بسم اهللا الرحمن الرحيم

Irenic co Dr. kalantari (PhD)

Pasteur, Semmelweis, Lister

The risk of infection is always present.

1877 Separate facilities 1910 Antisepsis and disinfection 1950-60 Closure of Infectious disease and TB hospitals. 1970 CDC “Isolation Techniques for use in Hospitals”

Ignaz Philipp Semmelweis

Joseph Lister

1983 CDC Guideline for isolation precautions in Hospitals (Disease-specific and category-based precautions including blood and body-fluids)

1985 Universal Precautions 1987 Body Substance Isolation

(Mostly focused on worker protection)

1996 Publication of CDC/HICPAC revised guidelines

definition

Patient may acquire infection before admission to the hospital (Community acquired infection). Patient may get infected inside the hospital ( Nosocomial infection = HCAI)

It includes infections

not present nor incubating at admission, infections that appear more than 48 hours after admission, those acquired in the hospital but appear after discharge also occupational infections among staff.

Nosocomial infections occur worldwide. The incidence is about 5-8% of hospitalized patients, 1/3 of which is

preventable. The highest frequencies are in East Mediterranean and South-East Asia. A high frequency of N.I. is evidence of poor quality health service

delivered. East Mediterranean and South-East Asia: 10- 11.8% Europe and west of Pacific ocean: 7.7- 9 % An estimated 1 to 4 extra days for a urinary tract infection, 7 – 8 days for a

surgical site infection, 7 – 21 days for a blood stream infection, and 7 – 30 days for pneumonia.

Reduce the risk of hospital-acquired infection,thereby protecting the :

Patients Employees Health care student Visitors

Contact indirect: infected pt staff & env another pt

direct: infected pt another pt

Autoinfection Air borne Droplet Common source spread

food salmonellosis

Humans Cross-infection

Environment

clinical case e.g. chickenpox streptococcal pharyngitis wound infection

symptomless carrier e.g. MRSA gent-resistant GNRs

auto-infection e.g. some

Staph aureus wound infections

IVI e.g. Staph aureus, diphtheroids, staph epidermidis

ventilator e.g.Pseudomonas

air/dust Staph aureus , legionella disinfectants, solutions etc

e.g.. Pseudomonas

endoscopes e.g. mycobacteria

H. pylori

Humans

Indirect contact transmission Autoinfection Direct contact transmission Air borne & droplet transmission Common source transmission

Urinary tract infection: most common type of N.I. (30-40% of reported cases), associated with an indwelling urinary catheter or instrumentation.

Lower respiratory infection: mostly in ICU (about 15%). surgical wound infections: about 1-18 %. Bacteraemia: (5%) Less frequent include intravenous site infection,

gastrointestinal tract and skin infections.

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

13%

BLOOD INFECTIONS Vascular catheter Neonatal age Critical care Severe underlying disease Neutropenia Immunodeficiency New invasive technologies Lack of training and supervision

5%

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 17%

URINARY TRACT INFECTIONS Urinary catheter

Urinary invasive procedures Advanced age

Severe underlying disease Urolitiasis

Pregnancy Diabetes

34%

Most common sites of health care- associated infection and the risk factors

underlying the occurrence of

infections

LACK OF HAND

HYGIENE

The microbial agent

Patient susceptibility

Environmental factors

Bacteria are the most common pathogens. 1. Commensal bacter ia: found in normal flora of healthy humans, prevent pathogenic bacterial colonization on skin, colon, vagina. 2. Pathogenic bacter ia: have great virulence and cause

infection as : - Anaerobic gram +ve rods e.g Clostridium causing

gangrene. - Gram (+) bacteria: Staph. aureus found on skin & nose. - Gram (-) bacteria as E.coli, Proteus, Klebsiella, legionella

species.

