1. DR. MAZIN BARRY, MD, FRCPC, FACP, DTM&H
Infection Control
DR. MAZIN BARRY, MD, FRCPC, FACP, DTM&H
Infectious Disease Consultant
Assistant Professor of Medicine

2. Outline Hospital Acquired Infections (HAI) Hand Hygiene (HH)
Isolation Precautions
Injection Practices and vaccinations

3. HAI
At any time, over 1.4 million people worldwide are suffering from infections acquired in hospital
Between 5% and d10% of patients admitted to hospitals acquire one or more infections
Causes more serious illness
Prolong hospital stay
Long-term disability
High additional financial burden
High personal burden on patients and their families
Deaths

4. Most frequent sites of infection and their risk factors
URINARY TRACT INFECTIONS
Urinary catheter
Urinary invasive procedures
Advanced age
Severe underlying disease
Urolitiasis
Pregnancy
Diabetes
34%
13%
LOWER RESPIRATORY TRACT INFECTIONS
Mechanical ventilation
Aspiration
Nasogastric tube
Central nervous system depressants
Antibiotics and anti-acids
Prolonged health-care facilities stay
Malnutrition
Advanced age
Surgery
Immunodeficiency
LACK OF HAND HYGIENE
Most common sites of health care- associated infection and the risk factors underlying the occurrence of infections
SURGICAL SITE INFECTIONS
Inadequate antibiotic prophylaxis
Incorrect surgical skin preparation
Inappropriate wound care
Surgical intervention duration
Type of wound
Poor surgical asepsis
Diabetes
Nutritional state
Immunodeficiency
Lack of training and supervision
BLOOD INFECTIONS
Vascular catheter
Neonatal age
Critical care Severe underlying disease
Neutropenia
Immunodeficiency
New invasive technologies
Lack of training and supervision
17%
14%

5. Prevention of HAI
Validated and standardized prevention strategies have been shown to reduce HAI
At least 50% HAI could be prevented
Most solutions are simple and not resource-demanding and can be implemented

6. Colonization Versus Infection
People who carry bacteria without evidence of infection (fever, increased WBC) are colonized
If an infection develops, it is usually from bacteria that colonize patients
Bacteria that colonize patients can be transmitted form one patient to another by hands of healthcare workers
Bacteria can be transmitted even if the patient is not infected.

7. The Iceberg Effect
Infected
Colonized

8. The inanimate environment can facilitate transmission

9. Hand transmission
Hands are the most common vehicle to transmit healthcare associated pathogens
Transmission of healthcare associated pathogens from one patient to another via healthcare worker’s hands

10. Why should you clean your hands
Any HCW involved in health care needs to be concerned about hand hygiene
Their hand hygiene concerns you !
You must perform hand hygiene to :
- protect the patient against harmful microbes in your hands or present on your skin
- protect yourself and the healthcare environment from harmful microbes

11. Five moments of hand hygiene

12. 5 Moments of Hand hygiene

13. How to clean your hands
Handrubbing with alcohol-based handrub is the preferred routine method of hand hygiene if hands are not visibly soiled
Handwashing with soap and water – essential when hands are visibly dirty or visibly soiled (following exposure to body fluids)

15. Hand hygiene and glove use
The use of gloves does not replace the need to clean the hands
Remove gloves to perform ahnd hygiene, when an indication occurs while wearing gloves
Wear gloves only when indicated, otherwise they become a major risk for germ transmission

16. Compliance with Hand hygiene
Compliance with hand hygiene differs across facilities and countries
Main reasons for non-compliance reported by HCWs
- Too busy
- Skin irritation
- Glove use
- Don’t think about it

17. Hand hygiene improvement strategy
System change
- Access to safe, continuous supply of water, soap, towels, alcohol based hand rub at the point of care
Training / Education
- Regular training to all HCW
Evaluation and feedback
- Monitoring hand hygiene practices, perceptions and knowledge, while providing results feedback to HCWs
Reminders in the workplace
- Reminding HCWs
Safety culture
- Creating an environment that facilitates awareness, raising about patient safety issues

18. Isolation Precautions

19. Mode of transmission
A microorganism may be spread by a single or multiple routes.
Contact, direct or indirect
Droplet
Airborne
Vector-borne (usually arthropod) and
Common environmental sources or vehicles - includes food-borne and waterborne, medications e.g., contaminated IV fluids
Several main routes of transmission of microorganisms.
A microorganism may be spread by a single or multiple routes.
Types of mode of transmission:
Contact, direct or indirect
Droplet
Airborne
Vectorborne (usually arthropod) and
Common environmental sources or vehicles - includes foodborne and waterborne, medications e.g., contaminated IV fluids

20. Types of Isolation Precautions
Standard precautions
Transmission-based precautions
Contact precautions
Airborne precautions
Droplet precautions

21. Definition of standard precautions
Apply to all patients receiving care in hospitals regardless of their diagnosis or presumed infection status.
Apply to (1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain blood; (3) nonintact skin; and (4) mucous membranes.
Designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.
Apply to all patients receiving care in hospitals regardless of their diagnosis or presumed infection status.
Apply to (1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain blood; (3) nonintact skin; and (4) mucous membranes.

