide surveillance is needed to start a program of infec-
tion control and to identify the highest-risk areas. There is a trend
to focus surveillance in high-risk areas, specifically intensive
care units, because of the efficiency for detecting the most severe
health care associated infections and outbreaks, as compared
against hospital-wide surveillance. However, for hospitals begin-
ning surveillance, it may be better to institute a hospital-wide
system in order to know the particular characteristics of the insti-
tution. This will also facilitate the collection of endemic rates in
every ward. With time, surveillance activities may be limited to
high-risk areas. Institutional reports of infections must be made
periodically to promote the elimination of health care associated
infections.
Control of epidemics requires a reinforcement of general
measures of infection control. The infection control team should
talk to the personnel on the wards, emphasizing and monitoring
hand washing, isolation practices, and stringent adherence to
procedural recommendations and to the components of preven-
tive bundles. Depending on the characteristics of the outbreak,
specific recommendations must be given (see Table 13.1).
Organizing and Recording Problems Including Epidemics 81
References
Chitnis AS, Edwards JR, Ricks PM, Sievert DM, Fridkin SK, Gould
CV. Device-associated infection rates, device utilization, and antimi-
crobial resistance in long-term acute care hospitals reporting to the
National Healthcare Safety Network, 2010. Infect Control Hosp Epi-
demiol. 2012. 33:993–1000.
Gastmeier P, Stamm-Balderjahn S, Hansen S, Nitzschke-Tiemann F,
Zuschneid I, Groeneberg K, Rüden H. How Outbreaks Can Contrib-
ute to Prevention of Nosocomial Infection: Analysis of 1,022 Out-
breaks. Infect Control Hosp Epidemiol. 2005. 26:357–61.
Hong KB, Oh HS, Song JS, Lim JH, Kang DK, Son IS, Park JD, Kim
EC, Lee HJ, Choi EH. Investigation and control of an outbreak of
imipenem-resistant Acinetobacter baumannii Infection in a Pediatric
Intensive Care Unit. Pediatr Infect Dis J. 2012. 31:685–90.
Kaier K, Wilson C, Hulscher M, Wollersheim H, Huis A, Borg M,
Scicluna E, Lambert ML, Palomar M, Tacconelli E, De Angelis G,
Schumacher M, Wolkewitz M, Kleissle EM, Frank U. Implementing
strategic bundles for infection prevention and management. Infection.
Macias AE, Muñoz JM, Galvan A, Gonzalez JA, Medina H, Alpuche C,
Cortes G, Ponce de León RS. Nosocomial Bacteremia in Neonates
Related to Poor Standards of Care. Ped Infect Dis J. 2005. 24:713–16.
Ponce de León RS. Nosocomial Infections in Latin America: We Have to
Start Now. Infect Control. 1984. 5:511–12.
Ostrosky Zeichner L, Báez Martínez R, Rangel-Frausto MS, Ponce de
León RS. Epidemiology of Nosocomial Outbreaks: Fourteen-Year
Experience at a Tertiary Care Center. Infect Control Hosp Epidemiol.
Ponce de León RS, Macias AE. Global Perspectives of Infection Control
in Prevention and Control of Nosocomial Infections (4th Edition),
Wenzel RP (Ed). Baltimore: Lippincott Williams & Wilkins, 2003.
Pgs. 14–32.
Wenzel RP. Management Principles and the Infection Control Commit-
tee in Prevention and Control of Nosocomial Infections (2nd Edition),
Wenzel RP (Ed). Baltimore: Williams & Wilkins, 1993. Pgs. 207–13.
Wenzel RP, Thompson RL, Landry SM, Rusell BS, Miller PJ, Ponce
de León RS. Hospital Acquired Infections in Intensive Care Patients:
An Overview with Emphasis on Epidemics. Infect Control. 1983.
4:371–5.
Zaidi M, Sifuentes J, Bobadilla M, Moncada D, Ponce de León RS.
Epidemic of Serratia marcescens Bacteremia and Meningitis in a
Neonatal Unit in Mexico City. Infect Control Hosp Epidemiol. 1989.
10:14–20.
82 A Guide to Infection Control in the Hospital
Chapter 14
Horizontal vs Vertical
I nfection Control Strategies
Richard P. Wenzel, MD, MSc
Key Issues
There is an increasing literature supporting the idea that hor-
izontal infection control programs [targeting all organisms at
one or more anatomic sites] has been more effective than verti-
cal programs [targeting a single organism e.g. methicillin resis-
tant Staphylococcus aureus (MRSA)].
Known Facts
Hand washing performed assiduously before and after see-
ing patients has clearly impacted total infection rates, is easy
to perform, and is inexpensive.
Team based approaches to the insertion and management of
central vascular catheters (CVC) has been shown to reduce
CVC—associated bloodstream infections by almost 70%.
In separate studies the use of chlorhexidine baths have been
linked to the reduction of MDR acinetobacter bloodstream
infections and the colonization and bloodstream infections
due to vancomycin resistant enterococci (VRE) and MRSA.
A single switch from iodophor surgical prep to a chlorhexi-
dine-alcohol prep reduced surgical site infections by 40%.
A cluster randomized study of ICU patients given routine
nasal decolonization and chlorhexidine baths was shown to
be superior to options of 1) screening for MRSA and then
providing “positives” decolonization and baths or 2) screen-
ing and isolation alone.
Horizontal vs Vertical Infection Control Strategies 83
Controversial Issues
There are still those who maintain the value of some vertical
programs with a spectrum of approaches from total hospi-
tal patient culturing and isolation vs screening of high risk
surgical patients (those undergoing cardiac surgery and both
orthopedic and neurosurgical patients receiving implants).
Suggested Practice
The platform of a good infection control program should be
based on horizontal approaches. The question to be asked is:
What incremental value would an additional vertical
- 1. The functioning of these units includes multiple inva-
- policies to prevent infectious complications;
- 2. The improper re-use of disposable devices such as cath-
- 3. The lack of personnel with specific training in critical
- 2012. 40:225–8.
- 2000. 21:527–8.
Program Add And At What Cost And Adverse Consequences?
Summary
Horizontal infection control interventions have a marked effect
on total infection rates relative to vertical interventions and usu-
ally are much less costly.
References
Wenzel RP, Bearman G, Edmond MB. Screening for MRSA: A Flawed
Infection Control Intervention. Infect Control Hosp Epidemiol. 2008.
29:1021–8.
Wenzel RP, Edmond MB. Infection Control: The Case for Horizontal
Rather than Vertical Infection Interventional Programs. Internat J
Infect Dis. 2010. (Suppl 4):S 3–5.
Wenzel RP. Minimizing Surgical Site Infections. N Engl J Med. 2010.
362:75–7.
Huang SS, Septimus E, Kleinman K, et al. Targeted Versus Universal
Decolonization to Prevent ICU Infections. N Eng J Med 2013.
8:2255–65.
Edmond MB, Wenzel RP. Screening Inpatients for MRSA—Case
Closed. N Engl J Med. 2013. 368:2314–5.
84 A Guide to Infection Control in the Hospital
Chapter 15
Positive Deviance
in I nfection P revention
Alexandre Marra, MD
Keywords
Positive deviance; solutions, innovation, initiative, compliance,
leadership.
Key Issue
Positive Deviance (PD) is based on the observation that in
every community there are certain individuals or groups, whose
uncommon practices enable them to find better solutions to
problems than their neighbors or colleagues despite having
access to the same resources. These individuals are known as
positive deviants.
Known Facts
The PD approach is totally different form from the tradi-
tional approach for stimulating performance improvement in
any area.
In PD the healthcare workers (HCWs) decide how the work
should be done and they promote discovery among their
peers.
The leadership and managers support frontline workers in
implementing new ideas into their routine.
A core principle of PD is the belief that solutions to seem-
ingly intractable problems already exist. Another important
concept is that problems are discovered by members of the
community, and the positive deviants with a spirit of cre-
ativity and innovation will share experiences, discuss these
problems, and remove the barriers to find the solutions.
There are many descriptions of successful stories of PD in
different sectors from public health to education to business.
PD has also been used to control methicillin resistant
S. aureus (MRSA) in the healthcare setting.
Positive Deviance in Infection Prevention 85
Using PD can improve hand hygiene compliance. Nurse
managers need to facilitate discussion among frontline work-
ers and give positive deviants opportunities to express their
feelings about best practices for hand hygiene and to discuss
what needs to be changed, what needs to be improved, what
is wrong and what is right.
One of the strategies from the PD project for improving hand
hygiene compliance is to show the number of alcohol gel
aliquots dispensed per unit and to compare data and HCW
impressions.
All hospital personnel (doctors, nurses, physical therapists,
speech pathologists, nutritionists and pharmacists) need to
act as infection preventionists. Moreover, all hospital quality
indicators need to be discussed at group meetings. Priorities
need to be analyzed and strategies need to be defined. Every-
one should understand some specific processes, such as cen-
tral venous catheter insertion and hand hygiene compliance,
and bring valuable information that could be addressed
during PD meetings or case discussions.
Many solutions were suggested by the positive deviants
in hospital settings. Some examples include: changing the
position of the alcohol rub dispensers to allow easier access
and use; putting alcohol gel dispensers on mobile x-ray
machines; changing the procedure for monitoring the con-
sumption of alcohol handrub product, which was initially
performed by one single staff member each 48 hours and
gradually evolved to become the responsibility of every pro-
fessional involved with patient care at the end of their shifts.
Controversial Issues
Infection control personnel know that improvement pro-
cesses have a tremendous impact on the quality of care, but
the question remains as to how to initiate and sustain these
improvements.
The first step is to decrease the distance between infection
control unit personnel and healthcare workers.
PD promotes ownership of problems by frontline workers,
and empowers the positive deviants to implement infection
control prevention processes.
86 A Guide to Infection Control in the Hospital
The next step is to accept and support ideas that arise during
the team observations in their daily practice.
At first glance the strategies employed by the deviants may
not seem to be very unusual or innovative.
The PD challenge is to disseminate these strategies to others.
The leaders need to believe that PD can advance engage-
ment of front line staff in prevention efforts and implemen-
tation of all interventions.
Participants discuss ways to stimulate a discussion with non-
compliant individuals in a positive manner.
Suggested Practice
Positive deviance tries to improve processes every single
day, by analyzing work flow, questioning possible errors,
and promoting the view that all tasks are significant as they
are important for the final result. And the improvement is
continuous as staff, learns together, shares tasks, knowledge
and ideas, and continues analyzing all tasks and actions.
The goal is for the team to be responsible for identifying
opportunities for improvement, and to propose solutions and
to follow the proceedings.
The structure and the PD process offer a space for discus-
sion of experiences, ideas and plans that emerge from team
participation.
The exercise to practice thinking can lead to high-impact
actions. An example was the idea to place alcohol gel on
portable X-rays machines that traverse the hospital, so that
radiologic technicians have the ability to use alcohol gel at
any time during their activities.
Most important is that all the changes that have occurred or
are occurring are developed by people performing the tasks.
The socialization of thought and attitude become the main
role of PD.
Summary
Positive deviance (PD) may have an important role for infec-
tion prevention and patient safety in the hospital. PD has been
applied in the healthcare setting to improve hand hygiene com-
pliance, reduce methicillin resistant S. aureus (MRSA), and
Positive Deviance in Infection Prevention 87
reduce bloodstream infections in an outpatient hemodialyis cen-
ter. PD promotes dialogue among leaders, managers and health-
care workers (HCWs), which is a key factor in estabilishing a
safety culture. It also enables cultural changes aimed at empow-
ering frontline workers (the positive deviants) to innovate and
improve compliance with infection prevention measures.
References
Buscell P. More we than me: How the fight against MRSA led to a
new way of collaborating at Albert Einstein Medical Center. 2008.
http://c.ymcdn.com/sites/www.plexusinstitute.org/resource/resmgr/
docs/more-we-than-me-mrsa-vol1no5.pdf
Gawande A. Better—A surgeon’s notes on performance (1st Edition).
New York: Metropolitan Books, 2007.
Jain R, Kralovic SM, Evans ME, Ambrose M, Simbartl LA, Obrosky
DS, Render ML, Freyberg RW, Jernigan JA, Muder RR, Miller LJ,
Roselle GA. Veterans Affairs initiative to prevent methicillin-re-
sistant Staphylococcus aureus infections. N Engl J Med. 2011.
364:1419–30.
Lindberg C, Downham G, Buscell P, Jones E, Peterson P, Krebs V.
Embracing collaboration: A novel strategy for reducing bloodstream
infections in outpatient hemodialysis centers. In press: Am J Infect
Control. 2013. 41:513–9.
Marra AR, Guastelli LR, Araújo CMP, et al. Positive deviance: a new
strategy for improving hand hygiene compliance. Infect Control
Hosp Epidemiol. 2010. 31:12–20.
Marra AR, Guastelli LR, Araújo CMP, et al. Positive deviance: A pro-
gram for sustained improvement in hand hygiene compliance. Am J
Infect Control. 2011. 39:1–5.
Marra AR, dos Santos OFP, Cendoroglo Neto M, Edmond MB. Positive
Deviance: A new tool for Infection Prevention and Patient Safety.
Curr Infect Dis Rep. 2013 Sep 28. Epub ahead of print.
Marsh DR, Schroeder DG, Dearden KA Sternin J, Sternin M. The
power of positive deviance. BMJ. 2004. 329:1177–79.
Pascale R, Sternin J, Sternin M. The power of positive deviance: How
unlikely innovators solve the world’s toughest problems. Boston:
Harvard Business Press, 2010.
Positive Deviance Initiative. http://www.positivedeviance.org
Singhal A, Buscell P, Lindberg C. Inviting Everyone: Healing Health-
care through Positive Deviance. Bordentown: Plexus Press, 2010.
Ribeiro de Macedo RD, Oliveira Jacob EM, Pio da Silva V, et al. Pos-
itive deviance: Using a nurse call system to evaluate hand hygiene
practices. Am J Infection Control. 2012. 40:946–50.
88 A Guide to Infection Control in the Hospital
Chapter 16
Bundles in Infection
Prevention and Safety
Rebekah W. Moehring, M.D., M.P.H.
Key Issue
Delivery of evidence-based infection prevention interventions
is highly dependent on an individual provider’s knowledge,
motivation, and skills, which can result in poor or inconsistent
implementation of best practices. Care “bundles” are small,
straightforward, sets of evidence-based practices that,when
implemented collectively, improve the reliability of their deliv-
ery and improve patient outcomes.1
Known Facts
Elements of a care bundle are individual interventions with
high evidence-basis (Level 1, randomized controlled trial
evidence) of improving patient outcomes.
A small number of elements, between four and six, are con-
tained within a bundle for simplicity and ease of delivery.
Every element of the bundle must be implemented with
complete consistency to achieve the optimal effect of the
collective bundle. Providers must follow every bundle ele-
ment for every patient, every time. The goal of grouping
the elements is to promote positive habit-forming behavior
among providers and thus reliable care processes.
Bundle elements must occur at the same time or same care
setting in order to ensure they are performed together. As
an example, the central venous catheter insertion bundle is
completed once upon inserting a new catheter, followed by
daily reassessments while the catheter is in place.
Elements of a bundle are measured in an “all or nothing”
manner to simplify assessment of compliance for feedback
to providers and to emphasize the completion of every
component.2
Bundles in Infection Prevention and Safety 89
Three well-known and widely practiced care bundles pro-
moted by the Institute for Healthcare Improvement (IHI)3
include the following:
bloodstream infections4,5
a. Hand hygiene
b. Maximal barrier precautions upon insertion
c. Chlorhexidine skin antisepsis
d. Optimal catheter site selection, with avoidance
of the femoral vein for central venous access
in adult patients
e. Daily review of line necessity with prompt
removal of unnecessary lines
a. Elevation of the head of the bed
b. Sedation vacations and assessment of
readiness to extubate
c. Peptic ulcer disease prophylaxis
d. Deep vein thrombosis prophylaxis
e. Daily oral care with chlorhexidine
management of patients with severe infections8
a. Measure lactate level
b. Obtain blood cultures prior to administration
of antibiotics
c. Administer broad spectrum antibiotics
d. Administer 30mL/kg crystalloid for hypotension
or lactate ≥4mmol/L
The central line bundle is credited with the impressive
decline in incidence of central line associated infections over
the past decade.9
Bundled interventions are effective way to implement
change and improve the “culture” of patient safety by pro-
moting teamwork, and providing feedback and accountabil-
ity to improve care.3,10
90 A Guide to Infection Control in the Hospital
Controversial Issues
Additional bundle elements (e.g. greater than 6) will jeop-
ardize simplicity and may negatively impact the bundle’s
effectiveness or consistency of delivery.
Bundle elements must not be static, but must adapt to chang-
ing evidence and best practices.
When bundled interventions produce evidence of improved
patient outcomes, it is difficult to separate the relative impact
of any single element contained within the bundle. Thus,
when looking to update or improve the bundle, it is difficult
to remove any one element for another.
Individuals focused on performance improvement may con-
fuse a “bundle” with a “checklist.”1In general, checklists
may include elements that have good evidence or theoret-
ical basis for best practices, but not the high-level evidence
that make up the key elements of a bundle. Checklists may
include extra, optional tasks or reminders; in contrast, every
element of a bundle is critical and must be completed every
time for every patient.
Given the recent popularity and success of the central line
and ventilator bundles, individuals may be tempted to label
any multifaceted intervention as a “bundle.” However, a true
bundle must contain scientifically proven, simple interven-
tions, with the goal of adding consistency for optimal patient
outcomes.
Care bundles may include elements that do not directly
relate to infection prevention (e.g. deep venous thrombosis
prophylaxis in the ventilator bundle).
Suggested Practice2
Identify areas where evidence-based infection prevention
practices are inconsistently followed to target for a bundled
intervention. Existing bundles promoted by the IHI are a
good place to begin (see above).3
Identify a set of 4 to 6 evidence-based interventions that
apply to a group of patients with a common disease ina com-
mon practice setting, and that can be delivered as part of a
single process of care.
Bundles in Infection Prevention and Safety 91
Recruit and motivate providers to deliver the interventions
every time for every patient with an indication.
Measure compliance as “all or nothing;” feed back compli-
ance data to providers.
Adjust the delivery system and address logistical concerns
to make it easy to deliver the bundle as part of the system of
care and workflow.
Measure relevant patient outcomes to determine the effect of
the bundle.
Summary
The concept of care bundles grew out of the quality movement,
largely driven by the Institute for Healthcare Improvement’s
100,000 lives campaign launched in 2006.11 Well-known and
successful, nationwide quality initiatives resulted in widely
implemented standards for processes of careto improve the
delivery of evidence-based infection prevention practices.
Care bundles are made up of four to six elements that each
has a high level of evidence basis for incorporation into routine
practice. Consistent delivery of each element is achieved by
grouping these elements together as a single process, encourag-
ing and motivating providers to deliver them for every patient
every time, measuring compliance with the bundle as a whole,
and then feeding these data back to further motivate and estab-
lish accountability.
The most well-known model of a successful infection pre-
vention care bundle is the central line bundle. This intervention
includes elements at the time of insertion and for daily reassess-
ments while the catheter remains in place. Implementation of
the central line bundle is supported by a high level of evidence
demonstrating reduction in rates of central-line associated
bloodstream infections.5 Similarly, this bundle of interventions
has been credited with the nationwide decline in incidence of
central line associated infections over the last decade.9 These
standard, bundled practices are now routine for many providers
caring for patients with central lines. Executing all components
of the central line bundle and reporting compliance data for the
bundle processes are now considered a standard for accredited
hospitals.4
92 A Guide to Infection Control in the Hospital
Due to prior success of bundled interventions, it is tempting
to create new management and prevention bundles for many
different disease processes. In fact, the word “bundle” has
taken on a magical quality in the infection prevention literature.
However, there is one significant problem with grouping mul-
tifaceted interventions together when testing them in research
or quality improvement settings: the effect of each element of
the bundle cannot be distinguished from the other concurrently
implemented elements. Thus, it is difficult to determine which
part of a bundle may be responsible for the positive effect on
patient outcomes if each element is not tested individually.
When the time comes to update or adjust a bundle to incor-
porate new evidence-based practice, it is challenging to define
which elements are essential and which can be retired. Further,
the addition of additional steps in the process may cause the
bundle to lose its simplicity, which is the essential quality that
makes a care bundle easy to implement and effective in real-
world practice.
Care bundles serve to improve healthcare worker practice,
and as with any intervention, the implementation of the bundle
must be carefully planned and supported. Simply using the term
“bundle” and declaring it to be the standard will not achieve
success without ongoing motivation and data feedback.12 For
programs wishing to capitalize on the implementation success
of bundling, a key step to ensure reliable use is measurement
and feedback of bundle compliance. Auditing of bundle com-
pliance should be as an “all or nothing” measurement; in other
words, if one element is not followed then there is no partial
credit for bundle compliance. This ensures that every element
is followed every time, instead of inconsistent or partially com-
pliant practice.
Given the prior successes, we can expect to see development
of more bundled interventions for infection prevention, patient
safety, and healthcare quality initiatives of the future. Indeed,
the use of care bundles can systematically improve the consis-
tent delivery of high-quality care and evidence-based practice.
Bundles in Infection Prevention and Safety 93
References:
1Haraden C. Institute for Healthcare Improvement Website: What is a
bundle? http://www.ihi.org/knowledge/Pages/ImprovementStories/
WhatIsaBundle.aspx (Accessed 14 October 2013).
2 Marwick C, Davey P. Care bundles: The holy grail of infectious risk
management in hospital? Current opinion in infectious diseases.
August 2009. 22(4):364–369.
3 Institute for Healthcare Improvement Website: Evidence-Based Care
Bundles. http://www.ihi.org/knowledge/Pages/Changes/default.aspx
(Accessed 14 October 2013).
4 O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the preven-
tion of intravascular catheter-related infections. Clin Infect Dis. May
5 Pronovost P, Needham D, Berenholtz S, et al. An Intervention to
Decrease Catheter-Related Bloodstream Infections in the ICU.
N Engl J Med. December 28, 2006. 355(26):2725–2732.
6 Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T.
Using a bundle approach to improve ventilator care processes and
reduce ventilator-associated pneumonia. Joint Commission journal
on quality and patient safety/Joint Commission Resources. May
7 Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines
for preventing health-care-associated pneumonia, 2003: Recommen-
dations of CDC and the Healthcare Infection Control Practices Advi-
sory Committee. MMWR. March 26, 2004. 53(RR-3):1–36.
8 Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign:
international guidelines for management of severe sepsis and septic
shock: 2012. Critical Care Medicine. February 2013. 41(2):580–637.
9 Vital signs: Central line-associated blood stream infections—United
States, 2001, 2008, and 2009. MMWR. March 4, 2011. 60(8):243–248.
10 Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU
adverse events, nosocomial infections and cost through a quality
improvement initiative focusing on teamwork and culture change.
Quality and Safety in Health Care. August 2006. 15(4):235–239.
11 Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The
100,000 lives campaign: Setting a goal and a deadline for improving
health care quality. JAMA. January 18, 2006. 295(3):324–327.
12 Furuya EY, Dick A, Perencevich EN, Pogorzelska M, Goldmann
D, Stone PW. Central line bundle implementation in US intensive
care units and impact on bloodstream infections. PLoS One. 2011.
6(1):e15452.
94 A Guide to Infection Control in the Hospital
- 1. Central Line Bundle for prevention of catheter related
- 2. Ventilator Bundle6,7
- 3. Severe Sepsis 3-Hour Resuscitation Bundle for
- 2011. 52(9):e162–193.
- 2005. 31(5):243–248.
Chapter 17
The Hospital Environment
William A. Rutala, PhD, MPH and
David J. Weber, MD, MPH
In the last thirty years, evidence has accumulated that the hos-
pital environment represents an important source of health care
associated pathogens for hospitalized patients. Potential envi-
ronmental sources of pathogens include air (e.g., Aspergillus),
water (e.g., Legionella), environmental surfaces (e.g., Clos-
tridium difficile), medical devices e.g., endoscopes), and many
other items in the patient’s environment.
Key Issues
Pathogens may spread from an inanimate environmental res-
ervoir to the patient by one or more routes including airborne,
common-vehicle, contact or vector-borne. Airborne transmis-
sion describes organisms that have a true airborne phase as
part of their pattern of dissemination, such as tuberculosis and
varicella. In common-vehicle spread, a contaminated inanimate
vehicle serves as the mechanism of transmission of the infec-
tious agent to several people. Common vehicles may include
ingested food or water; blood and blood products; and infused
products such as medications or intravenously administered flu-
ids. In contact spread, the patient has contact with the source
and that contact is either direct, indirect, or droplet. Direct con-
tact occurs when actual physical contact occurs between the
source and the patient. Indirect contact refers to transmission
from the source to the patient through an intermediate object,
which is usually inanimate (e.g., endoscopes). Finally, droplet
spread refers to the brief passage of an infectious agent through
the air when the source and patient are within several feet of
each other. Arthropod-borne health care associated infections
have not been reported in the United States.
The Hospital Environment 95
Known Facts
In this section, we will briefly review environmental reser-
voirs and the pathogens that have been linked with infection
in patients admitted to the hospital (Table 17.1). We attempt to
indicate the strength by which the linkage to health care associ-
ated infections has been investigated and the control measures.
Controversial Issues
Few of the aforementioned recommendations (Table 17.1)
regarding methods to prevent transmission of pathogens from
the environment to patients are based on controlled trials.
Rather, the recommendations are based on the success of inter-
ventions used to control outbreaks.
There are many unresolved issues associated with the envi-
ronment that are related either to the degree to which some
specific environmental items poses a hazard (e.g., computer
keyboards) or to the appropriate control to a known environ-
mental hazard (e.g., routine microbiologic sampling of water
for Legionella). Among the unresolved issues in the area of
environmental hazards or their control are:
the risks and benefits of animals used for animal-assisted
the hazard posed by contaminated personal devices such as
the hazards associated with bioinformatic devices such as
the benefit of new surface decontamination technologies
the need for protective isolation (including limitation of
the role of potable water as a source of fungal infections in
Role of attire (e.g., long sleeves, coats).
96 A Guide to Infection Control in the Hospital
Table 17.1 Reservoirs of Infectious Agents in the Environment a,b
Reservoir Reservoir Associated Pathogens Transmission Significancea Prevention and Control
Air Filters Aspergillus Moderate Replace soiled filters periodically
Laundry chutes Pseudomonas, Staphylococcus Airborne Low Proper design and placement, chute doors
False ceilings Rhizopus Airborne Moderate Barrier protection during reconstruction
Fireproof materials Aspergillus Airborne Low Add fungicide to moist material
Pseudomonas disinfect between uses
Inadequate ventilation filter all hospital air
Pigeon droppings Aspergillus Airborne Low Maintain filter efficiency; filter all hospital air
Inhaled medications Pseudomonas, Klebsiella, Serratia Inhalation Moderate Sterile preparation by pharmacy
Showers Legionella, Group A Streptococcus Inhalation Low Prohibit with immunocompromised patients
Ventilators Pseudomonas Inhalation Moderate Follow current CDC guidelines
Bronchoscopes Pseudomonas, Mycobacteria Contact High Pseudoepidemics common; follow disinfection guidelines
Contaminated germicides Pseudomonas, Bacillus Contact High Avoid extrinsic contamination and seek verification
of manufacturer’s microbicidal efficacy claims
water >200 organisms/ml
ECG electrodes S. aureus, GNR Contact None Disinfect after use or use disposable leads
The Hospital Environment 97
Table 17.1 Reservoirs of Infectious Agents in the Environment a,b (continued)
Reservoir Reservoir Associated Pathogens Transmission Significancea Prevention and Control
Elasticized bandages Zygomycetes Contact Moderate Avoid in immunocompromised patients or
over nonintact skin
Electronic thermometers C. difficile Contact Low New probe cover for each patient, disinfect each day
and when visibly contaminated
Endoscopes Salmonella, Pseudomonas Contact High Follow proper disinfection procedures
Faucet aerators Pseudomonas, Stenotrophomonas Contact, Droplet Low No precautions necessary
use closed system for thermodilution
Intraaortic balloon pump Pseudomonas Contact Low Add germicide to water reservoir
Mattresses Pseudomonas, Acinetobacter Contact Moderate Use intact plastic cover, disinfect cover between patients
Plaster Pseudomonas, Bacillus Contact Moderate Use judiciously in immunocompromised patients or
over nonintact skin
Potable water Pseudomonas, Serratia, Contact, Droplet, High Follow CDC and public health guidelines
98 A Guide to Infection Control in the Hospital
non-tuberculous Mycobacteria, Ingestion
Acinetobacter, Legionella
Water Walls, Legionella Droplet Moderate Prudent to avoid in immunocompromised
Decorative Fountains patient care areas
Pressure transducers Pseudomonas, Enterobacter, Contact Moderate Disinfect transducer between patients and replace
Serratia disposable dome/transducer; use aseptic technique
Sinks Pseudomonas Contact, Droplet Low Use separate sinks for hand washing and disposal
of contaminated fluids
Table 17.1 Reservoirs of Infectious Agents in the Environment a,b (continued)
Reservoir Reservoir Associated Pathogens Transmission Significancea Prevention and Control
Suction apparatus Klebsiella, Salmonella, Contact, Droplet Low Avoid backflow and aerosolization; disinfect
Pseudomonas, Proteus between patient use
Thermometers (glass) Salmonella Contact Moderate Disinfect between use
(rectal)
Tubs for immersion Pseudomonas Contact Moderate Add germicide to water; drain and disinfect after each use
Urine-measuring devices Serratia Contact Moderate Disinfect between patients, good hand washing
Water baths Pseudomonas, Acinetobacter Contact Moderate Add germicide to water bath or use plastic overwrap
Electric breast pumps Pseudomonas, Klebsiella, Serratia Ingestion Moderate Follow guidelines
refrigerate; minimize manipulation; use closed
administration set
Fooda Salmonella, S. aureus, Clostridium, Ingestion High Follow local public health guidelines
Vibrios, hepatitis A, Norovirus
Ice/Ice machines Legionella, Enterobacter, Ingestion, Contact Moderate Periodic cleaning; use automatic dispenser
Pseudomonas, Salmonella,
Cryptosporidia
Medications (extrinsic) Staphylococcus, Streptococcus, GNR Injection, Inhalation High Use aseptic technique
Compounding pharmacies Fungi Injection High Ideally, conform with federal manufacturing standards on
on sterile/aseptic preparation
The Hospital Environment 99
Table 17.1 Reservoirs of Infectious Agents in the Environment a,b (continued)
Reservoir Reservoir Associated Pathogens Transmission Significancea Prevention and Control
Air-fluidized beds Enterococcus Contact Low Follow manufacturer’s recommendations
Carpets — — None Prudent to avoid in areas of heavy soiling
Privacy curtains MRSA, VRE Contact None Prudent to minimize risk (e.g, disinfect, laundry after
Contact Precaution patients)
Flowers GNR — None Prudent to avoid in the ICU and immunocompromised
patients’ rooms
Fresh vegetables Aerobic GNRs, Listeria — None Prudent to avoid in immunocompromised patients
Pets Malassezia, S. aureus Contact Low Prudent to avoid in hospital setting (except service
animals or animal-assisted therapy)
Stethoscopes Staphylococcus — None Prudent to clean periodically with alcohol
Toilets GNR Droplet Low Utilize good hand washing
Medical waste (not sharps) — — None Follow state and federal regulations
Eyewash stations Pseudomonas, Legionella Contact Low Have potable water available for eye flush
100 A Guide to Infection Control in the Hospital
Toys Pseudomonas, Rotavirus Contact Low Disinfect toys between patients, avoid water-retaining
bath toys
Computer keyboards S. aureus, Acinetobacter Contact Low Disinfect periodically, hand wash after use
Surfaces VRE, MRSA, C. difficile Contact Moderate Hand wash with soap and water/alcohol after contact
with patient environment; disinfect surfaces periodically
and terminally
a High, multiple well-described outbreaks due to this reservoir; moderate, occasional well-described outbreaks; low, rare well-described outbreaks; none, actual infection not
demonstrated; GNR, gram-negative rods; VRE, vancomycin-resistant Enterococcus; MRSA, methicillin resistant Staphylococcus aureus.
b Modified from 1, 2.
Suggested Practice
Fortunately in the past ten years, a number of authoritative
guidelines have been published that provide scientifically-based
recommendations to prevent transmission of health care asso-
ciated pathogens to the patient from environmental reservoirs.
Hand hygiene before and after patient contact is crucial to
prevent transmission of pathogens from the patient’s envi-
ronment to other patients.3
All hospital construction and renovation must utilize recent
guidelines to prevent acquisition of airborne fungi (such as
Aspergillus) to immunocompromised patients.4
Proper cleaning, disinfection/sterilization of reusable medi-
cal devices.1,2,5–7
Aseptic manipulation of all medications.1
Proper surveillance for Legionella and institution of control
measures in the event of Legionella cases.4
Surface disinfection of the environment to prevent transmis-
sion of methicillin resistant S. aureus, vancomycin-resistant
Enterococcus, and C. difficile.1
Summary
The environment continues to serve as a source of health care
associated infections. Key measures to reduce environment
appropriate evaluation of excess cases (epidemics); proper
cleaning, disinfection, and sterilization of patient devices and
the surface environment; and adherence to recommendations
for protecting patients during building renovations and con-
struction. New issues (e.g., computer keyboards, reprocessing
prion contaminated medical devices, emerging pathogens such
as multidrug-resistant organisms, SARS) will continue to chal-
lenge the infection control clinician for the foreseeable future.
The Hospital Environment 101
References
1 Weber DJ, Rutala WA. The Environment as a Source of Nosocomial
Infections in Prevention and Control of Nosocomial Infections
(4th Edition), Wenzel RP (Ed). Baltimore: Lippincott Williams &
Wilkins, 2003. Pgs. 575–595.
2 Rutala WA, Weber DJ. Environmental Issues and Nosocomial Infec-
tions in Infection Control in Intensive Care. Farber BF (Ed). Church-
ill Livingstone, 1987. Pgs. 131–171.
3 Boyce JM, Pittet D. Healthcare Infection Control Practices Advisory
Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
Guideline for Hand Hygiene in Healthcare Settings. Infect Control
Hosp Epidemiol. 2002. 23:S3–S40.
4 Centers for Disease Control. Guidelines for Environmental Infec-
tion Control in Healthcare Facilities, 2003. MMWR. 2003. 52(No.
RR-10):1–44.
5 Rutala WA, Weber DJ. Healthcare Infection Control Practices Advi-
sory Committee, 2008. CDC Guideline for Disinfection and Steri-
lization in Healthcare Facilities. http://www.cdc.gov/hicpac/pdf/
guidelines/Disinfection_Nov_2008.pdf
6 Rutala WA, Weber DJ. Selection and use of disinfectants in healthcare
in Hospital Epidemiology and Infection Control, Mayhall CG (Ed).
New York: Lippincott Williams & Wilkins, 2012. Pgs. 1180–1212.
7 Petersen B, Chennat J, Cohen J, Cotton PB, Greenwald DA, Kow-
alski TE, Krinsky ML, Park WG, Pike IM, Romagnuolo J, Rutala
WA. Multisociety guideline on reprocessing flexible GI endoscopes:
102 A Guide to Infection Control in the Hospital
- therapy;
- stethoscopes, hand-held computers, pagers;
- computer keyboards and touch-screen devices;
- such as UV light, hydrogen peroxide vapor;
- fresh fruits/vegetables, flowers, potted plants);
- immunocompromised patients;
- the need to routinely culture potable water for Legionella;
- Humidifiers/nebulizers Acinetobacter, Legionella, Airborne, Droplet High Avoid when possible; use sterile water;
- Outside construction/ Rhizopus, Aspergillus Airborne High Use at least 95% efficiency filters in hospital;
- Dialysis water GNR Contact Moderate Follow guidelines: dialysate >2000 organisms/ml;
- Ice baths Staphylococcus, Ewingella Contact Moderate Avoid direct contact with ice to cool IV solution/syringes;
- Enteral feeds GNR Ingestion Low Use sterile commercial feeds or aseptically prepared feeds;
- associated nosocomial infections include ongoing surveillance;
- 2011. Infect Control Hosp Epidemiol. 2011. 21:527–537.
Chapter 18
Food: Considerations for
H ospital Infection Control
Susan Assanasen, MD, and
Gonzalo M.L. Bearman, MD, MPH
Key Issues
The responsibility of a hospital food service is to provide
nutritious and safe food to patients and employees.
Although food safety has dramatically improved in the last
decades, outbreaks of health care associated gastroenteritis
continue to occur worldwide.1,2
A growing number of hospitalized patients are susceptible to
infectious diseases. These include the elderly and immuno-
compromised hosts.
Additionally, complex and large-scale production of food
and water is a potential target for bioterrorism.
The outbreaks may result from breakdown in only one-step
of food safety control measures.
Known Facts
Foodborne illnesses can be caused by bacteria, virus, para-
sites, prions, toxins, or chemical contaminants.
The clinical presentations are broad and can be quick in
onset, such as in toxin mediated outbreaks. Others have long
incubation periods, such as hepatitis A, and prion associated
diseases.
Due to highly susceptible and frail populations, such as the
elderly, outbreaks of health care associated gastroenteritis
have a higher crude mortality than their community acquired
equivalents.2,3
Outbreaks of highly contagious organisms such as norovi-
rus (attack rates>50%) may also affect staff and visitors.
This has resulted in ward closure in up to 44% of reported
outbreaks.4
Food: Considerations for Hospital Infection Control 103
Common foodborne pathogens that are easily transmitted
through food and can cause severe illness are norovirus,
Salmonella, Clostridium perfringens, Shigella, Enterohem-
orrhagic or Shigatoxin producing E. coli, Campylobacter,
Listeria monocytogenes, Vibrio, Yersinia enterocolitica,
Staphylococcus aureus, Hepatitis A virus, Giardia, and
Cryptosporidium.5 Incidence varies according to geographic
area, season, and availability of laboratory diagnosis, and
change over time.1,2
Fresh vegetables or fruits have been implicated as vehicles
for foodborne pathogens as these products are typically sold
to the consumer in ready-to-eat form, do not generally con-
tain preservatives, and rarely undergo any heat processing
prior to consumption.
Noroviruses (formerly called Norwalk-like viruses) are con-
sidered the most common cause of sporadic gastroenteritis
in developed countries. These are particularly prevalent in
nursing homes and hospitals.6
Health care associated outbreaks caused by noroviruses are
difficult to prevent and control due to:6,7
routine chlorine of water, low pH levels, and treatment
with ethanol, or detergent-based cleaners.
route and probable respiratory spread via aerosols of
vomitus.
Eggs are major vehicles for Salmonella infection in humans.
Egg-associated salmonellosis is linked to external contam-
ination of the shell during passage through the hen cloaca,
and internal contamination by penetration of the bacteria
through the eggshell, via microscopic cracks.8
104 A Guide to Infection Control in the Hospital
Currently, there are increasing reports of multidrug-resis-
tant zoonotic foodborne infections. Emerging resistance of
Salmonella and Campylobacter species contribute to excess
mortality and morbidity in both outbreaks and sporadic
cases of illnesses.9
Listeria monocytogenes is a ubiquitous pathogen and has
been recovered in plants, soil, silage, sewage, slaughter-
house waste, human feces (1–10%), animal feces, processing
environments, and catering facilities. Although Listeriosis is
uncommon, the fatality rate in high-risk individuals (such
as pregnant women, older people, and immunocompromised
hosts) is as high as 20–50%. The organism can proliferate at
–18 to 10˚C.10 Consequently, Listeria may be transmitted in
foods that have been kept properly refrigerated. Thorough
cooking to 75˚C can destroy the Listeria. In developed coun-
tries, the contamination in ready-to-eat (RTE) meats is pri-
marily due to post-cooking contamination.
Cryptosporidium, and Giardia are resistant to routine chlori-
nation of water. In 1993, Cryptosporidium caused the largest
documented outbreak of gastrointestinal disease in a devel-
oped country (estimated 403,000 cases) due to contaminated
drinking water supply.11
Although Clostridium difficile, a common cause of health
care associated diarrhea, is transmitted via contaminated
hands and environment, community-acquired C.difficile
may be acquired by exposure to spores from soil, contami-
nated foods, and exposure to household contacts with C.dif-
ficile diarrhea.12
Hazard Analysis Critical Control Point (HACCP) is a sys-
tematic approach for the identification, evaluation, and con-
trol of potential hazards at every stage of food operation.
This system emphasizes the role of continuous problem
solving and prevention rather than solely relying on spot-
checks of manufacturing processes and random samples of
finished food products.13
HACCP involves major seven principles:
Food: Considerations for Hospital Infection Control 105
ing properly; and
HACCP system.
Currently, HACCP is recognized as an effective food safety
assurance system. The success of a HACCP system depends
on training and constant supervision of employees in the
importance of their role in producing safe foods.
Although implementation of HACCP system on hospital
food service is still voluntary in most countries, several hos-
pitals have adopted these principles to ensure that hospital
food is safe for consumption by high-risk patients.
To provide safe food in hospitals, adherence to HACCP is
critical. In a study by the Food and Drug Administration
(FDA), important foodborne illness risk factors in US hospi-
tals were:14
contamination; and
hand washing facilities.
Food-borne bacteria can multiply if food is not maintained at
an appropriate temperature (below 5˚C or 41˚F for refriger-
ation and above 57˚C or 135˚F for hot holding), and if there
are delays between food preparation and distribution. Enteric
viruses are particularly problematic pathogens as they are
more resistant to heat, disinfection, and pH changes than
enteric bacteria. In addition, viral contamination does not
alter the appearance, smell or taste of food. Lastly, viruses
can survive for days or weeks on hospital environment.
Hand washing can effectively reduce the transmission of
bacteria and viruses.
106 A Guide to Infection Control in the Hospital
Hand washing with soap and water followed by hand drying
with paper towels (not hot air dryers) is the standard pro-
cedure for hand decontamination in food safety practices.15
Alcohol-based hand rubs are inferior as these products nei-
ther inactivate viral pathogens such as norovirus, nor can
destroy the spores of C.difficile.
Controversial Issues
Most health care associated foodborne pathogens are spread
by the faecal-oral route. The primary source of outbreaks
may be contaminated food/water, and infected/colonized
patient, visitor, staff, or food handler. Contact with infected/
colonized animals may also cause enteric diseases, espe-
cially in immunocompromised hosts.16
Most enteric outbreaks are caused by a single agent, but
coinfections may occur, especially if the source is sewage
contaminated food or water.
DNA fingerprinting of foodborne bacteria by PFGE is avail-
able for E coli O157:H7, Salmonella, Listeria monocyto-
genes, Shigella, and Campylobacter isolates.
The CDC estimates that approximately 18–20% of food-
borne outbreaks are associated with an infected food
worker.17 Transmission of foodborne pathogens can occur
from pre-symptomatic, symptomatic and post-symptomatic
food handlers. Transmission of infections is dependent upon
the amount of infectious agent excreted, the degree of con-
tamination, the compliance and effectiveness of personal
hygiene, the stability of pathogens in food and environment,
the virulence of organisms, the food type/amount consumed,
cooking process, food preservation techniques, and immune
status of patients.
Outbreak investigations of health care associated gastro-
enteritis are complicated and only few illnesses are defini-
tively linked to food.
cause or the victims of enteric outbreaks. This is because
some healthcare workers may deny infection or illness for
a variety of reasons.
Food: Considerations for Hospital Infection Control 107
occurs by multiple sources, including person-to-per-
son contact, contaminated environments (fomites), con-
sumption of contaminated food or water, and airborne
inhalation.
Suggested Practice
For the control of foodborne infections in the hospital, it is
necessary to:
outbreaks at an early stage;18
and management systems; and
these organisms by foodhandlers and promote the good
hygienic practices.
The hospital food service must develop a food safety man-
agement system, such as HACCP, that meets food standard
requirements. This should be fully reviewed by certified
food safety professionals or local, external inspections. All
food should be obtained from approved sources in compli-
ance with Federal, State, and local laws and regulations.
Foods containing raw or partially cooked eggs, fish, and
meat should not be served.
Food containing unpasteurized milk and fruit juices should
not be served.
Pests and flies should be controlled to reduce the risk of food
contamination in hospitals.
Powdered infant formula (PIF) is not a sterile product. To
reduce the risk of infection, the reconstitution of powdered
formula should be undertaken by caregivers using good
hygienic measures and in accordance with the product man-
ufacturer’s food safety guidelines.19
All food handlers must be aware that high standards of per-
sonal hygiene are important. In the hospital setting, food
handlers also include nurses or domestic staff who distribute
or serve meals. Therefore, these personnel should be edu-
cated about food hygiene and HACCP.
108 A Guide to Infection Control in the Hospital
Bare hand contact of ready-to-eat foods should be eliminated
through the use of gloves, bakery papers and food handling
utensils.
The “touchless or hands free” faucets and paper towel dispens-
ers are preferred to reduce the risk of cross-contamination.
All food handlers should wash their hands and exposed por-
tions of their arms:20
with exposed food, clean equipment and utensils, and
soil and contamination and to prevent cross contamina-
hands.
All food handlers shall keep their fingernails trimmed, filed,
and maintained so the edges and surfaces are cleanable and
not rough.
Food handlers who have direct contact to unwrapped food,
clean equipment, utensils, and linens should wear clean
outer clothing and wear hair restraints such as hats, hair cov-
erings or nets, beard restraints, and clothing that effectively
covers body hair.
All food handlers with vomiting, diarrhea, jaundice, sore-
throat with fever, and infected or draining skin lesions must
stop working immediately and report to their manager and to
the hospital’s Occupational Health Department.20
Food: Considerations for Hospital Infection Control 109
Any cuts, wounds, or open sores on the hands and exposed
portions of their arms must be completely covered by imper-
meable bandage. The lesions on other parts of the body must
be covered by a dry, durable, tight-fitting bandage.
Criteria for the return to work of an infected or colonized
food handler with a foodborne pathogen are varied. The
details are available at http://www.cfsan.fda.gov/~acrobat/
fc05-2.pdf.
Early case identification of foodborne illnesses can prevent
further transmissions. Through early detection, the identifi-
cation and removal of contaminated products from the com-
mercial market can be expedited.
Physicians should promptly report hospitalized cases of
enteric infections to the infection control team and to the
appropriate public health authorities. In addition, physicians
and other healthcare professionals can help prevent and con-
trol foodborne diseases by educating their patients about the
risks of foodborne illness, and providing sound advice on
safe food-handling and consumption practices.
Once an outbreak of health care associated gastroenteritis
is suspected, infection control measures should be instituted
immediately, prior to the results of confirmatory tests. The
three most important actions during an outbreak are:
with appropriate disinfectants, such as sodium hypo-
chlorite at 1000 ppm for suspected norovirus outbreaks,
and at 5000 ppm (1:10 dilution of household bleach) for
C.difficile outbreaks.21,22
The IC team should be invited to help in the evaluation of the
catering contract, set up quality measures such as HACCP,
and participate in the inspection of hospital food handling
areas.
110 A Guide to Infection Control in the Hospital
In high prevalence areas of Hepatitis A virus (HAV)
infections, vaccination should be considered for all food
handlers not immune to HAV. Due to the low incidence of
HAV infection and high cost of vaccine, mass immunization
for all food service workers in the US is not cost effective,
except during epidemics.
A low microbial diet is recommended for hematopoietic
stem cell transplant (HSCT) recipients for at least 3 months
after transplantation and until all immunosuppressive drugs
are discontinued.23 Besides general food safety practices,
HSCT recipients should not eat any raw or undercooked
meat, seafood, and eggs or foods that might contain them
(e.g., certain preparations of hollandaise sauce, Caesar and
other salad dressings, homemade mayonnaise, and home-
made eggnog). HSCT recipients should avoid contact with
animal feces to reduce the risk for toxoplasmosis, cryptospo-
ridiosis, salmonellosis, and campylobacteriosis.
Strain-specific recombinant norovirus-like particles (VLPs)
are being evaluated as a potential vaccine for prevention of
norovirus infection or illness.
Summary
Health care associated enteric outbreaks, although rare, have
been reported.
Incorporation of HACCP principles at every stage of food
handling is crucial for ensuring food safety.
Food processors, manufacturers, wholesalers, retail outlets,
and restaurants play a key role in maintaining the safety of
food products and food ingredients.
Strict implementation of temperature control and hygienic
measures is the most important preventive measure in the
hospital setting.
Effective hand washing with soap and water before and after
the handling of all foodstuffs is critical for infection control.
To reduce the fecal oral transmission of gastrointestinal
pathogens from the contaminated hospital environment,
patients and their families should be educated on proper per-
sonal hygiene and sanitation.
Food: Considerations for Hospital Infection Control 111
References
1Lynch M, Painter J, Woodruff R, Braden C, Centers for Disease
Control and Prevention. Surveillance for Foodborne-Disease
Outbreaks—United States, 1998–2002. MMWR Surveill Summ.
November 10, 2006. 55(10):1–42.
2Meakins SM, Adak GK, Lopman BA, O’Brien SJ. General Outbreaks
of Infectious Intestinal Disease (IID) in Hospitals, England and
Wales, 1992–2000. J Hosp Infect. January 2003. 53(1):1–5.
3Kendall PA, Hillers VV, Medeiros LC. Food Safety Guidance for Older
Adults. Clin Infect Dis. May 1, 2006. 42(9):1298–304.
4Hansen S, Stamm-Balderjahn S, Zuschneid I, Behnke M, Ruden
H, Vonberg RP, et al. Closure of Medical Departments During Noso-
comial Outbreaks: Data From a Systematic Analysis of the Literature.
J Hosp Infect. April 2007. 65(4):348–53.
5American Medical Association; American Nurses Association-Amer-
ican Nurses Foundation; Centers for Disease Control and Preven-
tion; Center for Food Safety and Applied Nutrition, Food and Drug
Administration; Food Safety and Inspection Service, US Department
of Agriculture. Diagnosis and Management of Foodborne Illnesses:
A Primer for Physicians and Other Healthcare Professionals. MMWR
Recomm Rep. April 16, 2004. 53(RR-4):1–33.
6Centers for Disease Control and Prevention (CDC). Norovirus
Activity—United States, 2006–2007. MMWR August 24, 2007.
56(33):842–6.
7Estes MK, Prasad BV, Atmar RL. Noroviruses Everywhere: Has Some
thing Changed? Curr Opin Infect Dis. October 19, 2006. (5):467–74.
8Braden CR. Salmonella enterica Serotype Enteritidis and Eggs: A
National Epidemic in the United States. Clin Infect Dis. August 15,
9Molbak K. Human Health Consequences of Antimicrobial Drug-Re-
sistant Salmonella and Other Foodborne Pathogens. Clin Infect Dis.
December 1, 2005. 41(11):1613–20.
10Ramaswamy V, Cresence VM, Rejitha JS, Lekshmi MU, Dharsana
KS, Prasad SP, et al. Listeria—Review of Epidemiology and Patho-
genesis. J Microbiol Immunol Infect. February 2007. 40(1):4–13.
11Dawson D. Foodborne Protozoan Parasites. Int J Food Microbiol.
August 25, 2005. 103(2):207–27.
12McFarland LV, Beneda HW, Clarridge JE, Raugi GJ. Implications of
the Changing Face of Clostridium difficile Disease for Healthcare
Practitioners. Am J Infect Control. May 2007. 35(4):237–53.
13Center for Food Safety and Applied Nutrition, U.S. Food and Drug
Administration (FDA). Hazard Analysis Critical Control Point
(HACCP). April 17, 2006. Available at: http://www.fda.gov/Food/
GuidanceRegulation/HACCP/ucm2006811.htm (Accessed 24 Octo-
ber 2007).
112 A Guide to Infection Control in the Hospital
14FDA National Retail Food Team, U.S. FDA Report on the Occur
rence of Foodborne Illness Risk Factors in Selected Institutional
Foodservice, Restaurant, and Retail Food Store Facility Types.
September 14, 2004. Available at: http://www.fda.gov/Food/Guid-
anceRegulation/RetailFoodProtection/FoodborneIllnessRiskFac-
torReduction/ucm089696.htm (Accessed 24 October 2007).
15Michaels B, Keller C, Blevins M, Paoli G, Ruthman T, Todd E, et al.
Prevention of Food Worker Transmission of Foodborne Pathogens:
Risk Assessment and Evaluation of Effective Hygiene Intervention
Strategies. Food Service Technology. March 2004. 4(1):31–49.
16Steinmuller N, Demma L, Bender JB, Eidson M, Angulo FJ. Out-
breaks of Enteric Disease Associated with Animal Contact: Not Just
a Foodborne Problem Anymore. Clin Infect Dis. December 15, 2006.
43(12):1596–602.
17Todd E., Greig J. Outbreaks Where Food Workers Have Been Impli-
cated in the Spread of Foodborne Disease. September 28, 2006.
Available at: http://www.fsis.usda.gov/PDF/Slides_092806_ETodd2.
pdf (Accessed 24 October 2007).
18Scallan E. Activities, Achievements, and Lessons Learned During the
First 10 years of the Foodborne Diseases Active Surveillance Net-
work: 1996–2005. Clin Infect Dis. March 1, 2007. 44(5):718–25.
19Drudy D, Mullane NR, Quinn T, Wall PG, Fanning S. Enterobacter
sakazakii: An Emerging Pathogen in Powdered Infant Formula. Clin
Infect Dis. April 1, 2006. 42(7):996–1002.
20U.S. Department of Health and Human Services Public Health Ser-
vice. U.S. The 2005 FDA Food Code. October 5, 2007. Available at:
http://www.fda.gov/food/guidanceregulation/retailfoodprotection/
foodcode/ucm2016793.htm (Accessed 24 October 2007).
21Chadwick PR, Beards G, Brown D, Caul EO, Cheesbrough J, Clarke
I, et al. Management of Hospital Outbreaks of Gastroenteritis Due
to Small Round Structured Viruses. J Hosp Infect. May 2000.
45(1):1–10.
22Blossom DB, McDonald LC. The Challenges Posed by Reemerg-
ing Clostridium difficile Infection. Clin Infect Dis. July 15, 2007.
45(2):222–7.
23Centers for Disease Control and Prevention; Infectious Disease Soci-
ety of America; American Society of Blood and Marrow Transplan-
tation. Guidelines for Preventing Opportunistic Infections Among
Hematopoietic Stem Cell Transplant Recipients. MMWR Recomm
Rep. October 2000. 49(RR-10):1–125.
Food: Considerations for Hospital Infection Control 113
- 1. Low infectious dose (10–100 viral particles).
- 2. Very short incubation period (12–48 h).
- 3. Resistance to inactivation by freezing, heating to 60˚C,
- 4. Multiple routes of transmission, including faecal-oral
- 5. Genetic variability and short-term immunity.
- 6. Prolonged viral shedding after recovery (several weeks).
- 1. Analyzing hazards;
- 2. Identifying critical control points (CCPs);
- 3. Establishing preventive measures with critical limits
- for each control point;
- 4. Establishing procedures to monitor the critical control
- points;
- 5. Establishing corrective actions to be taken when monitor-
- ing shows that a critical limit has not been met;
- 6. Establishing procedures to verify that the system is work-
- 7. Establishing effective recordkeeping to document the
- 1. Improper holding, time and temperature of the food;
- 2. Contaminated equipment and inadequate protection from
- 3. Poor personal hygiene and lack of adequate toileting and
- 1. In some situations, it is not clear whether workers are the
- 2. Transmission of organisms during outbreaks frequently
- 1. Optimize and standardize methods for the detection of
- foodborne pathogens;
- 2. Develop rapid surveillance networks to detect and report
- 3. Emphasize the importance of food safety quality control
- 4. Heighten awareness about the presence and spread of
- 1. Before engaging in food preparation, including working
- unwrapped single service and single-use articles;
- 2. After touching bare human body parts other than clean
- hands and clean, exposed portions of arms;
- 3. After using the toilet room;
- 4. After caring for or handling service or aquatic animals
- 5. After coughing, sneezing, using a handkerchief or dispos-
- able tissue, using tobacco, eating, or drinking;
- 6. After handling soiled equipment or utensils;
- 7. During food preparation, as often as necessary to remove
- tion when changing tasks;
- 8. When switching between working with raw food and
- working with ready-to-eat food;
- 9. Before donning gloves for working with food; and
- 10. After engaging in other activities that contaminate the
- 1. Effective hand hygiene with soap and drying with hand
- towels;
- 2. Isolation of affected patients, restriction of movement of
- staff, patients and visitors and exclusion of affected staff;
- 3. Enhanced cleaning of the environment and equipment
- 2006. 43(4):512–7.
Chapter 19
Hospital Water
M. Sigfrido Rangel-Frausto, MD, MSc, MQ
Key Issue
Hospital water is frequently an overlooked, important and con-
trollable source of health care associated infections. Numerous
outbreaks have been linked to contaminated water. Potable
water is still an unmet need in many developing countries. CDC
and WHO had published guidelines for water quality in health
care facilities.
Known Facts
Hospital potable water must have <1 coliform bacterium/100
mL. High levels of bacteria in hospital water, dialysate
water, sinks, faucets, shower heads has been associated with
outbreaks or hand colonization.
The buildup of biofilms and the corrosion of distribution
lines and tank surfaces resulting from poor design or aging
of distribution systems and water stagnation are the primary
cause of diminished water quality.
Colonization in more than 30% of hospital water has been
associated with cases of Legionnaires’ disease. Hospital
water colonization by Legionella spp. could be long lasting
and associated periodically with outbreaks.
Risk of illness may be influenced by several factors beside
water contamination.
In developing countries, high levels of water contamination
correlating with low levels of chlorination have been linked
to bloodstream infections outbreaks by enterobacterias,
including Klebsiella spp, Enterobacter spp.
Patient exposure to waterborne organisms occurs while
showering, bathing, drinking, or with the contact of medical
equipment (tube feed bags, endoscopes, respiratory equip-
ment) rinsed with tap water.
114 A Guide to Infection Control in the Hospital
The development of a safety program for water intended
for human consume must be implemented in every health-
care facility.
Controversial Issues
Use of sterile water for all patients.
Maintaining high concentration of chlorine to reduce Legio-
nella colonization.
Routine point-of-use water filtration.
Copper may decrease water and environment colonization.
Suggested Practice
A high level of suspicion for cases of water borne infections
should be maintained, especially if clusters of infections
occur.
Hospital water should not routinely cultured.
Water used for dialysis should be sampled monthly, and bac-
teria must be <200 bacteria/mL.
Dialysate should be also cultured and similar levels of bacte-
ria must be maintained.
Use sterile water for rinsing nebulization devices and other
semicritical respiratory-care equipment.
Chloride levels in hospital water should be tested periodi-
cally. Chlorination should be tested not only in the incom-
ing tap water, but across the hospital, especially in high-risk
areas like intensive care units or where immune-compro-
mised patients exist.
Hospital tap water should be not given to immunosuppressed
patients. Use sterile water instead. If not possible filters or
boiling could be a safe alternative.
Cooling towers should be, if possible, directed away from
hospital’s air-intake system, and the design the cooling tow-
ers should be such that volume of aerosol drift is minimized.
Install drift eliminators and regularly use a effective biocide,
according manufacturers recommendations.
In case of a single confirmed case of health care associated
Legionnaires’ disease, or two possible cases in less than
6 months, begin an epidemiological and environmental
Hospital Water 115
investigation. Alert hospital personnel so a high level of
suspicion for the detection of new cases is maintained. This
prospective surveillance should be maintained at least 2
months after the last case. If there is evidence of continuous
transmission, hospital water should be sampled, and poten-
tial areas for aerosolized water should be looked. If hospital
water is contaminated with Legionella spp., start decontam-
ination procedures:
water =65˚C, (post warning signs at each outlet being
flushed to prevent scald injury) or
Follow up cultures should be done at 2 weeks intervals for
three months to evaluate actions taken. If no further pos-
itive cultures are found. Then cultures should be obtained
monthly for another 3 months. If positive cultures are found
reassess the implemented control measures, modify them
accordingly, re-implement decontamination and considerer
combinations.
Summary
Many bacteria can survive in water and have been linked to
health care associated infections including: Pseudomonas aeru-
ginosa, Burkholderia cepacia, Serratia marcescens, Citrobacter
freundii, Clostridium difficile, Acinetobacter baumani, Flavo-
bacterium meningosepticum, Aeromonas hydrophila, atypi-
cal Mycobacteria, Legionella spp, parasites and virus among
others. Furthermore Salmonella, Vibrio, Rotavirus, Crypto-
sporidium and other enteric organisms have been reported in
developing countries. In Table 19.1 some examples of hospital
water linked outbreaks are shown.
Routine cleaning, disinfection and policies for use and
changing of water from potential reservoirs should be imple-
mented and periodically reviewed. In high-risk units the routine
use of point-of-use filters may be a cost effective intervention to
decrease colonization and health-care associated infection rates.
116 A Guide to Infection Control in the Hospital
Table 19.1 Examples of Hospital Water-linked Outbreaks
Microorganism Reservoir Infection
P. paucimobilis water bottles for Pneumonia
rising tracheal suction
S. marcescens water of humidifiers Pneumonia
M. xenopi hot water taps Pneumonia
M. chelonae contaminated equipment Otitis
M. chelonae contaminated water tank Nasal Septum Cellulitis
L. pneumophila hospital water, cooling towers Pneumonia
Acinetobacter spp. water bath used to Bacteremia
thaw fresh plasma
P. aeruginosa water bath used to thaw Bacteremia, Pneumonia
cryoprecipitate, hospital water
P. aeruginosa tub water contamination Folliculitis, Skin Infections
C. difficile bath Diarrhea
S. maltophilia hospital water Bacteremia
Cryptosporidium hospital water Diarrhea
References
Weber, DJ, Rutala WA. Environmental Issues and Nosocomial
Infections in Prevention and Control of Nosocomial Infections
(3rd Edition), Wenzel RP (Ed). Baltimore: Williams & Wilkins,
Centers for Disease Control and Prevention. Guideline for Prevention of
Nosocomial Pneumonia: Part 1. Issues on Prevention of Nosocomial
Pneumonia. Resp Care. 1994. 39:1191–1236.
Centers for Disease Control and Prevention. Guideline for Hand Wash
ing and Hospital Environmental Control. MMWR. 1985. 37(24).
Rangel-Frausto MS, Rhomber P, Hollis RJ, et al. Persistence of
Legionella Pneumophila in a Hospital’s Water System: A 13-year
Survey. Infect Control Hosp Epidemiol. 1999. 20:793–797.
Anaissie EJ, Penzak SR, Dignani M. The Hospital Water Supply
as a Source of Nosocomial Infections. Arch Intern Med. 2002.
162:1483–92.
Hospital Water 117
Ortolano GA, McAlister MB, Angelbeck JA, Schaffer J, et al. Hospital
Water Point-Use-Filtration: A Complementary Strategy to Reduce the
Risk of Nosocomial Infection. Am J Infect Control. 2005. 33:S1–19.
Dyck A, Exner M, Kramer A. Experimental based experiences with
the introduction of a water safety plan for a multi-located university
clinic and its efficacy according to WHO recommendations. BMC
Public Health. 2007. 7:34.
Macias AE, Muñoz JM, Herrera LE, Medina H, Hernandez I, Alcantar
D, Ponce de León RS. Nosocomial Pediatric bacteriemia: The role of
intravenous set contamination in developing countries. Infect Con-
trol Hosp Epidemiol. 2004. 25:226–30.
Zhou ZY, Hu BJ, Lin YE, Watanabe H, Zhou Q, Gao XD. Removal of
waterborne pathogens from liver transplant unit water taps in pre-
vention of healthcare-associated infections: a proposal for a cost-ef-
fective, proactive infection control strategy. Clin Microbiol Infect.
World Health Organization. Guidelines for drinking water quality.
Geneva Switzerland. WHO. 2004.
Centers for Disease Control and Prevention. Guidelines for environ-
mental infection control in health care facilities: Recommendations
of CDC and the healthcare infection control practices advisory com-
mittee (HICPAC) MMWR. 2003. 52:1–48.
118 A Guide to Infection Control in the Hospital
Chapter 20
Laboratory Areas
Betty A. Forbes, Ph.D.
Key Issue
Laboratory workers are exposed to a variety of potential occu-
pational health risks that include infectious materials and cul-
tures. Laboratory-acquired infections (LAIs) are defined as all
infections acquired through laboratory activities, regardless of
their clinical or subclinical manifestations. Biosafety guidelines
have evolved from the efforts of the microbiological and bio-
medical communities to reduce LAIs. The actual risk of a labo-
ratory-acquired infection is difficult to measure because there is
no systematic reporting to appropriate government agencies or
at a professional society level to monitor the number of labora-
tory workers that acquire infections associated with the work-
place. More recent surveys have revealed a shift in the pattern
of LAIs from the early collective studies published by Sulkin
and Pike who reported on over 4000 laboratory-associated
infections between 1949 and 1974, with a mortality of 4.1%.
For example, in a 2002–2004 survey of clinical laboratory
directors, approximately one-third of laboratories reported the
occurrence of at least 1 laboratory-acquired infection with shig-
ellosis, brucellosis, and salmonellosis being the 3 most common
LAIs followed by Staphylococcus aureus, Neisseria meningitis,
E. coli 0157:H7, Coccidiodes immitis, Clostridium difficile and
Bacillus anthracis. To minimize the risk of LAIs, a program that
encompasses a combination of engineering controls (including
laboratory design), safe laboratory practices, employee educa-
tion, personal protective equipment (PPE), and medical mea-
sures that include surveillance, risk assessment, vaccination,
and postexposure prophylaxis is required. Of significance, the
development of such programs to minimize risks associated
with the handling and disposal of infectious agents is based
on an understanding of the pathogenicity of the agent, host
Laboratory Areas 119
susceptibility, source of infection, and the method of transmis-
sion of the infectious agent. Most risks from biological hazards
can be reduced through the use of appropriate microbiological
procedures and techniques, containment devices and facilities,
and protective barriers.
Known Facts
More recent surveys in the US from 1978 through 1982, and
in 1986, reported an annual incidence of 3 to 3.5 infections
per 1,000 laboratory employees per year Wilson and Reller
estimated that the annual rate of LAIs in the US is approxi-
mately 1 to 5 infections per 1000 employees.
Harding and Byers indicated that clinical diagnostic labo-
ratories accounted for 45% of all laboratory-acquired infec-
tions. Laboratory workers, especially those in microbiology,
are at greater risk of becoming infected than is the general
population.
The causative incident or source for most laboratory-ac-
quired infections is unknown.
There is a dearth of evidence-based research and publica-
tions focused on biosafety. In 2008, the Centers for Disease
Control and Prevention (CDC) convened a Blue Ribbon
Panel of laboratory representatives from a variety of agen-
cies, laboratory organizations, and facilities to review labo-
ratory biosafety in diagnostic laboratories. These guidelines
were intended to improve safety specifically for diagnostic
laboratories that handle specimens from humans and ani-
mals. Finally, the Clinical and Laboratory Standards Institute
also has published guidelines for the protection of laboratory
an updated version of these guidelines is expected to be pub-
lished in early 2014.
Principal Routes of Laboratory Transmission
Inhalation—aerosols are a serious hazard because they are com-
mon in laboratory procedures.
Pipetting, blenders, pouring, non-self contained centrifuges,
sonicators, vortex mixers, flaming a loop that may generate
respirable-size particles (<0.05 mm in diameter) that remain
airborne for protracted periods.
120 A Guide to Infection Control in the Hospital
Other materials that can act as droplet nuclei include lyo-
philized cultures, dried materials on laboratory benches and
stoppers and bacterial and fungal spores.
Procedures and equipment that generate respirable size parti-
cles also generate larger size droplets (>0.1 mm in diameter)
that can contain multiple copies of an infectious agent. These
larger size droplets settle out of the air rapidly, contaminat-
ing gloved hands, work surfaces and possibly mucous mem-
branes of the persons performing the procedure.
Technique can significantly impact aerosol output and
dose—experiments show that aerosol burden with maximal
aeration is about 200 times greater than aerosol burden with
minimal aeration.
Inoculation
Parenteral inoculation of infectious materials with syringe
needles or other contaminated sharps such as blades and bro-
ken glassware.
One of the leading causes of laboratory-associated infections.
Contamination of skin and mucous membranes
Spills, sprays and splashes into eyes, mouth or nose and
hand-to-face actions.
Spills, sprays and splashes on intact or non-intact skin.
Contaminated surfaces and equipment.
Ingestion
Occurs through mouth pipetting, transfer of organisms to the
mouth from contaminated items such as pencils or fingers.
Consumption of food or drink in the laboratory.
Accidental splashes that fall into the mouth.
Levels of Containment
In general, the strategy for minimizing the occupational expo-
sure of laboratory workers to infectious agents is based on
microorganism containment which includes physical factors
such as facility design and safety equipment, standard micro-
biological practices, and administrative controls. Microorgan-
isms encountered and the procedures performed are stratified by
risk. The primary risk criteria used to define the four ascending
levels of containment, biosafety levels (BSL) 1 through 4 are
Laboratory Areas 121
infectivity, severity of disease, transmissibility and the nature of
the work being conducted. Each increasing BSL number implies
increased occupational risk from exposure to a microorganism
or performance of a procedure and thus, is associated with more
stringent control and containment practices:
Primary containment: provides physical separation of the
infectious agent from the laboratory worker.
