Preventing/Controlling the Transmission of Infectious Agents�

Objectives

• The participant will be able to list the different types of isolation.
• The participant will be able to list the benefits of vaccinating patients against influenza and pneumonia.

Therapeutic and Diagnostic Procedures and Devices

​

The risk for HAI is related to the mode of transmission

of the infectious agent, type of patient care activity or

procedure being performed and the individual’s underlying

host defenses

Increased Risk for Infection

• Associated with stays in the ICU, High-risk procedures
• Intravascular devices, esp. central lines
• Mechanical ventilation
• Surgical and invasive procedures
• Intracranial monitoring
• Parenteral nutrition (e.g. hyperalimentation)
• Urinary tract instrumentation, esp. indwelling catheterization
• Extracorporeal membrane oxygenation
• Ventricular assist devices (used to maintain a patient with a heart transplant)
• The risk for infection associated with devices and certain procedures can be reduced by adherence to appropriate infection prevention measures (e.g., hand hygiene, barrier precautions, device-specific bundles)

Infection types in acute care setting

Prevention of Surgical Site Infections (SSIs)

• Endogenous bacteria - bacteria that naturally reside in a closed system. Disease can occur when microbes included in normal bacteria flora enter a sterile area of the body such as the brain or muscle. Normal flora change to pathogenic bacteria.

Occur by:

change of normal habitat

damage of skin

Inappropriate use of antibiotics

• Exogenous sources – can become pathogenic exogenous bacteria which can enter a closed biological system and cause disease. Mainly through hands of healthcare workers, visitors, patients.

​

• Personnel

​

Prevention of Surgical Site Infections (SSIs)

• Procedure risk factors include:
• Operative technique
• Hair removal technique
• Timing of antibiotic prophylaxis
• Duration of procedure
• Warmth of patient
• Blood glucose levels
• Use of immediate use sterilized instruments
• OR room traffic

HICPAC Guideline

• Recommended rankings
• Category IA
• Category IB
• Category II

Pre-Operative Control

• Measures to improve host factors
• Surgical site skin prep
• Timing of preoperative antibiotic prophylaxis

​

​

​

Intra-Operative Control

• Measures
• Post-Op Control
• Measures-Incision Care

​

Elimination of Catheter-Related Bloodstream Infections (CRBSI)

• Mortality
• Sources
• Invasion of percutaneous tract
• Risk Factors
• APIC Elimination Guide

Elimination of Catheter-Related Bloodstream Infections (CRBSI)

• General Measures
• At Catheter insertion:
• Insertion Bundle
• Who inserts
• Cutaneous antisepsis
• Subclavian site preferred
• Dressing

Elimination of Catheter-Related Bloodstream Infections (CRBSI)

• Maintenance
• Removal
• Monitoring
• Dressings
• Topical ointments
• Administration sets
• Routine Catheter replacement

Elimination of CAUTIs

• CAUTIs are the most frequent type of infection in acute care settings, comprising more than 30% of total HAI estimate
• A urinary catheter provides a portal of entry into the urinary tract; bacteria may ascend into the tract via either the external or internal surface of the catheter
• APIC’s Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIS) provides evidence-based practice guidance for the prevention of CAUTI in acute and long-term care settings.

Elimination of CAUTIs

• Strategies to prevent CAUTIs include:
• Assess need
• Insertion technique
• Who inserts?
• Device Securement
• Closed System
• Hygiene
• Urine flow
• Where does the bag belong?

Elimination of VAP

• Pneumonia accounts for approximately 11% to 15% of all HAIs, and 24% to 27% of all infections acquired in the medical intensive care unit (MICU) and coronary care unit (CCU), respectively
• Risk factors for pneumonia are patient-related; device-related, people related and procedure-related factors include extremes of age, chronic lung disease, immunosuppression, depressed consciousness.

Elimination of VAP

• Key prevention strategies:
• Hand Hygiene
• Antibiotic Stewardship
• Mouth Care
• Positioning of patient
• Duration
• Routine Ventilator changes
• Condensate
• Disinfection and storage
• Minimize gastric distention
• Education
• Observation
• Conduct regular surveillance for outcome measures

​

​

Elimination of Infection Risk Associated with Hemodialysis

• Patients receiving hemodialysis are vulnerable to HAIs because of
• Human factors
• Environmental factors
• Procedural factors
• Multitude of patient comorbidities