Viruses: HIV, HBV, HCV can be also be transmitted through

blood & B F (transfusion, injections, dialysis) respiratory syncytial virus, rota virus, ebola, infleunza, herpes

simplex viruses. Parasites & Fungi: e.g. Giardia lamblia is easily transmitted

between adults or children, Aspergillus sp. affecting imunocompromised.

Scabies an ectoparasite causing outbreak.

Age: infants and old age have decreased resistance to infection.

Immune status: Patients with chronic diseases as malignancy, leukemia, diabetes mellitus, renal failure or AIDS have increased susceptibility to infection.

Immunosuppressive drugs or irradiation

Healthcare settings are environment where both infected persons and persons at high risk of infection congregate.

Crowded conditions within hospital, frequent transfers of patients between units.

Microbial flora may contaminate objects, devices and materials which subsequently contact susceptible body sites of patients.

- Standard precautions: minimal level of infection control

- Assume that every person is potentially infected or colonized with an

organism( blood-borne pathogens). applied to blood, body fluids, secretions, excretions( except sweat), nonintact skin and mucous membranes. for all patients in the hospital (regardless of suspected or confirmed infection status).

There are 9 elements to Standard Precautions

Hand Hygiene

linen

Clinical waste

Body fluid spills

Accommodation

Clean environment

Preventing exposure

Patient care 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

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Standard precautions – Gloves (PPE)

1. Exposure to blood, body fluids, secretions, excretions, mucous membranes and non-intact skin, and contaminated items

3. Perform hand hygiene immediately after glove removal

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2. Change gloves when heavily contaminated

4. Disposable glove should not be reused

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

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3. Select an appropriate gown for the procedure

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

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Gloves are not a substitute for handwashing!

≠

Prevent needles and other sharps instrument injuries

Prevent mucous membrane exposures Safe work practices and PPE to protect

mucous membranes and non-intact skin

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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

FDO-registered disinfectants or detergents

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Standard precautions: Patient Care equipment and instruments/devices

Clean and maintain medical equipment and instruments/devices according to the manufacturers’ instructions

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Key principles for handling of soiled laundry:

Don’t shaking items or handle them in any way that may aerosolize infectious agents

Avoid contact with one’s body and personal clothing

Contain soiled items in a laundry bag or designated bin

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2/25/2015

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Classification of chemical disinfectants. Risk stratification of hospital sections. Classification of medical devices

Cleaning and disinfection of instrument &surfaces

Spaulding classification of chemical disinfectants

Level of disinfection Spores TB Vegetative

bacteria Fungi Nonlipid &

small viruses

Lipid & medium-

size viruses

High + * + + + + +

Inter-mediate - + + + +/- +

Low - - + +/- +/- +

* high-level disinfectants may not be able to kill large numbers of spores

Low risk area : Financial , Official

Moderate risk areas : Hospital ordinarily wards

High risk areas : ICU, NICU, Isolated rooms

Very high risk areas : Operation rooms

Spaulding classification of medical devices

Class of item Use of item Example Decont. level needed

Critical Enter vascular system or sterile body tissues

Hypodermic needle, Scalpels

and other surgical instruments,

Biopsy forceps

Sterilization

Semi-critical Comes in contact with

intact mucous membranes

Vaginal spec., Anaesthetic

equipment, flex. Endoscopes

High-level disinfection (by heat or chemicals)

Non-critical Touches only intact skin

Blood pressure cuff, Baby weigh scale, Examining

table top

Intermediate-level or low-

level disinfection

Classification of Disinfectants High Level

Hydrogen Peroxide Peracetic acid Glutaraldehyde Formaldehyde

Intermediate Level Chlorine Iodine Alcohols

Low level Phenolics Quaternary Ammonium Compounds

Physical: dry heat: 160 c for 1-2 h moist heat:121c for 15min Ionizing radiation :UV & gama Chemical: glutaraldehyde peracetic acid Ethylen oxide

Instrument Cycle

Using Deconta-minating Cleaning

Disinfecting Sorting / Packing

Sterilizing