Primary barriers: strict adherence to microbiological prac-
tices and techniques and use of biological safety cabinets
(BSCs; Table 20.1), safety centrifuge containers, and PPE
(for example, gloves, masks, face shields, coats, gowns, res-
pirators), sharps protection.
Table 20.1 Classes and types of BSCs
BSC CLASS Type of Protection Miscellaneous Comments
I Personnel and Partial containment
environmental a,b cabinets
II A1, A2, Personnel, environmental All have HEPA-filtered,
B1, and B2 and product c vertical laminar airflow.
Cabinet types vary by minimum
air velocity, exhaust, type of
ducting, agents allowed for use
(eg. biological,volatile radio-
nucleotides, toxic chemicals)
III Personnel, environmental Totally enclosed with
and product gas-tight construction
Provides a physical barrier
between the user and the
agents for maximum
protection
a Personnel protection: protects personnel from harmful agents used inside the cabinet
b Environmental protection: protects the environment from harmful agents/contaminants generated
or used in the cabinet
c Product protection: protects products/experiment from contaminants in the room environment
and from cross contamination inside the cabinet
122 A Guide to Infection Control in the Hospital
Secondary containment: includes facility design and serves
as a secondary barrier to protect all works within the facility
and protect the outside environment.
A brief overview of practices and techniques, safety equip-
ment and facilities for recommended BSLs is shown in Table
20.2. In addition, the more common agents that cause laborato-
ry-acquired infections with their corresponding routes of trans-
mission and primary practices, containment and facilities in the
laboratory are summarized in Table 20.3. In light of significant
national and international events, biosecurity measures have
been implemented and subsequently expanded to protect micro-
bial agents from loss, theft, diversion or intentional misuse. In
the US, Select Agent regulations have led laboratory managers,
scientists, scientific and institutional leaders and others to imple-
ment and improve the security of biological agents and toxins
within their facilities; advisory recommendations for biosecu-
rity programs are detailed in the CDC Biosafety in Microbiolog-
ical and Biomedical Laboratories (BMBL), 5th edition. Agents
that could pose as severe threats to animal or plant health (i.e.
select agents) are identified in Table 20.3. Detailed information
regarding biosafety levels that are recommended for specific
bacteria, fungus, parasites and viruses can be found in textbooks
and a variety of websites such as those listed below:
http://www.cdc.gov/od/ohs/biosfty/bmbl5/bmbl5toc.htm
http://whqlibdoc.who.int/publications/2004/9241546506.pdf
http://www.phac-aspc.gc.ca/ols-bsl/lbg-ldmbl/index.html
http://www.cdc.gov/mmwr/preview/mmwrhtml/su6101a1.htm
Risk Assessment
The assignment of an infectious agent to a biosafety level must be
based on a risk assessment. Occupational risk assessment criteria
are influenced by the type of manipulations or activities per-
formed with the agent, the experience of the laboratory worker,
and the infectious agent. Thus, each task, procedure, or activity
performed in the laboratory must be analyzed for its potential
risk to the employee who performs the task. The international
community has developed a common risk classification scheme
in which infectious agents are categorized into 4 risk groups based
on their relative risk to cause laboratory-associated infections.
Laboratory Areas 123
Table 20.2 Summary of Essential Components of BSLs for Activities Involving Infectious Agents
(Adapted from CDC-NIH guidelines, 2007).
BSL Practices Primary Barriers and Safety Equipment Facilities (2˚ Barriers)
1 Standard microbiological practices: eg. hand hygiene; – Wear PPE (laboratory coats, gloves and/ – Bench tops impervious to water,
no mouth pipetting, eating, drinking, smoking, applying or protective eyewear or face protection resistant to heat, organic solvents.
cosmetics or storing food; policies for safe handling of when indicated) – Laboratory chairs covered with
sharps; decontaminate work surfaces after completion non-porous material.
of work or any spill; universal biohazard symbol signage; – Sink for handwashing
pest management program; appropriate training.
2 BSL-1 practice plus: biohazard signs, limited access, – Class I or II BSCs and other physical BSL-1 plus autoclave available
‘sharps’ precautions, biosafety manual defining waste containment devices used for all manipulations
decontamination and medical surveillance, demonstrated of agents that result in splashes or aerosols
proficiency in standard and special microbiology practices – PPEs (laboratory coats, gloves,
before working with BSL-2 agents. face protection) as needed
3 BSL-2 plus controlled access, decontamination of all waste, – Class I or II BSCs and other physical – BSL-2 plus controlled access,
124 A Guide to Infection Control in the Hospital
protective clothing and baseline serum of laboratory containment devices used for all self-closing, double door access,
personnel for certain agents (eg. hepatitis B virus). open manipulations of agents air exhaust to outside, negative
– PPEs as for BSL-2 plus respiratory airflow into laboratory
protection as needed
4
BSL-3 plus clothing change before entering and – All procedures conducted in class III BSCs or – BSL-3 plus separate building or
showering on exit, all material decontaminated Class I or II BSCs in combination with full body, or isolated zone, dedicate supply
on exit from facility air-supplied, positive-pressure personnel suit and exhaust, vacuum, and
decontamination systems
Table 20.3 The More Common Causes of Hospital Clinical Laboratory-Acquired Infections
(Adapted from WHO, 2004 and CDC, 2007 publications)
Agent Laboratory-Acquired Infections: Primary Practices, Containment SELECT AGENT
Sources and Routes of Transmission and Facilities
Bacillus anthracis Primarily cutaneous anthrax by either direct and indirect BSL-2 Yes
contact of broken skin with culture and contaminated
surfaces or accidental parenteral exposure.
Brucella species Most frequently reported laboratory infection by airborne BSL-2 Yes
and mucocutaneous routes. Cases have occurred by
sniffing cultures or working on open bench tops aerosols,
mouth pipetting, accidental parenteral inoculation,
sprays into eyes, nose and mouth.
Burkholderia mallei Aerosol and cutaneous exposures usually while BSL-2 when handling clinical specimens; BSL-3 Yes
and Burkholderia handling bacterial cultures. whenever infectious aerosols or droplets are
pseudomallei generated. Gloves should be worn particularly
when working with infectious material.
E. coli—Shiga toxin Unknown route of transmission but suggested that BSL-2. Gloves should be worn when hands No
producing prolonged survival on stainless steel surfaces and may come in contact with potentially
low infectious dose may contribute to laboratory infectious materials.
transmission by accidental ingestion.
Laboratory Areas 125
Table 20.3 The More Common Causes of Hospital Clinical Laboratory-Acquired Infections (continued)
(Adapted from WHO, 2004 and CDC, 2007 publications)
Agent Laboratory-Acquired Infections: Primary Practices, Containment SELECT AGENT
Sources and Routes of Transmission and Facilities
Franciscella tularensis Tularemia commonly reported laboratory-associated BSL-2 when handling clinical specimens. Yes
infection by direct contact of skin and mucous Laboratory personnel should be informed of
membranes with infectious material. the possibility of tularemia when specimens
are submitted for diagnostic testing. BSL-3 for
all other manipulations or suspect cultures.
Leptospira species Ingestion, parenteral inoculation, direct and indirect BSL-2. Gloves should be worn when No
contact of skin or mucous membranes with cultures handling cultures.
or infected tissues or body fluids.
Mycobacterium Primary acquisition by exposure to laboratory-generated BSL-2 for non-aerosol-producing manipulations No
126 A Guide to Infection Control in the Hospital
tuberculosis aerosols; tubercle bacilli may survive on heat-fixed smears. of clinical specimens. BSL-3 for laboratory
complex activities associated with the propagation and
manipulations of cultures.
Neisseria gonorrhoeae Rare. Accidental parenteral inoculation and direct BSL-2. Gloves should be worn when hands may No
or indirect of mucous membranes with contact come in contact with potentially infectious materials.
infectious or contaminated solutions.
Table 20.3 The More Common Causes of Hospital Clinical Laboratory-Acquired Infections (continued)
(Adapted from WHO, 2004 and CDC, 2007 publications)
Agent Laboratory-Acquired Infections: Primary Practices, Containment SELECT AGENT
Sources and Routes of Transmission and Facilities
Neisseria meningitidis Parenteral inoculation, droplet exposure of mucous BSL-2 for specimens and cultures. All sterile-site No
membranes, infectious aerosol and ingestion. isolates should be manipulated in a BSC.
Salmonella and Risk primarily from the ingestion of the organism or BSL-2 No
Shigella species infectious material (numerous cases of laboratory-
acquired infections have resulted from handling proficiency
testing strains); less common, parenteral injection.
Treponema pallidum Parenteral inoculation, contact with mucous membranes BSL-2 No
or broken skin with infectious clinical materials.
Yersinia pestis Direct contact with cultures and infectious materials, BSL-2; BSL-3 for laboratory activities associated Yes
inhalation of infectious aerosols or droplets during with high potential for droplet or aerosol production.
manipulation.
Blastomyces Inoculation and presumably by inhalation of conidia. BSL-2; BSL-3 for propagating and manipulating No
dermatitidis sporulating cultures.
Laboratory Areas 127
Table 20.3 The More Common Causes of Hospital Clinical Laboratory-Acquired Infections (continued)
(Adapted from WHO, 2004 and CDC, 2007 publications)
Agent Laboratory-Acquired Infections: Primary Practices, Containment SELECT AGENT
Sources and Routes of Transmission and Facilities
Coccidioides immitis Inhalation of arthrospores and accidental BSL-2 for clinical specimens; BSL-3 for No
percutaneous inoculation. propagating and manipulating sporulating cultures.
Histoplasma Inhalation of conidia, accidental BSL-2 for clinical specimens; BSL-3 for
capsulatum cutaneous inoculation. propagating and manipulating sporulating cultures. No
Blood and tissue Majority of laboratory-acquired infections involved BSL-2 No
protozoal parasites need-stick or other cutaneous exposure to infectious
stages through abraded skin.
128 A Guide to Infection Control in the Hospital
Intestinal protozoal Primarily by ingestion BSL-2 No
parasites
Trematodes Primarily through accidental needlesticks and by BSL-2 No
contamination of mucosal membrane and skin abrasions
Nematodes Ingestion of infective eggs or skin penetration by BSL-2 No
infective larvae
Table 20.3 The More Common Causes of Hospital Clinical Laboratory-Acquired Infections (continued)
(Adapted from WHO, 2004 and CDC, 2007 publications)
Agent Laboratory-Acquired Infections: Primary Practices, Containment SELECT AGENT
Sources and Routes of Transmission and Facilities
Rickettsial agents— Exposure to infectious aerosols and BSL-2 for non-propagative laboratory procedures Yes
Coxiella burnettii and parenteral inoculation
Rickettsia prowazekii
Common blood-borne Parenteral inoculation, droplet exposure of mucous BSL-2; BSL-3 may be indicated for activities No
viruses—hepatitis membranes, and contact exposure of broken skin with potential for droplet or aerosol production,
viruses (A, B, C, and D) other activities involving concentrations of
and HIV infectious materials. Gloves should be worn
when working particularly with infectious material.
Parvovirus B19 Exposure to infectious aerosols BSL-2 No
Arboviruses and related Exposure to infectious aerosols, inoculation, and/or contact BSL-2 through 4 based on risk assessment Many are
zoonotic viruses: with skin or mucous membranes derived from information provided by a variety classified as
597 viruses listed in of sources, viral mode of transmission, frequency select agents
CDC document. and severity of laboratory- acquired infections,
and the availability of a vaccine
Laboratory Areas 129
These groups are categorized based on particular characteris-
tics of the infectious agent such as their pathogenicity, infec-
tious dose, mode of transmission, host range, and availability
of effective preventive measures and effective treatment. These
risk groups were developed to help laboratories determine the
best laboratory practices and environmental requirements for
containment. Other factors associated with laboratory opera-
tions including specimen volume, potential for aerosol gener-
ation, quantity and concentration of infectious agents, agent
stability in the environment, and type of work proposed should
also be taken into consideration.
Administrative Elements of a Safe Clinical Laboratory
Biosafety, exposure control, and chemical hygiene plans
including accidental spills of infectious organisms or release
of infectious microorganisms into the laboratory or facility
environment.
Comprehensive plan for management and disposal of infec-
tious waste including blood and blood products.
Respiratory protection program.
Personal protective equipment program and procedures.
Provision of medical surveillance for infections that may
result from exposure to agents encountered in the perfor-
mance of routine duties or when early diagnosis reduces the
risk of serious consequences of the infection (eg. rickettsial
infections).
Safety manual that is understood by employees and includes
the occupational risks and consequences of infection.
Promotion of safety awareness through training programs
and required adherence to safety procedures.
Consistent observance by all workers of proven safety and
microbiological practices.
Documentation and reporting of all occupational injuries,
illnesses and incidents of potential exposure.
130 A Guide to Infection Control in the Hospital
References
Baron EJ, Miller M. Bacterial and fungal infections among diagnostic
laboratory workers: Evaluating the risks. Diagn Microbiol Infect Dis.
Centers for Disease Control and Prevention. Biosafety in Microbiologi-
cal and Biomedical Laboratories (BMBL), (5th edition) U.S. Depart-
ment of Health and Human Services and the Institutes of Health, US
Government Printing Office, Washington. 2007.
Centers for Disease Control and Prevention. Guidelines for safe work
practices in human and animal medical diagnostic laboratories: Rec-
ommendations of a CDC-convened, Biosafety Blue Ribbon Panel.
- 1. Superheating: flushing outlet for at least 5 minutes with
- 2. Hyperchlorination: >10 mg/L of free residual chlorine.
- 1997. Pgs. 491–514.
- 2014. 20:310–14.
- workers from occupationally acquired infections (M29-A3);
- 2008. 60:241–246.
Mmwr. 2012. 61:1–105.
Clinical Laboratory Standards Institute. Protection of laboratory work-
ers from occupationally acquired infections: Approved guideline
(3rd edition). CLSI document A49-A3 2005.
Collins CH, Kennedy DA. Laboratory Acquired Infections (4th edi-
tion). Butterworth-Heineman, Oxford, England, 1999.
Harding AL, Byers, KB. Epidemiology of laboratory-associated infec-
tions in Biological Safety: Principles and Practices (3rd edition),
Fleming, DO, Hunt, DL, (Eds). Washington, DC: ASM Press, 2000.
Pgs. 35–54.
Health Canada. Laboratory Biosafety Guidelines (3rd edition). Ottawa,
Canada, 2004.
Pike RM. Laboratory-associated infections. Health Lab Sci. 1976.
13:105–114.
Pike RM. Laboratory-associated infections: Incidence, fatalities, causes
and prevention. Annu Rev Microbiol. 1979. 33:41–66.
Sewell DDL. Laboratory-associated infections and biosafety. Clin
Microbiol Rev. 1994. 8:389–405.
Singh K. Laboratory-associated infections. Clin Infect Dis. 2009.
142–147.
Sulkin SE, Pike RM. Viral infections contracted in the laboratory. N
Engl J Med. 1949. 241:205–213.
Wilson ML, Reller LB. Clinical laboratory-acquired infections in Hos-
pital Infections, Bennett JV, Brachman PS (Eds). Pgs. 343–355.
World Health Organization Laboratory Biosafety Manual (3rd edition).
World Health Organization, Geneva, Switzerland, 2004.
Laboratory Areas 131
Chapter 21
The Pharmacy
Patricia Pecora Fulco, PharmD.
Key Issue
The pharmacy plays a pivotal role in infection prevention and
safety in the hospital.
Known Facts
Infections occur when pharmacological formulations are
contaminated with microbes. This may occur during manu-
facture, or when medications are improperly prepared, han-
dled, stored, or become outdated.
Contamination may occur within the pharmacy or in other
areas of the hospital when healthcare workers finalize the
preparation of medications and administer them.
Contamination of medications and solutions occurs through
3 routes:
Contamination of intravenous fluids is particularly problem-
atic because of the potential to cause serious illness.
Inappropriate prescribing of antimicrobials is an important
cause of drug-resistance. Pharmacists should participate in
an antimicrobial stewardship program (ASP) (in coordi-
nation with an infectious diseases physician and microbi-
ologist) to optimize antimicrobial usage in the healthcare
setting. The goal of an ASP is to decrease antimicrobial
resistance, secondary infections (e.g., Clostridium difficile)
and to prevent toxicities. ASPs are cost effective and have
demonstrated a decrease in suboptimal antimicrobial use.
Optimizing antimicrobial dosing for patient-individualized
characteristics (organism, pharmacokinetic/pharmacody-
namic parameters and renal/hepatic alterations) is an addi-
tional role fulfilled by the clinical pharmacist.
132 A Guide to Infection Control in the Hospital
Many pharmacies now monitor antimicrobial concentrations
(e.g., vancomycin) to ensure optimal pharmacotherapy for
the correct infectious diseases indication and adjust dosing
according to established algorithms.
Pharmacists often dispense discharge medications to
patients. Patient education may ensure that antimicrobials
are used properly after discharge.
Controversial Issues
Although national regulatory agencies and hospital committees
have set standards for aseptic practices within the pharmacy, the
extent to which asepsis needs to be confirmed is controversial.
Should all products that are compounded in the pharmacy be
tested by culturing samples? Should products obtained from an
outside vendor be tested? Due to the emergence of large com-
panies that supply intravenous solutions to multiple hospitals,
infections caused by low-level contamination may be scattered
over a large number of hospitals. An individual hospital may see
only one infusate or injection medication related infection, which
would not normally trigger an investigation within the hospital.
Although controversial, a national surveillance system could
be developed to monitor bloodstream isolates and, potentially,
serve as a means to trace the source of such scattered infections.
Rational use of antimicrobials has been shown to reduce the
emergence of resistance pathogens. The pharmacy, working as a
member of an ASP committee, should play a key role in devel-
oping institution guidelines for the rational use of antimicrobi-
als to prevent drug resistance, minimize adverse drug events,
enhance patient outcomes and prevent hospital acquired infec-
tions. Controversy exists over how much autonomy should be
given to the individual provider. In some cases, a short course
of therapy is allowed until laboratory results return. In other
cases, medications have been made available only for highly
selected indications. Controversy usually arises when policies
are perceived to impair a prescriber’s ability to treat a patient
effectively, or when restrictions are perceived as being driven
by finances rather than health concerns.
Suggested Practice
The pharmacy should implement and follow procedures from
the United States Pharmacopeia, Chapter 797, to prevent
The Pharmacy 133
compounded sterile products (CSPs) from the following:
Employees should be trained in aseptic technique before
making preparations or administering medications.
Limit the activities of staff members who exhibit symptoms
of infection.
Single-dose vials should be used within one and six hours,
respectively, if compounded outside or inside a laminar air-
flow workbench (ISO Class 5 environment). Multiple-dose
vials may be discarded after 28 days from initial use. All
vials should be labeled with beyond use dates.
For products that are reconstituted, only sterile diluents
should be used. Utmost care should be taken not to intro-
duce contaminants from the outside of containers into the
interior. If liquid is to be injected through a vial membrane,
the membrane should be disinfected before being pierced.
Syringes that are used to inject medications or liquids into
the container should be sterile and preferably single-use dis-
posable ones.
Recommend proper labeling, dating, and storage of sterile
products.
Establish ASP strategies for minimizing the development of
resistant strains of microorganisms as well as for optimizing
therapeutic outcomes in individual patients. Individual phy-
sicians or departments should be involved in the develop-
ment and implementation of policies that affect them.
A tracking system should be devised in case of a product
recall. The tracking system should allow identification of
patients who received potentially contaminated medications.
Pharmacy areas should be kept clean. Food should not be
consumed in areas where CSPs are handled. Clean rooms,
where CSPs are prepared, should be free of visible dust, and
access should be limited. Detailed policies should be main-
tained for the activities allowed in the clean room.
134 A Guide to Infection Control in the Hospital
Personnel preparing sterile medications should wear clean
clothing covers and gloves along with completing annual com-
petencies to ensure proper aseptic technique. Hands should
be washed before and after CSPs are prepared. Employees
should not prepare sterile products if they have rashes, sun-
burn, weeping sores, broken skin, conjunctivitis or respiratory
infections. When preparing sterile or potentially toxic solu-
tions such as chemotherapies, laminar airflow workbenches
(ISO Class 5 environment) are strongly recommended.
The pharmacy should ensure that medications are appro-
priately handled and stored throughout the institution.
Medications should be stored according to manufacturers’
instructions. All CSPs should have an appropriate beyond-
use-date (expiration) printed on the outside of the container.
Environmental conditions should be checked periodically,
including the daily temperature log of refrigerators and the
competency of laminar airflow workbenches.
The pharmacy should educate providers to help minimize
medication side effects.
The infection control committee should include representa-
tion from the pharmacy.
An ASP pharmacist should have specialty training in infec-
tious diseases.
Summary
The pharmacy plays various roles in infection prevention and
safety. The pharmacy should ensure that medications and solu-
tions are not contaminated. Policies should address training and
annual performance evaluation of employees, and they should be
reviewed annually to ensure they reflect current best practices.
Employees with acute respiratory, gastrointestinal, and skin infec-
tions should not be permitted to handle medications. To promote
rational use of antimicrobials, pharmacists should work closely
with hospital committees and physicians, encourage multi-dis-
ciplinary collaboration within the health system and evaluate
compliance with policies. Importantly, pharmacists often have
an opportunity to counsel patients about medication adherence,
proper storage and handling of medications/devices, and medical
waste disposal. In all of these areas, the pharmacy may have a
major impact on the success of an infection control program.
The Pharmacy 135
References:
American Society of Health-System Pharmacists. ASHP Statement on
the Pharmacist’s Role in Infection Control. Am J Health-Syst Pharm.
American Society of Health-System Pharmacists. ASHP Statement on
the Pharmacist’s Role in Antimicrobial Stewardship and Infection
Prevention and Control. Am J Health-Syst Pharm. 2010. 67:575–7.
Chiller TM, Roy M, Nguyen D, Guh A, Malani AN, Latham R, et al.
Clinical findings for fungal infections caused by methylprednisolone
injections. N Engl J Med. 2013. 369:1610–9.
Climo MW, Israel DS, Wong ES, Williams D, Coudron P, Markowitz
SM. Hospital-wide restriction of clindamycin: Effect on the inci-
dence of Clostridium difficile-associated diarrhea and cost. Ann Int
Med. 1998. 128:989–95.
Dellit TH, Owens RC, McGowan JE, Gerding DN, Weinstein RA,
Burke JP, et al. Infectious Diseases Society of America and the So-
ciety of Healthcare Epidemiology of America Guidelines for devel-
oping an institutional program to enhance antimicrobial stewardship.
Clin Infect Dis. 2007. 44:159–77.
Kastango ES. American Society of Health-System Pharmacists (ASHP).
Blueprint for Implementing USP Chapter 797 for Compounding
Sterile Preparations. Am J Health-Syst Pharm. 2005. 62:1271–88.
Mattner F, Gastmeier P. Bacterial contamination of multiple-dose vials:
A prevalence study. Am J Infect Control. 2004. 32:12–6.
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP National Survey
of Pharmacy Practice in Hospital Settings: Monitoring and Patient
Education—2006. Am J Health-Syst Pharm. 2007. 64:507–20.
Rybak M, Lomaestro B, Rotschafer JC, Moellering R, Craig W, Billeter
M, et al. Therapeutic monitoring of vancomycin in adult patients: A
consensus review of the American Society of Health-System Phar-
macists, the Infectious Diseases Society of America, and the Society
of Infectious Diseases Pharmacists. Am J Health-Syst Pharm. 2009.
66:82–98.
Schwartzberg E, Rubinovich S, Hassin D, Haspel J, Ben-Moshe A,
Oren M, et al. Developing and Implementing a Model for Changing
Physicians’ Prescribing Habits—The Role of Clinical Pharmacy in
Leading the Change. J Clin Pharm Ther. 2006. 31:179–85.
Smith RM, Schaefer MK, Kainer MA, Wise M, Finks J, Duwve J, et al.
Fungal infections associated with contaminated methylprednisolone
infections. N Engl J Med. 2013. 369:1598–609.
United States Pharmacopeia. Pharmaceutical Compounding—Sterile
Preparations. 2012. Chapter 797, Pgs. 1–38.
136 A Guide to Infection Control in the Hospital
- 1. Direct contact;
- 2. Use of contaminated ingredients; and
- 3. Air-borne contamination.
- 1. Microbial contamination;
- 2. Exposure to excessive bacterial endotoxins;
- 3. Variability in the intended strength of correct ingredients;
- 4. Unintended chemical and physical contaminants; and
- 5. Ingredients of inappropriate quality.
- 1998. 55:1724–6.
Chapter 22
The Operating Room
Marie-Claude Roy, MD, MSc
Key Issues
Two to five percent of patients undergoing surgical procedures
suffer from surgical site infections (SSIs). These infections
continue to burden patients with important morbidity, mortality
and immense costs, the latter mainly explained by a doubling of
the hospital length of stay. Because SSIs are primarily acquired
during the surgical procedure while the wound is opened, a
number of infection control practices merit scrutiny in the OR.
The measures presented herein address environmental and sur-
gical issues as well as some patient-related risk factors which
are controlled once the patient is in the OR.
Known Facts
Most SSIs arise from the patient’s endogenous flora which
contaminate the wound by direct contact. Therefore, preparing
patients for surgery should aim at decreasing the microbiologic
burden of the patient’s bowels, skin, respiratory tract, geni-
tal tract, etc…, depending on the procedure being performed.
Examples of measures which decrease the microbiologic bur-
den include: showering the patient with chlorhexidine before
surgery, giving antimicrobial prophylaxis immediately before
skin incision and applying mupirocin to the nares. Accord-
ingly, the extent of endogenous bacterial contamination at sur-
gery depends on the type of procedure being performed: clean,
clean-contaminated, contaminated or dirty. The risk of SSI
increases from <2% for the former to as high as 40% for the
latter. The traditional wound classification is only a moderate
predictor of the risk of SSI because other factors, host and sur-
gical factors, also influence this risk.
Exogenous contamination of wounds is also important in
the pathophysiology of SSIs, particularly for clean surgical
The Operating Room 137
procedures. Airborne particles contaminated with live bacteria
can enter sterile surgical fields during operation, particularly
when implants are being placed (e.g., total hip prostheses).
The main source of airborne bacteria in the OR originate pri-
marily from the skin of individuals in the room. The number of
persons present in the OR as well as their level of activity, the type
of surgery, the quality of air provided, the rate of air exchange, the
quality of staff clothing, the quality of cleaning process and the
level of compliance with infection control practices all influence
airborne contamination. Although these may seem trivial issues
for contaminated or dirty procedures, they are very important to
consider in clean and clean-contaminated surgery.
Suggested Practices
Environmental Issues
The surgical suite should be divided into three designated areas:
unrestricted, semi-restricted and restricted. Personnel can wear
street clothes and there is no traffic limitation in the unrestricted
area. A semi-restricted area is limited to authorized person-
nel only and patients. Surgical attire is recommended as well
as headgear in this area. In the restricted area (i.e. ORs, clean
core, scrub sink areas), surgical attire and head covering but
also masks are required where open sterile supplies or scrubbed
persons are present.
Modern operating rooms which meet current air standards in
the United States should be virtually free of particles larger than
0.5mm when no people are in the room. To achieve this, ORs
should be equipped with positive-pressure systems to ensure
that air travels from ORs to adjacent areas, thus minimizing
inflow of air to the room. This positive pressure system is chal-
lenged every time a door is opened.
Ventilation of ORs should filter air at a minimum of 15
changes/hour of which at least three changes should be with
fresh air. In developed countries, this air should be high-effi-
ciency filtered (HEPA). The temperature of ORs should be kept
between 18˚C and 24˚C, with humidity of 30% to 60%.
For hospitals with limited resources where the aforemen-
tioned recommendations could not be attained, less expensive
strategies to keep air as clean as possible are listed here:
138 A Guide to Infection Control in the Hospital
keep doors closed; and
keep entries into the OR to a minimum during a procedure.
Cleaning and disinfection of the operating theatre should
follow a precise schedule: all horizontal surfaces should be
cleaned every morning before any intervention, horizontal
surfaces and all surgical items (e.g., tables, buckets) should be
cleaned between procedures. At the end of the working day, a
complete cleaning of the operating theatre should be performed.
Once a week, a complete cleaning of the operating room area,
including all annexes such as dressing rooms, technical rooms,
cupboards is advisable.
On the other hand, routinely culturing the OR environment
is unnecessary because inanimate objects and surfaces are sel-
dom the cause of SSI.
Preparation of the Surgical Team
All members of the surgical team who will work on the operat-
ing field should scrub arms and hands with chlorhexidine, iodo-
phors or hexachlorophene for at least 5 minutes before the first
procedure of the day, and for 2 to 5 minutes between subsequent
procedures. The first scrub of the day should include a thorough
cleaning underneath fingernails. The use of an alcoholic chlor-
hexidine solution has a greater residual antimicrobial activity,
which could give a theoretic advantage during a long surgical
procedure. Hand rubbing with aqueous alcoholic solution may
be as effective as traditional hand scrubbing and also better tol-
erated by the surgical team.
All jewelry should be removed, and artificial nails must not
be worn as these are associated with enhanced hand coloniza-
tion with bacteria and fungi.
After performing the surgical scrub, members of the surgical
team should keep hands up and away from the body so that the
water runs from the tips of the fingers toward the elbows.
Sterile gloves should be of good quality, as approximately
10% of gloves are inadvertently punctured during surgery.
Wearing two pairs of gloves is advisable in orthopedic surgery
where as many as 50% of gloves are punctured. Because 30%
of glove perforations are invisible, some experts recommend
routinely changing gloves in long procedures. Gloves should
The Operating Room 139
be changed immediately after any accidental puncture. Some
experts also recommend routine changing of the outer gloves
after draping, as this procedure is likely to contaminate gloves.
The operative site should be scrubbed with a detergent and
an antiseptic soap should be applied, working from the pro-
posed operative site outward. Antiseptics recommended for this
practice include chlorhexidine, iodophors, and iodine. The best
reduction in bacteria at the surgical site has been achieved with
chlorhexidine-alcohol when compared with povidone-iodine in
a surgical population undergoing clean-contaminated surgery.
In this report, a greater than 40% decrease in total SSI rates was
achieved in the chlorhexidine-alcohol group.
Sterile drapes must be placed on the patient and on any
equipment included in the sterile field. Once a sterile drape is in
position, it must not be moved.
Members of the surgical team entering the OR when an oper-
ation is about to begin or already underway should wear a mask
and headgear which fully covers hair, sideburns and neckline.
Experimental studies using tracer particles have shown that bac-
teria can be shed from hair, exposed skin, and mucous mem-
branes of both OR personnel and the patient’s skin. This is why
we use barriers (masks, gowns, hoods and drapes) in the OR.
Although no clinical studies have proved that the use of these
barriers have led to a decrease in SSI rates, they are recom-
mended not only for the purpose of reducing shedding of micro-
organisms in the OR but also as part of standard precautions.
Shoe covers can be replaced by ordinary shoes dedicated
exclusively to the operating theater, because no significant dif-
ference was found in floor contamination whether personnel
wear shoe covers or ordinary shoes. These latter shoes must be
easy to wash.
Scrub suits should cover most bare skin to decrease shedding
of microorganims from uncovered skin, because individuals
shed up to 10 9 epithelial cells per day, many of which carry bac-
teria. This practice should be followed by all personnel working
in the OR, not just those working in or near the operating field.
Strike-through in operating gowns is also a potential source
for contamination, particularly at the sleeve or abdominal area.
For procedures at high risk of blood contamination, a water-
proof apron or more resistant gowns should be worn.
140 A Guide to Infection Control in the Hospital
Meticulous operative techniques reduce the risk of SSI: sur-
geons should obliterate dead spaces, where possible, they should
handle tissues gently, limit use of electrocautery and remove all
devitalized tissue before closure. Good surgical technique may
be reflected in shorter durations of procedures which are clearly
associated with a lower risk of SSI.
Scheduling dirty cases at the end of the day is a practice
which should be abandoned.
Antibiotic-coated sutures should not be used for the purpose
of decreasing SSI rates.
Any member of the surgical team who suffers from a skin lesion
such as a boil should refrain from working in the OR for such an
individual may be dispersing tremendous amounts of bacteria,
namely Staphylococcus aureus, in the air of the OR. Dermatitis
of the hands sometimes caused by glove allergy should also be
taken seriously for the same reason.
Patients Issues
Antibiotic prophylaxis is a very important preoperative prac-
tice and excellent guidelines have recently been published.
The choice of antibiotic according to the procedure, the dose
according to the patient’s weight and the timing of adminis-
tration are all important issues to consider and are part of the
process measures of the Surgical Care Improvement Project
(SCIP) launched in the US in 2002. Proper antimicrobial pro-
phylaxis involves administering the first dose within 60 minutes
before incision to obtain adequate tissue levels of antibiotic.
Thus, the antibiotic should be administered in the OR by a des-
ignated person who should also make sure that it is repeated if
the intervention is prolonged (for example, cefazolin should be
repeated every 3–4 hours if the procedure lasts longer than 4
hours). Using a checklist for preoperative briefing ensures that
the antibiotic is correctly administered in the OR.
Any perioperative event that causes vasoconstriction, for
example hypothermia or subtle hypovolemia, alters the oxygen-
ation of normal soft tissues, which in turn may result in higher
infection rates. The effect of hypothermia on the development
of SSI has been studied particularly well in patients undergoing
colorectal surgery, but also in breast, varicose vein, and hernia
surgeries.
The Operating Room 141
Avoiding hypothermia reduces SSI rates and has led to
the mandate from the Joint Commission of the Surgical Care
Improvement project (SCIP) in the US to warm patients to
36˚ C in the OR and within 15 minutes of their arrival in the
post-anesthesia care unit. Recent draft guidelines recommend
maintaining normothermia for all types of procedures but the
best approach to do this is not yet determined.
Hyperglycemia is a risk factor for SSI independent from dia-
betes. It has been associated with an increase in SSI after col-
orectal, spinal surgery, pancreatic, vascular, cardiac surgery and
mastectomy. A more stringent glucose control should be fol-
lowed intra-operatively as well as post-operatively. Experts rec-
ommend less than 200 mg/dL for a maximum glucose target for
all operations and for diabetic patients as well as non-diabetics.
Another process measure included in SCIP is hair removal.
As hair removal with a razor is clearly associated with increased
risk of SSI, hair removal before surgery should be done with a
clipper immediately before the intervention if necessary, or no
hair removal.
Controversial Issues
ORs equipped with laminar airflow system provide almost
sterile air, yet a very few studies show a significant decrease in
SSI rates for surgical procedures performed in this type of OR.
Some of these experiments did not control for the antimicro-
bial regimen received as surgical prophylaxis, thus precluding
any conclusion on the exact role of the laminar flow system.
Furthermore, a recent review evaluating SSIs following ortho-
pedic prostheses, concludes it would be a waste of resources to
establish new ORs with laminar airflow and even questionable
as to whether laminar flow systems in existing ORs should be
replaced by conventional ventilation systems. The CDC offers
no recommendation for performing orthopedic implant opera-
tions in rooms supplied with laminar airflow.
The association between wearing nail polish by surgical team
members and the risk of SSI has not been studied adequately.
The design and composition of surgical attire should mini-
mize bacterial shedding into the environment. Cotton does not
reduce airborne contamination because the pore size between
142 A Guide to Infection Control in the Hospital
threads largely exceeds the size of skin scales. Furthermore,
wet cotton fabric allows easy passage of bacteria to the out-
side of a gown as a result of the surgeon’s sweating or from
fluids such as blood. A number of other fabrics (close-woven
polyester, disposable non-woven, plastic-membrane) have
been tested against strike-through and examined for transfer of
bacteria from skin scales from underneath the clothe. It is not
known which type of fabric reduces airborne contaminants
while also providing comfort.
Likewise, there are also conflicting data regarding the differ-
ence in SSI rates when adhesive plastic drapes are used instead
of conventional one (cotton). It appears that theses adhesive
drapes impregnated or not with antibiotic, are not necessary for
the purpose of decreasing SSI rates.
Not all studies show a benefit of supplemental oxygen to
the wound during surgery. Those who are in favor recommend
starting supplemental oxygen at induction and suggest it should
be given for at least 2 hours after closure. Although the optimal
concentration of oxygen to prevent SSI is unknown, experts rec-
ommend its use for ventilated patients during general anesthesia
and for all types of surgical procedures.
No well-controlled studies evaluate whether restricting the
use of surgical scrubs to the OR suite or allowing them out-
side the OR will make a difference on SSI rates. Some hospitals
require covering gowns when surgeons/nurses leave the OR still
wearing surgical scrubs. It would make sense to change grossly
soiled scrubs, scrubs worn while changing dressings on wards
between surgical procedures, and probably changing scrubs
after wearing them for 8 hours or more. No recommendation
can be made on how and where to launder scrub suits.
Some surgeons irrigate the open wound with an antiseptic or
antibiotic solution before closure. No recommendation can be
made because of insuffisant data to support this measure.
Summary
Preparation of the surgical team and maintaining a clean oper-
ating environment are important because a number of intra-
operative risk factors contribute to the development of SSIs.
Very little has changed over the years concerning the surgical
The Operating Room 143
rituals of scrubbing, gowning and gloving perhaps because of
a lack of scientific data or for ethical reasons. Many of these
rituals still hold today not only for the prevention of SSIs but
also for the protection of the surgical team. In clean surgical
procedures, particularly when an implant is inserted, these ritu-
als merit attention because airborne contamination by members
of the surgical team from their skin contribute to SSIs. Wear-
ing proper surgical attire, keeping OR doors closed and traf-
fic to a minimum are simple measures that decrease airborne
contamination. Applying basic principles of antisepsis in the
OR should be a priority for every member of the surgical team.
Newer approach to prevention of SSIs (eg, glucose control, nor-
mothermia, increased oxygen) may decrease SSI rates, thereby
decreasing morbidity and healthcare costs.
References
Mangram AJ, Horan TC, Pearson ML, et al. Guideline for Prevention of
Surgical Site Infection. Am J Infect Control. 1999. 27:97–134.
World Health Organization. Prevention of Hospital-Acquired Infec-
tions: A Practical Guide. Ducel G, Fabry J, Nicolle L, (Eds). World
Health Organization, 2002.
Roy M-C. Modern Approaches to Preventing Surgical Site Infections.
in Prevention and Control of Nosocomial Infections (4th Edition),
Wenzel RP (Ed). Baltimore: Lippincott Williams & Wilkins, 2003.
Pgs. 369–384.
Lafreniere R. Infection Control in the Operating Room: Current Prac-
tices or Sacred Cows? J Am Coll Surg. 2001. 193:407–416.
American Institute of Architects. Guidelines for Design and Construc-
tion of Healthcare Facilities. 2006.
Boyce JM, Pittet D. Guidelines for Hand Hygiene in Healthcare Set-
tings: Recommendations of the Healthcare Infection Control Prac-
tices Advisory Committee and the HICPAC/SHEA/APIC/IDSA
Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002.
23:S3–S40.
Wong ES. Surgical Site Infections in Infection Control and Hospital
Epidemiology, Mayhall CG (Ed). Baltimore: Lippincott Williams &
Wilkins, 2004.
Gastmeier P, Breier A-C, Brandt C. Influence of laminar airflow on
prosthetic joint infections: A systematic review. J Hosp Infect. 2012.
81:73–78.
144 A Guide to Infection Control in the Hospital
Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines
for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm.
Alexander JW, Solomkin JS, Edwards MJ. Updated recommen-
dations for control of surgical site infections. Ann Surg. 2011.
253:1082–1093.
Darouiche RO, Wall MJ, Itani KMF, et al. Chloehexidine-alcohol ver-
sus povidone-iodine for surgical-site antisepsis. New Engl J Med.
Bratzler DL. Update on the draft CDC/HICPAC guidelines for preven-
tion of SSIs. Symposium presented during Infectious Diasease Week,
San Francisco, October 2013.
The Operating Room 145
Chapter 23
Keeping the Environment Safe in
Infection Prevention and Control :
Focus on Countries with
Limited Resources
Adriano G Duse, MT, MBBCh, DTM&H, MScMed,
MMed (Microbiology), FCPath (SA)
Key Issues
Ever-increasing budgetary constraints and contracting out
cleaning services have resulted in an overall deterioration in
hospital hygiene practices in healthcare facilities (HCFs) of
many developing countries.
The increasing numbers of health care associated infections
(HAIs) and, disturbingly, the emergence of multiple- and exten-
sively-drug resistant HAI pathogens over the last decade are of
major concern. Microorganisms such as methicillin resistant
S. aureus (MRSA), glycopeptide-resistant enterococci (GRE),
C. difficile, and Acinetobacter species, can survive on environ-
mental surfaces for weeks to months.
Although the extent to which environmental cleanliness
contributes to HAIs remains hotly debated and controversial, an
increasing body of recent evidence has shown that removal of
these microorganisms by cleaning with or without disinfection
can reduce HAI pathogen transmission. However, environmen-
tal cleaning, particularly of hand-touch surfaces, is performed
inadequately in many HCFs.
Currently available automated area decontamination tech-
nologies using UV light or hydrogen peroxide vapor or mists
could be a useful adjunct to routine manual cleaning and disin-
fection in some hospital settings.
In addition to reducing environmental reservoirs for micro-
organisms, environmental cleaning has an important aesthetic
purpose and is crucial for patient confidence.
146 A Guide to Infection Control in the Hospital
Environmental aspects covered in this chapter include air,
water, hand-touch surfaces, curtains, carpets, specialized patient
care areas, linen, flowers and waste disposal.
Known Facts
Air. The role of air in the transmission of microorganisms
is best discussed on an organism-specific basis. Airborne
transmission of Mycobacterium tuberculosis, Varicella-zos-
ter, measles and influenza viruses is clearly established,
and guidelines to reduce risks of transmission are available
(CDC). Shedding or dispersal into the air of Gram-positive
organisms such as Staphylococcus aureus and Streptococ-
cus pyogenes in operating theatres or newborn nurseries has
been documented. Legionella pneumophila outbreaks have
been associated with contaminated cooling towers and hot
water systems with subsequent dispersal into the air. Asper-
gillus and other fungal spores are easily dispersed through
the air during building constructions/renovations/mainte-
nance and are of major concern in wards with neutropaenic
patients.
Water. There are numerous reports in the literature detail-
ing the association of health care associated infections
with medical devices (e.g., respiratory therapy equipment,
fibre-optic endoscopes etc.) that have been exposed to con-
taminated hospital water reservoirs (e.g., potable tap water,
sinks, faucet aerators, etc.) Furthermore, environmental
water reservoirs have been convincingly associated with
infection involving aerosolization from these sources: faucet
aerators associated with Pseudomonas infections and show-
erheads associated with Legionella. Ice machines have been
implicated in the transmission of various pathogens includ-
ing Cryptosporidium parvum.
Several reports have linked hydrotherapy pools and tanks
with the infection. The combination of organic debris from
infected patients and elevated temperatures in these reser-
voirs favours growth of microorganisms.
Carpets. The evidence that floors are directly associated
with infection risks is scant. However, microbes are present
in greater numbers on carpeting and if carpets are installed
Keeping the Environment Safe with Limited Resources 147
they should be washable, have waterproof backing and
sealed joints, and not be damaged by application of com-
monly used disinfectants. Noroviruses can remain viable
for up to 10 days in carpets and it is therefore essential to
clean them thoroughly. Steam cleaning is recommended for
carpets and soft furnishings. To prevent fungal growth, wet
carpets should be thoroughly dried. It is prudent to avoid
carpets in isolation wards, high-traffic zones, and areas with
frequent or large volume blood and other body fluid spillage
such as surgical and obstetric wards.
Specialized Patient Care Areas. The role of the operating
room environment in causing surgical site infections is dealt
with elsewhere in this handbook.
The use of ultraclean rooms for certain patient categories in
a general hospital remains controversial. These facilities are
expensive and do not seem to provide clear benefit.
Linen. Bed linen can become rapidly contaminated with col-
onized skin scales. Frequent changing is therefore of limited
value. Linen should be changed on discharge of the patient
or if it becomes soiled, wrinkled, stained or contaminated
with potentially infective material. Privacy curtains have
been shown to harbour organisms such as MRSA, GRE,
Acinetobacter and C difficile and should be washed if visibly
soiled and in certain outbreak situations. Although there is no
clear guidance on how frequently privacy curtains must be
routinely changed it seems prudent that, particularly during
non-outbreak situations, they are removed and washed on a
regular (e.g. monthly) basis.
Plants/Flowers. Potted plants and flowers (particularly
vase water) are well-established reservoirs of opportunistic
pathogens. Since the mechanism for transmission requires
that plant or vase water is handled, hands become contami-
nated and patient care is subsequently provided, hand wash-
ing after handling these items should eliminate the risk of
hand contamination.
Waste Disposal. There is no evidence to suggest that most
clinical (potentially infectious) waste (with the exceptions
of microbiological waste and contaminated syringe needles)
constitutes a significant public hazard. Household waste
148 A Guide to Infection Control in the Hospital
contains a least 100 times as many potential human patho-
gens as clinical waste. Segregation of clinical and domestic
wastes in healthcare settings is important to contain costs,
and avoid accidents and litigation. In areas where munici-
pal waste disposal is not provided, e.g., in some developing
countries and rural areas, burial of waste is common.
Controversial Issues
The extent to which environmental reservoirs contribute to
health care associated infections remains controversial. It
is clear that the importance of cleaning needs to be backed
up by robust scientific evidence. Although there is a lot of
emerging literature highlighting the importance of a clean
environment in infection prevention and control more stud-
ies, backed by established methods of assessment, need to be
conducted.
Use of detergents versus disinfectants for environmental
(surfaces, noncritical) cleaning.
Impact of disinfectant use on the emergence of antimicrobial
resistance and need for biocide rotation.
Routine use of automated area decontamination (AAD)
technologies (e.g. using hydrogen peroxide, peracetic acid
or UV irradiation).
Microbial sampling of the environment.
Suggested Practice
General
Meticulous hand washing is extremely important in prevent-
ing the transmission of microorganisms from the environ-
ment to patients, since most pathogens that may survive for
prolonged periods of time in the environment are most likely
to be transmitted by hand transfer. The use of non-aqueous,
alcohol-based hand antiseptics is ideally suited to all health-
care facilities including those where hand washing facilities
are scant and water is scarce.
The environment should not be conducive to the multipli-
cation of microorganisms and should be kept dry, clean,
well-ventilated and ideally exposed to sunlight. Maintaining
surfaces and equipment dry is important, as wet surfaces and
equipment promote microbial growth and possible spread of
pathogens.
Keeping the Environment Safe with Limited Resources 149
Cleaning procedures should be defined, applied consistently,
and compliance to these validated. Cleaning personnel
should be properly trained and responsibility for implemen-
tation of cleaning practices needs to be assigned.
Contaminated near-patient hand-touch sites (e.g. drip stands,
overbed tables, monitors, etc.) are likely to provide the great-
est risk to patients as healthcare personnel frequently touch
them. As ward cleaners infrequently clean hand-touch sites,
nursing personnel should assume responsibility to ensure
that they are regularly decontaminated.
Products used for cleaning and decontamination of the
environment should be used according to the hospital pol-
icy, manufacturer’s instructions, and available scientific
information.
Infrequently touched (“non-hand-contact”) environmental
surfaces should be cleaned with a detergent when visibly
soiled and as required to maintain an aesthetically pleasing
environment.
Dedicated noncritical equipment should be used on patients
infected with multiply antibiotic resistant organisms. If this
is not possible, shared noncritical items must be cleaned and
disinfected between patient use.
Specific Interventions
Air. Good air management is difficult to achieve in many
healthcare facilities. An air maintenance programme should
be in place and filters should be replaced periodically. Air-re-
lated outbreaks of legionellosis or aspergillosis, particularly
in facilities where there are immunocompromised patients,
prompt immediate investigation and consultation with a
competent engineer. Potential sites of contamination need
to be determined and appropriate corrective action must be
taken.
Patients with an airborne communicable disease (e.g. TB)
should be isolated in a single room, if possible, or cohorted.
Rooms with good airflow (open windows in many rural hos-
pitals, use of extractor fans to the outside environment, or
high volume ventilation greater than six air changes per hour
including a good fresh air mix) lead to a reduced risk of TB
transmission. Use of ultraviolet germicidal irradiation (UVGI)
150 A Guide to Infection Control in the Hospital
may be considered in designated enclosed areas or booths for
sputum induction. In rural healthcare facilities, where engi-
neering controls are lacking, collection of sputum in sunny,
open-air environments (outside the building) is advocated.
Water. Legionellosis is an important disease for which an
environmental reservoir (hot water in buildings) has been
identified and for which specific preventive measures (e.g.
water system management, superheating and/or use of bio-
cides such as chlorine) are well described and advocated.
Hydrotherapy pool water should be adequately filtered and
chlorinated, hydrotherapy tanks should be cleaned thor-
oughly between each treatment and sharing of facilities by
patients with open skin lesions should be avoided.
Haemodialysis water has been clearly demonstrated to cause
pyrogenic reactions (from endotoxins from Gram negative
bacteria) and/or bacteraemia. Several types of bacteria are
capable of surviving and multiplying in distilled, deionised,
reverse osmosis and softened water, all of which may be
used in haemodialysis. Water used to prepare dialysis fluid
and the dialysate should be sampled monthly. The micro-
biologic limits for haemodialysis fluids vary in different
countries according to the standard used. It should however
be noted that the more stringent standards become the more
difficult and impractical they become to implement in devel-
oping countries.
Healthcare facilities should develop a routine maintenance
programme for water filtration equipment to prevent bacte-
rial overgrowth in filters and replace faulty ones. Water used
for hand washing in oncology wards, diluting disinfectants,
haemodialysis units, and rinsing semicritical items, may be
heavily contaminated with organisms such as Pseudomonas
and may pose a risk.
Facilities should be prepared for situations where water is
inaccessible (e.g. disaster situations, disruptions in water
supply): ready-to-use disinfecting products that do not
require rinsing must be available.
Water in under-resourced areas can be made safer by solar
disinfection using solar box cookers that reach pasteurisa-
tion temperatures, boiling (10 minutes), chemical disinfec-
tion, and filtration.
Keeping the Environment Safe with Limited Resources 151
Environmental Surfaces:
Walls and ceilings are unlikely to pose a significant infec-
tion hazard and should be periodically cleaned and not rou-
tinely disinfected in non-outbreak situations unless known
contamination (e.g. blood splashes) has occurred. Cleaning
of floors without the use of a disinfectant suffices in most
instances. Levels of bacterial contamination on floors can be
restored to their original values within 2 hours of cleaning,
regardless of whether disinfectants are used or not.
Linen. Although infectious risks associated with linen are
low, it should be handled with care both in the ward and in
the laundry. Persons handling soiled linen should do so with
minimum agitation and must wear gloves. Linen should be
transported to the laundry in a sealed bag. Linen from par-
ticularly hazardous and transmissible infections (e.g. viral
hemorrhagic fevers) should be autoclaved before washing.
Linen can be disinfected by heat (70˚C for 3 minutes or
80˚C for 1 minute) or with an appropriately diluted chlorine
solution.
Pest Control. A pest-control strategy in areas like kitchens
cafeterias, laundries, central sterile supply services, operat-
ing rooms, and other areas prone to infestation is particularly
important in healthcare facilities in developing countries.
Screens on windows that open to the outside may be of
particular Importance in regions where insect vector-borne
infections are endemic.
Waste Disposal. Disposal of waste must comply strictly with
legislation. Clinical waste must be contained to prevent leak-
age, and sharps must be discarded into puncture-resistant
containers. Disposal strategies include incineration, auto-
claving followed by disposal with regular waste, mechani-
cal/chemical disinfection, microwave decontamination and
compacting. Waste such as blood, suctioned fluids, excre-
tions and secretions can be poured down a sanitary sewer.
Alternatives for disposal of medical waste commonly seen
in countries with limited resources include: incineration of
small amounts of waste in a metal drum, landfills or burial
in refuse pits that are securely fenced off to prevent access
to human and animal scavengers. Alternating layers of waste
and ash help to reduce the smell.
152 A Guide to Infection Control in the Hospital
Dealing with the Controversies
- keep personnel to minimum in the OR during a procedure;
- limit idle conversations as this creates dispersion of bacteria;
- 2013. 70:195–283.
- 2010. 362:18–26.
Detergent Or Disinfectant?
Cleaning with detergent and water is usually adequate for
surfaces and items remote from the patient or in contact with
healthy, intact skin (“noncritical” items). Thorough cleaning
renders most items free of infection risk and safe to handle.
Disinfectants should only be used on environmental sur-
faces where potential risks are identified (e.g. decontamina-
tion of potentially infectious spills or of isolation rooms).
Wet cleaning and damp dusting procedures are required
to ensure that microorganisms are not made airborne from
the surfaces that are being cleaned. All cleaning solutions
should be changed regularly and cleaning utensils should be
thoroughly washed, cleaned and dried before reuse.
Terminal cleaning (when patient is discharged from the
room or when isolation is discontinued) should be done as
an opportunity to clean areas not routinely accessible.
Currently accepted guidelines should be used for the disin-
fection and sterilization of semicritical and critical items.
Biocide rotation and antimicrobial resistance:
Although there is laboratory evidence that low-level biocide
resistance can be associated with cross-resistance to other
biocides and some antibiotics, the significance of these phe-
nomena in the clinical setting remains controversial.
Rotation of biocides is probably unnecessary. No evidence is
currently available that appropriately and correctly selected
biocides have resulted in failures (arising from the selection
or development of, non-susceptible microorganisms) in the
clinical setting. Greater attention directed to environmental
cleanliness, hand washing and personal hygiene is much
more important.
Environmental cultures:
Routine culturing of environment air is not advocated; it
should only be performed when there is an epidemiological
indication and for educational or research purposes. Because
environmental sampling is costly, overused and misused, it
should be conducted only with the approval and under the
guidance of a competent infection control practitioner.
Keeping the Environment Safe with Limited Resources 153
Use of automated area decontamination (AAD) technologies:
The contribution of the environment in health care associ-
ated infections has been increasingly recognized in recent
years. Manual cleaning and disinfection is carried out inad-
equately in many settings making the introduction of AAD
technologies, as an adjunct and not a replacement to routine
cleaning, a persuasive option. It will however be important
to determine the clinical impact of the introduction of an
AAD system in lowering health care associated infection
rates rather than only measuring the impact of this technol-
ogy on lowering environmental bioburden.
Summary
Inappropriate use of disinfectants, excessive microbiological
sampling of the hospital environment and excessive and com-
plex cleaning policies are neither cost-effective nor conducive
to compliance in countries with limited resources. Healthcare
facilities in developing countries will find it increasingly more
difficult to comply with stringent protocols from developed
countries. Adaptation of these protocols to realistically take
into account the constraints of local situations and available
resources is crucial to the success of environmental infection
control programs. Rational, simple protocols based on sound
principles of infection control, hand washing, and common
sense will go far in minimizing environmental risks of infection.
References
Babb J. Decontamination of the Environment, Equipment and the Skin
in Control of Hospital Infection (4th Edition), Ayliffe GAJ, Fraise
AP, Geddes AM, Mitchell K, (Eds). London: Arnold, 2000. Pgs.
92–129.
Boyce JM. Environmental contamination makes an important contri-
bution to hospital infection. J Hosp Infect. 2007. 65(Suppl 2):50–54.
Dancer SJ. Mopping up hospital infection. J Hosp Infect. 1999.
43:85–100.
Dancer SJ. The role of environmental cleaning in the control of hospital
acquired infection. J Hosp Infect. 2009. 73:378–385.
Daschner F. The Hospital and Pollution: Role of the Hospital Epidemi-
ologist in Protecting the Environment in Prevention and Control of
Nosocomial Infections (2nd Edition), Wenzel RP (Ed). Baltimore:
Williams and Wilkins, 1993. Pgs. 993–1000.
154 A Guide to Infection Control in the Hospital
Department of Health, United Kingdom. Standard principles for
preventing hospital acquired infections. J Hosp Infect. 2001.
47(Suppl):S21–S37.
Dharan S, Mouroga P, Copin P, Bessmer G, Tschanz B, Pittet D. Rou-
Tine Disinfection Of Patient’s Environmental Surfaces. Myth Or Reality?
J Hosp Infect. 1999. 42:113–117.
Global consensus conference on infection control issues related to anti-
microbial resistance. Global consensus conference: Final recommen-
dations. Am J Infect Control. 1999. 27:503–513.
Lederer W. Infection control in a small rural hospital in Uganda. J Hosp
Infect. 1997. 35:91–95.
Lynch P, Jackson M, Preston GA, Soule BM. Infection Prevention
with Limited Resources. Chicago: Etna Communications, 1997.
Pgs. 71–74.
Guidelines for Environmental Infection Control in Healthcare Facili-
ties. Recommendations of CDC and the Healthcare Infection Control
Practices Advisory Committee (HICPAC). MMWR. June 6, 2003.
Vol. 52, No. RR-10.
Murtough SM, Hiom SJ, Palmer M, Russell AD. Biocide rotation in the
healthcare setting: Is there a case for policy implementation? J Hosp
Infect. 2001. 48:1–6.
Phillips G. Microbiological aspects of clinical waste. J Hosp Infect.
Rhame FS. The Inanimate Environment in Hospital Infections (4th
Edition), Bennett JV, Brachman PS (Eds). Philadelphia: Lippincott-
Raven, 1998. Pgs. 299–324.
Rutala WA, Weber DJ. Surface disinfection: Should we do it? J Hosp
Infect. 2001. 48(Suppl A):S64–S68.
Talon D. The role of the hospital environment in the epidemiology of
multi-resistant bacteria. J Hosp Infect. 1999. 43:13–17.
Vesley D, Streifel AJ. Environmental Services in Hospital Epidemiol-
ogy and Infection Control (2nd Edition), Mayhall CG (Ed). Philadel-
phia: Lippincott Williams and Wilkins, 1999. Pgs. 1047–1053.
Weber DJ, Rutala WA. Environmental Issues and Nosocomial Infections
in Prevention and Control of Nosocomial Infections (2nd Edition),
Wenzel RP (Ed). Baltimore: WiIliams and Wilkins, 1993. Pgs.
420–449.
Keeping the Environment Safe with Limited Resources 155
- 1999. 41:1–6.
Chapter 24
The Emergency Department
and R eceiving A reas
Pawan Suri, MD, and
Ravindra Gopaul, MD,
Key Issue
Healthcare workers in the emergency department and receiving
areas need to be aware of the risks posed by blood and air-borne
infections, and take measures to limit exposure through early
identification and isolation of high risk patients.
It is mandatory to identify and isolate patients with highly
contagious infections (e.g. tuberculosis) or when exposure to a
bioterror agent is known or suspected.
Known Facts
Universal precautions are promoted by the Centers for Disease
Control and Prevention because when patients initially present
seeking medical care, it is often not known if their blood may
contain the hepatitis B or C viruses, human immunodeficiency
virus (HIV), or other pathogens. All blood should be considered
potentially contaminated, and efforts should be made to avoid
direct contact, mucous membrane exposure, and sharp injuries.
In addition, respiratory protection is prudent when caring
for patients with suspected or confirmed tuberculosis or other
highly contagious air-borne infections (e.g., SARS).
Controversial Issues
With respect to isolation, there is limited data comparing the
cost and efficacy of different methods (provider face masks,
negative pressure rooms etc.).The type of isolation used
is based on the mode of disease transmission. Overall, the
costs associated with initiating basic isolation precautions
are usually low and the benefits far outweigh the expense.
156 A Guide to Infection Control in the Hospital
The benefit of ventilation measures in the hospital on
tuberculin conversion in healthcare providers is still under
investigation. Higher tuberculin conversion rates have been
reported among personnel who work in nonisolation patient
rooms or rooms with fewer than 2 air exchanges per hour.
Guidelines for the prevention of health care associated trans-
mission of tuberculosis recommend minimum air change
rates of 2 to 15 per hour.
There is scarce data on the ability of healthcare workers to
identify patients at risk for transmitting infections. Patients
with active pulmonary tuberculosis are often missed at
emergency triage. In retrospect, some of these patients may
have presented with typical symptoms and risk factors that
are easily overlooked in a busy triage environment. Each
emergency department should evaluate its process to see if
opportunities for earlier diagnosis of tuberculosis exist.
Suggested Practice
Provide patient educational material about hand and respi-
ratory hygiene/cough etiquette in emergency receiving and
waiting areas.
Mandatory careful hand hygiene, preferably with alcohol
based hand sanitizer, before and after each patient encounter.
Gloves and isolation gowns should be worn when contact
with blood and body fluids is likely.
Goggles or face masks should be worn when splashing of
blood or body fluids is anticipated.
Appropriately sized face masks should be worn in cases of
suspected air-borne infection (e.g. tuberculosis, SARS).
Triage personnel should be trained to identify high risk
patients with potential communicable infections.
Patients who appear unusually ill, especially with cough,
should be isolated (>3 feet distance) or provided a mask to
limit risk to healthcare personnel and other patients.
Patients who may have had a chemical exposure from a bio-
terror attack should be isolated and decontaminated as soon
as possible.
Efforts should be made to minimize staff flow between iso-
lated and non-isolated patients.
The Emergency Department and Receiving Areas 157
Summary
The adoption of reasonable healthcare safety precautions, as
listed above, can minimize transmission of most contact-related
infections in the emergency department. All personnel handling
blood, body fluids or sharps should be vaccinated against hepa-
titis B. Providing and using sharp containers reduces the risk of
blood borne infections.
Risk of airborne infections can be minimized through use of
rooms with exhaust fans or adequate ventilation.
Occupational exposure to blood or droplets should be
reported. Post-exposure counselling and therapy, if necessary,
should be offered to all clinical personnel.
References
Centers for Disease Control and Prevention. Updated U.S. Public Health
Service Guidelines for the Management of Occupational Exposures
to HBV, HCV, and HIV and Recommendations for Postexposure
Prophylaxis. MMWR. 2001. 50 (RR-l l):l–54.
Centers for Disease Control and Prevention. Guidelines for Environ-
mental Infection Control in Healthcare Facilities. MMWR. 2003.
52(RR-10):1–42.
Menzies D, Fanning A, Yuan L, et al. Hospital Ventilation and Risk for
Tuberculous Infection in Canadian Healthcare Workers. Ann Intern
Med. 2000. 133:779–789.
Sokolove PE, Rossman L, Cohen SH. The Emergency Department
Presentation of Patients with Active Pulmonary Tuberculosis. Acad
Emerg Med. 2000. 7:1056–1060.
Siegel, JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare
Infection Control Practices Advisory Committee: 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings, June 2007. Available at: http://www.
cdc.gov/hicpac/2007IP/2007isolationPrecautions.html.
158 A Guide to Infection Control in the Hospital
Chapter 25
HIV Infection and AIDS in
Low- and Middle-Income Countries
Philippe Van de Perre, MD, PhD
Key Issues
Thirty years after it was first recognized in Africa, HIV infec-
tion is one of the leading cause of adult deaths in many cities
in low- and middle-income countries, and it has significantly
increased childhood mortality. Despite considerable efforts to
control the epidemic, HIV continues to spread at a rapid pace
in developing countries. Of an estimated 34 million people
infected by HIV world-wide(as of December 2010), 3.4 million
were children less than 15. For the sole year 2010, new HIV
infections were 2.7 million in adults and 390,000 in children.
Although the yearly number of newly acquired infections con-
tinues to decline, most people newly infected with HIV live in
sub-Saharan Africa.1 An estimated 1.8 million people died of
HIV infection during 2010.
In the last decades, the development of new antiretroviral
(ARV) drugs (Table 25.1 and 25.2) and the extended access to
Antiretroviral Therapy (ART) for HIV-infected patients have
been accompanied by a dramatic reduction in HIV-associated
mortality. Today, for those who have access to ARV drugs, HIV
infection should be considered as a manageable chronic illness.
In 2010, the World Health Organization estimated that 6.65 mil-
lion people from low- and middle-income countries received
Art, Including 456,000 Children.1 The Coverage Of Antiretrovi-
ral drugs for preventing Mother-to-Child Transmission (MTCT)
of HIV has also steadily increased over the last years and was
estimated to be 48% in 2010.1 The global challenge remains to
scale up access to ARV drugs for all HIV-infected individuals
who need it together with preventing the acquisition of new
infections.2
HIV Infection and AIDS in Low- and Middle-Income Countries 159
Table 25.1 Antiretroviral Drugs Used in the Treatment of HIV Infection
As of February 8, 2013
Multi-class Combination Products
Brand Name Generic Name Manufacturer Name*
Atripla efavirenz, emtricitabine and Bristol-Myers Squibb
tenofovir disoproxil fumarate and Gilead Sciences
Complera emtricitabine, rilpivirine, and Gilead Sciences
tenofovir disoproxil fumarate
Stribild elvitegravir, cobicistat, Gilead Sciences
emtricitabine, tenofovir
disoproxil fumarate
Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
Brand Name Generic Name Manufacturer Name
Combivir lamivudine and zidovudine GlaxoSmithKline
Emtriva emtricitabine, FTC Gilead Sciences
Epivir lamivudine, 3TC GlaxoSmithKline
Epzicom abacavir and lamivudine GlaxoSmithKline
Hivid zalcitabine, dideoxycytidine, Hoffmann-La Roche
ddC (no longer marketed)
Retrovir zidovudine, azidothymidine, GlaxoSmithKline
Azt, Zdv
Trizivir abacavir, zidovudine, GlaxoSmithKline
and lamivudine
Truvada tenofovir disoproxil fumarate Gilead Sciences, Inc.
and emtricitabine
Videx EC enteric coated didanosine, ddI EC Bristol Myers-Squibb
Videx didanosine, dideoxyinosine, ddI Bristol Myers-Squibb
Viread tenofovir disoproxil fumarate, TDF Gilead
Zerit stavudine, d4T Bristol Myers-Squibb
Ziagen abacavir sulfate, ABC GlaxoSmithKline
Nonnucleoside Reverse Transcriptase Inhibitors (NNRTIs)
Brand Name Generic Name Manufacturer Name*
Edurant rilpivirine Tibotec Therapeutics
Intelence etravirine Tibotec Therapeutics
Rescriptor delavirdine, DLV Pfizer
continued
160 A Guide to Infection Control in the Hospital
Table 25.1 Antiretroviral Drugs Used in the Treatment of HIV Infection
As of February 8, 2013 (continued)
Nonnucleoside Reverse Transcriptase Inhibitors (NNRTIs)
Brand Name Generic Name Manufacturer Name
Sustiva efavirenz, EFV Bristol Myers-Squibb
Viramune nevirapine, NVP Boehringer Ingelheim
(Immediate Release)
Viramune XR nevirapine, NVP Boehringer Ingelheim
(Extended Release)
Protease Inhibitors (PIs)
Brand Name Generic Name Manufacturer Name*
Agenerase amprenavir, APV (no longer marketed) GlaxoSmithKline
Aptivus tipranavir, TPV Boehringer Ingelheim
Crixivan indinavir, IDV, Merck
Fortovase saquinavir (no longer marketed) Hoffmann-La Roche
Invirase saquinavir mesylate, SQV Hoffmann-La Roche
Kaletra lopinavir and ritonavir, LPV/RTV Abbott Laboratories
Lexiva fosamprenavir calcium, FOS-APV GlaxoSmithKline
Norvir ritonavir, RTV Abbott Laboratories
Prezista darunavir Tibotec, Inc.
Reyataz atazanavir sulfate, ATV Bristol-Myers Squibb
Viracept nelfinavir mesylate, NFV Agouron Pharmaceuticals
Fusion Inhibitors
Brand Name Generic Name Manufacturer Name*
Fuzeon enfuvirtide, T-20 Hoffmann-La Roche
& Trimeris
Entry Inhibitors – CCR5 Co-Receptor Antagonist
Brand Name Generic Name Manufacturer Name*
Selzentry maraviroc Pfizer
HIV Integrase Strand Transfer Inhibitors
Brand Name Generic Name Manufacturer Name*
Isentress raltegravir Merck & Co., Inc.