Elimination of Infection Risk Associated with Hemodialysis

• Environmental cleaning/ disinfection
• Equipment cleaning/ disinfection
• Hand hygiene
• Immunizations
• Medication/ injection safety
• Education
• Presurgical/ postsurgical infection prevention
• Standard/ Transmission –Based Precautions
• Vascular access
• Water treatment/ testing
• Infection surveillance
• Quality improvement program

Cardiac Catheterization and Electrophysiology

• Early onset infections
• Late onset of infection
• Normal skin flora and skin pathogens are often the causative agents of infection
• To reduce infection:
• Follow standard precautions
• Patient preparation includes:
• Clipping hair prior to arrival in procedure room
• facility approved skin antisepsis
• sterile draping for all vascular access procedures
• sterile surgical technique
• antibiotic prophylaxis
• Post-procedure
• Detect remote infections early and treat appropriately
• Implantable device infections

Recalls

• Contaminated equipment and supplies
• Food and Drug Administration (FDA) and the CDC should be notified
• Removed from use
• Outbreak investigation must be initiated

ISOLATION PRECAUTIONS

Standard Precautions: HICPAC Synthesis of Universal Precautions and Body Substance Isolation

• Applies to all persons receiving healthcare regardless of medical diagnosis or presumed infection status

​

​

​

• Basic concept is to treat all patients’ blood or body fluids as if they are infectious material; applies to blood, body fluids, secretions and excretions; nonintact skin; and depending on anticipated exposure

Contact Precautions

• Diseases transmitted by contact

​

• Single room is preferred

​

• Gloves and gown required on entry

​

• Limit patient transport outside the room

​

• Discontinue Contact Precautions

Droplet Precautions

• Prevent transmission of diseases caused by large respiratory droplets

​

• Single room preferred

​

• Wear surgical mask on room entry

​

• Use gloves when handling items contaminated with respiratory secretions

​

• Limit patient transport

​

• Discontinue droplet precautions

Airborne Transmission

• Used to prevent transmission of infectious organisms that remain suspended in air and travel great distances

​

• Place patient in an airborne infection isolation room

​

• Wear N95 or higher respirator when entering room

​

• Limit transport of patients to essential medical procedures

​

• Discontinue Airborne Precautions according to pathogen-specific recommendations

Protective Environment

• Recommended for allogenic hematopoietic stem cell transplant recipients
• Environmental controls-filter incoming air with positive pressure HEPA filtration
• Limit time spent outside of protected environment
• Implement Droplet and Contact Precautions as needed

Prevention of Multidrug-Resistant Organisms (MDRO)

• Administrative measures
• Active Surveillance
• Computer alerts
• Hand Hygiene
• Maintain staffing levels
• Education:
• Antibiotic stewardship
• Surveillance
• Isolation precautions
• Decolonization

From CDC’s ANTIBIOTIC RESISTANCE THREATS in the United States, 2013

ENVIRONMENTAL HAZARDS

Linen and Laundry

• General guidelines-all used/ soiled linen should be handled as though contaminated
• Clean Linen
• Employee garments/ uniforms/ scrubs

​

​

​

Trash and Biohazard Waste

• Definition of Medical waste
• Factors for infection :
• Presence of a pathogen(this does not always result in infection)
• Pathogen must be of sufficient virulence
• Pathogen must be present in sufficient dose
• Organism must have a portal of entry (into the body)
• Must be a susceptible host

​

Trash and Biohazard Waste

• Categories of infectious waste
• Contaminated sharps
• Microbiological cultures and stocks of infectious agents
• Animal wastes
• Blood and blood products
• Selected isolation wastes-materials contaminated
• Pathology wastes
• Waste management plan
• Definition of infectious waste
• Designation-policy/procedures
• Segregation
• Packaging, storage, transport, treatment, disposal
• Contingency planning
• Training

​

Needles and Sharps

• Place used needles and sharps in puncture-resistant containers
• Avoid unnecessary recapping
• Use needle and sharps safety devices
• Mandated by OSHA Needlestick Safety and Prevention Act of 2000 and OSHA Bloodborne Pathogen Standard (2001)

Laboratory Specimens and Tissue Samples

• Handle all specimens as if they were known to be infectious
• Wear gloves when handling specimen containers until container can be placed into a biohazard bag
• Transport specimens in a manner that minimizes the chance of spillage
• Label all specimen containers, freezers, incubators and refrigerators with “biohazard”

IMMUNIZATION OF PATIENTS

Standing Orders Programs

• Protocols

​

• Can be used in inpatient and outpatient facilities, long-term-care facilities, managed-care organization, assisted living facilities, correctional facilities and home health-care agencies