22. Standard Precaution - Hand hygiene
Handwashing with either plain or antiseptic
containing soap and water, and use of alcohol-based
products (gels, rinses, foams) that do not requre the
use of water
Perform hand hygiene:
Before and after patient contact
After removing gloves or any other PPE item
After touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn
Handwashing is the single most important procedure for preventing the spread of communicable diseases.
Perform hand hygiene:
Before and after patient contact
After removing gloves or any other PPE item
After touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn
2. Improved hand hygiene practices associated with a sustained decrease of MRSA and VRE infections primarily in ICU.
Unit 6 - Infection Control Measures

23. Standard precautions Personal protective equipment (PPE)
The selection of PPE based on
The nature of patient interaction and/or
The likely mode(s) of transmission
Designated containers for used disposable or reusable PPE should be placed in a convenient to the site of removal
Hand hygiene is always the final step after removing and disposing of PPE
Refers to a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents

24. Standard precautions – Gloves (PPE)
Exposure to blood, body fluids, secretions, excretions, mucous membranes and non-intact skin, and contaminated items
Change gloves when heavily contaminated
Perform hand hygiene immediately after glove removal
Personal Protective Equipment - Gloves
The primary design of personal protective equipment (PPE) is to protect healthcare workers (HCWs) and reduce opportunities for transmission of microorganisms in Healthcare facilities.
Gloves
Wear gloves when the procedure may expose you to blood, body fluids, secretions, excretions, mucous membrane and non-intact skin, and contaminated items
Change gloves after contact with material that may contain a high concentration of microorganisms, e.g. it may happen between tasks and procedures on the same patient
Wash hands immediately after gloves are removed.
Do not disinfect clean gloves after donning and disposable gloves should not be reused
References:
Centers for Disease Control and Prevention. (1996). Guidelines for Isolation Precautions in Hospitals Hospital Infection Control Advisory
Committee. Retrieved September 30, 2006, from
HA Infection Control Plan for Avian Influenza Jul 2006
4. Disposable glove should not be reused
Unit 6 - Infection Control Measures

25. Standard precautions – Gown (PPE)
1. When splashes or sprays of blood and body fluids, secretions and excretions to skin and working clothes are likely
2. When working clothes has substantial contact with patient, environmental surfaces or patient items
Personal Protective Equipment - Gown
A gown is used to prevent contamination of skin or working clothes
Gown
Wear a gown to protect skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions
When the working clothes has substantial contact with the patients, patient equipment and environment in contact precautions.
Gowns should be selected according to the amount of fluid encountered to ensure adequate protection.
3. Select an appropriate gown for the procedure
Unit 6 - Infection Control Measures

26. Standard precautions – Mask and eye protection (PPE)
Surgical masks and eye protection:
When splashes or sprays of blood
and body fluid, secretions and excretions
are likely
Sterile technique
Respiratory etiquette
Change PPE promptly if heavily
contaminated during the procedure
Personal Protective Equipment – Mask & eye protection
Masks are used for 3 primary purposes in healthcare facilities:
Placed on HCW to protect them from contact with infectious material from patients e.g., resp. secretions and sprays of blood or body fluids, consistent with Standard precautions
Placed on HCW when engaged in procedures requiring sterile technique to protect patients from exposure to infectious agents carried in a HCW’s mouth or nose.
Placed on coughing patients to limit potential dissemination of infectious resp. secretions from patient to others.
Surgical masks and eye protection:
Wear surgical mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood and body fluids, secretions and excretions are likely
.Health care workers should change PPE promptly if it is heavily contaminated during the procedure.
Unit 6 - Infection Control Measures

27. Standard precautions - prevent hcws exposure to bloodborne pathogens
Prevent needles and other sharps instrument injuries
Prevent mucous membrane exposures
Safe work practices and PPE to protect mucous membranes and non-intact skin
Needles and other sharps instrument injuries associated with transmission of HBV, HCV, HIV to HCW
Prevention of mucous membrane exposures has been an element of standard precautions for routine patient care
Safe work practices and wear PPE to protect mucous membranes and non-intact skin from contact with potentially infectious material.