Source: FDA http://www.fda.gov/ForConsumers/ByAudience/ForPatientAdvocates/HIVandAIDSActivities/ucm118915.htm
HIV Infection and AIDS in Low- and Middle-Income Countries 161
Table 25.2 FDA approved generic formulations of antiretroviral
drugs used in the treatment of HIV infection
As of February 8, 2013
Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
Generic Name Manufacturer Name
abacavir tablets USP, 300 mg Mylan Pharmaceuticals, Inc.
nevirapine tablets USP, 200 mg Prinston Pharmaceutical, Inc.
nevirapine tablets USP, 200 mg Apotex Corporation
nevirapine tablets USP, 200 mg Matrix Laboratories Limited
nevirapine tablets USP, 200 mg ScieGen Pharmaceuticals, Inc
nevirapine tablets USP, 200 mg Mylan Pharmaceuticals, Inc.
nevirapine tablets USP, 200 mg Hetero Labs Limited, Unit-III
nevirapine tablets USP, 200 mg Micro Labs Limited
nevirapine tablets USP, 200 mg Strides, Inc.
nevirapine tablets USP, 200 mg Cipla Limited
nevirapine tablets USP, 200 mg Aurobindo Pharma Limited
nevirapine oral suspension USP, 50 mg/5 mL Aurobindo Pharma Limited
lamivudine and zidovudine tablets, Aurobindo Pharma Limited
150 mg/300 mg
lamivudine and zidovudine tablets, Lupin Limited
150 mg/300 mg
lamivudine and zidovudine tablets, TEVA Pharmaceuticals USA
150 mg/300 mg
zidovudine Injection USP, 10 mg/mL, PharmaForce Inc.
packaged in 200 mg/20 mL Single-use Vials
didanosine (ddI) delayed release capsules, Matrix Laboratories Limited
125 mg, 200 mg, 250 mg, and 400 mg
zidovudine 60 mg tablets for pediatric dosing Aurobindo Pharma Limited
stavudine for oral solution, 1 mg/mL Aurobindo Pharma Limited
stavudine capsules Aurobindo Pharma Limited
(15 mg, 20 mg, 30 mg, and 40 mg)
stavudine capsules Hetero Drugs Limited
(15 mg, 20 mg, 30 mg, and 40 mg)
continued
162 A Guide to Infection Control in the Hospital
Table 25.2 FDA approved generic formulations of antiretroviral
drugs used in the treatment of HIV infection
As of February 8, 2013 (continued)
Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
Generic Name Manufacturer Name
didanosine (ddI) delayed release capsules, Aurobindo Pharma Limited
125 mg, 200 mg, 250 mg, and 400 mg
zidovudine oral solution USP, Cipla Limited
50 mg/5 mL, oral solution—zidovudine,
AZT, azidothymidine, ZDV
(Pediatric formulation—50 mg/ 5 mL)
zidovudine, AZT, azidothymidine, Matrix Laboratories, Inc.
ZDV (300 mg tablet)
zidovudine, AZT, azidothymidine, Cipla Limited
ZDV (100 mg capsule)
didanosine (ddI) for oral solution Aurobindo Pharma Limited
(pediatric powder), 10 mg/mL
zidovudine, AZT, azidothymidine, Aurobindo Pharma Limited
ZDV (100 mg capsule)
zidovudine, AZT, azidothymidine, Aurobindo Pharma Limited
ZDV (300 mg tablet)
zidovudine oral solution USP,
50 mg/5 mL, oral solution—zidovudine, Aurobindo Pharma Limited
AZT, azidothymidine, ZDV
(Pediatric formulation—50 mg/ 5 mL) Ranbaxy Laboratories Limited
zidovudine, AZT, azidothymidine,
ZDV (300 mg tablet)
zidovudine, AZT, azidothymidine, Roxane Laboratories
ZDV (300 mg tablet)
didanosine (ddI) delayed release capsules Barr Laboratories, Inc.
Source: FDA http://www.fda.gov/ForConsumers/ByAudience/ForPatientAdvocates/HIVandAIDSActivities/ucm118944.htm
Known Facts
Both HIV type 1 (HIV-1) and HIV type 2 (HIV-2) are circu-
lating in low- and middle-income countries. HIV-2, which is
mostly spread in West Africa where it co-exists with HIV-1,
is less transmissible and less pathogenic than HIV-1. HIV-2
as HIV-1 group O are naturally resistant to non nucleosidic
reverse transcriptase inhibitors.
HIV Infection and AIDS in Low- and Middle-Income Countries 163
All groups of HIV-1 (group M, N and O) as well as all geno-
typic subtypes of HIV-1 group M (subtypes A to K) and
Recombinant Circulating Forms (CRFs) are co-circulating
in low- and middle-income countries but regional distribu-
tion of groups, subtypes and CRFs varies considerably.
Transfusion of HIV contaminated blood is still responsible
for about 10% of overall transmission events.
Blood banking organization, selection of blood donors and
HIV testing of blood donations are effective in preventing
transfusion-associated infections.
Sexual transmission remains by far the most frequent route
of transmission in adults. Sexually Transmitted Infections
(STI) are facilitating HIV transmission by sexual intercourse.
Control of STI at the community level is a cost-effective
strategy to prevent sexual transmission of HIV.
MTCT of HIV involves almost exclusively HIV-1 and can
occur in utero, during labor and delivery and postnatally by
breastfeeding. MTCT rate is estimated 20–30% in breast-
feeding populations in the absence of prophylaxis.
Prevention of MTCT by treating HIV-infected pregnant
women and their neonates with antiretrovirals is highly effi-
cacious.3 Postnatal HIV transmission through breastfeeding
poses a difficult public health problem that can be prevented
by administering antiretroviral prophylaxis to lactating
mothers or, as a pre exposure prophylaxis (PreP) to their
breastfed babies.3,4
Susceptibility to acquisition of HIV and clinical course of
HIV disease are highly variable and may be determined
at the individual level by the existence of genetic factors
such as deletions on the genes coding for cellular cofac-
tors for viral entry (such as CCR5) or their promotors.
New strategies to prevent sexual transmission are in devel-
opment, the efficacy of some of them, such as vaginal micro-
bicides5 and PreP,6 having been demonstrated.
More than 85% of fatal overwhelming infections associ-
ated with HIV as well as the first five causes of mortality in
HIV-infected African patients (Table 25.3) are potentially
amenable to a simple, effective and frequently affordable
164 A Guide to Infection Control in the Hospital
anti-infectious treatment or prophylaxis, such as the use of
cotrimoxazole.7 The most devastating public health impact of
HIV-1 infection on other endemic diseases is on tuberculosis.
In sub-Saharan Africa, the annual incidence of tuberculosis is
more than 15-fold greater in HIV-infected individuals than in
HIV-uninfected individuals. In patients eligible for ART with
active TB, antiretroviral therapy should be initiated shortly
(2 weeks) after the initation of TB treatment.8
Table 25.3 Principal causes of death in HIV-infected African patients
(autopsy study, n = 247; Abidjan, Côte d’Ivoire, 1991)
Rank order Causes of death Prime cause of death*
1 Tuberculosis 32 %
2 Bacteremia 11 %
3 Cerebral toxoplasmosis 10 %
4 Pyogenic pneumonia 8%
5 Pyogenic meningitis 5%
Proportion of deaths considered as primarily caused by the given condition.
Clinical management of HIV-infected patients is based on
access of healthcare quality services: diagnosis and treat-
ment of tuberculosis and of other infectious diseases (pneu-
mococcal disease, bacteraemia,). As a priority, lifelong
Art Should Be Administered In A Patient With Hiv Associ-
ated signs or symptoms (WHO clinical stage 3 or 4) and/
or with less than 350 CD4+ T cells per ml. ART should be
initiated in all adult individuals with HIV with CD4 count
> 350 cells per mland < 500 cells per ml regardless of WHO
clinical stage.2 In infants and children with HIV infection,
Art Should Be Initiated As Soon As The Hiv Diagnosis Is Con-
firmed, if possible during the first year of life.
HIV is highly sensitive to physic and chemical environ-
ment and to widely used disinfectants. Reinforced hospital
hygiene measures are of practical importance to minimize
the risk of exposure to HIV-containing blood and body flu-
ids in the healthcare settings. Postexposure prophylaxis by
means of a combination of ARV [generally three drugs given
HIV Infection and AIDS in Low- and Middle-Income Countries 165
as soon as possible after exposure, for one month] is highly
efficacious in preventing acquisition of HIV-1 infection after
accidental exposure to the virus in the healthcare setting.9
An adjustment of regimen according to the index patient
profile of antiretroviral resistance may be necessary.
Controversial Issues
Scaling up access to ART in low- and middle-income coun-
tries, and monitoring it in terms of adherence, efficacy, toler-
ance and sustainability remain major challenges. Adherence
is critical for treatment success and the best ways for opti-
mizing adherence are under scrutiny. The most optimal way
to follow up the biological efficacy of ART in low- and mid-
dle-income countriesremainsdebatable. Several schemes
have been proposed: clinical follow up only, clinical follow
up and CD4 counts, or same with viral load measurements to
detect viral escape.
In HIV infected individuals,co-infections with hepatitis C
(HCV) or B (HBV) viruses are frequent. Although consid-
erable progress have been accomplished in treating these
co-infections jointly with HIV, the access to anti-HCV and
some anti-HBV drugs remains problematic in many low-
and middle-income countries.
Access to second and third lines of ART remains extremely
problematic in many low- and middle-income countries. The
best combinations to propose in second and third lines are
under evaluation.
The interactions between HIV infection and other tropical
diseases, such as malaria, other parasitosis, or malnutrition,
remain largely undetermined. Also, the complex interac-
tions between HIV disease progression and reactivations of
chronic infections, such as infections with herpesviruses,
and immune activation remain to be clarified.
The recent WHO guidelines on prevention of MTCT of
HIV have the ambition to eliminate the MTCT of HIV and
recommend, in particular in generalized epidemics,that
all pregnant and breastfeeding women infected with HIV
should initiate ART which should be maintained at least
for the duration of MTCT risk. Particularly in generalized
epidemics, all pregnant or breastfeeding women with HIV
166 A Guide to Infection Control in the Hospital
infection should initiate lifelong ART, regardless of clinical
or immunological stage.2 The individual benefit of this strat-
egy, in particular for asymptomatic women with high CD4
count, the long term maternal adherence and even the effi-
cacy in preventing postnatal HIV transmission and MTCT in
subsequent pregnancies are all unknown, since these guide-
lines have been based mostly on expert advice and less on
scientific evidence.10 Several studies on prolonged maternal
and/or infant ARV prophylaxis during breastfeeding are
ongoing in order to determine if it can achieve elimination
of breastfeeding transmission of HIV-1.
Treatment as Prevention (TasP) strategy, consisting as
administering ART to all HIV infected individuals regard-
less of their CD4 T cell count or HIV viral load with the aim
of both interrupting transmission and universalizing ARV
treatment for the individual’s own benefit, is attractive. The
long term individual and societal benefits and the cost-effec-
tiveness of this strategy remain, however, controversial and
are the subjects of ongoing large-scale trials.
Although some encouraging results have been obtained in
recent years, a preventive HIV vaccine has remained elu-
sive. Various existing preventive strategies combined in
comprehensive packages are presently under investigation.
Suggested Practices
Prevention and clinical and psychosocial management and a
continual struggle against discrimination/stigmatisation are
all integral parts of HIV/AIDS control programmes. Each
of these components is not sufficient in itself but all are
synergistic.
Voluntary counselling and testing for HIV is the entry point
of HIV prevention and care and has to be made available
widely.
In terms of prevention the following strategies should be
implemented:
– STI diagnosis and treatment at the community level (based
on well validated treatment algorithms) as well as large
access to male and female condoms and, in some circum-
HIV Infection and AIDS in Low- and Middle-Income Countries 167
– Blood bank organization, blood donors’ selection and HIV
– Increased accessibility of mother and child to high qual-
ity healthcare services (antenatal clinics, basic obstetrical
needs, nutritional education) including a thoughtful pack-
age of antenatal care. Provision of ART to breastfeeding or
pregnant women as per 2013 WHO recommendations;2
– Reinforcement of available health programmes (TB con-
trol, malaria control, expanded programme on immuniza-
– Access of all health professionals to post exposure prophy-
laxis in case of accidental exposure to blood or body fluids
potentially containing HIV and hepatitis viruses.
In terms of psychosocial and clinical management the fol-
lowing strategies should be implemented:
– Skilled, acceptable, accessible and sustainable voluntary
– Simple clinical algorithms for clinical management of HIV
disease and treatment of infectious episodes by means of
– As a priority, initiation of a combination of two nucleoside
reverse-transcriptase inhibitors (NRTIs) plus a non-nucle-
oside reverse-transcriptase inhibitor (NNRTI), preferen-
tially as a fixed-dose combination, in all individuals with
HIV related signs and symptoms and/or of a CD4+ T cell
count of less than 350 per ml together with a meaningful
encouragement for adherence and careful clinical and
biological monitoring (biochemistry in search for drug
toxicity, CD4 count and HIV viral load for monitoring
of treatment efficacy). ART should also be initiated in all
individuals with HIV and a CD4 count > 350 cells per ml
– In patients not eligible for ART, prophylaxis of opportunis-
tic infections by antibiotics (such as daily cotrimoxazole),
together with a careful monitoring of HIV clinical course
is to be implemented.
168 A Guide to Infection Control in the Hospital
References
1
WHO/UNAIDS/UNICEF Global HIV/AIDS response—Epidemic
update and health sector progress toward Universal Access—Pro-
gres Report 2011 http://www.who.int/hiv/pub/progress_report2011/
summary_en.pdf
2
World Health Organization. Consolidated guidelines on the use of
antiretroviral drugs for treating and preventing hiv infection—
Recommandations for a public health approach. June 2013. http://
apps.who.int/iris/bitstream/10665/85321/1/9789241505727_eng.pdf
3
The Kesho Bora Study Group. Triple-antiretroviral prophylaxis dur-
ing pregnancy and breastfeeding compared to AZT/sdNVP prophy-
laxis to prevent mother-to-child transmission of HIV-1: The Kesho
Bora randomized controlled clinical trial. Lancet Infect Dis. 2011.
11:171–80.
4
Coovadia HM, Brown ER, Fowler MG, Chipato T, Moodley D, Manji
K, Musoke P, Stranix-Chibanda L, Chetty V, Fawzi W, Nakabiito
C, Msweli L, Kisenge R, Guay L, Mwatha A, Lynn DJ, Eshleman
SH, Richardson P, George K, Andrew P, Mofenson LM, Zwerski
S, Maldonado Y; HPTN 046 protocol team. Efficacy and safety of
an extended nevirapine regimen in infant children of breastfeeding
mothers with HIV-1 infection for prevention of postnatal HIV-1
transmission (HPTN046): A randomized, double-blind, placebo-con-
trolled trial. Lancet. 2012. 379:221–228.
5
Abdool Karim Q, Abdool Karim SS, Frohlich JA, Grobler AC, Baxter
C, Mansoor LE, Kharsany AB, Sibeko S, Mlisana KP, Omar Z, Gen-
giah TN, Maarschalk S, Arulappan N, Mlotshwa M, Morris L, Taylor
D; CAPRISA 004 Trial Group. Effectiveness and safety of tenofovir
gel, an antiretroviral microbicide, for the prevention of HIV infection
in women. Science. 2010. 329:1168–1174.
6
Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J,
Tappero JW, Bukusi EA, Cohen CR, Katabira E, Ronald A, Tum-
wesigye E, Were E, Fife KH, Kiarie J, Farquhar C, John-Stewart
G, Kakia A, Odoyo J, Mucunguzi A, Nakku-Joloba E, Twesigye R,
Ngure K, Apaka C, Tamooh H, Gabona F, Mujugira A, Panteleeff
D, Thomas KK, Kidoguchi L, Krows M, Revall J, Morrison S, Hau-
gen H, Emmanuel-Ogier M, Ondrejcek L, Coombs RW, Frenkel L,
Hendrix C, Bumpus NN, Bangsberg D, Haberer JE, Stevens WS,
Lingappa JR, Celum C; PartnersPrEPStudy Team. Antiretroviral
prophylaxis for HIV prevention in heterosexual men and women.
N Engl J Med. 2012. 367:399–410.
HIV Infection and AIDS in Low- and Middle-Income Countries 169
7
Anglaret X, Chene G, Attia A, Toure S, Lafont S, Combe P, Manlan
K, N’Dri-Yoman T, Salamon R. Early Chemoprophylaxis With
Trimethoprim-Sulphamethoxazole for HIV-1-Infected Adults in
Abidjan, Cote d’Ivoire: A Randomized Trial. Cotrimo-CI Study
Group. Lancet. 1999. 353:1463–1468.
8
Blanc FX, Sok T, Laureillard D, Borand L, Rekacewicz C, Nerrienet
E, Madec Y, Marcy O, Chan S, Prak N, Kim C, Lak KK, Hak C,
Dim B, Sin CI, Sun S, Guillard B, Sar B, Vong S, Fernandez M,
Fox L, Delfraissy JF, Goldfeld AE; CAMELIA (ANRS 1295–CIPRA
KH001) Study Team. Earlier versus later start of antiretroviral ther-
apy in HIV-infected adults with tuberculosis. N Engl J Med. 2011.
365:1471–81.
9
Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public
Health Service Guidelines for the Management of Occupational
Exposures to Human Immunodeficiency Virus and Recommenda-
tions for Postexposure Prophylaxis. Infect Control Hosp Epidemiol.
10
Van de Perre P, Tylleskar T, Delfraissy JF and Nagot N. Evidence-based
public health policies: The case of the prevention of mother-to-child
HIV transmission. Brit Med J. 2013. 346:f3763.
170 A Guide to Infection Control in the Hospital
Chapter 26
Tuberculosis
Paul R. Allyn, MD, and Timothy F. Brewer, MD, MPH
Key Issue
Tuberculosis (TB) remains one of the leading causes of
preventable deaths in adults worldwide. The vast majority of TB
cases and deaths occur in low resource areas. Health care asso-
ciated transmission of TB to healthcare workers and patients
occurs in both high and low-income countries. Effective infec-
tion control practices can reduce the risk of TB transmission in
healthcare settings.
Known Facts
Transmission of TB primarily occurs via inhalation of infec-
tious airborne droplet nuclei.
Transmission of TB to healthcare workers and health care
associated outbreaks of TB among patients, including mul-
tidrug-resistant TB (MDR-TB), have been well documented
in industrialized and low resource countries.
Healthcare workers are at increased risk for both latent TB
infection (LTBI) and active TB disease compared to the gen-
eral population.
Human immunodeficiency virus (HIV) infected healthcare
workers with latent TB infection have a high risk of pro-
gressing to active TB disease.
Patient factors associated with TB transmission include
coughing, smear-positivity, disease of the larynx or lungs,
cavitary disease on chest radiography, and inappropriate
anti-TB therapy.
Procedures that result in the aerosolization of Mycobacte-
rium tuberculosis such as bronchoscopy, sputum induction,
endotracheal intubation, respiratory suction, and autopsies
have resulted in TB transmission to healthcare workers.
Tuberculosis 171
Many TB patients, including those with MDR-TB, may be
effectively treated in community-based settings avoiding
hospitalization and reducing the risk of health care associ-
ated transmission.
Treatment of LTBI reduces the risk of active TB disease.
Effective infection control practices lower the risk of new
TB infections in healthcare workers and patients.
Controversial Issues
The benefit of environmental controls such as ultraviolet
germicidal irradiation (UVGI) or increasing the number of
air changes per hour (ACH) to > 12 in reducing health care
associated transmission of TB is unknown.
Universal screening of healthcare workers in TB endemic
countries for HIV infection.
Screening and treatment of healthcare workers in TB
endemic countries for LTBI.
Use of surgical masks worn by suspected or confirmed TB
patients to prevent health care associated transmission.
Efficacy of N95 masks in reducing health care associated
transmission of TB when other controls are in place.
Suggested Practice
Preventing TB transmission in healthcare facilities requires
early identification, isolation, and treatment of patients with
active TB disease. Recommended infection control strategies
to reduce TB transmission depend on the prevalence of active
TB in the patient population and the resources available to
implement control programs. Unfortunately, the areas with the
greatest need for TB infection control policies often have the
fewest resources for creating and maintaining effective control
programs. Many inexpensive interventions can significantly
reduce the risk of TB transmission in healthcare settings.
Administrative Controls
Administrative controls are the first and most-important level
of TB control in healthcare settings. The following measures
should be taken:
Assign responsibility to an infection control officer, nurse,
or other employee for implementation, enforcement, and
evaluation of TB infection control policies.
172 A Guide to Infection Control in the Hospital
Conduct a TB risk assessment at the facility to include iden-
tifying the number of TB patients seen at the facility, the
amount of time TB patients spend in different areas such as
emergency rooms (ER), waiting rooms, or wards, the prev-
alence of HIV among healthcare workers and patients, the
specific role of the healthcare workers and their potential
exposures to infectious droplets.
Develop and implement a TB infection control policy to
ensure prompt detection, isolation, and treatment of persons
with suspected or confirmed TB disease. Once policies have
been established and put into place, ongoing enforcement
and education for healthcare workers are crucial as studies
have shown that adherence to TB control measures falls over
time without continuous education and monitoring. Repeat
risk assessments at least yearly to determine if control mea-
sures are sufficient and effective.
Evaluate the use of current facilities and the need for reno-
vation or development of new spaces to provide adequate
implementation of controls.
Ensure timely availability of laboratory testing, processing,
and reporting, specifically by providing and optimizing the
turnaround time for sputum testing and culture.
Ensure proper cleaning and disinfection of potentially con-
taminated equipment (e.g. endoscopes).
Perform active surveillance of healthcare workers for active
TB disease. Consider screening healthcare workers for LTBI
and treating them if present.
Develop an educational program for all healthcare workers.
This should provide information on TB transmission, recog-
nizing the signs and symptoms of active TB, understanding
the interaction between TB and HIV, and the control policies
in place to prevent TB transmission to healthcare workers
and patients.
Provide HIV screening to healthcare workers. HIV-positive
healthcare workers should limit time spent in high-risk TB
transmission areas (e.g. emergency rooms, TB wards, spu-
tum collection areas, and bronchoscopy suites), undergo
routine screening for active TB, and have access to both
antiretroviral therapy and isoniazid preventive therapy.
Tuberculosis 173
Promptly identify patients with TB symptoms and sepa-
rate them from other patients, including those with active
TB, until they can undergo sputum testing, preferably with
a World Health Organization (WHO) recommended rapid
diagnostic test. Specific symptom criteria for triage will
depend on the setting and patient population, but should
include cough greater than 2 weeks, hemoptysis, fever,
weight loss, and night sweats.
Isolate patients diagnosed with active TB from other patients,
especially from those patients with known or suspected HIV.
Specific criteria for isolation (e.g. smear positivity, culture
status) will depend on local settings and patient popula-
tion. MDR-TB and extremely drug-resistant TB (XDR-TB)
patients should also be separated from other patients, includ-
ing those with drug sensitive TB, as transmission may occur
between groups. If individual isolation rooms are not avail-
able, a cohort system may be used.
Continue airborne isolation of patients with active TB until
they are no longer infectious.
Educate patients with suspected or confirmed TB about
respiratory hygiene and cough etiquette at the time of tri-
age. They should be provided with surgical masks, tissues,
or cloths and instructed to turn their heads and cover their
mouths when coughing or sneezing.
Promptly initiate anti-TB therapy in patients diagnosed with
active TB according to treatment guidelines developed by
the WHO, United States Centers for Disease Control (CDC),
or similar expert group.
Minimize time spent in healthcare settings. Routine hospi-
talization to commence TB treatment is not necessary and
should be reserved for those patients who otherwise require
inpatient care. Pursue outpatient evaluation and treatment
where appropriate.
Use appropriate signage to indicate isolation areas and to
promote cough etiquette.
Environmental Controls
Environmental controls consist of those measures that prevent
the spread and reduce the concentration of infectious droplet
nuclei in ambient air.
174 A Guide to Infection Control in the Hospital
Adequate ventilation in healthcare settings is essential for
preventing the transmission of TB and other airborne infec-
tions. Particular attention should be paid to high-risk trans-
mission areas such as emergency rooms, waiting rooms,
sputum collection areas, TB wards, procedure areas, and TB
isolation rooms.
Natural, mixed-mode, and mechanical ventilation systems
may be used. The choice of ventilation system depends on
an assessment of the facility and should be informed by local
programmatic, climatic, and socioeconomic conditions. Any
ventilation system requires ongoing monitoring and mainte-
nance on a regular schedule.
Regardless of the type of ventilation system used, design
should seek to achieve airflow from the source of potential
contamination to air exhaust points or to areas away from
other patients that allow for sufficient air dilution.
In high-income nations, TB patients and those undergoing
evaluation for TB should be isolated in airborne infection
isolation (AII) rooms. These rooms are designed with nega-
tive pressure so that air flows from the corridor into the room
and not from the room into the corridor. Such rooms should
be mechanically ventilated to a minimum of 12 air changes
per hour (ACH).
Natural ventilation systems may be used where resources
preclude the construction or maintenance of AII rooms. In
fact, studies have shown that natural ventilation may provide
better ventilation than rooms with mechanical ventilation
with up to 28–40 ACH. Factors associated with improved
ventilation include opening windows and doors, larger win-
dow and door openings, cross-ventilation, and wind speed.
As noted above, careful attention should be paid to direc-
tion of airflow to avoid contamination of surrounding areas.
Consider placing high-risk isolation areas on upper floors of
buildings, higher elevations, or downwind of non-TB and
HIV wards.
Well-designed, maintained, and operated fans can improve
ventilation and air mixing. Such mixed-mode ventilation
systems may be used if natural ventilation alone does not
provide adequate ventilation. A window fan exhausting air
outside is also a relatively inexpensive way of creating a
negative pressure room, though the efficacy of this approach
Tuberculosis 175
in preventing health care associated TB transmission is
unknown.
Other low-cost strategies to reduce transmission in TB-en-
demic, low-resource settings include separate open-air
shelters or waiting rooms for patients with suspected TB
awaiting or undergoing evaluation, installation of large win-
dows, skylights, high-level windows or vents installed just
under the ceiling, or opening vents or windows on doors to
help improve cross-ventilation. Consider designing build-
ings with up-sloping ceilings or roofs with open gaps or win-
dows at the high points to allow for stack ventilation. This
also creates natural airflow as hot air rises. Simple wind-
driven turbines placed on the roof may also help extract air
from the building and improve ventilation.
Conduct periodic air exchange measurements and airflow
evaluation.
For closed mechanical ventilation systems where resources
allow, air from TB isolation rooms should be exhausted
outside away from intake fans or waiting areas and passed
through high-efficiency particulate (HEPA) filters before
being re-circulated. Though the effectiveness of HEPA fil-
ters in preventing health care associated transmission of TB
is not well established, they remove 99.7% of particles ≥ 0.3
μm in size. M. tuberculosis droplet nuclei are between 1 μm
and 5 μm in size and should be removed by filtration.
Consider the use of ultraviolet germicidal irradiation (UVGI)
where resources and expertise allow. The goal of UVGI is
to inactivate airborne droplet nuclei. The two most common
forms of UVGI are upper room irradiation and duct irradi-
ation. In upper room air irradiation, UV lights are shielded
and directed towards the ceiling away from patients to
reduce the risk of skin and eye toxicity while providing ger-
micidal benefit. Well-designed UVGI upper room systems
can disinfect Mycobacteria or surrogate organisms in a test
room equivalent to 10–20 ACH. Duct irradiation is used
to disinfect air exhausted from TB isolation rooms. UVGI
should not be used in place of optimized ventilation systems
or HEPA filters. These systems are potentially hazardous if
not installed correctly, so need to be designed and installed
by well-qualified engineers and technicians.
176 A Guide to Infection Control in the Hospital
Personal Protection
All healthcare workers should wear N95 particulate respira-
tors when caring for patients with infectious TB, especially
during high-risk procedures such as sputum induction, intu-
bation, or bronchoscopy, and when caring for patients with
drug-resistant TB. N95 masks filter ≥ 95% of particles 1 μm
in size when used properly with a tight facial seal. Surgical
masks are useful for TB patients to reduce the number of
infectious particles in the air, but have only 50% filter effi-
ciency and lack a tight facial seal, so should not be used by
healthcare workers in place of N95 masks.
Summary
TB remains one of the leading causes of preventable morbid-
ity and mortality worldwide with approximately 8.7 million
new cases and 1.4 million deaths every year. 98% of cases and
deaths occur in low resource countries. About one-third of the
world’s population is estimated to be infected with M. tubercu-
losis and therefore at risk for developing active TB. Individuals
co-infected with HIV and TB, including healthcare workers,
have a very high risk of developing active TB and should be
treated with isoniazid preventive therapy if they have no con-
traindications. Institutional transmission of TB has occurred
throughout the world and healthcare workers are at high risk
for acquiring TB infection and active disease. Many adminis-
trative steps for TB control, such as improving the evaluation
and separation of suspected TB cases, cough etiquette, prompt
initiation of anti-TB treatment, and avoiding unnecessary hos-
pitalization may be possible without a large financial invest-
ment. Some environmental controls such as AII rooms, HEPA
filters, and UVGI may be cost prohibitive in many settings in
TB endemic countries, but opening windows and doors, adding
fans to improve airflow and create negative pressure, or install-
ing skylights will improve ventilation and may reduce the risk
of TB transmission for relatively low cost. Personal protection
of healthcare workers and visitors with N95 particulate respira-
tors is also recommended whenever caring for infectious TB or
suspected TB patients. Even in low resource settings, healthcare
workers should be provided with N95 particulate respirators,
Tuberculosis 177
especially in high-risk transmission settings such as aerosoliza-
tion procedures or when in contact with MDR-TB or XDR-TB
infected patients. Ongoing assessment, proper implementation,
and continuous reinforcement of TB infection control prac-
tices should reduce or eliminate the spread of TB in healthcare
settings.
References
Centers for Disease Control and Prevention, Jensen P, Lambert L, Iade-
marco M, Ridzon R. Guidelines for preventing the transmission of
Mycobacterium tuberculosis in healthcare settings. MMWR. 2005.
54:1–141.
Shenoi SV, Escombe AR, Friedland G. Transmission of drug-suscep-
tible and drug-resistant tuberculosis and the critical importance of
airborne infection control in the era of HIV infection and highly
active antiretroviral therapy rollouts. Clin Infect Dis. 2010. 50(Suppl
3):S231–7.
World Health Organization. Implementing the WHO policy on TB
infection control in health-care facilities, congregate settings and
households. World Health Organization, Geneva, 2010.
World Health Organization. Policy on TB infection control in health-
care facilities, congregate settings and households. World Health
Organization, Geneva, 2009.
178 A Guide to Infection Control in the Hospital
- stances, vaginal microbicides and PreP;
- testing of blood donations;
- tion, maternal and child care, family planning, et cetera);
- HIV counselling and testing services;
- available essential drugs and including nutritional support;
- – Decentralised management and community support;
- – Improved integrated strategies to diagnose and treat TB;
- and < 500 cells per ml regardless of WHO clinical stage;
- 2013. 34:875–92.
Chapter 27
Diarrhea
Made Sutjita MD, PhD, and Herbert L. DuPont, MD
Key Issues
A diarrheal disease outbreak in a healthcare facility may affect
patients, healthcare workers, and visitors. Surveillance, and ini-
tiation of prompt infection control management practices will
reduce the morbidity and mortality rate.
Known Facts
Definitions of diarrhea vary but generally include the pas-
sage of liquid or watery stools, three or more times per day.
Microorganisms that invade or inflame the intestinal mucosa
often elicit a febrile response in addition to causing diar-
rhea. Diarrhea in a patient with unexpected fever should be
considered as infectious gastroenteritis regardless of culture
results. If diarrhea occurs in a febrile patient whose fever has
other likely causes, the identification of pathogenic microor-
ganisms is necessary to establish the diagnosis.
The known incubation period of an infectious agent is
important in determining whether a given infection is health
care associated. The interval between the time of admission
and the onset of clinical symptom must be longer than the
known minimum incubation period of the infectious agent.
Alternatively, health care associated gastroenteritis can be
determined if a stool culture obtained shortly before or just
after admission is negative for a given pathogenic agent and
the agent is subsequently cultured from the patient’s stool.
Microorganisms that cause diarrhea outbreaks in the commu-
nity are also able to cause health care associated outbreaks.
Some forms of diarrheal disease, such as food poisoning
caused by enterotoxin-producing strains of Bacillus cereus,
Clostridium perfringens and Staphylococcus aureus have not
been demonstrated to be directly transmissible from person
Diarrhea 179
to person in the hospital. Common bacteria reported
to cause health care associated gastroenteritis include various
strains of diarrheagenic Escherichia coli, Salmonella spp.,
Yersinia enterocolitica, V. cholerae, and most importantly
Clostridium difficile.
The most important viral agents include rotaviruses in non-
immunized infants and young children and noroviruses in
all age groups. In an epidemiologic investigation in England
during the period 2002–03, noroviruses were found in 63%
of health care associated gastroenteritis outbreaks. Other
viruses such as adenoviruses type 40 and 41 have also been
implicated in health care associated outbreaks. In a child-
care setting, the low inoculum enteric pathogens are most
important: rotaviruses, noroviruses, Shigella strains and
Giardia strains.
It is important to distinguish between non-infectious diarrhea
and infectious gastroenteritis in the hospital setting. Health
care associated diarrhea or diarrhea of non-infectious origin,
such as that caused by cathartics, tube feeding, inflammatory
bowel disease, surgical resection, and anastomoses should
be differentiated from diarrhea of infectious origin.
The rate of health care associated gastroenteritis varies
among hospitals and services. The NNIS (National Nosoco-
mial Infections Surveillance) in the USA reported a health
care associated gastroenteritis infection rate of 2.27 per 1000
discharges, for the period of January 1990 through Decem-
ber 1994. C. difficile is the most commonly identified cause
of health care associated diarrhea. Since 1996, rates of C.
difficile associated diarrhea (CDAD) have tripled. Infection
rates and causes of health care associated gastroenteritis in
developing countries have not been well studied. Nonetheless,
outbreaks are reported with increasing frequency. Salmonella
spp are the most common cause of health care associated gas-
troenteritis in India, Pakistan, and Tunisia.
Risk factors for health care associated gastroenteritis can be
classified by intrinsic and extrinsic factors. Intrinsic factors
include an abnormality in the mucosal defense, such as ach-
lorhydria, impairment of intestinal motility, and alteration of
180 A Guide to Infection Control in the Hospital
normal enteric flora. Neonates with undeveloped immunity
or patients with an immune deficiency state, such as those on
immuno-suppressive drugs or with HIV infection and AIDS,
are at increased risk to develop health care associated gastro-
enteritis. Extrinsic factors include nasogastric tube feeding
while receiving cimetidine or proton pump inhibitors, which
allow intestinal colonization of bacteria. Such a setting is
normally found in an intensive care unit.
Modes of transmission of infectious agents causing gas-
troenteritis are typically through the fecal-oral route. The
transmission occurs either by contact spread from patient
to patient, patient to healthcare worker (HCW), or HCW to
patient (either direct or indirect), or through common vehi-
cle spread. Contaminated vehicles such as food, water, med-
ications, or devices and equipment can play a significant role
in the transmission of the agents.
Controversial Issues
Salmonella spp were reported as the most common cause
of health care associated gastroenteritis in some developing
countries but the infection rate of other enteric pathogens is
not well known. Without the established mechanism for rou-
tinely reporting health care associated outbreaks, the ‘true’
infection rate of given pathogens is underestimated.
The availability of “over-the-counter” antibiotics without
a physician’s prescription in many developing regions has
led to the development of resistant microorganisms in many
regions. This often complicates the management of a diar-
rheal disease outbreak.
Antibiotics given to poultry for growth promotion leads to
the development of resistant microorganisms which can be
potentially harmful and cause disease in humans.
Suggested Practice
Diarrheal diseases can be prevented by following simple
rules of personal food hygiene.
Effective hand washing is among the most important mea-
sures to reduce the risks of transmitting microorganisms
Diarrhea 181
from one person to another or from one site to another
in the same patient. HCWs should wash their hands with
a non-antimicrobial soap and water or an alcohol-based
waterless antiseptic agent. An anti-microbial soap and water
should be used when hands are visibly dirty or contaminated
with feces.
C. difficile is the most important cause of health care asso-
ciated diarrhea in industrialized countries. If an outbreak
of CDAD is suspected or identified soap and water should
be used for hand hygiene when caring for diarrhea patients
since alcohol-based hand rubs are not effective against these
spore-forming bacteria.
Gloves play an important role in reducing the risk of micro-
organism transmission, and preventing contamination of the
hands when touching patients and fomites. Attempts should
be made to reduce the likelihood of the hands of the HCW
being contaminated with microorganisms from a patient or a
fomite and of infecting another patient. In this case, gloves
must be changed between patient contacts and hands must
be washed after gloves are removed.
Gowns and other protective apparel provide barrier protec-
tion and reduce the likelihood of transmission of microor-
ganisms. Gowns, boots, or shoe covers provide protection
against splashes or exposure to infective material. When a
gown is worn during the care of a patient infected with an
epidemiologically important microorganism, it should be
removed before leaving the patient’s environment.
A private room is important to prevent direct or indirect con-
tact transmission of the microorganism. Whenever possible,
a patient with infectious diarrhea is placed in a private room
with hand washing and toilet facilities. A sign of “contact iso-
lation” should be placed in front of the door to warn visitors
or other HCWs. Patients infected by the same microorganism
may share a room (cohorting), provided they are not infected
with another potentially transmissible microorganism.
Limiting the transport of a hospitalized patient with infec-
tious diarrhea may also reduce the opportunities for trans-
mission of the microorganism in the hospital.
182 A Guide to Infection Control in the Hospital
The patient’s room, bed and bedside equipment should be
cleaned thoroughly. In a patient with stool positive for VRE
(vancomycin resistant enterococci), adequate disinfection
of environmental surfaces, i.e., bed rails, tables, carts, com-
modes, doorknobs, or faucet handles, is indicated. Entero-
cocci are not causing diarrhea, but may cause blood stream
infection in susceptible patients. Enterococci are known to
survive in the inanimate environment for prolonged periods
of time.
Urine, feces, and soiled linen should be considered poten-
tially infectious and handled or disposed appropriately as
discussed elsewhere. Personnel handling these materials
should wear gloves and other protective apparel as described
above.
For rooms housing a patient with CDAD household bleach
(1000 ppm sodium hypochlorite or 5 tablespoons of 6%
bleach to 1 gallon water) should be used for disinfecting
hard surfaces routinely or after cleaning a soiled area. If pos-
sible allow the surfaces to remain wet for 10 minutes then
air dry.
Education of hospital personnel through initial orientation
and annual in service education should include food han-
dling sanitation, hand washing and hand hygiene techniques,
personal hygiene and employee health.
Unprocessed vegetables and fruits should be thoroughly
washed under running water before preparation or use.
Foods should be prepared and served with clean utensils to
avoid direct contact.
Food grinders, choppers, mixers and other kitchenware
should be cleaned, sanitized, dried, and reassembled after
each use.
Prepared foods should be transported to other areas in closed
food carts or covered containers.
Food must be stored sufficiently above floor level and away
from walls. Perishable foods should be stored at or below
40o F and frozen food at 0o F or lower. Stored food should be
rotated and used first before newly prepared food.
Diarrhea 183
Please review Chapter 18 Food: Considerations for Hospital
Infection Control, for more detailed information.
Summary
It is important to establish a hospital surveillance program in
which clinical patterns of infection are monitored on a regu-
lar basis. A “low-budget” surveillance program probably can
be carried out by daily review and tabulation of bacteriologic
reports from the hospital microbiology laboratory. Both coop-
eration and effective communication between hospital epidemi-
ology and the microbiology laboratory personnel are essential.
In addition to the patient population, surveillance must
include hospital personnel, particularly food handlers, nurses
and other medical staff. An employee health service or an
employee clinic ideally should be easily accessible to each
employee. Food handlers, nurses, and ancillary staff having
direct contact with patients should report to the employee health
service when they experience an episode of diarrhea. In this
case, stool cultures should be performed and the ill employee
temporarily removed from work until the clinical course of the
disease and culture result can be evaluated. Workers should not
return to work until their diarrhea is resolved and two stool cul-
tures obtained at least 24 hours apart show negative results.
A health care associated infectious gastroenteritis outbreak
may occur due to the transmission from carriers of a specific
pathogenic microorganism. Carriers can be patients or hospi-
tal personnel. Surveillance carried out on a regular basis should
detect any episodes of gastroenteritis among patients and
hospital personnel. Temporal clustering of cases should alert
infection control personnel to the possibility of an outbreak.
Occasionally, an outbreak may occur due to contaminated
vehicles such as food, equipment, or oral medication. If such
a vehicle is identified, its removal or disinfection may help to
terminate the outbreak.
Patients with infectious gastroenteritis should be discharged
from the hospital as soon as their condition allows them to be
managed on an outpatient basis.
184 A Guide to Infection Control in the Hospital
References
Books
Crookson ST, Hughes JM, and Jarvis WR. Nosocomial Gastrointestinal
Infections in Prevention and Control of Nosocomial Infections (3rd
Edition), Wenzel RP (Ed). Baltimore: Williams & Wilkins, 1997.
Pgs. 925–75.
DuPont HL, Ribner BS. Infectious Gastroenteritis in Hospital Infections
(4th Edition), Bennet JV, Brachman PS (Eds). Philadelphia: Lippin-
cott-Raven, 1998. Pgs. 537–50.
Slutsker L, Villarino ME, Jarvis WR, Goulding J. in Hospital Infections
(4th Edition), Bennet JV, Brachman PS (Eds). Philadelphia: Lippin-
cott-Raven, 1998. Pgs. 333–41.
Weinstein JW, Hierholzer W Jr, Garner JS. Isolation Precautions in Hos-
pitals in Hospital Infections (4th Edition), Bennet JV, Brachman PS
(Eds). Philadelphia: Lippincott-Raven, 1998. Pgs. 189–98.
Guideline for Hand Hygiene in Healthcare Settings. MMWR. 2002.
51:1–56.
Blaser MJ, Smith PD, Ravdin JI, Greenberg HB, Guerrant RL (Eds).
Infections of the Gastrointestinal Tract (2nd Edition). Philadelphia:
Lippincott Williams & Wilkins, 2002.
Manuscripts
Lopman BA, Reacher MH, and Vipond IB, et al. Epidemiology and
Cost of Nosocomial Gastroenteritis, Avon, England, 2002–2003,
Emerging Inf Dis. 2004. 10:1827–34.
Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva J Jr.
Clostridium difficile-associated diarrhea and colitis. Infect Control
Hosp Epidemiol. 1995. 459–77.
On Line Resources
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6034a7.htm
(Accessed 10 July 2013).
http://www.cdc.gov/mmwr/pdf/ss/ss6202.pdf (Accessed 10 July 2013).
Diarrhea 185
Chapter 28
Skin and Soft Tissue Infections
Antoni Trilla, MD, MSc
Key Issue
Skin and soft tissue (SST) infections are not uncommon in the
hospital setting. SST infections attended most frequently in
hospitalized patients are mainly cellulitis/erysipelis, the major-
ity being community acquired. Methicillin resistant S. aureus
(MRSA) infections are mainly health care related, but increas-
ingly community-acquired MRSA strains are being recognized.
In addition to localized complications, skin and soft tissue
infections may cause life-threatening bacteremia or a sepsis
syndrome. Currently, linezolid seems to be more effective than
vancomycin for treating people with SST infections, including
SST infections caused by MRSA.
Known Facts
The most common agent is Staphylococcus aureus, followed by
Streptococcus pyogenes and anaerobic gram-negative bacilli.
Amongst special populations (diabetic patients, patients with
burn wounds), aerobic gram-negative bacilli, including Pseu-
domonas aeruginosa, should be considered. Staphylococcus
aureus is found in the normal skin, as a transient coloniz-
ing organism, often linked to nasal carriage (anterior nares).
Pre-existing conditions, such as tissue injury (surgical wounds,
trauma, pressure sores) or skin inflammation (dermatitis), as
well as other diseases (insulin-dependent diabetes, cancer,
chronic renal failure on hemodialysis, intravenous drug abuse,
and HIV infection) are risk factors for skin colonization and/or
secondary infection by Staphylococcus aureus.
Staphylococcal Skin Infections
Key Issue: Impetigo is the most common skin infection. It is a
superficial primary skin infection, often caused by Streptococcus
pyogenes (90%) or Staphylococcus aureus (10%) infection.
186 A Guide to Infection Control in the Hospital
Impetigo may appear as a complication of other skin disorders,
like eczema, varicella, or scabies.
Known Facts: Often seen in children, impetigo is readily trans-
mitted in households and hospitals. The increasing frequency of
skin disorders in HIV-infected patients should also be noted and
the diagnosis of impetigo considered.
Controversial Issues: The use of several antibiotics (mupirocin,
fusidic acid, erythromycin, tetracycline) as topical treatment for
impetigo has been shown to have a ~90% efficacy in clinical
trials. The use of topical antibiotics decreases bacterial coloni-
zation and infection, and promotes faster wound healing. Oral
antibiotic treatment (erythromycin, an antistaphylococcal peni-
cillin, amoxicillin + clavulanic acid) has been used with a simi-
lar success rate. The emergence of multidrug-resistant S.aureus
strains, including MRSA mupirocin-resistant strains, is a matter
of concern. The introduction of these strains (from the commu-
nity setting) should be monitored in hospitals, also if topical
treatments with agents like mupirocin are widely used for long
periods of time.
Suggested Practice: Standard hygienic measures and contact
isolation procedures should be used in patients with impetigo.
This practice must be encouraged, especially in neonatal and
pediatric intensive care units, as well as for patients with HIV
infection and a rash.
Staphylococcal Scalded-Skin Syndrome (SSSS)
Key Issue: SSSS is a severe Staphylococcus aureus infection
with extensive bullae and exfoliation.
Known Facts: It occurs in children, but rarely in adults. Several
epidemics have been reported in nurseries and neonatal inten-
sive care units (NICU). Its clinical picture is related to the
production of a powerful exotoxin by the S. aureus strains.
Most cases develop acute fever and a scarlatiniform skin rash.
Large bullae soon appear, followed by exfoliation. Also known
as toxic epidermal necrolysis, this disease can be due to other
infections or drug reactions.
Controversial Issue: The use of corticosteroids alone is not
recommended for SSSS.
Skin and Soft Tissue Infections 187
Suggested Practice: The use of an antistaphylococcal penicillin
is the antibiotic treatment of choice. Topical treatment includes
cool saline compresses.
Skin and Soft Tissue Infections in Patients with Diabetes
Key Issue: Diabetic patients are at higher risk for developing
skin and soft tissue (SST) Staphylococcus aureus infections.
Known Facts: Hyperglycemic states are linked with a higher
nasal and skin carriage rate of S.aureus. The impaired cell-me-
diated immunity of these patients is an important factor.
Controversial Issues: Diabetic patients may develop SST infec-
tions with organisms different from those in non-diabetics. The
most severe condition is the acute dermal gangrene syndrome.
This syndrome, related to a deep tissue infection and dermal
necrosis, is often associated with prior trauma or surgery. It
includes two different conditions:
the complete necrosis of subcutaneous tissue. It is often
associated with high fever, sepsis and septic shock. The
mortality rate is very high (30%).
sive infection, related to surgical wounds, ileostomy sites,
and exit site of drains (intra-abdominal or thoracic), which
affects the hypodermis. The patient has a low grade fever
or no fever at all. Local signs of infection are prominent.
Other syndromes include Meleney’s gangrene, where the
clinical picture is slowly progressive and without deep fas-
cial involvement; Fournier’s gangrene, if the perineal zone is
involved; streptococcal gangrene, if Streptococcus pyogenes
is the causative agent, or nonclostridial anaerobic synergistic
myonecrosis if the muscles are also involved. These SST dis-
orders are nearly always due to polymicrobial infections, with
Streptococcus pyogenes and Staphylococcus aureus being the
most commonly isolated microorganisms.
Autologous platelet-rich plasma (PRP) is a treatment that
contains fibrin and high concentrations of growth factors and
has the potential to aid wound healing. There is currently no
evidence to suggest that autologous PRP is of value for treating
chronic wounds.
188 A Guide to Infection Control in the Hospital
Suggested Practice: Systemic antimicrobial treatment based on
the most likely pathogens (including penicillin, antistaphylo-
coccal penicillin, amoxicillin+clavulanic acid, a first or second
generation cephalosporin), together with extensive and repeated
surgical débridement are needed and must be started early.
Diabetic foot complications are responsible for more than 1
million of leg amputations every year. Diabeticd foot infection
(DFI) can dramatically increase the risk of amputation. Many
ulcer classification systems have been proposed to stratify the
severity of the infectious process, but the definition of a spe-
cific therapeutic approach still remains an unsolved problem.
The microbiology of these infections is often complex and can
be polymicrobial. Treatment of these infections depends on
the severity and extent of infection. Treatment should involve
a multi-disciplinary team approach involving surgeons and
infectious disease specialists. No single agent or combination
of agents has been shown to be superior to others. Empiric anti-
biotics for DFIs vary based on the severity of the infection, but
must include anti-staphylococcal coverage.
Burn Wound Infections
Key Issue: Burn wound patients and burn wound units are poten-
tial portals of entry for health care associated outbreaks due to
MRSA and Pseudomonas aeruginosa infections. Staphylococ-
cus aureus is responsible for 25% of all burn wound infections,
followed by P. aeruginosa.
Known Facts: The most likely reservoirs for these infections are
the hands and nares of healthcare workers (S. aureus, MRSA),
the burn wound itself and the GI tract of burn patients (S. aureus,
P. aeruginosa), and the inanimate environment of the burn unit,
including the surfaces and/or the equipment (S. aureus, MRSA,
P. aeruginosa).
Suggested Practice: Common standard isolation precautions,
together with contact isolation precautions are important to
prevent health care associated infections in burn units. Topical
treatment using mafenide acetate, silver sulfadiazine, bacitra-
cin/ neomycin/polymyxin, 2% mupirocin, together with sys-
temic, antistaphylococcal and anti-Pseudomonas antibiotics
should be reserved for documented or clinical infections.
Skin and Soft Tissue Infections 189
Pressure Sores (Decubitus Ulcers)
Key Issue: Pressure sores appear in 6% of patients admitted to
healthcare institutions (range 3 to 17%), and are the leading
cause of infection in long-term care facilities.
Known Facts: The prevention of pressure sores includes the
control of local factors such as unrelieved pressure, friction,
moisture, or systemic factors such as low serum albumin, fecal
incontinence, and poor hygienic measures. The infection is
polymicrobial, and includes gram-negative bacilli, Staphylo-
coccus aureus, Enterococcus spp and anaerobes. The average
number of isolates in infected pressure sores is four, includ-
ing three aerobic and one anaerobic bacteria. Pressure sores
are sometimes associated with severe systemic complications,
including bacteremia, septic thrombophlebitis, cellulitis, deep
tissue and fascial necrosis, and osteomyelitis. The development
of clinical tetanus is unlikely, although still possible. In patients
with bacteremia and pressure sores, the sores were considered
to be the source of the bacteremia in half the cases. Overall mor-
tality was 55%, with approximately 25% of deaths attributable
to the infection. Therefore, pressure sores must be considered a
potential source for nosocomial bacteremia.
Controversial Issues: A Cochrane review conclude that honey
dressings do not increase rates of healing significantly in venous
leg ulcers when used as an adjuvant to compression. Honey
might be superior to some conventional dressing materials,
but there is considerable uncertainty about the replicability and
applicability of this evidence. There is insufficient evidence to
guide clinical practice in other types of wounds.
Iodine is often used in the treatment of wounds. A systematic
review concludes that Iodine did not lead to a reduction or pro-
longation of wound-healing time compared with other (antisep-
tic) wound dressings or agents. In individual trials, iodine was
significantly superior to other antiseptic agents (such as silver
sulfadiazine cream). Based on the available evidence from clin-
ical trials, iodine is an effective antiseptic agent and does not
impair wound healing.
Suggested Practice: Antibiotic treatment, together with surgi-
cal care and débridement of the sores, is needed. Taking into
190 A Guide to Infection Control in the Hospital
account the most likely microorganisms, a second-generation
cephalosporin is one of the drugs of choice. The combination of
a beta-lactam antibiotic with an aminoglycoside, or clindamy-
cin plus an aminoglycoside, or a cephalosporin plus metronida-
zole are other therapeutic options, but one must be especially
cautious in using aminoglycosides in diabetic patients.
Nosocomial Bacteremia Due to SST Infection
Key Issue: Nosocomial bacteremia secondary to SST infections
has a low frequency rate. According to National Nosocomial
Infections Surveillance (NNIS) data, only 5 to 8% of all bacte-
remic episodes were secondary to SST infections.
Known Facts: Patients with poorly controlled diabetes and can-
cer are a high-risk group for developing this infection. In one
large series from the US National Cancer Institute, 12% of all
bacteremic episodes in cancer patients were secondary to SST
infection. However, only 6% of those cases were associated
with severe neutropenia. In neutropenic patients, ecthyma gan-
grenosum due to Pseudomonas aeruginosa SST infection must
be considered. Intravenous drug abuse (IVDA) is a worldwide
problem. SST infections are common among IVDA, S. aureus is
the most common microorganism (30% of cases). The common
clinical presentations are subcutaneous abscesses, cellulitis, and
lymphangitis, most often (60%) located in upper extremities.
Bacteremia is one of the most severe and common complica-
tions among IVDA, with 40% of all episodes due to S. aureus.
Suggested Practice: If bacteremia develops in an IVDA, sep-
tic thrombophlebitis or endocarditis should be considered, and
antibiotic treatment started as soon as possible.
References
Braunstein I, Wanat KA, Abuabara K, McGowan KL, Yan AC, Treat
JR. Antibiotic Sensitivity and Resistance Patterns in Pediatric Staph-
ylococcal Scalded Skin Syndrome. Pediatr Dermatol. 2013 Aug 23.
doi: 10.1111/pde.12195.
Caravaggi C, Sganzaroli A, Galenda P, Bassetti M, Ferraresi R, Gabri-
elli L. The management of the infected diabetic foot. Curr Diabetes
Rev. January 1, 2013. 9(1):7–24.
Jull AB, Walker N, Deshpande S. Honey as a topical treatment
for wounds. Cochrane Database Syst Rev. February 28, 2013.
2:CD005083. doi:10.1002/14651858.CD005083.pub3.
Skin and Soft Tissue Infections 191
Martinez-Zapata MJ, Martí-Carvajal AJ, Solà I, Expósito JA, Bolíbar I,
Rodríguez L, Garcia J. Autologous platelet-rich plasma for treating
chronic wounds. Cochrane Database Syst Rev. October 17, 2012.
10:CD006899. doi:10.1002/14651858.CD006899.pub2.
May AK. Skin and soft tissue infections: the new surgical infection
society guidelines. Surg Infect (Larchmt). June 2011. 12(3):179–84.
doi:10.1089/sur.2011.034.
Park H, Copeland C, Henry S, Barbul A. Complex wounds and their
management. Surg Clin North Am. December 2010. 90(6):1181–94.
doi:10.1016/j.suc.2010.08.001.
Raya-Cruz M, Ferullo I, Arrizabalaga-Asenjo M, Nadal-Nadal A,
Díaz-Antolín MP, Garau-Colom M, Payeras-Cifre A. Skin and
soft-tissue infections in hospitalized patients: Epidemiology, micro-
biological, clinical and prognostic factors. Enferm Infecc Microbiol
Clin. May 15, 2013. pii:S0213-005X(13)00077-3. doi:10.1016/j.
eimc.2013.03.004.
Roberts AD, Simon GL. Diabetic foot infections: the role of microbiol-
ogy and antibiotic treatment. Semin Vasc Surg. June 2012. 25(2):75–
Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Gold-
stein EJ, Gorbach SL, Hirschmann JV, Kaplan EL, Montoya JG,
Wade JC; Infectious Diseases Society of America. Practice guide-
lines for the diagnosis and management of skin and soft-tissue infec-
tions. Clin Infect Dis. November 15, 2005. 41(10):1373–406.
Yue J, Dong BR, Yang M, Chen X, Wu T, Liu GJ. Linezolid versus van-
comycin for skin and soft tissue infections. Cochrane Database Syst
Rev. July 12, 2013. 7:CD008056. doi:10.1002/14651858.CD008056.
pub2.
Vermeulen H, Westerbos SJ, Ubbink DT. Benefit and harm of iodine
in wound care: A systematic review. J Hosp Infect. November 2010.
76(3):191–9. doi:10.1016/j.jhin.2010.04.026.
192 A Guide to Infection Control in the Hospital
Chapter 29
Bloodstream Infections
Melanie Brown MD, Gonzalo Bearman MD, MPH
Definition
Blood stream infections(BSIs) are defined as one or more pos-
itive blood cultures associated with systemic signs of infection
such as fevers, chills, and/or hypotension. BSIs can be divided
into primary BSIs vs. secondary BSIs. Primary BSIs occur
without another known nidus of infection. Secondary BSIs
develop from another detectable area of infection thought to be
the source of the bacteremia. An example of a secondary BSI
includes a patient with a urinary tract infection and subsequent
bacteremia.
Key Points
BSI are often are iatrogenic owing to invasive procedures or
devices such as placement of central catheter lines.
Catheter-related BSIs are the most common cause of health
care associated bacteremia.
In contrast, peripheral venous catheters rarely cause BSI.
Prevention of catheter-related BSIs is a high priority infec-
tion control initiative.
Known Facts
An estimated 250,000 cases of BSIs occur annually in the
USA.
80,000 of these are catheter-related BSIs that occur in ICUs.
BSIs greatly increase hospital cost and length of stay.
The estimated BSI attributable mortality rate is between
12–25%.
Catheter-related bloodstream infections account for 11% of
health care associated infections.
Most frequently isolated BSI organisms include coagulase-
negative staphylococci (31%), S. aureus (20%), enterococci
(9%), Escherichia coli (6%), Klebsiella species (5%), and
Candida species (9%).
Bloodstream Infections 193
Implementation of proven infection reduction techniques is
associated with 60% decrease in catheter related BSI rates in
US intensive care units.
Suggested Practices to Prevent BSI:
Education and training of healthcare workers.
Hospital infection control policy with surveillance for intra-
vascular device-related infection.
The use of central line bundles comprised of five key
components:
hol-based waterless hand cleaner or antibacterial soap and
water with adequate rinsing.
adherence to hand hygiene, the wearing of surgical cap,
mask, sterile gown and sterile gloves, and use of sterile
drapes.
alcohol.
avoidance of femoral site.
removal as soon as possible.
Disinfection of injection ports prior to use and stopcocks
should be capped when not in use.
Use Teflon or polyurethane catheters instead of polyvinyl
chloride or polyethylene catheters.
Sterile gauze dressing changes should occur every 2 days.
Transparent dressing changes should occur every 7 days.
Chlorhexidine-impregnated sponge (Biopatch) placed at
catheter site is associated with significant reduction in BSI
rates.
Daily skin cleansing with 2% chlorhexidine wash reduces
BSI rates.
Use of antimicrobial-coated catheters should be considered
if duration of device use is longer than 5 days.
Replace tubing used for blood products, lipid emulsions and
propofol infusions.
194 A Guide to Infection Control in the Hospital
Use sutureless securement devices to reduce intravascular
catheter infection risk.
Use peripheral catheters as opposed to central venous cathe-
ters whenever possible.
Tunneled central venous catheters should be preferentially
employed for long term use(>7days of catheterization).
Practices Currently Not Recommended
Do not use topical antibiotics at insertions sites except when
using dialysis catheters.
Do not use in-line filters for infection prevention.
Do not use prophylactic systemic or intranasal antibiotics
prior to central line insertion to prevent catheter colonization
or BSI.
Do not use antibiotic lock solutions routinely. Antibiotic
locks should only be used under special circumstances such
as patients with history of multiple catheter related blood-
stream infections despite adequate precautions.
Do not use guidewire catheter exchanges to prevent infec-
tion or to change out suspected infected catheters.
Do not routinely use anticoagulant therapy to reduce cathe-
ter-related infection risk.
Summary
The most common cause of health care associated bacteremia
is catheter-related bloodstream infection. These infections
increase morbidity, mortality, length of stay and hospital costs.
Implementing the above practices has been shown to decrease
these rates and improve quality of care for our patients.
References
O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard
SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad I, Ran-
dolph A, Rupp ME, Saint S, and the Healthcare Infection Control
Practices Advisory Committee (HICPAC). Guidelines for the Pre-
vention of Intravascular Catheter-Related Infections. CDC. 2011.
O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO,
Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad
I, Randolph A, Weinstein RA. MMWR. August 9, 2002. 51(RR-10).
Abad CL, Safdar N. Catheter-related Bloodstream Infections. Infectious
Disease Special Edition. September 2011. 14.
Bloodstream Infections 195
Fagan RP, Edwards JR, Park BJ, Fridkin SK, Magill SS, Incidence
Trends in Pathogen-Specific Central Line–Associated Bloodstream
Infections in US Intensive Care Units, 1990–2010. Infect Control
Hosp Epidemiol. September 2013. 34(9):893–899.
Mermel LA, Farr BM, Sherertz RJ, Raad I, O’Grady NP, Harris JS,
Craven DE. Guidelines for the Management of Intravascular Cath-
eter-Related Infections. Infect Control Hosp Epidemiol. April 2001.
22(4):222–242.
Timsit J-F, Schwebel C, Bouadma L, Geffroy A, Orgeas MG, Pease
S, Herault M-C, Haouache H, Calvino-Gunther S, Gestin B,
Armand-Lefevre L, Leflon V, Chaplain C, Benali A, Francais A,
Adrie C, Zahar J-R, Thuong M, Arrault X, Croize J, Lucet J-C,
Chlorhexidine-impregnated sponges and less frequent dressing
changes for prevention of catheter-related infections in critically
ill adults: A randomized controlled trial. JAMA. March 25, 2009.
301(12):1231–1241.
Pronovost P, Needham D, Berenholtz S, et al. An Intervention to
Decrease Catheter-Related Bloodstream Infections in the ICU.
N Engl J Med. 2006. 355:2725–2732.
196 A Guide to Infection Control in the Hospital
- 1. Necrotizing fasciitis, affecting the fascia and producing
- 2. Progressive bacterial gangrene, a more slowly progres-
- 81. doi:10.1053/j.semvascsurg.2012.04.010.
- 1. Appropriate hand hygiene involving the use of alco-
- 2. The use of maximal barrier precautions meaning strict
- 3. Skin preparation with 2% chlorhexidine in 70% isopropyl
- 4. Using the optimal catheter site such as the subclavian and
- 5. Ongoing daily reviews of central line necessity and
Chapter 30
Managing Vascular Catheters
Andreas F. Widmer, MD, MS
Key Issues
Intravascular (IV) catheters are frequent sources of blood-
stream infections. Surveillance belongs to the basic require-
ments of any infection control program.
Reports should be given in number of infections per 1000
catheter days rather than per 100 patients.
Catheter-associated bloodstream infection (CA-BSI) is
the most commonly used for surveillance and is defined
as a central line that was in use during the 48-hour period
before development of the bloodstream infection (BSI) and
no other obvious source was identified (subset of primary
bacteremia).
Catheter-related BSI (CR-BSI) is defined as CA-BSI with
the addition of a positive catheter tip culture or positive dif-
ferential time to positivity.
Current scientific evidence allows to decrease the incidence
to below one per 1000 catheter days.
Known Facts
IV-catheters are a frequent source for bloodstream infections.
The incidence of infection depends on the catheter type, type
of hospital setting (intensive care unit vs ward), the cathe-
ter care, underlying diseases of the patient, and the type and
resources for the prevention program.
Polyurethane or silicon catheters have a lower risk of com-
plications than others. Triple-lumen catheters have similar
risks for infection as have single-lumen catheters, but more
lumens are associated with more manipulations.
A common portal of bacterial entry is the insertion site
during the first 2 weeks after catheter placement.
Managing Vascular Catheters 197
After 2 weeks, the hub (the connection between the catheter
and the infusing tube) becomes the predominant source of
bacterial entry.
Most CA-BSIs are observed in intensive care units or burn
units.
Each catheter day adds to the overall risk of CR-BSI:
Remove catheters as soon it is clinically possible is a key
component for prevention of CA-BSI.
Healthcare education, training and monitoring or insertion,
maintenance are paramount to prevent CR-BSIs.
Full barrier precautions with gloves, gown, cap and large
drapes prevent early infections.
Hand hygiene, specifically the alcoholic hand rub, must be
enforced before placing any catheter.
Infusion time for lipids should not exceed 24 hours, for
blood 4 hours.
Routine replacement of intravascular catheters does not pre-
vent CA-BSIs.
Clinical signs and symptoms have a poor sensitivity and
specificity for CA-BSIs.
Suggested Practice
Catheters in general
Perform surveillance for device-use and CA-BSIs in inten-
sive care units, burn units and hematology-oncology units.
Daily check indication for intravascular line, use automatic
removal orders, if necessary.
General recommendation for the choice of intravenous access
– < 5 days: Peripheral catheter.
– 5–10 days: CVC: jugular site preferred: higher rate of
infection compared to the subclavian access, but lower
non-infectious risk (bleeding, pneumothorax).
– 5–28 days: CVC: Subclavian access site.
– Alternative: Percutaneous peripherally inserted CVC
(PICC-lines) for outpatient therapy.
– 28 days: tunneled (eg. Hickmann) or totally implanted
catheters (e.g., port-a-cath).
– Avoid the femoral access site.
198 A Guide to Infection Control in the Hospital
Replace catheters that are placed under emergency condi-
tions under poor aseptic conditions, once the hemodynamic
condition of the patient has stabilized, but at least within 48
hours.
Check proper fixation of the catheter, discourage idle
catheters.
Do not routinely culture IV catheters.
Antisepsis, dressings and tubing
Use sterile alcohol to disinfect the insertion site. In
resource-limited areas, the WHO hand hygiene alcohol may
be used.
Chlorhexidine is state-of-the art disinfectant for catheter
care. Convenient, but more expensive are chlorhexidine
containing dressings.
Infusate tubing: replace not more frequently than ≥3 days.
Use clean or sterilized gauze as dressing immediately after
insertion. After 1 day, use gauze after routine disinfection
with alcohol with chlorhexidine, and change every other
day. More expensive, chlorhexidine-containing transparent
dressings are highly effective to prevent CA-BSIs, any may
be left in place for 5–7 days.
Gauze dressings should be replaced every two days or
transparent dressing every 7 days, or if they do not adhere
anymore.
Minimize numbers of stopcocks attached to the catheter.
Do not routinely use in-line filters.
Peripheral intravenous catheters
CR-BSIs by peripheral catheters are always preventable, the
incidence of phlebitis (a physicochemical problem) should
not exceed 20%.
Do not routinely replace peripheral catheters, but daily
check the need for the catheter and the insertion site.
Central venous catheters
Use maximal barrier precautions including gown, sterile or
at least new gloves, and large sterile drapes when placing a
central-venous line.
Managing Vascular Catheters 199
Use guide wire exchange for malfunctioning catheters and
in febrile episodes, where the source of infection is unlikely
the catheter. A new puncture for a catheter is recommended
if the insertion site has evidence of infection (e.g., redness,
pus, pain).
Consider a coated catheter (minocycline-rifampin or chlor-
hexidine/sulfodiazine), if the patient is at high risk of
CA-BSI and the incidence of CA-BSI exceeds 5/1000 cath-
eter days. However, full adherence to simple training in IV
insertion, full barrier precautions and chlorhexidine for cath-
eter care can cut CA-BSIs close to zero.
Use chlorhexidine as disinfectant for the regular care of the
insertion site. Octenidine is an alternative in Europe, if no
commercial chlorhexidine-containing dressing is used.
Long-term catheters
Never replace long-term catheters for diagnostic purposes
only. Negative blood cultures taken through the cathe-
ter have a very high negative predictive value to rule out
CR-BSI in patients with fever of unknown origin. For
suspected episodes of CR-BSI, take simultaneously blood
cultures through the catheter and by venipuncture if an auto-
mated BC system is available (time to positivity: 2 hours
difference meets the case definition of CR-BSI).
Do not administer prophylactic antibiotics before insertion.
CR-BSIs due to coagulase-negative staphylococci can be
successfully treated by the antibiotic lock technique (Vanco-
mycin or EDTA-Minocycline). The ethanol lock is a prom-
ising alternative.
Arterial catheters
Replace peripheral arterial catheters routinely not more fre-
quently than every 5 days.
Routinely replace disposable or reusable transducers, tub-
ing, continues-flush device and flush solution at 96-hour
intervals.
Minimize manipulations of the pressure monitoring system
and use a closed-flush system.
Disinfect the diaphragm before accessing the system or use
a stopcock.
Use disposable transducers.
200 A Guide to Infection Control in the Hospital
Controversial Issues
Needleless devices reduce the risk for sharp injuries to
healthcare workers, but are associated with higher risk for
CRIs.
Maximum hang time of other parenteral fluids.
Routine replacement of CVC after episodes of secondary
bloodstream infections from another body site.
Use of impregnated catheters and chlorhexidine sponges in
small children.
Treatment of febrile patients with a positive microbiologic
for coagulase-negative staphylococci from a removed cathe-
ter and negative blood cultures. Treatment is recommended
if S.aureus is isolated, even if blood cultures are negative.
Summary
Two principal pathways are involved in the pathogenesis of
catheter-related infections: First, bacteria can colonize the
outer surface of the catheter, migrate from the catheter-skin
interface over the external surface of the catheter to the cath-
eter tip. Second, bacteria can colonize the hub, the connection
between the infusion set and the catheter followed by migra-
tion down the internal surface of the catheter. Clinical signs and
symptoms are commonly lacking even in established CA-BSIs.
A bundle of prevention strategies (education, hand hygiene and
full barrier precautions prior insertion, use of chlorhexidine for
catheter insertion care, and appropriate selection of catheter and
insertion site) has been shown to almost eliminate CA-BSIs
(zero-risk), or at least < 1/1000 catheter days. Coated catheters
should only be considered for high-risk patients and/or if other
strategies have failed to reduce the rate of CR-BSIs <3/1000
catheter days.