​

• The Advisory Committee on Immunization Practices (ACIP) recommends standing orders for influenza and pneumococcal vaccinations

​

• Other vaccines that should be offered to adults as necessary include hepatitis A, hepatitis B, MMR, Td/Tdap, meningococcal, HPV, zoster

​

• Children and teens may require the following vaccines: Varicella, Dtap, hepatitis A, hepatitis B, Haemophilus infuenzae type b, HPV, MMR, Td/Tdap, meningococcal, inactivated polio vaccine (IPV), HPV, rotavirus (infants)

Practice Questions

A woman in active labor with confirmed influenza has been admitted to an acute care facility. Recommendations for preventing influenza transmission between hospitalized infected mothers and their infants includes all of the following EXCEPT:

1. The mother should be placed on droplet precautions
2. The baby should stay in the same room as the mother
3. Keep the isolette at least 3 feet away from the mother when she is not interacting with the baby
4. The baby should receive formula during the 5-day period following the mother’s symptom onset

Answer

• D- the baby should receive formula during the 5-day period following the mother’s symptom onset
• Rationale: Pregnant women and infants are at increased risk of hospitalization from influenza complications. Pregnant women with influenza in the L&D Suite should be placed on Droplet Precautions. The pregnant woman does not need to wear a mask during the time of delivery.
• Newborn infants of influenza infected mothers should stay in the same hospital room as the mother and should be housed in an isolette when available. The isolette should be placed at least 3 feet from the mother when she is not interacting with the baby.

Practice Questions

A Patient is admitted with pruritic lesions on the hands, webs of fingers, wrists, extensor surfaces of elbows and knees, and the outer surfaces of the feet, armpits, buttocks, and waist. What type of isolation does this person require?

​

• Contact
• Droplet
• Airborne
• No isolation required

Answer

• A- Contact
• Rationale: Skin infestation by the mite Sarcoptes scabiei var, hominis is commonly known as scabies. Mites are transmitted through direct contact with infested persons; less frequently, transmission may occur through contact with clothing or bedding.

Practice Questions

An autopsy is ordered on a patient who was diagnosed with TB. Which of the following statements is correct regarding postmortem care of the deceased TB patient?

​

• Autopsy rooms should be at positive pressure with respect to adjacent areas, and room air must be exhausted directly outside
• An oscillating autopsy saw should be used to reduce the infectious aerosols
• An approved mask is necessary for respiratory protection
• Standard Precautions are sufficient because Mycobacterium tuberculosis needs a living host to survive.

Answer

• C –an approved mask is necessary for respiratory protection
• Rationale: OSHA classifies performance of an autopsy on a known or suspected case of TB to be a high-hazard procedure requiring personnel to use approved respiratory protection. In areas where TB is prevalent and the health history is unknown, respiratory protection is prudent, especially for medical examiner’s cases.

Practice Questions

• What type of respiratory protection is recommended for immune and nonimmune healthcare personnel when caring for a patient with smallpox?
1. Surgical Mask
2. Exam Mask
3. N95 or higher level respirator
4. Procedure mask

Answer

• C-N95 or higher level respirator
• Rationale- Smallpox is a disease caused by variola viruses, members of the Orthopoxvirus genus. Smallpox was eradicated in the 1970s as the result of a massive worldwide immunization program.
• Smallpox does not have an animal reservoir and has been eradicated from the human population, the only way that smallpox can occur is as a result of intentional exposure from a bioterrorism attack.

Practice Questions

• The US Pharmacopoeia (USP) recommends that multidose vials be disposed of :
1. 14 days after opening
2. 30 days after opening
3. 28 days after opening
4. When all the medication has been used

Answer

• C- 28 days after opening
• Rationale- A multi-dose vial is a vial of liquid medication intended for parenteral administration that contains more than one dose of medication. Multi-dose vials are labeled as such by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria.

Practice Questions

• Of the following methods of disinfection and sterilization, which will kill all organisms, including all bacterial spores?
• Pasteurization
• Orthophthalaldehyde
• Steam Sterilization
• Ethylene oxide
1. 1,2
2. 2,3
3. 1,3
4. 3,4

Answer

• D- 3,4
• Rationale: Both steam sterilization and ethylene oxide gas sterilization will kill bacterial spores and all other microorganisms. Steam sterilization can only be used for items that are tolerant of high temperatures, such as metal surgical tools.
• Ethylene oxide gas sterilization is a low-heat method for items that are not heat tolerant, Items that are sterilized by ethylene oxide must be allowed time for aeration before use.

References

• Certification Study Guide; 6^th edition APIC

​