Basic Concepts in Infection Prevention and Control

JULY 2023
 Introduction

▪Healthcare Associated Infection (HCAI) is an infection in a patient during the

process of treatment within a hospital or in any healthcare facility, which was
not present or incubating at the time of admission.
▪ This term replaces both Hospital acquired infections and nosocomial
infections.
▪HCAI can occur during healthcare delivery in any setting (e.g. hospitals, long-
term care, or ambulatory settings).
▪According to the WHO, the four commonest HCAIs in low-and middle-income
countries are Surgical Site Infections (SSI), catheter-associated urinary tract
infection (CAUTI), central line associated blood stream infection (CLABSI), and
ventilator associated pneumonia (VAP)
 Surveillance of healthcare-associated infections

▪Surveillance is defined as the ongoing systematic collection,

analysis and interpretation of health data essential to the planning,
implementation and evaluation
▪To clinicians and other stakeholders, surveillance and feedback
of infection rates is a cornerstone of HCAI prevention program.
▪Surveillance to determine the incidence of HCAI is an important
part of the strategy to minimize the occurrence of these infections
and is the foundation for organizing, implementing, and
maintaining an effective infection prevention and control (IPC)
program in healthcare facilities
 Factors Influencing Healthcare associated Infections
Factors related to microorganisms
➢Each microorganism has an infective dose defined as the number of microorganisms
required to cause an infection.
➢f the person is immunosuppressed, the infective dose required to cause infection
becomes reduced. The pathogenicity of microorganisms or virulence is the capacity of
a microbial strain to produce disease.

Factors related to the host.

 Sources of infections
Infections can be acquired from two sources
(i) an endogenous route when the source of microorganisms is
from the patient’s own microflora, e.g. from the gut due to break
in intestinal mucosal barriers caused by chemotherapy in cancer
patients; or
(ii) an exogenous route when the microbes are from outside
sources, e.g. from contaminated hands of healthcare workers,
items, equipment, and/or the environment.
 Impact of healthcare associated infections

▪Establishing and enhancing effective delivery of IPC services is part of the

quality and safety of healthcare, which can contribute to the following
improvements in health outcomes:
➢Reduction in length of stay.
➢Reduction in cost.
➢Reduction in hospital attendance.
➢Effective utilization of beds.
➢Reduction in the spread of multi-drug resistant organisms (MDROs).
➢Improved patient satisfaction, safety and quality of care.
➢Impact on individuals and families.
A strong health system, which includes a culture and system of IPC is critical to
preventing the spread of infection and responding to disease outbreaks.
Organizational structure in healthcare facility
 IPC Unit
There should be an official notification of a formal IPC structure at the Hospital level with
clearly defined objectives, functions, and responsibilities.
The IPC unit or department should be responsible for development of the national IPC
policy and strategic plan, provide guidance of IPC program at all healthcare institutions
An experienced technical full time health professional, preferably experienced in IPC.
The unit should be duly supported by dedicated technical teams from relevant disciplines
such as microbiology, nursing, medical epidemiology, IT etc., and should also include
administrative support
*** PerMenKes RI 2017 no 27 ( Pencegahan dan Pengendalian Infeksi )
 The main functions of the IPC unit should include

1. Development of IPC guidelines in collaboration with provinces

and other local stakeholders and partners.
2. Design a standardized healthcare associated infections
(HCAIs) surveillance program.
3. Advise on implementation of multimodal strategies to prevent
transmission of infections and antimicrobial resistance.
4. Develop/adapt IPC training curriculum, and establish a system
for monitoring, evaluating, and reporting key IPC indicators.
5. Prepare and disseminate an annual report of IPC activities at
the Local level.
 Hospital Infection and Control Program

1. Implementing the IPC Program

is everybody’s responsibility
and does not rest with the IPC
team alone.
2. The Team must ensure
adequate management
arrangements for
implementation and effective
delivery of IPC practices,
including standard precautions
in every aspect of patient care
as a routine practice
 Important components of the IPC program

▪Availability of basic infrastructure (Hand hygiene facility)

▪Availability of basic IPC supplies ( PPEs)
▪Implementation of basic measures for IPC, including triage,
isolation of patients & Standard Precautions
▪Education ( orientation Policies/procedures refreshing )
▪Availability and regular update of IPC and antimicrobial guidelines.
▪Protection of healthcare workers.
Important components of the IPC program, cont.