Managing Vascular Catheters 201
References
Widmer AF. Intravenous-Related Infections in Prevention and Control
of Nosocomial Infections (3rd Edition), Wenzel RP (Ed). Baltimore:
William & Wilkins, 1997. Pgs. 771–806.
Pronovost P, Needham D, Berenholtz S, et al. An Intervention to
Decrease Catheter-Related Bloodstream Infections in the ICU.
N Engl J Med. 2006. 355:2725–2732.
Bouza E, Alvarado N, Alcala L, Perez MJ, Rincon C, Munoz P.
A Randomized and Prospective Study of Three Procedures for the
Diagnosis of Catheter-Related Bloodstream Infection Without Cath-
eter Withdrawal. Clin Infect Dis. 2007. 44:820–6.
O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard
SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II, Ran-
dolph AG, Rupp ME, Saint S. Healthcare Infection Control Prac-
tices Advisory Committee (HICPAC) Guidelines for the prevention
of intravascular catheter-related infections. Clin Infect Dis. 2011.
52(9):e162–93.
Rosenthal VD, Maki DG, Salomao R, Moreno CA, Mehta Y, Higuera F,
Cuellar LE, Arikan OA, Abouqal R, Leblebicioglu H. International
Nosocomial Infection Control Consortium. Device-associated noso-
comial infections in 55 intensive care units of 8 developing countries.
Ann Intern Med. October 17, 2006. 145(8):582–91.
202 A Guide to Infection Control in the Hospital
Chapter 31
Hospital Acquired Urinary
Tract Infection
Emanuele Nicastri MD, PhD and
Sebastiano Leone MD
Key Issues
“The decision to use the urinary catheter should be made with
the knowledge that it involves risk of producing a serious dis-
ease.” Even through this statement was formulated by Paul
Beeson about fifty years ago, it still maintains relevant for both
patients and healthcare workers (HCWs). Urinary catheters
represent the major risk factor related to the acquisition of
hospital acquired urinary tract infection (HUTIs). Catheter-
associated urinary tract infection (CA-UTI) is the most com-
mon type of hospital acquired infection, accounting for approx-
imately 40% of such infections and for most of the 900,000
patients with health care associated bacteriuria in the U.S. each
year. Each year approximately 96 million urethral catheters
are sold world-wide, nearly a quarter of which are sold in the
United States. Approximately 30% of initial urinary catheter-
izations are unjustified, and one-third to one-half of days of
continued catheterization are unjustified. Many of these cathe-
ters are inserted in the emergency room without a documented
order, and providers are not aware that the catheter is in place in
21–8% of cases. The reduction of inappropriate use of indwell-
ing urinary catheters, the use of a closed drainage system, and
the early removal “as soon as possible” of the catheter already
in place, are the main tools to reduce HUTIs.
Known Facts
In the United States, between 16% and 25% of hospitalized
patients have an indwelling urinary catheter in place. The daily
rate of acquiring bacteriuria among hospitalized patients with
urinary catheters is approximately 3% to 10%, and between 10
Hospital Acquired Urinary Tract Infection 203
to 25% of patients with bacteriuria will develop symptoms of
UTI. Of patients with a symptomatic CA-UTI, 1–4 % develop
bacteraemia and, of these, 13–30 % die.
The costs of CA-UTI are modest compared with other
device-associated infections but the large number of patients
with indwelling urinary catheters results in a substantial burden.
Each CA-UTI adds approximately $675 to the costs of hospi-
talization and when bacteraemia develops, this additional cost
increases to at least $2800.
Micro-organisms causing endemic HUTIs derive from the
patient’s own flora or from the hands of HCWs during cathe-
ter insertion or manipulation of the collection system. Bacteria
can enter the urinary tract in catheterized patients in three ways:
introduction of organisms into the bladder at the time of catheter
insertion or periurethal route or intraluminal route.
The most frequent pathogens associated with CA-UTI in hos-
pitals reporting to National Healthcare Safety Network between
2009–2010 were Escherichia coli (26.8%) and Pseudomonas
aeruginosa (11.3%), followed by Klebsiella spp. (11.2%), Can-
dida albicans (8.9%), Enterococcus faecalis (7.2%%), Proteus
spp. (4.8%), other Enterococcus spp. (4.8%), Enterobacter spp.
(4.2%), other Candida spp (3.8%) and Enterococcus faecium
(3.1%). A smaller proportion was caused by Staphylococcus
aureus (2.1%), coagulase-negative staphylococci (2.2%), Ser-
ratia spp. (1.0%), Acinetobacter baumannii (0.9%), and other
pathogens (7.7%). Urinary tract pathogens such as Serratia
marcescens and Pseudomonas cepacia have special epidemio-
logical significance. Since these micro-organisms do not com-
monly reside in the gastrointestinal tract, their isolation from
catheterized patients suggests acquisition from an exogenous
source, likely through the hands of personnel. HUTIs comprise
perhaps the largest institutional reservoir of health care associ-
ated antibiotic-resistant pathogens, the most important of which
are vancomycin-resistant enterococci and extended-spectrum
β-lactamase–producing Enterobacteriaceae.
A continuously closed urinary drainage system is pivotal to
the prevention of CA-UTI. For short-term catheterization, this
measure alone can reduce the rate of infection from an inevita-
ble 100% when open drainage is employed to less than 25%.
204 A Guide to Infection Control in the Hospital
Breaches in the closed system, such as unnecessary emptying of
the urinary drainage bag or taking a urine sample, will increase
the risk of catheter-related infection and should be avoided.
Before manipulating the closed system, hands must be washed
with an antiseptic agent and gloves worn.
Noninfectious complications secondary to indwelling uri-
nary catheters are common, and in case of long-term cathe-
terization are 4 times higher than CA-UTI. Although the most
frequent complications are minor (for example, leakage around
the catheter), serious complications, such as urethral stric-
tures and gross hematuria, occur in a substantial proportion of
patients. Moreover, long-term catheterization and catheter use
in patients with spinal cord injury result in even greater illness,
with more than 30% of patients having several complications.
Studies comparing meatal cleansing with a variety of anti-
septic/antimicrobial agents or soap and water demonstrated no
reduction in bacteriuria when using any of these preparations
for meatal care compared with routine bathing or showering.
Meatal cleansing is not necessary and may increase the risk
of infection. Daily routine bathing or showering is all that is
needed to maintain meatal hygiene. The most important, poten-
tially modifiable risk factor, identified in every study, is pro-
longed catheterization beyond 6 days (RR 5.1-6.8); by the 30th
day of catheterization, infection is near-universal. Thus, every
operative strategy should be aimed to reduce the duration of the
urinary catheter at minimum.
Controversial Issues
Systemic antimicrobial prophylaxis is likely to reduce the
risk of HUTIs for short-term catheterizations in critical care
areas. In a recent Cochrane review of antibiotic prophylaxis
for short-term catheter bladder drainage in adults, the authors
concluded that there are limited evidence that antibiotic prophy-
laxis reduce the rate of bacteriuria and other signs of infection,
such as pyuria, febrile morbidity and Gram-negative isolates
in surgical patients who undergo bladder drainage for at least
24 hours postoperatively, and there was also limited evidence
that prophylactic antibiotics reduced bacteriuria in non-surgical
patients. Moreover, there are concerns about selection of antibi-
otic-resistant bacteria and yeasts.
Hospital Acquired Urinary Tract Infection 205
Another proposed approach to prevent CA-UTI is to coat
catheters with antibacterial materials. Randomized clinical
trials suggest the use of medicated urinary catheters to reduce
urinary catheter-related bacteriuria. Small studies have demon-
strated a significant reduction in bacterial HUTIs with the use
of catheters impregnated with anti-infective solutions such as
nitrofurazone and minocycline combined to rifampin. Catheters
coated with minocycline and rifampin had significantly lower
rates of Gram-positive bacteriuria (7.1% vs. 38.2%; p<0.001).
Nevertheless similar rates of Gram-negative bacteriuria and
candiduria have been reported, and the risk of developing anti-
microbial resistance needs to be further investigated. A similar
concern on the selective antibiotic drug pressure has been raised
with regard to an indwelling urethral catheter coated with gen-
tamicin sulphate on the inner and outer surface. A multicentre
study including 177 patients was conducted to determine the
CA-UTIs inhibition effect by nitrofurazone-coated catheters.
In this study, the incidence rate of CA-UTI was lower in the
nitrofurazone-coated catheter group compared with the control
group. When the catheters were maintained for >5 days but <7
days, the incidence rate of catheter-related infection was statis-
tically significantly lower in the experimental group compared
with that in the control group. Finally, Johnson conducted a
meta-analysis of randomized or quasi-randomized clinical tri-
als of antimicrobial urinary catheters to assess the efficacy of
these for preventing CA-UTIs. The author observed that, com-
pared with control catheters, antimicrobial urinary catheters can
prevent or delay the onset of catheter-associated bacteriuria in
selected hospitalized patients. However, it is necessary to con-
firm further the effectiveness of antibiotic-coated catheters over
long-term periods.
An alternative option to the use of antibiotic impregnated
catheters, coating the catheter surface with an antiseptic, such
as a silver compound, could reduce the presence of the bio-
film on the surface of the catheter. Early studies with a silver
oxide-coated catheter reported no benefit for preventing bacte-
riuria, but silver alloy catheters were subsequently reported to
decrease acquisition of bacteriuria, although symptomatic infec-
tion was not adequately evaluated. In a meta-analysis, Crnech
206 A Guide to Infection Control in the Hospital
and Drinka found that commercially available silver-coated sil-
icone urinary catheters only offer modestly greater benefits than
uncoated catheters made of silicone and that silicone catheters
simply have better properties than latex catheters and they are
only minimally improved by silver coating. More recently, in a
multicentre randomized controlled trial, Pickard et al. observed
that silver alloy-coated catheters were not effective for reduc-
tion of incidence of symptomatic CA-UTI. In conclusion, cur-
rent evidence does not support a clinical benefit for use of silver
alloy-coated indwelling catheters, and routine use of these cath-
eters is not recommended.
A novel silicone urinary catheter with a trefoil cross-sec-
tion was found to result in decreased rates of bac teriuria,
urethroscopic damage and histopathological inflammation
compared to a standard indwelling urinary catheter in a rab-
bit model. More innovation is required with respect to cathe-
ter design and the trefoil silicone catheter should be evaluated
in human clinical trials, but based on the preliminary animal
model data it appears promising for short-term catheterization.
Suggested Practices
Educate HCWs about the appropriate indications for
indwelling urinary catheters:
– patients with anatomic or physiologic outlet obstruction,
– patients undergoing surgical repair of the genitourinary
tract,
– critically ill patients who need to measure the daily urinary
output.
Educate HCWs about alternative strategies for the manage-
ment of urinary incontinence (for example, condom or inter-
mittent catheters and special undergarments).
Provide patients with information about the need, insertion,
maintenance and removal of their catheter.
Educate HCWs about the infectious complications and
adverse events associated with urinary catheterization.
Educate HCWs about the optimum selection of the smallest
gauge catheter for free urinary outflow.
Educate HCWs about the correct techniques for catheter
insertion and care.
Hospital Acquired Urinary Tract Infection 207
Educate HCWs to adopt and maintain the sterile continu-
ously closed system of urinary drainage.
Educate HCWs about avoiding catheter irrigation unless
needed to prevent or relieve obstruction.
Educate HCWs about maintaining unobstructed urine flow.
Maintain adequate urine flow at all times. Ideally, suffi-
cient fluid to maintain urine output of greater than 100 ml/h
should be given if it is not contraindicated by the patient’s
clinical condition.
Gravity drainage should be maintained.
Educate HCWs about minimizing the duration of the urinary
catheter.
Do not change catheters unnecessarily or as part of routine
practice.
Consider the use of catheters with anti-infective surface at
least for those patients at high risk of serious complications
of catheter-associated bacteriuria.
Consider automatic “stop orders” for indwelling urinary
catheters; these orders should require that the catheter
either be removed or reordered after a specified period of
catheterization.
Use quality-control patient audits to design programs to
decrease inappropriate use of indwelling urinary catheters.
Develop and implement a periodic surveillance system of
Huti.
Document all procedures involving the catheter or drainage
system in the patient’s records.
Bundle Strategy
The implementation of bundle programs against CA-UTI should
be part of the minimum requirements to develop a patient-based
infection control program. Recently in the West Georgia Medi-
cal Center a significant reduction from 5.2 to 1.5 per 1000 cath-
eters (p=0.03) was obtained using a bundle policy based on four
evidence-based interventions (IB recommendations from the
Guideline for the Prevention of CA-UTI HICPAC 2009): (i) the
208 A Guide to Infection Control in the Hospital
exclusive use of silver alloy catheters, (ii) the use of securing
devices to prevent movements of the catheter, (iii) repositioning
of the catheter if it was found on the floor and (iv) stop order
for most surgical patients. Similar policy based on the Keystone
Bladder Bundle Initiative was introduced in the Michigan Hos-
pitals in 2009 with a 25% reduction in CA-UTI rates.
Strategies to limit barriers to a bundle implementation pro-
gram could include: incorporating urinary management as part
of patient safety program, such as a fall reduction program,
explicitly discussing the risks of indwelling urinary cathe-
ters with patients and families, and engaging with emergency
department nurses and physicians.
Summary
The development of a nursing, physician, and laboratory team
to review and revise protocols and procedures for better cathe-
ter management can promote the proper indications for urinary
catheter placement and management. A continuously closed sys-
tem of urinary drainage is the cornerstone of infection control
and clear criteria for the removal of urinary catheters without a
physician’s order are part of bundled strategies for the reduction
of CA-UTI. Novel urinary catheters impregnated with antibi-
otic drugs or coated with anti-infective material exhibit anti-
microbial activity that significantly reduces the risk of HUTI
for short-term catheterizations. These represent the first major
advance for preventing HUTIs since the wide-scale adoption of
closed drainage systems. It remains unclear whether medicated
urinary catheters will also lead to decreases in the clinically
important outcomes of catheter-related bacteraemia and mor-
tality. Each medicated catheter exceeds the cost of a standard,
non-coated non-impregnated urinary catheter tray. In the future,
a major biotechnology effort to reduce the prevalence rate of
HUTIs and indeed of all hospital-related infections is likely to
be represented by vaccines against important multi-drug resis-
tant micro-organisms such as enteric Gram-negative bacilli and
staphylococci.
Hospital Acquired Urinary Tract Infection 209
References
Agency for Healthcare Research and Quality. Evidence Report/Technol-
ogy Assessment No. 43, Making Healthcare Safer: A Critical Anal-
ysis of Patient Safety Practices, AHRQ Publication No. 01-E058.
Available at: http://archive.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf
(Last access 15 January 2003).
Beeson PB. The Case against the catheter. Am J Med. 1958. 24:1–3.
Clarke K, Tong D, Pan Y, et al. Reduction in catheter-associated urinary
tract infections by bundling interventions. Int J Qual Health Care.
Crnich CJ, Drinka PJ. Does the composition of urinary catheters influ-
ence clinical outcomes and the results of research studies? Infect
Control Hosp Epidemiol. 2007. 28:102–3.
Darouiche RO, Smith JA Jr, Hanna H, et al. Efficacy of antimicro-
bial-impregnated bladder catheters in reducing catheter-associated
bacteriuria: A prospective, randomized, multicenter clinical trial.
Urology. 1999. 54:976–81.
Ha US, Cho YH. Catheter-associated urinary tract infections: New
aspects of novel urinary catheters. Int J Antimicrob Agents. 2005.
28:485–90.
Hollingsworth JM, Rogers MA, Krein SL, et al. Determining the Nonin-
fectious Complications of Indwelling Urethral Catheters: A System-
atic Review and Meta-analysis. Ann Intern Med. 2013. 159:401–10.
Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention,
and treatment of catheter-associated urinary tract infection in adults:
2009 International Clinical Practice Guidelines from the Infectious
Diseases Society of America. Clin Infect Dis. 2010. 50:625–63.
Johnson JR, Kuskowski MA, Wilt TJ. Systematic Review: Antimicro-
bial urinary catheters to prevent catheter-associated urinary tract
infection in hospitalized patients. Ann Intern Med. 2006. 144:116–26.
Krein SL, Kowalski CP, Harrod M, et al. Barriers to reducing urinary
catheter use: A qualitative assessment of a statewide initiative. JAMA
Intern Med. 2013. 173:881–6.
Lee SJ, Kim SW, Cho YH, et al. A comparative multicentre study on
the incidence of catheter-associated urinary tract infection between
nitrofurazone-coated and silicone catheters. Int J Antimicrob Agents.
Lusardi G, Lipp A, Shaw C. Antibiotic prophylaxis for short-term cath-
eter bladder drainage in adults. Cochrane Database Syst Rev. 2013.
7:CD005428.
210 A Guide to Infection Control in the Hospital
Nicolle LE. Urinary catheter-associated infections. Infect Dis Clin
North Am. 2012. 26:13–27.
Pickard R, Lam T, MacLennan G, et al. Antimicrobial catheters for
reduction of symptomatic urinary tract infection in adults requiring
short-term catheterisation in hospital: A multicentre randomized con-
trolled trial. Lancet. 2012. 380:1927–35.
Saint S, Greene MT, Kowalski CP, et al. Preventing catheter-associated
urinary tract infection in the United States: A national comparative
study. JAMA Intern Med. 2013. 173:874–9.
Sievert DM, Ricks P, Edwards JR, et al. Antimicrobial-resistant path-
ogens associated with healthcare-associated infections: Summary
of data reported to the National Healthcare Safety Network at the
Centers for Disease Control and Prevention, 2009–2010. Infect Con-
trol Hosp Epidemiol. 2013. 34:1–14.
Sun Y, Zeng Q, Zhang Z, et al. Decreased urethral mucosal damage and
delayed bacterial colonization during short-term urethral catheteriza-
tion using a novel trefoil urethral catheter profile in rabbits. J Urol.
Tambyah PA, Knasinski V, Maki DG. The direct costs of nosocomial
catheter-associated urinary tract infection in the era of managed care.
Infect Control Hosp Epidemiol. 2002. 23:27–31.
Trautner BW, Hull RA, Darouiche RO. Prevention of catheter-associ-
ated urinary tract infection. Curr Opin Infect Dis. 2005. 18:37–41.
Hospital Acquired Urinary Tract Infection 211
Chapter 32
Pneumonia
Javier Ena, MD, MPH
Key Issues
Implementation of guidelines for preventing, diagnosing and
treating pneumonia can reduce the mortality and morbidity
associated with this condition.
The implementation of various measures at a time (Preven-
tion bundles) have proven in clinical trials to be more effective
than isolated single measures to reduce the risk of acquisition of
health care associated pneumonia (Objective zero pneumonia).
Known Facts
Hospital acquired (or nosocomial) pneumonia, ventilator
associated pneumonia, and health care associated pneumonia
are leading causes of morbidity and mortality in hospitalized
patients.
According the criteria defined by the American Thoracic
Society/Infectious Disease Society of America there are three
types of pneumonia related with healthcare:
Hospital aquired (or nosocomial) pneumonia is pneumonia
that occurs 48 hours or more after admission and did not
appear to be incubating at the time of admission.
Ventilator associated pneumonia is a type of hospital-
acquired pneumonia that occurs more than 48 to 72 hours
after endotracheal intubation.
Health care associated pneumonia is defined as pneumo-
nia that occurs in non-hospitalized patients that have had
extensive healthcare contact, as defined by one or more of
the following: intravenous therapy, wound care, intrave-
nous chemotherapy within the prior 30 days, or residence
in a nursing home or other long term facility, or hospitaliza-
tion in an acute care hospital for two or more days within
the previous 30 days, or attendance at a hospital or hemo-
dialysis clinic within the prior 30 days. The last category
212 A Guide to Infection Control in the Hospital
identifies patients at risk of being infected by multidrug
resistant microorganisms and clearly differentiates from
those patients with community-acquired pneumonia.
Controversial Issues
Most studies have relied on clinical criteria to diagnose pneu-
monia, which is known to be unreliable. Therefore outcomes
evaluated in clinical trials are prone to bias.
The use of selective decontamination of the digestive tract
has been evaluated in several randomized clinical trials and
meta-analysis showing controversial results. In addition, there
is concern about promoting the growth of resistant bacteria.
Monitoring of gastric residual volume at regular intervals
prior to starting or increasing enteral feedings did not prove to
reduce the rate of ventilator associated pneumonia.
The use of silver-coated endotracheal tubes has produced
controversial results regarding the risk of ventilator associated
pneumonia and mortality.
Subglottic drainage: the use of specially designed endotra-
cheal tubes that allow continuous or intermittent aspiration of
subglottic secretions has shown to reduce the risk of ventila-
tor associated pneumonia in a meta-analysis of 13 studies (RR
0.55, 95% CI 0.46–0.66). However, these tubes cost more than
standard endotracheal tubes and are not widely available. Inter-
mittent suction and continuous suction showed similar benefit
with no impact on mortality. Studies analyzing the potential
cost-benefit of using tubes with subglottic secretion drainage
showed unclear results.
Hydrocortisone (200 mg per day for five days followed by
100 mg per day on day six and 50 mg per day on day seven)
showed in a modified intention-to-treat analysis to reduce the
risk of health care associated pneumonia in patients with severe
trauma compared with placebo. However, in other populations
such as patients with traumatic brain injury glucocorticoids
have shown to increase mortality.
Suggested Practice
The Society of Healthcare Epidemiology of America and the
Infectious Diseases Society of America published in 2008 a
series of recommendations to reduce the risk of ventilator asso-
ciated pneumonia [SHEA, IDSA]. However, the method that
Pneumonia 213
has been gaining ground in the last decade is the “care bun-
dle.” The idea is that recommendations used in combination,
all of the time, have a greater effect on the positive outcome of
patients than single measures. The elements of the care bundle
based on the highest level of evidence, i.e. systematic review
of randomized trials and single randomized clinical trials are:
is significantly reduced by oral antiseptics such as chlorhex-
idine (relative risk [RR] 0.56, 95% CI 0.39–0.81). The sug-
gested regimen is chlorhexidine 0.12% oral solution (15 mL
twice daily until 24 hours after extubation).
patients to aspiration and the development of health care
associated pneumonia. A recent meta-analysis of 5 clinical
trials showed that semirecumbent position was associated
with a reduction of ventilator associated pneumonia com-
pared to supine position (RR=0.57, 95% CI 0.39–0.83).
interruption decrease the time patients are connected to ven-
tilator. Patients therefore can assist extubation and control
their secretions. Despite concerns on self extubation, pain,
anxiety and, poor synchronization with ventilator, literature
shows patients undergoing daily interruptions experienced
complications at 2.8% vs. 6.2% compared to those subjected
to conventional techniques. For every 7 patients treated with
the intervention, 1 life was saved (number needed to treat
was 7.4, 95% CI 4.2 to 35.5).
ence: multi-modal programs incorporating education, per-
formance feedback, and hand hygiene devices resulted in
reduction in ventilator-acquired pneumonia. Provider hand
contamination during patient care in the ICU is a modifiable
risk factor for reducing ventilator associated pneumonias. A
study carried out in a single ICU showed that ventilator-as-
sociated pneumonia (rate per 1000 ventilator-days) were sig-
nificantly reduced after introduction of the program [3.7 vs.
6.9] P < .01.
esis of health care associated pneumonia is still controversial.
214 A Guide to Infection Control in the Hospital
Bacterial colonization of the stomach is enhanced by drugs
that lower the gastric acidity (i.e. histamine H2 agonists,
antacids, proton pump inhibitors). The administration of
sucralfate prevented stress ulcers without modifying the
gastric pH.
talized medical patients at increased risk of thrombosis, the
American College of Chest Physicians recommend anticoag-
ulant thromboprophylaxis with low-molecular-weight hepa-
rin, low-dose unfractionated heparin bid, or fondaparinux
(Grade 1B). In acutely ill hospitalized medical patients who
receive an initial course of thromboprophylaxis, guidelines
suggest against extending the duration of thromboprophy-
laxis beyond the period of patient immobilization or acute
hospital stay. For critically ill patients who are bleeding, or
are at high risk for major bleeding, the recommendation is
to use mechanical thromboprophylaxis with graduated com-
pression stockings (Grade 2C) or intermittent pneumatic
compression (Grade 2C) until the bleeding risk decreases,
rather than no mechanical thromboprophylaxis.
The latter 6 measures were grouped together by the Joint Com-
mission on Accreditation of Healthcare Organization (JCAHO)
to form the ventilator-care bundle. All of the measures, except
measure 3, can be applied to prevent any type of health care
associated pneumonia.
Summary
Nosocomial pneumonia is currently classified as hospital
acquired pneumonia, ventilator associated pneumonia, and
health care associated pneumonia. It constitutes the second most
common cause of health care associated infection overall. The
primary mechanism for acquisition of health care associated
pneumonia is the presence of microaspiration or macroaspira-
tion of upper respiratory secretions into the lungs. Preventive
measures are directed to reduce the risk of overt or subclini-
cal aspiration of bacteria colonizing the upper respiratory tract.
A series of 6 measures grouped together to form the ventila-
tor-care bundle have proven to be more effective than single
measures to improve patients’ outcomes.
Pneumonia 215
References
Blanquer J, Aspa J, Anzueto A, Ferrer M, Gallego M, Rajas O, Rello J,
Rodríguez de Castro F, Torres A; Sociedad Española de Neumología
y Cirugía Torácica. SEPAR Guidelines for Nosocomial Pneumonia.
Arch Bronconeumol. October 2011. 47(10):510–20.
Koff MD, Corwin HL, Beach ML, Surgenor SD, Loftus RW. Reduction
in ventilator associated pneumonia in a mixed intensive care unit
after initiation of a novel hand hygiene program. J Crit Care. Octo-
ber 2011. 26(5):489–95.
Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Pre-
vention of ventilator-associated pneumonia with oral antiseptics: A
systematic review and meta-analysis. Lancet Infect Dis. November
Leng YX, Song YH, Yao ZY, Zhu X. Effect of 45 degree angle semire-
cumbent position on ventilator-associated pneumonia in mechanical
ventilated patients: A meta-analysis. Zhongguo Wei Zhong Bing Ji
Jiu Yi Xue. October 2012. 24(10):587–91.
Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun
BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC,
Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM,
Hall JB, Dittus RS, Bernard GR, Ely EW. Efficacy and safety of a
paired sedation and ventilator weaning protocol for mechanically
ventilated patients in intensive care (Awakening and Breathing Con-
trolled trial): A randomized controlled trial. Lancet. January 2008.
12;371(9607):126–34.
216 A Guide to Infection Control in the Hospital
- 2013. 25:43–9.
- 2004. 24(Suppl 1):S65–9.
- 2011. 186:1497–01.
- 1. Oral care: the incidence of ventilator associated pneumonia
- 2. Patient positioning: supine positioning appears to predispose
- 3. Daily assessment of readiness to extubate: daily sedation
- 4. Hand hygiene, glove and gown recommendations adher-
- 5. Stress ulcer prevention: the role of gastric pH in the pathogen-
- 6. Deep venous thrombosis prevention: for acutely ill hospi-
- 2011. 11(11):845–54.
Chapter 33
Mechanical Ventilation
Caroline Landelle, PharmD, PhD, and
Didier Pittet, MD, MS
Key Issue
Tracheal intubation and mechanical ventilation (MV) are the
most important risk factors for health care associated pneumo-
nia in critically ill patients (3- to 21-fold increase in the risk).
Known Facts
Ventilator-associated pneumonia (VAP) is a common and
highly morbid condition in critically ill patients. Incidence
varies between 5% and 67%, depending on case mix and
diagnostic criteria. The overall attributable mortality of VAP
is 13%. In surviving patients, it causes substantial morbidity,
resource utilization, and extends hospital length of stay by at
least 4 days.
Early-onset VAP accounts for at least one-third of pneu-
monia cases in the critical care setting. This entity should be
distinguished from late-onset episodes because of the dif-
ferent microbiologic spectrum, risk factors, and outcome.
As pathogens causing aspiration pneumonia reflect the oro-
pharyngeal microbial flora at time of aspiration, those caus-
ing early-onset VAP more likely reflect normal oral flora or
pathogens responsible for community-acquired pneumonia
(Staphylococcus aureus, Streptococcus pneumoniae, and
Haemophilus influenzae). Nevertheless, multidrug resistant
(MDR) pathogens may also be involved in early-onset pneu-
monia, especially in settings with a high prevalence of anti-
biotic overuse.
Pathogens colonizing the respiratory tract and causing VAP
are derived from either endogenous or exogenous sources.
Those colonizing the upper respiratory tract (oropharynx,
sinus cavities, the nares, and dental plaque) may be aspi-
rated. Potential exogenous sources are a contaminated
environment (sinks, faucets, etc.), contaminated equipment
Mechanical Ventilation 217
(MV devices, ventilator circuits, etc.), contaminated enteral
feeding, contaminated aerosols, and other colonized patients
in the intensive care unit (ICU). Ventilator associated pneu-
monia can result when the inoculum is large, the microbes
virulent, and host defenses impaired. The stomach is an
uncommon source of microorganisms for pneumonia in
ventilated patients. Hematogenous spread from infected
intravascular or bacterial translocation of the gastrointestinal
tract lumen occurs much less frequently.
Emergent intubation, prolonged MV through an endotra-
cheal tube, repeated intubation and contaminated ventilator
circuits increase the risk of VAP.
Unnecessary intubation should be avoided at all times.
Non-invasive positive-pressure ventilation (NIPPV) could
be used as an alternative ventilation mode in ICU patients.
Adequate initial antimicrobial treatment decreases the clini-
cal impact of VAP.
Controversial Issues
The United States Centers for Disease Control and Prevention
(CDC) definitions of health care associated pneumonia have
been widely used for infection control surveillance and rely
predominantly on clinical and radiographic criteria (sensitiv-
ity and specificity range between 45−100% and 7–76% for
clinical variables, and 8−88% and 27−96% for radiographic
features, respectively), although the results of additional diag-
nostic tests may also be used. However, the greatest challenge
is the absence of a simple and reliable gold standard to verify
the value of diagnostic procedures. Histologic and bacterio-
logic examination of lung tissue remains the optimal standard
to establish the diagnosis of pneumonia, but these techniques
require an open-lung biopsy or autopsy.
A working group driven by the CDC to improve VAP sur-
veillance recently proposed new definitions of ventila-
tor-associated events, i.e., ventilator-associated conditions
(VAC), infection-related ventilator-associated complica-
tions (IVAC), and possible and probable pneumonia. VAC
are defined as at least 2 calendar days of stable or decreasing
daily minimum positive end-expiratory pressure (PEEP),
or a daily minimum fraction of inspired oxygen (FiO2)
218 A Guide to Infection Control in the Hospital
followed by an increase in daily minimum PEEP by at
least 3cmH2O sustained for at least 2 calendar days, or an
increase in daily minimum FiO2 by at least 20 points sus-
tained for at least 2 calendar days. VAC includes pulmonary
oedema, atelectasis, acute respiratory distress syndrome, and
VAP. In patients with VAC, IVAP is defined by concurrent
inflammatory signs and at least 4 days of new antibiotics.
Possible and probable pneumonia are defined by concurrent
pulmonary Gram stains and cultures. Chest radiography is
no longer required. The impact of these new definitions on
strategies for VAP surveillance and prevention is unknown.
Obviously, their practicality and usability in low-resource
settings deserves further attention.
Numerous studies have evaluated the performance of
bronchoscopic and non-bronchoscopic procedures for the
diagnosis of VAP. Invasive techniques include protected
bronchoalveolar lavage (BAL), non-bronchoscopic (“blind”)
BAL, and “blind” protected specimen brush. The use of any
of these techniques should be encouraged in patients at high-
risk for MDR or other difficult-to-treat pathogens. Diagnosis
by invasive methods requires a considerable commitment of
resources, but can potentially reduce cost of care and may
lower the use of broad-spectrum antibiotics and the subse-
quent development of antimicrobial resistance. However,
the clinical impact of BAL remains a subject of debate and
controversy persists about the optimal diagnostic strategy
for VAP. The interpretation of the sensitivity and specificity
of any given sampling technique may be severely hampered
by the distorting effect of previous antibiotic exposure on the
yield of bacterial cultures. In patients pre-treated with anti-
biotics, sampling should be performed before introducing a
new antibiotic regimen.
A number of adjunctive or alternative methods for VAP
diagnosis have been proposed, such as sputum or endotra-
cheal aspirates’ culture, identification of intracellular micro-
organisms (ICOs) by Giemsa stain of BAL specimens and
measurements of cytokines (e.g. soluble triggering receptor
expressed on myeloid cells-1 [sTREM-1]), or inflammatory
mediators (e.g. procalcitonin). But studies show contradic-
tory results and their values are unclear.
Mechanical Ventilation 219
Selective oropharyngeal decontamination (SOD) and selec-
tive digestive decontamination (SDD) have been studied for
many years. These involve the use of topical oral antibiotics
for SOD, and topical oral and intestinal antibiotics, often
with a systemic antibiotic added during the first few days
of the regimen for SDD, with the goal being the elimination
of potential pathogens from the oropharynx and/or gastroin-
testinal tract. With the eradication of endogenous bacterial
sources, infection may be avoided. SOD and SDD are effec-
tive in reducing the incidence of VAP in the ICU. The use of
topical antibiotics seems to be effective also in preventing
all ICU-acquired infections, while the effectiveness on mor-
tality needs to be investigated in further research. Impor-
tantly, the main concern associated with the use of SOD or
SDD remains the development and spread of antimicrobial
resistance. Overall, the currently available evidence does not
support the use of SOD or SDD as a preventive strategy on a
large scale, particularly in settings with endemic cross-trans-
mission of multidrug resistant microorganisms.
It was uncertain whether a 45˚ bed head elevation was
effective or harmful with regard to the occurrence of clin-
ically suspected VAP, microbiologically confirmed VAP,
and decubitus and mortality. Furthermore, it was unknown
whether 45˚ elevation for 24 hours a day increased the risk
for thromboembolism or hemodynamic instability. Experts
recommend elevating the head of the bed of mechanically
ventilated patients to a 20˚ to 45˚ position and preferably
to a ≥30˚ position, as long as it does not pose any risks or
conflicts with other nursing tasks, medical interventions, or
patients’ wishes.
Since the early 2000s, several multimodal strategies to pre-
vent VAP have been applied in before-after studies. Most have
been associated with VAP reduction. “Bundle” strategies are
now applied in the ICU, but it remains difficult to assess the
significance and effect of each individual measure on VAP
prevention. A great deal of attention must be given to factors
that might improve adherence with preventive measures.
Suggested Practice
in 2005 by the American Thoracic Society with a high- or
220 A Guide to Infection Control in the Hospital
moderate-level of evidence. Since then, some studies and
meta-analyses have confirmed their efficacy:
Effective infection control measures: education and train-
ing of healthcare workers, high compliance with alco-
hol-based handrubbing as the main measure for hand
hygiene, and isolation to reduce cross-infection with MDR
pathogens should be used routinely.
Surveillance of high-risk patients to determine trends and
detect outbreaks of VAP within the ICU. Infection rates
should be presented to intensive care physicians and nurses
on a regular basis (feedback).
Low or reduced staffing levels have a negative impact on
patient safety and health care associated infections in criti-
cally ill patients and are associated with lapses in infection
control practices, thus facilitating cross-transmission of
pathogens. A substantial proportion of VAP could be avoided
if nurse staffing could be maintained at a higher level.
Keeping the teeth and mouth clean, preventing the build-up
of dental plaque on teeth or secretions in the mouth may
help to reduce the risk of developing VAP. Effective oral
hygiene care (OHC) is important for ventilated patients.
OHC that includes either chlorhexidine mouthwash or gel
is associated with a 40% reduction in the odds of develop-
ing VAP in critically ill adults. There is no evidence that
OHC including both chlorhexidine and tooth brushing is
different from OHC with chlorhexidine alone. There is
only weak evidence to suggest that povidone iodine mouth
rinse is more effective than saline in reducing VAP.
Limiting the use of continuous sedation and paralytic
agents that depress cough coupled with sedation vacations
and weaning protocols that facilitate removal of the endo-
tracheal tube are strongly recommended to reduce days of
mechanical ventilation (MV) and lower VAP rates.
Unnecessary intubation and repeated intubation should
be avoided. Non-invasive positive-pressure ventilation
(NIPPV) should be used whenever possible.
Orotracheal intubation and orogastric tubes should be
preferred over nasotracheal intubation and nasogastric
tubes to prevent health care associated sinusitis and to
reduce the risk of VAP.
Mechanical Ventilation 221
The endotracheal tube cuff pressure (Pcuff) should be
maintained at approximately 20–30 cm H2O to prevent
leakage of contaminated oropharyngeal secretions and gas-
tric content around the cuff into the lower respiratory tract.
Pcuff continuous regulation using an automatic device that
continuously displays the levels of Pcuff in real time has
been evaluated with contradictory results.
The main cause of VAP is due to the aspiration of secre-
tions containing bacterial pathogens into the lower respira-
tory tract. Aspiration of subglottic secretions requires the
use of specially designed endotracheal tubes containing a
separate dorsal lumen that opens into the subglottic region.
The use of endotracheal tubes with subglottic secretion
drainage has shown to be effective for the prevention of
VAP, but the cost-effectiveness of the strategy deserves
further investigation.
Contaminated condensate should be carefully emptied
from ventilator circuits and condensate should be pre-
vented from entering either the endotracheal tube or inline
medication nebulizers.
Enteral nutrition is preferred over parenteral nutrition to
reduce the risk of complications related to central intrave-
nous catheters and to prevent reflux villous atrophy of the
intestinal mucosa that may increase the risk of bacterial
translocation.
A restricted transfusion trigger policy for transfusion of red
blood cell and other allogeneic blood products is recom-
manded; leukocyte-depleted red blood cell transfusions
can help to reduce VAP in selected patient populations.
saline instillation before tracheal suctioning; cleaning, dis-
infection, and sterilization of reusable components and
appropriate maintenance of equipment; use of sterile water
for rinsing reusable equipment; not implementing ventilator
circuit changes unless specifically indicated; change of fil-
ters in the breathing circuit every 7 days; use of gloves when
handling respiratory secretions; use of heat and moisture
exchangers; and stress bleeding prophylaxis.
222 A Guide to Infection Control in the Hospital
entific evidence of their benefit: silver-coated endotracheal
tube; use of probiotics; closed-suction systems; use of SOD
or SDD; kinetic bed therapy, PEEP; physiotherapy; inclined
position; intensive insulin therapy; and mucus shaver.
cacy: early tracheotomy; prone position; and iseganan.
Summary
VAP is the most frequent ICU-acquired infection in mechan-
ically ventilated patients and is associated with considerable
morbidity and costs, significant antibiotic use, and high mor-
tality rates. Microaspiration of oropharyngeal secretions con-
taminated by endogenous flora around the endotracheal tube
cuff is the major route for microbial invasion. Diagnosis can
be difficult and considerable controversy remains regarding the
optimal approach. A large number of preventive measures and
strategies have been proposed with variable degrees of effec-
tiveness. Consequently, physicians should first consider preven-
tive measures with a demonstrated impact on patient outcomes,
such as optimal infection control practices (particularly, hand
hygiene), NIPPV, sedation and weaning protocols, oral hygiene
care, and endotracheal tube with drainage of subglottic secre-
tions. Clearly, there is no single preventive mechanism that will
completely avert this complication, and patients at risk of VAP
must be approached with a package or bundle of preventive
measures. The use of a “ventilator bundle” appears attractive
in many ways, although the choice of practices incorporated in
this bundle needs critical evaluation. Successful VAP preven-
tion relies on multimodal, multidisciplinary strategies.
References
Girou E, Schortgen F, Delclaux C, Brun-Buisson C, Blot F, Lefort Y,
Lemaire F, Brochard L. Association of noninvasive ventilation with
nosocomial infections and survival in critically ill patients. JAMA.
- 1. Numerous preventive measures have been recommended
- 2. The following measures are recommended in the absence of
- a strong level of evidence: avoid unnecessary aspirations;
- 3. The following measures are suggested without definitive sci-
- 4. The following measures have not demonstrated their effi-
- 2000. 284:2361–67.
Jama. 2007. 297:1583–93.
Klompas M. Ventilator-associated events surveillance: A patient safety
opportunity. Curr Opin Crit Care. 2013. 19:424–31.
Berton DC, Kalil AC, Teixeira PJ. Quantitative versus qualitative
cultures of respiratory secretions for clinical outcomes in patients
Mechanical Ventilation 223
with ventilator-associated pneumonia. Cochrane Database Syst Rev.
Pileggi C, Bianco A, Flotta D, Nobile CG, Pavia M. Prevention of ven-
tilator-associated pneumonia, mortality and all intensive care unit
acquired infections by topically applied antimicrobial or antiseptic
agents: A meta-analysis of randomized controlled trials in intensive
care units. Crit Care. 2011. 15:R155.
Niël-Weise BS, Gastmeier P, Kola A, Vonberg RP, Wille JC, van den
Broek PJ; Bed Head Elevation Study Group. An evidence-based
recommendation on bed head elevation for mechanically ventilated
patients. Crit Care. 2011. 15:R111.
Klompas M.Ventilator-associated pneumonia: Is zero possible? Clin
Infect Dis. 2010. 51:1123–6.
American Thoracic Society; Infectious Diseases Society of America.
Guidelines for the management of adults with hospital-acquired,
ventilator-associated, and healthcare-associated pneumonia. Am J
Respir Crit Care Med. 2005. 171:388–416.
Hugonnet S, Chevrolet JC, Pittet D. The Effect of Workload on Infec-
tion Risk in Critically Ill Patients. Crit Care Med. 2007. 35:76–81.
Shi Z, Xie H, Wang P, Zhang Q, Wu Y, Chen E, Ng L, Worthington HV,
Needleman I, Furness S. Oral hygiene care for critically ill patients
to prevent ventilator-associated pneumonia. Cochrane Database Syst
Rev. 2013. 8.
Burns KE, Adhikari NK, Keenan SP, Meade MO. Noninvasive positive
pressure ventilation as a weaning strategy for intubated adults with
respiratory failure. Cochrane Database Syst Rev. 2010. (8).
Muscedere J, Rewa O, McKechnie K, Jiang X, Laporta D, Heyland DK.
Subglottic secretion drainage for the prevention of ventilator-associ-
ated pneumonia: A systematic review and meta-analysis. Crit Care
Med. 2011. 39:1985–91.
Subirana M, Solà I, Benito S. Closed tracheal suction systems versus
open tracheal suction systems for mechanically ventilated adult
patients. Cochrane Database Syst Rev. 2007. (4).
Delaney A, Gray H, Laupland KB, Zuege DJ. Kinetic bed therapy to
prevent nosocomial pneumonia in mechanically ventilated patients:
A systematic review and meta-analysis. Crit Care. 2006. 10:R70.
Wang F, Wu Y, Bo L, Lou J, Zhu J, Chen F, Li J, Deng X. The timing
of tracheotomy in critically ill patients undergoing mechanical ven-
tilation: A systematic review and meta-analysis of randomized con-
trolled trials. Chest. 2011. 140:1456–65.
Abroug F, Ouanes-Besbes L, Elatrous S, Brochard L.The effect of prone
positioning in acute respiratory distress syndrome or acute lung
injury: A meta-analysis. Areas of uncertainty and recommendations
for research. Intensive Care Med. 2008. 34:1002–11.
224 A Guide to Infection Control in the Hospital
- 2012. 1.
Chapter 34
Diphtheria, Tetanus, Pertussis
Jack Levy, MD
Key Issues
Active immunization of the general population is effective to
control the transmission of these infections in the community,
as well as an eventual risk of infection in the hospital setting.
Known Facts
Diphtheria and pertussis are transmissible from person to
person, whereas tetanus is not. Transmission of diphtheria
occurs mainly from close contact with secretions from the
nose, throat, eye or skin of a patient, according to the site of
infection, or with a carrier. Transmission of pertussis occurs
by close contact via aerosolized droplets from patients with
disease. Infants <4 months are at highest risk of severe dis-
ease. Transmission of tetanus occurs by introduction of teta-
nus spores into the organism through a contaminated wound.
Tetanus spores can be introduced via the umbilical cord
during delivery, causing tetanus neonatorum, an important
health problem in developing countries.
Diphtheria, tetanus and pertussis are mainly community
acquired infections. The high immunization coverage
obtained by local programs in industrialized countries and
by the WHO EPI has considerably reduced the global bur-
den of diphtheria, tetanus and pertussis.
Universal vaccination in infancy against these 3 illnesses is
done using a combination vaccine.
Diphtheria and tetanus vaccines consist of single purified
antigens: diphtheria and tetanus toxoids. Diphtheria vac-
cines used for children until the age of 6 years contain 6.7 to
30 floculation units (Lf) of toxoid, whereas a vaccine with
a reduced amount of antigen (not more than 2 Lf) should be
used for individuals older than 6 years.
Diphtheria, Tetanus, Pertussis 225
There are 2 types of pertussis vaccines: whole cell vaccine
(Pwc) and acellular vaccines (Pa). The oldest and globally
most widely used is thePwc vaccine. This vaccine is highly
protective, although there are differences between prepara-
tions. However, Pwc vaccines are usually not administered
after the age of 7 years. Pa vaccines consist of 2 or 3 purified
antigens. They are less reactogenic than Pwc vaccines and
have demonstrated their protective efficacy in clinical tri-
als. However the duration of protection is probably shorter
than that afforded by Pwc preparations. Combination of Pa
vaccines with other vaccines recommended for infant immu-
nization (Diphtheria, tetanus, IPV, Hib and HBV) exist.
Pa-based vaccines remain significantly more expensive than
whole cell preparations.
Long term protection against diphtheria, tetanus and pertussis
by vaccination requires primary immunization followed by
the administration of booster doses of these vaccines. Pa vac-
cines suitable for use in adolescents and adults have now been
developed. As older children and adults with mild or atypical
disease remain a source of contamination for young infants
who are at highest risk for severe manifestation, administra-
tion of these vaccines to adolescents or young adults is now
widely recommended in industrialized countries in an attempt
to obtain longer term protection and to provide indirect pro-
tection to infants. Different strategies have been proposed to
achieve the latter objective (the so-called cocoon vaccination,
vaccination during pregnancy).
Transmission of diphtheria, tetanus and pertussis in the
hospital setting, although very rare, can occur. An infected
patient can be the source of diphtheria or pertussis trans-
mission whereas contaminated surgical material has been
reported as a possible cause of tetanus.
Controversial Issues
Rare severe neurological events leading to permanent
brain damage occurring in infancy have been attributed to
immunization with Pwc vaccine in the 1970s, leading to the
interruption of pertussis vaccination programs in some indus-
trialized countries. This has been followed by a recrudes-
cence of pertussis in these countries, thereby demonstrating
226 A Guide to Infection Control in the Hospital
the role of vaccination in controlling the disease. Whether
these neurological events were only temporally related or
caused by vaccination has been a source of controversy.
One large case control study performed in England has not
established a causal relationship between such neurological
events and pertussis vaccination.
Pa vaccines have been demonstrated to be effective in large
clinical trials. However, in recent years, a recrudescence in
the number of cases of pertussis has been reported in a num-
ber of countries where the Pa vaccines have replaced Pw
vaccines in the immunization programs, warranting the use
of booster doses in adolescence and adulthood.
Pwc vaccines remain widely used in countries with lim-
ited resources. In a number of industrialized countries, Pwc
vaccines are still preferred on the basis of cost benefit eval-
uations and/or because they have demonstrated their effec-
tiveness over the long term.
Suggested Practice
All interventions that allow reaching high vaccine coverage
should be promoted (Table 34.1). Vaccination schedules
vary according to local practice; guidelines are proposed by
WHO Extended Program of Immunizations (EPI).
Measures to prevent hospital transmission should be imple-
mented. For diphtheria and pertussis, they aim at protecting
other patients and hospital personnel. For tetanus, which is
not transmissible from person to person, they aim at avoid-
ing the rare case of infection from contaminated hospi-
tal material and maintaining adequate standard of care for
wound management and obstetrical practice (Table 34.2).
Table 34.1 Interventions to Reach High Vaccine Coverage Against
Diphtheria, Tetanus and Pertussis
– Universal childhood vaccination against diphtheria, tetanus and pertussis consisting
of 3 to 4 doses of combination vaccine starting not later than 3 months of age.
– Administration of a booster dose of diphtheria-tetanus vaccine at the age of 4 to 6
years, combined with acellular pertussis if affordable and of a booster dose of
diphtheria-tetanus every 10 years thereafter.
continued
Diphtheria, Tetanus, Pertussis 227
Table 34.1 Interventions to Reach High Vaccine Coverage Against
Diphtheria, Tetanus and Pertussis (continued)
– In countries using Pa vaccines in their childhood immunization programs, the booster
used at adolescence should be a diphtheria- tetanus-Pa formulation suitable for use in
adults. Strategies of adult vaccination should be implemented for indirectly protecting
very young infants).
– When managing a wound, review of the history of tetanus immunization and
administration of a booster dose of diphtheria-tetanus and human tetanus immune
globulins according to previous vaccination and to the severity of the wound.
– In countries where a significant proportion of women of childbearing age are not
immunized against tetanus, implementation of vaccination programs of pregnant
women according to WHO EPI guidelines.
Table 34.2 Measures to Prevent Hospital Transmission of
Diphtheria, Tetanus and Pertussis
Diphtheria
– Patient isolation: standard + droplets / and contact if cutaneous.
– Identification of exposed individuals and implementation of the following measures:
– Throat culture for C. diphtheriae, as pharyngeal carriage is possible despite
antitoxic immunity,
– Review of prior history of vaccination, completion of primary program if pending
or administration of a booster dose of vaccine appropriate for age if last dose not
given within the preceding 5 years,
– Surveillance for 7 days for evidence of disease, and
– Antimicrobial prophylaxis with erythromycin for 7 days to previously
unimmunized or insufficiently immunized individuals, and to carriers; to be
prolonged if carriage not eradicated.
Tetanus
– Appropriate wound management: includes cleaning and debridment of the wound
if necessary and administration of tetanus (and diphtheria) vaccination and human
tetanus immune globulin according to the characteristics of the wound and of the
history of previous vaccination.
– Appropriate sterilization of hospital supplies (surgical, injections and sutures material).
– Appropriate obstetrical practices, including sterile umbilical cord cutting.
continued
228 A Guide to Infection Control in the Hospital
Table 34.2 Measures to Prevent Hospital Transmission of
Diphtheria, Tetanus and Pertussis (continued)
Pertussis
– Patient isolation: standard + droplets.
– Identification of exposed individuals and implementation of the following measures:
– Review of prior history of vaccination, completion of primary program if pending
or administration of a booster dose of vaccine if last dose of vaccine has been
given > 3 years,
– Surveillance for 21 days for evidence of disease, and
– Antibiotic prophylaxis with erythromycin for 14 days to close contacts regardless
of immunization status advocated by most authorities on the basis that vaccine
induced protection is not absolute and wanes with time (no booster given after
the age of 7 years).
References
Plotkin SA, Orenstein WA, Offit PA (Eds). Vaccines. WB Saunders
Company, 2008.
Red Book, Report of the Committee on Infectious Diseases. American
Academy of Pediatrics, 2012.
Last JM, Wallace RB (Eds). Public Health and Preventive Medicine.
Appleton and Lange, 2007.
ACIP recommended immunization schedules for persons aged 0
through 18 years and adults aged 19 years and older—United States
2013. Mmwr. 2013. 62.
Pertussis vaccines: WHO position paper. WHO Weekly Epidemiological
Record. 2010. (85)40:385–400.
Diphtheria, Tetanus, Pertussis 229
Chapter 35
Measles
Patrick De Mol, MD, PhD, and Philippe Lepage, MD, PhD
Key Issue
Measles is caused by rubeola virus, one of the most contagious
pathogenic agents known. Despite progress in global immuni-
zation, measles remains a major infectious cause of mortality in
developing countries and is responsible for more than 100,000
deaths in children each year. The importance of health care
associated transmission of measles varies substantially from
one region to another according to local measles epidemiology
and to vaccine coverage. Whatever the local incidence of mea-
sles, the hospital represents a critical site for cross-infection.
Characteristics of hospital care settings present numerous risk
factors for measles transmission.
Known Facts
Measles virions remain viable for a few hours when suspended
in air. Therefore, cough of infected patients can be an important
source of virus for susceptible individuals exposed in confined
rooms. Infection has been described without face-to-face con-
tact with an infected subject. Transmission may occur when the
contagious individual has left the room up to 2 hours before the
arrival of susceptible subjects.
Patients with measles are contagious from 3 to 5 days before
the onset of rash and 1 to 2 days before the onset of fever. This
highly contagious prodromal phase significantly facilitates the
spread of measles in the hospital and complicates control mea-
sures. Patients with measles remain contagious until 4 days after
the onset of rash.
Even in populations with good vaccine coverage, medical
facilities can be the place for transmission of measles to patients
and to healthcare workers. Indeed, the hospitals combine the
factors of infected children, susceptible persons (e.g., those too
young for immunization, debilitated patients), and crowding.
230 A Guide to Infection Control in the Hospital
In industrialized countries, most cases of health care asso-
ciated measles are transmitted patient-to-patient. However,
non-immune healthcare workers are also often involved.
Healthcare staff in developed countries who acquire measles
most frequently are those in direct contact with patients (physi-
cians, nurses). In contrast, most healthcare workers in develop-
ing countries have been definitively immunized by wild viruses
during childhood and do not contribute significantly to health
care associated transmission.
Healthcare infected children with measles have higher
case-fatality and complication rates and recover more slowly
than community-infected patients. The increased complication
rate in children with healthcare associated measles is likely due
to young age (infants) and the presence of underlying disease.
In African countries, HIV infection is frequent in hospitalized
children and is associated with prolonged measles infection and
increased mortality.
Immunization is generally performed in children 9 months of
age or older in developing countries and in children 12 months
of age or older in industrialized nations. Young non-immune
infants are therefore highly susceptible to health care associated
measles. Young children are also at increased risk of health care
associated infection because of frequent contacts with health-
care facilities such as maternal and child healthcare clinics. In
addition, young age is an important risk factor for severe illness.
Several studies have suggested that hospital transmission is
important in developed nations and that attendance at hospital
facilities is a significant risk factor for acquiring measles. All
types of healthcare settings have been implicated; direct or indi-
rect exposure to measles virus in waiting rooms and in emer-
gency departments has been shown to be a significant risk factor
during community outbreaks in the US. Low relative humidity
and lack of fresh-air circulation in waiting rooms may facilitate
measles transmission.
During outbreaks in developing countries, hospital transmis-
sion appears to contribute to measles incidence in urban com-
munities. In rural populations, however, no significant level of
transmission appears to be linked to hospital contact, especially
if vaccination coverage remains moderate.
Measles 231
Controversial Issues
Safe and effective measles vaccines that can be administered
before 6 to 9 months or age are needed to reduce the number of
susceptible individuals and the burden of disease.
Fears contribute to poor vaccination rates in some parts of
the population, particularly in industrialized countries. Links
between measles vaccination and autism or inflammatory bowel
diseases have been proposed. There is now strong scientific evi-
dence against the hypothesis that measles vaccination may be
implicated as a causative agent in these two diseases.
Suggested Practice
High rates of measles vaccination coverage must be main-
tained in the community for herd immunity. This interven-
tion will minimize the number of susceptible individuals.
In industrialized nations, 2 doses of measles vaccine are
required to obtain prolonged protection.
A high level of awareness of the dangers of measles must
be maintained among medical staff. Healthcare personnel
should be informed about the risk of hospital transmission
of measles to non-immune subjects.
Patients with fever and rash must be placed in respiratory
precautions. These subjects should not enter the common
waiting areas of healthcare facilities. Where possible, these
patients should be taken to a room reserved for respiratory
isolation. It is also important that waiting and treatment
rooms be adequately ventilated.
For developing countries, WHO recommends that children
between 6 months and 9 years of age should be vaccinated
against measles upon admission to hospital, even if there is
evidence of previous measles immunization. The protection
rate of measles vaccination is about 80 to 90% in develop-
ing countries. In industrialized countries, only unvaccinated
patients need to be vaccinated upon admission.
Various studies have shown that measles vaccination is
effective in preventing measles in exposed subjects if
vaccination is given within 72 hours of exposure. The
vaccine efficacy varied between 68 and 100%.
232 A Guide to Infection Control in the Hospital
Gamma globulins should only be used for patients with
congenital immune function disorders or during immuno-
suppressive therapy.
Staff members should be immune to measles. Most adults in
developing countries have natural measles immunity.
In industrialized countries, healthcare personnel without
adequate measles antibody titers or documented vaccination
should be vaccinated. Strong recommendations and high
vaccination coverage against measles in health-care work-
ers could contribute to eliminate measles in the general
population.
Summary
Measles is a serious and very contagious disease. Health care
associated transmission of measles remains a threat and may
prove to be an important obstacle to the elimination of measles.
Maintaining a high coverage of measles vaccination in the com-
munity is the most important preventive strategy against the dis-
ease. Other helpful interventions to limit health care associated
transmission include: postexposure vaccination, immunization
of hospitalized patients, increasing awareness of the clinical
presentation of measles in healthcare facilities, and respiratory
isolation of suspected or proven cases. Newer, safe vaccines
that are more immunogenic in the first year of life and more
stable in tropical countries are needed.
References
Biellik RJ, Clements CJ. Strategies for Minimizing Nosocomial Mea-
sles Transmission. WHO Bull. 1997. 75:367–375.
Botelho-Nevers E, Gautret P, Biellik R, Brouqui P. Nosocomial Trans-
mission of Measles: An Updated Review. Vaccine. June 8 2012.
30:3996–4001.
Botelho-Nevers E, Cassir N, Minodier P, et al. Measles among Health-
care Workers: A Potential for Nosocomial Outbreaks. Euro Surveill.
January 13, 2011. 16(2). doi:pii:19764.
CDC. Prevention of Measles, Rubella, Congenital Rubella Syndrome,
and Mumps, 2013. Summary Recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR Recommen-
dations and Reports. 2013. 62:1–64.
Chen RT, Goldbaum GM, Wassilak SG, Markowitz LE, Orenstein WA.
An Explosive Point-Source Measles Outbreak in a Highly Vacci-
nated Population. J Epidemiol. 1989. 129:173–182.
Measles 233
Choi WS, Sniadack DH, Jee Y, et al. Outbreak of Measles in the Repub-
lic of Korea, 2007: Importance of Nosocomial Transmission. J Infect
Dis. July 2011. 204(Suppl 1):S483–490.
Davis RM, et al. Transmission of Measles in Medical Settings: 1980 to
1984. Jama. 1986. 255:1295–1298.
Groth C, Bottiger B, Plesner A, Christiansen A, Glismann S, Hogh B.
Nosocomial Measles Cluster in Denmark Following an Imported
Case, December 2008–January 2009. Euro Surveill. February 26,
Liu L, Johnson HL, Cousens S, et al. Global, Regional, and National
Causes of Child Mortality: An Updated Systematic Analysis for 2010
with Time Trends since 2000. Lancet. 2012. 379:2151–2161.
Madsen KM, Hviid A, Vestergaard M, et al. A Population-Based Study
of Measles, Mumps, and Rubella Vaccination and Autism. N Engl J
Med. 2002. 347:1477–1482.
Marshall TM, Hlatswayo D, Schoub B. Nosocomial Outbreaks—A
Potential Threat to the Elimination of Measles? J Infect Dis. 2003.
187(Suppl 1):S97–101.
Ruuskanen O, Salmi TT, Halonen P. Measles Vaccination After Expo-
sure to Natural Measles. J Pediatr. 1978. 93:43–45.
234 A Guide to Infection Control in the Hospital
Chapter 36
Herpes Zoster Vaccine
Richard P. Wenzel, MD, MSc
Key Issues
An effective vaccine is available to minimize the risk of zoster
infection and its related morbidity.
Known Facts
There is a 30% lifetime risk of zoster among people who have
had chicken pox. Zoster can cause severe pain at times and can
be complicated by post-herpetic neuralgia, central nervous sys-
tem issues including encephalitis, and peripheral nerve palsies.
The currently available zoster vaccine now recommended
for people aged 50 or over will reduce the attack rate by 50%
and will reduce post-herpetic neuralgia by 67%. It is a live
attenuated vaccine.
The vaccine is administered subcutaneously—given at a 45˚
angle. It is stored frozen but can be kept in a refrigerator for
up to 72 hours before reconstitution and then administered to
the patient. The diluent for reconstitution should be stored sepa-
rately at room temperature (68˚–77˚F) or in a refrigerator.
The vaccine contains 19,400 pfu/dose—higher than the
1,350 pfu/dose of the monovalent varicella vaccine.
Contraindications include failure to administer the vaccine
within 30 minutes of reconstitution; pregnancy; immune sup-
pression; active or untreated tuberculosis; and a history of ana-
phylactoid reactions to gelatin, neomycin or the vaccine.
Controversies
It is not clear if the vaccine should be used routinely in people
who have already experienced shingles. However, retrospec-
tive analyses show no harm, and thus prior shingles is not a
contraindication.
Herpes Zoster Vaccine 235
Suggested Practice
If available, this vaccine should be administered to people aged
50 or older who have no contraindications.
References
Oxman MN, Levin JM, Johnson GR, et al. Shingles Prevention Study
Group. A Vaccine to Prevent Herpes Zoster and Postherpetic Neural-
gia in Older Adults. New Engl J Med. 2005. 352:2271–84.
Yawn B, Saddier P, Wollan PC, et al. A Population—Based Study of the
Incidence and Complication Rates of Herpes Zoster before Zoster
vaccine introduction. Mayo Clin Prog. 2007. 82L 1341–9.
Kimberlin DW and Whitley RJ. Varicella Zoster Vaccine for the Preven-
tion of Herpes Zoster. N Engl J Med. 2007. 356:1338–43.
Schmader KE, Levin MJ, Gnann JW, Jr., et al. Efficacy, Safety and Tol-
erability of Herpes Zoster Vaccine in Persons Aged 50–59 years. Clin
Infect Dis. 2012. 54:922–8.
236 A Guide to Infection Control in the Hospital
Chapter 37
Human Papillomavirus
Joshua White, MD
Key Issue
HPV transmission by fomites has been hypothesized leading
to concern for health care associated transmission from patient
to patient via transvaginal ultrasound probes, biopsy forceps
and cryotip probes used for gynecologic procedures. Concern
also exists for respiratory transmission of HPV to the health-
care practitioner through inhalation from the smoke plume pro-
duced by laser treatment of HPV lesions, including cutaneous
and anogenital warts as well as respiratory papillomas. Finally,
health care associated transmission of HPV has been postulated
to occur through the shedding of fomites from warts onto envi-
ronmental surfaces, given its ability to survive for up to 7 days
in both wet and dry environments.
Known Facts
HPV is a circular, double stranded, non-enveloped DNA
virus of the Papillomaviridae family and Papillomavirus
genus of which there are more than 100 different types.
Most HPV infections are subclinical and transient, generally
involving the male and female genital tract.
Risk factors for HPV acquisition include early age of first
intercourse, an increased number of sexual partners, smok-
ing tobacco, HIV infection (even in the absence of AIDS)
and immunosuppression.
Transmission is primarily through sexual intercourse,
including through oral and anal sex, as well as perinatally
from mother to child.
A well-established link exists between HPV and cervical
cancer, with approximately 70% of cases due to HPV types
16 and 18. Other common HPV types that can cause cervical
cancer include 31, 33 and 45.
Human Papillomavirus 237
HPV has been linked to other cancers including vulvar, vagi-
nal, penile and anal squamous cell carcinoma as well as oro-
pharyngeal squamous cell carcinoma.
HPV causes anogenital condylomata (“genital warts”), pri-
marily HPV types 6 and 11. HPV is the most common STI
worldwide, with an estimated prevalence of 25% in sexually
active young women.
HPV has been linked to a disease process know as recur-
rent respiratory papillomatosis, which presents as wart-like
lesions on the vocal folds but may also involve the supra-
glottic or subglottic regions and the respiratory tract. Chil-
dren often present with hoarseness and an abnormal cry, or
even respiratory distress, while adults are more often asymp-
tomatic. Pathogenesis is unclear in adults but is thought to
be due to the spread of HPV types 6 and 11 from anogenital
lesions through oral contact. Children are thought to acquire
the virus through contact with an infected birth canal. The
incubation period ranges from one to several months.
Controversial Issues
Fomites represent a less established mode of HPV transmis-
sion, either from dehydrated squames shed from the epider-
mal surface of warts or in secretions from the genital tract.
This presents concern for health care associated spread on
medical instruments, surfaces, and even clothing, as HPV
has been shown to persist in both wet and dry environments
for a number of days.
Concern exists for potential person to person transmission
of HPV via fomites from genital secretions through contam-
ination of transvaginal ultrasound and other endocavitary
probes. However, there are no case reports that prove this
form of transmission.
A number of cases of genital HPV infection have been
reported in presumed virgins, suggesting but not proving
that environmental fomites shed from genital secretions
were the causative vector rather than through sexual contact.
Similarly, genital HPV has been reported in children unlikely
to have been sexually abused, suggesting the possibility of
infection through acquisition of environmental fomites.
238 A Guide to Infection Control in the Hospital
The development of respiratory papillomatosis has been
linked to inhalation of HPV types 6 and 11 from the smoke
plume generated during laser ablation of genital warts.
Suggested Practice
All transvaginal ultrasound probes should be cleansed with
a high-level disinfectant after every patient exam, even if
they were covered by a condom/ probe cover given their
proven breakage/ failure rate. All other ultrasound exams
that involve contact with tissue other than intact skin (eg.
mucous membranes) should undergo the same type of
disinfection.
Vaginal/gynecologic instruments including, but not lim-
ited to cryotip probes and biopsy forceps should undergo
high-level disinfection procedures as listed in the CDC’s
“Guideline for Disinfection and Sterilization in Healthcare
Facilities” (2008).
All disinfecting agents must be virucidal, as many com-
monly used agents (such as 70% ethanol) may be highly bac-
tericidal but not adequately virucidal for eradicating HPV.
Ultraviolet C is a promising method of sterilization for the
eradication of HPV from instruments but current evidence
does not clearly support its use.
Condoms or probe sheaths should be securely fastened to
the ultrasound probe by an elastic band or similar device to
prevent gross contamination of the probe with blood or cer-
vico-vaginal secretions.
Practitioners performing transvaginal ultrasound exams or
other gynecologic procedures should wear gloves, masks
and goggles/ eyewear to protect against fluid splashes into
mucous membranes including the mouth and eyes, with
consideration of gowns as well depending on the specific
procedure.
Practitioners performing laser ablation of cutaneous or vagi-
nal warts, as well as respiratory papillomas, should hold the
vacuum tip of the smoke evacuator on the laser apparatus
within 1cm of the treatment field, as up to 50% of particulate
matter has been demonstrated to escape into the air if held
greater than 2cm away. This places the practitioner at risk of
inhaling HPV particles.
Human Papillomavirus 239
Practitioners performing laser ablation of cutaneous or vagi-
nal warts, as well as respiratory papillomas, should wear basic
PPE including but not limited to gloves and surgical masks.
Summary
HPV transmission from patient to patient through the use of
endovaginal ultrasound for diagnostic and therapeutic proce-
dures has been hypothesized but never clearly demonstrated.
Endovaginal ultrasound is used commonly by both obstetrician/
gynecologists and emergency room physicians as a diagnostic
tool during the work-up of pelvic pain and vaginal bleeding.
The ultrasound probe is an ideal vector for cross-transmission
of HPV if not sterilized correctly, as it makes close contact with
the cervix and vaginal wall during examination. The CDC’s
“Guideline for Disinfection and Sterilization in Healthcare
Facilities” defines endovaginal ultrasound as a semicritical
device given its direct contact with mucous membranes. The
guideline states that the use of a condom or probe cover does not
change this definition given their proven failure rate. Although
ultrasound manufacturers generally provide ultrasound sheaths
for coverage of the probe, many hospitals utilize latex condoms
as a more affordable alternative. A single comparative study
supports the use of condoms over probe sheaths, citing signifi-
cantly less perforations in condoms at 1.7% (3 of 180) versus
8.3% (15 of 180) of probe covers during routine use for endo-
vaginal ultrasound over a 10 month period.
Contamination of transvaginal ultrasound probes with blood
or vaginal fluids despite the use of a latex condom has been
demonstrated during the course of routine patient care. A study at
an academic medical center in Houston, Texas explored this issue
with a sample size of 173 patients seen over 9 months in their
emergency department. Visual contamination of the probe was
noted in 2% of patients (3 of 173), while contamination by means
of positive hydrogen peroxide testing was recorded in 5% (8 of
173), indicating that many cases of probe contamination were not
visible. Notably, the duration of the ultrasound exam was not cor-
related with a positive test. Two cases of visible contamination
occurred at the rim of the condom, leading the authors to suggest
securing the rim for each exam (eg. with an elastic band). This
report suggests that the lack of visible blood or body fluids does
240 A Guide to Infection Control in the Hospital
not rule out contamination of the probe and therefore disinfection
must occur between each and every patient examination.