28. Standard precautions: Environmental measures
Clean and disinfect non-critical surfaces in patient-care areas are part of SP.
Clean and disinfect all frequently touched surfaces in patient-care areas
FDA-registered disinfectants or detergents
SP – Environmental measures
Clean and disinfect non-critical surfaces in patient-care areas are part of SP.
Clean and disinfect all patient-care areas is important for frequently touched surfaces, especially those closet to the patient, e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the patient.
EPA-registered disinfectants or detergents that best meet the overall need of the healthcare facility for routine cleaning and disinfection should be selected
Unit 6 - Infection Control Measures

29. Respiratory hygiene and cough etiquette
Three elements include:
Educate healthcare workers, patients, and visitors
Post signs in appropriate language(s)
Source control measures:
Cover the nose/mouth when coughing or sneezing
Use tissue paper respiratory secretions and dispose in the waste receptacle
Perform hand hygiene after contact with respiratory secretions and contaminated objects
Place a surgical mask on the coughing person when tolerated and appropriate
Spatial separation, ideally >3 feet
Three elements include:
Education of healthcare workers, patients, and visitors
Post signs appropriate language(s)
Source control measures:
Cover the nose/mouth when coughing or sneezing
Use tissue paper to contain respiratory secretions and dispose in the waste receptacle
Perform hand hygiene after contact with respiratory secretions and contaminated objects
Place a surgical mask on the coughing person when tolerated and appropriate
Spatial separation, ideally >3 feet

30. TRANSMISSION-BASED PRECAUTIONS - Management of visitors
Visitors as sources of healthcare associated infections – e.g., pertussis, influenza, tuberculosis
Cough etiquette
Use of barrier precautions by visitors
Educate patients and family members
Follow signs for isolation precautions

31. TRANSMISSION-BASED PRECAUTIONS - Contact Precautions
Infections spread by direct or indirect contact with patients or patient-care environment –C. difficle, MRSA, VRE, ESBL and MDR GNR
Limit patient movement
Private/SINGLE room or cohort with patients with same infection
Wear disposable gown and gloves when entering the patient room
Remove and discard used disposable gown and gloves inside the patient room
Wash hands immediately after leaving the patient room
Clean patient room daily using a hospital disinfectant, with attention to frequently touched surfaces (bed rails, bedside tables, lavatory surfaces, blood pressure cuff, equipment surfaces)
Use dedicated equipment if possible (e.g., stethoscope)
Consists of standard precautions (see previous frames) plus precautions for direct and indirect contact
Infections spread by direct or indirect contact with patients or patient-care environment – shigellosis, C. difficle, MRSA
Limit patient movement
Private room or room shared with patients with same infection status
Wear disposable gown and gloves when entering the patient room
Remove and discard used disposable gown and gloves inside the patient room
Wash hands immediately after leaving the patient room
Clean patient room daily using a hospital disinfectant, with attention to frequently touched surfaces (bed rails, bedside tables, lavatory surfaces, blood pressure cuff, equipment surfaces)
Use dedicated equipment if possible (e.g., stethoscope)

32. Contact precautions signs

33. Droplet Precautions
Reduce the risk of transmission by large particle droplets (larger than 5 m in size).
Requires close contact between the source person and the recipient
Droplets usually travel 3 feet or less
E.g., influenza including H1N1, other respiratory viruses, rubella, parvovirus B19, mumps, H. influenzae, and N. meningitidis
Consists of standard precautions plus specifics for droplet precautions
Ues to reduce the risk of transmission of microorganisms transmitted by large particle droplets (larger than 5 m in size).
Droplet transmission requires close contact between the source person and the recipient because droplets do not remain suspended in the air.
Droplets usually travel 3 feet or less within the air and thus special air handling is not required.
Droplet transmission involves contact of the conjunctiva of the eyes or the mucous membranes of the nose or mouth of a person with the microorganism generated from the infected source person during coughing, sneezing or talking, or during the performance of procedures such as suctioning and bronchoscopy.

34. Droplet Precautions cont.
A private/single room or
Cohort with patient with active infection with same microorganism
Use a mask when entering the room and definitely if within 3 feet of patient
Limit movement and transport of the patient. Use a mask on the patient if they need to be moved and follow respiratory hygiene/cough etiquette
Keep at least 3 feet between infected patient and visitors
Place the patient in a private/single room or if not available
Cohort with patient with active infection with same microorganism
Use of respiratory protection such as a mask when entering the room recommended and definitely if within 3 feet of patient
Limit movement and transport of the patient. Use a mask on the patient if they need to be moved and follow repiratory hygiene/cough etiquette
Keep patient at least 3 feet apart between infected patient and visitors
Room door may remain open

35. Droplet precautions signs

36. Airborne Precautions Tuberculosis, measles, varicella, MERS-CoV
Place the patient in an airborne infection isolation room (AIIR)
Pressure should be monitored with visible indicator
Use of respiratory protection (e.g., fit tested N95 respirator) or powered air-purifying respirator (PAPR) when entering the room
Limit movement and transport of the patient. Use a mask on the patient if they need to be moved
Keep patient room door closed.

37. Airborne precautions signs

38. Safe injection practices
Large outbreaks of HBV and HCV among patients in the United States
The primary breaches
Reinsertion of used needles into a multiple-dose vial or solution container (e.g., saline bag)
Use of a single needle/syringe to administer intravenous medication to multiple patients.

39. Vaccination
Annual Influenza vaccine
HBSAB
VZV