▪Identification of hazards and unsafe IPC practices and minimizing the

risks.
▪Environmental management practices
▪Implementation of IPC practices essential to the provision of safe patient
care e.g. aseptic techniques, usage of single-use disposal devices,
adequate reprocessing of reusable medical devices/Equipment.
▪Surveillance of healthcare associated infections, and outbreak
investigation.
▪Regular audits and incident monitoring, and reporting to the appropriate
authorities.
▪Education, practical training and research
 Roles and Responsibilities of Hospital Management

1. The hospital’s chief executive/administrators/ MS/director is

ultimately responsible for the provision of IPC services.
2. It is essential that adequate resources, both financial and
human, and managerial support are available to the IPC team
so that IPC programs are implemented effectively.
 Role and responsibilities of employers

1. All employers have a legal obligation to ensure that all

employees are appropriately trained and proficient in the
procedures for patient care and safety.
2. Every employee is equally responsible for taking all
reasonable steps while working to ensure their own health and
safety and that of others who may be affected by their acts and
IPC omissions at work
 Types of IPC precautions
Standard precautions are the basic level of IPC precautions which are to be used
routinely as a minimum, in the care of all patients at all times
Five Moments of Hand Hygiene
Six Steps of Effective Hand
hygiene
 HAND HYGIENE FACILITY
To prevent spread of microorganisms hand
wash sink should not be used to dispose of
clinical waste irrespective of quantity and do
not clean patient care or other items in hand
wash basin dedicated for hand washing.
Never use a multi - use towel to dry hand as
they are responsible for the spread of
bacteria and cause outbreaks.
 Transmission-based
precautions
The application of additional precautions (also called transmission-based precautions) is
necessary and if the patient’s status of infection is a known infection.
The most common modes of transmission of infections in a healthcare facility are by
contact, droplet and airborne
The three most common routes, infection in a healthcare facility (HCF) can also result
from inoculation, especially in healthcare workers due to injuries acquired from
contaminated needles during use and disposal
 Patient placement
The main aim of triage is to assess risk and segregate suspected
and/or confirmed infected patients with transmissible infections and
patients with multidrug-resistant organisms in a single room,
preferably with ensuite toilet facility.
Implementation of the Triage system in the Accident &
Emergency (A&E) and out-patient department is essential in all
healthcare facilities to prevent cross-infection due to overcrowding.
 Types of Isolation Rooms
Source Isolation Room
➢Infected patients are nursed in single rooms preferably with ensuite toilet and shower
facilities require a negative pressure ventilation room and anteroom.
➢A minimum of 6– 12 exchanges of air change (ACH) per hour
➢ It should be adequate temperature and humidity regulation, such that windows need
not be opened, and doors can be kept closed when the rooms are in use.
Protective Isolation
➢To prevent transfer of infection from inanimate environment and other personnel to
immunosuppressed patients (severely neutropenic, patients undergoing any
transplantation, and who have received intensive chemotherapy )
➢A positive pressure ventilation room
AIR FLOW OF TYPE OF ISOLATION ROOM
Personal Protective Equipment
Personal protective equipment (PPE) acts as a physical barrier that prevents healthcare
staff, from becoming contaminated with blood and other body fluids.
It is important to remember that an understanding of the principles of transmission of
microorganisms, alongside effective risk assessment and appropriate selection of PPE,
can help in avoiding unnecessary PPE use and reduce wastage.
 Do’s and Don’ts for PPEs
Don’t reuse gloves, surgical face masks, gown and aprons— they are single-
use disposable items.
Don’t spray any disinfectants (e.g. hypochlorite solution) to ‘disinfect’ PPE nor
use hypochlorite solution to disinfect your hands.
Don’t routinely use PPE for visitors in the Intensive care, neonatal unit etc.
Respiratory hygiene and cough
etiquette
All persons with respiratory symptoms should cover their nose and mouth when
coughing or sneezing or wiping and blowing noses with a tissue or mask.
Discard used tissues and masks, and perform hand hygiene after contact with
respiratory secretions.
If no tissues are available, cough or sneeze into the inner elbow then perform
hand hygiene.
For aerosol generating procedures, N95 mask should be used.
 Handling of linen
It is essential that all healthcare facilities must have documented policies on safe
handling of linen.
All used linen should be handled and transported with care
➢to avoid dispersal of microorganisms into the environment
➢to avoid contact with staff clothing.
 Disinfection and Sterilization
Cleaning: It is the first step required to physically remove contamination by foreign
materials; It also removes organic materials, such as blood, secretions, excretions, and
microorganisms, to prepare a medical device for disinfection or sterilization.
Disinfection: It is the process of reducing the number of viable microorganisms to a less
harmful level. This process may not, however, inactivate bacterial spores, prions, and
some viruses.
Sterilization: It is a validated process used to render an object free from viable
microorganisms, including viruses and bacterial spores, but not prions.
*** It is also essential that prior to the purchase of any items/equipment which require
decontamination, a pre-purchase questionnaire is used that requires input and acceptance
from the CSSD
 Do’s and Don’ts for Cleaning
Instruments
Don’t soak any surgical instruments in hypochlorite solution during transport, as