HPV DNA has been detected on the surface of properly cov-
ered transvaginal probes after standard disinfection following
routine patient care. In one prospective study, 3.5% (7 of 198)
of endovaginal ultrasound probes were HPV DNA positive over
a 5 month period in a gynecology department of a university
hospital in Lyon, France. Probe samples were obtained within
15 minutes of removal of the disposable probe cover. This was
followed by standard disinfection of the probe with a low level
disinfection wipe. The majority of the HPV strains isolated (6 of
blood/ body fluids were observed by visual inspection.
HPV transmission from patients to healthcare workers the-
oretically may occur through the inhalation of smoke during
the laser ablation of cutaneous and anogenital warts as well as
laryngeal papillomas. The concern for cross-transmission of
HPV is related to the laser’s mechanism of action. When the
laser interacts with tissue, a “smoke plume” forms and consists
of vaporized material, steam, particulate matter and potentially
intact HPV virions or viral DNA. A primary theoretical concern
is the development of laryngeal papillomatosis through inha-
lation of the smoke plume, esp. from genital warts containing
HPV types 6 and 11. A smoke evacuator, which functions as
a vacuum system with a filter attached to the laser, is consid-
ered the most effective precaution in preventing inhalation of
the smoke plume. Use of a standard surgical mask, surgical
gloves and gowns are also recommended for HPV risk reduc-
tion during laser ablation of HPV lesions.
A single case of healthcare acquired laryngeal papilloma-
tosis is reported in the literature, postulated to have occurred
through inhalation of genital or colorectal HPV in a smoke
plume. The healthcare worker reported the use of appropriate
PPE as well as a built-in suction device in the endoscope itself
for removal of the laser plume, but notably the operating room
did not possess a stand-alone smoke evacuator system.
The authors of one small series of patients measured the
amount of HPV DNA present in the smoke plume created from
the laser ablation of laryngeal papillomas. No HPV DNA was
detected; the authors’ argued that their results were due to the
Human Papillomavirus 241
fact that laryngeal papillomas contain much lower copy num-
bers of HPV DNA (1 to 50 copies per cell) as compared to sev-
eral hundred per cell present in plantar warts.
A number of studies have detected HPV DNA in the smoke
plume produced by CO2 lasers during the ablation of anogenital
condylomata. The authors of one study found that 30% (3/10) of
smoke plumes contained HPV DNA, all of which were HPV type
6 and matched the HPV type of the corresponding patients. HPV
DNA has also been detected from the smoke plume produced
from the ablation of plantar and mosaic warts. One series col-
lected vapor from the laser plume using a bubble filled chamber
filled with PBS solution and found that 29% (2 of 7) were HPV
positive. A similar study collected the laser plume vapor with a
vacuum device with filter from 8 plantar warts and found a higher
rate of HPV positivity at 62.5% (5 of 8) of samples.
The ability of HPV to survive on environmental surfaces in
the form of fomites is supported by several scientific reports.
Bovine papillomavirus type 1 obtained from cattle warts and
pseudotype HPV 16 virions (which have the same capsid pro-
teins as wild type HPV16 virions) are often used as surrogates
for wild-type HPV, given the difficulty of producing large
amounts of HPV from human warts or lesions. Supportive
findings include the ability of pseudotype HPV 16 virions to
resist desiccation for one week; the ability of BPV1 and HPV16
to resist the effects of 10mM EDTA; and the ability of small
amounts of BPV1 to survive after treatment with 70% ethanol.
All BPV1 and pseudovirus HPV16 notably were inactivated by
autoclave treatment at 121C for 30 minutes.
HPV DNA has been detected on surgical gloves, biopsy for-
ceps and cryoprobe tips before and after disinfection (with 30%
Savlon and 90% ethanol solution) after use on patients with exter-
nal anogenital condylomata acuminate, cervical condylomata and
cervical intraepithelial neoplasia. Fifty percent of gloves (8 of 16)
tested positive for HPV DNA after they were used to examine
patients with anogenital condylomata acuminate; 1.6 % (1 of
finally 4.5% (1 of 22) of the cryoprobe tips were HPV positive.
Genital type HPV DNA strains have been detected on envi-
ronmental surfaces in a genitourinary clinic where cryotherapy
treatment for genital warts was routinely performed. HPV DNA
242 A Guide to Infection Control in the Hospital
was detected on the surface of cryotherapy guns, on patient equip-
ment throughout the clinic, and even in male and female patient
bathrooms in the medical office. Notably, a total of 19 HPV types
were detected, all of which were associated with genital infection.
References
Abramson AL, DiLorenzo TP, Steinberg BM. Is Papillomavirus detect-
able in the plume of laser-treated laryngeal papilloma? Arch Otolar-
yngol Head Neck Surg. 1990. 116:604–607.
Casalegno J-S, et al. High risk HPV contamination of endocavitary
vaginal ultrasound probes: An underestimated route of nosocomial
infection? PLOS one. 2012. 7:10.
CDC. Guideline for Disinfection and Sterilization in Healthcare Facil-
ities. 2008.
Ferenczy A, Bergeron C, Richart RM. Human papillomavirus DNA in
fomites on objects used for the management of patients with genital
human papillomavirus infections. Obstetrics and Gynecology. 1989.
74:6.
Garden JM, et al. Papillomavirus in the vapor of carbon dioxide laser-
treated verrucae. JAMA. 1988. 259:1199–1202.
Gloster HM, Roenigk R. Risk of acquiring human papillomavirus from
the plume produced by the carbon dioxide laser in the treatment of
warts. J Am Acad Dermatol. 1995. 32:436–41.
Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavi-
rus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol.
Lewin JM, Brauer JA, Ostad A. Surgical smoke and the dermatologist.
J Am Acad Dermatol. 2011. 65:636–41.
Roden RBS, Lowy DR, Schiller JT. Papillomavirus is resistant to desic-
cation. JID. 1997. 176:1076–9.
Rooks VJ, et al. Comparison of probe sheaths for endovaginal sonogra-
phy. Obstet Gynecol. 1996. 87 (1):27–9.
Sawchuck WS, et al. Infectious papillomavirus in the vapor of warts
treated with carbon dioxide laser or electrocoagulation: Detection
and protection. J Am Acad Dermatol. 1989. 21:41–9.
Storment JM, Monga M, Blanco JD. Ineffectiveness of latex condoms
in preventing contamination of the transvaginal ultrasound trans-
ducer head. Southern Medical Journal. 1997. 90:2.
Strauss S, et al. Contamination of environmental surfaces by genital
human papillomaviruses. Sex Transm Infect. 2002. 78:135–138.
Weyandt GH, et al. Low risk of contamination with human papilloma
virus during treatment of condylomata acuminata with multilayer
argon plasma coagulation and CO2 laser ablation. Arch Dermatol
Res. 2011. 303:141–144.
Human Papillomavirus 243
- 2009. 14(8).
- 7) represented high risk types. No breakage in probe covers or
- 62) of biopsy forceps after disinfection were HPV positive, and
- 1991. 248:425–427.
Chapter 38
Transfusions
Kimberly Williams Sanford, MD
Key Issues
In the United States, approximately 30 million units of blood
components are transfused annually and though steps are taken
to ensure the blood supply is safe, there are infectious and
non-infectious transfusion related adverse events. In 2011, the
Food and Drug Administration reported 58 documented trans-
fusion related mortalities. Due to the risks and the high costs
associated with transfusion and treatment of adverse events,
hemovigilance programs and blood utilization/management
programs have been the subject of national organizations and
transfusion services to improve patient safety.
Known Facts
Most patients are concerned about the transmission of blood
borne pathogens from transfusion; however, the greatest risk
to patients is the non-infectious complications of transfusion.
Three of the most common causes for transfusion related
mortality are transfusion related acute lung injury (TRALI),
transfusion associated sepsis and hemolytic transfusion reac-
tions. Most hemolytic events are related to human errors.
Bacterial screening is still a major concern primarily in
platelets because they are stored at room temperature and
without a preservative. It is estimated that between 1:1000
and 1:4000 units are contaminated, but the incidence of
septic transfusion reaction is much lower: 1:25,000 platelet
transfusions and 1:250,000 red cell transfusions.
Approximately 41,000 blood donations are needed daily in
the United States to support patients requiring transfusion.
Nucleic acid testing to screen for blood-borne pathogens and
excluding donors with high-risk backgrounds or behaviors
have decreased the risk of transfusion related disease trans-
mission considerably.
244 A Guide to Infection Control in the Hospital
To reduce the cost of donor testing, all DNA testing of
donors is performed in mini-pools where 8 to 16 donor sera
are pooled together and the nucleic acid testing is performed
on the pool. If the mini-pool nucleic acid test (MP-NAT) is
positive then each donor in the pool is individually tested.
Currently, the risk of transfusion transmitted infections in
the United States is low and therefore pathogen reduction
technology, although theoretically attractive, does not pro-
vide additional benefit. At this time there is no pathogen
reduction technology used in the United States although
some of these technologies are utilized in other countries.
Leukocyte reduction of blood products reduces the transmis-
sion of CMV and reduces the risk of HLA alloimmunization
to prevent platelet transfusion refractoriness.
Controversial Issues
Directed donations increase the risk of post transfusion hep-
atitis since most donors feel obligated to donate and may not
answer questions regarding high risk behavior honestly.
Autologous donations are not recommended because it
induces a presurgical anemia in the patients, patients still
experience transfusion reactions from storage issues, and
the risk of mistransfusion with the wrong unit of blood still
exists.
Leukocyte reduction theoretically decreases the incidence
of febrile non-hemolytic transfusion reactions (FNHTR)
caused by cytokines released from leukocytes in stored
cellular blood components; however, universal leukocyte
reduction has not decreased the incidence of FNHTR. This
suggests there are other causative agents for FNHTR.
Transfusion related immunomodulation (TRIM) related to
non-leukocyte reduced blood components is associated with
suppression of the recipient’s immune defenses and related
with increased infections and risk of malignancy. There-
fore, universal leukocyte reduction was believed to reduce
the clinical sequelae caused by TRIM but these results have
been contradictory.
Transfusions 245
Suggested Practices
Consider alternatives before transfusion and optimize the
patient’s pre-surgical hemoglobin.
Hemoglobin levels alone should not be an indication for
transfusion. Patients should be assessed for signs and symp-
toms of anemia.
Blood collections facilities must follow a standardized
protocol for screening and interviewing potential donors
(Table 38.2).
The FDA requires routine screening for syphilis (non-trepo-
nemal test), Hepatitis B virus, Hepatitis C virus, Human
Immunodeficiency Virus (HIV1-2), Human T-leukemia
Virus (HTLV-I/II), Trypanosoma cruzi and West Nile Virus.
Blood transfusion and the use of derivatives should follow
a careful protocol with registration of donor, serological
studies, recipient, reasons to be transfused, and amount
transfused.
Platelets should be subject to strict protocols to make sure
bacterial contamination has not occurred, including 24–48
hours cultures.
Discontinue all transfusions immediately when a patient
is experiencing adverse symptoms, check that the unit is
labelled with the correct patient and medical record number
and report it to the blood bank.
Patients experiencing dramatic elevations in temperature
(>2C) during transfusion or fevers associated with chills and
hypotension should have cultures of the blood component
bag and the recipient’s blood performed to exclude transfu-
sion associated microbial infections.
246 A Guide to Infection Control in the Hospital
Table 38.1 Infectious Disease Agents Associated with
Transfusion-Associated Infections
Infectious Disease Agents Risk of Transfusion Transmission
Hepatitis B virus Low (1 in 1/220,000–357,000 units
when anti-HBc is performed)
Hepatitis C virus Very low (1 in 1.1 million units when
MP-NAT used)
Human immunodeficiency virus 1–2 Very low (1 in 1.5 million when
MP-NAT used)
Hepatitis A, D, E viruses Low to very low
Hepatitis G virus Absent
Cytomegalovirus Risk of transmission in susceptible
patients transfused with seronegative
cellular components is 1–2%, risk of
transmission with leukoreduced cellular
components is 2–3%
vCJD, Dengue virus, Babesia spp, Agents with significant scientific
evidence of risk to blood safety
Chikungunya virus, St Louis encephalitis virus, Agents with scientific evidence of risk
Leishmania spp, Plasmodium spp, to blood safety
Trypanosoma cruzi
Chronic wasting disease, Hepatitis A, HHV-8, Agents with absent to low scientific
HIV variants, Human parvovirus B19, evidence of risk to blood safety
Influenza A (H5N1), Spumavirus,
Borrelia burgodorferi
Viruses: Colorado Tick fever virus, Agents evaluated but no prioritization
Crimean-Congo hemorrhagic fever virus, for risk to blood safety
Eastern equine encephalitis, Epstein-Barr virus,
Hepatitis G virus, Hepatitis B virus variants,
Hepatitis E virus, Herpes viruses (excluding
CMV & HHV-8), HTLV variants, Influenza A & B,
Japanese encephalitis virus, La Crosse virus,
Lassa virus, Lymphocytic choriomeningitis,
Marburg virus, Monkeypox virus, Mumps,
Papillomaviruses, Polyomavirus, Porcine
endogenous retrovirus,Porcine parvovius,
Rhabdovirus, SARS coronavirus, Tick-borne
encephalitis, Torque teno virus, Vaccinia virus,
Variola virus, Western equine encephalitis virus
Transfusions 247
Table 38.1 Infectious Disease Agents Associated with
Transfusion-Associated Infections (continued)
Infectious Disease Agents Risk of Transfusion Transmission
Rickettsial Agents: Anaplasma Agents evaluated but no prioritization
phagocytophilium, Erlichia chaffeensis, for risk to blood safety
Orientia tsutsugamushi, Rickettsia prowazekii,
Rickettsia rickettsii
Bacterial Agents: Coxiella burnetti, Agents evaluated but no prioritization
Borrelia spp, Brucella spp, Yersinia for risk to blood safety
enterocolitica, Yersinia pestis
Protozoan & Nemotode Agents: Filariae, Agents evaluated but no prioritization
Toxoplasma gondii, Trypanosoma brucei for risk to blood safety
Table 38.2 Physical Examination Requirements of Donors
General Appearance Must Appear in Good Health
Skin Venipuncture site must be free of lesions and free
of stigmata of IV drug abuse
Temperature ≤37.5 C, measured orally
Pulse Regular and between 50–100 beats per minute,
<50 bpm may be accepted if an athelete
Blood pressure Not > 180 systolic and 100 diastolic
Hemoglobin and Hematocrit ≥12.5 g/dL or 38%, respectively
Table 38.3 Criteria for Protection of Recipients of Donor Blood
Reason for Deferral Length of Deferral Period
Viral hepatitis after 11th birthday Indefinite
Family history of CJD Indefinite
Travelers who have spent more than 3 months Indefinite
in the United Kingdom or 5 years total in Europe
due to risk of vCJD areas
Received a blood transfusion in the Indefinite
United Kingdom or France
248 A Guide to Infection Control in the Hospital
Table 38.3 Criteria for Protection of Recipients
of Donor Blood (continued)
Reason for Deferral Length of Deferral Period
Received bovine insulin manufactured in UK Indefinite
Receipt of dura mater or pituitary growth hormone Indefinite
of human origin
Confirmed positive test for HbsAg or repeatedly Indefinite
reactive test for anti-HBc
Laboratory evidence of HCV infection Indefinite
Laboratory evidence of HTLV-1 infection
Have donated the only unit of blood to a patient Indefinite
who developed HIV or HTLV and had no other
probable cause of infection
Use of bovine insulin manufactured in UK Indefinite
Use of Etretinate (Tegison) Indefinite
History of babesiosis or Chagas disease Indefinite
Obvious stigmata of parenteral drug use or use Indefinite
of a needle to administer non-prescription drugs
Receiving money or drugs for sex Indefinite
Acitretin (Soriatane) 3 years after last dose
Malarial infection 3 years after resolution
of symptoms
Lived for more than 5 years in 3 years after departure
malaria-endemic areas if asymptomatic
Paying for sex 12 months
History of syphilis or gonorrhea, treatment 12 months after
for syphilis or gonorrhea, or positive syphilis completing treatment
screening test
Receipt of blood products, human tissue, or 12 months
plasma-derived clotting factors
Hepatitis B immune globulin administration 12 months
Any other unlisted vaccine 12 months
Transfusions 249
Table 38.3 Criteria for Protection of Recipients
of Donor Blood (continued)
Reason for Deferral Length of Deferral Period
Tattoo 12 months
Mucous membrane exposure to blood 12 months
Nonsterile skin penetration, including tattoos 12 months
or permanent makeup, unless applied by a
state-regulated entity with sterile needles and
ink that has not been re-used
Residing with or having sexual contact with 12 months
an individual with viral hepatitis
Sexual contact with an individual with HIV 12 months
or high risk for HIV
Incarceration >72 consecutive hours 12 months
Travelers to malaria-endemic areas 12 months after departure
regardless if asymptomatic or
prophylaxis
Dutasteride (Avodart) 6 months after last dose
Recent blood donation 8 weeks for whole blood
donation, 16 weeks for
48 hours for plasma-, platelet-
or leukopheresis
Pregnancy Defer until 6 weeks post-partum/
post-termination. Exceptions are
for transfusion to the infant w/
physician approval
Live attenuated vaccines: German measles 4 weeks
(rubella) and Chicken pox (varicella zoster)
vaccines
Finasteride (Proscar, Propecia) 1 month after last dose
Isotretinoin (Accutane) 1 month after last dose
Clopidogrel (Plavix) and Ticlopidine (Ticlid) 14 days (donor excluded from
platelet donation)
250 A Guide to Infection Control in the Hospital
Table 38.3 Criteria for Protection of Recipients
of Donor Blood (continued)
Reason for Deferral Length of Deferral Period
Live attenuated vaccines: Measles (rubeola), 2 weeks
polio (Sabin oral), mumps, typhoid (oral),
and yellow fever vaccines
Smallpox vaccine 21 days or until scab falls off in
a donor without complications
from vaccine. In donors with
severe complications from the
vaccine, 14 days after resolution
of symptoms. Asymptomatic
contacts of vaccine recipient
doesn’t require deferral
West Nile virus 14 days after resolved or
28 days after onset, whichever
is longer. Positive WNV ab test
without symptoms, no deferral.
Warfarin (Coumadin) 7 days
(excluded from platelet donation)
Aspirin and piroxicam (Feldene) 48 hours
(excluded from platelet donation)
Toxoids, synthetic or killed vaccines: Anthrax, None (if donor is afebrile and
Cholera, Diphtheria, Hepatitis A, Hepatitis B, symptom-free)
Influenza, Lyme, Paratyphoid, Pertussis,
Plague, Pneumococcal polysaccharide,
Polio (Salk injection), Rabies, Rocky Mountain
spotted fever, Tetanus, Typhoid (injection),
Recombinant HPV vaccine
Stigmata of alcohol intoxication or habituation Exclude donor, no specific period
of time stated
Other travel Refer to www.cdc.gov/travel
Antibiotics As defined by medical director
Transfusions 251
Transfusion transmitted blood borne infections have decreased
considerably after implementation of more rigorous donor
screening and routine testing for the most common transfu-
sion-associated pathogens. The FDA requires donor testing
for HBsAg and anti-HBc which reduces the risk of transfusion
transmission to 1/220,000-357,000 units. The HBV DNA testing
does not further reduce this risk because during the infectious
period, HBV DNA levels are low and are below the threshold
of detection for mini-pool nucleic acid testing (MP-NAT). This
method works well for HCV, HIV and WNV DNA testing but
is not effective for HBV. Hepatitis C was one of the most com-
mon causes of post-transfusional hepatitis, but with the use of
serologic assays to detect HCV antibodies combined with HCV
MP-NAT the risk of transfusion transmitted HCV is now 1 in
1.1 million units. The window period from time of infection
to time of detection of HCV virus with MP-NAT is only 7.4
days. Due to the high incidence of HIV transfusion transmit-
ted infections in the mid to late 1980’s, more rigorous donor
screening to exclude donors engaged in high risk behavior, such
as intravenous drug use, high risk heterosexual behavior and all
males who have ever had sex with other males. This rigorous
screening combined with serologic testing to detect antibodies
to HIV-1, HIV-2, and MP-NAT reduced the window period to
9 days and dramatically reduced the risk of transmission to 1 in
1.5 million.
Bacterial contamination of blood products has become a
growing concern and is one of the top 3 causes for transfusion
related fatalities. The source of the contamination is the donor’s
skin during the phlebotomy or the donor has asymptomatic bac-
teremia at the time of collection. The amount of bacteria initially
contaminating the unit is small, but the bacteria proliferate during
storage. This is a higher risk for platelets because they are incu-
bated at room temperature whereas red blood cells are refriger-
ated during storage. The different storage temperatures also select
for different bacteria. Gram positive skin contaminants prolifer-
ate best in platelets and psychrophilic enteric organisms are the
most common contaminating bacteria in refrigerated red blood
cells. To reduce the risk of bacterial contamination, in 2008 the
AABB required all donor centers to use collection bags that divert
252 A Guide to Infection Control in the Hospital
the first 10–40 ml of blood to minimize the risk of skin bacteria
contaminating the collected product. Also in 2004, the AABB
required all blood collection centers to implement a process to
limit the bacterial contamination of all platelets. Most blood cen-
ters store the platelets for 24 hours before sampling the units for
culture and then incubate the cultures 12–24 hours before releas-
ing the units to transfusion services.
References
AABB Association Bulletin #04-07. Actions Following an Initial Pos-
itive Test for Possible Bacterial Contamination of a Platelet Unit.
October 14, 2004.
AABB Association Bulletin #12-04. Recommendations to Address
Residual Risk of Bacterial Contamination of Platelets. October 14,
2012.
American Red Cross Blood Facts and Statistics. Available at http://
www.redcrossblood.org/learn-about-blood/blood-facts-and-statis-
tics. (Accessed 22 January 2014).
Busch MP, Glynn SA, Stramer SL, et al. A new strategy for estimat-
ing risks of transfusion-transmitted viral infections based on rates of
detection of recently infected donors. Transfusion. 2005. 45:254–64.
Food and Drug Administration. Fatalities reported to FDA following
blood collection and transfusion: Annual summary for fiscal year
and Development, 2011. Available at http://www.fda.gov/down-
loads/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/
TransfusionDonationFatalities/UCM300764.pdf. (Accessed 22 Jan-
uary 2014).
Herbert PC, Fergusson D, Blajchman MA, et al. Clinical outcomes fol-
lowing institution of the Canadian universal leukoreduction program
for red blood cell transfusions. JAMA. 2003. 89:1941–9.
Klein HG, Anderson D, Bernardi MJ, et al. Pathogen Inactivation: Mak-
ing decisions about new technologies. Report of a consensus confer-
ence. Transfusion. 2007. 47:2338–47.
Standards for Blood Banks and Transfusion Services (28th edition).
Bethesda, MD: AABB.
Stramer SL, Hollinger FB, Katz LM, et al. Emerging infectious disease
agents and their potential threat to transfusion safety. Transfusion.
Zou S, Stramer SL, Notari EP, et al. Current incidence and residual risk
of hepatitis B infection among blood donors in the United States.
Transfusion. 2009. 49:1609–20.
Transfusions 253
- 2 unit RBC apheresis;
- 2011. Rockville, MD: CBER Office of Communication, Outreach,
- 2009. 49:2S; 1S–235S.
Chapter 39
Preparing the Patient for Surgery
Helen Giamarellou, MD, PhD
Key Issue
Appropriate skin preparation plus antimicrobial prophylaxis
decrease the incidence of both superficial and deep wound
infections (surgical site infection) after certain operations.
Known Facts
A preoperative shower, preparation of the skin with antiseptics
in the operating room, and a single preoperative dose of a first-
or second-generation cephalosporin are extremely important to
significantly decrease wound infection rates. Regrettably, sev-
eral postoperative doses of prophylaxis are generally adminis-
tered in several medical centers leading to excess cost and the
emergence of multiresistant bacteria.
Controversial Issues
Hair removal from the operative site is still disputed.
Assessment of risk factors in clean operations requires more
studies.
Weight-based dosing for antimicrobial prophylaxis in obese
patients should be clarified.
Duration of prophylaxis for cardiothoracic procedures
should be determined.
The safety and efficacy of topical antimicrobials in
non-opthalmic procedures have not been clearly established.
Definitions
Wound infection has been defined as purulent discharge from an
incision, regardless of whether organisms are cultured. In 1992,
the CDC redefined the term as “surgical site infections,” and
divided them into superficial and deep infections. The superfi-
cial infections involve only the skin and subcutaneous tissues
while deep infections involve at least muscle and fascial lay-
ers. Incisions may be contaminated by the patient’s own normal
254 A Guide to Infection Control in the Hospital
flora or by flora from the environment, including the operative
team. Correct surveillance of wound infection extends to 30
days following surgery. In the case of implants, surveillance is
extended for up to 1 year.
The traditional surgical wound classification system was
established based on the exposure of the incision to bacterial
contamination (Table 39.1). Infection was reported in 3.3% of
clean wounds, in 10.8% of clean-contaminated, in 16.3% of
contaminated, and in 28.6% of dirty wounds. In the Study of the
Efficacy of Nosocomial Infection Control (SENIC), a new clas-
sification based on patients’ risk assessment rather than wounds
was developed. Risk factors included abdominal operations,
operations exceeding 2 hours, and having three or more associ-
ated discharge diagnoses. Patients with no risk factors were at
low risk for infection (1%), those with one factor at moderate risk
(3.6%), and those with two or more factors at high risk (8.9% to
27%). The National Nosocomial Infection Surveillance (NNIS)
system, in 1991, attempted to redefine risk factors. The follow-
ing risk factors provided a greater discrimination for the patient
at risk of wound infection: (1) a contaminated or dirty wound
class; (2) high preoperative risk as defined by an American Soci-
ety of Anesthesiologists (ASA) preoperative assessment score of
three or more; and (3) a duration of operation exceeding the 75th
percentile for a given procedure since long operations generally
include greater blood loss, increased complexity and violations
of asepsis. Malnutrition, advanced age, obesity, diabetes melli-
tus, renal insufficiency, cirrhosis, coexisting remote body-site
infections, recent surgical procedure, length of preoperative hos-
pitalization, known colonization with MRSA or VRE, extremes
of age, placement of foreign bodies, malignancy, and the use of
steroids or immunosuppressive drugs represent additional risk
factors for wound infection.
Patient Preparation for Surgery
Preparation of patients for surgery aimed at preventing postop-
erative wound infection is based on appropriate skin care and
antimicrobial prophylaxis. Nevertheless, appropriate treatment of
remote infections before elective operations and adequate control
of blood glycose levels perioperatively are also recommended.
Decolonization of nasal carriage of S. aureus before placement of
foreign material with intranasal mupirocin is indicated.
Preparing the Patient for Surgery 255
Table 39.1 Classification of Surgical Wounds
Clean
Elective, not emergency
No entry into the gastrointestinal, respiratory, genital or uninfected urinary tracts
No signs of acute inflammation or infection
Nontraumatic
No violations of aseptic technique
Non penetrating trauma
Wounds primarily closed and drained (if necessary) with closed drainage
Clean-Contaminated
Urgent or emergency case that is otherwise clean
Entry into the gastrointestinal, respiratory, genital or urinary tract under controlled
conditions and without significant contamination
Biliary tract, oropharynx, vagina and appendix included if no evidence of infection
is present
No major break in aseptic technique is encountered
Contaminated
Major contamination following entry into the gastrointestinal or respiratory tracts
Entrance of genitourinary or biliary tracts in the presence of acute infection
Fresh traumatic wounds(<4 hours old)
Chronic open wounds to be grafted or covered
Major break in aseptic technique
Dirty
Penetrating trauma > 4 hours old
Acute bacterial inflammation or pus encountered
Perforated viscus encountered
Traumatic wound with retained devitalized tissue, foreign material, fecal contamination,
and/or delayed treatment
Decontamination of the skin preoperatively is very important
to prevent wound infection, particularly in clean procedures. A
preoperative shower with an antiseptic soap seems to reduce the
256 A Guide to Infection Control in the Hospital
incidence of postoperative infections. Chlorhexidine gluconate
was significantly superior when compared to povidone-iodine
and triclocarban medicated soap showers. Hair removal at the
operative site by shaving, particularly the night before surgery,
should be abandoned since shaving produces significant injury.
Subsequently, the injured skin sites are colonized and serve as
a niche of bacterial contamination of surgical wounds. The risk
of wound infections from clippers or a depilatory cream have
been found to be lower than that from shaving and if necessary
it should be done immediately before operation. Interestingly,
patients with no hair removal may have even lower rates of
wound infection. Skin preparation in the operating room should
be performed by trained personnel. The preparation starts with
a careful cleansing of the operative site with a detergent (with or
without a degreasing agent). The antiseptic is applied in concen-
tric circles starting at the proposed operative incision site. An
alcoholic (70%) plus chlorhexidine gluconate or an iodophor
scrub are usually used.
Suggested Practice in Antimicrobial Prophylaxis
A single, full therapeutic dose of an antibiotic should be given
intravenously within 60 minutes before surgical incision (15–
60 minutes) to ensure effective tissue concentrations through-
out the operative period. An exception to this rule is cardiac
surgery where two doses of the selected antibiotic seem to
be necessary. However, prophylaxis should not be extended
beyond 24 hours following surgery. Antibiotics are effective
when given before inoculation of bacteria at the surgical site,
whereas they are ineffective if given three to four hours after
the surgical incision. Continuing prophylaxis until all indwell-
ing drains and intravascular catheters are removed is strongly
discouraged. As long as adequate serum and tissue drug level
against probable pathogens are maintained during the opera-
tion, a single dose is as effective as multiple doses.
The selection of the appropriate drug should be based on
the most likely bacteria to cause infection in each situ-
ation, its safety profile as well as the local resistance sur-
veillance patterns. A single drug should be used, whenever
possible. Cephalosporins, in particular, cefazolin, is ideal
for prophylaxis because of its broad spectrum of activity,
Preparing the Patient for Surgery 257
the moderately long serum half-life, low toxicity, ease of
administration, and low cost. In clean-contaminated cases
and in clean operations involving the surgical placement of
foreign material (e.g., heart valves, vascular grafts, orthope-
dic hardware, etc) or whenever risk factors coexist, cefazolin
alone should be administered. In clean contaminated opera-
tions with entry into the gastrointestinal tract as well as in
penetrating abdominal trauma or primary appendectomy,
cefazolin plus an agent active against anaerobes like met-
ronidazole as well as cefotetan or cefoxitin as single agents,
should be used. However, administration in contaminated
and dirty operations is considered therapy and not prophy-
laxis. Third-generation cephalosporins are more costly and
promote the emergence of resistant strains. In general, they
should not be used for routine prophylaxis.
In colorectal surgery and in institutions where there is
increasing resistance to first and second generation cepha-
losporins among gram-negative isolates from SSIs, ceftriax-
one plus metroniadazole should be preferred over ertapenem.
For patients with beta-lactam allergies, metronidazole or
clindamycin plus an aminoglycoside or a fluoroquinolone or
aztreonam could replace as above the suggested regimens.
In the case of massive hemorrhage (>1,5 Lt), or whenever
the duration of operation exceeds two half-lives of the pre-
administered antibiotic(s), intraoperative redosing should be
given. The redosing interval should be measured from the
time of administration of the preoperative dose, not from the
beginning of the procedure.
Since staphylococci are the major threat in infected pros-
theses, vancomycin instead of cefazolin should be used in
institutions with a high predominance of methicillin resistant
strains as well as in ß-lactam allergic patients. Because of pro-
longed infusion time required for vancomycin (1h) it should
be administered within 120 min before surgical incision.
In cardiac and orthopaedic procedures mupirocin should be
given intrnasally to all patients known to be colonized with
S. aureus.
In colorectal procedures mechanical bowel preparation com-
bined with oral neomycin sulfate plus erythromycin base or
258 A Guide to Infection Control in the Hospital
metronidazole should be given in addition to IV prophylaxis.
In laparoscopic biliary tract procedures where some risk fac-
tors can not be determined before the procedure, it may be
reasonable to give a single dose of antimicrobial prophylaxis
to all patients.
With the exception of ophthalmic procedures, topical admin-
istration of antibiotics as prophylaxis, based on their lack
of efficacy and the possibility of adverse reactions, is not
recommended.
Conclusions
There is no doubt that appropriate antibiotic prophylaxis reduces
morbidity and costs by preventing surgical site infections. How-
ever, it should be emphasized that antibiotic overuse and misuse
for surgical prophylaxis accounts for as many as half of all anti-
biotics costs prescribed in USA hospitals and contributes to the
emergence of multidrug-resistant microorganisms particularly
whenever the one single preoperative dose is exceeded. Based
on the importance of the application of correct perioperative
antibiotic prophylaxis as well as the appropriate preparation of
patients for surgery, it has been recently suggested that hospitals
should establish a multidisciplinary team including surgeons,
anaesthesiologists, nurses, pharmacists, infection control spe-
cialists and clinical microbiologists, who should develop and
implement a relevant protocol.
References
Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines
for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm.
Classen DC, Evans RS, Restomic SL, et al. The timing of prophylactic
administration of antibiotics and the risk of surgical wound infection.
N Engl J Med. 1992. 326:281–6.
De Lalla F. Surgical prophylaxis in practice. J Hosp Infect. 2002.
50(Suppl A):9–12.
European Center for Disease Prevention and Control Technical Report:
Systemic review and evidence-based guidance on perioperative
antibiotic prophylaxis. Stockholm: ECDC, 2013 Catalogue number
- Nonpurulent inflammation;
- 2013. 70:195–283.
Tq-01-13-279-En-C.
Mangram AC, Horan TC, Pearson ML, et al. Guideline for prevention
of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999.
20(4):250–78.
Preparing the Patient for Surgery 259
Chapter 40
Infection Control in Obstetrics
J.A.J.W. Kluytmans, MD, PhD, J. Veenemans, MD, PhD
Key Issue
Neonatal sepsis and postpartum endometritis (PPE) are mostly
caused by organisms in the mothers’ vaginal flora. The risk of
these infections can be substantially reduced by simple infec-
tion control measures. However, in developing countries they
still cause substantial morbidity and mortality, in both hospital
and community settings.
Known Facts
The most important microorganisms causing neonatal sepsis
are group B streptococci (GBS) and Escherichia coli.
Neonatal GBS sepsis can be prevented by administering
intravenous antibiotics to the mother during labour. The
decision to provide such prophylaxis is guided by the pres-
ence of risk factors for neonatal GBS sepsis (see below), or
by the presence of vaginal GBS colonization.
Caesarean section is the most important risk factor for
post-partum maternal infection and is associated with a 5
to 20-fold increased risk of infection compared to vaginal
delivery.
Single dose antibiotic prophylaxis reduces the risk of infec-
tions after caesarean section (wound infection, endometritis
and urinary tract infection) in all patients (both emergency
and elective procedures).
Outbreaks of classical childbed fever caused by group A
hemolytic streptococci still occur albeit sporadically. They
warrant prompt investigations into the source, including a
search for carriers among HCW.
During labour there is frequent and often uncontrolled con-
tact with blood and other body fluids. Transmission rates of
blood borne pathogens are high when preventive measures
are neglected.
260 A Guide to Infection Control in the Hospital
In developing countries, vaginal deliveries often take place in
settings with limited resources and under unhygienic circum-
stances. Cheap and accessible interventions to reduce the risk of
both neonatal and maternal infections are necessary. Examples
of such measures include cleaning of the birth canal with an
antiseptic and washing of the cord stump with chlorhexidine.
Controversial Issues
There is debate about whether antibiotic prophylaxis in
caesarean sections should be given before skin incision
or after cord clamping. Current evidence suggests that the
administration of prophylaxis before skin incision is supe-
rior to prophylaxis after cord clamping in reducing the risk
of infection, with no evidence of increased risk of neonatal
complications.1,2
Suggested Practice
Standard infection control measures should be taken before,
during and after labour. During labour, gloves should be
worn at all times and it is advisable to wear a gown, a mask
and eye protection during all procedures.
Antibiotic prophylaxis should be administered during vag-
inal delivery at 4 hour intervals to high risk patients (see
below) to prevent GBS sepsis in the neonate.
In case of a caesarean section, a single dose antibiotic pro-
phylaxis (cefazolin) should be administered intravenously to
all patients, preferably 30 min before incision.
In limited resource settings, cleaning of the birth canal with
a disinfectant during vaginal examinations and other (instru-
mental) procedures can be used to reduce the risk of both
neonatal sepsis and maternal infections.
Vaginal exams should be kept to a minimum to limit the risk
of infection.
Anti-tetanus prophylaxis should be provided in case of
delivery outside the hospital and of unsafe abortion.
In settings with high infection risk, post-delivery care of
the cord stump should be performed with chlorhexidine
washings.
Infection Control in Obstetrics 261
Summary
The importance of infection control in obstetrics was established
when Semmelweis made his historical observations during the
second half of the nineteenth century. Standard hygienic pre-
cautions by health care professionals are the best way to avoid
health care associated spread of pathogens In addition, sim-
ple measures can largely prevent infections that are caused by
micro-organisms of the mother’s endogenous flora. In devel-
oped countries most infectious complications of delivery are
now relatively rare, but in developing countries the burden of
neonatal and maternal postpartum morbidity and mortality due
to bacterial infections remains high.
Neonatal Sepsis
The most important pathogens causing neonatal sepsis are
group B streptococci (GBS) and Escherichia coli. The new-
born becomes colonized with these micro-organisms during the
passage of the birth canal. Prevention of infections with GBS
can be achieved by providing intravenous high dose antibiot-
ics every 4 hours until delivery to women who are colonised
with GBS and/or to women with risk factors for neonatal GBS
sepsis (delivery at <37 weeks gestation, membrane rupture for
> 18 hours, intra-partum temperature > 100.4 F). The feasibil-
ity and cost-effectiveness of screening for GBS colonisation
during pregnancy depend on the setting. GBS prophylaxis
should always be given to women who had GBS bacteriuria
earlier in the course of pregnancy, and to those who previously
had a child with GBS sepsis. High dose intravenous penicillin
or ampicillin are the drugs of first choice. In patients who are
allergic to penicillin, clindamycin is administered.
In poor resource settings, implementation of sterile proce-
dures during cord clamping, and proper care of the cord area are
of major importance. Infection of the cord stump (omphalitis) is
an important cause of neonatal morbidity and mortality in com-
munity and primary care settings in developing countries, and
recent review of the evidence shows that a substantial reduction
in neonatal mortality can be achieved when using antiseptics
to care for the cord stump instead of dry cord care (as recom-
mended by the World Health Organisation) (RR all-cause mor-
tality 0.77, 0.63 to 0.94).4
262 A Guide to Infection Control in the Hospital
Post-partum Endometritis
Post-partum endometritis (PPE) is a serious complication of
delivery. Infections are often polymicrobial, caused by the moth-
er’s endogenous flora, and outbreaks are rare. The incidence of
PPE is much higher following caesarean sections than following
vaginal deliveries. As for the prevention of any surgical infec-
tion, general principles to prevent PPE include sound surgical
technique, skin antisepsis and timely antimicrobial prophylaxis.
Although emergency Caesarean sections are associated with a
higher infection rate then elective procedures, antibiotic pro-
phylaxis is effective in both high-risk patients (in labour after
membrane rupture) and low risk patients (intact membranes, not
in labour).3 In addition, single dose prophylaxis (cefazolin plus
metronidazole) is recommended by WHO following operative
vaginal delivery, manual removal of the placenta, curettage of
the uterus, or in case of fourth degree tears.7 Despite adequate
antimicrobial prophylaxis, the rate of PPE after caesarean sec-
tion remains high (10–20%), and further prevention depends
largely on the elimination of risk factors, such as reducing the
number of vaginal examinations during labour. Manual removal
of the placenta after a caesarean section is associated with a
higher incidence of endometritis than spontaneous extraction of
the placenta, which is preferred when possible.
In poor resource settings, when antibiotic prophylaxis is not
available, cleaning of the birth canal with an antiseptic (chlor-
hexidine 0.25–0.50%) at every vaginal examination during
active labour can prevent both maternal and neonatal infections.
Data from non-randomised studies have suggested a reduction
in infection risk as well as in colonisation rate,4 but evidence
from subsequent randomised trials is inconclusive.5,6 The effi-
cacy of this intervention may strongly depend on the back-
ground infection risk, and because it is a safe and inexpensive
measure to reduce the risk of infection, it should certainly be
used when other alternatives are not available.
Although classical childbed fever caused by group A
beta-hemolytic streptococci is rare, outbreaks do occur. If so,
immediate control measures, including screening for carriers
among healthcare workers and other patients, are mandatory.
Infection Control in Obstetrics 263
Blood Borne Pathogens During Delivery
Blood borne pathogens are a threat to mother, child and health-
care worker during delivery. Scalp electrodes are contraindi-
cated if the mother is infected with hepatitis B, C or HIV, and
in mothers with hepatitis B the newborn should be immunized
after delivery. In mothers infected with HIV, antiretroviral ther-
apy during pregnancy and in the newborn reduces the risk of
vertical transmission.9
Blood exposure occurs frequently during labourlabour.
Gloves are frequently punctured. Needle stick injuries and
splashes occur frequently. Therefore, gloves should be worn
at all times, and it is advisable to wear gowns, masks and eye
protection.7
Herpes Simplex Virus (HSV)
Mothers with active genital HSV infections should be han-
dled with barrier precautions. HCW and the mother should
wear gloves when touching the infected area or materials
(gauzes etc.).
References
1
Sun J, et al. Prophylactic administration of cefazolin prior to skin inci-
sion versus antibiotics at cord clamping in preventing postcaesarean
infectious morbidity: A systematic review and meta-analysis of ran-
domized controlled trials. Gynecol Obstet Invest. 2013. 75:175–178.
2
Sullivan SA, Smith T, Chang E, et al. Administration of cefazolin prior
to skin incision is superior to cefazolin at cord clamping in prevent-
ing postcaesarean infectious morbidity: A randomized, controlled
trial. Am J Obstet Gynecol. 2007. 196:455.e1-e5.
3
Smaill FM, Gyte GML. Antibiotic prophylaxis versus no prophylaxis
for preventing infection after cesarean section. Cochrane Database
of Systematic Reviews. 2010. Issue 1. Art. No.: CD007482. DOI:
10.1002/14651858.CD007482.pub2.
4
Imdad A, Bautista RMM, Senen KAA, et al. Umbilical cord antiseptics
for preventing sepsis and death among newborns. Cochrane Data-
base of Systematic Reviews. May 31, 2013. (5):CD008635.
5
Stade BC, Shah VS, Ohlsson A. Vaginal chlorhexidine during labour
to prevent early-onset neonatal group B streptococcal infection.
Cochrane Database of Systematic Reviews. 2004. Issue 3. Art. No.:
CD003520. DOI: 10.1002/14651858.CD003520.pub2.
264 A Guide to Infection Control in the Hospital
6
Lumbiganon P, Thinkhamrop J, Thinkhamrop B, Tolosa JE. Vaginal
chlorhexidine during labour for preventing maternal and neonatal
infections (excluding Group B Streptococcal and HIV). Cochrane
Database of Systematic Reviews. 2004. Issue 4. Art. No.: CD004070.
DOI: 10.1002/14651858.CD004070.pub2.
7
World Health Organization 2000. Managing complications in preg-
nancy and childbirth: A guide for midwives and doctors. http://
whqlibdoc.who.int/publications/2007/9241545879_eng.pdf
8
Mead PB, Hess SM, Page SD. Prevention and Control of Nosocomial
Infections in Obstetrics and Gynecology in Prevention and Control
of Nosocomial Infections (3rd Edition), Wenzel RP (Ed). Philadel-
phia: Williams and Wilkins, 1997. 995–1016.
9
Siegfried N, van der Merwe L, Brocklehurst P, Sint TT. Antiretrovirals
for reducing the risk of mother-to-child transmission of HIV infec-
tion. Cochrane Database of Systematic Reviews. 2011. Issue 7. Art.
No.: CD003510. DOI: 10.1002/14651858.CD003510.pub3.
Infection Control in Obstetrics 265
Chapter 41
The Infection Hazards of
Human Cadavers
P.N.Hoffman, T.D.Healing, and S.E.J.Young
Key Issue
Cadavers may pose hazards to those handling them. The recently
dead may have been infected by a wide range of pathogens,
those presenting particular risks include tuberculosis, strepto-
coccal infection, gastro-intestinal organisms, the agents causing
transmissible spongiform encephalopathies (e.g. Creutzfeld-Ja-
cob disease), hepatitis B and C, HIV infection, severe acute
respiratory syndrome (SARS), hemorrhagic fever viruses, and
possibly meningitis and septicaemia (especially meningococ-
cal). None of the organisms that caused mass death in the past
(e.g. plague, cholera, typhoid, tuberculosis, smallpox) is likely
to survive long in burials.
Known Facts
Most of the micro-organisms that cause death do not survive
for long after the host dies or are not readily transmissible in
that context.
Soft tissues remaining on a cadaver could present an infec-
tion risk.
Long buried bodies reduced to skeletons are not a hazard.
A possible hazard in old burials is anthrax, which can form
resistant spores but this is unlikely.
Controversial Issues
There is a theoretical concern that smallpox may survive in
buried bodies, but the risk from minimal residual virus in dry
scabs is not considered to present a valid infectious threat.
People should not be vaccinated specifically to deal with this
hazard as the risk of smallpox vaccination greatly outweighs
the infection risk.
266 A Guide to Infection Control in the Hospital
Suggested Practice
Whether dealing with the recently dead or with old burials, and
regardless of which infectious agents may be present, the risk of
acquiring infection can be greatly reduced by:
good personal hygiene; and
the use of appropriate protective clothing (see Table 41.1).
Text
Most people have little to do with the dead, although they may
at some time in their lives need to deal with the cadavers of
relatives or friends during burial rituals. Some have jobs that
regularly bring them into contact with cadavers, exposing them
to the risk of acquiring infections. These include doctors (espe-
cially pathologists), nurses, mortuary attendants, members of
the emergency services, forensic scientists, embalmers, funeral
directors, religious officials or others who routinely prepare
bodies for the funeral or who perform final rites, and members
of the emergency services.
In most circumstances the diseased living are a much greater
hazard than are the dead, even those who have died of infec-
tious disease. Whilst a person is alive, invading pathogens can
multiply and are readily transmitted. The patient is a continuing
source of infection. Once the host is dead, most micro-organ-
isms stop multiplying and die rapidly as a result of microbial
competition as the body decomposes.
The Recently Dead
The diseases and organisms which may pose particular risks vary
in different parts of the world but include tuberculosis, strepto-
coccal infection, gastro-intestinal organisms, Creutzfeld-Jacob
disease, viral hepatitis and HIV infection, a number of viral
infections (particularly viral hemorrhagic fevers such as Lassa,
Marburg or Ebola), SARS-like viruses, and possibly meningitis
and septicaemia (especially meningococcal) (see Table 41.2). In
general, the use of appropriate protective clothing will greatly
reduce the risk of acquiring infection but some additional pre-
cautions may be advisable for particular infections.
The Infection Hazards of Human Cadavers 267
Table 41.1 Use of Protective Clothing
Hands
Examination gloves (latex or nitrile). For handling hazardous material. Wear whenever
handling bodies. Should be worn once only and then discarded. Always wash hands after
use. Latex gloves provide short-term (10-minute) protection against formaldehyde; nitrile
gloves give longer-term protection.
Respiratory Protection
Filter masks. Filter mask to EN 149 FFP2 (or equivalent, e.g. N95) for specific hazards
(e.g. lead dust, fungal spores and other aerosols)
Specifically-manufactured surgical masks. These may provide protection against
splashes, particularly if water-repellent, but cannot be as effective as filter masks as their
fit to the wearer’s face allows particles to bypass any filtration the mask fabric may offer
Cloth surgical masks. These provide little protection and may give a false sense of security
but are better than nothing.
Splash Protection
Face: Visor. Protection against hazardous splashes to eyes, nose and mouth
(also mechanical protection).
Respiratory protective masks and cloth or paper surgical masks normally provide splash
protection to mouth and nose only. Some surgical masks incorporate a transparent
eye-protecting visor.
Body: Apron. Where splashing to body may occur (hygienic preparation, embalming,
collection of traumatised bodies, post-mortem examinations). Best worn under gowns or
coats if splashing is likely to be profuse.
Feet: Rubber boots. In wet situations (mortuaries, embalming rooms, collecting severe
multiple trauma cases).
Whole Body Protection
Gowns/Coats. To protect clothing against splashing.
Coverall with hood. To protect clothes and hair from impregnation with dusts, spores etc.
Other protective clothing (safety helmets, boots, safety glasses, work gloves) should be
worn as required to protect against mechanical injury.
Tuberculosis
Opening cadavers of individuals infected with tuberculosis is
dangerous and workers in morbid anatomy, pathologists, mortu-
ary technicians and medical students have a comparatively high
rate of tuberculin conversion. BCG vaccination and an annual
chest X-ray is advised for such individuals.
268 A Guide to Infection Control in the Hospital
Table 41.2 Infections Where Bagging is Essential and Viewing,
Embalming Cosmetic Enhancement and Hygienic Preparation
Should Not Be Done
- covering cuts or lesions with waterproof dressings;
- careful cleansing of any injuries sustained during procedures;
Infection
Anthrax
Plague
Rabies
Smallpox
Viral hemorrhagic fevers
Yellow fever
Transmissible spongiform encephalopathies (e.g. Creutzfeldt-Jakob Disease)
Streptococcal disease (group A)
Viral hepatitis (B, C, non-A non-B)
Bagging = placing the body in a leak-proof plastic body bag.
Viewing = allowing the bereaved to see, touch and spend time with the body prior
to disposal.
Embalming = injecting chemical preservatives into the body to slow the process of decay.
Cosmetic enhancement of the appearance of the body may be undertaken to improve
the appearance for viewing.
Hygienic preparation = cleaning and tidying the body so it presents a suitable appearance
for viewing (an alternative to embalming).
Meningitis and Septicaemia
Meningitis can be caused by a wide range of organisms but
only tuberculosis (see above) and meningococci are likely to
present a risk.
Septicaemia is a common terminal event and can be caused
by many different organisms (often the patient’s own flora)
most of which present no hazard. Only cases of meningo-
coccal septicaemia or of infection with group A streptococci
pose a risk. Life threatening infections with the latter can
result from quite trivial contact and injuries.
Gastrointestinal Organisms
Faecal leakage from bodies is very common. All those handling
cadavers should:
Take care not to contaminate their instruments or their work-
ing environment; and
The Infection Hazards of Human Cadavers 269
Wash their hands carefully after procedures and before
eating, drinking or smoking.
The bodies of those who have died of diseases such as cholera
or typhoid should not be buried in places where they could con-
taminate water sources.
Transmissible Spongiform Encephalopathies (TSEs)
These are rare conditions typically presenting as Creutzfeldt-Ja-
kob and variant Creutzfeldt-Jakob disease. The causative agents
of these diseases are highly resistant to most disinfectants and to
heat. They are not inactivated reliably by chemical disinfection
or conventional heat sterilisation. Only fully trained staff should
undertake post mortem examinations in patients thought to be
at risk of, or who are known or suspected as having, TSEs. If
examination of the brain only is required, the skull should only
be opened inside a large plastic bag fitted over the head and
neck of the cadaver. In addition full single-use PPE (including
coverall, apron, double gloves, full face visor or surgical mask
with visor) should be used. If a full post mortem is required,
including the removal of viscera and spinal cord, the body
should be examined in a high risk autopsy suite.
Hepatitis
Hepatitis A is transmitted by the faecal-oral route and pres-
ents the same hazard as other gastro-intestinal pathogens. A
highly effective vaccine is available.
Hepatitis B is extremely infectious and the incidence of this
infection continues to increase in many countries. A highly
effective vaccine is available and staff working in hospital
mortuaries, and embalmers, should routinely receive immu-
nisation against this infection. The bodies of those who have
died of, or were known to be infected with, this virus should
be handled only by those wearing full protective clothing.
Hepatitis C is also highly infectious although probably less
so than hepatitis B. It is transmitted by the same routes as
hepatitis B, there is no vaccine, and similar precautions to
those for hepatitis B should be taken.
270 A Guide to Infection Control in the Hospital
HIV
The routes of transmission of hepatitis B and of HIV are similar
and the precautions required to prevent the transmission of the
former should be adequate to prevent transmission of the latter.
HIV is less infectious than hepatitis B and the risk to those han-
dling infected cadavers is therefore proportionately less. HIV
can survive for many days post-mortem in tissues preserved
under laboratory conditions. Care should be taken when han-
dling unfixed, HIV-infected material from cadavers, or when
undertaking post-mortem examinations on those infected with
HIV. Embalming the bodies of those known or suspected of
being infected is not recommended.
Those infected with HIV are often infected with other organ-
isms (such as mycobacteria) which may be more infectious
(albeit less dangerous) than the HIV infection itself.
Viral Hemorrhagic Fevers
Viruses such as Ebola and Marburg are highly infectious and
are readily transmitted by contact with infected blood, secre-
tions and organs. Most of the known outbreaks have been health
care associated. Great care should be exercised when dealing
with those who have died of such infections. Staff should wear
gloves, protective gowns, masks and eye protection. Post mor-
tem examinations should not be carried out. Bodies should be
bagged as soon as possible and should be buried with appropri-
ate precautions (see below) or cremated.
Reduction of Risk
Post-mortem Rooms
Post-mortem rooms should be structured such that the risks
to those working in them are minimised. Provision of proper
ventilation, lighting, running water and good drainage is
essential.
Workers must use single-use gloves for each procedure and,
after removal, wash their hands immediately.
The environment should be cleaned with a broad spectrum
disinfectant daily.
Instruments should be washed in a washer-disinfector,
autoclaved or immersed in a broad-range, non-corrosive
The Infection Hazards of Human Cadavers 271
disinfectant after initial cleaning. The reasons for the use of
a disinfectant other than hypochlorite are:
instruments, and
ii) Formaldehyde is likely to be present in postmortem rooms
(and embalmers’ premises) and the reaction between
hypochlorite and formaldehyde can produce a potent
carcinogen (bis-chloromethyl ether).
Some hospital post-mortem departments bag all bodies for
transfer to funeral directors. This can be counter-productive in
terms of safety as bagging a body may be the main means by
which the hospital can communicate to the funeral director that
the body may present special risks. In countries where confiden-
tiality precludes reference to specific infections, the type of risk
involved can be identified by attaching labels advising generic
precaution types (e.g. enteric, blood borne) to the bag.
Preparation of the Dead for Funerals
Often only a simple “hygienic preparation” may be carried
out, frequently by relatives or religious officials. This usu-
ally involves washing the body, dressing the cadaver, tidying
the hair and possibly trimming the nails and shaving. Such
rapid procedures are frequently followed in many countries,
particularly the hotter ones, where burial or other disposal of
the cadaver follows death within 24 hours (either for prac-
tical or religious reasons). Under these circumstances many
pathogens may still be viable but, provided there is consid-
ered to be only a low level of risk, then the use of gloves and
simple protective clothing and/or good personal hygiene by
anyone handling the bodies is an acceptable and effective
safety measure.
In some instances, for example where the person has died of
a highly infectious disease such as Ebola or hepatitis B, even
hygienic preparation is not safe. A list of such infections is
given in Table 41.2.
Embalming may be undertaken as a means of temporary
preservation by reducing microbial activity and slowing
decomposition and is usually a straightforward process, but
272 A Guide to Infection Control in the Hospital
the embalming of cadavers which have been in accidents or
which have been the subjects of post-mortem examination is
more difficult. They may be badly damaged and present par-
ticular hazards because of damaged bones, bone splinters,
and (occasionally) due to sharp items, such as intravenous
cannulae, left in the body. Cosmetic work on cadavers may
also present hazards if the body has been damaged. There can
sometimes be considerable contamination of the body with
blood, faeces and other body fluids if it is bagged, presenting
an extra risk to embalmers and others involved in preparation
of the body. This is another reason to avoid universal bagging
of bodies by hospitals. Embalming practices such as the open
drainage of the vascular system lead to excessive environ-
mental contamination and should be avoided.
All instruments used for embalming or for preparing bod-
ies for the funeral should be cleaned in hot water and deter-
gent and can be sterilised in an autoclave, heat disinfected
or soaked in a disinfectant after careful cleaning. Disinfec-
tants should be used to clean up any spills of blood or body
fluid, single-use gloves being used to protect the hands from
contact with the spill. Hands should always be washed after
finishing a session.
Emergency Service Personnel
The major hazard facing emergency service personnel is
spilt blood and any risk can be greatly reduced by preventing
contact with blood (use of gloves, face and eye protection,
and protective clothing where necessary).
Bodies that have been decaying for some time, including
those that have been in water for extended periods of time,
present little risk. The organisms likely to be present are their
own body flora and water or environmental organisms. The
use of proper protective clothing and good personal hygiene
will protect personnel handling such material.
Bodies should always be transported to mortuary facilities
in waterproof body bags or cleanable, fluid retentive (e.g.
fibreglass) temporary coffins.
The Infection Hazards of Human Cadavers 273
Disposal of the Dead
Each society has its own methods of disposal of the deceased.
These must be respected as far as possible although in a few
instances (such as deaths due to highly infectious agents such as
Ebola) cremation or deep burial with the cadaver in a leak-proof
plastic body bag may be the only safe procedures.
Immediately following disasters where there has been sub-
stantial loss of life, there seems to be a tradition to bury or cre-
mate the dead as quickly as possible “to prevent the spread of
disease”. In reality however, the dead bodies of disaster victims
pose a minimal infectious risk to the survivors. The spectrum of
disease amongst the deceased in a rapid onset natural disaster
(such as a tsunami) will be the same as that amongst the sur-
vivors. Of those deceased that had an infectious disease at the
time of their death, the risk that they will disseminate it will be
lower than it was during their life and those that did not have
an infectious disease offer a negligible risk. The imperative of
immediate disposal of the dead diverts resources from searching
for and caring for the survivors at a critical time in any rescue
operation. It also hampers or prevents the identification of the
dead, removing part of the grieving process from their relatives
as well as prolonging their uncertainty as to the possible sur-
vival of the victims. The legal consequences of lack of iden-
tification (e.g. uncertainty of spouses about death of partners,
inheritance or welfare benefit problems) can cause long-term
hardship for the deceased relatives.
If bodies cannot immediately be identified and sufficient
temporary mortuary space with refrigeration is not available
they should be buried in marked graves with at least one metre
of earth over the cadavers (to prevent access by scavengers and
pests) to allow subsequent exhumation. Careful and detailed
records of such interments must be kept. Once identified, they
should be dealt with following the normal religious and social
practices of the affected areas as far as possible. Burial sites
must be chosen so as to avoid the risks that water sources may
be contaminated.
Those handling the bodies should take basic infection con-
trol precautions: Impervious gloves, single-use or disinfected
274 A Guide to Infection Control in the Hospital
after use), impervious apron or coverall, impervious footwear,
face protection if splashing is likely. Respiratory-protective
masks are not necessary. The use of chloride of lime to prevent
the spread of infection in these circumstances is to be avoided.
It has little effect and is dangerous to those applying it. This
applies equally to emergency and non-emergency situations,
such as exhumations of graves and crypts.
References
Advisory Committee on Dangerous Pathogens. Management of Hazard
Advisory Committee on Dangerous Pathogens. Management of Haz-
ard Group 4 viral haemorrhagic fevers and similar human infectious
diseases of high consequence. 2012. Available at: http://www.hpa.org.
uk/webc/HPAwebFile/HPAweb_C/1194947382005
Ball J, Desselberger U, Whitwell H. Long-lasting viability of HIV after
patient’s death. Lancet. 1991. 338:63.
Department of Health England. Guidance on prevention of CJD and
vCJD by Advisory Committee on Dangerous Pathogens’ Trans-
missible Spongiform Encephalopathy (ACDP TSE) Risk Manage-
ment Subgroup. Annex H: After death. 2012. Available at: https://
www.gov.uk/government/uploads/system/uploads/attachment_data/
file/209766/Annex_H_-_After_death.pdf
Gamble MR. Hazard: Formaldehyde and Hypochlorites. Laboratory
Animals. 1977. 11:61.
Hawkey PM, Pedler SJ, Southall PJ. Streptococcus pyogenes: A forgot-
ten occupational hazard in the mortuary. BMJ. 1980. 281:1058.
Health and Safety Executive. Health Services Advisory Committee.
Safe working and the prevention of infection in the mortuary and the
post-mortem room (2nd Edition). 2003. Available at: http://www.hse.
gov.uk/pubns/priced/mortuary-infection.pdf
Health and Safety Executive. Controlling the risks of infection at work
from human remains: A guide for those involved in funeral services
(including embalmers) and for those involved in exhumation. Health
and Safety Executive. 2005. Available at: http://www.hse.gov.uk/
pubns/web01.pdf
Morris SI. Tuberculosis as an occupational hazard during medical train-
ing. Am Rev Tuberculosis. 1946. 54:140–58.
Morgan O. Infectious disease risks from dead bodies following natural
disasters. Rev Panam Salud Publica. 2004. 15(5):307–12.
Newsom SWB, Rowlands C, Matthews J, Elliott CJ. Aerosols in the
mortuary. J Clin Pathol. 1983. 36:127–32.
Smith GS. Tuberculosis as a necropsy room hazard. J Clin Pathol. 1953.
6:132–4.
The Infection Hazards of Human Cadavers 275
de Ville de Goyet C. Stop propagating disaster myths. Lancet. 2000.
356:762–764.
West DJ. The risk of hepatitis B infection among health professionals in
the United States: A review. Am J Med Sci. 1984. 287:26–33.
Wolff HL, Croon JAB. The survival of smallpox virus (Variola Minor)
in natural circumstances. Bull World Health Organ. 1968. 38 492–3.
World Health Organization/Pan American Health Organization. Manage-
ment of dead bodies in disaster situations. Washington, DC: WHO/
PAHO, 2004. Available at: http://www.paho.org/
276 A Guide to Infection Control in the Hospital
Chapter 42
Streptococcus pyogenes
(G roup A Streptococcal Infections)
Belinda Ostrowsky, MD, MPH
Keywords
Streptococcus pyogenes, Group A streptococcus, standard pre-
cautions, postpartum infections, post surgical infections, long
term care facilities, evaluation of clusters, typing.
Key Issues
Handwashing is one of the most important infection con-
trol practices for the prevention of spread of infection with
Streptococcus pyogenes [Group A streptococcus (GAS)].
One health care associated postpartum or postsurgical inva-
sive GAS infection should prompt enhanced surveillance
and streptococcal isolate storage; two or greater cases caused
by the same strain of GAS should prompt an epidemiologi-
cal investigation that includes the culture of specimens from
epidemiologically linked health care workers (HCWs).
There are relatively new guidelines and specific actions to
address potential clusters/outbreaks of GAS infections in
long term facilities.
In a larger context GAS remains a challenge in terms of best
prevention strategies for developing countries.
Known Facts
Group A streptococci frequently colonize the throats of
asymptomatic persons and may also colonize the skin, rec-
tum and vagina.
Streptococcal disease is ordinarily spread by direct per-
son-to person contact. In cases of pharyngitis and respiratory
infections, droplet nuclei of saliva or nasal secretions are the
mode of spread. Crowding such as occurs in schools or mil-
itary barracks favors interpersonal spread of the organism
in community outbreaks. Fomites can also be a source of
streptococcal transmission.
Streptococcus pyogenes 277
A variety of clinical presentations may occur, including
pharyngitis, otitis media, quinsy, skin and soft tissue infec-
tions (pyoderma, impetigo, erysipelas, and scarlet fever),
pneumonia and puerperal fever.
Most GAS infections are relatively mild illnesses. More
recently invasive and serious GAS infections have become
concerning.
Invasive Group A streptococcal infection is defined as isola-
tion of GAS from a normally sterile site (e.g., blood) or by
the isolation of GAS from a nonsterile site in the presence
of the streptococcal toxic shock syndrome or necrotizing
fasciitis.
Postinfectious complications of GAS infections include
Rheumatic Fever with secondary aortic and mitral valve
injury and glomerular nephritis. Pharyngeal strains of GAS
can result in either syndrome. Infections of the skin are only
associated with the acute glomerular nephritis.
Streptococcal infections should be treated to limit secondary
complications.
Outbreaks of pharyngitis and impetigo in school-age chil-
dren or in group settings are common.
Clusters/outbreaks are less common, but have been described
mainly in two healthcare settings, postpartum and postsurgi-
cal populations. There has also been recent interest in health
care associated clusters in long term care facilities.
Controversial Issues
No controlled trials have evaluated the effectiveness of che-
moprophylaxis in preventing invasive GAS disease among
household contacts of persons with invasive GAS infections.
Given the infrequency of these infections and the lack of
a clearly effective chemoprophylaxis regimen, the available
data do not support a recommendation for routine testing for
GAS colonization or for routine administration of chemo-
prophylaxis to all household contacts of persons with inva-
sive GAS at this time.
The global strategies for prevention of GAS on larger scale
remain complex.
278 A Guide to Infection Control in the Hospital
Suggested Practice
Standard precautions, including handwashing are the most
important infection control practices for the prevention of
spread of infection with GAS such as minor/limited skin
infections, wounds and burns and endometritis (puerperal
sepsis).
HCWs should wear gloves and gowns for contact with the
skin of patients with major lesions, wounds and purulent
discharge. Place the patient in a private room. When a pri-
vate room is not available, place the patient in a room with
a patient(s) who also has infection with the S. pyogenes
(cohorting). Discard the gloves after use and wash hands
thoroughly between patient contacts. Contact isolation may
be discontinued after 24 hours of directed antistreptococcal
therapy.
For GAS infections that involve the pharynx and respiratory
tract, such as pneumonia and Scarlet Fever in infants and
children, HCWs should use standard and droplet precau-
tions, including use of a surgical mask when working within
3 feet of the patient. Logistically, some hospitals may want
to implement the wearing of a mask to enter the room of
affected patients. Place the patient in a private room. When
a private room is not available, cohorting should be used.
When a private room is not available and cohorting is not
achievable, maintain spatial separation of at least 3 feet
between the infected patient and other patients and visitors.
Special air handling and ventilation are not necessary, and
the door may remain open.
HCWs who are known or suspected to have infection or col-
onization of their respiratory tract with S. pyogenes should
wear a mask to reduce respiratory spread of their organism.
Attempt to eradicate colonization in those HCWs who are
proven sources of outbreaks (description evaluation of clus-
ter/outbreak in healthcare setting below).
Newer typing modalities, including whole-genome sequenc-
ing (compared to traditional pulsed field gel electrophoresis)
may be needed to elucidate the epidemiology in some
clusters.
Streptococcus pyogenes 279
Summary
Streptococcus pyogenes (Group A β-hemolytic streptococcus)
is a gram-positive, catalase-negative cocci. It can be carried in
the pharynx, skin, vagina and rectum asymptomatically. There
are a wide variety of clinically presentations of GAS. Although
the most common GAS infections are mild (i.e. pharyngitis,
skin infections) if left untreated there can be serious secondary
sequelae, including Rheumatic Fever and glomerular nephritis.
More concerning in recent years are invasive GAS infec-
tions. Invasive GAS infection is defined as isolation of GAS
from a normally sterile site (e.g., blood) or by the isolation of
GAS from a nonsterile site in the presence of the streptococcal
toxic shock syndrome or necrotizing fasciitis.
Worldwide, rates of invasive disease increased from the
mid-1980s to early 1990s. Rates of invasive disease have been
stable over the last several years in the United States. However,
there have been increases in the severity of disease, including
those associated with M-1 and M-3 serotypes (emm gene types
1 and 3). Resistance to erythromycin has increased worldwide.
By estimates from Centers for Disease Control and Pre-
vention (CDC), using the Active Bacterial Core Surveillance
(ABCs) Report in the year 2012 there were approximately
10,700 cases of invasive GAS and 1150 deaths due to GAS
infection in the United States.
Direct contact with patients or carriers and large respira-
tory droplets are the primary means of acquisition. Disease
caused by S. pyogenes is most common in late winter and early
spring. In the community setting, outbreaks of pharyngitis in
school children and other congregate settings are common in
these months. Contaminated hands of HCWs are an important
means of transmission, particularly outside of the setting of the
operating room. Appropriate gloving and good handwashing
techniques are important to emphasize in efforts to control an
outbreak. The addition of contact precautions for wound, skin
and soft tissue and droplet precautions for pharyngeal and respi-
ratory infections in infants and children are appropriate infec-
tion control practices. Prompt identification and investigation of
an outbreak of healthcare associated S. pyogenes infection will
assist in its control.
280 A Guide to Infection Control in the Hospital
In health care settings outbreaks have been described mainly
in two populations; postpartum and postsurgical patients. GAS
infections are also reported in burn patients (wound), bacte-
remias in the setting of intravascular catheters devices and
pneumonias.
There are two recent guidelines (since 2002) that are excel-
lent resources for addressing infection control related to GAS
infections and particularly in these high risk settings, one related
to an expert panel meeting by CDC in the United States and the
second by Public Health Agency of Canada. Highlighted from
these comprehensive guidelines are distilled below.
In 2000, CDC hosted a workshop to formulate recommen-
dations for household contacts of those with invasive GAS
infections and for responding to healthcare associated clusters,
including postpartum and postsurgical invasive GAS infections.
The recommendations from this panel were published in 2002.