it destroys the instruments.
Don’t use skin antiseptics for cleaning instruments.
Don’t disinfect any single-use invasive devices e.g. CVC, urinary catheters and
nasogastric tube.
Don’t soak respiratory therapy items, e.g. endotracheal tube, ventilator tubing in
disinfectant solution (esp. glutaraldehyde as it is a respiratory irritant) —Send it
to the sterile service department for decontamination.
Limit the utilization of ‘Immediate use’ (flash) sterilization system to disinfect
instruments.
 Environmental Cleaning
Microorganisms survival in the environment depends on various factors, i.e.
moisture, temperature, humidity, and type of material.
The published evidence indicates that a contaminated environment plays an
important role in the spread of microorganisms in a healthcare facility
➢regular and thorough cleaning of environmental surfaces, items and equipment is
essential to reduce bioburden, to minimize transfer of pathogens directly via hands
touching the contaminated environmental surface or indirectly via contaminated
hands, items, and equipment.
Examples of ‘high-touch’ items and surfaces in the healthcare environment
Example of a cleaning strategy for environmental surfaces, moving in a
systematic manner around the patient care and in the general ward.
 Measurements of cleanliness
Visual inspection
Fluorescent marker systems
Culture methods (swab or agar plate)
➢Routine environmental swabbing is not recommended (no correlation with
cleanliness).
 Management of potentially infectious spills
All spills of blood and high-risk body fluids should be carefully
removed as soon as possible, and the area washed with
detergent/disinfectant and dried.
It is not necessary to use hypochlorite solution for managing ‘low-
risk’ body fluids, but it may be used if the circumstances indicate
that it is necessary.
 Management of Healthcare
Waste
The waste generated by any healthcare facility (esp. hospital) is a
specialized type of waste.
Healthcare waste not only contains pathogenic microorganisms,
but also sharp items and appropriate treatment of these items must
be made mandatory.
The waste generated by a healthcare facility should be dealt with
by a waste management team.
The team should develop a written waste management plan or if it
is a small setup, a person or persons should be appointed to
manage the health facility’s waste.
Types of healthcare waste and colour coding
Types and categories of healthcare waste
 Sharp container
All sharp containers should be puncture-proof and fitted with covers
They must be correctly assembled and used according to the manufacturer’s instructions.
Sharps boxes or procedure tray should ideally be within arm’s reach
Used sharps boxes must be suitably marked for identification from wards or departments
of the hospital or the healthcare facility.
Sharps containers must be properly closed when three- quarters full and stored in a
designated secure point whilst awaiting collection.
Where plastic or metal containers are unavailable or too costly, containers made of dense
cardboard are recommended -these folds for ease of transport and may be supplied with
a plastic lining. Label ‘DANGEROUS CONTAMINATED SHARPS’.
 Do’s and Don’ts for Sharps
Don’t reuse needles and syringes.
Don’t administer unnecessary IM/ IV injections when the oral route is
appropriate.
Replace sharps container when 3/4 full.
Keep sharps container out of reach of children.
Don’t re-sheath needles as it is the most common method of needle injuries.
 Food Safety
Key Points in Food Preparation: Food handlers and consumers should
Keep Clean Know the food they use.
Read labels on food packaging, make an
Separate raw and cooked food
informed choice, and be familiar with
Cook thoroughly common food hazards.
Keep food at safe temperatures Handle and prepare food safely.
Use safe water and raw materials Face masks are recommended for
people who may cough or sneeze while
handling food.
Wear gloves that can be used to cover
any cuts or lesions and should be
changed frequently.
 ENDOSCOPY UNIT
Decontamination of flexible endoscopes should take place in a dedicated, well ventilated
room (up to 12 air changes per hour), away from the procedure room.
The room should be equipped with a sink having sufficient capacity and a dedicated hand
wash basin equipped with soap and disposable paper towels.
There should be a workflow direction within the room from dirty to clean
There should be sufficient storage of the consumables for use, during the
decontamination procedure.
Endoscopes must be stored in an area that is clean, well-ventilated and dust-free
➢ Endoscopes should hang freely
➢ Endoscopes should be stored in accordance with the manufacturer’s manual and in the storage
cabinet.
 Protection of Healthcare Workers
Protection of staff is an integral part of health and safety.
➢It is the responsibility of all healthcare facilities (HCFs) to ensure that all their
employees are appropriately trained and proficient in the procedures necessary for
working safely.
All healthcare workers (HCWs) must be given adequate
education and practical training on all issues relating to Infection
Prevention and Control (IPC) as part of their induction/orientation
program and this training should be made mandatory.
All HCWs should be immunized against vaccine- preventable
diseases and should have up to date record of their routine
immunizations.
 Safe burial practices
As a general rule, standard IPC precautions should be continued
after death.
If the person has died of a communicable disease, the risk of
transmitting infection is usually less and occurs mainly from
contact with the infected body and any fluids
If a person is known or suspected to have died of a serious
communicable disease, the mortuary staff, post-mortem room, and
funeral personnel are aware that there is a potential risk for
transmission of infection.
Summary of the hierarchy of IPC prevention and control
measures.