In this CDC expert panel review, a household contact is
defined as a person who spent at least 24 hours in the same
household as the index patient during the seven days before the
onset of the case patient’s symptoms. Review by the committee
of two prospective studies that were designed to identify sub-
sequent cases among household contacts (who were observed
for a total of 66.5 million person-years) identified only five
confirmed cases of subsequent invasive disease. There are no
controlled trials that have evaluated the effectiveness of che-
moprophylaxis in preventing invasive GAS disease among
household contacts of persons with invasive GAS infections.
In addition, antimicrobial therapy can have undesirable side
effects, including adverse reactions and selection for resistant
organisms.
Thus, the committee did not recommend routine screening
for and chemoprophylaxis to household contacts. However,
they suggested that providers and public health officials may
choose to offer chemoprophylaxis to household contacts who
are at an increased risk of sporadic disease [HIV infection, dia-
betes mellitus, varicella zoster (Chicken pox) patients <10 years
of age, cancer, heart disease, injection drug use, steroid use, ≥65
years of age] or mortality due to GAS (≥65 years of age). HCWs
should routinely inform all household contacts of persons with
Streptococcus pyogenes 281
invasive GAS disease about the clinical manifestations of phar-
yngitis and invasive GAS infection (e.g. fever, sore throat, and
localized muscle pain and emphasize the importance of seeking
medical attention if contacts develop such symptoms).
Given the potential for prevention of additional cases, the
CDC panel recommended that even one case of postpartum or
postsurgical GAS infection should prompt an epidemiologi-
cal investigation by the hospital’s infection control personnel,
which should include enhanced surveillance and storage of
GAS isolates from the index patients and any other cases for at
least six months. Enhanced surveillance should include one or
both of the following: 1) review of microbiological records and
autopsy reports from the previous six months and/or 2) review
of operative, labor and delivery, and medical records from
within the hospital.
If two or greater cases are identified within a 6-month
period, they may have a common source of GAS transmission.
Isolates should be compared by an appropriate typing method
(i.e., PFGE, serotyping, other molecular methods). Isolates that
differ probably are community acquired, but enhanced surveil-
lance should be initiated.
If two cases are found to be caused by the same strain within
a 6-month period, screening of HCWs is strongly recommended
to prevent further cases of serious infection. If infection-con-
trol personnel choose to screen healthcare workers, screening
should be considered for HCWs who were present at delivery
and for those who perform vaginal examinations before deliv-
ery (for postpartum cases) and for all HCWs present in the oper-
ating room during surgery and those who change dressings on
open wounds (for postsurgical cases). If screening of HCWs
is undertaken, sites from which specimens should be obtained
and cultured include throat, anus, vagina, and any skin lesions.
Screened HCWs may return to work pending culture results.
However, HCWs identified as colonized should be suspended
from patient care duties until they have received chemopro-
phylaxis for 24 hours and their streptococcus strains should be
compared with patient strains using the same typing methods.
If a HCW is epidemiologically linked to the case patient and
the strain the HCW is carrying is the same as the strains isolated
282 A Guide to Infection Control in the Hospital
from patients, the committee suggests follow-up cultures should
be done for the HCW (CDC suggestions 7–10 days after the
completion of therapy). If no colonized HCW is identified or
if HCWs are colonized with strains unrelated to the outbreak
strain, the search for colonized HCWs could be broadened to
include those HCWs without immediate epidemiological links
to all case patients. This might include, for example, HCWs
who had direct contact with most but not all case patients.
The Public Health Agency of Canada published their Guide-
lines for the Prevention and Control of Invasive Group A Strep-
tococcal Disease in October, 2006. This 26 page resource adds
to the previously described US review in that it offers simple
and clear definitions, an extensive glossary, review of the lit-
erature and references by topic area, and particular sections on
GAS infection control and investigation in the childcare and
long term care facilities settings. Two areas of difference from
the US guideline relevant for the infection control community
are summarized below.
The Canadian workgroup’s consensus on chemoprophylaxis
for contacts was slightly more inclusive than the U.S. guide-
line above, in that it does suggest prophylaxis for the closest
contacts of confirmed severe cases of GAS infections, includ-
ing streptococcal toxic shock syndrome, soft tissue necrosis,
meningitis, pneumonia, other life-threatening conditions or
a confirmed case resulting in death (and did not identify the
underlying conditions of the contacts as a factor as strongly as
the U.S. guideline).
For the long term care setting, in addition to strict enforce-
ment of standard infection control precautions, this guideline
lays out what may constitute a cluster/outbreak and steps to
investigate for and address a potential clusters/outbreaks. It sug-
gests that in this setting 1) an incidence rate of culture-confirmed
invasive GAS infections of > 1 per 100 residents per month or
tion in one month in a facility with fewer than 200 residents
or 3) an incidence rate of suggested invasive or non-invasive
GAS infection of > 4 per 100 residents per month should be an
impetus for action.
Streptococcus pyogenes 283
This guideline suggests when a confirmed case of GAS
infection in a long term care facility is identified that the fol-
lowing additional steps should be taken: 1) retrospective chart
review of facility’s residents over the four–six weeks prior to
the case for other culture confirmed or any suggestive cases of
invasive or non-invasive GAS infection and 2) assess the poten-
tial sources of infection from outside the facility. If an excess of
these infections is identified, then the next steps would be: 1)
screen patient care staff for GAS, 2) based on size of the facility
screen some or all facility residents for GAS (using a cut off of
100 beds, < 100 beds screen all residents, > 100 beds screen
residents within the same care unit as the case), 3) offer pro-
phylaxis for all those identified with colonization with GAS, 4)
question non-patient care staff about recent GAS infection and
screen those with positive history 5) obtain genotyping of GAS
isolates and “test of care” those with outbreak related strains, 6)
rescreening of GAS positive residents and staff identified and 7)
active surveillance for GAS infections for one to two months.
If no excess if identified, especially if there is evidence of out-
side source for the index case, then active surveillance alone
for two–four weeks to establish absence of additional cases is
warranted.
In summary, handwashing is the corner stone of infection
control for GAS infections. Additional precautions includ-
ing contact and droplet precautions are appropriate for use by
HCWs for specific other presentations of GAS infection. For
certain high-risk household contacts of GAS infection, pro-
phylaxis maybe appropriate. For healthcare associated GAS
infections enhanced surveillance, saving isolates and screening/
prophylaxis of epidemiologically-linked HCW in certain setting
may aid in prevention of further infections. Some additional
surveillance and investigation in the long term care setting may
also be appropriate when there is suspicion of clusters/breaks
in this setting. CDC also has web-based tools to aid in investi-
gations of clusters of GAS (Available at CDC website: http://
www2.cdc.gov/ncidod/dbmd/abcs/calc/calc_new/index.htm).
Several clusters have been described in the U.S. and inter-
national literature that have suggested that traditional typing
protocols, such as pulse-field gel electrophoresis, may not be
284 A Guide to Infection Control in the Hospital
sensitive enough to allow fine epidemiological discrimination
of GAS isolates. Whole-genome sequencing presents a valid
alternative that allows accurate fine scale epidemiological
investigation of clusters of GAS. Examples include a postpar-
tum GAS cluster in Australia in 2010 that using this technic to
prove relatedness of strain type emm 28 isolated from puerperal
sepsis cases from the same hospital from isolates from other
hospitals (supporting suspected patient to patient transmission
or common sources). CDC and several other referral laborato-
ries are available with expertise and resources to help with typ-
ing of suspected clusters (CDC strep labs: http://www.cdc.gov/
ncidod/biotech/strep/strepindex.htm).
In 2005, WHO published A Review of the Technical Basis
for the Control of Conditions Associated with Group A Strep-
tococcal Infections looking more from an international, global-
public health perspective. Although not completely related to
healthcare associated transmission, it lays out a broader plan
for GAS control. It sites that the most successful GAS control
activities have combined multiple strategies including primary
prophylaxis, treatment of skin infections, health promotion,
secondary prophylaxis and RHD registers. Although effective,
these comprehensive programs require a substantial commit-
ment from individuals and organizations (including Ministries
of Health). It also suggests that in light of the current lack of a
clear strategy for primary prevention of GAS infections, there is
definitely a place for a safe, effective, affordable and practical
GAS vaccine. It appears likely that the vaccine most advanced
in development—a multivalent, type-specific vaccine—will not
provide sufficient and long-lasting protection in less developed
countries, although this should be assessed. This document
underscores that GAS remains a challenge throughout the world
in the community and in healthcare settings.
References
CDC. The Prevention of invasive Group A Streptococcal infections
workshop participants. Prevention of invasive Group A Streptococ-
cal disease among household contacts of case patients and among
postpartum and postsurgical patients: Recommendations from the
Centers for Disease Control and Prevention. Clin Infect Dis. 2002.
35:950–959.
Streptococcus pyogenes 285
Public Health Agency of Canada. Guidelines for the Prevention and
Control of Invasive Group A Streptococcal Disease. CCDR 2006.
32S2:1–26.
CDC. National Center for Immunization and Respiratory Diseases:
Division of Bacterial Diseases Group A Streptococcal (GAS) Dis-
ease. Frequently asked questions. CDC website, revised 4/3/08,
Available at: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/groupas-
treptococcal_g.htm
CDC. Active Bacterial Core Surveillance Report, Emerging Infections
- Wear single-use gloves and impervious single-use aprons;
- i) Hypochlorite is corrosive and may damage surfaces or
- 2) at least two cases of culture confirmed invasive GAS infec-
Program Network, Group A Streptococcus, 2012. Available At: Http://
www.cdc.gov/abcs/reports-findings/survreports/gas12.html
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare
Infection Control Practices Advisory Committee. 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings. June 2007. Available at: http://www.
cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
Ben Zakour NL, Venturini C, Beatson SA, Walker MJ. Analysis of a
Streptococcus pyogenes puerperal sepsis cluster by use of whole-ge-
nome sequencing. J Clin Microbiol. July 2012. 50(7):2224–2228.
CDC. The CDC Streptococcus Laboratory, revised 8/30/12. Available
at: http://www.cdc.gov/ncidod/biotech/strep/strepindex.htm
WHO. A Review of the Technical Basis for the Control of Conditions
Associated with Group A Streptococcal Infections. 2005. Available
at: http://whqlibdoc.who.int/hq/2005/WHO_FCH_CAH_05.08.pdf
286 A Guide to Infection Control in the Hospital
Chapter 43
S taphylococcus aureus
Michael P. Stevens, MD, MPH and
Michael B. Edmond, MD, MPH, MPA
Key Issue
Staphylococcus aureus is a major human pathogen that com-
monly causes healthcare associated and community-acquired
infections. It is a highly virulent organism that is exhibiting
increasing antibiotic resistance.
Known Facts
Colonization with S. aureus is common. A national, popu-
lation-based study of non-hospitalized persons in the U.S.
found 32% of persons to be colonized with methicillin sus-
ceptible S. aureus (MSSA) and 1% colonized with methicil-
lin resistant S. aureus (MRSA).
S. aureus is a major cause of healthcare associated infections
(HAIs), accounting for 15% of all HAIs in the United States.
Regarding antimicrobial resistance, S. aureus is typically
characterized by its susceptibility patterns to penicilli-
nase-resistant penicillins (e.g., methicillin) and vancomycin.
The mecA gene encodes for penicillin binding pro-
tein 2a(PBP2a) which confers resistance to all ß-lactam
antibiotics.
Over half of all S. aureus strains acquired in U.S. healthcare
facilities are resistant to methicillin.
Historically, MSSA strains were mostly acquired in the
community, whereas MRSA strains were typically acquired
in healthcare facilities. However, community-associated
MRSA (CA-MRSA) is now the predominant cause of puru-
lent skin and soft tissue infections in the outpatient setting.
CA-MRSA tends to differ from health care associated
MRSA in that community-associated strains are more likely
to be susceptible to TMP/SMX and tetracyclines.
Staphylococcus aureus 287
CA-MRSA often manifests as skin and soft tissue infections
and may be misdiagnosed as a “spider bite.” CA-MRSA is
responsible for the majority of purulent skin and soft tissue
infections presenting to U.S. emergency rooms.
Virtually all of the community-associated strains contain
the Panton-Valentine Leukocidin (PVL) gene which is asso-
ciated with lysis of white blood cells and tissue necrosis.
These strains characteristically cause skin and soft tissue
infections, often in healthy children and young adults, as
well as a severe, multilobar, necrotizing pneumonia that
often occurs with or following influenza.
Classification of MRSA strains into community-associated
and hospital-associated based on exposure to the healthcare
setting is no longer reliable.
Risk factors for staphylococcal colonization and infection
include disruptions of the skin (insulin injections, hemo-
dialysis, allergy therapy, IV drug use, eczema, burns),
underlying diseases (respiratory infections, HIV infection),
prolonged hospitalization, and exposure to other infected
or colonized individuals. However, in many patients with
CA-MRSA infections, these risk factors are not present.
>80% of cases of S. aureus bacteremia are caused by endog-
enous strains (i.e., a strain colonizing the patient is responsi-
ble for invasive infection).
The most common sources of S. aureus bloodstream infec-
tion are catheters (46%), skin/soft tissue/bone (27%), lower
respiratory tract (11%), and urinary tract (10%).
Vancomycin intermediate Staphylococcus aureus (VISA),
vancomycin resistant Staphylococcus aureus (VRSA), and
heteroresistant Staphylococcus aureus (hetero-VRSA) have
all been reported.
The Clinical and Laboratory Standards Institute defines
staphylococcal vancomycin minimum inhibitory concen-
trations (MICs) of ≤2 μg/mL as susceptible, 4–8 μg/mL as
intermediate, and ≥16 μg/mL as resistant. Practically speak-
ing, vancomycin should be avoided for severe infections
where the staphylococcal isolate has an MIC of ≥2 μg/mL
due to a high likelihood of treatment failure.
288 A Guide to Infection Control in the Hospital
Hetero-VRSA are defined as strains of S. aureus that contain
subpopulations of vancomycin-resistant daughter cells but
for which the MICs of the parent strain are only 1–4 μg/mL.
These subpopulations typically have MICs 2–8 fold higher
than the original clinical isolate. When grown in the absence
of vancomycin, the subpopulation of cells reverts back to the
lower MIC of the parent strain.
Patients who develop infection with VISA and VRSA often
have serious comorbid disease states such as renal failure
and diabetes, a previous history of infections with MRSA,
recent vancomycin use, the presence of foreign material
(including intravenous catheters and prosthetic devices) and
recent hospitalizations.
Major route of transmission for S. aureus is direct or indirect
contact; airborne transmission is uncommon.
Colonized healthcare workers may be the source of out-
breaks in the hospital setting.
Controversial Issues
The effectiveness of routine surveillance cultures to detect
MRSA colonized patients followed by isolation of the
patient in order to reduce MRSA infection and colonization
in high prevalence settings is probably not effective.
The role of decolonizing agents in the non-outbreak clinical
setting remains undefined. In particular, use of mupirocin
for all patients in the ICU setting (universal decoloniza-
tion), raises concerns for the development of high rates of
resistance.
Suggested Practice
Mssa
Use standard precautions.
Mrsa/Visa
Use contact precautions (gloves and gowns). Enforce hand
washing with antiseptic agents (chlorhexidine gluconate or
alcohol-based products) for staff, visitors, and infected or
colonized patients.
Consider private room or cohorting the infected or colonized
patient with other MRSA patients.
Staphylococcus aureus 289
Offer decolonization with intranasal mupirocin for patients
with recurring infections and for colonized personnel.
If the MRSA patient is transferred, notify receiving health-
care facility.
emphasize good hand washing.
- No special precautions for home discharge are required;
Vrsa
Contact precautions, including a private room, are
recommended.
Minimize the number of people in contact with or caring for
the patient.
Educate all healthcare personnel about the epidemiology of
VRSA and the appropriate infection control precautions.
Initiate epidemiologic and laboratory investigations with the
assistance of the public health department.
Consult with the public health department before transfer-
ring or discharging the patient.
Summary
In the community, S. aureus is best known as the cause of furuncles
and soft tissue infections. In the hospital environment, S. aureus
may cause life-threatening infections, such as pneumonia,
bloodstream or surgical site infections, and is considered one of
the most important health care associated pathogens.
The nares are the usual reservoir for S. aureus, but other loca-
tions such as moist or hairy body areas, skin defects, wounds,
and burns also can become colonized. Methicillin resistant
S. aureus carriage may be eradicated with application of topical
mupirocin to the anterior nares, although recolonization often
occurs. This therapy should be limited to patients with recurring
MRSA infections or colonized hospital personnel to prevent the
development of resistance.
The most common mode of S. aureus transmission is direct
contact of body surface to body surface. Sexual transmission
of MRSA has been described and manifests as folliculitis
or abscesses of the pubic, vaginal or perineal areas. The air-
borne route is less efficient but may occur in patients with S.
aureus pneumonia or large burn wounds. It has been shown that
290 A Guide to Infection Control in the Hospital
colonized individuals with viral upper respiratory tract infec-
tions may shed S. aureus into the air. Transmission via indirect
contact with inanimate objects such as instruments can occur,
and S. aureus can be detected on many surfaces in hospitals,
including stethoscopes and laboratory coats.
Strategies for the management of S. aureus and especially
MRSA colonization or infection must focus on the type of
spread. Epidemic outbreaks are successfully handled with
prompt application of infection control measures. Application
of precautions such as patient isolation, hand washing with anti-
septic agents, and glove usage can interrupt the chain of trans-
mission and control the outbreak. Institutions with repeated
introduction of MRSA from the community or other facilities
are unlikely to be able to eradicate this pathogen.
Vancomycin remains the mainstay of therapy for systemic
MRSA infections. For MRSA-associated necrotizing pneumo-
nia some experts recommend the addition of an antibiotic active
at the ribosomal level (e.g., rifampin or clindamycin) to termi-
nate toxin production. For relatively minor skin infections, the
use of doxycycline or trimethoprim/sulfamethoxazole (TMP/
SMX) is typically recommended in addition to incision and
drainage of abscesses.
Fortunately, infections due to VISA and VRSA have
remained uncommon. In the United States, there have been
thirteen cases ascribed to VRSA. Importantly, strict compliance
with infection control guidelines is necessary to minimize cross
transmission within healthcare facilities. When identified, pub-
lic health departments should be involved in the management
of these cases.
Treatment options for VISA and VRSA are few, and clinical
experience is limited. Quinupristin-dalfopristin and linezolid
are bacteriostatic for VISA/VRSA. Newer potential thera-
pies include daptomycin, ceftaroline, ceftobiprole, telavancin
and tigecycline. Susceptibility of VISA/VRSA has also been
reported to chloramphenicol, minocycline, tetracycline, dox-
ycycline and trimethoprim/sulfamethoxazole (TMP/SMX).
Expert consultation with an infectious diseases specialist should
be sought for the management of VISA and VRSA cases.
Staphylococcus aureus 291
References
Chang S, Sievert DM, Hageman JC, et al. Infection With Vancomy-
cin-Resistant Staphylococcus aureus Containing the vanA Resist-
ance Gene. N Engl J Med. 2003. 348:1342–7.
Drew RH. Emerging Options for Treatment of Invasive, Multidrug-Re-
sistant Staphylococcus aureus Infections. Pharmacotherapy. 2007.
27:227–49.
Graham PL 3rd, Lin SX, Larson EL. A U.S. Population-Based Sur-
vey of Staphylococcus aureus Colonization. Ann Intern Med. 2006.
144:318–25.
Liu C, Bayer A, Cosgrove SE, et al. Clinical Practice Guidelines by the
Infectious Diseases Society of America for the Treatment of Methi-
cillin-Resistant Staphylococcus aureus Infections in Adults and Chil-
dren: Executive Summary. Clin Infect Dis. 2011. 52:285–92.
Talan DA, Krishnadasan A, Gorwitz RJ, et al. Comparison of Staphy-
lococcus aureus from Skin and Soft-Tissue Infections in US Emer-
gency Department Patients, 2004 and 2008. Clin Infect Dis. 2011.
53:144–9.
von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal Carriage
as a Source of Staphylococcus aureus Bacteremia. N Engl J Med.
Wenzel RP, Edmond MB. Vancomycin-Resistant Staphylococcus
aureus: Infection Control Considerations. Clin Infect Dis. 1998.
27:245–9.
Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, Edmond
MB. Nosocomial Bloodstream Infections in US Hospitals: Analysis
of 24,179 Cases from a Prospective Nationwide Surveillance Study.
Clin Infect Dis. 2004. 39:309–17.
Hidron AI, Edwards JR, Patel J, et al. NHSN Annual Update: Anti-
microbial-Resistant Pathogens Associated with Healthcare-Associ-
ated Infections: Annual Summary of Data Reported to the National
Healthcare Safety Network at the Centers for Disease Control and
Prevention, 2006–2007. Infect Control Hosp Epidemiol. 2008.
29:996–1011.
Centers for Disease Control and Prevention (CDC). Antibiotic Resist-
ance Threats in the United States, 2013. Available online at: www.
cdc.gov/drugresistance/threat-report-2013. (Accessed 1 October
2013).
Huang SS, Septimus E, Kleinman K, et al. Targeted Versus Univer-
sal Decolonization to Prevent ICU Infection. N Engl J Med. 2013.
368:2255–65.
292 A Guide to Infection Control in the Hospital
- 2001. 344:11–6.
Chapter 44
Enterococcal Species
Michael P. Stevens, MD, MPH, and
Michael B. Edmond, MD, MPH, MPA
Key Issue
Enterococci are important health care associated pathogens
because: 1) they are normal flora in the human gastrointestinal
tract, 2) antimicrobial resistance allows for their survival in an
environment with heavy antimicrobial usage, 3) they contami-
nate the hospital environment and survive for prolonged periods
of time, and 4) contamination of the hands of healthcare work-
ers coupled with poor hand washing compliance provides the
potential for spread in the hospital.
Known Facts
Enterococci are common health care associated pathogens,
accounting for 12% of all healthcare associated infections.
The organism is of relatively low virulence but may be dif-
ficult to treat in the compromised host, particularly when
multidrug resistant.
Resistance to nearly every known antibiotic has been
described for various strains of enterococci.
The vanA gene, which confers high-level vancomycin resis-
tance in enterococci, has been detected in Staphylococcus
aureus strains in a small number of patients in the United
States.
Vancomycin resistance due to vanC is intrinsic and found in
E. casseliflavus and E. gallinarum. vanC organisms do not
appear to be epidemiologically important, and isolation of
patients harboring these organisms is not necessary.
Currently 30% of all enterococcal isolates in the United
States involved in HAIs are resistant to vancomycin. How-
ever, the two most common species display marked variabil-
ity in vancomycin susceptibility, with 77% of E. faecium and
9% of E. faecalis isolates resistant to vancomycin.
Enterococcal Species 293
Risk factors for acquisition of vancomycin resistant entero-
cocci (VRE) include prior use of antimicrobial agents (van-
comycin, third generation cephalosporins, antianaerobic
drugs), length of hospital stay, enteral feedings, intraabdom-
inal surgery, presence of a decubitus ulcer, high colonization
pressure, and severity of illness.
Patient populations at highest risk for VRE colonization and
infection include dialysis patients, organ transplant patients,
patients with hematologic malignancies, and bone marrow
transplant patients. Studies have found that approximately
30% of patients following liver transplantation are colonized
with VRE, of whom over 25% develop infection. Up to 40%
of allogeneic hematopoietic stem cell transplant patients are
colonized, of whom over 33% develop VRE bloodstream
infections in the early period post-transplant.
Treatment with antianaerobic drugs has been shown to pro-
mote high density colonization.
Colonization of the GI tract with VRE is typically of long
duration, in some cases persisting for years.
Rectal swab cultures for VRE have suboptimal sensitivity.
Colonization of healthy healthcare workers in the United
States is unusual.
Risk factors for VRE bacteremia include neutropenia, gas-
trointestinal colonization, and hematologic malignancy.
VRE colonization is highly prevalent in some long-term care
facilities, which serve as reservoirs of resistant organisms
for importation into acute care facilities. However, morbid-
ity due to VRE in the nursing home population is low.
Controversial Issues
Treatment of VRE infections is problematic. Therapy should
include drainage of localized infections, when possible.
Daptomycin, a cyclic lipopeptide, is bactericidal against
VRE. Quinupristin/dalfopristin may be clinically useful for
the treatment of infections due to E. faecium but is inactive
against E. faecalis. Linezolid has good activity against VRE
and an advantage is its 100% oral bioavailability, allowing
for oral therapy. Quinupristin/dalfopristin, linezolid, and
tigecycline are bacteriostatic against enterococci. Resistance
has been detected for all three of these agents.
294 A Guide to Infection Control in the Hospital
A few reports have described attempts to decolonize the gas-
trointestinal tract of VRE but results have been suboptimal.
Ramoplanin has been shown to suppress carriage of VRE,
but following discontinuation of the drug, the organism can
again be detected in the stool.
Infection control controversies include the effectiveness of
active surveillance cultures and subsequent isolation of col-
onized patients to control health care associated transmis-
sion, whether drugs that suppress GI colonization result in
decreased health care associated transmission and whether
vancomycin restriction leads to decreased rates of VRE
infection and colonization.
Suggested Practice
Prudent use of antimicrobial drugs
For patients with VRE infection or colonization:
– Place in private room or cohort with other VRE infected/
colonized patients. Gloves and gowns should be worn on
entering the patient’s room.
– Strict compliance with hand washing is critical—a med-
icated hand washing agent (e.g., chlorhexidine or alco-
hol-based hand rub) should be used.
– Noncritical items (e.g., stethoscopes, thermometers, etc.)
should be left in the patient’s room.
– Isolation can be discontinued when three stool cultures,
each one week apart, are all negative.
– Phenolic and quaternary ammonium disinfectants are
effective against VRE; however, adequate contact time is
essential.
Summary
Enterococci are ubiquitous gram-positive cocci that are part of
the normal flora of humans and other animals. Infections caused
by enterococci include urinary tract infections, abdominal-
pelvic infections, wound (especially decubitus ulcers and
diabetic foot) infections, and endocarditis.
Strains of enterococci have acquired resistance to virtually
all available antimicrobial agents. In general, antimicrobial
resistance has been more problematic for E. faecium than
E. faecalis.
Enterococcal Species 295
The prevalence of vancomycin resistance among the
enterococci has reached high levels. In 1989, less than 0.5%
of enterococcal isolates from ICU and non-ICU settings were
vancomycin resistant. Currently, 30% of all enterococcal iso-
lates involved in HAIs in the United States are vancomycin
resistant. However, when stratified by species, E. faecium iso-
lates demonstrate a markedly higher proportion of vancomycin
resistance than E. faecalis isolates.
Numerous case-control studies have evaluated risk factors
for the development of colonization and/or infection with VRE.
A variety of antimicrobial agents have been implicated and
include vancomycin, ceftazidime, aminoglycosides, ciprofloxa-
cin, aztreonam, and antianaerobic drugs. Other risk factors have
included severity of illness, length of hospital stay, hematologic
malignancy or bone marrow transplantation, and mucositis.
Colonization of the GI tract has been shown to be a risk factor
for the development of VRE bacteremia. Environmental con-
tamination with VRE is common, especially when the patient
has diarrhea.
To control VRE in the hospital setting, we recommend plac-
ing colonized/infected patients in a private room. Gloves and
gowns should be worn on entering the patient’s room, and strict
attention paid to hand hygiene. In addition, there should be no
sharing of noncritical items (i.e., BP cuffs, stethoscopes, etc.,
should remain in the patient’s room). Housekeeping staff should
wipe down all horizontal surfaces in VRE patient rooms daily.
In addition to infection control measures, controlling VRE
requires prudent use of antibiotics. Vancomycin should be
avoided for routine surgical prophylaxis unless high rates of
MRSA exist. Vancomycin should also be avoided for the treat-
ment of a single positive blood culture growing coagulase-neg-
ative staphylococci if contamination is likely. Vancomycin
should not be used for selective gut decontamination or for rou-
tine prophylaxis of low-birth weight infants, continuous ambu-
latory peritoneal dialysis patients, or intravascular catheters.
296 A Guide to Infection Control in the Hospital
References
de Bruin MA, Riley LW. Does Vancomycin Prescribing Intervention
Affect Vancomycin-Resistant Enterococcus Infection and Coloniza-
tion in Hospitals? A Systematic Review. BMC Infect Dis. 2007. 7:24.
DeLisle S, Perl TM. Vancomycin-Resistant Enterococci: A Road Map
on How to Prevent the Emergence and Transmission of Antimicro-
bial Resistance. Chest. 2003. 123:504S–518S.
Hayden MK. Insights into the Epidemiology and Control of Infection
with Vancomycin-Resistant Enterococci. Clin Infect Dis. 2000.
31:1058–1065.
McNeil SA, Malani PN, Chenoweth CE, et al. Vancomycin-Resistant
Enterococcal Colonization and Infection in Liver Transplant Candi-
dates and Recipients: A Prospective Surveillance Study. Clin Infect
Dis. 2006. 42:195–203.
Rice LB. Emergence of Vancomycin-Resistant Enterococci. Emerg
Infect Dis. 2001. 7:183–187.
Weinstock DM, Conlon M, Iovino C, et al. Colonization, Bloodstream
Infection, and Mortality Caused by Vancomycin-Resistant Entero-
coccus Early After Allogeneic Hematopoietic Stem Cell Transplant.
Biol Blood Marrow Transplant. 2007. 13:615–621.
Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, Edmond
MB. Nosocomial Bloodstream Infections in US Hospitals: Analysis
of 24,179 Cases from a Prospective Nationwide Surveillance Study.
Clin Infect Dis. 2004. 39:309–317.
Hidron AI, Edwards JR, Patel J, et al. NHSN Annual Update: Anti-
microbial-Resistant Pathogens Associated with Healthcare-Associ-
ated Infections: Annual Summary of Data Reported to the National
Healthcare Safety Network at the Centers for Disease Control and
Prevention, 2006–2007. Infect Control Hosp Epidemiol. 2008.
29:996–1011.
Centers for Disease Control and Prevention (CDC). Antibiotic Resist-
ance Threats in the United States, 2013. Available online at: http://
www.cdc.gov/drugresistance/threat-report-2013/ (Accessed 1 Octo-
ber 2013).
Enterococcal Species 297
Chapter 45
Pneumococcus
Roman Pallares, MD, and Imma Grau, MD
Key Issues
Streptococcus pneumoniae (pneumococcus) remains a major
pathogen worldwide, mainly in young children (<5 years),
adults with immunosuppressive or chronic diseases as well as
smokers and alcohol abusers, and older adults (>=65 years).
Pneumococcal disease is more common in developing coun-
tries, and occurs more often during winter and early spring. In
recent years, important changes in the epidemiology of pneu-
mococcal infections have been observed:
pneumococci which make pneumococcal infections
elderly and in young adults with serious underlying diseases
in patients admitted to healthcare institutions and nursing
homes, childcare centers, and other closed institutions (e.g.,
jails, military camps). Several of these infections appeared
as outbreaks due to antibiotic-resistant pneumococci; and
incidence of pneumococcal infections after the introduction
of 7-valent pneumococcal conjugate vaccine (PCV7) in
children.
Infection control measures for preventing pneumococcal
infections in hospital and healthcare settings, and nursing home
facilities have not been widely considered in the literature.
Known Facts
Streptococcus pneumoniae is the leading cause of community-
acquired pneumonia, otitis media, sinusitis, exacerbation of
298 A Guide to Infection Control in the Hospital
chronic bronchitis and adult meningitis. Patients with severe
pneumonia or meningitis may have a mortality rate of about
20–30%.
Pneumococcus is transmitted from person-to-person by
close contact and can colonize the nasopharynx of healthy
people. The prevalence of nasopharyngeal colonization varies
widely with age as well as environmental and seasonal con-
ditions. Thus, the nasopharyngeal carrier rates in children are
approximately 30–50%, and over 95% of them were initially
colonized before the age of 2. The pneumococcal serotypes that
colonize the nasopharynx in children show a high rate of antibi-
otic resistance. In adults, the rates of nasopharyngeal pneumo-
coccal colonization decrease to approximately 5–10%.
Several studies have shown a link between age and suscep-
tibility to pneumococcal infection, with an incidence peak in
children aged less than 2 and another one in elderly people.
Pneumococcal disease in young adults occurs mainly in patients
with underlying conditions (e.g., chronic and immunosuppres-
sive diseases, smoking, high alcohol intake).
Failure to produce antibodies is a determining factor for the
susceptibility to pneumococcal infection, and it occurs mainly
in patients with multiple myeloma, chronic lymphocytic leuke-
mia and lymphoma, as well as in HIV-infected patients. Patients
with splenectomy, diabetes mellitus, malnutrition, chronic renal
failure, chronic liver disease, heart failure, chronic obstructive
pulmonary disease (COPD), asthma, smoking and high alcohol
intake are also at risk of pneumococcal infection.
A previous viral infection, mainly due to influenza virus, is
a major predisposing condition of pneumococcal pneumonia.
Viral infections modify the local defense mechanisms of the
respiratory tract, contributing to nasopharyngeal colonization
and facilitating the entrance of microorganisms into the pul-
monary alveolus. Other processes that modify the local defense
mechanisms of the respiratory tract such as chronic bronchitis,
allergic conditions, and smoke or toxic inhalation may also pre-
dispose to pneumococcal pneumonia.
The pneumococcus can be transmitted among persons in
closed institutions. For example, children attending day care
centres have an increased risk of pneumococcal nasopharyngeal
Pneumococcus 299
colonization and pneumococcal infections; this increased risk
also occurs in adults who live with these young children. The
spread of Streptococcus pneumoniae leading to colonization or
infection has been documented in hospitalized patients, in nurs-
ing home residents as well as in persons admitted to military
camps and prisons and other closed communities, being likely
to cause epidemic outbreaks.
The emergence of antibiotic resistance in pneumococci has
become a problem worldwide. Resistance to penicillins, cepha-
losporins as well as to macrolide and fluoroquinolones has been
increasingly reported. Prior antibiotic use and health care asso-
ciated acquisition of the infection are important risk factors for
antibiotic-resistant pneumococcal infection.
Controversial Issues
Little is known about the prevalence of nasopharyngeal car-
riage and the modes of transmission of Streptococcus pneumo-
niae among hospitalized patients or nursing home residents.
Moreover, there is little information regarding pneumococcal
infections occurring in the hospital setting. It is often difficult
to differentiate between endemic health care associated pneu-
mococcal infections and small outbreaks in hospitals. Studies
on serotypes and clones may help to identify the pneumococcal
strains causing outbreaks in the hospital.
While it is well known that health-care workers (HCWs) can
transmit infections to patients, the extent to which this occurs
for Streptococcus pneumoniae is less appreciated. We can
hypothesize the following modes of transmission:
mococcus. This may occur when the HCW is a nasopha-
ryngeal carrier and has close contact with the patient using
tory secretions (sputum or saliva). In this case, HCWs can
disseminate the pneumococcus through contact with con-
taminated material when using inappropriate barrier precau-
tions (e.g., gloves, gowns, masks); and
coccus in overcrowded hospitals and long-term care institu-
tions where space and ventilation are inappropriate.
300 A Guide to Infection Control in the Hospital
Once colonized, hospitalized patients are at risk for pneumo-
coccal infections when:
immunity, chronic pulmonary conditions, and other debili-
cocci; and
pharyngeal tubes) or surgical procedures (e.g., surgery of
abdominal cavity, lungs, and head and neck).
Recent studies of health care associated pneumonia have
found that Streptococcus pneumoniae, among other gram-posi-
tive cocci, is increasingly recognised as an important agent.
Health care associated pneumococcal pneumonia can be
classified into two categories:
require emergent tracheal intubation (e.g., head trauma with
low level of consciousness). This infection is usually caused
by the own patient’s flora (previous pneumococcal carriers),
and the intubation process spreads the pneumococcus into
the lower respiratory tract.
patients undergoing surgery, who are immunosuppressed
or debilitated, as well as in intubated patients in ICUs. This
is more often caused by drug-resistant strains. Other health
care associated pneumococcal infections may include:
health care associated sinusitis in patients with nasogastric
tube; meningitis after otic surgery or neurosurgery; and
post-surgical intra-abdominal infection.
Few data are available regarding the global burden of
pneumococci in health care associated pathogens. In our insti-
tution (Hospital Bellvitge, University of Barcelona) among
all episodes of pneumococcal bacteremia, about 10–15% are
health care associated. In addition, Streptococcus pneumo-
niae accounted for 1–2% of all health care associated bactere-
mias, and for 10–15% of all health care associated bacteremic
pneumonias.
Suggested Practices
The hospital epidemiologist and infection control practitioners
should know the target population at high risk for pneumococcal
Pneumococcus 301
infections (see Controversial Issues), and identify possible out-
breaks caused by multiple antibiotic resistant strains in the hos-
pital setting. It is fundamental for the microbiology laboratory
to conduct a surveillance of all pneumococcal isolates and their
antibiotic susceptibility and to study, when necessary, serotypes
and clones.
Infection control measures for health care associated pneu-
mococcal infections have not been widely established. In order
to properly implement these measures, we should consider the
following:
Although it is thought that transmission of pneumococci in
the hospital is uncommon, the application of isolation measures
and barrier precautions could be necessary, particularly when
an outbreak caused by multiple antibiotic-resistant strains is
detected. During an outbreak, these patients should be isolated
in a single room, and HCWs should ensure the following infec-
tion control measures: appropriate hand washing and correct
utilization of gloves, gowns and masks when in contact with
respiratory secretions. In addition, disinfection of respiratory
equipment should be strengthened.
During an outbreak caused by a multi-resistant pneumococ-
cal strain in a closed institution, the screening of nasopharyn-
geal carriers could be appropriate. However, the administration
of antibiotics to persons in contact with infected patients to
eradicate the carriers is a controversial issue.
Prudent use of antibiotics is essential to prevent the emer-
gence of resistant pneumococci. Prolonged use of beta-lactams,
particularly at low doses, is associated with carriage of peni-
cillin resistant pneumococci in children. Thus, antibiotics may
produce a selective pressure of pneumococci harbouring in the
nasopharynx, eliminating the susceptible strains and emerging
the resistant ones, mostly concentrated in a few serotypes and
clones. The appropriate use of antibiotics is particularly import-
ant in the hospital setting, nursing homes and other closed
institutions where the emergence and spread of resistant pneu-
mococcal clones is easier.
302 A Guide to Infection Control in the Hospital
Prevention of pneumococcal infection by means of vaccina-
tion programs is essential. The use of PPV-23 may prevent the
development of pneumococcal bacteremia in adults, but it is not
immunogenic in children. Recently, the use of conjugate pneu-
mococcal vaccines (PCV7, PCV9, and PCV13)) in children has
been associated with a decreased incidence of pneumococcal
disease. However, it is not well elucidated if these vaccines pro-
duce a permanent reduction of carriers or if there would be a
replacement with serotypes not included in the vaccine. Future
vaccine developments including the pneumococcal surface
proteins, which are non-serotype dependent, may substantially
improve the current options.
Summary
Streptococcus pneumoniae is increasingly reported as a
pathogen causing infections in hospitals, healthcare settings
and nursing homes. These infections are often due to multiple
antibiotic resistant pneumococcal serotypes and are likely to
appear as small outbreaks. Therefore, it is mandatory for the
microbiology laboratory to survey all invasive pneumococcal
isolates together with their antibiotic susceptibility and study of
serotypes and clones whenever necessary.
Currently, there is scarce information about the prevalence
of pneumococcal carriers and the transmission mechanisms
of Streptococcus pneumoniae in hospitals and nursing homes.
Besides, infection control measures to prevent endemic and epi-
demic health care associated pneumococcal infections have not
been properly undertaken. However, compliance with barrier
precautions, prudent use of antibiotics in the hospital setting and
the administration of pneumococcal vaccine should be strength-
ened when an outbreak is suspected.
Since the introduction of pneumococcal conjugate vaccines
in children, there has been a decline in the incidence of invasive
pneumococcal disease. However, there are some preliminary
data suggesting that emergence of virulent clones of non-vac-
cine serotypes may be a problem in the near future. Epidemio-
logical surveillance is essential to evaluate the best vaccination
strategy in different patient populations.
Pneumococcus 303
References
Nuorti JP, Butler JC, Crutcher JM, et al. An outbreak of multidrug-resis-
tant pneumococcal pneumonia and bacteremia among unvaccinated
nursing home residents. N Engl J Med. 1998. 338(26):1861–1868.
Cimolai N, Cogswell A, Hunter R. Nosocomial transmission of peni-
cillin-resistant Streptococcus pneumoniae. Pediatr Pulmonol. 1999.
27(6):432–434.
Bresnitz E, Grant C, Ostrawski S, et al. Outbreak of pneumococcal
pneumonia among unvaccinated residents of a nursing home—New
Jersey. JAMA. April 2001. 286(13):1570–1571.
Weiss K, Restieri C, Gauthier R, et al. A nosocomial outbreak of fluo-
roquinolone-resistant Streptococcus pneumoniae. Clin Infect Dis.
Melamed R, Greenberg D, Landau D, et al. Neonatal nosocomial pneu-
mococcal infections acquired by patient-to-patient transmission.
J Infect Dis. 2002. 34(5):385–386.
Tan CG, Ostrawski S, Bresnitz EA. A preventable outbreak of pneu-
mococcal pneumonia among unvaccinated nursing home residents
in New Jersey during 2001. Infect Control Hosp Epidemiol. 2003.
24(11):848–852.
Subramanian D, Sandoe JAT, Keer V, et al. Rapid spread of penicil-
lin-resistant Streptococcus pneumoniae among high-risk hospital
inpatients and the role of molecular typing in outbreak confirmation.
J Hosp Infect. 2003. 54(2):99–103.
Bouza E, Pintado V, Rivera S, et al. Nosocomial bloodstream infections
caused by Streptococcus pneumoniae. Clin Microb Infect. 2005.
11(11):919–924.
Whitney CG, Pilishvili T, Farley MM, et al. Effectiveness of seven-
valent pneumococcal conjugate vaccine against invasive pneu-
mococcal disease: A matched case-control study. Lancet. 2006.
368(9546):1495–1502.
Lyytikainen O, Klemets P, Ruutu P, et al. Defining the population-based
burden of nosocomial pneumococcal bacteremia. Arch Intern Med.
Pallares R, Liñares J, Vadillo M, et al. Resistance to penicillin and ceph-
alosporin and mortality from severe pneumococcal pneumonia in
Barcelona, Spain. N Engl J Med. 1995. 333(8):474–80.
Guillet M, Zahar JR, Timsit MO, et al. Horizontal transmission of Strep-
tococcus pneumoniae in the surgical ward: A rare source of nosoco-
mial wound infection. Am J Infect Control. 2012. 40(1):71–72.
304 A Guide to Infection Control in the Hospital
- 1. The emergence and spread of multiple antibiotic-resistant
- (e.g., meningitis) difficult to treat;
- 2. The increasing prevalence of pneumococcal disease in the
- (e.g., HIV, malignancies);
- 3. The increasing recognition of pneumococcal infections
- 4. In the last decade (2000s), there was a reduction in the
- 1. From HCWs to patients by exhaling or coughing the pneu-
- inadequate precautions;
- 2. From patient to patient by means of contaminated respira-
- 3. From patient to patient by exhaling or coughing the pneumo-
- 1. They suffer from serious underlying diseases with impaired
- tating diseases;
- 2. They receive antibiotics which may select resistant pneumo-
- 3. They undergo instrumentations (e.g., endotracheal or naso-
- 1. Early pneumonia (<5 days) occurs mainly in patients who
- 2. Late pneumonia (>= 5 days) may occur more often in
- 1. Compliance with barrier precautions;
- 2. Prudent use of antibiotics; and
- 3. Use of pneumococcal vaccination.
- 2001. 33(4):517–522.
- 2007. 167(15):1635–1640.
Chapter 46
Legionella
Marc Struelens, MD, PhD
Key Issue
Health care associated legionellosis (also called Legionnaires’
disease) is a serious pneumonia caused by inhalation of Legio-
nella in aerosols from a contaminated hospital water system.
Prevention should be based on a risk management plan includ-
ing targeted surveillance for cases, adequate design and mainte-
nance of water distribution system and adherence to appropriate
respiratory care practices.
Known Facts
Legionella cause up to 10% of health care associated pneu-
monias; depending on the country, surveillance data indicate
that 2 to 15% of cases of legionellosis are health care associ-
ated. Cases may occur sporadically or as epidemics.
The majority of cases are caused by Legionella pneumoph-
ila, with over 80% caused by L. pneumophila serogroup 1.
The mortality is 10–15% and is increased by a delay in diag-
nosis and starting specific antimicrobial treatment.
Legionella sp are part of the normal flora of fresh water bod-
ies and proliferate to high concentrations as biofilms in man-
made hot water systems with a temperature of 25–42˚C.
Hospitals with contaminated water systems are at increased
risk of health care associated legionellosis.
Transmission to hospitalized patients occurs most frequently
by inhalation of aerosols generated by using outlets (faucets,
shower) of a heavily contaminated domestic water system
and less commonly by direct bronchial instillation during
respiratory care using tap water.
Risk factors for transmission include the concentration of
Legionella in water, the virulence of the strain, the extent of
aerosol exposure and patient immune status.
Legionella 305
Patients at increased risk are those under immunosuppresion,
particularly organ transplant recipients, treated with cortico-
steroids, male, elderly, smokers and those with chronic lung
diseases.
Diagnosis requires the use of special methods, including cul-
ture of respiratory secretions on special media, detection of
urinary antigen (L. pneumophila serogoup 1 mainly), serol-
ogy and PCR.
Most outbreaks were reported in hospitals with extensive
contamination (>30% positive outlets) and high concentra-
tion (>103/L) of Legionella in water.
Health care associated outbreaks can be controlled effec-
tively once the source is identified and adequate water disin-
fection is carried out (shock treatment followed by long-term
suppressive measures).
Controversial Issues
The true incidence of health care associated legionellosis is
unknown due to under-diagnosis and under-reporting.
The predictive value of monitoring the concentration of
Legionella in hospital water systems is undefined, due to
non-standardization of sampling, wide temporal variation in
bacterial concentration over time and variation in patients’
exposure and susceptibility in different institutions. Public
authorities in different countries have issued various norms
of maximal Legionella concentration for hospital water sys-
tems (ranging from 101 to 104 /L).
The optimal methods of water disinfection including ther-
mal disinfection (>60˚C), hyper-chlorination, ultra-violet
light, copper-silver ionization, monochloramine and chlo-
rine dioxide treatment have not been defined.
Suggested Practice
Each hospital should develop and implement a Legionella
Risk Management Plan, with the assistance of Manage-
ment, Technical Plant, Microbiology and Infection Control
departments.
This plan is composed of the following parts: (1) plan &
technical description of the water systems, and identification
306 A Guide to Infection Control in the Hospital
of weak points (eg, temperature below 55˚C, stagnation,
corrosion); (2) bacteriological survey of Legionella contam-
ination of the system; (3) analysis of patients population at
risk and surveillance for cases of pneumonia; (4) risk control
measures and maintenance of the systems to prevent cases or
control transmission after a cluster of cases, if any.
Surveillance for cases of Legionella pneumonia should use
the combination of at least two diagnostic methods such as
culture and urinary antigen tests.
Prevention and control measures should aim at reducing the
proliferation of Legionella and avoiding the generation of
aerosols. Codes of good engineering practice exist in most
countries and should be consulted. The main rules are to
ensure water temperature <20˚C or >50˚C, regular water cir-
culation and cleanliness of the system.
The selection and operation of a water treatment program
including Legionella disinfection should be made by com-
petent technical services. Microbiological water monitoring
is useful to assess the efficacy of the program.
Respiratory care and flushing of naso-gastric tubing should
be done with sterile water.
The detection of sporadic or cluster of cases of health care
associated legionellosis should prompt an immediate inves-
tigation to identify the source of contamination. Genotyping
Legionella isolates from cases and the suspected environ-
mental source is useful to confirm the source. Shut down
the suspected source and disinfect it or remove the aerosol
producing equipment. Consider general shock treatment of
water system if it is extensively contaminated.
References
Exner M, Kramer A, Lajoie L, Gebel J, Engelhart S, Hartemann P.
Prevention and Control of Healthcare-Associated Waterborne Infec-
tions in Healthcare Facilities. Am J Infect Control. 2005. 33(Suppl
5):S26–40.
O’Neill E, Humphreys H. Surveillance of Hospital Water and Primary
Prevention Of Nosocomial Legionellosis: What Is The Evidence?
J Hosp Infect. 2005. 59:273–9.
Legionella 307
Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. CDC: Health
care Infection Control Practices Advisory Committee, Guidelines for
Preventing Healthcare-Associated Pneumonia. 2003; Recommen
dations of CDC and the Healthcare Infection Control Practices Advi-
sory Committee. MMWR. 2004. 53(RR-3):1–36.
Kim BR, Anderson JE, Mueller SA, et al. Literature Review—Efficacy
of Various Disinfectants Against Legionella in Water Systems. Water
Res. 2002. 36:4433–44.
Health and Safety Commission 2000. Legionnaires’ Disease. The
Control of Legionella Bacteria in Water Systems. Approved Code
of Practice and Guidance L8. Sudbury, UK: HSE Books. ISBN
0-7176-1772-6.
CDC. Legionellosis—United States, 2000–2009. MMWR. 2011.
60:1083–6.
Irons JF, Dunn MJ, Kefala K, et al. The Effect of a large Legionnaires’
Disease Outbreak in Southwest Edinburgh on Acute and Critical
Care Services. QMJ. 2013. 106:1087–94.
308 A Guide to Infection Control in the Hospital
Chapter 47
Carbapenem-resistant
E nterobacteriaceae
Eva-Brigitta Kruse, MD and Hilmar Wisplinghoff, MD
Key Issues
Carbapenem-resistant Enterobacteriaceae (CRE), especially
carbapenem-resistant Escherichia coli and Klebsiella pneu-
moniae, are increasingly prevalent pathogens in hospitalized
patients and can cause a variety of infections such as urinary
tract infections, wound infections and respiratory tract infec-
tions. Their importance derives from the fact that they can
spread rapidly in the hospital setting, and that they are com-
monly multi-drug resistant, leaving few therapy options.
Known Facts
Enterobacteriaceae like E. coli, Klebsiella spp., Enterobacter
spp., Citrobacter spp. or Proteus spp. are gram-negative rods
that can be part of the normal enteric flora. Previous antibiotic
therapy, underlying systemic illness, and prolonged hospital
stays have been identified as risk factors for colonization of
patients with carbapenem resistant strains. The use of cathe-
ters and mechanical ventilation (MV) is also associated with
an increased risk of CRE colonization. In addition, CRE can
be transmitted through direct contact with contaminated sur-
faces, colonized or infected patients, or more frequently by
the hands of health care workers and other hospital personnel.
Some species, such as Klebsiella spp., have demonstrated a pro-
pensity to cause large health care associated outbreaks. Since
most Enterobacteriaceae are part of the normal intestinal flora,
asymptomatic colonization with CRE is common, however, as
with other resistant organisms, CRE colonization increases the
risk of CRE infection. This is of special importance in neonates,
ICU patients and immunocompromised patients.
Carbapenem-resistant Enterobacteriaceae 309
The prevalence of CRE varies widely between different spe-
cies and different geographical regions. In the US, carbapen-
em-resistance rates are quoted as 0.1% and 5.3% for E. coli and
K. pneumoniae, respectively, while in Europe, most countries
report resistance rates below 1% for both pathogens. However,
local and regional differences can be enormous: All over the
world, several regions have been identified where CRE are
endemic, e.g. in Greece, parts of South-east Asia or the north-
eastern region of the USA. Even in settings where resistance
rates are still low, a steady rise over the past decade has been
observed.
Depending on the virulence of the particular pathogen, the
site of colonization, and a variety of host-related factors, CRE
can cause nearly all kinds of infections, most commonly uri-
nary tract infections, pneumonia (usually ventilator-associated
(VAP)), wound infections or bloodstream infections. As CRE
are commonly multi-drug resistant, comprehensive antimicro-
bial susceptibility testing is mandatory and treatment should be
adapted accordingly.
In most countries, scientific societies and/or public health
agencies have published guidelines and recommendations on
how to handle CRE colonization and infection, and how to pre-
vent transmission and limit spread. These can be used as a basis
and should be adapted to local circumstances to implement an
effective programme in the hospital or other health care facilities.
Controversial Issues
Generally, there are currently only limited data available on a
number of important issues regarding detection, management
and treatment of CRE. There is currently no generally agreed
recommendation for the laboratory detection of carbapenem
resistance. Currently available methods include screening
via routine antibiotic susceptibility testing using ertapenem,
meropenem or faropenem and/or the cultivation of bacteria on
different CRE-selective media. For confirmation, several meth-
ods including the modified Hodge test, inhibitor-based assays,
molecular methods or mass spectrometry (MALDI-TOF) may
be used. Molecular methods, while having a high specificity and
sensitivity, are currently not widely used in the routine detection
due to various practical and financial issues.
310 A Guide to Infection Control in the Hospital
The impact of routine surveillance cultures throughout the
hospital stay is currently not supported by strong evidence and
therefore not generally recommended. They may, however, be
useful during outbreak situations and in high-risk patients with
prolonged hospital stays.
While cohorting patients and staff in an outbreak setting
seems to be beneficial, it is uncertain if the spread of CRE in
non-outbreak situations can be successfully limited by these
practices as well.
There is currently no decolonization strategy with proven
efficacy, even though attempts have been made to eradicate
CRE from the gastrointestinal tract through selective diges-
tive decontamination. The long-term effectiveness and adverse
effects of this approach, especially in an endemic setting, are
unclear so that it is not a generally recommended measure.
Similarly, daily chlorhexidine bathing has been performed to
contain outbreaks, but its value in eradicating CRE and limiting
spread is still under investigation.
Suggested Practice
Identify high-risk patients on admission to the hospital
and/or on admission to high-risk areas such as intensive
care units. High-risk patients should include those from
regions, countries or institutions where CREs are endemic,
patients with a recent history of CRE colonization, and those
who have had a recent contact with a known CRE carrier
(e.g. shared a hospital room).
Screen high-risk patients on admission to the hospital.
Pre-emptive single-room isolation should be performed until
a negative screening result is confirmed.
Work together with a laboratory that uses fast and accurate
methods for CRE detection and is able to provide rapid noti-
fication of the results. Early identification is vital both for
effective therapy and infection control measures.
Notify the hospital infection control team if transmission
on the ward is suspected and suggest appropriate control
measures, including potentially additional screening on the
ward affected.
Carbapenem-resistant Enterobacteriaceae 311
Observe hand hygiene as suggested by the WHO at all times,
with all patients, and with all procedures. Of special importance
are hand disinfection before and after contact with a patient
and his or her surroundings, and the correct use of gloves.
Use full contact precautions for CRE patients, including the
wearing of gowns and gloves and single-room isolation. If
care in a single room is not possible, at least provide a sep-
arate toilet for the patient and perform barrier precautions at
the bedside.
Perform daily decontamination of the patient environment,
using effective disinfectants. Single-use equipment should
be preferred where possible. All other equipment must be
properly decontaminated before use on another patient.
Restrict the use of devices (venous catheters, urinary catheters
etc.) as far as possible and review their need on a daily basis.
Implement an antimicrobial stewardship programme in the
hospital to improve antimicrobial therapy and decrease the
development of resistance and therefore colonization pressure.
Make sure all staff are aware of the standard hygiene mea-
sures and additional barrier precautions and know when
monitoring of compliance with infection control measures
is recommended. CRE measures should be part of a compre-
hensive institutional infection control program.
Be aware of national guidelines and notification systems as
appropriate. If CRE patients are transferred to other hospi-
tals or care facilities, ensure CRE status is communicated
before transfer.
Summary
Carbapenem resistance has increased in all regions of the world
over the past decade. Colonization and infection rates are rising
and have reached endemic levels in some regions. Although there
is little specific evidence for many infection control measures,
there is agreement on the general components of an adequate
control programme. These include surveillance and rapid identi-
fication of CRE carriers, barrier precautions for all CRE patients
(single-room care, wearing protective equipment), adherence to
hand hygiene and standard hygiene regimes, safe and effective
312 A Guide to Infection Control in the Hospital
disinfection measures, education, and continuous training of
all staff, organizational awareness of the problem of multi-drug
resistant organisms and the implementation of appropriate infec-
tion control and antimicrobial stewardship programmes.
References
CDC. CDC National Center for Emerging and Zoonotic Infectious
Diseases, Division of Healthcare Quality Promotion. Guidance
for Control of Carbapenem-Resistant Enterobacteriaceae (CRE).
2012 CRE Toolkit. http://www.cdc.gov/hai/organisms/cre/cre-
toolkit/index.html (Accessed 19 August 2013).
Swaminathan M, Sharma S, Poliansky Blash S, et al. Prevalence and
Risk Factors for Acquisition of Carbapenem-Resistant Enterobacte-
riaceae in the Setting of Endemicity. Infect Control Hosp Epidemiol.
CDC. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. MMWR.
Glasner C, Albiger B, Buist G, et al. for the European Survey on Car-
bapenemase-Producing Enterobacteriaceae (EuSCAPE) working
group. Carbapenemase-producing Enterobacteriaceae in Europe: A
survey among national experts from 39 countries. Eurosurveillance.
February 2013. 18(28):pii=20525.
Hara G, Gould I, Endimiani A, Pardo P, Daikos G, Hsueh P, et al.
Detection, treatment, and prevention of carbapenemase-producing
Enterobacteriaceae: Recommendations from an International work-
ing group. J Chemother. 2013. 25:129–40
Mattner F, Bange FC, Meyer E, Seifert H, Wichelhaus TA, Chaberny IF.
Preventing the spread of multidrug-resistant gram-negative patho-
gens: Recommendations of an expert panel of the German Society for
Hygiene and Microbiology. Dtsch Arztebl Int. 2012. 109(3):39–45.
Robert-Koch-Institut, Kommission für Krankenhaushygiene und Infek-
tionsprävention (KRINKO). Hygienemaßnahmen bei Infektionen
oder Besiedlung mit multiresistenten gramnegativen Stäbchen.
http://www.rki.de/DE/Content/Infekt/Krankenhaushygiene/Kom-
mission/Downloads/Gramneg_Erreger.pdf;jsessionid=C958194A6
A51315CB103A63FCCCF05F7.2_cid372?__blob=publicationFile.
(Accessed 19 August 2013).
WHO. WHO Guidelines on Hand Hygiene in Health Care.
http://whqlibdoc.who.int/hq/2009/who_ier_psp_2009.07_eng.pdf.
(Accessed 19 August 2013).
Kruse EB, Aurbach U, Wisplinghoff H. Carbapenem-Resistant Entero-
bacteriaceae: Laboratory Detection and Infection Control Practices.
Curr Infect Dis Rep. October 12, 2013.
Carbapenem-resistant Enterobacteriaceae 313
Chapter 48
Bacterial Enteric Pathogens :
C lostridium difficile, Salmonella,
Campylobacter, Shigella,
Escherichia coli and others
Olivier Vandenberg, MD, PhD, Michèle Gerard, MD
and Awa Aidara Kane, PhD,
Key Issue
Clostridium difficile, Salmonella, Campylobacter, Shigella,
Escherichia coli, Yersinia enterocolitica, Vibrio cholerae, and
Vibrio parahaemolyticus are among the various agents which
may cause acute gastrointestinal infections in long-term care
facility residents and health care workers.
Known Facts
Clostridium difficile-associated diarrhea (CDAD) a very
common health care associated infection, is associated with
substantial morbidity and mortality and imposes an import-
ant financial burden on healthcare institutions. Three steps
are necessary for the development of CDAD: distortion of
the normal faecal flora (usually by antibiotics), acquisition
of the pathogen (i.e., Clostridium difficile), and toxin pro-
duction by the Clostridium difficile strain. Risk is modified
by host susceptibility factors including older age, manipu-
lation of the gastrointestinal tract (enemas, surgery), che-
motherapy, laxative use, antiperistaltic drugs, length of
hospital stay, and rate of endemic disease in the hospital.
Clostridium difficile persistently contaminates the hospital
environment through the formation of spores that persist for
prolonged periods. The hands of hospital workers have been
documented to be contaminated frequently by Clostridium
difficile following contact with patients who are asymptom-
atically colonized or who have CDAD, or by contact with
the environment of these patients. Clostridium difficile has
314 A Guide to Infection Control in the Hospital
been transmitted by commodes, bathing tubs for neonates
and rectal thermometers.
Salmonellosis is the most commonly reported foodborne
disease resulting from improperly handled animal and poul-
try products. Ninety-two percent of all cases are due to raw
or partially cooked eggs but undercooked poultry, beef, and
pork also are significant sources. Contamination may occur
either during food processing by contact with animal prod-
ucts/faeces, or during food preparation from food handlers.
Chronic carriers of Salmonella pose a particular risk for
transmitting this infection.
In developing countries, nontyphoid Salmonella spp are
increasingly important health care associated pathogens,
causing septicemia in children. Most of these Salmonella
spp are resistant to multiple antibiotics. The dissemination
of these resistant strains occurs from person-to-person. The
majority of outbreaks have occurred in neonatal and paedi-
atric wards, but community outbreaks in villages have also
been reported.
Campylobacter is one of most commonly recognised causes
of bacterial gastroenteritis in man. Raw or inadequately
heat-treated milk and inadequately treated water have been
incriminated as sources of massive outbreaks of infection.
Direct transmission is mainly occupational (farmers, butchers,
abattoir workers, poultry processors), but domestic animals
can bring infection into ordinary homes. Inter-human trans-
mission has been described infrequently in young children.
Health care associated spread within neonatal units has been
observed on rare occasions. The putative causes of these out-
breaks were an inadequately disinfected communal baby bath
and an incubator that was not disinfected between babies.
Shigellosis is one of the most common causes of gastro-
enteritis. Transmission is due to improper handwashing and
inadequate toilet facilities and occurs via food items such as
soups, salads, and sandwiches; however, person-to person
spread and transmission by flies may also occur, since few
organisms are necessary to cause disease. After ingestion of
a very low inoculum (< 100 of shigella organisms), patients
typically present with dysentery and fever. Patients are
infectious during the acute infection and until the organism
is no longer present in the faeces.
Bacterial Enteric Pathogens 315
Enterohemorrhagic Escherichia coli (EHEC), particularly
E.coli serotype O 157:H7, is the leading cause of hemor-
rhagic colitis and hemolytic uremic syndrome (HUS).
EHEC infections have been associated with the ingestion of
contaminated hamburgers, milk, water, fruit, and vegetables.
However person-to person transmission is possible.
Transmission of enterotoxigenic E.coli (ETEC) occurs mainly
by food and water. It rarely occurs from person—to person.
Enteropathogenic Escherichia coli (EPEC) is an infrequent
cause of outbreaks of diarrhoea in hospitalised infants.
Enteroaggregative Escherichia coli is an emergent entero-
pathogen which has been associated with both health care
associated and community outbreaks worldwide.
Vibrio cholerae is transmitted primarily via contaminated
water and by the ingestion of contaminated shellfish. Per-
son-to-person spread is uncommon. Hospital workers rarely
contract the disease.
Vibrio parahaemolyticus is a common pathogen in countries
where raw and undercooked seafood is consumed. Symp-
toms can vary but patients usually present with nausea, vom-
iting, and cramps. Fever and chills sometimes can occur.
Yersinia enterocolitica is a common cause of enterocolitis in
children in developed countries. It is characterized by either
watery or bloody diarrhoea with abdominal pain and fever.
Improperly cooked pork and milk are the main sources of
transmission. Health care associated transmission occurs
very rarely.
Controversial Issues
Gastroenteritis caused by bacterial pathogens often may be
confused with enteric infections caused by parasitic, fungal,
or viral agents.
The decision whether or not to use antibiotics or antimotility
drugs is difficult in the absence of specific laboratory diag-
nosis of the bacterial pathogens.
Indiscriminate treatment with antibiotic agents or antimotility
drugs may create serious problems by encouraging the devel-
opment of multi-drug resistant bacteria or chronic carriers.
316 A Guide to Infection Control in the Hospital
The incidence of acute gastroenteritis caused by enteric
pathogens is greatly underestimated in many locations
because of limited surveillance, limited laboratory facilities
to diagnose the common bacterial agents, or both.
Suggested Practice
Most bacterial enteric pathogens are transmitted by direct
contact. Effective handwashing practice is the most import-
ant measure to prevent transmission. Additional interven-
tions include:
Hand hygiene after glove use is essential and often
tion of rectal thermometers between use by different
patients, proper disinfection of endoscopes, proper
terminal disinfection of rooms and surface disinfection
commode.
Food service personnel must be very careful about personal
hygiene, working habits, and their health. All health care
and food service personnel with an acute diarrhoeal illness
should stop working until diarrhoea has resolved.
Antibiotics should not be routinely used to prevent transmis-
sion. When antibiotics are used to treat patients, appropriate
doses and duration of therapy should be used.
Adequate laboratory facilities are mandatory allowing all
enteric bacteria isolated from health care associated infec-
tions to be well characterized. Establishing a provisional
microbiology laboratory is also a valuable tool to investigate
and control outbreaks even in remote areas.
Bacterial Enteric Pathogens 317
Summary
A wide variety of organisms may cause outbreaks in long-term
facilities (Clostridium difficile, Salmonella, Campylobacter,
Shigella, Escherichia coli O157:H7, and others). Gastroenteritis
caused by these different groups of bacteria is a leading cause
of morbidity and mortality in developing countries. However,
difficulty in identifying certain enteric pathogens in many labo-
ratories leads to marked under-reporting.
The majority of the gastrointestinal pathogens are transmit-
ted through the faecal-oral route. These pathogens can survive
in soil, water, and food. Outbreaks are frequently related to
ingestion of contaminated food or water and occur more fre-
quently in developing countries. Improvements in hygiene and
socio-economic conditions can dramatically reduce the trans-
mission of these organisms.
Many studies from the developing world have emphasized
the emerging importance of multidrug-resistant Salmonella spp
as health care associated pathogens in children. The clinical
microbiologist should be responsible for the identification of
all isolates of health care associated infections and work effec-
tively with all other members of the infection control committee
to identify and control outbreaks.
References
Knight CL, Surawicz CM. Clostridium difficile Infection. Med Clin
North Am. 2013. 97:523–36.
Wadula J, von Gottberg A, Kilner D, de Jong G, Cohen C, Khoosal M,
Keddy K, Crewe-Brown H. Nosocomial outbreak of extended–spec-
trum beta-lactamase-producing Samonella isangi in pediatric wards.
Pediatr Infect Dis J. 2006. 9:843–844.
Vandenberg O, Skirrow MB, Butzler JP. Campylobacter and Arcobac-
ter in Topley and Wilson’s Microbiology and Microbiolial Infections
(10th Edition), Boriello SP, Murray PR, Funke G (Eds). London:
Hodder Arnold, ASMA Press, 2005. Pgs. 1541–1590.
Villaseca JM, Hernández U, Sainz-Espuñes TR, Rosario C, Eslava
C. Enteroaggregative Escherichia coli an emergent pathogen with
different virulence properties. Rev Latinoam Microbiolo. 2005.
47:140–159.
Murni I, Duke T, Triasih R, Kinney S, Daley AJ, Soenarto Y. Preven-
tion of nosocomial infections in developing countries, a systematic
review. Paediatr Int Child Health. 2013. 33:61–78.
318 A Guide to Infection Control in the Hospital
- and how to perform them. Regular training is important;
- 2013. 34(8):809–17.
- 2013. 62(9):165–70.
- 1. Glove use when handling faecally contaminated items.
- forgotten;
- 2. Improvements in hygiene and socio-economic conditions;
- 3. Safe water supply and sanitary disposal of faecally
- contaminated materials;
- 4. Environmental interventions including proper disinfec-
- with hypochlorite;
- 5. Thorough cooking of food; and
- 6. Isolation of ill persons with personal sanitary or
Chapter 49
Other Enterobacteriaceae
Heike von Baum, MD, Constance Wendt, MD
Key Issue
Enterobacteriaceae (other than enteropathogenic Salmonella,
Shigella, and E. coli) are important health care associated patho-
gens. Hundreds of different types of beta-lactamases including
extended spectrum beta-lactamases (ESBL) have been charac-
terized in multiresistant Enterobacteriaceae. A new challenge
is the worldwide spread of carbapenemase-producing and thus
panresistant Enterobacteriaceae (CRE). Most prominent are
carbapenemase-producing Klebsiella pneumoniae (KPC) as
well as New Delhi metallo-ß-lactamase (NDM) or OXA-48 car-
bapenemase positive strains. Multiresistant Enterobacteriaceae
have emerged as significant health care associated pathogens
and are frequently isolated from urine, respiratory secretions
and wounds.
Known Facts
In an endemic situation, colonization or infection among
hospitalised patients results primarily from the patients’
preexisting indigenous flora.
Hospital transmission of Enterobacteriaceae frequently
involves the hands of healthcare workers or contaminated
inanimate surfaces.
Outbreaks of multiresistant Enterobacteriaceae have been
linked to understaffing, overcrowding and poor hygiene
practices in the hospital.
Colonization with Enterobacteriaceae predisposes the
hospitalized patient for health care associated infections.
Risk factors for acquiring (multiresistant) Enterobacteriaceae
are severity of illness, mechanical ventilation (MV) and
presence of indwelling devices.
CRE acquisition outside of healthcare institutions has been
linked to food products, travel to high risk areas and medical
tourism.
Other Enterobacteriaceae 319
Patients with CRE bacteremia have high mortality rates
(up to 50%) due to limited treatment options.
Alcohol-based hand rubs are the most efficacious agents for
reducing the number of Enterobacteriaceae on the hands of
healthcare providers.
Controversial Issues
The impact of antibiotic restriction on the emergence and
spread of multiresistant Enterobacteriaceae in the hospital
is under investigation. Several studies examined the effect
of restricted use of antibiotics particularly third-generation
cephalosporins and carbapenems on the prevalence of
resistant Enterobacteriaceae offering conflicting results.
Many patients are colonized with (multiresistant)
Enterobacteriaceae at the time of admission to ICUs. Thus
it remains controversial whether policies confined to ICUs
or selected departments have an impact on the overall
prevalence of Enterobacteriaceae. Several studies have
shown a low rate of hospital transmission of ESBL producing
Enterobacteriaceae (susceptible to carbapenems) except for
specific high risk areas e.g. NICUs.
Detection of ESBL producing Enterobacteriaceae remains a
challenge for the microbiology laboratory. Routine methods
may fail to identify all ESBL producing strains. Laboratory
detection and reporting have to be improved according to
approved standards e.g. the NCCLS guidelines.
Detection of CRE has been facilitated by removing the
requirement for carbapenemase testing through a change in
the definition of susceptibility breakpoints.
Suggested Practice
Prevention of Transmission
Strict hand hygiene.
Identification and elimination of environmental sources.
Multiresistant Strains
– Isolation of patients colonized or infected with CRE.
– Consider isolation of colonized or infected patients with
ESBL producing strains (susceptible to carbapenems) in
specific high risk areas.
320 A Guide to Infection Control in the Hospital
– Contact precautions: gowns, gloves, and single-use or ded-
icated equipment.
– Education of staff and evaluation of nursing care practices.
– Increase nurse-to-patient ratio, if feasible.
– Screen high-risk patients for CRE at admission.
– Screen epidemiologically linked cases to CRE patients.
Outbreak Situation
– Cohort patients and healthcare providers.
– Consider chlorhexidine bathing of CRE patients.
– Identify further colonized and/or infected patients.
– Intensify communication with microbiology laboratory.
– Review the antibiotic policy of the affected wards.
– Contact the Health department and discuss public health
support.
Prevention of the Evolution of Colonization with
Enterobacteriaceae to Infection:
Discontinue the use of indwelling devices as soon as possible.
Promote antibiotic stewardship.
For specific recommendations concerning enteropathogenic
Enterobacteriaceae, bladder catheterisation, ventilators, and
preoperative patient care, see the appropriate chapter.
Summary
The predominant genera of Enterobacteriaceae are Escherichia,
Klebsiella, Enterobacter, Citrobacter, Proteus, Serratia, Salmo-
nella and Shigella. Enteric pathogens are not discussed in this
chapter.
Colonization of the gastrointestinal tract and less frequently
the respiratory tract is common in non-hospitalized patients.
Colonized patients in the hospital have a significantly increased
risk to develop an infection. Hospital transmission occurs via
the hands of healthcare workers or via contaminated equipment
and supplies.
Since 1983, the prevalence of Gram-negative rods pro-
ducing extended-spectrum-ß-lactamases (ESBL) has steadily
increased. A recent threat is the worldwide spread of carbap-
enemase producing, panresistant strains (CRE). Outbreaks
have been described most frequently with ESBL-producing
Other Enterobacteriaceae 321
Klebsiella or multiresistant Enterobacter strains. Identification
of ESBL-producing Enterobacteriaceae and CRE remains diffi-
cult due to the limited sensitivity of diagnostic standard proce-
dures in the microbiology laboratory.
References
Centers for Disease Control and Prevention: Guideline for Hand
Hygiene in Health—Care Settings. MMWR. 2002. 51(RR-16):1–47.
Clinical and Laboratory Standards Institute (CLSI). Performance Stand-
ards for Antimicrobial Susceptibility Testing. Twenty Second Infor-
mational Supplement (January 2012), CLSI document M 100-S22.
Wayne, Pennsylvania, 2012.
Harbarth S, Sudre P, Dharan S, et al. Outbreak of Enterobacter cloacae
Related to Understaffing, Overcrowding, and Poor Hygiene Prac-
tices. Infect Control Hosp Epidemiol. 1999. 20:598–603.
Centers for Disease Control and Prevention: Guidance for Control of
Carbapenem-resistant Enterobacteriaceae (CRE) 2012 CRE Toolkit
http://www.cdc.gov/hai/organisms/cre/cre-toolkit/index.html.
Ben-David D, Maor Y, Keller N, et al. Potential role of active sur-
veillance in the control of a hospital-wide outbreak of carbape-
nem-resistant Klebsiella pneumoniae infection. Infect Control Hosp
Epidemiol. 2010. 31:620–626.
Gupta N, Limhago BM, Patel JB, Kallen AJ. Carbapenem-resistant
Enterobacteriaceae: Epidemiology and Prevention. Clin Infect Dis.
Marchaim D, Chopra T, Bhargava A, et al. Recent exposure to anti-
microbials and carbapenem-resistant Enterobacteriaceae: The role
of antimicrobial stewardship. Infect Control Hosp Epidemiol. 2012.
33:817–830.
Tschudin-Sutter S, Frei R, Dangel M, et al. rate of transmission of
extended-spectrum beta-lactamase-producing Enterobacteriaceae
without contact isolation. Clin Infect Dis. 2012. 55:1505–1511.
322 A Guide to Infection Control in the Hospital
- 2011. 53:60–67.
Chapter 50
Pseudomonas aeruginosa
H. Wisplinghoff, MD, and Harald Seifert, MD
Key Issue
Pseudomonas aeruginosa is an important health care associated
pathogen that causes serious health care associated infections
and contributes significantly to morbidity and mortality.
Known Facts
P. aeruginosa is an aerobic Gram-negative rod that can
be isolated from soil, water, plants, animals and humans,
where it is uncommonly encountered as part of the normal tran-
sient flora. Human colonization occurs mostly at moist sites
such as perineum, axilla and the ear. High concentrations of
P. aeruginosa, among other pathogens, may also be found in
the subungual areas of the hands.
Even though colonization in healthy individuals outside the
hospital is rare, colonization rates may exceed 50% in patients
with severe burns (skin), on mechanical ventilation (MV)
(lower respiratory tract), receiving chemotherapy (GI-tract) or
antimicrobial agents (any site).
Minimal nutritional requirements, the ability to grow in
distilled water, and tolerance against a wide range of physical
conditions contribute to the success of this opportunistic patho-
gen. Hospital reservoirs are predominantly moisture-associated
and include sinks, showers, respiratory equipment, IV fluids,
disinfectants, food mixers and vegetables. Outbreaks have been
traced to a variety of sources including respiratory therapy
equipment, endoscopes, contaminated mattresses, disinfectants,
contaminated water supplies, iv solutions and environmental
sources such pools used for physical therapy or hydrotherapy.
P. aeruginosa is the overall fifth most common health care
associated pathogen, with a crude mortality ranging from 28%
(ward) to 48% (ICU) in patients with health care associated
bloodstream infection. Clinical manifestations include mostly
Pseudomonas aeruginosa 323
nosocomial or healthcare associated infections such as pneumo-
nia (second most common cause of health care associated pneu-
monia), urinary tract infections (UTI, fourth), wound infections
(surgical, fourth), bone and joint infections, and bloodstream
infection (BSI, seventh), but also infections that are usually
community-acquired such as gastrointestinal infections, skin
and soft tissue infections, bacterial keratitis or (“malignant”)
otitis externa. A different clinical entity is lower respiratory
tract infection in CF patients. Increasing resistance of P. aeru-
ginosa to many commonly used antimicrobial agents leading to
multi-drug resistant (MDR) strains often leaves few therapeutic
options. Repeated susceptibility testing is warranted, due to the
potentially rapid development of resistance to certain antimi-
crobial agents.
This organism is also a major cause of infection in highly
compromised patients especially patients with cystic fibrosis
(CF), neutropenia (and other immunosuppressive conditions) or
severe burns.
Controversial Issues
Data on the impact of common environmental sources or patient-
to-patient transmission on morbidity due to P. aeruginosa
are still limited. The original source of the organism and the
mode of transmission are often difficult to assess in an outbreak
situation.
Suggested Practice
Adherence to standard infection control guidelines should limit
the spread of P. aeruginosa. However, special attention is war-
ranted in high-risk patients and hospital environments with
endemic P. aeruginosa. Measures include:
Hand disinfection between patient contacts using antiseptic
agents (e.g., chlorhexidine or alcohol-based disinfectants).
Wearing gloves when attending a patient, especially in venti-
lated patients, patients with severe burns and patients known
to be colonized with P. aeruginosa.
Mechanical cleaning of all medical equipment before ster-
ilization, especially equipment used for mechanical ventila-
tion (MV) and endoscopes.
Proper sterilization of all respiratory therapy equipment
including nebulizers and resuscitation bags.
324 A Guide to Infection Control in the Hospital
Using sterile fluids for nebulizers and preventing contamina-
tion of medication nebulizers and humidifiers.
Using sterile water instead of tap water to rinse tracheal suc-
tion catheters.
Avoiding the use of stock solutions for preparation of IV
fluids.
Avoiding the re-usage of a previously opened vial of water
or sodium chloride solution for injection.
Appropriate handling and storage of medical solutions.
Surveillance, i.e. monitoring the prevalence of P. aerugi-
nosa, especially of MDR strains.
Detecting and eliminating potential reservoirs of cross-
transmission.
If a cluster of infections due to P. aeruginosa is detected, poten-
tial reservoirs including all medical solutions such as IV flu-
ids and sterile water should be screened in order to quickly
detect and eliminate a potential reservoir. High-risk patients
such burn-patients and immunocompromised patients should
be monitored closely so that appropriate infection control mea-
sures can be implemented early.
Summary
P. aeruginosa is a major cause of health care associated infec-
tions that affects all patient populations and contributes signifi-
cantly to morbidity and mortality. Colonization usually precedes
manifest clinical infection. P. aeruginosa has been found to be
an independent predictor of mortality in some studies of health
care associated bloodstream infection.
Outbreaks have been traced to contaminated solutions (tra-
cheal irrigate, mouthwash, iv-fluids), water, disinfectants and
inadequately disinfected or sterilized endoscopes, ventilators or
contaminated mesh grafts in burn patients but have also been
linked to direct transmission via the hands of hospital person-
nel. Important measures of prevention include the detection and
elimination of potential reservoirs, especially moist areas, the
appropriate storage and handling of medical solutions, the mon-
itoring of high-risk patients such as ICU- or burn-patients and
the immediate investigation of detected clusters of infections
due to P. aeruginosa.
Pseudomonas aeruginosa 325
References
Wisplinghoff H, et al. Nosocomial Bloodstream Infections in United
States Hospitals: Analysis of 24,179 Cases from a Prospective
Nationwide Surveillance Study. Clin Infect Dis. 2004. 39:309–17.
Kang, C-I, et al. Clinical Features and Outcome of Patients with Com-
munity-Acquired Pseudomonas aeruguinosa Bacteraemia. Clin
Microbiol Infect. 2006. 11:415–418.
Wisplinghoff H, Seifert H. Pseudomonas aeruginosa, Acinetobacter
baumannii and other non-fermenting gram-negative bacilli in Cohen,
Powderly & Opal: Infectious Diseases. 2010.
Jefferies JM, et al. Pseudomonas aeruginosa outbreaks in the neonatal
intensive care unit—A systematic review of risk factors and environ-
mental sources. J Med Microbiol. 2012. 61:1052–61.
Otter JA, et al. The role played by contaminated surfaces in the trans-
mission of nosocomial pathogens. Infect Control Hosp Epidemiol.
Kerr KG, Snelling AM. Pseudomonas aeruginosa: A formidable and
ever-present adversary. J Hosp Infect. 2009. 73:338–44.
Tamma PD, et al. Combination therapy for treatment of infections with
gram-negative bacteria. Clin Microbiol Rev. 2012. 25:450–70.
Fujitani S, et al. Pneumonia due to Pseudomonas aeruginosa: Part I: Epi-
demiology, clinical diagnosis, and source. Chest. 2011. 139:909–19.
326 A Guide to Infection Control in the Hospital
- 2011. 32:687–99.
Chapter 51
Helicobacter pylori
Veronique Y. Miendje Deyi, PharmD, PhD,
and Anne Dediste, MD
Key Issue
Helicobacter pylori (H. pylori) is the most prevalent chronic
bacterial infection in humans, colonizing the stomach of approx-
imately 50% of the world’s population. Appropriate cleaning
and disinfection (called reprocessing procedures) of endoscopes
is mandatory to avoid health care associated transmission.
Known Facts
H. pylori infection is associated with peptic ulcer disease,
dyspepsia, idiopathic thrombocytopenic purpura, iron
deficiency anemia, low-grade gastric Mucosa-Associated
Lymphoid Tissue (MALT) lymphoma and non-cardiac
gastric cancer.
Most persons infected with H. pylori are asymptomatic.
H. pylori is commonly acquired in childhood, and in devel-
oping countries the prevalence of H. pylori infection is as
high as 50% by the age of 5 years.
The rate of acquisition is higher in developing countries.
In industrialized countries, H. pylori transmission has
decreased over the last years, but lower socioeconomic sta-
tus and household hygiene practices are key factors leading
to a higher prevalence of colonization.
Treatment is strongly recommended in peptic ulcer disease
and low-grade MALT lymphoma when H. pylori is present.
Iatrogenic transmission of H. pylori by upper gastrointesti-
nal endoscopy has been documented but is nowadays limited
in developed countries due to the use of single-use biopsy
forceps and traceability of reprocessing of the endoscopes.
Helicobacter pylori 327
H. pylori is susceptible to most commonly used high level
disinfectants and, therefore, iatrogenic inoculation of the
bacterium by endoscopy is unlikely if appropriate reprocess-
ing procedures are strictly adopted.
Controversial Issues
Humans are the natural reservoir of H. pylori. The patho-
gen is spread mainly through person-to-person transmission,
either by fecal-oral or oral-oral routes. However, at least
three other possible vectors have been suggested as possible
routes of transmission: water, food and animals.
Risk factors for infection include overcrowded households,
institutionalization, low education of the parents, poor sani-
tation and poor water supply but both positive and negative
studies have been published around these issues.
There is no evidence to suggest that asymptomatic patients
should be treated. It is reported that H. pylori colonization
may confer protection against several disorders including
esophageal diseases, asthma and allergic disorders.
In developing countries, presumptive treatment seems to be
followed by recurrence in many cases. Reinfection is also
not infrequent in developed countries.
There is increasing evidence to suggest that H. pylori plays
a role in modulating systemic disease processes.
A recent meta-analysis including 15 studies demonstrated an
increased risk of H. pylori infection among gastroenterology
personnel.
Active or passive immunization is important for future pre-
vention efforts; unfortunately, research in vaccine develop-
ment is still unsuccessful.
Suggested Practice
Wear personal protective equipment (gloves, gowns, mask
and protective eyewear) during potentially contaminating
procedures such as endoscopy, exposure to patient’s secre-
tions (feces, vomitus, gastric aspirates) and when possibly
contaminated objects (syringes, biopsy forceps, pH elec-
trodes) are handled.
328 A Guide to Infection Control in the Hospital
Strictly observe reprocessing procedures of gastrointesti-
nal endoscopes and biopsy forceps as well as endotherapy
devices (if not single-use) between patients.
Wash instruments before disinfecting them.
Use an appropriate disinfectant.
Leave endoscopes in the disinfectant as long as
recommended.
If single-use biopsy forceps are not available, wash them
before sterilization as well as devices breaching the gastric
mucosa, because they are regarded as critical items.
Summary
Overwhelming evidence now confirms that H. pylori is
a worldwide infection and plays a major etiologic role in the
development of chronic superficial gastritis and peptic ulcer
disease. H. pylori infection is also strongly associated with
distal gastric adenocarcinoma and MALT lymphoma. The bac-
terium colonizes 25 to 50% of the general population in devel-
oped countries while in most developing countries colonization
rates can be as high as 80 to 90%, especially in poor socioeco-
nomic and sanitary conditions. Most infected persons tend to be
asymptomatic, with only a minority (3–15%) developing peptic
ulceration and even fewer gastric cancers (<3%).
How exactly H. pylori is transmitted and spreads in the com-
munity remains unclear. The human stomach is the only sub-
stantial reservoir of H. pylori that has been identified thus far,
and the bacterium is believed to spread through person-to-per-
son transmission. Both fecal-oral and oral-oral routes of trans-
mission have been substantiated in different studies. On the one
hand, the fecal-oral route is supported by both the presence of
H. pylori in feces, although rarely detected and epidemiological
evidence gathered in developing countries. On the other hand,
the presence of the bacterium in gastric juice, dental plaque
and saliva supports the assumption of an oral-oral transmis-
sion route. Indeed, African mothers feeding their infants with
pre-masticated food have been identified as a risk factor for H.
pylori infection in young children and several studies showed an
increasing risk of infection within gastroenterology personnel.
Helicobacter pylori 329
Nevertheless both routes of transmission may co-exist, and
besides, new potential reservoirs of H. pylori have now been
identified, such as nonhuman primates, cats, flies, and environ-
mental sources such as water.
The third and least common route of H. pylori transmission
is iatrogenic inoculation of strains from one patient to another
through a contaminated endoscope. Fiberoptic endoscopic
examination of the gastrointestinal tract is known to result in
iatrogenic transmission of infectious agents, such as Salmonella
spp, Pseudomonas spp, Acinetobacter spp and viruses. Since
the proportion of individuals positive for H. pylori is about
half the world’s population, the potential for endoscopic con-
tamination with H. pylori and further iatrogenic transmission is
high. Several studies have shown that endoscopes and biopsy
forceps readily get contaminated after endoscopic examina-
tion of H. pylori-positive patients. Iatrogenic transmission of
the bacterium has been estimated to occur in 4/1000 endosco-
pies when the infection rate in the population is about 50% but
reprocessing (disinfection) and traceability has been improved.
H. pylori has been found in vitro to be sensitive to common
chemical disinfectants within 15 to 30 seconds, but a strict min-
imum of 10 min immersion is recommended. It is important to
note that cleaning with soap and water and rinsing with alcohol
have proved to be insufficient to decontaminate endoscopes and
biopsy forceps. Cleaning followed by the use of 2% glutaralde-
hyde (or automated peracetic acid or chlorine dioxide 30 ppm)
has been shown to effectively prevent H. pylori transmission.
A number of guidelines for cleaning endoscopes have been
published. Endoscopes are classified by Spaulding as semicrit-
ical items, and should at least undergo high-level disinfection.
Accessories such as biopsy forceps (if not single use) that breach
the mucosa, are regarded as critical devices and therefore must
be mechanically cleaned and then sterilized after each use.
How medical equipment should be disinfected is detailed
elsewhere in this guide, and only a few points related to upper
gastrointestinal endoscopy will be described here:
As the status of the patient is often not known, all patients
should be considered as potentially contaminated and,
hence, the material used to treat them should be subjected to
the same procedure.
330 A Guide to Infection Control in the Hospital
Every endoscopic procedure should be performed with a
clean, disinfected endoscope.
Endoscopic units must have written guidelines for decon-
tamination and traceability.
Manual brushing of the endoscope surface, valves, all inter-
nal channels (they should be thoroughly flushed with water
and detergent), and endoscopic accessories (biopsy forceps,
pH electrodes) must be done immediately after each patient
to prevent secretions from drying. This step is mandatory
before the disinfection process (even if an automated washer
is used). Water, mechanical action, and suitable detergents or
enzymatic products are used.
Disinfection: the endoscope should be immersed in 2% glu-
taraldehyde or other equivalent chemical disinfectant. All
channels must be filled with the disinfectant. A 20-minute
exposure time is recommended to achieve high-level dis-
infection. However, if this is impracticable due to turnover
pressure and when Mycobacterium tuberculosis is not sus-
pected, an immersion of 10 to 20 minutes is usually consid-
ered acceptable.
It is then necessary to rinse the instruments with preferably
sterile water, internally and externally to remove all traces
of disinfectant, as glutaraldehyde and most chemical disin-
fectants can have serious side effects. If tap water is used,
rinsing the external surface as well as all channels with 70%
alcohol and thoroughly drying them with compressed air are
recommended.
Alternatively, automatic wash machine endoscope can be
used after manual brushing to wash, disinfect and rinse the
endoscopes.
In all cases, drying the channels with compressed air will
prevent bacteria from growing in a moist environment.
The equipment should be stored with care and it is best to
hang the endoscopes to drain any excess water in channels
(especially in areas where forced air drying is not possible).
In conclusion, although much more understanding of the exact
ways of transmission of Helicobacter pylori in the community
is needed to develop specific guidelines to limit the spread of
Helicobacter pylori 331
the infection in the general population, it is clear already that
thorough cleaning and disinfection schedules can prevent iat-
rogenic transmission of common bacterial (including H. pylori)
and viral infections from one patient to the next one through
contaminated endoscopes.
References
Akamatsu T, Tabata K, Hironga M, et al. Transmission of Helicobacter
pylori Infection via Flexible Fiberoptic Endoscopy. Am J Infect Con-
trol. 1996. 24:396–401.
Azevedo NF, Guimarães N, Figueiredo C, Keevil CW, Vieira MJ. A
New Model for the Transmission of Helicobacter pylori: Role of
Environmental Reservoirs as Gene Pools to Increase Strain Diver-
sity. Crit Rev Microbiol. 2007. 33:157–169.
Cover TL, Blaser MJ. Helicobacter pylori in health and disease. Gastro-
enterology. May 2009. 136:1863–73.
Ford AC, Axon ATR. Epidemiology of Helicobacter pylori infection
and public health implications. Helicobacter. 2010. 15(Suppl 1):1–6.
Koletzko S, Jones NL, Goodman KJ, Gold B, Rowland M, Cadranel
S, Chong S, Colletti RB, Casswall T, Elitsur Y, Guarner J, Kalach
N, Madrazo A, Megraud F, Oderda G; H pylori Working Groups
of ESPGHAN and NASPGHAN. Evidence-based guidelines from
ESPGHAN and NASPGHAN for Helicobacter pylori infection in
children. J Pediatr Gastroenterol Nutr. August 2011. 53(2):230–43.
Malfertheiner P, Megraud F, O’Morain C, et al. Management of Hel-
icobacter pylori infection: The Maastricht IV/Florence Consensus
Report. Gut 2012. 61:646–664.
Mandeville KL, Krabshuis J, Ladep NG, Mulder CJ, Quigley EM, Khan
SA. Gastroenterology in developing countries: Issues and advances.
World J Gastroenterol. June 21, 2009. 15(23):2839–54.
Nelson DB, Muscarella LF. Current Issues in Endoscope Reprocessing
and Infection Control During Gastrointestinal Endoscopy. World J
Gastroenterol. 2006. 12(25):3953–3964.
Peters C, Schablon A, Harling M, et al. The occupational risk
of Helicobacter pylori infection among gastroenterologists
and their assistants. BMC Infectious Diseases. 2011. 11:154
doi:10.1186/1471-2334-11-154.
Rutala WA, Weber DJ. Sterilization, high-level disinfection, and envi-
ronmental cleaning. Infect Dis Clin North Am. 2011. 45–76.
Suerbaum S, Michetti P. Helicobacter pylori Infection. N Engl J Med.
332 A Guide to Infection Control in the Hospital
Chapter 52
Fungi
Sergio B. Wey, MD
Key Issue
The incidence of health care associated fungal infections has
increased in recent years, and antibiotic resistance is an issue in
some hospitals.
Known Facts
The incidence of candidemia is higher in critical-care units
than in other parts of the hospital. In developed countries, it
is the 4th leading cause of bloodstream infections.
The overall incidence of nosocomial fungemia has increased,
with most cases involving Candida species, and many such
infections are related to the use of intravascular catheters.
Most cases of nosocomial fungemia found in intensive care
unit patients are not associated with recognized immune
defense defects.
Fungemia is associated with a high short-term mortality rate.
It is already well documented that Candida infections, even
candidemia, can be transmitted on the hands of colonized
healthcare personnel.
The evidence for cross infection by Candida, particularly in
ICUs, has increased in the literature.
The incidence of Candida non-albicans infections is increas-
ing, and they tend to be more resistant to azoles than C. albi-
cans strains.
There is a strong relationship between Candida parapsilosis
fungemia or systemic infection and hyperalimentation using
intravascular devices.
C. glabrata has emerged as an important cause of candidemia,
especially among neutropenic patients who have received
fluconazole prophylaxis.
Fungi 333
Invasive candidiasis is usually caused by dissemination of
endogenous Candida species that have colonized a patient’s
gastrointestinal tract.
Up to 25% of episodes in the ICU of catheter-related UTI
are caused by different species of Candida. Candiduria is
especially common in patients receiving prolonged urinary
catheterization and broad-spectrum systemic antimicrobial
agents.
In breakthrough candidemia, the same risk factors seen in de
novo candidemia are encountered, although more frequently.
C. glabrata and C. krusei are the leading causes of breakthrough
candidemia in patients with cancer.
Hospital construction and renovation have been associated
with an increased risk for health care associated fungal
infection, particularly Aspergillosis, among severely immu-
nocompromised patients.
Controversial Issues
The role of susceptibility testing as a guide to selecting
appropriate therapy for all of these infections is still incom-
pletely defined.
The ideal population of ICU patients who would benefit
from antifungal prophylaxis. In part, the existing endemic
rate of candidemia is important in decision-making.
The efficacy of antibiotic prophylaxis for patients who
demonstrate colonization with Candida is undocumented.
No antimicrobial regimen has been reported to be clearly
effective in preventing aspergillosis. Further studies are
needed to determine the optimal strategy for aspergillosis
prevention.
Whether the hospital water-distribution system could be a
reservoir for airborne molds that leads to secondary aerosol-
ization of these molds in patient shower facilities.
Suggested Practice
Proper use of antibiotics and strict protocols for invasive
procedures.
Define therapy based on yeast identification.
334 A Guide to Infection Control in the Hospital
The most important infection control measures for the
prevention of fungal colonization of indwelling intravas-
cularcatheters are quite similar to those recommended for
bacterial infections. Standard practice in the treatment of
candidiasis is to remove existing intravascular catheters for
patients with candidemia or acute hematogenously dissemi-
nated candidiasis, especially in nonneutropenic patients.
Antifungal therapy is necessary in all cases of vascular cath-
eter-related candidemia.
Tunneled CVCs or implantable devices should be removed
in the presence of documented catheter-related fungemia.
The removal of all central venous catheters from all patients
with candidemia is considered to be standard care.
Bone marrow allogeneic recipients should be administered
antifungal prophylaxis to prevent invasive disease with
Candida species during neutropenia. The choice of drug will
depend on the level of fluconazole resistance and the risk of
Aspergillus.
Hospital construction or renovation areas should have nega-
tive air pressure relative to that in adjacent patient care areas,
if no contraindications exist for such pressure differential.
Patients with fungal infections of their catheters should be
monitored for dissemination.
Summary
The past three decades have witnessed major changes in hos-
pital populations and in the technology used in healthcare. As
some of these patients are highly susceptible to infection. These
patients often have diseases and complications that require the
use of invasive techniques for both monitoring and treatment.
Candida and Aspergillus are responsible for the vast major-
ity of health care associated fungal infections. However,
severalother species can cause infection in debilitated hospital-
izedpatients such as: Trichosporum, Fusarium, etc.
Fungemia is associated with a high short-term mortality rate.
The crude mortality is 40%. The attributable mortality due to
health care associated candidemia has been estimated to be half
or more of the crude mortality.
Fungi 335
Several studies have identified risk factors for the devel-
opment of health care associated fungemia. Among the clini-
cal characteristics that most consistently increase this risk are
neutropenia, use of wide-spectrum antibiotics, bone marrow or
solid organ transplant, diabetes, severe burns, premature birth,
hyperalimentation, antecedent surgery (especially abdominal
surgery), and indwelling catheters.
other risk factors are renal impairment, and multisite candidal
colonization, all of which are common in ICU patients.
It has been well documented that transmission of Candida
can occur via the hands of colonized healthcare personnel.
There have been several candidemia outbreaks in different
patient populations. Many of these were associated with cross
transmission by the hands of hospital personnel.
There is a strong relationship between Candida parapsilosis
fungemia, or systemic infection, and hyperalimentation using
intravascular devices. In fact, the adherence of C. parapsilosis
to plastic materials exceeds that of C. albicans.
There in increased variation in the proportion of cases due
to C. albicans relative to those caused by non-albicans species.
As is the case with antibacterial agents, the increased use
of antifungal agents has led to the development of antifungal
resistance.
The impact of fluconazole use in the ICUs has resulted in
selective pressure favoring the appearance of more resistant
species such as C. glabrata and C. krusei.
The incidence of Fusarium spp. infection is increasing, par-
ticularly in immunocompromised patients.
Disseminated fusariosis is an uncommon disease, and the
reasons for the increasing incidence are multiple.
Some reports suggest a strong correlation between Malasse-
zia furfur sepsis and the use of intravascular catheters.
Despite significant advances in the management of immuno-
suppressed patients, invasive aspergillosis remains an important
life-threatening complication.
In the past two decades, the incidence of invasive aspergil-
losis in this population has continued to increase. Factors that
predispose patients to invasive aspergillosis include prolonged
336 A Guide to Infection Control in the Hospital
granulocytopenia, the development of graft-versus-host disease,
immunosuppressive therapy, the use of adrenal corticosteroids,
and the prolonged impairment of host defenses associated with
diseases such as chronic granulomatous disease.
Environmental factors also play a key part in the pathogen-
esis of invasive aspergillosis, therefore, infection control mea-
sures play a critical role in reducing exposure of hospitalized
patients to Aspergillus.
References
Blumberg HM, Jarvis WR, Soucie M, Edwards JE, Patterson JE, Pfaller
MA, Rangel-Frausto MS, Rinaldi MG, Saiman L, Wiblin RT, Wen-
zel RP and the NEMIS Study Group. Risk Factors for Candidal
Bloodstream Infections in Surgical Intensive Care Unit Patients:
The NEMIS Prospective Multicenter Study. Clin Infect Dis. 2001.
33:177–86.
Garbino J. Secular Trends of Candidemia Over 12 Years in Adult
Patients at a Tertiary Care Hospital. Medicine (Baltimore). 2002.
81(6):425–33.
Pfaller MA, Diekema DJ. Epidemiology of Invasive Candidiasis: A Per-
sistent Public Health Problem. Clin Microbial Rev. 2007. 20:133–63.
Wenzel RP, Gennings C. Bloodstream Infections Due to Candida Spe-
cies in the Intensive Care Unit: Identifying Especially High-Risk
Patients to Determine Prevention Strategies. Clin Infect Dis. 2005.
41(Suppl S)389–393.
Herbrecht R, Denning DW, Patterson TF, et al. Voriconazole versus
Amphotericin B for Primary Therapy of Invasive Asperigillosis. N
Engl J Med. 2002. 347:408–415.
Maschmeyer G, Haas A, Comely OA. Invasive Aspergillosis: Epidemi-
ology, Diagnosis and Management in Immunucompromised patients.
Drugs. 2007. 67:1567–1601.
Gutiérrez SM, Heredia M, Gómez E, Gómez JI, Tamayo E. Candi-
demia in ICU patients with sepsis. Crit Care Med. November 2013.
41(11):e 385.
Ben-Ami R, Halaburda K, Klyasova G, Metan G, Torosian T, Akova M.
A multidisciplinary team approach to the management of patients
with suspected or diagnosed invasive fungal disease. J Antimicrob
Chemother. November 2013. 68(Suppl 3):iii 25–33.
Fungi 337
- 2002. 347(15):1175–1186.
- a result, there has been an improvement in patient survival;
- Candidemia generally occurs in patients who are debilitated;
Chapter 53
Viruses
M.W.H. Wulf, MD, C.M.A. Swanink, MD, PhD,
and Andreas Voss, MD, PhD
Key Issue
Viral infections are common in the community and can cause a
variety of symptoms.
Known Facts
The diagnosis is based on antigen detection, antibody
response, electron microscopy, virus isolation, or poly-
merase chain reaction, which may be laborious and/or
time-consuming. Based on the route of transmission, viral
infections can be classified into four categories:
Gastrointestinal Infection. Gastrointestinal infections are caused
by several viruses that can be found in feces, such as: entero-
viruses (polioviruses, coxsackieviruses A and B, echoviruses),
adenoviruses, rotaviruses, astroviruses, caliciviruses (e.g., noro-
virus, sapovirus), coronaviruses, hepatitis A virus and hepatitis
E virus. Some of these are also found in respiratory secretions
(enteroviruses, adenoviruses, coronaviruses, norovirus) and
may cause symptoms of an upper respiratory tract infection.
Outbreaks were reported in daycarecenters, sport facilities, hos-
pitals and nursing homes.
The route of transmission is predominantly fecal-oral,
often via contaminated hands. Transmission of norovirus
by aerosol during vomiting appears common. Thus, infec-
tion control strategies should focus on contact with fecally
contaminated items and include gowns, gloves, and hand
hygiene (see Table 53.1). In general, masks are not advised
338 A Guide to Infection Control in the Hospital
but should be worn during close contacts or high-risk proce-
dures (e.g., bronchial toilet) and when taking care of vomit-
ing patients with norovirus infections.
Most infections are mild, self-limiting, and do not require
any specific therapy.
Respiratory Tract Infection. Symptoms of respiratory tract infec-
tions may vary from common cold to life-threatening pneumonia
or pneumonitis.The severity of the clinical symptoms is largely
dependent on host defenses. Cytomegalovirus, for example,
can cause severe pneumonitis in the immunocompromised host
whereas most infections are subclinical in the immunocompe-
tent host. Viruses that cause respiratory tract infections include
influenza viruses, parainfluenza viruses, respiratory syncytial
virus, adenoviruses, enteroviruses, rhinoviruses, human metap-
neumovirus and coronaviruses (SARS, MERS CoV). Many
other viruses can be found in respiratory secretions, such as
cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes
simplex virus (HSV), human herpes virus type 6 (HHV-6), mea-
sles, mumps, human parvovirus B19, rabies virus, rubella virus,
poxviruses, and varicella-zoster virus (VZV).
Route of transmission is via airborne spread or via contam-
inated hands. Infection control measures should be aimed
at aerosol transmission and direct contact and may include
isolation, masks, gowns, gloves, and hand hygiene.
Influenza virus vaccination should be considered for high-
risk patients (for detailed information see the WHO website)
and healthcare workers. In case of an outbreak, especially
when the strain is not controlled by the vaccine, prophylaxis
with amantadine (only influenza A, within 48 hours of expo-
sure) or oseltamivir (influenza A & B) may be useful for both
patients and healthcare workers.
Avian Influenza A: Although the risk of health care associated
transmission is low, due to the high mortality of influenza A
H5N1 infections, precautions should be taken. Standard drop-
let and contact precautions are recommended. During aerosol
generating procedures, eye protection and a respirator as
protective as N95 /FFP2 is recommended. Suspected cases
should be reported to local health authorities. Post-exposure
prophylaxis with oseltamivir can be considered for HCW at
Viruses 339
high risk for infection (http://www.who.int/influenza/resources/
documents/pharmacological_management_h5n1_05_2006/
en/#Riskcategories) but resistance has been described. Up-to-
date information is available on http://www.who.int/csr/disease/
avian_influenza/en/index.html.
In case of exposure to rabies virus, injection of human rabies
immune globulin (HRIG) in the exposure site within 24
hours is recommended, followed by vaccination.
Exanthematous Disease. Many viral infections can cause exan-
thema, vesicles, or other skin lesions. The most common viruses
are enteroviruses, herpes simplex virus (HSV), human herpes
virus type 6 (HHV-6), varicella-zoster virus (VZV), measles,
human parvovirus B19, and rubella virus.
The routes of transmission are via respiratory secretions
(all), feces (enteroviruses), urine (congenital rubella) and
skin lesions (HSV, VZV, coxsackievirus A). Infection con-
trol measures are listed in Table 53.1.
A combined vaccine for mumps, measles, and rubella
(MMR) should be given to children at the age of 12 to 18
months or 6 and 9 months and to susceptible adults when
vaccination is not contraindicated.
Vaccines for mumps, measles, varicella and rubella are live
attenuated vaccines and should not be given to severely
immunocompromised patients.
Antiviral therapy is available for HSV and VZV.
Neonates and susceptible immunocompromised adults
and pregnant women who had contact with chickenpox or
shingles should be given a dose of varicella-zoster immune
globulin (VZIG) within 3 days after exposure. Varicella-zos-
ter immune globulin may not prevent infection but it may
reduce the severity of infection.
Susceptible HCW that have been exposed to VZV should
be excluded from work with patients at risk during the incu-
bation period (21 days). Susceptible contacts from patients
with chicken pox should be isolated during the incubation
period. VZIG lengthens the incubation period! HCW who
have received vaccination, may continue their work unless
they develop clinical signs of VZV infection.
340 A Guide to Infection Control in the Hospital
Table 53.1 Infection Control Measures for Selected Viral Pathogens
Isolation/ Single Prevention/
Virus/Infection Infective Material Precautions Gown Gloves Mask Room Postexposure Prophylaxis
Adenovirus resp. secretions, feces contact (+) + (+) –
AIDS/HIV blood, body fluids universal – + – – (+) eye protection, + triple therapy
Avian influenza resp. secretions, feces contact, + + + + eye protection & FFP2/N95 mask in
droplet aerosol generating procedures
Post-exposure prophylaxis
Astrovirus feces enteric (+) + – –
Calicivirus feces enteric (+) + – –
Coronavirus resp. secretions, feces contact (+) + (+) –
Coxsackie A virus resp. secretions, feces, contact (+) + (+) –
(hand-foot-mouth lesions, secretions
disease, herpangina)
Cytomegalovirus resp. secretions, urine, body fluids – + (–) – + avoid contact during pregnancy
breast milk (+) ganciclovir
(anti-CMV-immuneglobulin)
Dengue virus blood universal – + – – + avoid mosquito exposure, repellents
Enterovirus resp. secretions, feces contact (+) + (–) –
Hantavirus (e.g., Puumala) rodent excreta none – – – –
Hemorrhagic fever blood, body fluids strict + + + + (+) eye protection, + ribavirin may be
(Ebola, Marburg, Lassa) useful for Lassa fever
Hepatitis A and E viruses feces enteric (+) + – – + vaccination and immune globulin for HAV
Viruses 341
Table 53.1 Infection Control Measures for Selected Viral Pathogens (continued)
Isolation/ Prevention/
Virus/Infection Infective Material Precautions Gown Gloves Mask Single Room Postexposure Prophylaxis
Hepatitis B and D viruses blood, body fluids universal – + – – (+) eye protection, + vaccination and HBIG
Hepatitis C, F, G viruses blood, body fluids (?) universal – + – – (+) eye protection, (–) interferon
Herpes simplex lesions, secretions drainage, – + – – (+) acyclovir
virus (localized) lesions,
secretions
Herpes simplex virus lesions, secretions, contact + + (–) + (+) acyclovir
(disseminated) resp. secretions
Herpes zoster virus lesions, secretions drainage, – + – (–) (+) VZIG
(localized) lesions,
secretions
Herpes zoster virus lesions, secretions, strict + + + + (+) vaccination, VZIG
342 A Guide to Infection Control in the Hospital
(disseminated, resp. secretions
varicella)
HIV/HTLV blood, body fluids universal – + – – (+) eye protection, + triple therapy
Influenza virus resp. secretions respiratory – (+) (+) + (+) vaccination, amantadine,
oseltamivir, zanamivir
Measles resp. secretions respiratory – (–) (+) (–) + vaccination (MMR)
Metapneumovirus (human) resp. secretions respiratory + + (–) + + single room only in children
Table 53.1 Infection Control Measures for Selected Viral Pathogens (continued)
Isolation/ Prevention/
Virus/Infection Infective Material Precautions Gown Gloves Mask Single Room Postexposure Prophylaxis
MERS CoV resp. secretions strict + + + + + negative pressure room,
N-95/FFP-3 or FFP 2 mask,
Mumps resp. secretions respiratory – (–) (+) (–) + vaccination (MMR)
Norovirus resp. secretions, enteric (+) + (+) – + hand disinfection (!)
feces, vomit when vomiting
Parainfluenza virus resp. secretions contact – (+) (+) –
Parvovirus B19 resp. secretions, blood contact – + (+) – + avoid contact during pregnancy
Poliovirus resp. secretions, feces enteric (+) + (–) – + vaccination
Rabies virus resp. secretions respiratory (+) + (+) – + HRIG at exposure site, vaccination
RSV bronchiolitis resp. secretions contact + + (–) + + single room only in children
Rotavirus feces, resp. secretions contact + + (+) – + hand disinfection (!)
Rubella virus resp. secretions contact + + + + + avoid contact during pregnancy,
vaccination (MMR)
SARS: see Chapter 50 resp. secretions, feces strict + + + + + negative pressure room,
N-95/FFP-3 or FFP 2 mask,
+ eye protection (goggles or face shield)
Varicella resp. secretions, lesions strict + + + + (+) vaccination, VZIG
Yellow fever blood – – + – – + avoid mosquito exposure, vaccination
Viruses 343
(–) = questionable, probably not necessary; – = not necessary
Less frequently occurring viruses that can cause health care
associated infections include those causing hemorrhagic
fevers such as arenaviruses (Lassa, Machupo, Junin), and
Filoviruses (Marburg and Ebola). These viruses require strict
isolation because they are transmitted by blood and body fluids
(see Bloodborne Infection, below).
Several arboviruses, such as dengue and yellow fever, and
rickettsiae may cause hemorrhagic skin lesions but they
are vectorborne, and person-to-person transmission does
not occur.
Hantaviruses may cause hemorrhagic fever with renal syn-
drome but may also cause a pulmonary syndrome with rapid
respiratory failure and cardiogenic shock. Hantaviruses
are transmitted via infected rodent excreta. Person-to-per-
son transmission does not occur; therefore, no preventive
measures are required.
Bloodborne Infection. Hepatitis B virus (HBV), hepatitis C
virus (HCV), human T-cell leukemia/lymphoma virus (HTLV),
human immunodeficiency virus (HIV), and viral hemorrhagic
fevers (VHF) (e.g., Lassa, Marburg, Ebola) are examples of
bloodborne infections. Other viral infections that can be trans-
mitted by blood are CMV, EBV and HHV-6 because these
viruses persist in leukocytes. Transfusion-related transmission
of West-Nile virus has been described.
Routes of transmission are blood and body fluids, includ-
ing breast milk. The risk of infection after a needlestick is
5 to 40% for HBV, 1 to 10% for HCV, and <0.5% for HIV.
For VHF, exact data on transmission after needlestick acci-
dents are missing, but it is known that high concentration of
viruses are found in blood during the febrile period.
Universal precautions should be taken when handling blood
in all patients and attention given to save disposal of needles
and sharps.
Effective postexposure prophylaxis for HBV consists of
passive immunization with hepatitis B immune globulin
(HBIG) followed by active immunization with recombinant
hepatitis B vaccine.
344 A Guide to Infection Control in the Hospital
Interferon prophylaxis after exposure to HCV is questionable.
Triple therapy with a combination of a protease inhibitor and
two nucleoside reverse transcriptase inhibitors is probably
useful as HIV postexposure prophylaxis.
Ribavirin is an effective treatment for Lassa fever and may
be useful as prophylaxis for Lassa fever.
Vaccination
Vaccination is available for polioviruses, hepatitis A, hep-
atitis B, varicella, influenza, measles, mumps, rubella, and
rabies.
Vaccines for mumps, measles, varicella and rubella are nor-
mally live attenuated vaccines and should not be given to
severely immunocompromised patients.
References
Control of Communicable Diseases Manual (17th Edition), J Chin,
(Ed). Washington: American Public Health Association, 2000.
Fields Virology (4th Edition), DN Fields, DM Knipe, PM Howley,
(Eds). Philadelphia: Lippincott-Raven Publishers, 2001.
Hu DJ, Kane MA, Heymann DL. Transmission of HIV, Hepatitis B
Virus, and Other Bloodborne Pathogens in Healthcare Settings: A
Review of Risk Factors and Guidelines for Prevention. World Health
Organization. Bull World Health Organ. 1991. 69:623–630.
Bridges CB, Harper SA, Fukuda K, Uyeki TM, Cox NJ, Shingleton JA.
Prevention and Control of Influenza. MMWR. 2003. 52(RR08):1–36
Bridges CB, Harper SA, Fukuda K, Uyeki TM, Cox NJ, Shingleton JA.
Detection of West Nile Virus in Blood Donations. MMWR. 2003.
52(38):916–919.
Avian Influenza, Including Influenza A (H5N1) in Humans. WHO
Interim Infection Control Guideline for Healthcare Facilities. May
10, 2007.
Interim Infection Prevention and Control Recommendations for
Hospitalized Patients with Middle East Respiratory Syndrome
Coronavirus (MERS-CoV) http://www.cdc.gov/coronavirus/mers/
infection-prevention-control.html
Viruses 345
- 1. Gastrointestinal Infection;
- 2. Respiratory Tract Infection;
- 3. Exanthematous Disease (skin lesions, vesicles); and
- 4. Bloodborne Infection.
- + = advised; (+) = only during high-risk procedures (e.g., bronchial toilet, soiling), high-risk patients, or close contact;
Chapter 54
MERS and Lessons from SARS
Richard P. Wenzel, MD, MSc
Key Issue
Previously Severe Acute Respiratory Syndrome (SARS) was
one of the latest epidemics to challenge infection control experts
in the early years of the 21st century. The etiology is a novel
coronavirus especially capable of being transmitted in hospi-
tals. Only assiduous infection control practices were effective
for control. More recently a new coronavirus emerged in Saudi
Arabia and has spread to other portions of the Middle East and
to Europe: Middle East Respiratory Syndrome—MERS. The
important lessons from SARS for infection control are summa-
rized herein. These lessons could be employed in the early man-
agement of any new epidemic of respiratory infections when the
etiology is initially unknown.
Known Facts
SARS emerged in the Southern Chinese Province of Guang-
dong in November 2002, but was not recognized until Feb-
ruary 2003. Subsequently, a global epidemic occurred with
a crude mortality worldwide of almost 10% but with con-
siderably higher rates in some locales among patients older
than 65 years. In a small hospital outbreak of MERS, the
mortality was 65%.
The etiology of SARS was found to be a novel coronavirus
that very likely has a natural reservoir in one or more ani-
mals indigenous to Southern China, possibly the Himalayan
or masked palm civit.
The incubation period for SARS is 2–10 days, for MERS is
5 days.
Half of the victims were healthcare workers.
346 A Guide to Infection Control in the Hospital
The SARS virus spreads primarily via large droplets, thus
transmission usually requires close contact. It is possible
that occasionally droplet nuclei transmission (airborne) can
occur. Furthermore, because the virus is found in the blood-
stream early, transfusion-related or sharps injury-associated
infection remains a theoretic possibility. Lastly, because
the virus is shed in the stool for approximately 30 days and
can survive in the environment for 1–4 days, it is likely that
the environment plays an important role in some cases of
transmission.
Although steroids and ribavirin have been used empirically
for therapy, no efficacy data from controlled studies exist to
prove that either drug affects outcome favorably.
Healthcare workers who failed to use masks properly while
managing SARS patients were more likely to become
infected than those who used the masks properly.
MERS is an emerging new coronavirus, possibly with a
higher mortality than SARS and with possibly less transmis-
sibility. Infection control (~30% currently) will be critical in
containing this latest coronavirus.
Controversial Issues
Recognition of the SARs epidemic was important and much
credit goes to the late Carlos Urbani, MD, who alerted the
world from his hospital in Hanoi. Of interest, the web-based
international surveillance system for emerging pathogens—
ProMED-mail—had reports of SARS weeks before the
World Health Organization (WHO) reported the epidemic.
There is critical need for all countries to report new epidem-
ics immediately.
Quarantine, if used, must be employed with care and
compassion.
The WHO showed great leadership by coordinating much of
the global response to SARS.
Because of the fears of healthcare workers, more attention
to be paid to psychological support when epidemics affect
them and threaten their health and lives.
MERS and Lessons from SARS 347
Suggested Practice
Some of the key points in the management of SARS cases—
which may help with MERS—are shown in Table 54.1.
The wearing of tight-fitting masks, preferably N-95 with high
filtering ability, is the most essential part of infection control
protection of healthcare workers. Hand washing is also very
important for infection control. Double gloving is thought to
be important. Even if one has used gloves, a healthcare worker
should wash hands after removing the gloves. Gowns and eye
protection should be used and hair covers and shoe covers
used if available. If available, place the patient in a room with
negative air pressure.
Table 54.1 Management of Suspected MERS
Isolate the patient
Place the patient in a private room with negative pressure, if possible.
Wear two pairs of gloves, a gown, masks (N-95 if available), and eye protection
(with face shield, if available, rather than goggles).
Just before leaving the room, remove the gown and top set of gloves in the room.
After leaving the room, wash gloved hands with alcohol, remove face shield and mask,
placing both in disposable trash.
Remove and discard the second set of gloves.
Wash hands carefully after removing gloves.
Limit the number of healthcare workers caring for patient.
Limit the number of visitors.
Perform diagnostic studies if possible
To rule out known causes of community-acquired pneumonia and to rule in SARS.
Maintain a clean environment
Use chlorine solutions on bedside counters and on medical equipment that can tolerate
the disinfectant, such as IV poles, at least daily.
Supplemental oxygen for hypoxemia.
Antibacterial agents for community-acquired pneumonia.
Consider a neuraminidase inhibitor for treatment of influenza, if available.
348 A Guide to Infection Control in the Hospital
Whenever healthcare workers exposed to initially non-isolated
patients, it was ideal if they could be furloughed to their homes
alone for 10 days before returning to work in the hospital.
This may be very important for limiting transmission of MERS
within the hospital. Ideally, family members would move to a
relative’s home during the 10 day furlough.
Summary
MERS is a new and formidable epidemic that is challenging
infection control. Like SARS, the primary reservoir may be in
bats. Unlike SARS, the secondary reservoir is likely in camels.
Although close contact was necessary for transmission most
of the time, the possibility exists for coincident transmission
via airborne route and fomites. To contain this novel corona-
virus, there is no room for error or relaxation of the highest
standards of all features of infection control. The lessons from
SARS may help to control MERS while we learn more about its
epidemiology.
References
Abdullah A, McGreer A, Perl TM, et al. Hospital Outbreak of Mid-
dle East Respiratory Syndrome Coronavirus. N Engl J Med. 2013.
369:407–16.
Perlman S, McCray PB. Person-to-Person Spread MERS Coronavi-
rus—An Evolving Picture. N Engl J Med. 2013. 369:466–7.
Wenzel RP, Bearman G, Edmond MB. Lessons from SARS: Implica-
tions for Infection Control. Arch Med Res. Nov–Dec 2005. 36:610–6.
Wenzel RP, Edmond MB. Managing SARS Amidst Uncertainty N Engl
J Med. 2003. 348:1947–1948.
Holmes KV. SARS—Associated Coronavirus N Engl J Med. 2003.
348:1948–1951.
Seto WH, Tsang D, Ching TY, et al. Effectiveness of Precautions
Against Droplets and Contact in Prevention of Nosocomial Trans-
mission of Severe Acute Respiratory Syndrome (SARS). Lancet.
2003;. 361:1519–1520.
Wenzel RP, Edmond MB. Listening to SARS: Lessons for Infection
Control. Ann Intern Med. October 2003. 139(7):592–593.
MERS and Lessons from SARS 349
Chapter 55
Parasites
Claudia Jarrin MD, and Gonzalo Bearman, MD, MPH
Introduction
There are three categories of health care associated parasitic
infections: ectoparasites, enteric parasites, tissue and blood par-
asites. Children, post-transplant patients and patients infected
with HIV are especially at risk for severe infection.
Health care associated parasitic infections are infrequently
reported in developed countries which can result in underdiag-
nosis and unwanted delay of installment of proper preventive
measures. A study in 2009 including 1,265 intensive care units
in 75 countries showed that the overall incidence of parasitic
health care associated infections was 0.48%. Ectoparasitic
infections such as scabies and pediculosis can cause large hos-
pital outbreaks.
Enteric parasites are usually endemic in an important part
of the population living in developing countries. In this group,
parasitic health care associated outbreaks probably are more
common, but detection is hampered due to the high prevalence
of parasitic infections and the limited financial resources.
Ectoparasites
Potential health care associated infections caused by ectopara-
sites include the pediculoses, scabies, mites and myiasis.
Infestation with the itch mite Sarcoptes scabei is an import-
ant cause of health care associated infections. Scabies is
transmitted directly from person-to-person via skin-to-
skin or sexual contact. Infected fomites may contribute to
transmission within households and institutions. About half
percent of cases occur in individuals with poor hygiene.
However, about 30% of scabies cases affect people who
are very concerned with their hygiene. In the latter group,
diagnosis can be missed or delayed. There were 23 health
care associated outbreaks reported between 1985 and 2012.
350 A Guide to Infection Control in the Hospital
Clinical manifestations are intense pruritus and burrows
over the distal extremities, waist and axilla. Particularly
important, Norwegian or crusted scabies is associated with
cell-mediated immunodeficiencies such as HIV/AIDS.
The incubation period may be up to four or six weeks before
itching and scratching begin. This long period often delays
outbreak recognition with further transmission of mites by
asymptomatic contacts. Larger outbreaks correlate with
diagnostic delay and high mite density, such as the case of
Norwegian scabies. Patients with crusted scabies can have
thousands of mites on their skin as opposed to the average
five to 15 harbored by the usual symptomatic person with
common scabies. The presence of animals inside hospitals
can be source of mites which are unusual for humans.
Head lice infestation by Pediculis humanus capitis is trans-
mitted person-to-person by direct, even if only brief, head-
to-head contact. Health care associated transmission is low
apart from close patient-to-patient contact in i.e. pediat-
ric ward playrooms or institutions. P. humanus corporis,
agent of body lice, is transmitted via direct contact or with
exchange of infested clothing or bedding. It is of negligi-
ble risk in hospital settings in developed countries. This risk
is also true for transmission of the pubic louse, Phthirus
pubis, which are transmitted via direct venereal skin-to-skin
transfer.
The pigeon mite, Dermanyssus gallinae, has been involved
in health care associated outbreaks. Infection with this mite
causes pruritic papular rash which can be misdiagnosed as
scabies. Usual source of the mite are pigeon roosts found on
or near ventilatory ducts or outside air-conditioners.
Health care associated infestation of body tissues by larvae
of various fly species, myiasis, is not uncommon. Myia-
sis results from deposition of eggs of gravid flies in open
wounds, which can develop towards motile larvae within a
few days. Treatment involves mechanical removal of larvae
and wound debridement if needed. Myiasis most commonly
occurs in hospitals in the tropics and subtropics with open air
access to the patient, but is also reported in temperate areas
during warmer months.
Parasites 351
Enteric Parasites
Intestinal parasites can cause diarrhea in 12–17% of health
care associated epidemics and 1% of endemic outbreaks,
especially on surgical wards. Immunosuppressed patients
and those with prolonged antibiotic courses are at higher
risk.
Enteric protozoans are the most common agents involved
in health care associated outbreaks. These include: Crypto-
sporidium parvum, Giardia lamblia, Entamoeba histolytica/
dispar, Blastocystis sp., Balantidium coli, Cyclospora caye-
tanensis and Isospora belli.
Fecal material of infected patients may contain helminthic
eggs or larvae, or protozoan cysts, oocysts, or trophozoites.
All protozoan cysts or oocysts are immediately infective
when passed in stool. Trophozoites may only survive briefly
in the environment and are killed by gastric acid; therefore,
contributing less to transmission.
Giardia is the most common enteric protozoan infection in
the United States. Contaminated water is the most common
way of transmission. Person-to-person transmission occurs
occasionally and foodborne transmission is seldom.
Cryptosporidium can cause diarrhea in both immunocom-
promised and immunocompetent hosts. In the latter, diarrhea
is usually self-limited. This is an important agent causing
diarrhea in the HIV population.
Suboptimal hand washing or fomite contamination of
environmental surfaces can be involved in transmission.
Furthermore, the cysts are very resistant to environmental
conditions and most of the disinfectants commonly used
have low or none antiparasitic activity. Perinatal health care
associated transmission from mother to newborn is possible.
Suspected airborne transmission from animal to human has
been reported.
Helminths can cause isolated outbreaks in solid organ
transplant recipients. Infections are usually associated with
water or food contamination. Enteric helminth parasites
transmitted from person-to-person are Enterobius vermicu-
laris, Strongyloides stercoralis and Hymenolepis nana. This
is possible because an intermediate host is not required
352 A Guide to Infection Control in the Hospital
and eggs (E. vermicularis, H. nana) or larvae (S. stercoralis)
are directly mature (infective) in stool. These features are
also responsible for autoinfection. When conditions allow
fecal contamination of the healthcare environment (i.e. in
recreational areas) and helminth eggs are enabled to mature,
other roundworms, such as hookworm, trichuris and toxo-
cara species, can also be the source of outbreaks. Patients
shedding proglottids of Taenia solium in the hospital envi-
ronment are a potential important source of infection. Eggs
liberated from the proglottides are immediately infectious
and can, when swallowed by humans, cause severe pathol-
ogy of i.e. the central nervous system (cysticercosis). Stron-
gyloides stercoralis can cause hyperinfection in patients
on chronic immunosuppression with steroids and in those
infected with HIV and HTLV-1.
Other less frequent water-associated outbreaks include
Entamoeba histolytica/dispar, Balantidium coli, Cyclospora
cayetanensis, Microsporidium species, the tissue parasite
Toxoplasma gondii and the free living Acanthamoeba spe-
cies. Due to the small size and robust nature of the transmis-
sion stages of parasites, i.e. cyst, oocyst and spores, removal
by water treatment is difficult.
Free-living amoebae in water networks and oxygen humidi-
fier reservoirs of hospitals have been shown to be an import-
ant reservoir of pathogens as Legionella pneumophila.
In addition, these amoebas serve as reservoir for different
mycobacterial species and Alphaproteobacteria, such as
Rhodoplanes and Methylobacterium. The ability to multiply
in free-living amoeba offers these bacteria protection from
biocides and enhances their virulence in humans. Human
infection occurs via inhalation of aerosols containing free
bacteria or, alternatively, infected amoebae itself could be
the infectious particles that bring the pathogens to the longs.
Tissue and Blood Parasites
Organ transplant and blood transfusion recipients are at higher
risk.
The most common protozoan infection related to blood and
blood products transfusion is Plasmodium falciparum fol-
lowed by P. vivax. This is an important problem in endemic
Parasites 353
areas. Furthermore, all species of Plasmodium can remain
potentially invasive for 7 days in preserved blood and up
to 2 years in frozen blood. In most cases, post-transfusion
malaria results in death.
Plasmodium species can also be transmitted between hospi-
talized patients when physical barriers such as windscreens
and bed nets are not in use. In non-endemic countries health
care associated malaria is infrequently observed. However,
especially in patients hospitalized with high parasitaemia
of P. falciparum, small amounts of blood can result easily
in health care associated transmission to other patients and/
or staff. Other means of transmission are through organ
transplant, needle stick injuries, improper catheter use and
administration of intravenous drugs –especially in devel-
oping countries, and contact with a rogue mosquito that
escaped from a mosquito colony in the laboratory setting.
Babesia microti, cause of babesiosis and normally trans-
mitted to humans via the tick Ixodes scapularis, can cause
health care associated infections via blood transfusions.
This problem is especially recognized in North America.
Advanced age, immunosuppression and asplenia are risk
factors for severe disease.
African trypanosomiasis, normally transmitted by tse-tse
flies, can also be transmitted by blood transfusion. Donors
can remain asymptomatic for up to 6 months.
American trypanosomiasis, caused by T. cruzi is predomi-
nantly transmitted via the bite of an infected triatomid bug in
endemic areas and can be transmitted by blood transfusion.
It is the second most common means of acquiring this infec-
tion. Transmission by needle stick injury and kidney trans-
plantation has also been reported. For persons who have had
accidental exposures, administration of a two-week course
of presumptive therapy should be considered while awaiting
results.
Leishmania spp. causing visceral leishmaniasis can be
transmitted by blood transfusion. In blood the parasites are
observed in leukocytes. In endemic areas differentiation
between visceral leishmaniasis due to arthropod vector and
blood transfusion infection is difficult.
354 A Guide to Infection Control in the Hospital
Health care associated transmission of toxoplasmosis is
most often after heart or kidney transplantation and infre-
quently due to white blood cell transfusions. Laboratory-ac-
quired toxoplasmosis in research personal is not uncommon
due to contact with infectious (often cultured) material by
skin punctures, eye splashes or open wounds.
Microfilariae of the blood helminths Mansonella ozzardi,
Loa loa, Diptetolonema perstans and Wuchereria bancrofti
have been observed in blood of asymptomatic donors.
No illness or mild disease was recorded in recipients of
such blood.
Controversial Issues
For different reasons, report of parasitic health care asso-
ciated infections is suboptimal in both developing and
developed countries which presents a challenge to Infection
Control since this underestimation can result in delay of
diagnoses and installment of proper preventive measures.
Expertise in laboratory diagnoses of specific parasitic infec-
tions is often limited.
Even with high standards of treatment, including physical
and chemical disinfection methods, contamination with
enteric parasites occurs.
Screening for parasitic infections which potentially can be
transmitted by blood transfusion i.e. malaria and Chagas dis-
ease, requires locally adapted strategies to take into account
both care for the recipient as well as unnecessary waste of
blood donations.
Prevention
Effective hand washing and routine glove use are the most
important preventive measures since many immunocompe-
tent patients may be asymptomatic carriers. Sanitary control
is also important in preventing the presence of insects such
as mosquitos and flies that propagate parasitic infections.
Time of shedding of Cyclospora and Isospora oocysts in
stools can be shortened by treatment with cotrimoxazole and
Giardia by metronidazol or tinidazol.
Parasites 355
There is no established therapy for Cryptosporidium. HAART
is the only proven treatment in patients with advanced HIV
and C. parvum. Oocysts can be removed from drinking water
by either boiling for one minute or by filtering water. Full
details are provided by the CDC Preventions Website. Crypto-
sporidium can be inactivated on surfaces or instruments by i.e.
10% formal saline, 5% ammonia for 18 hours or full-strength
(12%) commercial bleach for 10–15 min.
The corner stone to prevent blood-transfusion-associated
protozoal infections, i.e. malaria, trypanosomiasis (Afri-
can and South American), babesiosis and leishmaniasis, is
donor selection using questionnaires and use of screening
tests. After a visit to a malaria endemic area blood donors are
deferred from blood donation for periods varying from 4–6
months, 3 years or even permanently, depending on the ori-
gin of the donor (born and lived in endemic area, European
visitor), having experienced febrile episodes in the period
after the visit and country of blood donation. In the USA and
Canada a deferral time of 12 months after return from an
endemic area is applied for blood donors. Use of serological
tests for malaria in the tropics is, given the high prevalence
of malaria in most countries, of little use and deferring on
basis of positive antibody tests too drastically can reduce the
local donor pool. Antigen tests and microscopy can be used
instead, but sensitivity is suboptimal. Routine screening for
babesiosis in not in common practice.
To prevent American trypanosomiasis (Chagas disease) in
endemic areas, questionnaires, serological tests for T.cruzi
and treatment of blood with gentian violet are used; the latter
being an effective strategy to prevent health care associated
blood transfusion. In non-endemic countries use of ques-
tionnaires for Chagas disease are often targeted to special
donor groups, i.e. visitors or immigrants of South America.
Performing serological screening is not done routinely in
non-endemic countries but is considered in the USA when a
FDA licensed test should be available.
To prevent transfusion-acquired leishmaniasis in some coun-
tries (USA, Ireland) donors are deferred for 12 months when
they visited endemic countries, especially Iraq. Also donors
356 A Guide to Infection Control in the Hospital
with multiple scars and fresh cutaneous leishmaniasis are
deferred. In other countries use of specific questionnaires or
antibody testing is not routinely performed.
Serological testing for T. gondii of both donor and recipient
in advance should, in case of mismatch, alert the clinician
of potentially life threatening complications. Prophylaxis
with pyrimethamine can be provided to the recipient. Alter-
natively anti toxoplasmosis treatment can be started when
seroconversion and clinical manifestations occur, although
clinical symptoms often are non-specific.
To prevent myiasis patients should be advised to keep wounds
and draining orifices clean and covered. Efforts should be
made to reduce flies in the health-care environment.
Prompt recognition of scabies followed by immediate
implementation of preventive measures is the mainstay for
the containment of health care associated outbreaks. Simul-
taneous mass prophylaxis is the most efficient strategy for
terminating ward outbreaks and may prevent ward closure.
In case of crusted scabies, contact precautions should be
strictly implemented including use of disposable gloves,
gowns and shoe covers. Local treatment with 5% permethrin
cream, applied overnight on two occasions one week apart,
is highly effective. Lindane lotion 1% is an effective, cheap
alternative but is potentially more toxic. In addition to local
treatment in crusted scabies oral treatment with ivermectine
at a dose of 200 ug/kg, at one to three doses, is beneficial.
Summary
Health care associated parasitic infections can be caused by
enteric, blood, tissue and ectoparasites. Frequency of infec-
tion is low in developed countries where infections are mostly
driven by ectoparasites. From developing countries only few
data are available. Proper detection of outbreaks requires ade-
quate diagnosis which, in both settings, often has restrictions. In
developing counties outbreaks are difficult to detect due to high
background prevalence. Enteric protozoan parasites, malaria,
American trypanosomiasis, toxoplasmosis, scabies (classic
or crusted) and myasis are among the most frequent reported
health care associated infections. Patients with AIDS, children
and transplant recipients are particularly at risk.
Parasites 357
References
Aygun G, Yilmaz M, Yasar H, Aslan M, Polat E, Midilli K, et al. Para-
sites in nosocomial diarrhea: Are they underestimated? J Hosp Infect.
Betancourt WQ, Rose JB. Drinking Water Treatment Processes for
Removal of Cryptosporidium and Giardia. Veterinary Parasitology.
Góralska K, Kurnatowski P. Parasites as etiological factors of nosoco-
mial infections. Annals of Parasitology. 2013. 59(1):3–11.
Herwaldt B. Laboratory-Acquired Parasitic Infections from Accidental
Exposures. Clinical Microbiology Reviews. 2001. 659–688.
Jain SK, Persaud D, Perl TM, Pass MA, Murphy KM, Pisciotta JM,
Scholl PF, Casella JF, Sullivan DJ. Nosocomial Malaria and Saline
Flush. Emerging Inf Dis. 2005. 11:1097–1099.
Khan A, O’Grady S, Muller M. Rapid control of a scabies outbreak at
a tertiary care hospital without ward closure. American Journal of
Infection Control. 2012. 40:451–455.
Karanis P, Kourenti C, Smith H. Waterbome Transmission of Protozoan
Parasites: A Worldwide Review of Outbreaks and Lessons Learnt.
Journal of Water and Health. 2007. 5:1–38.
Lettau LA. Nosocomial Tranmission and Infection Control Aspects of
Parasitic and Ectoparasitic Diseases: Part I. Introduction Enteric Par-
asites. Infect Control Hosp Epidemiol. 1991. 12:59–65.
Lettau, LA. Nosocomial Transmission Infection Control Aspects of Par-
asitic and Ectoparasitic Diseases Part II. Blood and Tissue Parasites.
Infect Control Hosp Epidemiol. 1991. 12:111–121.
Sherman RA, Roselle G, Bills C, Danko LH, Eldridge N. Health-
care-Associated Myiasis: Prevention and Intervention. Infect Control
Hosp Epidemiol. 2005. 26:828–832.
Thomas V, Herrera-Rimann K, Blanc DS, Greub G. Biodiver-
sity of Amoebae and Amoeba-Resisting Bacteria in a Hospital
Water Network. Applied and Environmental Microbiology. 2006.
72:2428–2438.
Vorou R, Remoudaki HD, Maltezou HC. Nosocomial Scabies. J Hosp
Infect. 2007. 65:9–14.
Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, et al.
International study of the prevalence and outcomes of infection in
intensive care units. JAMA. 2009. 302:2323–2329.
358 A Guide to Infection Control in the Hospital
Chapter 56
New Technologies in
Infection Prevention
Surbhi Leekha, MBBS, MPH
Key Issue
New technologies for the prevention of health care associ-
ated infections (HAI) are developing at a rapid pace. This
chapter provides a broad overview of emerging technologies
in the following categories: environmental cleaning and dis-
infection (including antimicrobial impregnated clothing),
automated hand hygiene monitoring, and HAI surveillance.
While a handful of these technologies have been associated
with reduction in either cross-transmission of micro-organ-
isms or prevention HAIs, many are in their nascent stage
and require further evaluation particularly with regards to
clinical efficacy.
The utilization of technology in infection prevention prac-
tice is exciting because many of these tools (e.g., self-disin-
fecting surfaces) are “passive” interventions that do not rely
on human behavior for implementation.
Known Facts
There has been a renewed interest in the role of the hospital
environment as a reservoir for pathogens. Various patho-
gens have been shown to survive for prolonged periods
on inanimate surfaces, and may be transmitted to patients
either through direct contact, or via the hands of healthcare
workers.
Patients admitted to hospital rooms that previously housed
patients colonized or infected with methicillin resistant
Staphylococcus aureus (MRSA), vancomycin resistant
Enterococcus (VRE), multidrug resistant Acinetobacter
baumannii, multidrug resistant Pseudomonas aeruginosa,
or Clostridium difficile, are more likely to acquire the same
pathogen during their hospital stay.
New Technologies in Infection Prevention 359
The inadequacy of routine hospital cleaning is well
described, and improved environmental cleaning has been
associated with reduction in HAI incidence. This has led
to the search for novel methodologies to reduce the risk of
acquiring a pathogen from the healthcare environment.
Technologies for monitoring the quality of environmental cleaning:
Traditionally, little attention has been paid to tools used
to monitor the cleaning of the hospital environment, with
visual inspection being used most frequently, and culturing
of surfaces limited to research or outbreak settings. More
recently, the use of objective tools for monitoring the quality
of cleaning has been promoted.
Two types of monitoring systems have been evaluated in
research studies, and adopted for routine use by many hospi-
tals. The first uses an invisible gel that dries on surfaces fol-
lowing application, and resists abrasion unless that surface is
thoroughly cleaned. This mark can be discovered using a flu-
orescent marker if effective cleaning has not been performed,
and thereby help evaluate the efficacy of cleaning practice.
The second tool uses adenosine triphosphate (ATP) biolumi-
nescence to measure organic ATP on surfaces using a lucif-
erase assay and a luminometer. This technology assesses the
cleanliness of a surface rather than the cleaning practice.
Both these systems have been shown to be effective in
improving the cleaning practice, but there is little evidence
to show that their use reduces the transmission of pathogens.
Evaluation of cleaning using these monitoring systems has
spurred the development and assessment of new technolo-
gies for cleaning and disinfection described below.
Disinfection technologies: Whole room disinfection
Known antimicrobial agents have recently been explored
for whole room surface decontamination utilizing novel
“no-touch” technologies. Two agents that have been studied
the most, and are available commercially, include hydrogen
peroxide (H2O2) and ultraviolet (UV) radiation.
Hydrogen peroxide based systems use either pressure-gen-
erated H2O2 aerosols or heat-generated H2O2 vapor delivered
in a high velocity air stream.
360 A Guide to Infection Control in the Hospital
The use of H2O2-based systems has been associated with
reduction in environmental contamination, control of health
care associated outbreaks, decrease in acquisition of patho-
gens such as MRSA and VRE, and decrease in the incidence
of Clostridium difficile infection (CDI). It has also been
recently shown to be useful in reducing the microbial contam-
ination of unused medical supplies, with potential cost sav-
ings associated with retaining supplies that would otherwise
be discarded.
UV light based disinfection systems have been associated
with reduction in microbial contamination. Reduction in the
incidence of CDI using a portable pulsed xenon UV light sys-
tem was observed in one single center non-randomized study.
Both H2O2 and UV radiation are toxic, necessitating that
staff and patients leave the rooms while these technologies
are being employed. This limits their use to terminal or dis-
charge cleaning, and potentially to clean unused supplies or
shared equipment.
The use of H2O2 vapor or aerosols also requires surfaces
to be free of debris that can only be accomplished through
manual cleaning.
The turnaround time for H2O2 vapor based cleaning in pub-
lished studies ranges from 2–8 hours which may be prohib-
itive for room turnover in many hospitals, although newer
delivery platforms that require less time are being developed.
While UV light disinfection promises shorter process times
(~ 10 minutes), because radiation can only travel in straight
lines, it can only disinfect objects in its direct path–“line-of-
sight” disinfection.
Both technologies require significant upfront expenditure
and may be cost-prohibitive for many hospitals.
Disinfection Technologies: Antimicrobial treated surfaces
Compounds with antimicrobial properties developed with
the intent of coating or impregnating surfaces include silver,
copper, triclosan, and quaternary ammonium.
While all these compounds have been shown to kill microor-
ganisms on contact in vitro, only copper containing surfaces
have been studied in the healthcare setting to any significant
degree.
New Technologies in Infection Prevention 361
In a recent randomized controlled trial in a single institution,
patients cared for in ICU rooms with copper alloy surfaces
had a significantly lower rate of incident HAI and coloniza-
tion with MRSA or VRE than patients cared for in standard
hospital rooms.
Two other technologies that are currently under evalua-
tion include surfaces with altered topography, and surfaces
containing light-activated germicides. The former utilizes
the science of microtopography to alter surfaces such its
configuration inhibits formation of biofilm and associated
microbial colonization. The latter technology is based on the
incorporating compounds that exhibit antimicrobial activity
when irradiated by visible light, into hospital surfaces—tita-
nium dioxide is the most developed product in this category.
Both these technologies require further evaluation in health-
care settings.
Disinfection technologies: Antimicrobial treated textiles
Similar to hard surfaces, several candidate compounds have
been explored for treatment of textiles for use in healthcare
settings.
In a double-blind, randomized controlled trial of a complex
element compound antimicrobial privacy curtains in ICUs,
a significant delay in time to microbial contamination of the
antimicrobial curtains was noted. However, when sampled
at time points beyond day 10, there was no difference in the
contaminated proportion between standard and antimicro-
bial curtains.
Results from studies evaluating healthcare worker uniforms
impregnated with antimicrobial compounds have been con-
flicting: while one crossover study showed a decrease in
MRSA (but not VRE or gram negative) burden with qua-
ternary ammonium impregnated scrubs, another randomized
controlled study failed to show a decrease in the overall
microbial burden with use of antimicrobial scrubs.
Automated Technology for Hand Hygiene Monitoring
Healthcare worker compliance with hand hygiene remains
suboptimal. Monitoring compliance with hand hygiene is
essential but resource-intensive for infection prevention
departments, and could be overcome through the use of
automated hand hygiene monitoring systems.
362 A Guide to Infection Control in the Hospital
Automated HH monitoring systems monitor the entrance
and exit of HCWs from patient rooms using motion sensing
technology, and link the movement to electronic monitoring
of alcohol-based hand rub dispensers.
Advantages of such systems include little ongoing resource
consumption (following initial installation), reducing bias
from Hawthorne effect of known observers on the unit, and
the ability to record large numbers of observations leading
to more robust rates, including rates individualized for each
HCW. Some of these systems also have the capability of pro-
viding real time monitoring and feedback to individuals.
Studies have shown that these systems are associated with
increase in hand hygiene compliance, and potentially with
improvement in rates of HAI.
The initial cost to set up such a system is likely to be signif-
icant, the opportunities most easily monitored (room entry
and exit) might not be most relevant to patient care, and
there is a possibility of losing the opportunities for detailed
observation, direct interaction and feedback from observers
including the infection preventionists.
There is some concern that radiofrequency and Wi-Fi based
devices may interfere with existing electronic medical
devices.
These systems are still being studied, and their accuracy, func-
tionality, and acceptability remain to be validated further.
Information Technology for Infection Surveillance
The focus of infection prevention programs has increasingly
shifted from being surveillance-centric to actively imple-
menting infection prevention practices. This could be greatly
facilitated by the use of automated surveillance systems that
can potentially save hours used in manually reviewing test
results or tracking information on presence of devices etc.
Hospitals have been using both indigenously developed and
commercially available software for infection surveillance.
In one study, hospitals that had adopted automated surveil-
lance technology were more likely than those that manually
track infections to have fully implemented evidence-based
practices to reduce HAI.
The ultimate impact of automated surveillance technology
on HAI prevention is unknown at this time.
New Technologies in Infection Prevention 363
Any automated surveillance technology will be highly
dependent on the quality of the clinical and laboratory data
captured by an existing hospital electronic medical record.
Controversial Issues
While it is recommended that an objective technology be uti-
lized for monitoring environmental cleaning, it is unclear
whether a fluorescent gel based cleaning practice monitoring
system or an ATP based cleanliness monitoring system rep-
resents the better method.
Although studies have shown reduction in the microbial bur-
den of the healthcare environment through the use of new
disinfection technologies, their role in reducing HAIs is not
well established.
The durability of effect of antimicrobial compounds intended
for long-term use (e.g., in HCW uniforms or hospital sur-
faces) is unknown.
Antimicrobial resistance to compounds used to coat or to
impregnate surfaces and clothing has not been evaluated.
The cost of acquisition of these technologies is likely to be
significant, and only a handful of studies have evaluated
potential cost savings with these technologies.
Suggested Practice
New technological advances may be used to supplement, not
substitute, basic evidence-based infection prevention and
control practices such as hand hygiene.
Ensure implementation of and adherence to proven basic
infection prevention practices prior to adopting new technol-
ogy e.g., in the case of environmental cleaning, this includes
ensuring thorough cleaning using traditional disinfectants.
There is some evidence to support the use of objective tech-
nology to monitor the quality of environmental cleaning.
Evidence to support routine use of new technologies for
environmental disinfection is lacking but may be useful in
the setting of an outbreak as a supplemental measure.
The following are some important considerations prior to
proceeding with routine use of a new product or technology
for infection prevention:
364 A Guide to Infection Control in the Hospital
Evidence of efficacy from clinical studies; evidence of anti-
microbial activity from in vitro studies should not be the
sole basis for introducing new technology for routine use.
Available alternatives.
Cost: weigh the cost of new technology against the cost of
attempting to improve human behavior and practice, and
potential impact on HAI incidence.
Impact of any new chemicals on the environment, medical
equipment, and on the safety of healthcare workers and
patients.
Effect on the day-to-day operation of the hospital.
Summary
New technologies are being developed, commercialized, and
offered to hospitals at a rapid pace; however, robust research to
support the use of most of these products is lacking. Ultimately,
technology hold great promise in eliminating many of the man-
ual steps in infection prevention but these technologies need to
be tested in well-designed clinical studies, and evaluated using
criteria such as those described above before adopting for rou-
tine use.
References
Otter, JA, Yezli S, French GL. The role played by contaminated surfaces
in the transmission of nosocomial pathogens. Infect Control Hosp
Epidemiol. 2011. 32(7):687–99.
Carling, PC, Parry MF, Von Beheren SM. Identifying opportunities to
enhance environmental cleaning in 23 acute care hospitals. Infect
Control Hosp Epidemiol. 2008. 29(1):1–7.
Dancer, SJ, et al. Measuring the effect of enhanced cleaning in a UK
hospital: A prospective cross-over study. BMC Med. 2009. 7:28.
Carling, PC, Bartley JM. Evaluating hygienic cleaning in health care
settings: What you do not know can harm your patients. Am J Infect
Control. 2010. 38(Suppl 5):S41–50.
Carling, PC, et al. Improving cleaning of the environment surrounding
patients in 36 acute care hospitals. Infect Control Hosp Epidemiol.
Boyce, JM, et al. Monitoring the effectiveness of hospital cleaning
practices by use of an adenosine triphosphate bioluminescence assay.
Infect Control Hosp Epidemiol. 2009. 30(7):678–84.
New Technologies in Infection Prevention 365
Otter, JA, et al., The role of ‘no-touch’ automated room disinfection
systems in infection prevention and control. J Hosp Infect. 2013.
83(1):1–13.
Falagas, ME, et al. Airborne hydrogen peroxide for disinfection of the
hospital environment and infection control: A systematic review. J
Hosp Infect. 2011. 78(3):171–7.
Otter, JA, et al. Saving costs through the decontamination of the pack-
aging of unused medical supplies using hydrogen peroxide vapor.
Infect Control Hosp Epidemiol. 2013. 34(5):472–8.
Levin, J, et al. The effect of portable pulsed xenon ultraviolet light after
terminal cleaning on hospital-associated Clostridium difficile infec-
tion in a community hospital. Am J Infect Control. 2013. 41(8):746–8.
Weber, DJ, Rutala WA. Self-disinfecting surfaces: Review of current
methodologies and future prospects. Am J Infect Control. 2013.
41(Suppl 5):S31–5.
Salgado, CD, et al. Copper surfaces reduce the rate of healthcare-ac-
quired infections in the intensive care unit. Infect Control Hosp Epi-
demiol. 2013. 34(5):479–86.
Bearman, GM, et al. A crossover trial of antimicrobial scrubs to reduce
methicillin-resistant Staphylococcus aureus burden on healthcare
worker apparel. Infect Control Hosp Epidemiol. 2012. 33(3):268–75.
Burden, M, et al. Bacterial contamination of healthcare workers’ uni-
forms: A randomized controlled trial of antimicrobial scrubs. J Hosp
Med. 2013. 8(7):380–5.
Boyce, JM. Measuring healthcare worker hand hygiene activity: Cur-
rent practices and emerging technologies. Infect Control Hosp Epi-
demiol. 2011. 32(10):1016–28.
Carling, PC. The need for clinically relevant studies of non-touch disin-
fecting systems. J Hosp Infect. 2013. 84(4):340.
Halpin, H, et al. Hospital adoption of automated surveillance technol-
ogy and the implementation of infection prevention and control pro-
grams. Am J Infect Control. 2011. 39(4):270–6.
366 A Guide to Infection Control in the Hospital
Chapter 57
Left Ventricular Assist Device—
R elated Infections
Richard P. Wenzel, MD, MSc.
Key Issue
With many of the world’s population developing congestive
heart failure, yet the known limited supply of hearts available for
transplantations, and improved medical technology, left ventric-
ular assist devices (LVADs) are increasingly being used as both
destination therapy and as bridges to transplantation. In late stage
congestive heart failure, patients with LVADs been shown to have
a 48% reduction in death vs those medically managed as shown
in the REMATCH study. Because LVAD related infections are
common and serious, a brief discussion is essential.
Known Facts
Infections after LVAD receipt occur in 18–59% of patients
and are usually caused by antibiotic resistant bacteria such
as MRSA, VRE, Candida species and highly resistant MDR
gram-negative rods
Infections after LVAD placement may be device specific (the
drive line, the pocket or the pump itself); device related (endo-
carditis, blood stream infection, mediastinitis or the surgical
site); or non-device related (pneumonia, urinary tract infection
or C.difficile infection).
LVAD endocarditis may present with few or no symptoms,
including only fever or progressive cachexia; sometimes the
patients may present with a device associated mechanical issue
only such as inlet obstruction, outflow rupture or bleeding
within the device.
Controversial Issues
Optimal perioperative antibiotics given to prevent infections after
LVAD placement are unclear. Many centers in the U.S. employ
a combination of Vancomycin, a Fluoroquinolone, Fluconazole
and a βeta-lactam antibiotic.
Left Ventricular Assist Device—Related Infections 367
Optimal therapy has not been clarified by clinical trials and
is usually empirical with broad coverage until the antibiograms
of isolated organisms are reported.
Suggested Practice
In the workup of LVAD patients with likely infection, the follow-
ing may be useful:
Peripheral blood WBC
Exit site culture of pus
Cardiac ECHO
Blood cultures
If a pocket infection is of concern:
Ultrasound, CT or nuclear scan
Image guided aspiration
If the LVAD is removed, obtain the following cultures:
Anterior and posterior LVAD surface
Outflow and inflow cannula
Tissue cultures
Drive line cultures
As for prophylaxis, a hospital performing LVAD placement
should consider being informed by those organisms recovered
and the associated antibiograms.
Summary
With only 4000 hearts each year available for transplantation
globally, there are increasing numbers of CHF patients receiv-
ing LVADs. Such patients have high risk of developing as infec-
tion, usually with MDR bacteria or yeast. Optimal perioperative
antibiotics have not been established.
References
Hannan MM, Husain S, Mattner F, et al. Working Formulation for the
Hannan MM, Husain S, Mattner F, et al. Working Formulation for the
Standardization of Definitions of Infections in Patients Using Ven-
tricular Assist Devices. J Heart Lung Transplant. 2011. 30:375–84.
Miller LW, Pagani FD, Russell SD, et al. Flow Device Patients Awaiting
Heart Transplantation. N Engl J Med. 2007. 357:885–96.
Topkara VK, Kondareddy S, Malik F, et al. Infectious Complications in
Patients with Left Ventricular Assist Device: Etiology and Outcomes
in the Continuous—Flow Era. Ann Thorac Surg. 2010. 90:1270–7.
Aslam S, Hernandez M, Thornby J, et al. Risk Factors and Outcomes
of Fungal Ventricular Assist Device Infections. Clin Infect Dis. 2010.
30:644–71.
368 A Guide to Infection Control in the Hospital
Chapter 58
Hand Hygiene Monitoring
Rekha Murthy, MD and Jonathan Grein, MD
Key Issues
Hand hygiene (HH) compliance by healthcare workers (HCW)
is an important quality measure in reducing healthcare associ-
ated infections, and monitoring compliance to provide feedback
is critical to improving performance.
Known Facts
HH remains the cornerstone of infection prevention, and
improvements in compliance have been associated with
reduction of health care associated infections and pathogen
transmission.
Healthcare facilities should take a comprehensive, system-
atic approach to assessing HH performance and provide
regular feedback to improve compliance based on estab-
lished goals.
The ideal approach to monitoring HH compliance should be
free of bias, not interfere with HCW activities or behavior,
assess the quality of each HH episode, and reliably capture
each HH opportunity even during complex care activities. It
should not require excessive staffing time or other resources,
and be able to provide real-time and specific feedback to
improve performance.
Bias plays a critical role in assessing compliance, and efforts
should be taken to minimize its impact. The major types of
bias are:
– Observation bias: The behavior of those being observed is
changed by the knowledge that they are being observed.
Otherwise referred to as the “Hawthorne” effect.
– Observer bias: The systematic error introduced by vari-
ations in the observation method. This bias can be min-
imized through the use of experienced observers that
conduct observations with a consistent, validated approach.
Hand Hygiene Monitoring 369
– Selection bias: The systematic error introduced through
the selection of time and setting for which the observation
occurs. This can be minimized by randomly choosing loca-
tions, time of day, and type of HCW to be observed.
The CDC and WHO both provide a variety of educational
material and tools to conduct HH surveillance. Additionally,
free applications for smartphones and tablets are available
(i.e., iScrub Lite).
A standardized approach to conducting HH surveillance has
not been widely adopted across healthcare institutions, mak-
ing inter-facility comparisons of compliance rates difficult.
The WHO provides a standardized HH observation method,
based on the “My five moments for HH” model. This tool
provides a consistent approach for trained observers.
A multidimensional approach utilizing HH compliance mon-
itoring with feedback has been shown to result in sustained
improvement in HH compliance, including in resource-lim-
ited settings.
Feedback of HH compliance is critical to improve perfor-
mance, and should optimally include accurate real-time
feedback specific to individual HCW.
Direct Observation
This is the most common approach, and typically involves
trained (and often covert) observers utilizing a standardized and
validated observation tool. This is considered the gold standard
for assessing HH compliance, and is the only approach that
can assess all HH opportunities. This method can assess HH
technique, provide immediate feedback, and can identify other
infection control opportunities. It may also allow observers to
troubleshoot and provide local solutions for barriers to compli-
ance. Importantly, this approach suffers from many limitations.
It is a time-consuming and labor-intensive process that only
captures a small proportion (<1–3%) of all HH opportunities. It
frequently excludes nighttime and weekend shifts, can be lim-
ited by visibility or patient privacy issues, can suffer from poor
inter-user reliability, and is subject to several types of bias (most
notably observation bias).
370 A Guide to Infection Control in the Hospital
Self-reporting or peer-reporting of HH compliance will
over-estimate compliance and is considered unreliable. Utilizing
patients as observers may be useful in settings where visibility
or patient privacy limit observation from trained observers (such
as ambulatory clinics). Experience with this approach is limited,
and it has suffered from poor response rates and inconsistency.
Concerns regarding negative impacts on patient-provider rela-
tionships have not been demonstrated in studies. Though only a
limited amount of information regarding HH compliance may be
provided, it may be a useful strategy in some settings, and may
help to further engage patients in their care. This approach may
not be easily scalable or appropriate for inpatient settings.
Indirect Assessment of Product Consumption
Monitoring product usage, such as soap, paper towels, or quan-
tity of alcohol-based hand rub (ABHR), has been used as a sur-
rogate for HH compliance. This approach can assess trends in
a large number of HH events, incorporates day and night shifts,
requires less manpower than direct observation, and minimizes
bias. Benchmarks have become available for ABHR usage (in
liters per 1,000 patient days), stratified by unit type, that allow
for trending and monitoring progress towards established goals.
This method does not assess the number of HH opportunities,
and can therefore only provide an estimation of compliance.
Patient acuity and other factors will impact usage and must be
accounted for when estimating compliance. Studies correlating
observed compliance with increased product utilization have
been mixed, though a correlation between increased ABHR
usage and reduced MRSA rates has been described. Other lim-
itations include the lack of HCW specific information, inability
to assess HH technique or provide immediate feedback, and
inability to account for usage by patients or visitors.
Electronic counting devices have been developed to offset
some of the above limitations. These devices allow for col-
lection of time and date-specific information, and can provide
dispenser-specific information helpful in assessing optimal
dispenser type and placement. Usage data can be wirelessly
downloaded to reduce manual data collection. Limiting factors
include significant technology support, cost of device installa-
tion, as well as maintenance and routine battery replacement.
Hand Hygiene Monitoring 371
Electronic HH Compliance Systems
A wide variety of electronic devices has become available to
assess HH compliance. These systems use a variety of sensors
to detect HCW entry into a room or patient “zone,” and can
prompt HCW if HH product is not dispensed within a certain
time after entry or exit. Some systems can detect the presence
of alcohol on HCW hands, and can allow HCW-specific track-
ing with special badges. Additionally, certain systems utilize
wireless technology (including WiFi, RFID, or ultrasound) to
track HCW location in real-time, which may offer other advan-
tages such as tracking inventory or assessing workflow patterns.
These systems capture a large number of HH opportunities, can
provide specific real-time feedback, and have been shown to
significantly improve HH compliance, though published data
has been limited to small settings over short periods of time.
Although advances in this technology appear promising,
certain limitations remain. These approaches may be costly,
require sensor installation and maintenance, and require signif-
icant technology support that may be limited by existing tech-
nology infrastructure. No electronic system is able to assess all
HH opportunities, such as HH prior to aseptic procedures, fol-
lowing exposure to bodily fluids, or when patients are outside
the hospital room. Although accuracy has been generally high
when compared to direct observation, even small inaccuracies
are significant if used to hold individual HCW accountable for
non-compliance. These systems have variable ability to assess
HH compliance during high frequency or complex care events.
Ensuring HCW acceptance of these methods requires organiza-
tional planning and advanced preparation.
Video monitoring to assess HH has been shown to improve
HH compliance. This approach requires careful camera place-
ment to limit patient privacy concerns, requires installation and
hard-wiring, and utilizes external auditors to evaluate compliance.
Controversial Issues
each has numerous advantages and limitations. Although direct
observation is considered the gold standard, it suffers from
many important limitations that limit its generalizability. The
accuracy and reliability of each approach is not well understood.
372 A Guide to Infection Control in the Hospital
There is variability in the assessment of “compliance.” Insti-
tution-specific approaches vary regarding their approach to
measuring compliance, training observers, and in the volume
or frequency of observations performed. This variability
makes comparison of compliance rates between institutions
difficult. Although tools are available to provide a consistent
approach, they are not yet widely adopted.
Although general improvements in HH have been associated
with reduced healthcare associated infections, the optimal
“threshold” for HH compliance to improve clinical out-
comes is not understood.
Outpatient and ambulatory care areas provide unique chal-
lenges to monitoring HH compliance, are less studied, and
optimal approaches in these areas are not well understood.
Public reporting of HH compliance is controversial. Incon-
sistent HH monitoring approaches between institutions,
resource constraints, and concerns that public reporting may
drive artificial increases without improving performance are
common arguments against public reporting.
Optimal approaches to improving and sustaining HH com-
pliance are not understood. Models utilizing HCW-specific
accountability and consequences for non-compliance may
be effective but remain poorly studied.
There are limited data on the long-term impact of various
approaches to sustaining HH compliance, including cost-
effectiveness, HCW acceptance, or impact on health care
associated infections.
Suggested Practice
The optimal approach to monitoring HH compliance is variable,
and depends on organizational goals and available resources.
A high degree of institutional leadership support and visibility,
coupled with allocation of resources for ongoing HH monitor-
ing and feedback, is critical to any successful HH campaign.
Healthcare institutions should develop a sustainable, credible,
and reliable process to monitor HH that is accurate and attempts
to minimize bias. Most often, direct observation by trained
observers utilizing a consistent approach with validated tools
is the primary method of choice, though this may be done in
Hand Hygiene Monitoring 373
conjunction with other methods. Efforts to improve performance
should utilize pre-existing quality-improvement structures, and
should emphasize a process for direct and timely feedback. If
the performance improvement process relies on HCW-specific
accountability and consequences for non-compliance, then a
high degree of accuracy for each observation is essential, along
with strong leadership support.
Summary
The growing recognition of the importance of HH monitoring
as a component of infection prevention programs in healthcare
facilities has led to advances in direct and indirect measurement
approaches. Though limitations apply to all of these methods,
tools are available to aid implementation of HH measurement
and feedback to support these efforts in a variety of settings.
References
Boyce JM. Measuring healthcare worker hand hygiene activity: Current
practices and emerging technologies. Infect Control Hosp Epidemiol.
WHO guidelines on hand hygiene in health care. First global
patient safety challenge. Clean care is safer care, 2009. http://
whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
(Accessed 1 November 2013).
Boyce JM, Pittet D. Guidelines for hand hygiene in health-care settings:
Recommendations of the Healthcare Infection Control Practices
Advisory Committee and the HICPAC/SHEA/APIC/IDSA hand
hygiene task force. Infect Control Hosp Epidemiol. 2002. 23:S3–S40.
Measuring hand hygiene adherence: Overcoming the challenges. The
Joint Commission, 2009. http://www.jointcommission.org/Meas-
uring_Hand_Hygiene_Adherence_Overcoming_the_Challenges_/
(Accessed 4 November 2013).
Gould DJ, Drey NS, Creedon S. Routine hand hygiene audit by direct
observation: Has nemesis arrived? J Hosp Infect. 2011. 77:290–3.
Muller MP, Detsky AS. Public reporting of hospital hand hygiene com-
pliance-helpful or harmful? JAMA. 2010. 304:1116–7.
Sax H, Allegranzi B, Chraiti MN, Boyce J, Larson E, Pittet D. The
World Health Organization hand hygiene observation method. Am J
Infect Control. 2009. 37:827–34.
- 2005. 60:283–285.
- 2004. 126:219–234.
- 2008. 29(11):1035–41.
- The ideal approach to monitoring HH compliance is not clear;
- 2011. 32:1016–28.
Larson E. Monitoring Hand Hygiene: Meaningless, Harmful, Or Helpful?
Am J Infect Control. 2013. 41:S42–5.
374 A Guide to Infection Control in the Hospital
Marra AR, Moura DF, Paes AT, dos Santos OF, Edmond MB. Measuring
rates of hand hygiene adherence in the intensive care setting: A com-
parative study of direct observation, product usage, and electronic
counting devices. Infect Control Hosp Epidemiol. 2010. 31:796–801.
Sroka S, Gastmeier P, Meyer E. Impact of alcohol hand-rub use on
methicillin-resistant Staphylococcus aureus: An analysis of the liter-
ature. J Hosp Infect. 2010. 74:204–11.
Rosenthal VD, Pawar M, Leblebicioglu H, Navoa-Ng JA, Villa-
mil-Gomez W, Armas-Ruiz A, et al. Impact of the International Con-
sortium (INICC) multidimensional hand hygiene approach over 13
years in 51 cities of 19 limited-resource countries from Latin Amer-
ica, Asia, the Middle East, and Europe. Infect Control Hosp Epide-
miol. 2013. 34:415–23.
Hand Hygiene Monitoring 375
Chapter 59
Healthcare Personnel Attire in
Non-Operating Room Settings
Tara Palmore MD, FACP and
Gonzalo Bearman MD, MPH, FACP
Key Issues
The role of healthcare personnel (HCP) attire in cross-transmis-
sion of pathogens remains unclear. Guidance on HCP attire in
non-operating room settings should attempt to balance profes-
sional appearance, comfort, and practicality with the potential
risk that attire will contribute to the spread of health care associ-
ated microbes. Institutions considering these optional measures
should introduce them with a well-organized communication
and education effort directed at both HCP and patients.
Known Facts
There is a growing awareness of the potential role of fomites
in the transmission of health care associated microorganisms.
Studies have demonstrated contamination of HCP apparel
(scrubs, white coats, ties) with potential pathogens, although
the role of clothing in transmission of these microorganisms
to patients has not been established.
Most studies on patient attitudes toward HCP attire indicate
that patients favor formal attire, including a white coat.
Patients generally do not perceive white coats, formal
attire, or neckties as posing infection risks; however, when
informed of potential risks associated with certain types of
attire, patients are willing to change their preferences for
physician attire.
No clinical studies have demonstrated cross-transmission of
health care associated pathogens from a HCP to a patient
via apparel. A number of small prospective trials have doc-
umented contamination of HCP apparel with a variety of
pathogens. These findings raise a hypothetical concern for
pathogen cross-transmission to patients.
376 A Guide to Infection Control in the Hospital
Name tags have been identified consistently by patients as
an important component of HCP attire.
Controversial Issues
The United Kingdom (UK) has adopted a “bare below the
elbows” (BBE) approach (wearing of short sleeves and no
wristwatch, jewelry, or ties during clinical practice), based
on the theory that the strategy will limit patient contact with
contaminated HCP apparel and promote better hand and
wrist hygiene.
The impact of BBE on HCP bacterial counts remains poorly
defined. One randomized trial comparing bacterial contami-
nation of white coats against BBE found no difference in total
bacterial or MRSA counts (on either the apparel itself or the
volar surface of the wrist) at the end of an eight-hour workday.
Uptake of BBE in healthcare settings has been variable.
To date there is no definitive evidence that a BBE approach
to inpatient care results in improved HAI outcomes.
The optimal frequency for laundering apparel is not clear
based on the current literature. Apparel worn at the bedside
that comes in contact with the patient or patient environment
should ideally be laundered after daily use.
Whether HCP attire for non-surgical settings should be
laundered at home or professionally remains uncertain. A
combination of washing at higher temperatures and tumble
drying or ironing has been associated with elimination of
both pathogenic Gram-positive and Gram-negative bacteria
from HCP clothing.
Suggested Practice
Although the choice of HCP attire may affect infection
rates, evidence-based measures to prevent HAIs (e.g. hand
hygiene, appropriate device insertion and care, isolation of
patients with communicable diseases, environmental disin-
fection) should take priority.
Facilities may consider adoption of a BBE approach to inpa-
tient care as an infection prevention adjunct. There are no
data to guide the optimal choice of alternate attire, such as
scrub uniforms or other short-sleeved personal attire. This
approach is supported by biological plausibility and is
unlikely to cause harm.
Healthcare Personnel Attire in Non-Operating Room Settings 377
In facilities where white coats are used for professional
appearance, commonsense measures should be considered.
HCPs engaged in direct patient care should possess two
or more white coats and have access to a convenient and
economical means to launder white coats. Also, institutions
should provide coat hooks that would allow HCP to remove
their white coat (or other long-sleeved outerwear) prior to
contact with patients or patients’ immediate environment.
Neckties should be secured to prevent them from coming
into direct contact with patients or patients’ immediate
environment.
Any apparel worn at the bedside that comes in contact with
patients or patients’ environment should be laundered after
daily use.
If laundered at home, apparel should be washed in a hot
water wash cycle followed by a cycle in the dryer.
All HCP footwear should have closed toes, low heels, and
non-skid soles.
Summary
The role of HCP attire in cross-transmission of health care asso-
ciated pathogens has not been established. HCP attire frequently
becomes contaminated with bacteria during the course of clin-
ical care. This includes scrubs, neckties, and white coats, with
pathogens such as S. aureus, MRSA, VRE, and Gram-negative
bacilli. The impact of apparel microbial burden on occurrence
of HAI is undefined. Although patients frequently express pref-
erences for certain types of HCP attire, including white coats,
they were willing to change their preferences when informed
of potential risks associated with HCP attire. Patient comfort,
satisfaction, trust, and confidence in their physicians is unlikely
to be affected by practitioners’ attire choice, with the exception
of name tags, which they viewed as essential.
this strategy may enhance hand hygiene to the level of the wrist,
but its impact on HAI rates remains unknown. Facilities may
consider adoption of a BBE approach to inpatient care as an
adjunctive infection prevention measure. The optimal choice
of alternate attire, such as scrub uniforms, remains unknown.
This strategy is supported by biological plausibility and is
378 A Guide to Infection Control in the Hospital
unlikely to cause harm. In facilities where white coats are used
for professional appearance, HCP engaged in direct patient care
should possess two or more white coats and have access to a
convenient means of laundering the white coats. The benefit of
institutional laundering of HCP scrubs versus home laundering
for non-OR use remains unproven. Institutions should provide
coat hooks that would allow HCP to remove their white coat (or
other long-sleeved outerwear) prior to contact with patients or
the patient’s immediate environment.
Ties should be fastened so as to not come into direct contact
with the patient or immediate patient care environment. Shoes
should have closed toes, low heels, and non-skid soles. Name
tags should be used and easily visible.
Reference
Ardolino A, Williams LA, Crook TB, Taylor HP. Bare below the elbows:
What do patients think? J Hosp Infect. 2009. 71:291–293.
Baevsky RH, Fisher AL, Smithline HA, Salzberg MR. The influence
of physician attire on patient satisfaction. Acad Emerg Med. 1998.
5:82–84.
Bond L, Clamp PJ, Gray K, Van D, V. Patients’ perceptions of doctors’
clothing: Should we really be ‘bare below the elbow’? J Laryngol
Otol. 2010. 124:963–966.
Fischer RL, Hansen CE, Hunter RL, Veloski JJ. Does physician attire
influence patient satisfaction in an outpatient obstetrics and gynecol-
ogy setting? Am J Obstet Gynecol. 2007. 196:186–5.
Gallagher J, Waldron LF, Stack J, Barragry J. Dress and address: Patient
preferences regarding doctor’s style of dress and patient interaction.
Ir Med J. 2008. 101:211–213.
- A BBE approach is in effect in the U.K. for inpatient care;
Gherardi G, Cameron J, West A, Crossley M. Are We Dressed To Impress?
A descriptive survey assessing patients’ preference of doctors’ attire
in the hospital setting. Clin Med. 2009. 9:519–524.
Hueston WJ, Carek SM. Patients’ preference for physician attire: A
survey of patients in family medicine training practices. Fam Med.
Ikusaka M, Kamegai M, Sunaga T, et al. Patients’ attitude toward con-
sultations by a physician without a white coat in Japan. Intern Med.
Li SF, Haber M. Patient attitudes toward emergency physician attire.
J Emerg Med. 2005. 29:1–3.
Major K, Hayase Y, Balderrama D, Lefor AT. Attitudes regarding sur-
geons’ attire. Am J Surg. 2005. 190:103–106.
Healthcare Personnel Attire in Non-Operating Room Settings 379
Matsui D, Cho M, Rieder MJ. Physicians’ attire as perceived by young
children and their parents: The myth of the white coat syndrome.
Pediatr Emerg Care. 1998. 14:198–201.
McKinstry B, Wang JX. Putting on the style: What patients think of the
way their doctor dresses. Br J Gen Pract. 1991. 41:270, 275–278.
Nair BR, Attia JR, Mears SR, Hitchcock KI. Evidence-based physi-
cians’ dressing: A crossover trial. Med J Aust. 2002. 177:681–682.
Palazzo S, Hocken DB. Patients’ perspectives on how doctors dress.
J Hosp Infect. 2010. 74:30–34.
- 2011. 43:643–647.
- 1999. 38:533–536.
Rehman Su, Nietert Pj, Cope Dw, Kilpatrick Ao. What To Wear Today?
Effect of doctor’s attire on the trust and confidence of patients. Am J
Med. 2005. 118:1279–1286.
Shelton CL, Raistrick C, Warburton K, Siddiqui KH. Can changes in
clinical attire reduce likelihood of cross-infection without jeopard-
ising the doctor-patient relationship? J Hosp Infect. 2010. 74:22–29.
Baxter JA, Dale O, Morritt A, Pollock JC. Bare Below the Elbows:
Professionalism vs Infection Risk. Bulletin of The Royal College of
Surgeons of England. 2010. 92:248–251.
Toquero L, Abournarzouk O, Owers C, Chiang R, Thiagarajah S, Amin
S. Bare below the elbows—the patient’s perspective. Quality and
Patient Safety 2. 2011.
Munoz-Price LS, Arheart KL, Lubarsky DA, Birnbach DJ. Differen-
tial laundering practices of white coats and scrubs among health care
professionals. Am J Infect Control. 2013. 41:565–567.
Burden M, Cervantes L, Weed D, Keniston A, Price CS, Albert RK.
Newly cleaned physician uniforms and infrequently washed white
coats have similar rates of bacterial contamination after an 8-hour
workday: A randomized controlled trial. J Hosp Med. 2011.
6:177–182.
Gaspard P, Eschbach E, Gunther D, Gayet S, Bertrand X, Talon D. Met-
icillin-resistant Staphylococcus aureus contamination of healthcare
workers’ uniforms in long-term care facilities. J Hosp Infect. 2009.
71:170–175.
Loh W, Ng VV, Holton J. Bacterial flora on the white coats of medical
students. J Hosp Infect. 2000. 45:65–68.
Lopez PJ, Ron O, Parthasarathy P, Soothill J, Spitz L. Bacterial counts
from hospital doctors’ ties are higher than those from shirts. Am J
Infect Control. 2009. 37:79–80.
Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich
EN. Bacterial contamination of health care workers’ white coats. Am
J Infect Control. 2009. 37:101–105.
Wiener-Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinnon
AM. Nursing and physician attire as possible source of nosocomial
infections. Am J Infect Control. 2011. 39:555–559.
380 A Guide to Infection Control in the Hospital
Munoz-Price LS, Arheart KL, Mills JP, et al. Associations between bac-
terial contamination of health care workers’ hands and contamination
of white coats and scrubs. Am J Infect Control. 2012. 40:e245–e248.
Burger A, Wijewardena C, Clayson S, Greatorex RA. Bare below
elbows: Does this policy affect handwashing efficacy and reduce
bacterial colonisation? Ann R Coll Surg Engl. 2011. 93:13–16.
Willis-Owen CA, Subramanian P, Kumari P, Houlihan-Burne D. Effects
of ‘bare below the elbows’ policy on hand contamination of 92
hospital doctors in a district general hospital. J Hosp Infect. 2010.
75:116–119.
Farrington RM, Rabindran J, Crocker G, Ali R, Pollard N, Dalton HR.
‘Bare below the elbows’ and quality of hand washing: A randomized
comparison study. J Hosp Infect. 2010. 74:86–88.
Jacob G. Uniforms and workwear: An evidence base for developing
local policy. NHS Department of Health Policy [serial online]. 2007.
Patel SN, Murray-Leonard J, Wilson AP. Laundering of hospital staff
uniforms at home. J Hosp Infect. 2006. 62:89–93.
Lakdawala N, Pham J, Shah M, Holton J. Effectiveness of low-tempera-
ture domestic laundry on the decontamination of healthcare workers’
uniforms. Infect Control Hosp Epidemiol. 2011. 32:1103–1108.
Chiu MC, Wang MJ. Professional footwear evaluation for clinical
nurses. Appl Ergon. 2007. 38:133–141.
Wilson JA, Loveday HP, Hoffman PN, Pratt RJ. Uniform: An evidence
review of the microbiological significance of uniforms and uniform
policy in the prevention and control of healthcare-associated infec-
tions. Report to the Department of Health (England). J Hosp Infect.
Healthcare Personnel Attire in Non-Operating Room Settings 381
- 2007. 6:301–307.
Chapter 60
Ebola Virus Disease
J. Daniel Markley, DO, Gonzalo Bearman MD, MPH,
and Richard P. Wenzel, MD, MSc
Key Issue:
The 2014 Ebola epidemic is the largest in history, with wide-
spread transmission in multiple countries in West Africa.
Several countries in Europe and the United States have received
patients with Ebola, most of whom are healthcare workers
transported home for care.
Known Facts
Ebola virus disease, previously known as Ebola hemorrhagic
fever, is a rare and deadly disease caused by infection with
one of the Ebola virus species (Zaire, Sudan, Bundibugyo, or
Tai Forest virus).
Ebola viruses are found in several African countries. The first
Ebola virus was discovered in 1976 near the Ebola River in
what is now the Democratic Republic of the Congo. A sec-
ond outbreak in Sudan occurred simultaneously. Since then,
over 20 outbreaks have appeared sporadically in Africa.
Ebola virus is spread through direct contact with the blood
or body fluids (including but not limited to feces, saliva,
sweat, urine, vomit, and semen) of a person who is sick with
Ebola. The virus in blood and body fluids can enter another
person’s body through broken skin or unprotected mucous
membranes in, for example, the eyes, nose, or mouth.
After the onset of symptoms, as the disease progresses high
grade viremia occurs.
Ebola virus is not thought to be spread through air or by
water.
People with Ebola symptoms become more infectious with
progressive symptoms. As a result, exposure to the virus is
more likely when someone is bleeding or vomiting.
382 A Guide to Infection Control in the Hospital
The incubation period for the disease, from exposure to
when signs or symptoms appear, is 2 to 21 days, but the
average is 8 to 10 days.
Signs of Ebola include fever and symptoms such as severe
headache, fatigue, muscle pain, vomiting, diarrhea, abdomi-
nal (stomach) pain, or unexplained hemorrhage (bleeding or
bruising).
Ebola poses minimal risk to travelers or the general public
who have not cared for or been in close contact (within 3 feet
or 1 meter) with someone sick with Ebola for a prolonged
period.
Controversial Issues
While transmission through indirect contact with Ebola
virus via fomites has been documented, current evidence
suggests this is a rare occurrence.
The risk of infection after skin contamination with Ebola
is unknown, therefore until further research provides
additional data, contamination of even intact skin must be
completely avoided.
Ebola virus has been detected in semen after patients have
recovered, however it is not known if the virus can be trans-
mitted through sex (including oral sex). Consequently, it is
recommended that men who have recovered from Ebola
abstain from sex (including oral sex) for three months.
Ebola virus has been detected in breast milk, however it
is not known if the virus can spread from mothers to their
infants through breastfeeding.
Because healthcare workers have accounted for up to 25%
of Ebola cases in prior outbreaks, personal protective equip-
ment (PPE) must be redesigned to be more comfortable and
easy to don.
Ideal PPE for healthcare workers must 1) be impervious to
fluid, 2) cover all skin and all underclothing, 3) be easy to
don, 4) be easy to remove while minimizing the risk for self
contamination, 5) provide maximal comfort for healthcare
workers, and 6) be easy to dispose of while minimizing con-
tamination of healthcare workers.
Ebola Virus Disease 383
Suggested Practice for the Management of
Ebola Virus Disease in Healthcare Settings
General Principles
Identify and isolate the Ebola patient in a single patient
room with a closed door and a private bathroom as soon as
possible.
Limit the number of healthcare workers who come into
contact with the Ebola patient (e.g., avoid short shifts), and
restrict non-essential personnel and visitors from the patient
care area.
Monitor the patient care area at all times, and log, at a mini-
mum, entry and exit of all healthcare workers who enter the
room of an Ebola patient.
Ensure that a trained observer watches closely each donning
and each doffing procedure, and provides supervisory assur-
ance that donning and doffing protocols are followed.
Ensure that healthcare workers have sufficient time to don
and doff PPE correctly without disturbances.
Ensure that practical precautions are taken during patient
care, such as keeping hands away from the face, limiting
touch of surfaces and body fluids, preventing needlestick
and sharps injuries, and performing frequent disinfection of
gloved hands using an alcohol-based hand rub (ABHR), par-
ticularly after handling body fluids.
Dedicated medical equipment (preferably disposable) should
be used to provide patient care.
All non-dedicated, non-disposable medical equipment used
for patient care should be cleaned and disinfected according
to the manufacturer’s instructions.
Personal Protective Equipment for Healthcare Worker:
Powered Air Purifying Respirator (PAPR): A PAPR with a full
face shield, helmet, or headpiece. Any reusable helmet or
headpiece must be covered with a single-use (disposable)
hood that extends to the shoulders and fully covers the neck
and is compatible with the selected PAPR. The facility
should follow manufacturer’s instructions for decontamina-
tion of all reusable components.
384 A Guide to Infection Control in the Hospital
– A PAPR with a self-contained filter and blower unit inte-
grated inside the helmet is preferred.
– A PAPR with external belt-mounted blower unit requires
adjustment of the sequence for donning and doffing, as
described below.
N95 Respirator: Single-use (disposable) N95 respirator in
combination with single-use (disposable) surgical hood
extending to shoulders and single-use (disposable) full face
shield.
Single-use (disposable) fluid-resistant or impermeable gown
that extends to at least mid-calf or coverall without inte-
grated hood.
Single-use (disposable) nitrile examination gloves with
extended cuffs. Two pairs of gloves should be worn. At a
minimum, outer gloves should have extended cuffs.
Single-use (disposable), fluid-resistant or impermeable boot
covers that extend to at least mid-calf or single-use
(disposable) shoe covers. Boot and shoe covers should
allow for ease of movement and not present a slip hazard to
the worker.
Single-use (disposable), fluid-resistant or impermeable
apron that covers the torso to the level of the mid-calf
should be used if Ebola patients have vomiting or diarrhea.
An apron provides additional protection against exposure of
the front of the body to body fluids or excrement.
Personal Protective Equipment for Trained Observer
A trained observer should not enter the room of a patient with
Ebola, but will be in the PPE removal area to observe and assist
with removal of specific components of PPE, as outlined below.
The observer should not participate in any Ebola patient care
activities while conducting observations.
Single-use (disposable) fluid-resistant or impermeable
gown that extends to at least mid-calf or coverall without
integrated hood.
Single-use (disposable) full face shield.
Single-use (disposable) nitrile examination gloves with
extended cuffs. Two pairs of gloves should be worn. At a
minimum, outer gloves should have extended cuffs.
Ebola Virus Disease 385
Single-use (disposable) fluid-resistant or impermeable shoe
covers. Shoe covers should allow for ease of movement and
not present a slip hazard to the worker.
Donning and Doffing:
Please refer to the CDC website:
http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html
Facilities should ensure that space and layout allow for clear
separation between clean and potentially contaminated areas.
It is critical that a one-way flow of care moving from clean
areas (e.g., area where PPE is donned and unused equipment
is stored) to the patient room and to the PPE removal area.
There should be an area outside the Ebola patient room (e.g.,
a nearby vacant patient room, a marked area in the hallway
outside the patient room) where clean PPE is stored and
where healthcare workers can don PPE before entering the
patient’s room.
Disinfection
Disinfect immediately any visibly contaminated PPE sur-
faces, equipment, or patient care area surfaces using a
registered disinfectant wipe.
Perform regular cleaning and disinfection of patient care
area surfaces, even absent visible contamination.
This should be performed only by nurses or physicians as
part of patient care activities in order to limit the number
of additional healthcare workers who enter the room.
Summary:
Ebola virus disease is a rare infection with high mortality and no
effective antiviral treatment. Ebola virus is spread through direct
contact with the blood or body fluids (including but not limited
to feces, saliva, sweat, urine, vomit, and semen) of a person who
is sick with Ebola. The cornerstone of infection prevention for
Ebola is prompt recognition of the disease, isolation patients
and meticulous use of personal protective equipment. The
donning and doffing of personal protective equipment should be
done by trained personnel and should be overseen by a trained
386 A Guide to Infection Control in the Hospital
observer. The ideal PPE for healthcare workers must be imper-
vious to fluid, cover all skin and all underclothing be easy to
don and doff while minimizing the risk for self-contamination,
provide maximal comfort for healthcare workers and be easy
to dispose of while minimizing contamination of healthcare
workers. Facilities should ensure that space and layout allow
for clear separation between clean and potentially contaminated
areas. It is critical that a one-way flow of care moving from
clean areas to the patient room and to the PPE removal area.
Visibly contaminated PPE surfaces, equipment, or patient care
area surfaces should be promptly disinfected using a registered
disinfectant. Disinfection should be performed by nurses or
physicians as part of patient care activities in order to limit the
number of additional healthcare workers who enter the room.
References:
Edmond MB, Diekema DJ, Perencevich EN. Ebola Virus Disease and
the Need for New Personal Protective Equipment. JAMA. 2014.
October 28.
Del Rio C, Mehta AK, Lyon GM, et al. Ebola Hemorrhagic Fever in
2014: The Tale of an Evolving Epidemic. Ann Intern Med. 2014.
November 18. 161(10):746-748.
CDC: Key Messages—Ebola Virus Disease, West Africa (updated
11/19/2014). http://www.cdc.gov/vhf/ebola/.
Ebola Virus Disease 387
Index
A
Acinetobacter, 12, 32, 41–42, 44, 69, 82–83, 97–99, 100, 116–117,
146, 148, 204, 326, 330, 359
Adenosine Triphosphate (ATP) Bioluminescence, 53, 360
Adenovirus, 34, 61, 180, 338–339, 341
Aids, 63, 65, 159, 161, 163, 165, 167, 169, 181, 237, 341, 351, 357
healthcare workers and, 65
Air, 95–101, 147, 150, 153
Airborne precautions, 32–36
Air filters, 39, 42, 97
Anthrax, 125, 251, 266, 269
Antibiotic resistance, 7, 11, 13–16, 68–71, 73–75, 287, 292, 297, 299,
300, 333
challenges, 14–16
management of, 68–76
Antimicrobial prophylaxis, 137, 141, 145, 205, 228, 254–255, 257,
259, 263
in contaminated operations, 254–255
postoperative dose, 254–255
preoperative dose, 254
Antimicrobial resistance, 10, 13, 23, 29, 68–70, 72–73, 75, 82, 132,
149, 153, 155, 206, 219–220, 287, 293, 295, 297, 364
prevention of, 72–73
Antifungal prophylaxis, 334–335
Antifungal resistance, 336
Antiretroviral therapy, 159, 165, 170, 173, 178, 264
Aspergillus, 42, 44, 95, 97, 101, 147, 335, 337
B
Bacille Calmette-Guérin (BCG), 63, 268
Bacteremia, 80, 81, 82, 117, 165, 186, 190, 191, 193, 195, 197, 252,
288, 292, 294, 296, 301, 303, 304, 320
nosocomial, 190–191, 301
pneumococcal, 301, 303
S. aureus, 288
VRE, 294, 296
Bare Below the Elbow (BBE), 70, 377–378
388 A Guide to Infection Control in the Hospital
Bathrooms, 43, 60
Beds, 183
air-fluidized, 42, 100
linen, 33, 41, 58, 147–148, 152, 183
mattresses, 42, 98, 323
Beta-hemolytic streptococci, 263
Biocide rotation, 149, 153
Biofilms, 114, 305
Biosafety, 119–131
levels, 121, 123
cabinets (BSCs), 122
guidelines, 119, 120
manual, 124
CDC Biosafety website, 123
Blood transfusions, 244–253
associated infections, 247–248
criteria for protection of recipients, 248–251
donor deferral, 248–251
donor screening, 244, 246, 249, 252
hepatitis and, 245–252
Bloodborne diseases
healthcare workers and, 63–65
Bloodborne infections, 338, 344–345
Bloodborne viruses, 344–345
Bone marrow
recipients, 61, 66, 294, 335
transplant, 61, 66, 294, 296, 336
Bordetella pertussis, 62, 225–229
Brucella spp, 125, 248
Brucellosis, 119
Bundles, 77, 81, 89–94, 194, 212
Burn wound infections, 189
C
Cabinets
biosafety (BSCs), 122
Cadavers
anthrax in, 266, 269
bagging, 269, 272–273
disposal of, 272, 274
Ebola in, 267, 271–272, 274
Index 389
Cadavers continued
hepatitis in, 266–272
hemorrhagic fever in, 266–267, 269, 271
HIV in, 266–267, 271
meningitis in, 266–267, 269
smallpox in, 266, 269
spongiform encephalopathies in, 266, 269, 270
tuberculosis in, 266–269
Caesarean section, 260–261, 263
Campylobacter spp, 60, 69, 104–105, 107, 314–315, 318
healthcare workers and, 60
Candida spp, 204
C. albicans, 204, 333, 336
C. glabrata, 333–334, 336
C. krusei, 334, 336
C. parapsilosis, 333, 336
infections, 333
non-albicans, 333, 336
species, 190, 333–335, 367
Carbapenem resistance, 309–312
Carbapenem resistant enterobacteriaceae (CRE), 69, 309, 319, 321
Carpets, 40, 100, 147–148
Catheters
and fungemias, 333, 335–336
arterial, 200
fungal colonization of, 335
indwelling, 59, 73, 203–209, 257, 319, 321, 335–336
intravascular, 59, 78, 194–195, 197–198, 218, 257, 281,
296, 333, 335–336
intravenous, 81, 198–199
sterilization/disinfection of, 49–51
urinary, 45, 50, 203–209, 312, 334
Cefazolin, 141, 257–258, 261, 263
Chickenpox, 62, 340
Chlorhexidine, 41, 74, 83, 90, 137, 139–140, 194, 199–201, 214, 221,
257, 261, 263, 289, 295, 311, 321, 324
Citrobacter spp, 116, 309, 321
Clostridium difficile, 14, 26–27, 34, 40, 43, 53–54, 69, 78, 95, 98, 100,
101, 105, 107, 110, 116–117, 119, 132, 146, 148, 180, 182, 314,
318, 359, 361, 367
and gastroenteritis, 180, 318
390 A Guide to Infection Control in the Hospital
Common cold, 61, 66, 339
Construction projects, 42, 97, 101, 147, 175, 334–335
Contact precautions, 34–35, 70, 72, 81, 280, 289–290,
312, 321, 339, 357
Cooling towers, 115, 117, 147
Coronaviruses, 247, 338–339, 341, 346–347, 349
Corynebacterium diphtheriae, 34, 228
Coxiella burnetii, 129, 248
Creutzfeldt-Jakob disease (CJD), 54, 269–270
Critical devices, 240, 330
Cryptosporidia, 99
Cryptosporidium, 65, 104–105, 116–117, 147, 352, 356
Cytomegalovirus, 247, 339, 341
D
Decubitus ulcers, 186, 190, 295
Dengue virus, 247, 341
Detergents, 23–24, 34, 40, 51, 104, 140, 149–150, 153, 257, 273, 331
Diabetic patients, 142, 186, 188, 191
Dialysate, 97, 114–115, 151
Diphtheria, 225–229
toxoid vaccine, 225, 251
Disinfectants, 40–41, 50–51, 55, 110, 148–149, 151–154, 165,
199–200, 239, 261, 270–273, 295, 312, 323–325, 328–331,
348, 352, 364
Disinfection, 39–44, 49–55
Disposable devices, 78
reutilization of, 45–48
Droplet precautions, 35, 279–280, 284
E
Early detection, 12, 77, 110
Ebola virus, 34, 341, 344, 382–387
in cadavers, 267, 271–272, 274
ECG electrodes, 43, 97
Embalming, 268–269, 271–273
Endoscopes, 49–50, 95, 98, 114, 147, 173, 241, 317, 323–325,
327, 329–332
Enteric diseases, 60, 107
healthcare workers and, 60, 65
Enterobacter, 98, 321–322
Index 391
Enterobacter spp, 32, 42, 114, 204, 309
Enterobacteriaceae, 12, 32, 69, 204, 309, 319–321
prevention of transmission, 32, 320–322
resistant, 69, 309, 319, 320, 322
transmission of, 204, 319–321
Enterococcal species, 293–296
risk factors, 294, 296
Enterococci
vancomycin resistant (VRE), 32, 69, 83, 100, 183, 255, 293–296,
359, 361–362, 367, 378
Enterovirus, 338–341
Environmental surfaces, 22, 39, 51, 55, 95, 146, 150, 152–153,
183, 237, 242, 352
recommendations for disinfection of, 51
Epidemics
control of, 77–81
Escherichia coli, 180, 193, 204, 260, 262, 309, 314–318
Ethylene oxide, 45, 50
Ewingella, 43, 98
Exanthematous disease, 338, 340
F
Flavobacterium, 41, 116
Flowers and plants, 37, 39, 41, 96, 100, 105, 147–148, 323
Fluconazole resistance, 335
Food, 103–111, 183
Formaldehyde, 268, 272
Francisella tularensis, 126
Fungemia, 333, 335–336
G
Gangrene, 188
Gastroenteritis
bacterial, 315–318
hospital acquired, 179–181, 184
infectious, 103–104, 107, 110, 179–181, 184
suggested practice, 110, 179–181, 184, 315
Gastrointestinal infections, 1, 314, 324, 338
bacterial, 314
viral, 338
392 A Guide to Infection Control in the Hospital
Germicides, 43–44, 53, 97–99, 362
contaminated, 43, 97
Giardia lamblia, 352
Gloves, 4, 27–28, 33–34, 36, 41, 53, 60–61, 65, 109, 122, 124–126,
129, 135, 139–140, 152, 157, 182–183, 194, 198–199, 205, 222,
239–242, 261, 264, 268–274, 279, 289, 295–296, 300, 302, 312,
321, 324, 328, 338–339, 341–343, 348, 357
Gowns, 122, 140, 143, 157, 182, 239, 241, 264, 268, 271, 279, 289,
295–296, 300, 302, 312, 321, 328, 338–339, 348, 357
Gram-negative rods, 8, 14, 16, 43, 69, 100, 309, 321, 367
H
Haemophilus influenzae, 34, 217
Hair removal, 142, 254, 257
Hand Hygiene (HH), 4, 22–29
compliance, 369–373
definitions, 23
indications for, 27
recommendations for, 27–29
Hand rub, 26, 29, 107, 139, 182, 198, 295, 320, 363, 371
Hantaviruses, 344
Health care associated/Hospital acquired/Nosocomial infections
by anatomic area, 1
costs of, 2–3
definitions of, 79–80
environmental sources of, 95
morbidity and mortality of, 212, 314, 323, 325
Healthcare personnel attire, 96, 138, 142, 144, 376–379
Helicobacter pylori, 327–332
and ulcers, 327, 329
transmission of, 327–332
Hemolytic uremic syndrome, 316
Hemorrhagic colitis, 316
Hemorrhagic fever
in cadavers, 271
viral, 34, 152, 247, 266–267, 269, 271, 341, 344
Hepatitis, 344
healthcare workers and, 61, 64–66
in cadavers, 270
post-transfusion, 252
Index 393
Herpes simplex virus, 34, 60, 66, 264, 339–340, 342
healthcare workers and, 60
transmission of, 339–340, 342
Herpes zoster, 34, 235, 342
Herpetic whitlow, 60
Hexachlorophene, 139
Horizontal Infection Control Strategies, 83–84
Human immunodeficiency virus (HIV), 53, 65–66, 129, 156,
159–168, 171–175, 177, 181, 186–187, 231, 237, 247, 249,
250, 252, 264, 266–267, 271, 281, 288, 298–299, 341–345,
350–353, 356
and breastfeeding, 164, 166–167
and blood donors, 164, 249–250
and blood transfusions, 247, 252
and tuberculosis, 165, 171–175, 177
healthcare workers and, 65–66, 171–173
in cadavers, 266–267, 271
management of, 167–168
mother-to-child transmission, 164, 166–167, 264
prevention strategies, 167–168
Humidifiers, 97, 117, 325
Hydrogen peroxide, 50, 52, 149, 240, 360
vapor, 54, 96, 146
I
Ice baths, 43, 98
Infection control
bundles, 89–93
management team, 6
morbidity and mortality and, 70, 177, 179, 212, 260, 262,
314, 318, 323, 325
Program, 8–9, 77–79, 83–84, 135, 154, 197, 208, 312
Influenza, 34, 61–62, 65–66, 147, 247, 251, 288, 299,
339–345, 348
healthcare workers and, 61–62
transmission of, 61–62, 147
Intensive care units, 68, 78, 115, 187, 194, 198, 311, 350
surveillance of, 81
Intravascular devices, 194, 197–201, 333, 336
394 A Guide to Infection Control in the Hospital
Intravenous fluids, 132
catheters, 81, 198–199
Intubation, 171, 177, 212, 217–218, 221, 301
Isolation
of communicable diseases, 31–37
indications for precautions, 34
implementation of precautions, 37
Iodine, 140, 190, 221, 257
Iodophors, 83, 139–140, 257
J
Jaundice, 66, 109
Jewelry, 139, 377
Joint infections, 324
K
Klebsiella, 97, 99, 193, 321–322
Klebsiella pneumoniae, 309, 319
Klebsiella spp, 41, 114, 193, 204, 309
L
Laboratory-acquired infection, 119–120, 123, 125–129, 355
Left Ventricular Assist Device (LVAD), 367–368
Legionella, 95–101, 115, 147, 305–307
Legionella pneumophila, 147, 305, 353
Legionella spp, 114, 116, 305
Legionnaires’ disease, 114–115, 305
Linen, 33, 41, 58, 147–148, 152, 183
M
Marburg virus, 247
Masks, 33, 35–36, 46, 61, 122, 138, 140, 156–157, 172, 174, 177,
194, 239–241, 261, 264, 268, 270–271, 275, 279, 300, 302, 328,
338–339, 341–343, 346–348
Malassezia, 100, 336
Measles, 230–233
controversial issues, 232
healthcare workers and, 63, 65–66
immunization, 230–233
Mechanically ventilated patients, 220, 223
Medications, 132–135
Index 395
Meningitis, 34, 119, 165, 247, 266–267, 269, 283, 298–299, 301
Methicillin resistant S. aureus (MRSA), 14–16, 32, 40, 54, 59, 66, 69,
83, 85, 87, 100, 146, 148, 186–187, 189, 255, 287–291, 296, 359,
361–362, 367, 371, 377–378
healthcare workers and, 59
risk factors, 288
transmission, 289–291
treatment, 291
Monkeypox, 247
Mumps, 34, 247, 251, 339–340, 343, 345
Mycobacteria, 50, 52, 97–98, 116, 176, 271, 353
Mycobacterium tuberculosis, 147, 171, 331
disinfection, 331
N
Necrotizing fasciitis, 188, 278, 280
Needles, 18–19, 33, 45, 78, 121, 128, 148, 250, 344
Neisseria meningitidis, 12, 127
Neonatal sepsis, 260–262
Noncritical items (devices), 49–51, 55, 150, 153, 295–296
Norovirus, 40, 99, 103–104, 107, 110–111, 148, 180, 338–339, 343
healthcare workers and, 61
Norwalk virus, 104
Nosocomial infections (see also Health care associated/Hospital
acquired/Nosocomial infections)
Nosocomial pneumonia, 212–215
prevention of, 212, 215
treatment of, 214–215
O
Operating Room, 137–144
P
Parasites, 350–357
Parvovirus, 34, 129, 247, 339–340, 343
Patient transport, 35–36
Pertussis, 225–229
healthcare workers and, 62
Pest control, 152
Pharyngitis, 34, 277–278, 280, 282
396 A Guide to Infection Control in the Hospital
Pneumococcus, 298–303
Pneumonia, 212–215
Poliovirus, 338, 343, 345
Positive Deviance (PD), 85–88
Post-mortem rooms, 271
Postpartum endometritis, 260
Pressure sores, 186, 190, 295
Prions, 54, 103
Proteus, 99, 204, 309, 321
Pseudomonas, 42–44, 97–100, 147, 151, 189
Pseudomonas spp, 41, 330
Pseudomonas aeruginosa, 32, 69, 116–117, 186, 189, 191, 204,
323–325, 359
Pseudomonas cepacia, 204
Puerperal fever, 278
Q
Quality of care, 3, 79, 86, 92, 195
Quaternary ammonium, 51–53, 295, 361–362
Quinolones, 14, 32, 69
R
Rabies virus, 251, 269, 339–340, 343, 345
Reservoirs, 11, 39, 42–44, 59, 96–101, 116, 146–149, 189, 294,
323, 325, 330, 353
environmental, 96–101, 146–147, 149
Respiratory diseases
healthcare workers and, 61
Respiratory tract infection, 291, 309, 324, 338–339
Rhizopus, 42, 97
Rickettsial agents, 129, 248
Rickettsial infections, 130
Rickettsiae, 344
Rotavirus, 81, 100, 116, 180, 338, 343
Rubella, 34, 250, 339–340, 343, 345
S
Salmonella, 12, 43–44, 69, 98–99, 104–105, 107, 116, 127, 314–315,
318–319, 321
Salmonella spp, 60, 65, 180–181, 315, 318, 330
diarrhea and, 60, 180–181
healthcare workers and, 60
Index 397
Sars, 247, 346–349
healthcare workers and, 346–349
management of, 348
transmission of, 347
Scabies, 34, 187, 350–351, 357
healthcare workers and, 58–59, 66
Scarlet fever, 34, 278–279
Semicritical items (devices), 49–51, 54–55, 115, 151, 153, 240, 330
Serratia, 43, 97–99, 321
Serratia marcescens, 41, 116, 204
Serratia spp, 204
Shigella, 12, 69, 104, 107, 127, 180, 314–315, 318–319, 321
Shigellosis, 119, 315
Smallpox
in cadavers, 266, 269
Standard precautions, 31–35, 57, 72, 140, 277, 279, 289
Staphylococcus aureus, 287–291
and bloodstream infections, 288
carriers and mupirocin, 59, 137, 187, 189, 255, 258, 289, 290
healthcare workers and, 59–60
MRSA and MSSA, 287–291
reservoirs of, 43, 97–100, 189
transmission of, 289–291
vancomycin resistant (VRSA), 15, 32, 69–70, 288–291
Sterilization, 20, 45–46, 48–50, 52, 54–55, 101, 153, 222, 228,
239–240, 324, 329
dry heat, 50, 52,
methods of, 50, 52, 54
monitoring of, 53
steam, 20, 50, 52, 54
Stethoscopes, 43, 45, 96, 100, 291, 295–296
Streptococcal pharyngitis, 34
Streptococcus
group A, 59, 66, 69, 97, 99, 277–285
group B, 69, 260, 262
healthcare workers and, 59, 66
Streptococcus pneumoniae, 69, 217, 298–303
antibiotic resistance of, 299–300
Streptococcus pyogenes, 147, 186, 188, 277–285
398 A Guide to Infection Control in the Hospital
Superheating, 116, 151
Surgical site infection (SSIs), 81, 83, 137–144, 148, 254, 258–259, 290
in the operating room, 137–144
Surgical team, 139–144
Surgical wounds, 186, 188, 256–257
classification of, 256
Surveillance, 77–81
laboratory-based, 7, 10–11, 119, 124, 130
recommendations for, 80–81
T
Tetanus, 225–229
Thermometers, 43, 98–99, 295, 315, 317
Transmissible spongiform encephalopathies (TSEs)
in cadavers, 266, 269–270
Tuberculosis, 171–178
and HIV, 165
healthcare workers and, 63, 65–66
transmission of, 171–178
U
Urinary tract infections, 3, 78, 193, 203–211, 260, 295,
309, 310, 324, 367
antimicrobial prophylaxis of, 205
hospital acquired, 203–211
Ultraviolet (UV)
disinfection, 361
germicidal irradiation (UVGI), 150, 172, 176
irradiation, 149, 150, 172, 176
light, 53–54, 96, 146, 176, 361
radiation, 360–361
V
Vaccination, 62–63, 111, 119, 266, 268, 302–303, 339–343, 345
influenza, 62, 339, 342, 345
diphtheria tetanus pertussis, 62, 225–229
mumps measles rubella (MMR), 231–233, 340, 343, 345
smallpox, 266
tuberculosis, 63
Vaccine-preventable diseases
healthcare workers and, 65
Index 399
Vancomycin resistance, 293, 296
Vancomycin resistant enterococci (VRE), 32, 69, 83, 100, 183, 255,
293–296, 359, 361–362, 367, 378
Varicella zoster, 62, 65, 250, 281
healthcare workers and, 62
Ventilation, 35–36, 42, 74, 97, 150, 157–158, 175–177, 271, 279, 300
in operating rooms, 138, 142
mechanical ventilation (MV), 74, 217–223, 309, 319, 323–324
Ventilator-associated pneumonia, 78, 81, 214, 217
Vertical Infection Control Strategies, 83–84
Viruses, 338–345
W
Waste disposal, 17, 20, 42–43, 98, 119, 130, 135, 147–149, 152
Waste infectious
management of, 17–21
Water, 41, 43–44, 114–118, 147–148, 151, 153, 305–307
chloride levels in, 115
linked outbreaks, 116–117
Water baths, 44, 99, 117
Wound infection, 1–3, 7–8, 59, 78, 189, 254–255, 256–257,
259–260, 304, 309–310, 324
X
Xenon ultraviolet (UV) light system, 361
Y
Yellow fever, 251, 269, 343–344
Yersinia enterocolitica, 104, 180, 248, 314, 316
Yersinia pestis, 127, 248
Z
Zidovudine, 160, 162, 163
Zygomycetes, 43, 98
400 A Guide to Infection Control in the Hospital
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